Clinical Cases in Physiotherapy

193

Transcript of Clinical Cases in Physiotherapy

The Curtis CenterIndependence Square WestPhiladelphia, Pennsylvania 19106

CLINICAL CASES IN PHYSICAL THERAPY, 2ND EDITION 0-7506-7394-XCopyright © 2004, Elsevier Science (USA). All rights reserved.

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NOTICE

Physical therapy is an ever-changing field. Standard safety precautions must be followed, but asnew research and clinical experience broaden our knowledge, changes in treatment and drugtherapy may become necessary or appropriate. Readers are advised to check the most currentproduct information provided by the manufacturer of each drug to be administered to verify therecommended dose, the method and duration of administration, and contraindications. It is theresponsibility of the licensed health care provider, relying on experience and knowledge of thepatient, to determine dosages and the best treatment for each individual patient. Neither the publishernor the authors assume any liability for any injury and/or damage to persons or property arisingfrom this publication.

Previous edition copyrighted 1995

International Standard Book Number 0-7506-7394-X

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Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

B U T T E R W O R T H

H E I N E M A N N

An Imprint of Elsevier

To Leslee, Jeanne, Eric, Christopher, Katie, and Michael,

whose love, patience, and understanding made this

contribution possible

Michael B. Ashley, PTAshley & Kuzma Physical Therapy and

PhotomedicineErie, Pennsylvania

Angela M. Baeten, PTConsultantAbrams, Wisconsin

Amy Tremback-Ball, MSPTAssistant Professor, Physical Therapy

DepartmentCollege MisericordiaDallas, Pennsylvania

Allison T. Behm, MSPTStaff Physical TherapistMercy HospitalScranton, Pennsylvania

Marybeth Grant Beuttler, PT, MSAssistant Professor, Physical Therapy

DepartmentUniversity of ScrantonScranton, Pennsylvania

Donna Bowers, PT, MPH, PCSInstructor, Department of Physical Therapy

& Human Movement ScienceSacred Heart UniversityFairfield, Connecticut

Nicole A. Boyle, MSPTBinghamton, New York

Trista L. Bratlee, MSPTPittston, Pennsylvania

Mark A. Brimer, PT, PhDAdministrator, OrthopaedicsHolmes Regional Medical CenterMelbourne, Florida

Laurie Brogan, MSPTStaff Physical TherapistSports Injury Treatment CenterScranton, Pennsylvania

Kathleen M. Buccieri, PT, MS, PCSClinical Education Director, Physical Therapy

DepartmentIthaca College at University of Rochester

CampusRochester, New York

Christopher R. Chelius, Jr., MSPTLead Physical Therapist and Center

Coordinator of Clinical EducationManatawny Manor Nursing and Rehabilitation

CenterPottstown, Pennsylvania

Stacia M. Ciak, MSPTHunlock Creek, Pennsylvania

Jason A. Craig, MCSP, DPhilAssistant Professor, Physical Therapy

DepartmentMarymount University (Ballston Campus)Arlington, Virginia

Kristina A. Dillon, MSPTBinghamton, New York

Carolyn J. Engdahl, MSPTMountain Top, Pennsylvania

Andrea Falcone, MSPTPediatric Physical Therapist with HFM

BOCESJohnstown, New York

vii

Contributors

Renee M. Hakim, PT, PhD, NCSAssistant Professor, Physical Therapy

DepartmentUniversity of ScrantonScranton, Pennsylvania

Jennifer Holmes, MSPTStaff Physical TherapistMassapequa Pain Management and

RehabilitationMassapequa, Long Island, New York

Rett Holmes, MSPTSenior Staff Physical TherapistPhysical Therapy PlusWashington, New Jersey

Thomas Hudson, MS, PT, PCSAssistant Professor, Physical Therapy

Department Consultant, Gannon University and Erie

Homes for Children and AdultsErie, Pennsylvania

Marianne Janssen, PT, EdD, ATCDirector of Clinical EducationDepartment of Physical Therapy EducationElon UniversityElon, North Carolina

Timothy L. Kauffman, PT, PhDKauffman-Gamber Physical TherapyLancaster, Pennsylvania

Edmund M. Kosmahl, PT, EdDProfessor, Physical Therapy DepartmentUniversity of ScrantonScranton, Pennsylvania

Nicholas J Kuharcik, MSPTLarksville, Pennsylvania

MaryAlice Lachman, MSPTStaff Physical TherapistNovaCare RehabilitationCollegeville, Pennsylvania

Amy S. Lambert, MSPTLake Ariel, Pennsylvania

Kevin J. Lawrence, PT, MS, OCSAssistant Professor, Physical Therapy

DepartmentCollege MisericordiaDallas, Pennsylvania

Holly Leaman, MSPTStaff Physical TherapistMaryview Rehabilitation HospitalPortsmouth, Virginia

Beatriz Lizaso, MSPTPembroke Pines, Florida

Mark V. Lombardi, MSPT, MA, ATCSports Injury Treatment CenterScranton, Pennsylvania

Michelle M. Lusardi, PT, PhDAssociate Professor, Department of Physical

Therapy and Human Movement ScienceSacred Heart UniversityFairfield, Connecticut

Diane E. Madras, PT, PhDAssistant Professor, Physical Therapy

DepartmentCollege MisericordiaDallas, Pennsylvania

Robert Marsico, PT, EdDAdjunct Assistant Professor, Physical Therapy

DepartmentRichard Stockton College of New JerseyPomona, New Jersey

Colleen Medlin, MSPTPhysical TherapistHealthSouth Spine Center of BaltimoreBaltimore, Maryland

Keith Meyer, CPDirector, Prosthetic ServicesKeystone Prosthetics and Orthotics Inc.Clarks Summit, Pennsylvania

viii Clinical Cases in Physical Therapy

Gerri M. Misunas, MSPTStaff Physical TherapistSports Injury Treatment CenterScranton, Pennsylvania

Georganne N. Molnar, MSPTNewport, Pennsylvania

Kelley A. Moran, MSPT, DPT, ATC, CSCSAssociate Professor, Physical Therapy

DepartmentCollege MisericordiaDallas, Pennsylvania

Michael Moran, PT, ScDProfessor, Physical Therapy DepartmentCollege MisericordiaDallas, Pennsylvania

Kristin E. Murray, MSPTPediatric Physical Therapist Archway Programs Early InterventionAtco, New Jersey

Karen W. Nolan, PT, MS, PCSAssistant Professor, Physical Therapy

DepartmentIthaca College at University of Rochester

CampusRochester, New York

Patricia O’Shea, MSPTLong Valley, New Jersey

Maureen Romanow Pascal, PT, MS, NCSAssistant Professor, Physical Therapy

DepartmentCollege MisericordiaDallas, Pennsylvania

David Patrick, MSPT, CPODirector, Orthotic ServicesKeystone Prosthetics and Orthotics Inc.Clarks Summit, Pennsylvania

Steven D. Pheasant, PT, PhDAssistant Professor, Physical Therapy

DepartmentCollege MisericordiaDallas, Pennsylvania

Kristen R. Pizzano, MSPTExeter, Pennsylvania

Pamela J. Reynolds, PT, EdDAssociate Professor, Physical Therapy

DepartmentGannon UniversityErie, Pennsylvania

Jonathan Sakowski, MSPTAdjunct Assistant Professor, Physical

Therapy DepartmentCollege MisericordiaDallas, Pennsylvania

John Sanko, PT, EdDAssociate Professor, Physical Therapy

DepartmentUniversity of ScrantonScranton, Pennsylvania

Dawn M. Schaeffer, MSPTPerkasie, Pennsylvania

Eric Shamus, PT, PhD, CSCSAssistant Professor, College of Osteopathic

MedicineNova Southeastern UniversityFort Lauderdale, Florida

Jennifer Shamus, PT, PhD, CSCSClinical Specialist, AdministratorHealthsouth Sports MedicinePembroke Pines, Florida

Colleen Kimberly Smith, MSPTSaylorsburg, Pennsylvania

Melissa A. Strohl, MSPTLehighton, Pennsylvania

Contributors ix

Amy L. Szumski, MSPTScranton, Pennsylvania

Gary Tomalis, MSPTWilkes-Barre, Pennsylvania

Barbara Reddien Wagner, PT, MHAAcademic Coordinator of Clinical EducationUniversity of ScrantonScranton, Pennsylvania

John Wojnarski, MSPTDallas, Pennsylvania

Loraine D. Zelna, MSRT (R)(MR)(ARRT)Associate Professor/Clinical Coordinator,

Medical Imaging DepartmentCollege MisericordiaDallas, Pennsylvania

x Clinical Cases in Physical Therapy

With the first edition of Clinical Cases in

Physical Therapy, Mark Brimer and MikeMoran set the standard for using clinicalsituations to exemplify the best aspects ofour practice. These cases illustrated howeach patient must be approached thought-fully, and how expert clinical decisions mustbe applied in each patient situation. This textlikewise “puts a face” on physical therapisteducation and practice. As students andclinicians, we are inundated with facts, con-cepts, and theories, often to the point thatwe begin to lose sight of what drew us to thisprofession in the first place. Descriptions ofclinical cases remind us that we deal withpeople, and that all our knowledge and skillmust ultimately be used to affect the life andwelfare of a single individual.

Continuing the tradition established in thefirst edition, the second edition of Clinical

Cases in Physical Therapy makes excellentuse of cases as a teaching tool. We are againable to see how experienced cliniciansexamine, evaluate, and intervene in specificsituations. To enhance pedagogy, learningobjectives have been added to the beginningof each case. References to the peer-reviewedliterature have likewise been included in thesecases. These references direct readers to addi-tional information on each topic and under-score the need to draw upon the growing bodyof knowledge that provides evidence for ourdecisions. The second edition also extendsthe use of case studies to encompass diverseaspects of physical therapist practice. We arenow given insight into how physical therapistsmight react to situations that do not directlyinvolve patient care, but situations that arenonetheless resolved successfully with skill,knowledge, and expertise. For example, casesare used to illustrate how therapists manageissues related to documentation, clinical edu-

cation, ethics, as well as many other areasrelated to physical therapist practice.

Hence, the second edition of Clinical Cases

in Physical Therapy has evolved to demon-strate how cases reflect the depth and scopeof our practice. Moreover, these cases are noworganized according to the practice patternsand elements of management established inthe Guide to Physical Therapist Practice,

second edition. Rather than turning thesecases into a fixed template or cookbook, thiseffort to organize and analyze according tothe Guide helps point the way through eachcase in a logical and effective manner. Thestructure and organization of the second edi-tion of Clinical Cases in Physical Therapy

represent an outstanding effort by Brimerand Moran to unite our profession and pro-vide us with a common language and strategyfor examining the way we practice.

As physical therapists, we now recognizethat case reports serve a vital role in our pro-fession. We must be comfortable with the ideathat clinical cases do not just documentunusual patients, but that cases represent theprimary way that we communicate and teachone another about the various aspects of ourpractice. Clinical Cases in Physical Therapy,

2nd edition, fulfills a vital role in classroomand clinical settings because it offers a com-pendium of knowledge about our profession.It is rare that a single text can be applicableto all aspects of a profession as diverse asphysical therapy, but Brimer and Moran andtheir contributors offer some genuine pearlsof wisdom to every reader. Once again,Clinical Cases in Physical Therapy showsus that each patient or clinical situationrequires our thoughtful and skilled approach,and this idea has been, and always will be,the cornerstone of our profession.

Charles D. Ciccone, PT, PhD

xi

Foreword

The profession of physical therapy has under-gone significant growth and developmentsince the first edition of Clinical Cases in

Physical Therapy was published almost10 years ago. Since then, the profession hasmade great strides in developing and imple-menting the Guide to Physical Therapist

Practice, 2nd edition, the foundation fordescribing and implementing physical therapyclinical practice. The goal of this text is tobuild upon the concepts presented in theGuide to Physical Therapist Practice, 2ndedition, and provide real-life examples ofhow therapists can use the Guide for patientcare opportunities.

Each case in Clinical Cases in Physical

Therapy, 2nd edition, begins with learningobjectives designed to assist the reader inexamining the multiple intricacies of clinicalpractice. Similar to the Guide, Clinical Cases

in Physical Therapy, 2nd edition, focusesupon enhancement of quality of care, promo-tion of appropriate utilization of services,recognition of variations in clinical practice,the importance of sound documentation, andthe value of professional ethics. Throughouteach case the reader is provided with ques-tions designed to stimulate further investiga-tion and enhance clinical decision making.Patient care outcomes are provided for mostcases. The outcomes serve to demonstratehow patient care issues were brought toclosure. Peer-reviewed and other referencesare provided at the end of each case.

Cases have been carefully organizedaccording to practice patterns and elementsof care management. Attention was given toavoiding a “cookie-cutter” case presentationso that variations of clinical analysis andapproaches can be used by the reader to find

the best patient care outcome. This includesencouraging the reader to evaluate the effi-cacy of intervention provided and determineif it aligns with the clinical and functionalgoals presented.

To provide a methodology for analysis andlearning, a matrix has been included at theend of the text. The matrix contains group-ings under which specific practice patternscan be examined. As the reader will note, thecases are also ordered by level of complexityto allow progression of learning opportu-nities. Additionally, several cases have thedistinction of being included in more thanone practice pattern, thereby reflecting thecomplexity of actual patient care oppor-tunities frequently encountered in the clinicalsetting.

More than anything else, Clinical Cases

in Physical Therapy, 2nd edition, furthersunderstanding of the complex role the pro-fession has in assimilating all patient careinformation with skill, knowledge, andexpertise. The cases have been designed toprovide a conceptual framework for under-standing how practice patterns can be usedto enhance the delivery of quality health careservices.

Mark A. Brimer

Michael L. Moran

The Preferred Physical Therapist PracticePatternsSM are copyright 2003 AmericanPhysical Therapy Association and are takenfrom the Guide to Physical Therapist Prac-

tice (Guide to Physical Therapist Practice, ed 2,Phys Ther 81:1, 2001), with the permission ofthe American Physical Therapy Association.All rights reserved. Preferred Physical Thera-pist Practice PatternsSM is a trademark of theAmerican Physical Therapy Association.

xiii

Preface

In any complex endeavor, many individualslend varying forms of assistance. We thankall of them. We would like to specifically thankthe library staff at College Misericordia fortheir tireless and good-natured help. Also, our

thanks go to Chuck Ciccone for his supportover the years and for writing the forewordto both editions. Finally, we gratefully thankKatie Moran for her sense of humor andeditorial skills.

xv

Acknowledgments

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Describe how the physical therapy examination process is important inestablishing patient-centered goals and outcomes.

2. Identify how deficiencies in documentation can affect communicationand result in inefficient care.

The reader should know that the patient was

entering his fifth week of physical therapy

intervention when he was added to the caseload.

ExaminationH I S T O R YThe patient was a 94-year-old male who livedindependently at home before sustaining afall that resulted in a displaced C-1 fracture.The initial physician’s order was for “PT evaland treat per plan of care.” The patient wasretired, and his son was the primary contact.The physician documented that a cervicalcollar was in place, that the patient reportedpersistent neck and left knee pain, and thatthe patient had full use of all extremities.Knee crepitus was recorded and documentedas osteoarthritis. Medications includedProcardia, Relafen, Darvocet, and Hytrin.Librium (25 mg t.i.d.) was discontinued.Nursing reported patient complaints of neckpain and noncompliance with the cervicalcollar. The assistance of two persons wasneeded to transfer the patient to a bedsidechair, and the patient’s tolerance for sittingwas 10 minutes.

Based on the medical record review of

admission information, what data might be

expected in the physical therapy documen-

tation after further history review, the

systems review, and the tests and measures

portion of the examination are completed?

The Guide to Physical Therapist Practice

(p. 42)1 defines patient history as “from boththe past and the present.” Therefore, one can

expect such information as the patient’s levelof education, history of therapy intervention,living environment (e.g., devices, environ-mental barriers), medical history, and func-tional status/activity level. It would also bereasonable to expect data on communicationability as well as on cardiovascular/pulmonary,musculoskeletal, and neuromuscular systems.Tests and measures might provide baselinedata in such areas as cognition, pain ratings,range of motion (especially the left knee),strength, positioning, bed mobility, endurance,transfers, balance, and gait.

The Initial ExaminationDocumentationThe following was a summary of the docu-mentation provided in the medical record bythe examining physical therapist:

The patient was a 94-year-old male wholived alone in a two-bedroom home. He wasusing a cane for ambulation when his left kneebuckled and he fell. He was found injured byhis county home health aide. The patient wasdiagnosed with a displaced fracture of C-1.A cervical collar was in place. He exhibitedfunctional mobility of all extremities exceptthat bilateral shoulder joint flexion and abduc-tion was limited to 100 degrees and his leftknee lacked 15 degrees of extension. He exhib-ited fair left quad strength within his activerange. General strength was fair to good. Hetransferred from bed to chair with a flexedposture and with moderate assistance of one.

Goals: Short-term—1. Minimally assisted transfers.

1

Case 1

2 Clinical Cases in Physical Therapy

2. Independent ambulation with assistivedevice to be determined.

Goals: Long-term—(blank)Rehabilitation potential—(blank)Plan of care: 5×/week for gait training,

general strengthening, transfer training,and left knee rehabilitation.

Discussion of the InitialExamination FindingsThe examining therapist did not address allof the expected examination areas. Some help-ful information, such as that the patient useda cane and lived in a two-bedroom home, wasobtained. However, many questions wereunasked, including whether there were anyenvironmental barriers, why home health carewas received, and what the patient’s priorfunctional level was.

The systems review portion of the examina-tion lacked baseline cardiovascular/pulmonarysystem data and provided only minimalmusculoskeletal system data pertaining torange-of-motion measurements and strengthgrades. The patient’s tolerance for activitywas only minimally defined, and there wasno documentation of pain or positioning.Transfers were briefly addressed; however,gait and bed mobility were not assessed. Itwould be reasonable to expect such data oran explanation as to why they were notobtained.

Despite the limited examination data avail-able, the therapist established two goals. Theambulation goal presented appears to be along-term goal, not a short-term goal, and lacksvalidity because baseline data are lacking. Thetransfer goal lacks a time frame for achieve-ment. All goals should be measurable, be func-tional, and have an achievement date. Useof the Guide to Physical Therapist Practice1

would be helpful to identify preferred prac-tice patterns and aid in the organization ofdocumentation.

What other information would be helpful for

establishing goals and outcomes? And how

might the information be obtained?

History information could be obtained byinterviewing the patient unless cognitionwas a problem, in which case the responsiblefamily member could be contacted. Baselineexamination data are needed to establishmeasurable goals.2

According to Randall and McEwen,3 toidentify functional goals, it is helpful tounderstand the patient’s activities as well aswhere they occur, and to establish goals thatcorrespond to the patient’s desired outcome.In this case, the documentation does not sup-port the development of functional goals thatare specific to the patient’s needs.

Further Screening BeforeInterventionThe most recent physical therapy progressreport indicated that the patient complainedof headaches, received therapy b.i.d. 5×/week, and improved ambulation with awalker from 20 feet × 2 with standby assis-tance to 100 to 120 feet with contact guardassistance. Transfers required minimal assis-tance for sit to stand with verbal cues tomove forward in the chair and for walkerplacement. No goals or contraindications totreatment were described. The therapist indi-cated that the patient could return homewith support if pain decreased.

The physical therapy progress report lackeda clear indication of patient management andwhat skilled intervention was provided.Nursing interviews revealed concerns regard-ing nutritional intake and social isolation.

Based on the available information, does

the patient demonstrate the potential to

return home independently, or is extended

care a realistic expectation? How might one

proceed with care for this patient and why?

In this case, the therapist recognized areexamination was warranted as data werelacking and the patient’s goals were unde-fined. Areas previously not addressed inthe physical therapy documentation wereexplored, and the patient, along with his

representative, helped formulate the criteriafor his return to home. After reexamination,the patient demonstrated a renewed interestin the quality of his performance. He achievedhis goals within 3 weeks and returned homewith supportive services.

SummaryThe relationship between the therapist andpatient is important to achieving successfuloutcomes. Effective documentation will aidthe exchange of information and delivery ofefficient care. Baker et al4 found that thera-pists seek to involve their patients in estab-lishing goals and determining outcomes, butdo not maximize the existing potential forthis involvement. This finding would seemtrue in this case study, because the patient’s

lack of involvement in establishing goals anda limited understanding of the patient’s totalneeds may have delayed the patient’s returnto home and hindered the transition of careto another therapist.

R E F E R E N C E S

1. American Physical Therapy Association: Guideto physical therapist practice, second edition,Phys Ther 81:1, 2001.

2. Baeten AM, Moran ML, Phillippi LM: Document-

ing physical therapy: the reviewer perspective.Boston: Butterworth-Heinemann, 1999, p 14.

3. Randall KE, McEwen IR: Writing patient-centered functional goals, Phys Ther 80:1199,2000.

4. Baker SM, Marshak HH, Rice GT, ZimmermanGJ: Patient participation in physical therapygoal setting, Phys Ther 81:1126, 2001.

Case 1 3

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Describe how to manage a physical therapy referral with aninappropriate diagnosis.

2. Describe how to utilize a home exercise program with a patient withlimited physical therapy visits.

3. Identify the symptoms of coccygodynia.

The reader should know that a 34-year-old

woman whose medical diagnosis was low back

pain was referred for outpatient physical

therapy.

ExaminationH I S T O R YOn interview, the patient reported symptomsincluding pain in the coccyx area thatincreased after sitting for a prolonged periodand then arising. She also reported pain inthe buttocks and sacroiliac joint areas. Thesymptoms began after she gave birth to twinsvaginally 4 months earlier. She initially soughtmedical treatment 2 months after the birth.Medical intervention at that point includedradiographs of the pelvis that were unremark-able, a prescription for Vioxx to relieve pain,and a donut pillow for sitting. She continuedto experience symptoms of pain, which madeit difficult to sit to feed her twins.

Systems ReviewVital signs were normal.

Tests and MeasuresObservation revealed that the patient had asitting posture of rounded shoulders, forwardhead tilt, and posterior pelvic tilt with mostweight-bearing on the coccyx. Palpationrevealed trigger points over the area of thepiriformis, gluteus maximus, and levator ani.Intravaginal palpation revealed increasedresting tone of the levator ani and 5/5

strength of the muscles of pelvic floor.1 Manualmuscle testing of the hip complex was normal.

EvaluationAt the time of referral, a physician had diag-nosed the patient with low back pain andrecommended moist heat and ultrasoundtherapy to the lumbar and sacral spine andlumbar stabilization exercises. On physicaltherapy examination, signs and symptomswere consistent with coccygodynia (painfulcoccyx), which in this case resulted frominjury to the coccyx area from the passage ofthe fetuses through the birth canal. Based onthese findings, treatment of the lumbar spinewas not an appropriate intervention.2 Thephysical therapy diagnosis was establishedas muscle spasm.

DiagnosisPractice Pattern 4D: Impaired Joint Mobility,Motor Function, Muscle Performance, andRange of Motion Associated With ConnectiveTissue Dysfunction.3

How should a physical therapist proceed?

What are appropriate interventions?

Prognosis (Including Planof Care)The therapist recommended that the patientbe seen three times a week for 4 weeks. Theplan of care included soft tissue mobilization

5

Case 2

6 Clinical Cases in Physical Therapy

to the buttocks and area of piriformis andfriction massage to trigger points in the levatorani. Biofeedback was incorporated into theplan to work on decreasing the resting toneof the levator ani utilizing a rectal electrode.In addition, postural training was included toencourage the patient to sit with her weighton the ischial tuberosities rather than thecoccyx. The therapist recommended that thepatient discontinue using the donut pillow andinstead use a coccyx cutout wedge cushionwhen sitting for a prolonged period, such aswhen feeding her babies.

InterventionC O O R D I N AT I O N ,C O M M U N I C AT I O N ,A N D D O C U M E N TAT I O NUnfortunately, the demand of being a motherto 4-month-old twins limited the patient’sability to attend therapy three times a week.The therapist and patient opted for a treat-ment program of once-weekly visits comple-mented by a home program. The patient feltthat this was practical and agreed to performthe home program two to three times a week.

The physical therapist also recognized theneed to communicate findings to the patient’sphysician. The therapist contacted the physi-cian via telephone and letter and detailedthe findings from the physical therapy exami-nation.

PAT I E N T / C L I E N T - R E L AT E DI N S T R U C T I O NThe therapist recommended a home exerciseprogram of self- or partner massage to thepiriformis, stretching of the piriformis, andfriction massage of trigger points in thelevator ani (see Figure 2-1). This was to befollowed by a session of biofeedback for thelevator ani utilizing a portable biofeedbackmachine with an anal electrode.

OutcomeThe patient and her husband attended a treat-ment session together for instruction in self-and partner massage, as well as home use of

the portable biofeedback machine. The patientadhered to the home exercise program twotimes a week and consistently attended phys-ical therapy treatment sessions for 4 weeks.Symptoms of pain resolved, and the patientwas able to feed her twins with a 5-minutebreak in between children. The posture ofrounded shoulders and forward head per-sisted, so the therapist discharged the patientwith a modified home exercise program toinclude thoracic and cervical posture exer-cises and recommendations for patient andchild positioning during feeding to decreaseback strain.

DiscussionCoccygodynia, or coccydynia, is a disordercommonly classified under the diagnosis ofpelvic pain, but it may be mistakenly diag-nosed as low back pain or sacroiliac jointpain, because pain may refer to the sacroiliacor lumbar areas.4 Because coccygodynia refersto a specific symptom (pain), it can have dif-ferent causes. It commonly results from a fallonto the buttocks or trauma during child-

F I G U R E 2 - 1 Partner massage of the piriformismuscle.

birth, causing a partial dislocation of a jointin the coccyx or overstretching of the liga-ments and muscles attached to the coccyx.2,5

Muscle spasm and pain in the tissues aroundthe coccyx may result. The symptom of painincreases when sitting for a prolonged periodor when making bed or chair transfers. There-fore, it is important to address the soft tissueinjury and resultant impairments in a casesuch as this.

Injury to the muscles, ligaments, and con-nective tissue of the pelvis is common duringvaginal deliveries as well as during the monthsleading up to the delivery. Increased ligamentlaxity, posture alterations, and increaseddemand on the pelvic floor to support theviscera may lead to musculoskeletal damage.The changes occurring during pregnancy anddelivery must be considered when examiningand evaluating patients in the antenatal andpostnatal period.

Massage, biofeedback, and postural train-ing were the treatments of choice for thispatient to decrease muscle spasm in the piri-formis, levator ani, and gluteus maximus. Thedonut pillow may have been exacerbating thepatient’s symptoms by distributing weight ontothe coccyx and promoting a posterior pelvictilt while sitting. A wedge-shaped cushion witha coccyx cutout would be much more appro-

priate for this patient, because it takes weightoff of the coccyx and redistributes weight tothe thighs while encouraging a more appro-priate position of the pelvis.

Stretching became part of the patient’shome exercise program to relieve some ofthe pain and spasm in the piriformis. Thepiriformis may shorten and develop spasmsduring pregnancy because of the altered posi-tion of the lower extremity and an alteredgait pattern. In this case it was contributingto the patient’s pelvic pain and generalincrease in tone of the pelvic floor muscles.

R E F E R E N C E S

1. Wilder E (ed): The gynecological manual,Alexandria, VA: American Physical TherapyAssociation, 1997.

2. Sapsford R, Bullock-Saxton J, Markwell S(eds): Women’s health: a textbook for physio-

therapists, London: WB Saunders, 1998.3. American Physical Therapy Association: Guide

to physical therapist practice, second edition,Phys Ther 81:1, 2001.

4. Stephenson RG, O’Connor LJ: Obstetric and

gynecologic care in physical therapy (ed 2),Thorofare, NJ: Slack, 2000.

5. Hall CM, Brody LT: Therapeutic exercise:

moving toward function, Philadelphia:Lippincott Williams & Wilkins, 1999.

Case 2 7

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Identify the roles of the academician, clinician, and student in dealingwith difficult issues in clinical education.

2. Develop a rationale for facilitating active student participation in thedesign of a remediation plan for clinical education.

The reader should know that a 22-year-old

student in the final year of an entry-level

5-year Master of Science in Physical Therapy

program was asked to leave the fourth

affiliation 4 weeks into a 6-week experience due

to patient safety concerns. Visual analog scale

markings and clinical instructor comments

scored the student below established grading

criteria for this level affiliation on the Clinical

Performance Instrument (CPI).1 Primary areas

of deficiency were safety, professional behavior,

professional demeanor, and communication

criteria. The student actively worked with the

academic Director of Clinical Education (DCE)

to design and participate in a remedial plan.

After completing the scheduled remediation

activities, the student returned to clinical

education and successfully completed the

remaining two 6-week affiliations with entry-

level scores on the visual analog scale and

positive comments from the clinical instructors

on safety, professionalism, and communication

criteria.

This case is discussed within the framework

of the Guide to Physical Therapist Practice2

elements of patient/client management. The

student’s ability to function as a competent

physical therapy practitioner is the desired

outcome. The elements of the model are applied

as follows: The student’s clinical performance on

affiliation is “examined,” competence is

“evaluated,” causes of deficient performance are

“diagnosed,” the student’s optimal level of

function and the time needed to achieve that

level are “prognosed,” activities to promote

improved performance are designed

(intervention), clinical performance is

“reexamined,” and “outcomes” are discussed.

Did the student have any issues on previous

affiliations? What were the concerns that

led to removal?

This student had demonstrated acceptableacademic and laboratory performance onexamination in individual courses in the pro-gram. Faculty evaluation determined accept-able readiness3 for clinical education based oncompleted coursework. The clinical instruc-tors evaluated clinical performance and iden-tified problems in the student’s developmentof appropriate professional communicationskills and demeanor on the second and thirdclinical affiliations. After each of these affili-ations, the faculty diagnosed the student’sneeds and designed and directed interven-tions in the form of remedial plans thatthe student completed. Despite remediation,similar concerns were raised with reexami-nation of performance on subsequent clinicaleducation experiences.

During the fourth clinical education affil-iation, the faculty planned an early site visitto examine the student’s performance. Issuesidentified by the Clinical Instructor (CI) andCenter Coordinator of Clinical Education(CCCE) during the visit were consistent withpreviously identified issues of communicationand professionalism. Studies4,5 have revealedthat behavior in these areas can be indicativeof success or failure in clinical education.The academic and clinical faculty discussedthe need for change with the student andemphasized the importance of these skillsin providing effective patient care. After thefaculty visit, the student’s performancedeteriorated. A learning contract was imple-

9

Case 3

10 Clinical Cases in Physical Therapy

mented with CI, CCCE, and DCE input toclarify the level of performance that thestudent needed to achieve. As examined bythe clinical faculty, the student’s performancecontinued to deteriorate. Five documentedsafety incidents occurred in a 2-day period.These incidents included failure to ascertaina weight-bearing status and proceeding withintervention without first reviewing medicalimaging reports.

The site evaluated the situation and askedthat the student be removed from the affil-iation. The student expressed an inability toperform and an awareness that skills werenot improving. The academic program con-curred with the site that, given the identifiedproblems, this student was not safe andneeded to be removed.

Given the above-described situation, the

student could choose to attempt another

affiliation immediately, to remediate

pertinent issues and then participate in

another affil-iation, or to take some time off

and resume study next year. Which of these

alternatives was chosen? Why?

The clinical instructor provided the academicprogram with a “final” CPI report and copiesof the safety incident reports (evaluation).These reports contained specific examplesof performance areas that were not accept-able. The student went home and was askedto take some time to reflect on clinicalperformance, examine specific situations,and evaluate reasons for the poor perfor-mance. Based on established grading criteria,the CPI’s comments, and input from the CIand CCCE, the DCE evaluated the data andassigned a “fail” grade for this pass/failcourse. Options were discussed, and thestudent expressed a clear desire to become acompetent physical therapist and applyeffort to remediate the pertinent issues in atimely manner.

The DCE’s evaluation of the data revealedthat similar issues were increasing in inten-sity despite faculty-directed attempts toimprove the student’s performance. It wasdecided that the student needed to take

responsibility for performance and identifyhow to improve it. This could be equated tothe diagnosis and prognosis elements of thepatient/client management model in theGuide to Physical Therapist Practice.2 Thestudent was asked to diagnose the causeof deficient performance and prognose theability to be a competent physical therapist.The DCE’s role involved facilitation andcoordination. With time and coaching toexpress individual needs, the student wasable to identify areas to remediate. The DCEand the student worked together to design awritten plan to address needs (plan of care)with specific activities (interventions) thatincluded a time frame for completion (prog-nosis). The DCE monitored the student’sprogress (reexamination) toward fulfillingthese activities. Together, the DCE and thestudent agreed that successful completion ofthe interventions would indicate a readinessto participate in another affiliation.

What specific interventions could be

included to address the areas of deficient

clinical performance?

The student was able to articulate an inabilityto adopt professional behaviors and usethem in the clinic (evaluation). After reflect-ing on performance, the student realized adesire to “be everyone’s friend” and “do whatthe CI wanted.” The student became awareof personal actions that were an attempt tomold behavior to fit what was learned inschool and what was perceived as beingdesired by the clinic. However, there was alack of depth and a lack of what the studenttermed the necessary “thought processes”for the student to become a competentphysical therapist (diagnosis). The studentexpressed a desire to succeed and a moti-vation to modify performance (prognosis).When asked to identify ways in whichgrowth might occur in this area, the studentoutlined a remediation plan (intervention)that included the following actions:1. Perform clinical observation of a practic-

ing physical therapist. The student felt thatvolunteering in a physical therapy clinic

would allow observation of profession-alism, communication, and documentationwithout the pressure to perform. Thiswould help the student identify specificbehaviors that professionalism entails.The student felt that 4 weeks of observa-tion could provide the knowledge neededto develop appropriate “thought processes”(a term that the student used repeatedlywhen describing the evaluation of perfor-mance deficits).

2. Read a textbook on professional commu-nications. Based on knowledge of avail-able resources that matched the student’sneeds, the DCE proposed suggested read-ings to the student. After reviewing severaloptions, Health Professional and Patient

Interaction6 was selected. The studentwas to read this text and incorporate theknowledge gained into the development ofpersonal thought processes needed to bea physical therapist.

3. Perform self-assessment and implementthe knowledge gained. The student andDCE agreed that there were lessons to belearned from the failed affiliation. Thestudent needed to identify behaviors thathad caused problems, articulate what couldhave prevented issues from occurring anddiscuss how to behave more competently.The student would define in writing7 the“thought processes” that were needed,identify and group criteria from the CPI andthe objectives for clinical education undereach process, and write clinical actionsthat would enhance effectiveness. Studentreflection on personal professional develop-ment8 combined with this activity led thestudent to outline concrete steps that wouldbe used to advance professionalism.

4. Provide practical application of the knowl-edge gained. The student expressed adesire to practice new skills before return-ing to a formal clinical education experi-ence. Working together, the student andDCE decided that paper cases and a prac-tical skill check would be valuable. Papercases were designed to give the studentpractice in designing appropriate interven-tions, setting realistic goals, and documen-

ting hypothetical treatment sessions. Thestudent also agreed to complete a “check-out” of mobility skills with a faculty mem-ber, demonstrating skill competency andsafety in transfers, bed mobility, and gaittraining. Modification of interventions anddiscussion of rationales for treatmentbased on changing patient scenarios wouldbe included.

5. Set clear, measurable objectives for thenext clinical experience. The student setgoals for the volunteer observation and forthe repeat clinical education experience.

What are potential outcomes demonstrating

student competency?

The student completed the remedial planwithin the established time frame. The DCEexamined the student’s content for accuracyand development (reexamination) and deter-mined the student’s apparent readiness toreturn to the clinic. A repeat affiliation wasscheduled at a site that (as requested by thestudent) was fully aware of the student’sspecific needs. The CI examined the student’sperformance and evaluated his competencyduring the affiliation. At midterm and finalCPI assessments, the CI discerned appropriatesafety, professionalism, and communicationperformance. The DCE reexamined this per-formance in the context of previously iden-tified issues and awarded a grade of “pass”for the affiliation. The student then progressedto the fifth and final affiliation with full dis-closure to the CI as to the competency areasbeing emphasized. The student actively soughtfeedback from the clinician in specific situa-tions and diligently modified his performanceto improve competency. At completion of thefinal affiliation, the student earned positivecomments and entry-level performance onall criteria of the CPI. The student went on tosuccessfully pass the state licensing boardsand secure full-time employment as a physicaltherapist. In a follow-up interview, the studentconcluded that taking responsibility for iden-tifying needs and designing the remediationactivities were effective in altering perform-ance as a clinician and achieving competency.

Case 3 11

R E F E R E N C E S

1. American Physical Therapy Association: Phys-

ical therapy clinical performance instruments.

Alexandria, VA: American Physical TherapyAssociation, 1998.

2. American Physical Therapy Association: Guideto physical therapist practice, second edition,Phys Ther 81:1, 2001.

3. Watson CJ, Barnes CA, Williamson JW: Deter-minants of clinical performance in a physicaltherapy program, J Allied Health 29:150, 2000.

4. Hayes K, Huber G, Rogers J, Sanders B: Behav-iors that cause clinical instructors to questionthe clinical competence of physical therapiststudents, Phys Ther 79:653, 1999.

5. Gutman SA, McCreedy P, Heisler P: Studentlevel II fieldwork failure: strategies for inter-vention, Am J Occup Ther 52:143, 1998.

6. Purtilo R, Haddad A: Health professional and

patient interaction (ed 5), Philadelphia, PA:WB Saunders, 1996.

7. Hobson E: Encouraging self-assessment writingas active learning. In Sutherland TE, BonwellCC (eds): Using active learning in college

classes: a range of options for faculty, SanFrancisco: Jossey-Bass, 1996, 45.

8. May WW, Morgan BJ, Lemke JC, Karst GM,Stone HL: Model for ability-based assessmentin physical therapy education, J Phys Ther Ed

9:3, 1995.

12 Clinical Cases in Physical Therapy

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Identify characteristics in this case that made an intense home exerciseprogram appropriate.

2. Discuss the benefits of providing therapy in the home environment.

The reader should know that an outpatient

physical therapist was seeing a 14-year-old

female diagnosed with spastic cerebral palsy

(CP). The patient was being seen once a month

for 30 minutes. The outpatient physical

therapist was frustrated with a lack of

improvement/ progress in the patient’s

ambulation. The patient was also being treated

by a physical therapist at her school, who was

seeing her once a week for 30 minutes.

Communication between the two therapists

suggested that the patient’s progress in all areas

of functioning had plateaued over the last year.

The patient, a high school freshman, would like

to attend her first high school social (a dance)

in approximately 4 weeks. The patient requested

that the therapist assist her with improving her

walking so that she could walk into her first

social at school. The patient and her mother also

voiced a goal to increase the patient’s ability to

ambulate safely within her house.

ExaminationH I S T O R YThe patient was the sole survivor of a twinpregnancy, delivered secondary to fetal dis-tress at 28 weeks’ gestation via cesareansection. She spent 4 months in the neonatalintensive care unit, with history of ventilation,bronchial pulmonary dysplasia, intercranialbleeding (grade IV), and severe feeding prob-lems. The patient was diagnosed with spasticdiplegic CP with left hemiplegia by age 3 years.She underwent a dorsal rhizotomy at age 6and right hip reconstruction at age 13. Beforethe right hip reconstruction surgery, thepatient was a community ambulator with oneforearm crutch; after the surgery, she used a

power chair for mobility in the communityand at school. The patient also had a historyof asthma and seizures, which were con-trolled with Albuterol p.r.n. and Tegretol.

The patient lives in a single-parent familywith three younger siblings. The patient’smother is employed and works the secondshift, and so is unavailable after school toassist the patient. In addition, the threeyounger siblings interfere with the patient’sambulation at home and constitute a poten-tial safety hazard for ambulation.

What baseline data were necessary?

S Y S T E M S R E V I E W / T E S T SA N D M E A S U R E SThe patient was initially ambulating with largebase quad cane for 10 feet on carpeted sur-faces with minimum to moderate assistance.She was ambulating exclusively into/out ofthe bathroom and with therapy at school (onceper week). She used a power wheelchair forthe remainder of the day for mobility.

Cardiovascular system. Initially, thepatient demonstrated a high oxygen saturationlevel (95% to 97%) before, during, and 1 minuteafter ambulating 10 feet. Immediately afterambulation, the patient demonstrated anincreased breathing rate and breathing effort,with a recovery time of 2 to 3 minutes. Herheart rate increased from 89 beats per minute(bpm) before walking to 167 bpm immedi-ately after ambulating 10 feet.

Musculoskeletal system. The patientwore bilateral single-axis molded ankle footorthoses (AFOs) for medial/lateral instabilityat her ankle. Range-of-motion (ROM) measure-ments were assessed with a goniometer.

13

Case 4

14 Clinical Cases in Physical Therapy

Generally, ROM measurements were limitedthroughout both lower extremities, especiallyat the ends of ROM in most directions. How-ever, ROM was not felt to be limiting func-tion. Specific pretest ROM data are given inTable 4-1. Muscle strength was assessed witha dynamometer (Nicholas Manual MuscleTester; Lafayette Instrument Company, NorthLafayette, Indiana); pretest values are listedin Table 4-2. Strength was measured threetimes, and these measures were averaged.Generally, strength was significantly decreased,with the right lower extremity weaker thanthe left lower extremity.

Neuromuscular system. A pedograph(footprint analysis) and stop-watch wereused to assess velocity of gait, cadence,stride length, right and left step length, andbase of support. The stride length, steplength, and base of support values reflect theaverage of three steps taken with each leg.The results of this testing are given in Table4-3. Generally, cadence and velocity weregreatly reduced, with step length shorter inthe right lower extremity and a large base ofsupport.

In addition to the pedograph, activeinfrared markers were placed on the patient’sright lower extremity, and a motion analysissystem (CODAmpx30; Charnwood DynamicsLimited, Leicestershire, U.K.) was used todetermine joint angles in the right lowerextremity during gait. Initially, the patientdemonstrated a maximum hip extension of

–23 degrees and maximum hip flexion of33 degrees, a maximum knee valgus flexionof 75 degrees, and a maximum ankle flexionof 62 degrees of eversion and 43 degrees ofinversion.

The BERG Balance Scale1 was used toevaluate initial functional balance skill. Thepatient’s BERG score was initially 23/56. Thepatient did well with sitting items, had prob-lems with standing items, and was unable toperform single-leg stance activities.

Behavioral assessment. The Activity-Specific Balance Confidence (ABC) Scale2

was modified to fit the patient and used tomeasure her confidence in her ability tofunction in her environment. Results of theinitial ABC are reported in Table 4-4.

What were the primary factors limiting the

patient’s ambulation?

EvaluationAfter the examination and discussion with thepatient and her mother, the therapist deter-mined that the major limitations to returningto household and limited community ambu-lation were:1. Decreased endurance2. Decreased strength3. Lack of opportunity to safely practice4. Decreased confidence5. Lack of a home exercise/ambulation

program.

TA B L E 4 - 1G O N I O M E T R I C R A N G E O F M O T I O N M E A S U R E S

PREINTERVENTION POSTINTERVENTION

RANGE OF MOTION LEFT RIGHT LEFT RIGHT

Hip flexion 19° to 131° 24° to 133° 18° to 138° 28° to 142°Hip extension –19° –24° –18° –24°Hip abduction 0° to 35° 0° to 17° 0° to 38° 0° to 16°Hip adduction 0° to 10° 0° to 7° 0° to 10° 0° to 8°Knee flexion 26° to 110° 17° to 112° 19° to 121° 12° to 131°Knee extension –26° –17° –19° –12°Ankle dorsiflexion 0° to 3° 0° to 1° 0° to 6° 0° to 5°Ankle plantarflexion 0° to 46° 0° to 49° 0° to 46° 0° to 50°

DiagnosisPractice Pattern 5C: Impaired Motor Functionand Sensory Integrity Associated with Non-progressive Disorders of the Central NervousSystem—Congenital Origin or Acquired inInfancy or Childhood.6

Prognosis (including planof care)After the examination, the therapist concludedthat this 14-year-old girl was capable ofincreasing her ability to ambulate in herhome and at school and to ambulate into herfirst high school social in 4 weeks secondaryto high motivation and availability of anintense home therapy program over the next4 weeks.

What research-based evidence could be

used to develop a plan of care?

Based on research by Bower et al,3 the ther-apist planned a short period of intense inter-vention to promote functional gains in thispatient. She was seen in her home five timesduring week 1, three times during week 2, twotimes during week 3, and one time during week4. The patient was contacted daily, either witha home visit or via telephone. A home exerciseprogram was developed to improve the func-tional and impairment-level problems asso-ciated with ambulation. The patient was givenan easy-to-read chart with check-off boxes foreach part of the exercise program to help herkeep a written record of her progress for themonth-long intense intervention program.Additional check-off charts were provided eachmonth after the intense intervention phase.

Case 4 15

TA B L E 4 - 2DY N A M O M E T E R M E A S U R E S I N N

IMMEDIATELY 2 WEEKS 4 WEEKSPREINTERVENTION POSTINTERVENTION POSTINTERVENTION POSTINTERVENTION

STRENGTH (N) LEFT RIGHT LEFT RIGHT LEFT RIGHT LEFT RIGHT

Hip flexion 4.01 1.89 3.41 2.02 6.60 3.73 8.97 6.37Hip extension 1.41 .53 1.11 .37 2.70 2.13 4.97 3.00Hip abduction 1.74 .50 2.23 1.79 4.47 3.87 5.80 5.20Hip adduction 3.94 3.86 5.59 4.68 10.00 9.80 9.90 8.23Knee extension 1.23 2.52 2.41 2.58 4.43 4.10 4.37 6.20

TA B L E 4 - 3P E D O G R A P H D ATA

STRIDESTEP

BASE OFVELOCITY CADENCE LENGTH

LENGTH (CM)SUPPORT

PEDOGRAPH DATA (M/MIN) (STEPS/MIN) (CM) LEFT RIGHT (CM)

Preintervention 15.47 21.46 61.47 41.63 20.42 20.02Immediately 25.83 22.95 76.78 56.03 21.34 24.23

postintervention2 weeks 22.09 26.46 72.24 44.60 27.15 23.19

postintervention4 weeks 26.78 25.66 73.56 52.76 28.23 23.02

postinterventionNormal range Variable 90–120 70–82 35–41 35–41 5–10

InterventionThe patient was seen in her home for aprogram of walking inside and outside of thehouse. The home program included pedalingon a foot bike; work on weight shifting instanding and functional reaching; stretchingof hamstrings, hip flexors, and knee exten-sors; and strengthening exercises for hipflexion, abduction, and adduction and kneeextension. The home program was designedto take 15 to 20 minutes each day, based onthe work of Schreiber et al.4 In this inter-vention, involvement of family members waslimited due to the mother’s work scheduleand the siblings’ young age. Reassessmentwas planned for immediately after comple-tion of the intense intervention phase, andthen 2 weeks and 4 weeks postintervention.

ReexaminationC A R D I O VA S C U L A R S Y S T E MThe patient’s oxygen saturation levels con-tinued to remain above 95% throughoutperiods of ambulation. Immediately afterambulation, the patient demonstrated noincreased breathing rate or increased breath-ing effort, and no recovery time was needed.Heart rate was now 82 to 86 bpm beforeambulating and 91 to 100 bpm after ambu-lating for 50 feet. These cardiovascularimprovements, seen immediately postinter-vention, were maintained the 2-week and4-week postintervention reassessments.

M U S C U L O S K E L E TA L S Y S T E MNo significant changes in ROM were notedimmediately postintervention (see Table 4-1).No changes in ROM were expected, becausethe original ROM was sufficient to allow thepatient to ambulate and this was not a majorfocus of the home exercise program. ROMwas not remeasured at the 2-week and 4-week postintervention follow-ups.

Strength measurement demonstrated animprovement immediately postintervention;however, these improvements continued andeven increased over the subsequent 4 weeks.Changes in strength were found in all musclesassessed 4 weeks postintervention.

N E U R O M U S C U L A R S Y S T E MPedograph data demonstrated an increase inambulation velocity, cadence, stride length,and step length (see Table 4-3). A small increasein base of support was also demonstrated, butthis was thought to be the result of improvedsymmetry in the lower extremity (i.e., de-creased valgus in the right lower extremity).(Normal values are based on those listed inMagee’s Orthopedic Physical Assessment.5)

Changes in gait were also observed in thejoints of the right lower extremity duringambulation. Based on the CODA movementanalysis system, the hip maximum rangeincreased to 42 degrees of flexion and –18degrees of extension, maximum knee valgusdecreased to 45 degrees, and maximum anklemotion decreased to 54 degrees of eversionand 1 degree of inversion.

16 Clinical Cases in Physical Therapy

TA B L E 4 - 4R E S U LT S O F A B C A S S E S S M E N T B O T H P R E A N D P O S T I N T E R V E N T I O N

How confident are you that you will not lose your balance or become Pretest Posttestunsteady when you …

Walk around the house? 25% 60%Bend over and pick up an object from the floor? 0% 0%Reach for a video off a shelf at eye level? 0% 25%Walk from the front door of your house to a car parked in the driveway? 35% 40%Get into or out of a car? 60% 75%Walk in a crowded place where people may bump into you? 0% 10%Walk outside on the grass or in your yard? 0% 80%

The patient’s Berg balance scale score alsoincreased, to 33/56 immediately postinterven-tion and then to 35/56 at 4 weeks postinter-vention. Specifically, improvements wereobserved in the following areas: standingunsupported, performing transfers, standingwith feet together, reaching forward withoutstretched arms, retrieving an object fromthe floor, turning to look behind, and turning360 degrees.

By the end of the first week of interven-tion in the home, the patient was independ-ent in performing her home exercise programexcept for needing minimum assistance tosecure her feet on the foot bike. In thesecond week, during one of the home visits,the patient reported that “I am walking somuch straighter and feel so much betterwhen I walk.”

B E H AV I O R A L A S S E S S M E N TReassessment with the modified version ofthe ABC scale demonstrated the patient’sincrease in confidence in such activities aswalking around the house, reaching for hervideos off her shelf in her room, walkingfrom her front door to a car in the driveway,getting into or out of a car, walking in acrowded place where she could be bumped,and walking outside in her own yard (seeTable 4-4). The ABC test was not readmin-istered at the 2-week or 4-week postinterven-tion assessment.

OutcomeThe patient improved her ability to ambulatein her home and at school (although limitedby staff availability to assist and supervise),and was able to ambulate into her first highschool social. The patient and her peers andfamily were able to share in her success inambulating 90 feet with a quad cane andstandby assistance into the dance. The socialsupport experienced by the patient at thisschool event made a significant impact onher confidence. She stated numerous timeshow much stronger she felt and how excited

she was about the improvements that shehad made. The patient was given charts tocontinue her home exercise program, andher outpatient therapist continued to followher program and update it as needed.

DiscussionA home exercise program as an adjunct tophysical therapy intervention is important tooptimize functional gains within the naturalenvironment. To be effective, an exerciseprogram must be easy to follow and becomepart of the daily routine. Ideally, successfulprograms should involve family members tohelp motivate and guide the child. In thiscase, parental involvement was limited bythe mother’s employment status, and it wasnot appropriate to seek sibling assistance. Alimited intense period of physical therapyallowed this patient to become independentin her home exercise program, gave her anability to function in her natural environ-ment, and positively impacted her socialinteraction with her peers.

R E F E R E N C E S

1. Berg KO, Wood-Dauphinee SL, Williams JI, etal: Measuring balance in the elderly: prelimi-nary development of an instrument, Physiother

Can 41:304, 1998.2. Powell LE, Myers AM: The activities-specific

balance confidence (ABC) scale, J Gerontol A

Biol Sci Med Sci 50:28, 1995.3. Bower E, McLennan DL, Arney J, Campbell MJ:

A randomized controlled trial of differentintensities of physiotherapy and different goal-setting procedures in 44 children with cerebralpalsy, Dev Med Child Neurol 50:28, 1996.

4. Schreiber JM, Effgen SK, Palisano RJ: Effective-ness of parental collaboration on compliancewith a home program, Pediatr Phys Ther 7:59,1995.

5. Magee DJ: Orthopedic physical assessment,

Philadelphia: WB Saunders, 1997.6. American Physical Therapy Association: Guide

to physical therapist practice, second edition,Phys Ther 81:1, 2001.

Case 4 17

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Identify the clinical tests necessary to distinguish the various upperextremity symptoms that a patient with cervical radiculopathy mayexperience.

2. Describe the proper position for the body and equipment during regularoffice computer use.

3. Discuss the incidence, prognosis, and typical rehabilitation of a patientwith cervical radiculopathy.

ExaminationH I S T O R YThe patient was a 47-year-old single whitefemale accountant with a chief complaint ofright upper extremity symptoms of 4 months’duration. Her symptoms began insidiously asa tingling and occasionally burning sensa-tion over the lateral forearm, hands, andthumbs. She also complained of a tingling inthe right palm, which began 2 months earlier.She reported that she began dropping things2 weeks earlier, and this caused her to seekmedical attention.

The forearm and thumb symptoms wereworse at the end of the day, after prolongedsitting or computer use, or after looking upfor more than 5 minutes. The tingling in thepalms awakened her after 1 hour of sleepand commonly occurred after 30 minutes ofcomputer use.

The patient’s past medical history includeda right radial head fracture at age 21 anda rear-end auto collision at age 35. She hadno ongoing complaints from either of thoseepisodes before the onset of the currentsymptoms. She reported jogging 3 miles perday. Cervical radiographs showed moderatedegenerative changes at C5-6 bilaterally andmild changes at C4-5 and C6-7. Magneticresonance imaging showed osteophyte for-mation in the region of the right C5-6 neuralforamen, and an electromyelography studyshowed mild sensory loss in the right mediannerve distribution and the lateral forearm.

Weakness was also noted in the thenarmuscles.

S Y S T E M S R E V I E WIntegumentary system. The patient

exhibited decreased sensation to pinprick atthe tip of the right thumb. She did notcomplain of any recent bruising or contactdiscoloration from the time that symptomsdeveloped.

Musculoskeletal system

Gross sym-metry. The patient presentedwith a marked forward head posture and aprominent angle at the cervical-thoracic (CT)junction. The upper extremities were inter-nally rotated, with visible tightness of theanterior cervical and both upper trapeziusmuscles. There was poor muscle definitionof the posterior scapular muscles and slightatrophy of the right thenar muscles.

Palpation. Palpation of the cervical spineat C5-7 on the right elicited tenderness anda reproduction of right forearm symp-toms. Accessory movements of the cervicalspine revealed hypomobility at C1-2, espe-cially during right rotation. Spinal segmentsat C3-5 were assessed as hypermobile, thoseat C6-7 could not be assessed because ofirritability of the segment, and those at C7-T3were found to be hypomobile.

There was increased muscle tightness ofthe right cervical paravertebral muscles andparascapular muscles, especially the sterno-cleidomastoid, levator scapulae, and scalenes.There was generalized tightness bilaterally in

19

Case 5

20 Clinical Cases in Physical Therapy

the flexor muscles of forearms, identified bya “ropelike” feeling.

Joint range of motion. Cervical flexionwas limited by 50% with no reversal of cer-vical lordosis. Cervical extension was full,but no motion occurred below the CT junc-tion. There was an increase in right forearmsymptoms with prolonged cervical extension.Side flexion to the right was 75% full rangewithout an increase in symptoms and sideflexion to the left was 50% of full range buteased the symptoms. Cervical rotation to theright was only 40% of full range, limited byincreased symptoms in the right forearm.Cervical rotation to the left was 80% of normalrange, and the symptoms in the right forearmdecreased.

Range of motion of the shoulders and theleft elbow was within normal limits. Flexionof the right elbow was full, extension was –7degrees, and pronation and supination wereboth 80 degrees. Bilateral extension of thewrists was measured at 60 degrees with thefingers flexed and 45 degrees with the fingersextended.

Strength. Weakness was noted in theabductor (3/5) and extensor (4/5) pollicisbrevis muscles of the right thumb. Noother weakness was observed bilaterally.Cervical motion was limited by the onsetof pain and other symptoms, but strengthwithin the available range was within normallimits.

Neurologic system. There was a dimin-ished brachioradialis reflex on the rightside compared with the left side. Nervetension testing utilizing full tension on themedian nerve pathway reproduced allsymptoms.

Special tests. The Adson’s, military, andhyperabduction tests were negative. Phalen’stest and Tinel’s sign were noted as positive.

From the foregoing information, how were

the severity, irritability and nature of the

symptoms rated?

The patient’s symptoms were considered ofmoderate severity. The irritability was mod-erate because of radicular symptoms (in

particular, the cervical symptoms), whichshould almost always be considered irrita-ble until proved otherwise. The nature wasidentified as C6 cervical radiculopathy withpotential secondary carpal tunnel syndrome,caused by the restricted mobility of the rightelbow and cervical spine secondary to earlierinjuries.

DiagnosisPhysical Therapist Practice Pattern 5H:Impaired Motor Function, Peripheral NerveIntegrity, and Sensory Integrity AssociatedWith Nonprogressive Disorders of the SpinalCord.

Prognosis (including planof care)The prognosis for conservative care of thecervical radiculopathy in this patient wasconsidered fair to good, because of motorchanges. The prognosis for surgical laminec-tomy/fusion was considered good; however,surgery would not be considered until con-servative management had been attempted.The prognosis for conservative managementof the carpal tunnel syndrome was consid-ered good as long as contributing factorswere eliminated or managed and if symp-toms were caught early. The prognosis forsurgical release of the carpal tunnel wasconsidered good.

S H O R T - T E R M G O A L SThe patient will:1. Have less pain and tenderness arising from

the neck by the end of the second week oftreatment.

2. Have decreased tingling sensation in theforearm and hand by the end of the firstweek of treatment.

3. Increase the available range of motion inthe cervical region by the end of the fourthweek of treatment.

4. Increase strength in the right upperextremity gradually over the course of thetreatment sessions.

L O N G - T E R M G O A L SThe patient will:1. Regain full range of motion in the cervical

region by the end of the eighth week oftreatment.

2. Have no lasting altered sensation in theright upper extremity 3 months after treat-ment has concluded.

3. Regain full strength in the right upperextremity by the end of the eighth week oftreatment.

4. Develop the knowledge during the first2 weeks of treatment that will ensure thatshe avoids situations that will lead tosimilar symptoms in the future.

InterventionThe patient was given a prescription for anonsteroidal antiinflammatory drug andreferred to physical therapy by her primarycare physician. The physician discussed sur-gical intervention with the patient, consistingof a decompression laminectomy or a spinalfusion. Initial treatment of the cervical radicu-lopathy began with extensive patient educa-tion in sitting posture, computer use withconsideration of both cervical position andhand position, sleeping posture, pillow selec-tion, avoidance of static positions, and avoid-ance of the closed-pack position of the rightcervical region. The necessity of attainingand maintaining correct posture during workand activities of daily living was reinforcedthroughout the treatment sessions.

Cervical traction was used on the first dayof treatment, with a very gentle 5 lb of trac-tion applied. Other techniques used to reducenerve root irritation included Maitland gradeI central vertebral pressure techniques directedin a posteroanterior direction. These tech-niques were applied in 30-second bouts sepa-rated by 1-minute rest and reevaluationperiods. A total of four bouts were applied.The patient was sent home with a home exer-cise program that included the open-packposition for symptomatic relief, modifieddorsal glides (McKenzie chin retraction exer-cises) with progression to improved mobilityas tolerated, stretching to correct upper

quadrant (including the upper extremities)alignment, and frequent stretching breaksduring the workday. Exercises for the fore-arm included gentle extrinsic flexor muscle-strengthening activities accompanied byfrequent stretching breaks.

The patient was also given soft tissuemobilization to the right upper quadrant mus-cles, especially the scalenes, pectoralis minor,sternocleidomastoid, and upper trapezius.

OutcomeThe patient stated that the traction initiallyproduced decreased symptoms in the neckfollowed by decreased symptoms in the fore-arm. However, she did report increased symp-toms immediately after the traction force wasremoved. The force was decreased for thesubsequent sessions such that the patient feltsymptomatic relief but did not experiencethe posttraction exacerbation. The Maitlandmobilization techniques produced a reductionin symptoms in the neck and forearm. Thepatient was very compliant with her homeexercise program and took steps at herworkplace to rearrange her desk and ensureproper postural alignment.

ReexaminationThe patient was treated three times per weekfor the first 3 weeks and then two times perweek for the following 3 weeks. The reexami-nation was done 6 weeks after the initialexamination, at which time the patient’s cer-vical spine mobility had improved, with for-ward flexion now 70% of normal range butstill without reversal of the normal lordosis.Cervical extension was full, with some limitedmotion at the CT junction. Side flexion to theright was 85% of full range with no increasein symptoms, and side flexion to the left was60% of full range with a slight decrease insymptoms. Rotation to the right was 60% ofnormal range with an increase in forearmsymptoms, and rotation to the left was 90%of normal range with an associated decreasein symptoms. Accessory motion of the cervi-cal spine was normal for the C1-2 segments,

Case 5 21

hypermobile for the C3-5 segments, and hypo-mobile for the C6-7 segments, and C7-T3 hadachieved more normalized motion.

Ranges of active elbow flexion and exten-sion were full, and pronation and supinationwere both 85 degrees actively. Wrist exten-sion was 75 degrees with the fingers flexedand 60 degrees with the fingers extended.

The patient exhibited improved sensationto pinprick at the tip of the right thumb, butweakness (4/5) of the abductor and extensorpollicis brevis muscles persisted. The brachio-radialis reflex was approaching normal, andfull pressure on the median nerve pathway(plus overpressure) reproduced symptoms inthe right forearm. Tinel’s sign and Phalen’stest remained positive.

How was the patient’s knowledge of

workplace ergonomics assessed?

Assessment of the patient’s knowledge ofworkplace ergonomics includes the following:1. The patient was seated at a work station

in the clinic.2. She was asked to state which parts of her

posture were not in an optimal position.3. She then demonstrated how to adjust that

work station to specifically suit her bodyshape and needs.

Discharge SummaryThis patient was progressing very well withtreatment up to this point and was educatedon the need for her to continue with her homeexercise program and to continue attendingthe clinic for at least another 4 to 6 visits.The patient was discharged from the cliniconce her maximum pain-free range of motionwas achieved at the cervical spine. Symptomsat the forearm and thumb persisted; however,the patient was advised to continue with herexercises and was reviewed every 3 monthsfor the following year.

R E C O M M E N D E D R E A D I N G S

Cailliet R: Neck and arm pain (ed 2),Philadelphia: FA Davis, 1991.

Maitland G, Hengeveld E, Banks K, English K:Maitland’s vertebral manipulation (ed 6),Melbourne, Australia: Butterworth Heinemann,2001.

American Physical Therapy Association: Guide tophysical therapist practice, second edition,Phys Ther 81:1, 2001.

22 Clinical Cases in Physical Therapy

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Define the term “scoliosis” and identify how the curves that occur in thespinal column are classified.

2. Identify the common postural deviations that occur with idiopathicscoliosis.

3. Discuss the common management principles utilized with patients withidiopathic scoliosis.

4. Identify the role of the physical therapist in the management ofidiopathic scoliosis.

ExaminationH I S T O R YThe patient, a 12-year-old white female, wasreferred to physical therapy by an orthopedicspecialist with a diagnosis of idiopathic sco-liosis. The referral requested that an exerciseprogram be implemented in conjunction withorthotic management of the spinal curve. Thepatient’s pediatrician initially detected the sco-liosis during an annual physical examination.The presenting curve was measured radio-graphically as a 33-degree right thoracic (T5-11) curve and a 30-degree left lumbar (T11-L4)curve. The patient received a Boston brace 2weeks before the initial physical therapy exami-nation and was advised to wear the brace 23hours each day. The patient reported some diffi-culty getting used to the brace, due to the initialdiscomfort associated with wearing it and gen-erally feeling self-conscious when wearing it;however, she also reported “no pain” in herback after wearing the brace for 2 weeks.

The patient was in the seventh grade andparticipated in gym at school but undertookno other extracurricular activities. She wasgenerally healthy, with no previous significanthistory of musculoskeletal injury. She had notstarted menses at the time of examination.

S Y S T E M S R E V I E WIntegumentary system. There was no

remarkable findings except for two smallslightly reddened areas noted on both iliac

crests after the brace was removed. Thisredness resolved within 10 minutes ofdoffing the brace.

Musculoskeletal system

Gross symmetry. No leg length discrep-ancy was seen. Observation from the posterioraspect revealed a thoracic curve with rightconvexity and a lumbar curve with left con-vexity. The curvature was generally wellcompensated for, but the patient presentedwith her head tilted to the right, her leftshoulder lowered, and her left waist foldhigher. Her right ribs humped posteriorly onforward bending, and she had a more promi-nent erector spinae muscle on the right side.Mildly winging scapulae were also apparentbilaterally. Observation from the anterioraspect revealed that the chest wall was moreprominent on the left side.

Palpation. No palpable muscle spasm wasnoted on either side of the spinal column.

Joint range of motion. The lower extrem-ity active range of motion (ROM) was withinnormal limits with the exception of tighthamstrings, which produced a poplitealangle of 145 degrees bilaterally. Active ROMtesting for the trunk identified that forwardflexion was decreased by 50% (i.e., thefingertips reaching only the middle of thethighs), lateral flexion to the right wasdecreased by 30% (i.e., the fingertips justreaching the knee), and rotation to the leftwas decreased by 30% when compared withthe opposite direction.

23

Case 6

24 Clinical Cases in Physical Therapy

Strength. In general, the patient’s strengthwas fair to good, with the following measure-ments noted: gross scores of 4/5 for the upperand lower extremities, 4/5 for the rectusabdominus, and 3/5 for the oblique abdomi-nals, trunk extensors, and scapular muscles.

Other joints. The patient had no com-plaints at either the hips or knees, with fullpain-free ROM available, aside from the specificsigns and symptoms previously identified.

Special tests. Both the Thomas test andthe Ober test were positive bilaterally, althoughno objective measure was taken. The patientwas independent with dressing and allactivities of daily living. She required someassistance to don the brace but was inde-pendent with doffing. She was able to walkfor 10 minutes on the treadmill at 2.5 mphand level grade. Conversational dyspneacommenced at 7 minutes with a verbalreport of fatigue. Values for heart rate andrespiratory rate were as given in Table 6-1.

The patient was well compensated, with a

right convex thoracic and left convex

lumbar curve. Which asymmetries identified

were expected for this patient?

The following asymmetries were expected: • Shoulder lower on the concave side of the

thoracic curve.• Scapula farther away from the spine on

the concave side of the thoracic curve.• Waist folds higher on the concave side of

the lumbar curve.• Iliac crest higher on the concave side of

the lumbar curve.• Rib hump on the convex side of the

thoracic curve.

• More prominent erector spinae muscula-ture on the convex side of the thoraciccurve.

• More prominent chest wall on the concaveside of the thoracic curve.

DiagnosisPhysical Therapist Practice Patterns 4A:Primary Prevention/Risk Reduction forSkeletal Demineralization, and 4B: ImpairedPosture.

Prognosis (including planof care)It was anticipated that with time, wearing thebrace, and a good home exercise program, thepatient would gradually regain a more normalalignment of the spinal column withoutlasting significant complications. The expectednumber of visits was between eight andtwelve. Initially, the patient was seen for fiveto six appointments for instruction in the homeexercise program, which was designed toimprove flexibility and strength as well as toestablish an aerobic program. The patientand her parents jointly established a check-list to document compliance with the exer-cise program and brace use. The patient wasfollowed up every 3 to 4 months to reevaluateand update the exercise program as neededthrough her growing years.

S H O R T - T E R M G O A L SThe patient will:1. Become more accustomed to wearing the

brace and more accomplished in donningand doffing the brace independentlyduring the first week after the brace isprescribed.

2. Undertake a home exercise program toprevent disuse atrophy associated withbrace wear beginning during the secondweek of treatment and continuing whileshe attends therapy.

3. Become more physically active whilewearing the brace to develop and improvespinal position.

TA B L E 6 - 1TA R G E T H E A R T R AT E : 1 5 6 T O 1 6 9

RESTING PEAK COOL DOWN

Heart rate 78 168 84Respiratory 18 36 24

rate

L O N G - T E R M G O A L SThe patient will:1. Develop increased strength in the trunk

muscles and continue to improve her staticposture by the end of the eighth week.

2. Increase trunk flexibility, trunk musclestrength, and endurance associated withdisuse muscle atrophy by the end of thetenth week.

3. Develop sufficient strength to ensure thatimprovements in static posture are main-tained during dynamic activity continuousfrom the early stages of treatment untilthe end of the twelfth week.

4. Gradually decrease her reliance on thebrace and become more independent, withmaintenance of normal spinal curvaturebeginning by the tenth week and graduallyworking toward independence withoutthe brace by the fifteenth week.

InterventionInitial treatment comprised passive move-ments of the thoracic and lumbar spinal sec-tions to assess the possibility for the scoliosisto resolve and return to a more appropriatespinal alignment. Once the curve was evalu-ated to be completely reversible, the patientand her parents were educated as to whatconstitutes a “normal” spinal position. Theend point of the treatment program was iden-tified, and a more specific exercise programwas devised to assist the patient in achievingher goals. The exercises were designed suchthat those muscles on the convex aspect ofthe curves were contracted to encourageflattening of the concavity on the oppositeside of the spine while the muscles on theconcave aspect of the curvature werestretched to allow the appropriate movement.There were a number of exercises performedindependently by the patient and a numberof exercises performed by the patient withher parents’ assistance. Electrical stimu-lation was used on the convex side of thecurve (at night) to alter the direction ofdeformity, decrease pressure on the concaveside, and allow for more normal vertebralgrowth.

OutcomeInitially, the patient was relatively noncom-pliant with both wearing the brace andperforming her exercise program. After somediscussion, the patient admitted that she feltvery self-conscious wearing the brace andhad been teased in school when she wore it.

What steps were taken to encourage the

patient to continue to wear the brace and

perform the exercise program?

The alternative to wearing the brace—surgical intervention—was discussed withboth the patient and her parents. Theyagreed to try using the brace for at least 6months to avoid the surgical route.

After wearing the brace and performingher exercises for 3 weeks, the patient statedthat she had experienced some discomfortwhen stretching the trunk muscles on theconcave aspect of her curve and also similardiscomfort when stretching her hamstrings.The therapist reviewed the patient’s stretch-ing technique and determined that thepatient was performing her stretching exer-cises correctly, but too vigorously. At thispoint, all of the strengthening exercises inthe patient’s program were also reviewedand any problems were corrected.

ReexaminationOn reexamination after 6 weeks, the patientcomplained of some slight discomfort whenstretching and occasional discomfort fromwearing the brace but little else. In terms ofpostural dysfunction, her head no longertilted to the right, her left shoulder remainedslightly lower, and her left waist fold wasnow equal to her right waist fold. The rightrib hump, which occurred posteriorly duringforward bending, remained. The prominenterector spinae muscles were also still visibleon the right side. The reddening of the iliaccrests was not present; however, there weresigns of old blister scars.

Active ROM remained within normal limits,and the tightness noted in the hamstringswas decreased somewhat, with the popliteal

Case 6 25

angles measured at 170 degrees bilaterally. TheThomas and Ober tests were still assessed asslightly positive bilaterally. ROM of the trunkhad improved with forward flexion from adecrease of 50% to one of 25%; lateral flexionto the right improved from a decrease of 30% toone of 15%; and rotation to the left improvedfrom a decrease of 30% to one of 15%.Strength measures had apparently improvedslightly, but not in all areas. The obliqueabdominals, trunk extensors and scapular mus-cles all improved to 4/5, whereas the upperextremities, lower extremities, and rectusabdominus remained at 4/5.

The patient was now independent withdressing and activities of daily living, includingindependent donning and doffing of the brace.Her endurance increased to 20 minutes on thetreadmill at 2.5 mph on a level grade. Conver-sational dyspnea commenced at 12 minuteswith report of fatigue. There were no signifi-cant changes in heart rate or respiratory rate.

Discharge StatementDischarge from physical therapy did notofficially take place; however, after 6 weeksof treatment the patient was given a revisedhome exercise program, and a return appoint-ment was scheduled for 6 months from thatdate. The patient was advised to adhere to herexercise program and to contact the therapistif anything untoward occurred before hernext appointment.

R E C O M M E N D E D R E A D I N G S

Calliet R: Scoliosis: diagnosis and management,

Philadelphia: FA Davis, 1985.Campbell SK: Physical therapy for children.

Philadelphia: WB Saunders, 1994.Tachdjian MO: Pediatric orthopedics, vol 3,

Philadelphia: WB Saunders, 1990.American Physical Therapy Association: Guide to

physical therapist practice, second edition,Phys Ther 81:1, 2001.

26 Clinical Cases in Physical Therapy

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Identify pertinent information to support a physical therapy diagnosis ofinefficient/ineffective movement patterns resulting in greater energydemand to perform tasks.

2. Explore approaches to address energy-conserving devices and movementpatterns.

3. Discuss aerobic activity benefits for those who have fatigue as animpediment to quality of life.

The reader should know the patient participated

in an outpatient education program for people

with multiple sclerosis (MS) and their

significant others. Each participant was

encouraged to bring questions, concerns, and

activity goals to the medical team. The team

assessed the patient’s physical capabilities and

interests, then formulated an activity program

congruent with the patient’s goals and abilities.

According to the Guide for Physical

Therapist Practice,1 the potential functional

limitations or disabilities displayed by patients

with MS include deconditioning from a cardio-

vascular, neuromuscular, or musculoskeletal

deficit that could lead to impaired endurance

and progressive loss of function. Neuromuscular

difficulties resulting from this patient’s

disorder included difficulty in coordinating

movement related to gait on home, work, or

community terrains. This impaired motor

function and impaired sensory integrity

impeded the patient’s ability to perform her

employment duties as a software technician

because her hands were involved, and she

complained of decreased fine motor skills

interfering with her ability at the keyboard.

ExaminationG E N E R A L D E M O G R A P H I C SThe patient, a 5-foot, 5-inch, 55-year-oldfemale software technician who weighed 149pounds with a body mass index (BMI) of24.4, had an 11-year diagnosis of MS (althoughher symptoms began 16 years earlier). She

had a Kurtzke expanded disability statusscale (EDSS) score (i.e., disability index) ofstage 2, meaning that she had minimal dis-ability, with slight weakness or stiffness,minor gait disturbances, or mild motor dis-turbances. She was married, lived with asupportive husband, and had two growndaughters who lived in a neighboring state.

What home modifications may have helped

this patient to conserve her energy and help

create a safe environment for her to work

and live in?

The patient’s house was equipped with anoffice so that she could perform her workduties at home without having to go outside.She lived in a three-bedroom, two-bathroom,single-level home. On the outside of the house,there were three steps to both the front andback doors. Handrails were installed on bothsets of steps. She was able to go up anddown the steep basement steps, but did soonly when absolutely necessary.

The patient enjoyed generally good health,although she experienced numbness in herhands and fatigue that required rest. Shewalked around the house without any assis-tive devices, but used a straight cane or a canewith a folding seat for outings. She was ableto manage her household with her husband’shelp. At times, she had difficulty managingmultiple tasks requiring short-term memory.She participated in physical activity aboutthree days per week, including stretching for

27

Case 7

28 Clinical Cases in Physical Therapy

15 minutes and cycling for 10 minutes. In thesummer months, she also swam for 1 hourthree times a week. The only medications thatshe took were Avonex (an interferon used toslow disease progression),2 Evista (for osteo-porosis prevention),3 and aspirin for preven-tion of heart disease and stroke.

What examination procedures could be

included for a patient with MS at Kurtzke

stage 2?

T E S T S A N D M E A S U R E SThe patient’s EDSS score was 3.5.4 Testing ofher aerobic capacity on a Schwinn Airdynecycle ergometer yielded the results given inTable 7-1.

Significant weakness was found in rightshoulder abduction, external rotation, andelbow flexion (4/5) and in left shoulder flex-ion and external rotation (4-/5). In the leftleg, strength was assessed at 4/5 in straight-knee hip flexion, 4/5 in hip external rotation,4-/5 in hip extension, and 3/5 in hip extension.In the right leg, strength was 4/5 in bent-kneehip flexion, hip external rotation, and kneeflexion. Strength in trunk flexion was 3/5.6 Ahip flexion contracture of 5 degrees on theleft was also noted.7

The patient was hyperreflexic in both lowerextremities and the left upper extremity, butexhibited no clonus or nystagmus. Her vibra-tory sense and stereognosis were intactbilaterally, although blunted on the left side.

On ambulation, the patient exhibited aforward head, anterior pelvic tilt, and mildataxia. She was able to walk 25 feet in 6.3seconds (the average of two trials), and her

score on the Tinetti balance assessment was25/28, indicating a low risk of falls.8

What modifications may enable someone

with sensory and cognitive loss (problems

with multiprocessing with short-term

memory) to perform their computer

technical support duties at work?

The patient worked as a software consultantfrom her home office, where she used anexercise ball as a chair during work. She triedto be as active as possible with cooking,cleaning, gardening, and other activities, butshe was limited by her energy levels. Shelearned to pace herself and to sit with properposture. At work, she kept a detailed diary ofconversations with customers. She statedthat others in her position might not need todo this, but that it helped her focus on oneproblem at a time.

EvaluationThe patient presented as a very functional,well-adjusted woman with minimal physicaldysfunction, although she stated she felt“wobbly” on her feet and thus used a straightcane for balance and reassurance. Herweight was within a healthy range, and herbalance and gait skills were good. She hadweakness in her hips and trunk flexors,which may have contributed to her feeling ofinsecurity while ambulating on level andunlevel surfaces. She had good exercisetolerance, and was in need of educationregarding safe levels of aerobic exercise anddaily activity.

TA B L E 7 - 1A E R O B I C C A PA C I T Y T E S T I N G

RESTING PEAK COMMENTS

Heart rate 79 142 Resting ECG showed nonspecific ST changesBlood pressure 144/90 160/92 Test duration: 6 min

Peak RPE 7 (1-10 Borg scale)5

ECG, Electrocardiogram; RPE, rate of perceived exertion.

DiagnosisPhysical Therapist Practice Patterns 5A:Primary Prevention/Risk Reduction for Lossof Balance and Falling, and 5E: ImpairedMotor Function and Sensory Integrity Asso-ciated with Progressive Disorders of theCentral Nervous System.

PrognosisFew factors that could prolong the need forcontinued intervention were present in thiscase. The patient had a consistently supportivehusband and employer. Her work setting wasadjusted to allow continued employment with-out interruption resulting from her disorder.She had no comorbidities, she maintainedadequate nutrition, and her disorder had notprogressed markedly over the past 11 years.She enthusiastically embraced the exerciserecommendations.

InterventionC O O R D I N AT I O N ,C O M M U N I C AT I O N ,A N D D O C U M E N TAT I O NAs part of a multidisciplinary approach, thepatient was given a binder in which to placelecture notes and exercise recommendations,as well as any questions that arose during theclass times, to maintain a record of what shelearned and to help her review material afterreturning home. The exercise prescriptionwas practiced throughout the educationalprogram, and was provided to the patient inboth audiotape and written formats on thelast day of the program.

Which interventions for decreasing muscle

tone are efficacious for patients with MS?

The exercise program included the followingactivities:• Flexibility: Daily stretching with empha-

sis on the lower back and lowerextremities.

• Aerobic: Stationary bike, four to five daysper week at a rating of perceived exertionof 3 to 4 (on a scale of 1 to 10), moderateto somewhat hard for 6 minutes. Includewarm-up and cool down periods. Increaseduration by no more than 10% per week,as tolerated, to 20 minutes.

• Balance and coordination: Swiss ball, pool,or counter exercises, two to three daysper week.

• Strength: Abdominal and lower extremitystrengthening exercises, two to three daysper week.

What strategies could be suggested to improve

the endurance of a patient complaining of

fatigue after walking with a standard cane

for 3 minutes at a moderate speed?

The patient’s cane height was adjusted andthe hand position altered for thumb andwrist safety (Figure 7-1).

ReexaminationThe patient was given a home exerciseprogram and ideas of how to integrate thesuggested activities into her life. She wassupplied with a log sheet to fill in as shecontinued her activities. She was to returnthe completed sheet with her subjectivecomments to have the exercise prescriptionmodified accordingly.

OutcomeThe patient was very aware of her activitiesduring the day and stated that she had a hardtime stopping before she became overtired.She improved in monitoring her activities(including rest periods and prioritizing tasks)and was learning to pace herself by keepinga diary of her activities and how she felt. Asshe controlled her life better, she found thatshe had more energy and focused on partici-pating in activities that she enjoyed and wasable to enjoy them even more.

Case 7 29

R E F E R E N C E S

1. American Physical Therapy Association: Guideto physical therapist practice, second edition,Phys Ther 81:9, 2001.

2. Rudick RA, Goodkin DE, Jacobs LD, et al:Impact of interferon beta-1a on neurologicdisability in relapsing multiple sclerosis,Neurology 57(12 Suppl 5):S25, 2001.

3. Barrett-Connor E: Raloxifene: Risks andbenefits, Ann N Y Acad Sci 949:295, 2001.

4. Kurtzke J: Rating neurological impairment in multiple sclerosis: an expanded disabilitystatus scale (EDSS), Neurology 33:1444, 1983.

5. Stuifbergen AK: Physical activity and perceivedhealth status in persons with multiple scle-rosis, J Neurosci Nurs 29:238, 1997.

6. Kendall FP, McCreary EK: Muscle testing and

function (ed 3), Baltimore: Williams & Wilkins,1983.

7. Hislop HJ, Montgomery J, Connelly, B: Daniels

and Worthingham’s muscle testing: Techniques

of manual examination (ed 6), Philadelphia:WB Saunders, 1995.

8. Berg KO, Maki BE, Williams JI, et al: Clinicaland laboratory measures of postural balance inan elderly population, Arch Phys Med Rehab

73:1073, 1992.

30 Clinical Cases in Physical Therapy

F I G U R E 7 - 1 Hand placement on the cane. A, Correct hand placement. B, Incorrect handplacement.

A B

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Classify a patient with Bell’s palsy according to preferred practicepattern, diagnostic classification, and ICD-9-CM codes.

2. Determine appropriate examination process, including tests andmeasures.

3. Evaluate to determine the appropriate diagnosis, prognosis, andinterventions.

The reader should know that the patient was

a 32-year-old male who was otherwise healthy.

On awakening, he noticed drooping of the right

corner of his mouth and an inability to

completely close his right eye. He later noted an

inability to keep food in the mouth when eating.

Later that day, he visited his physician, who

made the diagnosis of Bell’s palsy. The physician

prescribed oral corticosteroids for 1 week

(with gradual discontinuation during the

second week) and an eye patch and referred the

patient for physical therapy. The patient arrived

for the first physical therapy visit 1 day after

onset with a referral that read “Bell’s palsy—

right. Evaluate and treat.”

What components should the physical

therapist incorporate into the examination

process (including tests and measures)?

The referring physician gave the diagnosis asBell’s palsy. The physical therapist shouldcomplete a patient history and systems reviewto learn about issues that may influence theplan of care. For example, a history of cardiacarrhythmias may preclude the use of electricstimulation devices as an intervention. Thetherapist uses the information obtained fromthe history and systems review to screen forundiagnosed problems that may requirefurther evaluation by the referring physicianor other health care practitioner.

For a patient with Bell’s palsy, the thera-pist should conduct a detailed examinationof facial musculature and cranial nerve VIIfunction. This examination might include the

following components: muscle strength,power, and endurance during functionalactivities; electroneuromyography; strength-duration testing; and reaction to degenerationtesting.

Examination H I S T O R YThe patient, a high school English teacher,reported several bouts of low back pain inthe past that had resolved with modificationof activities for several days. He reported nosignificant health problems. He did not usetobacco, and he consumed alcohol onlyoccasionally.

S Y S T E M S R E V I E WThe systems review yielded no signs ofundetected health problems.

T E S T S A N D M E A S U R E SThe patient was unable to voluntarily contractany of the muscles innervated by the rightcranial nerve VII. He could not close theright eye voluntarily, and saliva drooled fromthe right corner of his mouth. The therapistwas able to produce strong twitch andtetanic contractions in the muscles inner-vated by the right cranial nerve VII usingpulsatile current. The stimulation parameterswere biphasic, asymmetric, balanced pulses;300 μsec initial negative phase duration and1200 μsec positive phase duration; no intervalbetween phases; 30 Hz and amplitude 1.5 mA(Figure 8-1). Contractions of similar quality

31

Case 8

32 Clinical Cases in Physical Therapy

and strength could be produced on the left(unaffected) side using the same pulsecharacteristics.

A 1-cm-diameter handheld electrode wasused to apply current to the seventh cranialnerve and the involved muscles, and a 10-cm× 10-cm electrode was applied to the rightarm. The therapist was able to produce twitchcontractions in the muscles innervated bycranial nerve VII bilaterally using directcurrent. Twitch contractions were observedwhen the cathode was applied to the musclemotor points and when the tap-key of thehand-held electrode was closed.

EvaluationThe ability to induce tetanic contractionswith pulsed current and twitch contractionswith sudden-onset cathodal direct currentindicated that Wallerian degeneration had nottaken place. Because there was no trauma,and considering the medical diagnosis (Bell’spalsy), it seemed likely that the patient hadsustained either a first-degree (neurapraxia)or second-degree injury to cranial nerve VII.1

Presumably, Bell’s palsy is due to compres-sion and ischemia of cranial nerve VII as itcourses through the temporal bone. This maybe due to swelling associated with immuneor viral disease.2

DiagnosisPhysical Therapist Practice Pattern 5D:Impaired Motor Function and SensoryIntegrity Associated With NonprogressiveDisorders of the Central Nervous System—Acquired in Adolescence or Adulthood.

What is the expected natural course of

recovery for this patient?

Prognosis (including planof care)If the patient had sustained a first-degreeinjury, then conduction distal to the injurysite would be preserved, and recovery wouldbe expected within a few weeks of onset. Ifhe had sustained a second-degree injury, thenthe prognosis for recovery would remain good.Axon regeneration would be expected tooccur at a rate of about 1 to 2 mm per day.1

Electrodiagnostic testing (i.e., nerve con-duction velocity testing) may aid in formu-lating a more accurate prognosis. If Walleriandegeneration had occurred, then signs ofgradual denervation would become evidentduring the 21-day period after the initialonset of symptoms. Signs of denervation thatthe therapist could elicit would includedecreasing response to increasing amplitudesof pulsatile current and a slow, wormlikeresponse to direct current.

S H O R T - T E R M G O A L SGoals for this patient included restoringmuscle performance (i.e., strength, power,endurance) and the ability to perform physicalactions, tasks, and activities related to self-care.3 The timeline for achieving these goalswas 8 weeks. The plan included five visitsduring the first week, then reevaluation ofvisit frequency at the beginning of the secondweek. Based on the identified preferredpractice pattern, ICD-9-CM code 351.0 wasselected for billing purposes.

InterventionPulsatile current, with pulse characteristicsas noted earlier, was used daily for the firstweek of treatment. A total of 20 contractionswere elicited in each of the affected muscles.The patient was taught how to performmassage to the affected muscles and how toattempt voluntary muscle contractions usinga mirror for feedback.4 At 1 week after onset,

F I G U R E 8 - 1 Biphasic, asymmetric, balancedpulse.

1.5ma

300 �s 1200 �s

obvious signs of denervation were present,and the therapist added direct current to thetreatment regimen. At 3 weeks after onset,the therapist could no longer elicit contrac-tions using pulsatile current. Direct currentwas continued, and the patient was instructedin the use of a home stimulator. The patientreturned for reevaluation weekly.

OutcomeAt 4 weeks after onset, contractions ofminimal strength could be elicited by maxi-mum voluntary effort in some of the affectedmuscles. During the next three weekly visits,the patient exhibited increasingly strongervoluntary contractions in increasingly moreof the affected muscles. By 8 weeks afteronset, muscle strength improved to “fair” (i.e.,complete range of motion against gravity),and electric stimulation was discontinued.The patient was able to consistently close hisright eye and no longer experienced droolingfrom the right corner of his mouth. Becausethe goals had been met, physical therapy wasdiscontinued. A follow-up visit was scheduledfor 6 months after onset. At the 6-monthfollow-up visit, muscle strength had improvedto “normal” (i.e., complete range of motionagainst strong pressure). The patient wassatisfied with the outcome and noted no con-tinuing impairments, functional limitations,or disabilities.

DiscussionEvidence for the efficacy of electric stimula-tion in treating Bell’s palsy is ambiguous.Ysunza et al5 studied the use of electricstimulation in patients who underwent nervegrafting after facial palsy and concluded thatelectric stimulation induced improvement.Targan et al6 studied the effect of electricstimulation on two groups of patients withchronic facial nerve palsy, one group withidiopathic Bell’s palsy and the other group

with acoustic neuroma excision, and con-cluded that long-term electrical stimulationmay facilitate partial reinnervation. It isworthwhile to note that stimulation was keptat submotor levels for this study. Jaweed1

has indicated that excessive physical orelectrical activity during reinnervation mayhave deleterious effects.

Given the ambiguity of the evidence, itseemed prudent to use motor-level electricstimulation in an attempt to maintain musclecontractibility while denervation, and thenreinnervation occurred. The therapist choseto induce 20 contractions of moderate strengthdaily, hoping that this regimen would notconstitute excessive activity. Massage wasused to maintain flexibility and perhapsincrease circulation in the affected muscles.The therapist believed that voluntary effortwith mirror feedback served to promotemuscle reeducation.

R E F E R E N C E S

1. Jaweed MM: Peripheral nerve regeneration. InDowney JA et al (eds): The physiological basis

of rehabilitation medicine (ed 2), Boston:Butterworth-Heinemann, 1994.

2. Beers M, Berkow R (eds): The Merck manual

of diagnosis and therapy (ed 17), WhitehouseStation, NJ: Merck & Co, 1999.

3. American Physical Therapy Association: Guideto physical therapist practice, second edition,Phys Ther 81:9, 2001.

4. Ross B, Nedzelski JM, McLean A: Efficacy offeedback training in long-standing facial nerveparesis, Laryngoscope 101:744, 1991.

5. Ysunza A, Inigo F, Oritz-Monasterio F, et al:Recovery of congenital facial palsy in patientswith hemifacial mocrosomia subjected to suralto facial nerve grafts is enhanced by electricfield stimulation. Arch Med Res 27:7, 1996.

6. Targan RS, Alon G, Kay SL: Effect of long-termelectrical stimulation on motor recovery andimprovement of clinical residuals in patientswith unresolved facial nerve palsy, Otolaryngol

Head Neck Surg 122:246, 2000.

Case 8 33

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Analyze the importance of a training schedule.2. Differentiate between a bone scan and a radiograph.3. Compare the physiological effects produced by aquatic, closed-chain, and

open-chain exercises.

The reader should know that a young woman

arrived at an outpatient facility. As the therapist

reviewed the intake form, it was noted that the

patient was 15 years old, and it was evident

that her parents or coach were not present.

She reported that a friend drove her to the

appointment. Because parental consent was

required for the therapist to examine and treat

a minor, the appointment was rescheduled for

the next evening.

When the parents were present, the therapist

inquired if they had brought a prescription.

The patient replied that she did not have one,

that her coach had referred her to the clinic.

The patient’s father added that it was extremely

important that his daughter be able to return to

competition as soon as possible, because they

were hopeful that she would receive a college

cross-country scholarship.

The patient reported that her hip pain started

about 21⁄2 weeks earlier. She described the pain

as “sharp” and “shooting,” in the right anterior

thigh. Initially, it occurred after a few miles of

running, but worsened to the point of hurting

when walking or climbing steps.

The patient reported that cross-country

season had started 4 weeks earlier, and that

she had done no training in the off-season.

The team ran 6 days a week; the runners did

not stretch before or after running and did no

supplemental weight training. The coach had

them performing walking lunges around the

track at school. She had not recently changed

her footwear for running. The team trained on

a combination of sidewalks and roadways.

The patient denied any relevant past medical

history except for exercise-induced asthma.

She was taking no medications nor applying

any heat or ice to the area of injury. She also

denied any changes in her menstrual cycle.

Examination andEvaluationPhysical examination revealed the followingfindings:• Strength MMT: Right quadriceps, 4/5; right

adductor and hamstring, 4+/5; right hipexternal rotators, 4/5; right hip abductors,3+/5; all of the foregoing for the left side,5/5.

• Sensation: Intact to light touch bilaterallower extremities.

• Posture: Increased lumbar lordosis, genurecurvatum.

• Balance: Unilateral stance with eyes open:right decreased compared with leftsecondary to pain.

• Squat test: Patient weight shifted to leftduring the flexion component of the squat.Single leg squat: right, 20 degrees of kneeflexion; left, 60 degrees of knee flexion.

• Gait analysis: Positive Trendelenberg’ssign, hyperpronation right greater thanleft at midstance.

• Biomechanical: Right Q-angle 20 degrees,Left Q-angle 18 degrees; leg lengths even;moderate forefoot varus, R>L; bilateralincreased external tibia torsion

• Arch height: Normal non–weight bearing,decreased in weight bearing.

• Range of motion: Spine and lowerextremity WFL

• Special tests: Negative Thomas, Faber,and Ober tests.

35

Case 9

36 Clinical Cases in Physical Therapy

• Lumbar spine: Negative for SLR andslump test.

• Flexibility: Moderate restrictions bilateralcalf, quadricep, hamstring, and piriformis.

• Palpation: No palpable tenderness in thehip or lumbar spine.

• Running shoes: More than 1 year old, sliplast, semicurved shoe with worn-out heelcounter.

DiagnosisPhysical Therapist Practice Pattern 4E:Impaired Joint Mobility, Motor Function,Muscle Performance, and Range of MotionAssociated With Localized Inflammation.

What information did the squat test

provide?

The unilateral squat test demonstrated thepatient’s ability to eccentrically control kneeflexion (Figure 9-1). It can demonstrate

abnormal biomechanics and weakness of thehip, knee, or ankle musculature. This is asport-specific skill that is needed during theshock-absorption phase of running.

What features should the patient’s running

shoes have had, based on her foot type?

The desired shoe features for a patient whopronates are a straight last, board construc-tion, and a strong heel counter with less than300 miles of wear.

What type of progressive intervention

could be used to return this patient to

cross-country running?

The early stages concentrated on cross-training to maintain endurance. This wasaccomplished with a bicycle and aqua jogger.Improving lower extremity flexibility wasalso important. Non–weight-bearing exerciseswere progressed to weight-bearing strengthen-

F I G U R E 9 - 1 Single-leg squat. A, Front view. B, Side view.

A B

ing, focusing on the eccentric gluteus medius,piriformis, quadriceps, and posterior tibialis.Closed-chain exercises, (e.g., step-downs andsquats) were then progressed to jumping in astep-jump-hop progression. Once this wasaccomplished, an interval-jogging programwas instituted.

InterventionW E E K 1The patient was referred to medical imaging;plain film radiographs were negative. Thepatient began her physical therapy treatmentwith a 10-minute warm-up on an exercisebike, followed by stretching of the piriformis,quadriceps, hamstring, and calves. Applicationof ice concluded the treatment. The therapistnoted a decrease in Trendelenburg’s sign withthe warm-up, but the patient still reportedpain on ambulation.

W E E K 2The patient began by continuing with the pre-vious treatment, then added non–weight-bearing strengthening exercises, including four-way straight-leg raises, prone hamstring curls,external hip rotation with tubing for resist-ance, and ankle inversion with a theraband.

The patient reported decreased pain afterexercising, but no change in the symptoms atschool. She was referred to an orthopedicphysician with a recommendation to usecrutches to ambulate and a request for abone scan.

What were the advantages of a bone scan

versus a plain film radiograph in this case?

The main advantages of a bone scan are theearly detection of and increased sensitivityfor detecting bone fractures.

W E E K 3The bone scan revealed periostitis of thefemur. The physician wanted to continuephysical therapy with a non–weight-bearingprogram with increased time on the exercisebike and the addition of a home aquatic exer-cise program with the aqua jogger.

What was the goal of increasing the time on

the bike or the aqua jogger?

The goal of increasing the time on the bikeor aqua jogger was to improve and maintainthe patient’s cardiovascular fitness.

W E E K S 4 T O 7Physical therapy was continued with anon–weight-bearing program, increasing thetime on the bike and adding a home exerciseprogram with an aqua jogger. At the end ofthe fourth week, the patient’s pain on walkingresolved.

W E E K S 8 T O 1 1Weight-bearing exercises were graduallyadded, with a slow progression of thefollowing: wall sits, step-ups, single-legbalance, leg press, BAPS board, closed chainsupination/pronation in ankle plantar flex-ion, lower extremity exercises, step-downs,plyo-ball toss, and resisted gait. At the end ofthe eleventh week, Trendelenburg’s signresolved.

OutcomeA running analysis revealed a greater amountof pronation than during ambulation. Thepatient was advised to purchase Spencoover-the-counter orthotics. A return to arunning program was initiated. This includ-ed a bike warm-up, stretching, and mini-trampoline jogging every other day,increasing the time from 5, to 7, to 9, to11 minutes.

The patient progressed to a treadmill for a2-minute walk, a 5-minute run, and a 2-minutewalk. She continued with the walk-run-walkcombination every other day, progressing to5-, 7-, 7-, 10-, 10-, 14-, 14-, 20-, and 20-minuteruns. The patient was discharged at the 10-minute run and was to continue the programon her own. At that time, the cross-countryseason was over.

What was the benefit of having the patient

jog on the mini-trampoline before running

on the treadmill or sidewalk?

Case 9 37

The main benefit of jogging on the mini-trampoline was the decreased impact forces.In this case the athlete had an overuse injurywith weight bearing.

Why did the therapist wait until the twelfth

week to start the patient jogging?

Certain progressive criteria needed to be metbefore the patient could return to sportsactivities. The patient needed to demonstratepain-free ambulation, a 45-degree unilateralsquat with good biomechanics, and theability to perform 25 unilateral heel raises.

R E C O M M E N D E D R E A D I N G S

O’Kane JW: Anterior hip pain, Am Fam Physician

60:1687, 1999.

Steele PM: Management of acute fractures aroundthe knee, ankle and foot, Clin Fam Pract

2:661, 2000Alonso JE, Lee J, Burgess AR et al: The

management of complex orthopedic injuries,Surg Clin North Am 76:879, 1996.

Eiff PM, Hatch RL, Walter CL: Fracture

management for primary care, Philadelphia:WB Saunders, 1998.

Greenspan A: Orthopedic radiology (ed 2), NewYork: Raven Press, 1992.

Kaufman D, Leung J: Evaluation of the patientwith extremity trauma: An evidence-basedapproach, Emerg Med Clin North Am 17:77, 1999.

Shamus E, Shamus J: Sports injury prevention

and rehabilitation, New York: McGraw-Hill,2001.

38 Clinical Cases in Physical Therapy

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Differentiate between work hardening and work conditioning.2. Compare the different levels of duty and lifting restrictions.3. Apply biomechanical factors to designing a desk workstation.4. Define the Occupational Safety and Health Administration (OSHA) and

Americans With Disability Act (ADA) guidelines.

The reader should know that a physical

therapist established a new ergonomic contract

with a large electronics production facility.

The facility had more than 200 employees with

many different job descriptions and physical

demands. Some employees needed to carry

boxes, whereas others had desk jobs.

The therapist was to develop an injury

prevention program, a prescreening program,

and education classes. In addition, the chief

executive officer (CEO) wanted her workstation

assessed.

DiagnosisGuide to Physical Therapist Practice, Proce-dural Interventions, p. S108: Functional Train-ing in Work (Job/School/Play), Community, andLeisure Integration or Reintegration (Includ-ing Instrumental Activities of Daily Living,Work Hardening, and Work Conditioning).

InterventionWhat were important sources of information

that the therapist used to help fulfill

contractual obligations?

The physical therapist obtained copies ofOSHA and ADA guidelines for review.

What was the main component of each

guideline?

OSHA: Each employer must furnish employeesemployment free from recognized hazards

that are causing or likely to cause death orphysical harm.

ADA: Main guidelines for developing jobdescriptions; requisite skills; essential job func-tions, and manner by which job is performed.

After reviewing all of the guidelines, thetherapist performed a job/work risk analysisfor one of the stock employees. The workanalysis consisted of analyzing the employee’sjob duties by observing the employee per-forming the essential duties of the job func-tion. This analysis included, but was notlimited to, posture, biomechanics, forces,temperature, vibration, repetitions, and pacing.It was important to also look at the floor,equipment, workstation, and office environ-ment. During the analysis, the therapistnoticed that the employee had to repetitivelylift 40-pound boxes to a height of 4 feet, andthat the employee did not have good liftingmechanics. The recommendation to thesupervisor was to train the employee in lift-ing mechanics and also to provide theemployee with a hydraulic lift.

This process was repeated for all of theemployees. Adapting the tasks, workstation,tools and equipment reduced physical stresses,which helped decrease musculoskeletaldisorders.

The next step was to design the CEO’sworkstation. The CEO spent most of her daysitting behind the desk working on thecomputer.

What were important areas to consider

when setting up a desk workstation?

39

Case 10

40 Clinical Cases in Physical Therapy

These areas included seat height, seat backangle, knee and ankle angle, back height andsupport, elbow alignment, wrist angle, tableheight, knee clearance, keyboard height,screen height, viewing angle and distance,keyboard and mouse design, screen glare,and room lighting. One factor that requiredchanging was the oversized leather chair. Itwas not suitable for proper body supportwhile working on the computer, so a newergonomic computer chair was ordered.

What were the benefits of physical therapy

intervention to the workers and the

company?

When all of the jobs were analyzed, properequipment was obtained, and the setup wascorrected, it was time to complete the injuryprevention program. All employees receivededucation in biomechanics of lifting andfitness evaluations of strength, flexibility,and cardiac condition based on their jobduties. Individualized programs were estab-lished. Educational classes were also imple-mented for nutrition, walking, flexibility,body mechanics, and other topics as needed.Many companies have realized decreasedmedical costs and decreased lost time fromwork by implementing various types ofwellness programs.

Before the therapist secured the contractwith the company, one employee working inthe packaging area sustained a back injuryand was placed on light duty.

What are the different levels of duty and

lifting restrictions?

According to the Department of Labor andthe Social Security Administration, all jobsfit into one of five levels of exertion: seden-tary work, light work, medium work, heavywork, or very heavy work. Jobs are also clas-sified into one of three skill levels: unskilled,semiskilled, and skilled. The NationalInstitute for Occupational Safety and Healthhas published guidelines for ergonomicmanual lifting.

The employee who sustained a back injurywas referred to the therapist for rehabili-tation. The referring physician requestedphysical therapy intervention, specificallywork-hardening and work-conditioningprograms.

What is the difference between work

hardening and work conditioning?

Work conditioning usually involves one ortwo disciplines, comprises primarily exerciseand education, takes 2 to 4 hours per day, andusually lasts up to 6 weeks. Work hardeningis a more complex program that involves atleast several disciplines, uses work simula-tion as a primary source of treatment inconjunction with exercise and education,takes 2 to 8 hours per day, and typically lastsfor 6 to 8 weeks. Once the employee com-pleted the work-conditioning and then thework-hardening programs, the employerwanted to know whether the employee wasready to return to full duty. To make this deter-mination, the therapist decided to perform afunctional capacity examination (FCE).

What is an FCE?

The therapist reviewed what was already donevia the work-hardening/work-conditioningprograms. Next, the therapist compared theemployee’s physical abilities with the physicaldemands of the job as specified by the U.S.Department of Labor in the U.S. Departmentof Transportation (DOT). The FCE was thenperformed using visual and objective measure-ments, as well as physiological measurementsof heart rate and blood pressure. Some of thecategories performed during the FCE werelift, carry, push/pull, elevated work, loweredor forward work, unweighted rotation, crawl,kneel, sustained crouch, repetitive squat, stairambulation, balance and stabilization, sitting,and upper extremity coordination. The em-ployee’s self-reported assessments (e.g., pain,fatigue) were also obtained. It is important toremember that prevention of injury to theemployee (i.e., safety) was the first concern.

OutcomeThe employee was able to perform all of herjob duties without complaints and withproper body mechanics. She returned to full-time duty without restrictions.

R E C O M M E N D E D R E A D I N G S

U.S. Department of Labor, Bureau of LaborStatistics: News release: Lost work-time injuriesand illnesses; characteristics and resulting timeaway from work, 1998. April 20, 2000.

National Institute for Occupational Safety andHealth: Work practices guide for manual

lifting (pub 81-122), Cincinnati, Ohio: USPublic Health Service, 1981.

Bunn III W: Health, safety, and productivity in amanufacturing environment, J Occup Environ

Med 43:47, 2001.King PM: A critical review of functional capacity

evaluations, Phys Ther 78:852, 1998. Harten JA: Functional capacity evaluation, Occup

Med 13:209, 1998.Isernhagen SJ: Work injury, Gaithersburg,

Maryland: Aspen, 1988.Towers Perrin: Regaining control of workers’

compensation costs: the second biennial

Towers Perrin survey report, New York:Towers Perrin, 1994.

Association for Worksite Health Promotion, USDepartment of Health and Human Services,William M. Mercer, Inc: 1999 national worksite

health promotion survey, Northbrook, Illinois:Association for Worksite Health Promotionand William M. Mercer, Inc, 2000.

Woo M, Yap AK, Oh TG, Long FY: The relationshipbetween stress and absenteeism, Singapore

Med J 40:1, 1999. Lechner L, deVries H, Adriaansen S, Drabbels L:

Effects of an employee fitness program onreduced absenteeism, J Occup Environ Med

39:827, 1997. Mobley EM, Linz DH, Shukla R, et al: Disability

case management: an impact assessment in anautomotive manufacturing organization, J Occup Environ Med 42:597, 2000.

Rubens AJ, Oleckno WA, Papaeliou L: Estab-lishing guidelines for the identification ofoccupational injuries: a systematic appraisal, JOccup Environ Med 37:151, 1995.

Wyman DO: Evaluating patients for return towork, Am Fam Physician 59:844, 1999.

US Department of Labor, Bureau of LaborStatistics: Workplace injuries and illnesses in

1995 (pub 97-76), Washington, DC: USGovernment Printing Office, 1997.

National Safety Council: Accident facts, Itasca,Illinois: National Safety Council, 1997.

Schibanoff J (ed): Workers’ compensation: health

care management guidelines, vol 7,Washington, DC: Milliman and Robertson,1998.

Case 10 41

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Analyze the role of the sesamoid and flexor hallicus longus (FHL)muscles.

2. Analyze the progression of return to sport activities.3. Explain the biomechanical role of the foot intrinsic muscles.

The reader should know that a 19-year-old male

college football player presented with complaints

of pain in the right great toe with walking.

He had stopped playing football a year earlier

because of the inability to run and cut.

He remembered injuring the toe last football

season but did not receive any formal treatment

at that time. He applied ice for a few days and

had hoped the pain would go away once football

season was over. Football practice was scheduled

to restart in 1 month, and he was frustrated

that the right great toe pain persisted.

The patient denied any previous lower

extremity injuries, and there was nothing

significant in the past medical history. He had

recently visited a podiatrist, who examined the

foot. Radiographs were negative for fracture

of bipartite sesamoids. The patient was referred

to physical therapy with a diagnosis of

sesamoiditis. The physician was optimistic

that no surgery would be required. The patient

was not taking any medication currently.

What are the roles of the sesamoid bones?

The sesamoids act as mechanical “pulleys” toallow for force generation. They allow fordistribution of force and provide a mechanicaladvantage. Another example of a sesamoid isthe patella.

What is a bipartite sesamoid?

A sesamoid is called bipartite if the bone didnot completely ossify and there can be twopieces instead of one (Figure 11-1).

Will a radiograph always detect a fracture?

A radiograph will not always detect a frac-ture. Depending on the view and osteoblastcalcification, a bone scan may be moreeffective.

Examination and EvaluationPA S S I V E R A N G E O F M O T I O NMobility testing (Table 11-1) revealed capsulartightness in the first metacarpophalangealjoint (MPJ) and decreased sesamoid mobilityalong with decreased flexibility in ham-strings and piriformis bilaterally, and the

43

Case 11

F I G U R E 1 1 - 1 Bipartite sesamoid.

Sesamoidbones

44 Clinical Cases in Physical Therapy

right gastrocnemius. Gait analysis revealeddecreased heel raise and push off on theright foot.

Single-leg balance on the right extremitywas 30 seconds with the patient’s eyes openand 3 seconds with the eyes closed. Archheights, both weight bearing and non-weightbearing, were normal.

DiagnosisGuide to Physical Therapist Practice Pattern4E: Impaired Joint Mobility, Motor Function,Muscle Performance, and Range of MotionAssociated With Localized Inflammation.

InterventionThe patient began with 7 minutes on the exer-cise bike to begin to increase blood flow andpliability of the musculature and soft tissue.This was followed by bilateral stretching ofthe calf, hamstring, and piriformis musclesfor 3 × 30 seconds. Pulsed ultrasound wasapplied to the plantar aspect of the great toe,followed by first MPJ Maitland mobilizationgrade III and IV dorsal glides/distraction andsesamoid grade III mobilization superior andinferior to decrease pain and inflammationand increase A/PROM, joint mobility, andflexibility. As A/PROM increased, neuromus-cular retraining and strengthening was initi-ated, with seated heel raises for toe exten-

sion (30 repetitions), towel crunches with a2-pound weight, and isometric first MPJflexion (10 × 10 seconds), with no flexion ofthe interphalangeal joint permitted. Ankleeversion strengthening was progressed totheraband therapy. Proprioception exercisesincluded single-leg balance with eyes closed,gait training for extension and first meta-tarsal stabilization, and resisted gait in allplanes with single-leg balance at the end posi-tion. After exercise, ice and electric stimu-lation were used to decrease pain and inflam-mation.

As range of motion and strength wererestored, the patient was progressed to sport-specific running and agility drills.

OutcomeThe patient had an excellent outcome. Hewas able to increase his 40-yard dash time by4/10 of a second and return to playing foot-ball. The patient continues with ongoing intrin-sic stabilization and strengthening of the FHLmuscle.

R E F E R E N C E S

1. Adelaar RS: Disorders of the great toe.Rosemont, Illinois: American Academy ofOrthopedic Surgeons, 1997.

2. Aper RL, Saltzman CL, Brown TD: The effectof hallux sesamoid excision on the flexorhallucis longus moment arm, Clin Orthop

325:209, 1996.3. Aper RL, Saltzman CL, Brown TD: The effect

of hallux sesamoid resection on the effectivemoment of the flexor hallucis brevis, Foot

Ankle Int 15:462, 1994.4. Aseyo D, Nathan H: Hallux sesamoid bones:

anatomical observations with special referenceto osteoarthritis and hallux valgus, Int Orthop

8:67, 1984.5. Baechle TR (ed): Essentials of strength train-

ing and conditioning, ed 2, Champaign, Illinois,2001, Human Kinetics.

6. Battista J: Pro football Testaverde may startagainst Giants despite toe injury. New York

Times August, 17:1, 2000.7. Boissonnault W, Donatelli R: The influence of

hallux extension on the foot during ambula-tion, J Orthop Sports Phys Ther 5:240, 1984.

TA B L E 1 1 - 1M O B I L I T Y / S T R E N G T H D ATA

DEGREES R L

Dorsiflexion 3 12Plantarflexion 50 50First MPJ extension 35 85

M A N U A L M U S C L E T E S T

R L

DF 5 5INV 5 5EV 4+ 5First MPJ extension 4+ 5Hip and knee 5 5

MPJ, Metacarpophalangeal joint.

8. Camasta CA: Hallux limitus and hallux rigidus:clinical examination, radiographic findingsand natural history, Clin Podiatr Med Surg

13:423, 1996.9. Canavan PK: Rehabilitation in sports medi-

cine: a comprehensive guide, Stamford, Conn,1998, Appleton and Lange.

10. Churchill RS, Donley BG: Managing injuriesof the great toe, Phys Sports Med 26:1, 1998.

11. Clanton TO, Ford JJ: Turf toe injury, Clin

Sports Med 13:731, 1994.12. Clanton TO, Butler JE, Eggert A: Injuries to

the metatarsophalangeal joints in athletes,Foot Ankle 7:162, 1986.

13. Cohn I, Kanat IO: Functional limitations ofmotion of the first metatarsophalangeal joint,J Foot Surg 23:477, 1984.

14. Coker TP, Arnold JA. Weber DL: Traumaticlesions of the metatarsophalangeal joint ofthe great toe in athletes, Am J Sports Med

6:326, 1978.15. Dananberg HJ: Functional hallux limitus and

its relationship to gait efficiency, J Am Podiatr

Med Assoc 76:648, 1986.16. David RD, Delagoutte JP, Renard MM: Anatom-

ical study of the sesamoid bones of the firstmetatarsal, J Am Podiatr Med Assoc 79:536,1989.

17. DeLauro TM, Positano RG: Surgical manage-ment of hallux limitus and rigidus in the youngpatient, Clin Podiatr Med Surg 6:83, 1989.

Case 11 45

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. State how knowledge gained in research on constraint-inducedmovement therapy (CIMT) can be applied in the clinic.

2. Express how application of CIMT was appropriate with a specific patient.3. Identify how intervention was planned using CIMT research and how

objective measures were used to measure the outcomes in a patient.

The reader should know that the parents of a

5-year-old child with hemiplegic spastic cerebral

palsy approached their physical therapist about

improving their child’s upper extremity use.

The parents were concerned that their child had

more ability to use his upper extremity than

he was demonstrating. This child’s physical

therapist had recently read a research article

about learned nonuse and intervention using

constraint-induced movement therapy (CIMT)

in adults after stroke, and was curious whether

this approach would be appropriate for her

young patient.

ExaminationH I S T O R YThis 5-year-old boy was the fourth pregnancyand birth for a 32-year-old mother and 30-year-old father. The mother experiencedbleeding 36 weeks into her pregnancy. Ultra-sonography determined that the baby was ina breech position. The mother and fatherdecided on a cesarean section at 36 weekssecondary to the mother’s history of earlydeliveries and quick labors.

The 4-lb, 2-oz infant was delivered withoutcomplications. Immediately after birth, theinfant exhibited respiratory problems, and hewas transferred to the hospital’s neonatalintensive care unit (NICU). In the NICU, theinfant received oxygen and was placed on awarming table secondary to problems withthermoregulation. After 2 days in the NICU,the infant was transferred to the newbornnursery; after 5 days, he went home with hisparents.

At age 3 years, the child was referred forphysical and occupational therapy after a diag-nosis of right hemiplegic cerebral palsy. Theparents initiated a neurologic examinationafter the child’s second birthday when theybecame concerned about his asymmetricalgait and lack of right upper extremity use. Justbefore his third birthday, the child began physi-cal therapy (Figure 12-1), 60-minute sessionstwice per week. Approximately 1 month beforethis initial consultation (nearly 2 years afterinitiation of therapy), physical therapy wasdecreased to one 60-minute session per week.

At the time of the initial evaluation toconsider CIMT, the parents reported that thechild did not spontaneously use his right(involved) upper extremity unless he neededto stabilize an object. The parents felt thatthe child had the ability to use the upperextremity more during his daily functioning.The physical therapist was not familiar withCIMT and was unsure whether this therapywould benefit this child.

Could CIMT be a useful intervention

technique for this child?

The therapist did a literature search on CIMTand found a significant amount of researchon CIMT in adults,1-13 but only limited reportsof CIMT in children.14-16 How could this ther-apist determine whether this type of treat-ment would be appropriate for this child?

The therapist needed to answer a fewquestions:1. Was there enough evidence in the litera-

ture to suggest that CIMT is an effective

47

Case 12

48 Clinical Cases in Physical Therapy

treatment? The therapist decided that theevidence in adults was very strong.Although the evidence for CIMT’s efficacyin children was not as strong, the thera-pist decided that it was sufficient toconsider CIMT a viable approach forspecific children.

2. Did this child fit the description of sub-

jects who have demonstrated improve-

ments after CIMT intervention? Most ofthe research on CIMT has been done onsubjects who have had a stroke or onchildren with hemiplegia.1-16 The child’sdiagnosis was consistent with that of pedi-atric subjects who have used CIMT.14-16

The therapist decided that the child’s diag-nosis of hemiplegic cerebral palsy wouldbe appropriate for this intervention method.This child was significantly younger thanthe adult subjects who had experiencedsuccess1-13; however, the therapist foundsome reports on pediatric subjects, rang-ing in age from 15 months to 13 years.14-16

The therapist decided the child’s age wasappropriate for this intervention.

3. Did this child meet the strict inclusion

criteria set forth in the evidence found on

CIMT?1-16 The therapist determined thatthe child met all of the following criteria:• The child was of normal intelligence.• The child was able to extend his wrist

10 degrees and his fingers to neutral.• The child did have sensation present in

his involved upper extremity, althoughthe therapist surmised that there mayhave been some decreased sensationbased on the child’s limited use of theinvolved upper extremity.

• The child had sufficient balance to havehis uninvolved upper extremity con-strained without compromising his safety,and the therapist judged that he wouldbe able to tolerate wearing a sling.

• The child relied primarily on his unin-volved upper extremity (left upperextremity) for all functional activities.He used his right (involved) upperextremity for weight bearing and ifasked to use it, but the parentsreported that he needed to be remindedto use it.

• The parents were agreeable to the inter-vention, understood the time requiredfor carryover at home, and were real-istic about the possible outcomes.

Based on this information, the therapistdecided the child would be an appropriatecandidate for CIMT intervention. Thetherapist then needed to find the spaceand a therapist or team of therapists toprovide this intensive intervention. Thetherapist enlisted the help of a localphysical therapist education program. Theprogram provided space and physicaltherapy students to carry out the inter-vention. A research review board at thelocal physical therapy education programapproved the intervention.

4. How was the intervention carried out?

Research on CIMT has focused on longdaily periods of intervention for an intenseperiod.4 The intervention has used shap-ing, defined as providing enough assistanceto ensure success while encouraging the

F I G U R E 1 2 - 1 Child with cerebral palsy, shownwith physical therapy student.

subject to do as much as he or she can.4 Inaddition, constraint of the uninvolvedupper extremity for 90% of waking hourshas been provided to ensure that theinvolved upper extremity is used. CIMThas emphasized functional intervention.4

The therapist and the parents determineda list of functions they wanted to improvewith the child’s right (involved) upperextremity. These included tooth brushing,hair combing, eating with a fork/spoon,picking up food, playing with toys, andthrowing a ball with the father and oldersiblings.

EvaluationBased on an examination of the child, thetherapist concluded that there were threemajor inhibitors to the child using his rightupper extremity: (1) poor coordinationbetween the fingers and thumb, (2) learnednonuse, and (3) decreased hand strength.During function, the child demonstratedpoor coordination between his fingers andpoor ability to prepare his hand for and gripobjects. Throughout his life, the child hadlearned that his left upper extremity workedmore efficiently, and consequently he choseto use the left upper extremity more. Thus,he had learned not to use the involved upperextremity. The therapist concluded thatforcing the child to use the right upperextremity would change the habit of usingthe left upper extremity exclusively. Thetherapist also concluded that poor strengthinterfered with the child’s ability to success-fully grip and manipulate objects. The thera-pist chose intervention that emphasized grip-ping a variety of objects and repeated use ofhand function to address the poor coordina-tion, learned nonuse, and decreased handstrength.

DiagnosisPhysical Therapist Practice Pattern 5C:Impaired Motor Function and SensoryIntegrity Associated With Nonprogressive

Disorders of the Central Nervous System—Congenital Origin or Acquired in Infancy orChildhood.

Prognosis (including Planof Care)The therapist used the following tests tomeasure the child’s abilities and improve-ment after the intervention. These tests werechosen because they were all objectivelymeasurable and related to the functions inwhich the parents wanted to see improvement:• Spoon transfer of cereal from one bowl to

another bowl in 30 seconds.• Picking up cereal from a tabletop and

placing them in a jar with a 1.5-inchdiameter opening in 30 seconds.

• Throwing a ball, with the maximumdistance and accuracy of the throwmeasured (when playing catch with familymembers).

• Stacking 1-inch blocks.• Picking up quarters from a tabletop and

placing them in a coin bank placed atshoulder height in 30 seconds.

• Picking up cards from a tabletop andturning them over in 30 seconds.

• Evaluating grip and pincher strength witha dynamometer.

• Having the parents use a motor log (basedon the Pediatric Evaluation of DisabilityInventory17) to monitor changes at home.

In an effort to gain accurate baseline mea-sures, the child was assessed on thesemeasures three times a week for 2 weeksbefore initiating the intervention. After thesebaseline measurements were obtained, thechild was seen for intensive intervention4 hours a day, 5 days a week for 2 weeks.

InterventionDuring the time spent in intervention, thechild played with many toys he enjoyed athome (e.g., soft molding clay, building blocks,a memory game with cards, a bean bag tossgame), and he performed functional skills

Case 12 49

(e.g., brushing his teeth/hair, making asandwich, eating with a spoon/fork, pickingup food). Throughout the intervention, mini-mal assistance was given to allow the childto be successful during functioning. Theparents were given training to carry out theintervention at home.

In addition to the daily sessions, the childwore a specially designed sling with a gloveover his uninvolved hand and a strap aroundhis waist. The glove was attached to the straparound his waist with Velcro to allow thechild to quickly release his hand if neces-sary for balance. The child wore the slingfor the 2-week intervention and then for thefollowing week, because the therapist wantedto ensure continued use of the involvedupper extremity.

ReexaminationThe improvements seen after the 3 weeks ofintervention therapy and sling use aresummarized in Table 12-1. After the inter-vention and sling use, the parents reported a

significant increase in the child’s sponta-neous use of the involved upper extremitythroughout the day. The parents reportedthat the child’s need for verbal cues to usethe involved upper extremity was decreased,but did note that the child still relied on hisleft (uninvolved) extremity for some func-tional activities.

OutcomeThe child demonstrated improvement in mostof the outcome measures used. The parentsreported an improvement in the child’s spon-taneous use of the involved upper extremityand a decrease in the amount of verbal cuesneeded to remind the child to use the involvedupper extremity. Three months after theintervention, the child was reassessed on theoutcome measures. All of the improvementswere maintained. The parents reported thatthe child continued to use the involved upperextremity during bilateral tasks, but continuedto prefer using his uninvolved upper extremityduring unilat-eral tasks.

50 Clinical Cases in Physical Therapy

TA B L E 1 2 - 1I M P R O V E M E N T S F O L L O W I N G I N T E R V E N T I O N

OBJECTIVE MEASURES PRETESTING POSTTESTING

Spoon transfer of cereal 34 to 86 pieces of cereal 107 to 135 pieces of cerealPicking up cereal and placing in jar 12 to 17 pieces of cereal 28 to 45 pieces of cerealBall throw 52-90 in; unable to hit target 77.5-131 in; hit target two

out of three attemptsStacking blocks 8 blocks in 28-31 seconds 10 blocks in 39-41 secondsQuarters in the bank 4-5 quarters 8-9 quartersPicking up cards 8-10 cards 12-13 cardsGrip strength 3-4 kg 6 kgPincher strength 1-2 kg 2.5-3 kgDaily log Did not use right upper Used upper extremity

extremity spontaneously with minimalassistance to independentfor brushing teeth/hair,using spoon/fork, andplaying with toys

R E F E R E N C E S

1. Ostendorf CG, Wolf SL: Effect of forced useof the upper extremity of a hemiplegic patienton changes in function, Phys Ther 61:1022,1981.

2. Taub E, Miller NE, Novack TA, et al: Tech-nique to improve chronic motor deficit afterstroke, Arch Phys Med Rehabil 74:347, 1993.

3. Russo SG: Hemiplegic upper extremity reha-bilitation: a review of the force-used paradigm,Neurol Rep 19:17, 1995.

4. Taub E, Crago JE, Uswatte G: Constraint-induced movement therapy: a new approachto treatment in physical rehabilitation, Rehabil

Psychol 43:152, 1998.5. Miltner W, Bauder H, Sommer N, et al: Effects

of constraint-induced movement therapy onpatients with chronic motor deficits afterstroke: a replication, Stroke 30:586, 1999.

6. Kunkel A, Kopp B, Muller G, et al: Constraint-induced movement therapy for motor recov-ery in chronic stroke patients, Arch Phys Med

Rehabil 80:624, 1999.7. Blanton S, Wolf S: An application of upper-

extremity constraint-induced movement ther-apy in a patient with subacute stroke, Phys

Ther 79:847, 1999.8. Van der Lee JH, Wagenaar RC, Lankhorst GJ,

et al: Forced use in the upper extremity inchronic stroke patients, Stroke 30:2369, 1999.

9. Taub E, Uswatte G, Pidikiti R: Constraint-induced movement therapy: a new family oftechniques with broad application to physicalrehabilitation. A clinical review, J Rehabil Res

Dev 36:237, 1999.

10. Taub E: Constraint-induced movement ther-apy and massed practice, Stroke 31:986, 2000.

11. Liepert J, Miltner W, Bauder H, et al: Motorcortex plasticity during constraint-inducedmovement therapy in stroke patients, Neurosci

Lett 250:5, 1998.12. Kopp B, Kunkel A, Muhlnickel W, et al: Plas-

ticity in the motor system related to therapy-induced improvement of movement after stroke,Neuroreport 10:807, 1999.

13. Liepert J, Bauder H, Miltner W, et al: Treatment-induced cortical reorganization after stroke inhumans, Stroke 31:1210, 2000.

14. Yasukawa A: Upper extremity casting: adjuncttreatment for a child with cerebral palsy hemi-plegia, Am J Occup Ther 44:840, 1990.

15. Crocker MD, MacKay-Lions M, McDonnell E:Forced use of the upper extremity in cerebralpalsy: a single-case design, J Occup Ther 51:824,1997.

16. Charles J, Lavinder G, Gordon AM: Effects ofconstraint-induced therapy on hand functionin children with hemiplegic cerebral palsy,Pediatr Phys Ther 13:68, 2001.

17. Haley SM, Faas RM, Coster WJ, et al: Pediatric

evaluation of disabilities inventory (PEDI),

Boston: New England Medical Center, 1989.

Case 12 51

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Describe the consultative role of physical therapy in primary preventionof falls for a community-dwelling older adult.

2. Identify major risk factors for falls in community-dwelling older adults.3. Determine appropriate examination/screening methods to determine fall

risk in a community-based setting.4. Determine appropriate interventions to reduce or eliminate fall risk

factors for a community-dwelling older adult.5. Discuss the need for follow-up to reexamine and determine outcomes in

a community-based setting.

The reader should know that the patient, Mrs. G,

was a 73-year-old female who lived alone in a

small urban community. She attended a health

fair and education program for fall risk

reduction sponsored by a local nonprofit

organization that serves senior citizens.

The program was designed and conducted by

a physical therapist. After an explanation of

the program, Mrs. G gave informed consent to

participate.

ExaminationH I S T O R YMrs. G completed an intake form that revealeda fall less than 6 months earlier in which shewas not injured, but experienced sorenessthat lasted a few days. She reported that thefall occurred in her kitchen while she wasgetting a late-night snack from the refrigera-tor. On further questioning, she revealed thatthe kitchen lights were not on (apart from therefrigerator light) and that she was walkingwith socks, but no shoes, on her feet.

Mrs. G also reported an active lifestyle. Sheparticipated in activities such as babysitting,baking, household chores, and bus trips threeto four times per week. She ambulated inde-pendently without an assistive device. Shereported a past medical history of cataractsand the use of eyeglasses. She rated hercurrent health as 7.4 on a 10-cm–long visualanalog scale anchored by poor health at one

end and excellent health on the other end.Her medications included Micro-K, Antacand,and Ocovite.

S Y S T E M S R E V I E WWhat type of screening is appropriate to

identify fall risk for a community-dwelling

older adult?

Based on a literature review, risk factors thatappear to be the most critical for both fallsand injury are (1) history of falls, (2) cogni-tive impairment, (3) gait and balance disorders,(4) lower extremity dysfunction, (5) use ofpsychotropic medications, and (6) visualimpairment.1 Because falls are typicallymultifactorial in nature, instrumentation forscreening was selected to address several ofthese targeted areas.

Cognitive status. Mrs. G’s knowledge offall risk factors was assessed by means of a“fall facts” check-off pretest to determine herbaseline.2 Her level of knowledge was basedon her ability to identify intrinsic andextrinsic fall risk factors and appropriatemethods to reduce or eliminate fall riskfactors from a list of correct and incorrectchoices. Mrs. G scored 85% correct.

Mrs. G also completed the activities-specific balance confidence scale to measureher confidence to perform particular activitieswithout losing her balance or becomingunsteady.3 The scale included 16 items that

53

Case 13

54 Clinical Cases in Physical Therapy

described common, everyday activities. Mrs. Gplaced a mark on a 10-cm line anchored with0% to 100% confidence for performing eachitem. Her average score was 90.1%.

Neuromuscular. Mrs. G’s balance wasmeasured by the multi-directional reach test(MDRT)4 and the timed-up-and-go test (TUG)test.5 For the MDRT she stood beside a yard-stick, with her feet comfortably apart, andraised her arm to 90 degrees elevation. Shethen reached as far as possible withouttaking a step. She performed the reach infour directions: forward, backward, and toeach side. The distance from the startingpoint to the finishing point was recorded bymeasuring the change in location (in inches)of the fingertips on the yardstick in eachdirection. This test measured postural stabilitybased on the patient’s ability to maintain hercenter of gravity over her base of supportand move toward the limits of stability with-out falling. Her scores were as follows:forward, 7.4 inches; backward, 9.1 inches;right, 8.1 inches; left, 6.4 inches.

For the TUG test, Mrs. G was seated in astandard-size armchair and asked to stand andwalk 3 meters, turn around, and return to sit-ting. This test was timed (in seconds) from thetime her back left the chair until she returnedto sitting and her back was again resting onthe chair. Her time was 10.4 seconds.

Musculoskeletal. Next, Mrs. G. performedthe 30-second chair-stand test6 to evaluateher gross lower extremity strength. In thistest, the patient is seated on a chairpositioned against a wall (to prevent it fromslipping) and instructed to fold both armsacross her chest and place her feet apart toshoulder width, positioned slightly behindher knees in a slightly staggered stance. Shewas encouraged to stand up completely andsit back down as many times as possiblewithin the 30-second time limit. Mrs. G.scored 14 repetitions.

DiagnosisPhysical Therapist Practice Pattern 5A:Primary Prevention/Risk Reduction for Lossof Balance and Falling.

PrognosisG O A LMrs. G. will reduce 10 or more risk factorsfor falls through instruction to promoteawareness and use of community resources,modification of her environment and life-style, and participation in a fitness program.

E X P E C T E D O U T C O M E SIn 3 months:1. Increased knowledge of intrinsic and

extrinsic fall risk factors, as evidenced bya 55 to 10% increase in the “fall facts”check-off score.

2. Improved sense of well being as indicatedby a 5% to 10% increase in the activities-specific balance confidence scale score.

In 6 months:3. Improved safety through reduction of five

or more intrinsic and extrinsic (each) fallrisk factors.

4. Maintained level of physical fitness andbalance through participation in tai chiexercise two to three times per week.

InterventionWhat type of intervention should be

developed based on evidence in the

literature for effective fall risk reduction

and prevention for community-dwelling

older adults?

Following a review of the literature, thetherapist found that the most effective inter-ventions to reduce fall risk included exerciseto improve balance and/or strength,7-11 homeenvironment modifications,10,11 and patienteducation.10,11 However, the subjects, methods,and instrumentation varied widely acrossstudies, making it difficult to compare resultsand determine the optimum approach. Overall,the most comprehensive programs weremultifaceted in nature, addressing bothintrinsic and extrinsic risk factors.10,11 Thetherapist decided to design a program basedon components from successful studies thattargeted well elderly in a community-basedsetting.7,8,10,11

E D U C AT I O NFall risk reduction program. The educa-

tional program was designed to instructcommunity-dwelling older adults on intrinsicand extrinsic risk factors for falls and onstrategies to reduce or eliminate these risks.Participants attended three 1-hour in-servicesessions that included education about riskfactors and prevention via lecture, groupdiscussion, and group activities. Participantswere given checklists of both intrinsic andextrinsic risk factors to perform self-assessments.1 The program also includedpracticing strategies to get up from the floorin case of a fall. A provocative video, “Fearof Falling,”12 was shown during the last edu-cational session; this video portrayed severalolder adults making changes to reduce fallrisks and overcome fear. The in-servicesessions were held at a local senior centerwhere the participants sat 5 to 6 persons pertable. The program was age-sensitive, basedon approaches appropriate for older adults.For example, written materials were in alarge, simple font (14-point, Arial rounded)and printed on off-white paper to facilitatereading. The reading level for all printedmaterials was at or below the seventh-gradelevel, as determined by a Gunning Fog indexbelow 7.0.13

Referral to begin a home exercise

program. As part of the fall risk reductionprogram, the importance of improving ormaintaining fitness and balance was empha-sized. Mrs. G attended tai chi lessons offeredat the senior center as a community resource.The class included instruction in 10 tai chiexercises that required weight shifting, rota-tion, trunk and extremity movements, and achanging base of support. The lessons wereoffered for 1 hour during three monthly in-service sessions. Participants were instructedto continue practicing the exercises at hometwo to three times per week and were givena written and illustrated handout includingwarm-up/cool-down exercises and the 10 taichi exercises.

Tracking of follow-up to reduce or

eliminate fall risks. During and aftercompletion of the education program, Mrs. G

was asked to record any attempt to reduceor eliminate a fall risk factor (e.g., schedulinga doctor’s appoint-ment, removing a throwrug, buying new footwear, or changing lightbulbs). She was also given an activity calendaron which to record her performance of thetai chi home exercise program. The physicaltherapist visited the senior center for 3consecutive months after the educationcomponent to track progress on risk factorreduction and to motivate participants.

ReexaminationThe screening examinations were repeatedafter 3 months, when the educational programwas completed. Mrs. G’s scores are given inTable 13-1.

The follow-up for risk factor reductionwas categorized based on whether Mrs. Gaddressed personal (i.e., intrinsic) risk orenvironmental (i.e., extrinsic) risk and onwhether the change required any cost.15

Mrs. G reported making a total of 16 changesto reduce or eliminate fall risk factors, aslisted in Table 13-2.

The follow-up for home exercise wasreported based on Mrs. G’s activity calendar.She recorded practicing the exercises athome either one to two or three to four timesper week over a 6-month period. At the endof the program, she rated her current healthas 8.2 on a 10-cm visual analog scale anchoredby poor health at one end and excellent healthon the other end.

OutcomeOn initial screening, Mrs. G scored withinnormal limits for all of the cognitive, neuro-muscular, and musculoskeletal screeningexaminations. However, her history revealeda recent fall at home, which signaled a needfor prevention. She was encouraged to attendthe educational program and begin an exerciseprogram to maintain fitness and balance.8,16

Mrs. G responded well to the educationalprogram by making 16 changes to reduce fallrisks. Most of her changes were to reduceenvironmental risk factors by performing

Case 13 55

such tasks as eliminating clutter, installingnightlights, and removing throw rugs. Inaddition, she focused on reducing risk-takingbehaviors, such as wearing unsafe footwearand walking in the dark. During the follow-up period, she also adhered to the tai chi exer-cise program as a personal preference for anenjoyable means to maintain fitness. Subjec-tively, Mrs. G stated that she enjoyed theprogram and believed that she was able tomake important changes to protect herself

from falling. She did not report any falls ornear falls during the 6-month period of con-tact with the physical therapist.

DiscussionWhen planning a prevention/wellness

program, what feasibility and design issues

should be addressed?

In a community-based setting, such issues astime, cost, and space are important to con-sider when selecting tests and measures fora fall risk screening program. More impor-tantly, instruments that have establishedreliability and validity (especially predictivevalidity for fall risk) should be selected. Basedon the literature, targeted fall risk factors mayinclude gait and balance disorders, lowerextremity dysfunction, use of psychotropicmedications, and visual impairment.1 Becausefalls are typically multifactorial in nature,screening should address a few of thesetargeted areas. In addition, a survey ofenvironmental/home safety can be accom-plished with a checklist.1,17

56 Clinical Cases in Physical Therapy

TA B L E 1 3 - 1S C R E E N I N G E X A M I N AT I O N D ATA

PRETEST POSTTESTSCREENING SCORE SCORE PUBLISHED NORMS

Cognition:Fall facts checkoff (% correct) (% correct) 100% indicates all items correct

85.4% 91.7%Activities-specific Balance (average (average 100% indicates complete

Confidence (ABC) scale confidence) confidence) confidence; highly mobile91% 94% elderly = 80.9% average3

Balance:Multidirectional reach (inches) (inches) (inches)4

TestForward 7.4 7.0 8.9 ± 3.3Backward 9.1 9.2 4.6 ± 3.0Right 8.1 6.8 6.8 ± 3.0Left 6.4 5.3 6.6 ± 2.8

Timed-Up-and-Go (TUG) (seconds) (seconds) (seconds)14

10.4 9.3 9–15Strength:

30-second chair-stand test (repetitions) (repetitions) (repetitions)6

14 13 13.1 ± 3.4

TA B L E 1 3 - 2C H A N G E S T O R E D U C E O RE L I M I N AT E A L L R I S K FA C T O R S

NUMBERRISK FACTOR CATEGORY OF CHANGES

Intrinsic risksPersonal behavior change/no cost 5Personal behavior change/with cost 1

Extrinsic risksEnvironmental change/no cost 7Environmental change/with cost 3

Designing a concise yet effective educa-tional program is a challenge in any setting.The teaching methods must match the needsof the target audience. This program wasconducted over a 3-month period to allowfor review, follow-up, and repeated contactfor motivation of participants. The methodswere age sensitive and incorporated the useof social support within the older adult peergroup. The program included opportunitiesfor observational learning (e.g., getting up fromthe floor) and improving self-efficacy by meansof self-assessment and tracking changes toreduce risks. Reinforcement was also providedvia prizes (e.g., household items) and praisefrom the physical therapist and peers.18

As the profession of physical therapy movestoward more of an emphasis on preventionand wellness, therapists may be involved indesigning programs such as this to meetcommunity needs.

R E F E R E N C E S

1. Tideiksaar R: Falling in old age (ed 2), NewYork: Springer, 1997.

2. Hakim RM: A fall risk reduction intervention

for community-dwelling older adults, Novem-ber 2001, available at http://www.lib.umi.com/dissertations/.

3. Powell LE, Myers AM: The activities-specificbalance confidence (ABC) scale, J Gerontol A

Biol Sci Med Sci 50:28, 1995.4. Newton RA: Multi-directional reach test: a

practical measure for limits of stability inolder adults, J Gerontol A Biol Sci Med Sci

56:1, 2001.5. Podsiadlo D, Richardson S: The timed up &

go: a test of basic functional mobility for frailelderly persons, J Am Geriatr Soc 39:142,1991.

6. Jones JC, Rikli RE, Beam WC: A 30-s chair-stand test as a measure of lower body strengthin community-residing older adults, Res Q Ex

Sport 70:113, 1999.

7. Shumway-Cook A, Gruber W, Baldwin M,Shiquan L: The effect of multidimensionalexercises on balance, mobility, and fall risk incommunity-dwelling older adults, Phys Ther

77:46, 1997.8. Wolf SL, Barnhart HX, Kutner NG, et al:

Reducing frailty and falls in older persons: aninvestigation of tai chi and computerizedbalance training, J Am Geriatr Soc 44:489,1996.

9. Campbell AJ, Robertson MC, et al: Ran-domised controlled trial of a general practiceprogram of home based exercise to preventfalls in elderly women, BMJ 315:1065, 1997.

10. Tinetti ME, Baker DI, McAvay G, et al: Amulti-factorial intervention to reduce the riskof falling among elderly people living in thecommunity, N Engl J Med 331:821, 1994.

11. Close J, Ellis M, Hooper R, et al: Preventionof falls in the elderly trial (PROFET): a ran-domized controlled trial, Lancet 353:93, 1999.

12. Fear of falling, Watertown, MA: New EnglandResearch Institutes (NERI) Media Develop-ment Center.

13. The Training Post: The Gunning Fog index,

available at http://www.trainingpost.org/3-2-inst.html.

14. Newton RA: Balance screening of an innercity older adult population, Arch Phys Med

Rehabil 78:587, 1997.15. Ryan J, Spellbring AM: Implementing strate-

gies to decrease risk of falls in older women,J Gerontol Nurs 22:25, 1996.

16. Wolfson L, Whipple R, Derby C, et al: Balanceand strength training in older adults: interven-tion gains and tai chi maintenance, J Am

Geriatr Soc 44:498, 1996.17. Tideiksaar R: Preventing falls: home hazard

checklists to help older patients protect them-selves, Geriatrics 41:26, 1986.

18. Bandura A: Social foundations of thought and

action: a social cognitive theory, EnglewoodCliffs, NJ: Prentice-Hall, 1986.

Case 13 57

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Identify the clinical signs and symptoms presented with poikilothermia.2. Describe the pathophysiology related to poikilothermia with spinal cord

injury patients.3. Discuss the appropriate physical therapy interventions to prevent

poikilothermia.

The reader should know that the patient was

a 32-year-old, married, African-American male

who sustained a spinal cord injury after a

bicycle accident 1 month earlier while riding

to his industrial job. Radiographs revealed a

C7-T1 fracture dislocation of C7 and severe

subluxation (90%) anteriorly on T1. Surgical

procedures included stabilization and fusion

both anteriorly and posteriorly at these spinal

levels. The patient was transferred to a facility

1 month later for rehabilitation, with an

examination consistent with C7 ASIA level A

quadriparesis (Table 14-1).

On physical therapy examination, the

patient had an unremarkable past medical

history with no abuse of drugs or alcohol

and was functionally independent before his

accident. The patient was to wear a Miami-J

collar and abdominal binder when out of bed, in

addition to compression stockings and bilateral

pressure-relief ankle-foot orthoses (PRAFO).

During the initial physical therapy sessions,

interventions focused on wheelchair mobility

using a manual chair, transfers with the use

of a sliding board, upper extremity supported

sitting balance, bed mobility, increasing

tolerance to vertical positioning with the use of

the tilt table, and patient education. The patient

made only minimal improvements in all aspects

of therapy during the initial 2 weeks, despite

his high motivational level. Further progress

was limited because of the patient’s persistent

low-grade fever since admission. The patient also

displayed occasional increased perspiration in

areas of his face and neck. Many physical

therapy sessions had been terminated

prematurely secondary to these issues.

There was concern about the patient’s medical

status and the negative effects on his

rehabilitative progress.

What would be the appropriate response in

this situation?

59

Case 14

TA B L E 1 4 - 1A S I A I M PA I R M E N T S C A L E

ASIA IMPAIRMENT SCALE

■ A = Complete: No motor or sensoryfunction is preserved in the sacralsegments S4 to S5.

■ B = Incomplete: Sensory but not motorfunction is preserved below theneurologic level and includes the sacralsegments S4 to S5.

■ C = Incomplete: Motor function ispreserved below the neurologic level,and more than half of key musclesbelow the neurologic level have amuscle grade less than 3.

■ D = Incomplete: Motor function ispreserved below the neurologic level,and at least half of key muscles belowthe neurologic level have a musclegrade of 3 or more.

■ E = Normal: motor and sensory functionsare normal.

CLINICAL SYNDROMES

■ Central cord■ Brown-Sequard■ Anterior cord■ Conus medullaris■ Cauda equina

From American Spinal Cord Injury Association: International Standardsfor Neurological and Functional Classification of Spinal Cord Injury,Chicago, 1996, p 26. Used with permission.

60 Clinical Cases in Physical Therapy

Examination and EvaluationH I S T O R YThe patient was illiterate and from a verypoor socioeconomic background. He wasextremely slender and appeared to be mal-nourished. His medications included Lovenoxas a deep-vein thrombosis prophylaxis,Didronel as a prophylaxis to avoid hetero-topic ossification, Zosyn as an antibiotic,Ambien for insomnia, Robitussin as a coughexpectorant, and Colace as a stool softener.

S Y S T E M S R E V I E WThe patient presented with decreased airentry in the bilateral lung bases, with no rales,rhonchi, or wheezing auscultated. S1 and S2heart sounds were noted, but no S3 or S4sounds were appreciated. There were noclubbing, cyanosis, dermatologic compromise,or edema, and dorsalis pedis pulsations were2+ bilaterally. His vital signs in a seated posi-tion revealed a blood pressure of 100/65 mmHg, respiratory rate of 23 beats per minute(bpm), heart rate of 92 bpm, and temperatureof 99.8° C.

T E S T S A N D M E A S U R E SSensation, range of motion, and musclestrength were normal in the preserved levels.Passive range of motion was within normallimits in the involved trunk and lower extrem-ities, and there was no evidence of increasedspasticity. No joint deformities, swelling,increased warmth, ligamentous laxity, or sub-luxations were noted in any of the extremities.

DiagnosisPhysical Therapist Practice Pattern 5H:Impaired Motor Function, Peripheral NerveIntegrity, and Sensory Integrity Associated withNonprogressive Disorders of the Spinal Cord.

What types of problems might be suspected

at this time?

The therapist reexamined the patient andconcluded that the patient was experiencingcomplications related to poikilothermia. One

neurologic complication with a spinal cordinjury is the inability to regulate body tem-perature. With damage to the spinal cord, thehypothalamus may no longer control cuta-neous blood flow or regulate sweating. Thepatient may lack the processes of vasocon-striction in response to cold and vasodilationin response to heat and lose the ability toshiver. The patient may also lack thermoreg-ulatory sweating below the level of thelesion, which may inhibit the necessaryevaporative cooling effects of perspiration inwarm environments. To compensate, thepatient may become diaphoretic and perspireabove the segmental level of the spinal cordlesion. As a result of these thermoregulatorychanges, the external environmental temper-ature profoundly affects the patient. Thetherapist noticed that the patient was alwayswearing thick, heavy-duty sweatpants andsweatshirts with a wool afghan wrappedaround him whenever he was seated in hiswheelchair. Furthermore, after performing abedside session one afternoon when thepatient stated he was not feeling well enoughto receive therapy in the gym, the therapistnoticed that the knob on the thermostat inthe patient’s room was turned all the way upto maximum heat.

PrognosisThe therapist anticipated that in approximately1 week the patient would be able to fullyparticipate in interventions.

G O A LThe patient and family will receive educationon poikilothermia and demonstrate 100%compliance within 3 to 5 days, to regulatethe patient’s body temperature and facilitateincreased participation in therapy sessions.

InterventionAfter a spinal cord injury, the patient and hisfamily face major lifestyle changes. Thehealth care team provided accurate informa-tion as early as possible, and teaching aboutthe effects of spinal cord injury was included

in the therapy treatments. The patient andfamily were taught about autonomic dysfunc-tion and the patient’s inability to control bodytemperature. They were informed that hispersistent low-grade fever and excessivesweating were the result of his excessiveclothing and increased room temperature.They were instructed to rely heavily on thesensory input from the head and neck regionsto assist in determining appropriate environ-mental temperatures. Because of the patient’sand family’s low educational levels, the ther-apist chose to use both verbal education andpictorial explanations to facilitate effectivelearning.

OutcomeAfter the patient and family were educatedabout poikilothermia, the patient’s roomtemperature was adjusted appropriately, andhis clothing consisted of sweat pants and a

long-sleeved shirt. His fevers subsided, andhe was able to actively participate in histherapy without complaints.

R E C O M M E N D E D R E A D I N G S

Baxter K, Russo S: Physical therapy manage-

ment of spinal cord injury: accent on inde-

pendence, Woodrow Wilson RehabilitationCenter, 1994.

Ciccone C: Pharmacology in rehabilitation

(ed 3), Philadelphia: FA Davis, 2001.Ekman L: Neuroscience: fundamentals for

rehabilitation, Philadelphia: WB Saunders,1998.

Kingsley R: Neuroscience, Philadelphia: LippincottWilliams & Wilkins, 2000.

O’Sullivan S, Schmitz T: Physical rehabilitation

assessment and treatment (ed 4), Philadelphia:FA Davis, 2001.

Watchie J: Cardiopulmonary physical therapy,Philadelphia: WB Saunders, 1995.

Case 14 61

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Identify the effects on bowel and bladder control related to a conusmedullaris spinal cord injury.

2. Describe a multidisciplinary approach necessary to successfully treat apatient diagnosed with a conus medullaris spinal cord injury.

The reader should know that a 30-year-old

African-American male sustained a spinal cord

injury from a motor vehicle accident after

falling asleep at the wheel. The patient was

found to have an L1 burst fracture with 80%

collapse and retropulsion of fragments with

resulting neurologic compromise. The patient

underwent posterior stabilization with

instrumentation and fusion, and 3 weeks later

was transferred to a facility for rehabilitation

with a conus medullaris spinal cord injury.

On physical therapy examination, the

patient had an unremarkable past medical

history without any abuse of drugs or alcohol,

and he was functionally independent before his

accident. The patient was to wear a TLSO

clamshell brace when out of bed, in addition to

bilateral compression stockings.

Physical therapy interventions focused on

improving bed mobility, transfers, quality of

gait, elevations, balance, and patient education.

The patient was very motivated and achieved

significant gains over the first 2 weeks of

therapy. Despite this increased level of function,

there was concern, for the patient became

incontinent of bowel about every other day

during physical therapy sessions. Not only was

this frustrating and embarrassing to this young

patient, but it also caused premature

termination of the sessions, providing a barrier

to the patient’s further progress. In addition, the

patient’s insurance company noticed how well

the patient was performing functionally and

was pressuring for an early discharge. The

discharge date was approaching quickly, and

there was only a short time to maximize this

patient’s rehabilitation potential.

What would be the appropriate response in

this situation?

Examination and EvaluationH I S T O R YThe patient lived with his mother in a two-story home that had 13 steps with no rail-ings. He worked at a factory where he per-formed heavy-lifting duties, and he understoodthat he would have to find a different occu-pation secondary to his injury. Medicationsincluded Rocephin as an antibacterial drugto prevent infection, Ambien for insomnia,Percocet as needed for pain, Colace as astool softener, and Dulcolax suppository withdigital stimulation to aid bowel evacuation.

S Y S T E M S R E V I E WThe patient was a very pleasant young malein no acute distress. He was alert and orientedto person, place, and time, and his cognitionwas intact. S1 and S2 heart sounds werenoted, but no S3 or S4 sounds were appre-ciated. The lungs were clear in all fields bilat-erally, and no rales, rhonchi, or wheezingwere auscultated. The patient had a healingchest tube site in place postpneumothoraxwhile acutely hospitalized, in addition to astage II coccygeal pressure ulcer.

T E S T S A N D M E A S U R E SManual muscle testing revealed 3+/5 strengthbilaterally in ankle dorsiflexors and plan-tarflexors and 4–/5 strength in hip abduc-tors, hip extensors, and knee flexors. All otherareas exhibited grade 5/5 strength. During

63

Case 15

64 Clinical Cases in Physical Therapy

dermatome testing, the patient was unable todetect light touch in the L5-S1 segmentalinnervations. In addition, in accordance withthe physician’s evaluation, numbness wasindicated in the perianal area and genitalia,with a vague bulbocavernosus reflex. Interms of functional status, the patient trans-ferred wheelchair to and from bed with con-tact guard, performed all bed mobility withminimal assistance, and ascended anddescended five stairs with one rail withcontact guard. During gait assessment, thepatient ambulated 150 feet on a level surfacewithout an assistive device with contactguard. The therapist did not notice any diffi-culties with toe clearance, push-off, or kneecontrol, but did appreciate “loose, swinging”hips bilaterally during lower extremity stancephases, characteristic of a Trendelenburg gait.Standing, dynamic, unsupported balance wasfair.

DiagnosisPhysical Therapist Practice Pattern 5H:Impaired Motor Function, Peripheral NerveIntegrity, and Sensory Integrity Associatedwith Nonprogressive Disorders of the SpinalCord.

PrognosisBased on examination and evaluation data,the therapist estimated that a 2-week periodwould be necessary for the patient to fullyparticipate in interventions.

How might physical therapy sessions

become more efficient when the patient

suffers from bowel incontinence on such

a consistent basis?

The conus medullaris, anatomically locatedat the inferior border of the first lumbarvertebrae, is the terminal point of the spinalcord. After injury to the conus medullaris,autonomous (or nonreflex) neurogenic boweland bladder develops, producing signs andsymptoms similar to a lower motor neuronlesion. A lesion in this area damages the

reflexive emptying circuit of S2-S4, producingflaccid, paralyzed musculature.

G O A L S1. (Nursing goal) The patient will decrease

the number of bowel accidents by 100%within 1 to 2 weeks.

2. The patient will participate in physicaltherapy sessions 100% to facilitate increasedfunctional mobility, within 1 to 2 weeks.

InterventionThe patient’s lack of bowel control became amajor issue due to its negative effects on therehabilitative effort and the resulting emo-tional distress that the patient experienced.While the therapist spoke with the patientabout the bowel program he was followingwhile at the facility, the patient stated thatthe nursing staff arranged an every-other-dayschedule that was performed in the evening.Furthermore, on inquiring about the patient’sbowel schedule before his injury, the thera-pist learned that the patient had a bowelmovement in the morning, every day. Consid-ering the patient’s previous bowel habits, thetherapist discussed altering the patient’s pro-gram with the nursing staff, suggesting thatthe bowel program be changed to the morning,every day, to acknowledge the patient’s pre-vious bowel habits.

OutcomeThe nursing staff was agreeable to the ther-apist’s request, and they helped the patientdevelop a bowel program that was consistent,timely, and regular. Once the patient was placedon a routine schedule where his bowel was“trained,” he experienced therapy without anynegative interruptions and became function-ally independent before discharge.

R E C O M M E N D E D R E A D I N G S

Baxter K, Russo S: Physical therapy manage-

ment of spinal cord injury: accent on independ-

ence, Woodrow Wilson Rehabilitation Center,1994.

Ciccone C: Pharmacology in rehabilitation

(ed 3), Philadelphia: FA Davis, 2001.Ekman L: Neuroscience: Fundamentals for reha-

bilitation, Philadelphia: WB Saunders, 1998.Kingsley R: Neuroscience, Philadelphia: Lippincott

Williams & Wilkins, 2000.

O’Sullivan S, Schmitz T: Physical rehabilitation

assessment and treatment (ed 4), Philadelphia:FA Davis, 2001.

Case 15 65

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Identify the functional skills that a spinal cord injury patient gains withthe ability to roll.

2. List six techniques that may be used to facilitate rolling.

The reader should know that an 18-year-old,

single, unemployed African-American male

sustained a spinal cord injury from a high-

speed motor vehicle accident 3 weeks earlier.

Computed tomography scan revealed a fracture

dislocation and subluxation of C6-C7. The

surgical procedures involved fixation, fusion,

and instrumentation. The patient also presented

with an ORIF of his left olecranon fracture and

scalp lacerations. The patient was transferred

to a facility 3 weeks later with an examination

consistent with C7-T1 ASIA level B quadriparesis

(Table 16-1).

On physical therapy examination, the

patient had an unremarkable medical history

for hypertension, diabetes, or other chronic

medical conditions. The patient had experienced

two previous motor vehicle accidents, resulting

in a pelvic fracture that was now healed. The

patient denied any alcohol or drug abuse and

was functionally independent before the latest

accident. The patient was to wear an abdominal

binder and Miami-J collar when out of bed, in

addition to a left arm splint and bilateral

pressure-relief ankle-foot orthoses (PRAFOs)

and compression stockings.

During the initial physical therapy sessions,

interventions focused on wheelchair mobility

using a manual chair, transfers using a sliding

board, sitting balance, bed mobility, increasing

tolerance to vertical positioning using a tilt

table, and patient education. The patient made

moderate improvements in most aspects of

physical therapy, but continued to experience

difficulty with bed mobility, especially rolling

supine to side-lying.

What would be the appropriate response to

this patient’s specific functional limitation?

Examination andEvaluationH I S T O R YThe patient lived with his parents and youngersister in a double-wide mobile home. He wasWBAT on his left upper extremity and was

67

Case 16

TA B L E 1 6 - 1A S I A I M PA I R M E N T S C A L E

ASIA IMPAIRMENT SCALE

■ A = Complete: No motor or sensoryfunction is preserved in the sacralsegments S4 to S5.

■ B = Incomplete: Sensory but not motorfunction is preserved below theneurologic level and includes the sacralsegments S4 to S5.

■ C = Incomplete: Motor function ispreserved below the neurologic level,and more than half of key musclesbelow the neurologic level have amuscle grade less than 3.

■ D = Incomplete: Motor function ispreserved below the neurologic level,and at least half of key muscles belowthe neurologic level have a musclegrade of 3 or more.

■ E = Normal: motor and sensory functionsare normal.

CLINICAL SYNDROMES

■ Central cord■ Brown-Sequard■ Anterior cord■ Conus medullaris■ Cauda equina

From American Spinal Cord Injury Association: International Standardsfor Neurological and Functional Classification of Spinal Cord Injury,Chicago, 1996, p 26. Used with permission.

68 Clinical Cases in Physical Therapy

in no acute distress. Medications includedLovenox as a deep vein thrombosis prophy-laxis, Didronel as a prophylaxis to avoidheterotopic ossification, Senekot as a laxative,Dulcolax suppository with digital stimulation,and ibuprofen for pain relief.

S Y S T E M S R E V I E WThe patient was alert and oriented to person,place, and time, and cognition was withinnormal limits. No clubbing, cyanosis, or edemawas noted, and dorsalis pedis pulsations were2+ bilaterally. No evidence of joint deformi-ties, increased warmth, ligamentous laxity, orsubluxations in the trunk or extremities wasseen. The lungs were clear on auscultationand percussion in all fields bilaterally. Stage Ibilateral heel pressure ulcers, as well as heal-ing scalp lacerations, were noted. Vital signswere temperature, 98.1° C; heart rate, 80 beatsper minute (bpm); respiratory rate, 20 bpm;and blood pressure, 132/70 mm Hg in thesupine position.

T E S T S A N D M E A S U R E SMotor strength was 5/5 grossly in bilateralupper extremities, 2/5 in trunk musculature,and 1/5 in bilateral hip movements. There wasno presence of a motor component in theknees and ankles bilaterally, yet passive rangeof motion was within normal limits in thelower extremities. Sensation was intact to C7bilaterally with the presence of “spotty” sen-sation below the level of injury. Sacral sparingwas equivocal, as per physician evaluation,and proprioception was intact in the feet.

DiagnosisPhysical Therapist Practice Pattern 5H:Impaired Motor Function, Peripheral NerveIntegrity, and Sensory Integrity Associatedwith Nonprogressive Disorders of the SpinalCord.

What recommendations helped facilitate

rolling from supine to side-lying?

Rolling is a functionally significant skill that,once mastered, improves overall bed mobility,

assists in dressing, and allows necessary posi-tional changes to aid pressure relief and skininspection. This skill helped this patient witha spinal cord injury develop functional patternsof movement by requiring him to use his upperextremities and trunk with momentum tomove the lower extremities.

PrognosisThe therapist predicted that the patientwould become independent in bed mobilitywithin 2 to 3 weeks.

G O A L S1. The patient will demonstrate supine to right

and left side-lying with the use of bilateral1-pound wrist cuff weights, bilateral legloops, and PNF upper extremity patternswith minimal assistance 100% of the timewithin 1 week.

2. The patient will demonstrate supine to rightand left side-lying with only the use of PNFupper extremity patterns independently100% of the time within 2 weeks.

InterventionVarious techniques can assist with supine toside-lying rolling, depending on the patient’sfunctional level. For this patient, pillows wereinitially placed under one side of the pelvisand scapula to initiate rotation in the directionof the roll. One may also choose to providemanual assistance to these areas at the begin-ning of the roll when the maximum effects ofgravity occur, and reduce assistance as thepatient moves more easily. Because thepatient’s cervical orthosis restricted his neckmovements, he relied on his upper extremi-ties and trunk to complete the task. Thepatient was instructed to maintain extensionin both arms, while symmetrically and rhyth-mically rocking his arms and head from sideto side to create enough momentum to roll.Various upper extremity PNF patterns, suchas D1F, reverse-chop, and lift patterns, werealso used. Additional strategies to aid rollingincluded using wrist cuff weights to helpincrease momentum and using leg loops to

position the lower extremities. The patientpulled up on the loops and crossed his anklesso that the upper limb was toward the direc-tion of the roll. This positioning facilitatedhip and lower extremity rotation as the upperextremities worked to complete the task.During the rolling movement, the patientcoordinated a deep inspiration halfwaythrough the roll, for once the shoulders wererotated, contraction of the diaphragm assistedwith rolling.

OutcomeThe patient’s active-assisted movements grad-ually progressed to independent active supineto side-lying rolling. With the accomplishmentof this task, the patient was educated on skininspection of his sacrum with the use of along-handled mirror. He also performed pres-

sure relief while in bed and further assisted hisoccupational therapist with lower extremitydressing. Furthermore, the physical therapistwas able to initiate more advanced mat activ-ities to help the patient become as function-ally independent as possible.

R E C O M M E N D E D R E A D I N G S

Baxter K, Russo S: Physical therapy manage-

ment of spinal cord injury: accent on inde-

pendence, Woodrow Wilson RehabilitationCenter, 1994.

Ciccone C: Pharmacology in rehabilitation

(ed 3), Philadelphia: FA Davis, 2001.O’Sullivan S, Schmitz T: Physical rehabilitation

assessment and treatment (ed 4), Philadelphia:FA Davis, 2001.

O’Sullivan S, Schmitz T: Physical rehabilitation

laboratory manual, Philadelphia: FA Davis,1999.

Case 16 69

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Summarize the challenges inherent in the management process of anadult with mental retardation who exhibits simultaneous and interactiveimpairments in neuromotor, musculoskeletal, developmental, cognitive,and affective domains.

2. Identify a functional management strategy that takes into considerationthe interactive effects of common impairments associated with mentalretardation.

3. Discuss the need, when working with a mentally retarded adult, forinnovatively developing, modifying, and sharing with other providers ahabilitation plan of care that promotes best function within theindividual’s environment.

4. Determine that an important outcome of the patient management processis the assurance that the habilitation plan of care is acceptable to thepatient.

ExaminationH I S T O R YThe patient was a 50-year-old male residentin a group home for adults with mentalretardation. He had diagnoses of cerebellaratrophy, degenerative joint disease of thehips and knees, seizure disorder, and mentalretardation. His medical history over theprevious 6 months included numerous falls,with frequent lacerations to the head. Grouphome staff reported a fall frequency of oneper week. He had been provided with one-to-one staffing/close monitoring at the grouphome, because most of his falls occurred atthe group home. His seizure disorder was notcompletely controlled by medication. He hada generalized type seizure of 30 secondsduration approximately every other month.His most recent seizure medications werephenobarbital, dilantin, and neurontin. At thetime of interview, the patient weighed 184pounds, but his weight had been as high as204. His “ideal weight” as listed in his medicalchart is 125 pounds.

The patient attends a day program atanother agency. He is required by the agencyto use a wheelchair for mobility at all times.

He does not use a wheelchair at the grouphome. His yearly physical examination resultsstate “restricted activity” and “needs to be wellsupervised with ambulation.” He was referredfor “physical therapy evaluation and treatmentas needed” by his family practice physician.

The physical therapy–related goals of thegroup home staff were for the patient to beable to get up from the floor safely, decreasehis number of falls, and keep him ambulating.

S Y S T E M S R E V I E WCognitive status. The patient demon-

strates perseverative behavior. He prefers toside sit or heel sit on the floor and engage ineither shredding paper or sorting smallobjects for extended periods. He avoids eyecontact when he does not feel comfortablewith individuals. When angry, he hits thefloor repeatedly with his hand. When angry,he also has thrown himself backward from astanding position, resulting in personalinjury. He does not attempt to engage peoplebut rather prefers to do activities by himself.He effectively communicates a strong senseof what activities he will and will not allowothers to engage him in within the grouphome. Staff reported that he can say a few

71

Case 17

72 Clinical Cases in Physical Therapy

words, indicate no by shaking his head, andrespond to simple commands.

Neurologic status. The patient canstand independently and cross his midlinewith his hand, but the action is tenuous. Hecan reach down and touch the floor to pickup items with and without using one handfor support. For control of balance, he usesan ankle strategy; the use of knee and hipstrategies for balance was not noted. Heprefers manual support from staff or asupport surface when walking short distanceswithin the group home.

Strength. The patient can rise to standingfrom a half-kneeling position but required asupport surface for balance. A completedetermination of functional strength was notpossible, because the patient was not willingto perform a full range of functional activi-ties for this evaluation.

Joint range of motion. The patientdemonstrated no significant joint contractures.A gross screen of upper extremity joint rangeof motion revealed a range within normallimits. He did not appear to have any painassociated with the degenerative joint diseaseof his hips and knees. His heel cords weremildly tight, as evidenced by approximately10 degrees of active dorsiflexion bilaterally.

Posture and ambulation skills. Thepatient stood with a wide base of support. Hehad a markedly forward head posture withforward rounded shoulders, forward flexedtrunk, and a pendulous abdomen. He walkedwith a varying step length. Staff reported thatthe quality of his ambulation skills tended todegenerate as the day progressed.

DiagnosisPhysical Therapy Practice Pattern 5A: PrimaryPrevention/Risk Reduction for Loss of Balanceand Falling.

PrognosisG O A LThe patient will reduce the risk of fallingthrough therapeutic exercise, balance training,and lifestyle modification.

The expected range and number of visitsper episode of care is between three andfive.

E X P E C T E D O U T C O M E SWithin 3 months, the patient will:1. Demonstrate the ability to reach down

without external support and pick up anitem from the floor three times within 2minutes without loss of balance.

2. Walk about the group home without seek-ing the use of a supporting surface (table,countertop).

3. Decrease the reported number of falls perweek by 100%.

4. Demonstrate 75% compliance with theplan of care.

D I S C H A R G E P L A NThe patient will be discharged from physicaltherapy services when there is a consen-sus among the group home manager andstaff that the patient is capable of safelywalking about the group home with anassistive device and without a contact guardor the need to remain within staff’s field of vision.

InterventionThe patient completed the Tinetti balanceand gait assessment to quantify his walkingand balance skills with and without a cane.His risk for fall without the cane, and whetherusing the cane objectively decreased his riskfor fall, were assessed.

A dietetic consult was initiated to developan appropriate weight control plan. Weightreduction will reduce stress on his hip andknee joints and move the patient’s center ofgravity more within his base of support.

An attempt was made to get the patient touse a weighted pistol-grip cane through aspecific training program. The weighted canebottom might make it easier for him to place the cane on the floor with each seriesof steps. It might also make him less likely to use the cane as an offensive weaponshould he have a behavioral outburst whileambulating.

The patient was observed walking aboutthe group home in his bare feet to assesswhether this provides better somatosensoryfeedback from his feet and helps improve hisbalance skills. Using a protective helmet orheadgear was considered. The appropriate-ness of the patient’s footwear was evaluated,and footwear that can help enhance staticand dynamic balance was recommended.

OutcomeThe patient completed the Tinetti balanceand gait assessment without using a cane toquantify his ambulation and balance skillsand his risk for falls. His scores were 5/12 forthe gait portion, 2/16 for the balance portion,and 7/28 for the combined gait/balance score.A score below 19 is considered to representa high risk for falls. With a total score of 7/28,this patient is considered to be at significantrisk for falls. The Tinetti assessment tool wasnot attempted with the patient using a cane,because he was unable to use the caneappropriately.

An attempt was made to have the patientuse a tip-weighted, pistol-grip cane to providehim with a wider base of support. He walkedwith the weighted cane in his hand, but didso with the cane never coming in contact withthe floor despite frequent verbal and physicalcues from the therapist. After three trials ofambulation training with the cane, the patientwalked with the therapist to his bedroom door.He opened the door, threw the cane againstthe far wall, closed the door, and then walkedaway from the therapist. A rolling walker wasalso tried, but the patient did not like how itimpeded his independent walking and simplypushed it enough to move it off to the side sohe could walk around it.

The patient’s two pairs of sneakers wereassessed to determine whether his footwearwas assisting or impeding his balance whilestanding and walking. With his flexed, forwardrounded posture, his sneakers (which hadangled, full soles) tipped him forward anddisplaced his center of gravity forward on hisbase of support. Flat, full-soled sneakers,which did not elevate his heels and alter his

center of gravity within his base of support,were determined to be the most appropriatefootwear to aid balance. The group homestaff was told that the patient did not need towear his sneakers when home. It was hopedthat walking without the sneakers at homemight give the patient enhanced propriocep-tive input, thereby enhancing his balance andpossibly preventing some falls.

The use of an assistive walking device was not feasible with the patient, because he did not want to use one even though itwas believed that he would benefit from itsuse. An alternative recommendation wasmade for the patient to walk with theassistance of staff when at all possible. Staffwould simply offer an arm as an externalsupport.

Discussion was initiated with the grouphome supervisor as to whether the use of aprotective helmet was reasonable and fea-sible for the patient. The patient has a strongaversion to any type of headgear, and is evenunwilling to wear a baseball cap or a stock-ing cap. Therefore, the use of any protectiveheadgear was considered unfeasible.

Group home staff followed up with thedietetic consultation and recommendationsregarding the optimum footwear for the patient.The issue of walking about the group homein bare feet was pursued but evaluated bythe group home supervisor versus the physicaltherapist.

In consultation with the group home staffand the referring physician, and consideringthat the anticipated goal and outcomes werenot achieved, this episode of physical therapycare was discontinued.

DiscussionDiscontinuing the plan of care was deemedappropriate for the following reasons:1. The plan of care was not acceptable to the

patient. The balance difficulties and riskfor falls were not considered problems bythe patient, and were of concern only tothose working with him. The patient hadno perceived need to be actively engagedin a program of therapeutic exercise

Case 17 73

related to addressing loss of balance andrisk of falling. Therefore, the gait trainingwith an assistive device was discontinued.

2. This was a situation wherein a patient withmental retardation refuses physical therapyservices that would be in his best interest.This is a confrontation between two oppos-ing moral principles, patient autonomy andtherapist beneficence. It would be in thepatient’s best interest to comply with theplan of care (therapist beneficence), yethe very clearly indicates, in his own way,that the plan of care is not acceptable tohim (patient autonomy). It is not appro-priate to choose an action deemed to bebeneficial for a patient simply because acaregiver thinks he or she knows better.That would be paternalism. The patient’sright to make choices for his life and toexpress those choices must be acknowl-edged. This patient had made it clear whathis choices were regarding the issues of

loss of balance and risk of falling. Therewas no other appropriate course but toimplement his free decision.

R E C O M M E N D E D R E A D I N G S

Bertoli DB: Mental retardation: focus on Downsyndrome. In Tecklin JS (ed): Pediatric

physical therapy (ed 3), Philadelphia: LippincottWilliams & Wilkins, 1999.

Long T, Toscano KH: Older persons with develop-mental disabilities. In Guccione AA (ed):Geriatric physical therapy (ed 2), St Louis:Mosby, 2000.

Davis CM: Identifying and resolving moraldilemmas. In Patient practitioner: an

experimental model for developing the art of

healthcare (ed 3), Thorofare, NJ: Slack, 1998.Davis CM: Influences of values on patient care:

foundation for decision making. In O’SullivanSB, Schmitz TJ (eds): Physical rehabilitation:

assessment and treatment (ed 4), Philadelphia:FA Davis, 2001.

74 Clinical Cases in Physical Therapy

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Differentially diagnose lumbopelvic instability, and other causes of lowback pain, that can be associated with urinary urge incontinence,especially in a female.

2. Explain the relationships between the pelvis, pelvic floor, low back pain,and urinary incontinence.

3. Discuss the importance of evidence-based practice (EBP) in physicaltherapy as it relates to women’s health.

4. Make sound clinical decisions based on EBP, thorough history, systemsreview, appropriate tests and measures, and diagnosis.

5. Develop a prognosis and an appropriate plan of care for a patient with acomplex presentation of low back pain, pelvic pain, and urinary urgeincontinence.

ExaminationH I S T O R YGeneral demographics. The patient was a42-year-old, left-hand-dominant, Caucasianfemale. Her obstetrician referred her tophysical therapy via telephone, with a diag-nosis of incontinence and low back pain. Herprimary language was English, and she had abachelor’s degree in business administration.She was employed as the administrativeassistant to the CEO of a cellular telephonemanufacturing company.

Social history. The patient was marriedwith two children, a 3-year-old girl and a6-month-old boy. Her husband traveled 3 or4 days every week, but was usually home onthe weekends.

Functional status and activity level.

The patient’s hobbies included reading andsinging, and she was an avid runner. She hadcompleted five marathons in the past 6 years,and before the last pregnancy ran at least5 days a week, for a cumulative distance ofup to 60 miles per week. She stopped run-ning as soon as she found out she was preg-nant, because she did not want to take anychances of a second miscarriage. She startedagain 3 months after the delivery, to help herlose her “baby weight.” Her job involved

prolonged episodes of sitting, spending atleast 6 hours a day at the computer. She hadnot been able to work for the past weekbecause of severe back and leg pain. She wasnot able to drive a car, and had a friend driveher to therapy. Before this current episode oflow back pain, she had been independentwith all activities of daily living (ADL) andhad had no problem fulfilling her roles ofmother, wife, and employee. At the time ofher first visit she could not pick up her babyor her daughter because of the pain, and hadto rely heavily on help from others (i.e.,mother, friends) with household chores aswell as care of her family.

General health status. The patient hadalways been in excellent health and she feltgreat until a week ago. At the time of the firstvisit, she reported trouble sleeping at night,because she couldn’t get comfortable, lead-ing to a feeling of exhaustion. She worriedabout what was going on, and if she wouldever be the same again.

Social/health habits. The patient is anonsmoker and a social drinker (up to twodrinks of wine or beer, no more than 5 nightsa week).

Family history. The patient’s father hadarthritis of the neck, hips, and low back. Hermother died at age 61 of myocardial infarc-

75

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76 Clinical Cases in Physical Therapy

tion. She had no other significant familyhistory.

Medications. The patient currently takesAdvil and Aleve. During previous episodes oflow back pain she took only Advil, whichalways proved effective. She took no otherprescription medications.

Medical/surgical history. Cardiovascular:

History of borderline high blood pressure forabout 1 year, up until 2 years ago. Since shestarted transcendental meditation, she stoppedtaking medication and no longer has highblood pressure.

Endocrine: De Quervain’s thyroiditis 6 yearsago, with no residual effects.

Gastrointestinal: A perforated colon anda temporary ileostomy 8 years ago. The causeof the perforation was unknown.

Genitourinary: Frequent urinary accidentsstarting about 3 years ago and worseningsince her last pregnancy. Her main problemis that she sometimes cannot make it to thebathroom in time. She also has nocturia threeor four times a night and a history of fourbladder infections in the past 10 years, butnone within the past 2 years. She takesCranactin (an over-the-counter herbal substi-tute) daily for urinary tract health. She reportsno pain or burning with urination and noproblems with bowel movement.

Gynecologic/obstetric: Gravida (pregnan-cies) 3, para (delivered) 2, miscarriage 2 yearsago. Her first pregnancy was without compli-cations. Her daughter was born at 39 weeks,via vaginal delivery in a semireclining position,using natural childbirth, without epidural anes-thesia. Her second pregnancy ended in a mis-carriage at 10 weeks. During her last preg-nancy, she gained 52 pounds. She had a vaginaldelivery in a semireclining position, after about10 hours of labor. She had an episiotomy anda tear through slightly more than half of theperineal body. The tear was sutured but hasremained tender. Since the delivery, sexualintercourse has been painful, and she cannotuse tampons because of the pain on insertion.

Integumentary: Unremarkable.Psychological: Unremarkable, except for

anxiety related to the pain and how it affectsher daily life.

Pulmonary: Unremarkable.Prior hospitalizations and preexisting

medical conditions: Emergency abdominalsurgery in 1996 with a temporary ileostomy,and a reversal 4 months later. Appendectomyat age 6. Otherwise unremarkable.

Musculoskeletal: Hyperextension injury tothe low back at age 18. History of occasionalback pain, described as a nagging feeling inthe small of her back with prolonged sittingor standing and with “window shopping.” Thatpain is always significantly less when she exer-cises regularly, including doing sit-ups. Tworight-ankle sprains more than 10 years ago.

Neuromuscular: Unremarkable.Other clinical tests. Radiography or

magnetic resonance imaging was not done.No specific urinary tests were performed.The gynecologist believed that the symptomsof incontinence were related to her pregnancyand would improve over time. When thepatient called the gynecologist about theback pain, she was referred to physicaltherapy without an examination.

Current condition/chief complaint.

The patient expressed concern about howher back pain interfered with her home,work, and social life. She was not currentlyreceiving any therapy, other than the Aleveand Advil. This was the first time she hadhad this much back pain. Current symptomswere severe pain in the small of her back, onthe right. This pain radiated into the right hipand buttock, and somewhat down the rightleg. Occasionally, when putting weight on theright leg, the pain shot down the right leg,and at those times was sharp and stabbing.The pain was also present with moving fromsitting to standing and vice versa. She hadhad some back discomfort over the past 3months, because of the extended long hoursspent sitting at work. Seven days before herfirst physical therapy visit, she had comehome from a 5-mile run, and when she bentover to pick up her 6-month-old son, some-thing “snapped.” The instant pain broughther to her knees. The pain had gotten some-what better since then. Sleeping was a chal-lenge, because she could not find a comfort-able position in bed.

Goals and expectations: The patient wantsto eliminate the pain, so she can participatein her daily life activities. She also desiresrelief of the pelvic pain and her incontinenceto normalize those aspects of her life as well.

S Y S T E M S R E V I E WCardiovascular /pulmonary. Bloodpressure, 128/78 mm Hg with the patientsitting, taken on the right arm; heart rate,82 beats per minute (bpm), taken at theradial pulse on the right arm; respiratory rate,13 bpm; no apparent presence of edema ofthe extremities.

Integumentary. No apparent skin break-down or discolorations were noted on thetrunk and extremities.

Musculoskeletal. Gross symmetry: Whensitting, weight bearing was greater on the leftside; forward head tilt and rounded shoulderswere also noted. No other deficits clearlyapparent.

Gross range of motion (ROM): With thepatient sitting, ROM of neck and upper andlower extremities was within age-appropriatenorms. ROM for forward flexion of thelumbar spine was painful and limited to 50%for all movements. The hip exhibited limitedright internal rotation (by approximately25%) and limited bilateral adduction (byapproximately 25%); neither was describedas painful, but both were described as“tightness” by the patient.

Gross strength: Results of myotome test-ing were strong and symmetric throughout,except for the right L5 myotome (right greattoe extension).

Neuromuscular. Gross sitting balanceappeared normal. The patient’s gait as shewalked into the clinic was antalgic, withdecreased weight bearing on the right side,slow deliberate movements, and lack ofreciprocal arm swing and trunk rotation,requiring support on her mother’s arm.Transfer stand to sit was very slow anddeliberate and clearly painful, with guardingof back movement (in an apparent attemptto avoid trunk rotation and flexion as muchas possible) and decreased weight bearingon the right side.

Communication/cognition. The patientexhibited no apparent deficits, other thandistress over the pain, and her inability tofunction in her normal roles in society. Sheanswered all questions appropriately andwas able to understand and follow complexcommands.

Based on the information from the history

and systems screen, what tests and

measures were appropriate and why?

The patient’s main complaint was pain,pointing to the need for a thorough painassessment. Because of the weakness of theL5 myotome and the complaint of radiatingpain, sensory testing of the dermatomes wasdone to rule out potential spinal involve-ment. The apparent asymmetry of posturecould be due to a muscular imbalance,misalignment in the spine or the sacroiliacjoint (SIJ), or lumbopelvic instability.1 There-fore, muscle length and strength testing andassessment of joint accessory mobility ofthe spine, the SIJ, and the pubic symphysiswere indicated. Palpation was needed tofurther pinpoint the possible source of thelow back pain and also to check whether thelow back and the radiating pain could bereproduced, which can help identify thestructures involved.

Because of the patient’s antalgic gait, athorough gait analysis and balance assess-ment were performed to identify possiblecontributing factors.

According to the Gynecological Manual

from the American Physical Therapy Asso-ciation’s Section on Women’s Health,2 it isvery important that a vaginal evaluation ofthe pelvic floor be performed to obtain spe-cific information about tone, location/presenceof pain and tenderness, sensation, function,and strength of the pelvic floor muscles andother supporting structures. This evaluationwas performed.

Another key assessment step was to havethe patient keep a bladder diary to providemore specific information about fluid intake(amount and type) and output. Ideally, thisshould be a 2-week diary.

Case 18 77

What could have been causing the patient’s

complaints?

Because of the patient’s history of occasionallow back pain, particularly during episodesof decreased exercise and hyperextensioninjury, as well as her recent pregnancy andthe hormonal changes associated with that,lumbopelvic instability1 was considered a verylikely cause of the complaints.

The urinary complaints appeared to be aresult of urge incontinence and were morethan likely based on learned behavior, althoughthe pregnancy and the delivery trauma cer-tainly could have aggravated the symptoms.The pelvic floor pain was probably related tothe episiotomy and subsequent tearing andsuturing of the perineal body. Researchindicates that the more severe tears are mostlikely to occur after an episiotomy, and thatsuturing of the scars results in greater andmore prolonged complaints.3,4

T E S T S A N D M E A S U R E SBased on the aforementioned considerations,an evidence-based practice (EBP) search onthe evaluation of lumbopelvic instability,1–3

and the American Physical Therapy Asso-ciation’s Gynecologic Manual and Guide to

Practice,5 the following tests and measureswere performed:• Bladder diary for 1 week, for inclusion in

treatment planning.• Gait, locomotion, and balance, as

described in Systems Review. Ambulationwhile performing dual tasks (countingbackward by seven and carrying a filledwater glass) reduced speed of ambulationby 50% on a 3-meter long, level surface.Walking speed was 1.0 meters/second. Nobackward ambulation was tested becauseof pain and the patient’s discomfort withthe request. Static balance in standing waswithin norms. Perturbations were nottested because of the patient’s pain onstanding and guarding of movement.

• Integument of the perineum. The patient’spelvic floor was examined with patient inhook lying, draped. A 1-inch-long scar wasvisible at 12 o’clock. The first half-inch,

closest to the vagina, was straight, where-as the more posterior half-inch was moreragged looking. The entire scar looked redand swollen and was tender to the touch,rated at 5/10. Adhesion was present inter-mittently over the entire length of thescar, for at least 75% of the total scar. Noother deficits were noted.

• Joint integrity and mobility, includingjoint accessory mobility of SIJ and specialtests for SIJ mobility. No decreased mobilityof the lumbar spine was apparent. Hypomo-bility was noted on the right SIJ.

• Motor function of the pelvic floor. Noapparent coordination difficulty with con-traction of the pelvic floor was noted. Co-contraction of abdominal and gluteal mus-cles, as well as the adductors, was notedwith pelvic floor contraction. There wasminimal lifting of the pelvic floor withcontraction.

• Performance of muscles of the abdomen,back, and pelvic floor, including observa-tion, palpation, strength, and biofeedback.Strength of the upper abdominals measured4/5; that of the lower abdominals, 2+/5.The patient was unable to stabilize herlower back when asked to perform activi-ties with either lower extremity whilesupine. Muscle spasm was noted on palpa-tion of lumbar paraspinal musculature andquadratus lumborum bilaterally, but greateron the right side than on the left side.Palpation of the right SIJ was tender onthe lateral aspect and reproduced some ofthe back pain. A trigger point was locatedin the right piriformis muscle. On the pelvicfloor, the tear adhered intermittentlythroughout the episiotomy scar, and wastender to palpation. Increased tone wasnoted, as was an inability to fully lower thepelvic floor to a normal resting position.The baseline reading on surface elec-tromyelography was 3.5 mV; the maximumreading with contraction was 6 mV. Clockpalpation elicited tenderness externally at12, over the scar, and on the right at 3.Vaginal tenderness was noted at 12, and atrigger point was found in the right obtu-rator internus. The strength of the pelvic

78 Clinical Cases in Physical Therapy

floor muscles was evaluated as 2+/5. Thepatient was able to hold for 6 seconds,became fatigued after three repetitions,and could do five fast 1-second contrac-tions before she fatigued. Strength of rightgreat toe extension was 3/5.

• Pain. The patient described the pain as10/10 when present as a shooting paindown the leg during weight bearing andotherwise as 6/10 at rest, increasing to8/10 with prolonged sitting, standing, orwalking and on transfers. The patientcharacterized the pain as a grabbing pain in the low back on the right, radiat-ing into the right buttock and somewhatto the back and outside of the right upper thigh.

• Posture in walking, standing and sitting.

Walking posture exhibited forward headposition, rounded shoulders, and increasedlumbar lordosis. Decreased hip extensionwas noted on the right side during terminalstance. Standing posture was marked by aforward head position, rounded shoulders,increased weight bearing on left, bilateralgenu recurvatum, pronated feet (left greaterthan right), slight lateral shift to the left ofthe spine on the pelvis, right iliac crestlower than left; forward rotation of rightilium (right PSIS higher, right ASIS lower);increased external rotation of the rightfoot. The sitting position was marked by aforward head position, rounded shoul-ders, and weight bearing mostly on theleft side.

• ROM of hip. Extension: right, 5 degrees; left,8 degrees. Flexion: 130 degrees bilaterally.Internal rotation: left, 45 degrees; right, 30degrees. External rotation: 45 degreesbilaterally. Abduction: 20 degrees bilaterally.Thomas test: positive on the right side.

• Reflex integrity (particularly to rule outneurologic causes of urinary and back painproblems). Patellar reflexes: 2+/4 (normal).Achilles tendon: 2+/4. Anal sphincter reflex:present and symmetrical. Cough reflex:pelvic floor reflexive contraction present.No sign of urine leakage with cough.

• Sensory integrity. The patient correctlyidentified pain sensation and light touch

5/5 in bilateral lower extremities, exceptfor lateral aspect of right foot (correctlyidentified 2/5). Sensation of the perineumwas 5/5 for light touch. The patient refusedpain assessment of perineum.

P R O B L E M L I S T• Radiating back pain• Decreased ROM of lumbar spine• Muscle-guarding in low-back musculature• Pelvic floor scar adhesion and pain• Pelvic floor increased tone, inability to

fully relax• Pelvic floor weakness• Frequency of urination and leaking of

urine a minimum of seven times a week.• Trigger point in right obturator internus

and right piriformis• Abdominal muscle weakness• Piriformis and hip flexor tightness• Postural deviation, patient unaware of

proper posture and body mechanics• Antalgic gait• Decreased SIJ mobility on right; forward

rotation of right ilium• Inability to perform functions as wife,

mother, and employee• Unable to drive a car; dysfunctional with

transfers; disrupted sleeping pattern

DiagnosisPhysical Therapist Practice Pattern 4D:Impaired Joint Mobility, Motor Func-tion, Muscle Performance, and Range ofMotion Associated with Connective TissueDysfunction.

PrognosisOver the course of 3 months of therapy, withvisits initially three times per week for 1week, decreasing to two times per week for2 weeks, and further decreasing to once everyother week or less, the patient will return toher preinjury level of daily work, home, com-munity, and leisure activities with minimal tono pain. ROM, muscle performance, muscletone, joint mobility, and posture will all returnto age-normal ranges.

Case 18 79

G O A L SWithin 6 weeks, the patient will: 1. Decrease back pain to 2/10.2. Return to work, life, and social activities,

with pain no higher than 4/10.3. Be able to do home ADLs and IADLs with

normal body mechanics and pain nogreater than 4/10.

4. Report decreased pelvic floor pain to3/10.

5. Exhibit decreased pelvic floor restingactivity to 3 mV.

6. Decrease adhesions to 50% of the epi-siotomy scar from 75%.

7. Exhibit decreased trigger point tendernessin piriformis and obturator musculature,to 4/10.

8. Demonstrate increased pelvic floorstrength, from 2+/5 to 3/5.

9. Exhibit increased strength of the lowerabdominals, to 3/5, increasing lum-bopelvic stability.

10. Correctly answer all questions aboutposture, bladder training, and bladderirritants.

11. Have normal muscle strength of piriformis,adductors, and hip flexors, as demon-strated by normal ROM for hip motion.

12. Decrease the number of urinary acci-dents from seven per week to three perweek.

13. Increase the voiding interval to 1 hour.The following goals were anticipated to be

reached in 2 to 3 months, with visits no morethan bimonthly during the last 2 months ofcare. The patient will:1. Function independently in all work, life,

and social activities, with back pain nogreater than 2/10.

2. Increase the voiding interval to 3 hours.3. Demonstrate independence with all

exercises.4. Report decreased pelvic pain, to 0–1/10.5. Report no pain on intercourse or tampon

insertion.6. Demonstrate absence of scar adhesion.7. Demonstrate a resting tone of the pelvic

floor 1.5 to 2 mV.8. Exhibit pelvic floor strength of 3+/5 or

greater.

9. Reduce the number of urinary accidentsto fewer than one per week.

10. Demonstrate independence with thehome exercise program and decisionmaking on progression of exercises.

D I S C H A R G E P L A NThe patient was to be discharged when shedemonstrated the ability to function independ-ently with subjective reported pain levels below2/10 during all social, home, and work ADLs,and when the number of urinary accidents haddecreased to less than one per week, andwhen the patient and therapist believed thatthe patient could perform her home exerciseprogram independently, including progres-sion of intensity and frequency of exercises.

Additional recommendations include refer-ral back to the obstetrician or a urologist forurinary testing to rule out other pathologies,including unstable detrusor muscle andobstruction to urine flow, and to evaluatebladder and kidney function.

InterventionUltrasound (US) is frequently used to pro-mote wound healing and soften scar tissue.Based on the results of an EBP search, thebenefits of US for postpartum perineal painand dyspareunia are neither conclusive nordefinite.6 Because there seems to be a smallimprovement of perineal pain from using UScompared with placebo, intermittent US wasused over the perineum, using a water-filledcondom for the first three treatments only,for 5 minutes per treatment.

The systematic review on guidelines fortreatment of low back pain by the Philadelphiapanel showed that the only intervention thatsignificantly improved low back pain andfunction for acute low back pain was returnto normal activities.7 The intervention for theback pain was decided to include grade 2joint mobilization to the right SIJ and the useof muscle energy techniques to derotate theright ilium. Trigger point massage of thepiriformis trigger point was also performed,as was myofascial release of the pelvis andthe abdominal region. Based on the findings

80 Clinical Cases in Physical Therapy

of the Philadelphia panel, no other interven-tions were performed, other than patienteducation on proper posture for standing,sitting, and walking and proper body mechanicsat both home and work. The patient was alsoeducated about the optimal workstationsetup at work, and on energy-preservationtechniques while performing work-, home-,and community-related activities.

Other specific interventions were per-formed as follows:• Soft tissue: Scar massage, along with

myofascial release of pelvic girdle, lumbarspine, and pelvic floor, as well as the scaradhesions, were performed. Trigger pointmassage was also performed vaginally tothe obturator internus.

• Strengthening: Pelvic floor strengtheningexercises (starting with two sets of 5-secondhold contractions, with a 5-second rest inbetween, followed by 10 quick [1-second]contractions) twice a day while supine;lower abdominal muscle strengthening exer-cises,8 and lumbar stabilization exercises.

• Biofeedback: To reduce the tone of pelvicfloor and teach isolation of the pelvic floorcontraction.

• Patient education: Topics include fluidintake, type of fluid, behavior modificationto normalize voiding pattern, self-massageof perineal body, body mechanics forlifting of children, sitting posture at work,desk setup, and postural training.

• Stretching of tight hip flexors, piriformis,and abductors.

OutcomeIt took the patient 2 weeks to complete herurinary diary. On the last day of the secondweek, she reported no incidence of urineleakage, and the voiding intervals hadincreased from a maximum of 45 minutes to75 minutes. The maximum void volume hadincreased from 3 oz to 4 oz. She still had toget up three times per night to void.

After the third visit (she was seen threetimes a week that first week), the adhesionshad reduced to about 50% of the scar. US wasdiscontinued at that time, but scar massage

and myofascial release continued. The perinealpain had decreased, and tampon insertionwas no longer painful, although sexual inter-course remained painful. The radiating painin the leg was centralizing. The PSIS and ASISwere symmetrical and pain free. The patientwas able to walk at a rate of 2 meters/second,and the pain in the back and leg with func-tional activities had decreased to 5/10. Pelvicfloor tone remained high, and no measurableincrease in the strength of muscle contractionswas seen.

The frequency of treatment was decreasedto twice a week for 1 week, and then to oncea week for the next 3 weeks. After 2 weeksof treatment, the patient was able to returnto work, with pain levels not exceeding 4/10throughout the day. Pain was present only inthe low back area, and was no longer con-tinuous. The perineal scar was without adhe-sions at this point, and piriformis and obturatortrigger points were no longer present. Scarmassage and trigger point massage werediscontinued. Stretching and strengtheningexercises were continued, and the strengthof the lower abdominals increased to 3/5, toaid reduction of lumbopelvic instability. HipROM also improved.

Subsequently, the frequency of treatmentwas further reduced to once every other weekfor 2 weeks, and then to once a month, as thepatient demonstrated the ability to performall her exercises independently, perform scarmassage correctly, and progress her exercisesappropriately. Treatment at this time consistedmostly of biofeedback with pelvic floormuscle training. Resting tone reading wasnow consistently at 2 mV, and her peak con-traction was at 8 mV. Urine leakage incidentshad decreased to between one and two perweek, and voiding intervals had increased to21⁄2 hours, with normal fluid intake. Sexualintercourse was no longer painful.

After a total of 12 visits, the patient wasdischarged, having met all of her goals.

DiscussionThe patient’s motivation to resume running,as well as her other social, work, and home

Case 18 81

activities, and her adherence to her homeexercise program resulted in an excellentoutcome, despite the complexity of the case.The support from her mother and friendsmade it possible for her to take the timeduring the day to do her exercises.

Based on EBP studies on the use of pelvicfloor muscle training for the treatment of uri-nary incontinence of women, this was addedto the behavior modification training of herurge incontinence.9 EBP has shown some(albeit not conclusive or definite) evidence thatadding pelvic floor muscle training to behav-ioral training is more beneficial than eitherpelvic floor muscle training or behavioralalone in the treatment of urge incontinence.11

Because the pelvic floor is attached to thepelvis, any adhesions and changes in tonecan create distortion of the pelvis. Therefore,it was important to treat the pelvic floor, aswell as strengthen the lumbopelvic stabi-lizing muscles, to prevent recurrence of thepelvic torsion. Restoring the muscle balanceof the pelvis, low back, and hip was alsoimportant to maintain proper alignment.

R E F E R E N C E S

1. http://www.coca.com.au/newsletter/2001/sep0101a.htm.

2. Wilder E (ed): The gynecological manual,Alexandria, VA: American Physical TherapyAssociation, Section on Women’s Health, 2000.

3. http://www.changesurfer.com/Hlth/episiotomy.html.

4. http://www.gentlebirth.org/format/woolley.html.

5. American Physical Therapy Association: Guideto physical therapist practice, second edition,Phys Ther 81:1, 2001.

6. Hay-Smith EJ: Therapeutic ultrasound forpostpartum perineal pain and dyspareunia,Cochrane Database Syst Rev 2002:CD000495.

7. Philadelphia Panel: Evidence-based clinicalpractice guidelines on selected rehabilitationinterventions for low back pain, Phys Ther

81:1641, 2001.8. Hodges PW: Is there a role for transversus

abdominis in lumbopelvic stability? Man Ther

4:74, 1999.9. Hay-Smith EJ, Berghmans LC, Hendriks HJ, et

al: Pelvic floor muscle training for urinaryincontinence in women, Cochrane Database

Syst Rev 2001:CD001407.

82 Clinical Cases in Physical Therapy

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Identify the specific signs that aid in differentially diagnosing potentialmusculoskeletal disorders that can affect the hip region.

2. Identify a treatment strategy that a patient may comply with and that isappropriate for the patient’s injury and lifestyle.

3. Identify common special tests for the hip joint, including the Thomas testand the Faber test.

ExaminationH I S T O R YThe patient was a 38-year-old athletic malewho presented with a main complaint of rightintermittent inner groin and thigh pain com-mencing 3 weeks earlier, after he began joggingin preparation for a 35-and-over basketballleague. His symptoms increased in severity,frequency, and duration. He received no treat-ment before his first visit except for restingfrom playing basketball over the past weekend.He worked out regularly using free weightsand a stationary bicycle, and he occasionallyused the swimming pool. He stated that hedid not stretch with any regularity. His jobwas mainly sedentary.

The patient reported that stepping upstairs immediately increased his pain from3/10 to 7/10. This pain settled within 3 minutes.He also stated that jogging immediatelyincreased his pain to 8/10; however, this easedwithin 5 to 10 minutes. Lying supine with hiship slightly flexed and a pillow under histhigh eased the pain to 0/10 after approximately20 minutes. His hip was stiff on waking, andthe symptoms were variable with activityduring the day. He noticed that he awakenedwhen turning in bed most nights.

The patient walked into the clinic with amildly antalgic gait and a decreased stridelength on the right. He reported a “clicking”in his right hip. His general health was good,with no recent unexplained weight loss. Theonly medication he was taking was ibupro-fen; however, he suffered from exercise-

induced asthma and used an oral inhaler asneeded. No radiographs had been taken ofthe painful hip.

S Y S T E M S R E V I E WIntegumentary system. There was notice-able bruising in the region of the right groinas well as the right upper thigh region. At thetime of assessment, the bruising was green-yellow and, according to the patient, haddecreased considerably.

Gross symmetry. No significant differ-ences in symmetry were seen. Leg length andweight bearing were deemed equal.

Palpation. There was marked tendernesson palpation of the origin of the adductorand pectineus muscles. Palpation reproducedthe patient’s complaint. There was also somespasm located in the deep paravertebralmuscles from L2-L5 on the right.

Joint range of motion. Active hip flexionwas 120 degrees with a stiff capsular painfulend feel. Extension was –10 degrees (active)and also stiff and painful. Active hip abduc-tion was 15 degrees with a painful, softcapsular end feel. External rotation wasmeasured actively as 35 degrees, and a stiffcapsular end feel was once again noted. Allother ranges were normal and pain free.

Strength. Muscle strength in all groupswas full and pain free except for adductionand flexion, which were 4-5/5 and inhibitedby pain.

Special tests. Straight leg raise waslimited to 80 degrees on both sides. Apositive Thomas test was noted for the right

83

Case 19

84 Clinical Cases in Physical Therapy

hip flexors, with a 10-degree hip flexioncontracture. The Faber test was also positivefor the reproduction of pain on the right.

Other joints. The lumbar spine waslimited by 20% during forward flexion andside flexion to the right. There was an asso-ciated increase in pain at the end of the avail-able range. ROM from posteroanterior centralvertebral pressures at L3-L4 were limited by25% and caused an increase in low-back andthigh pain. The knee had a full range of pain-free motion.

This patient could have presented with a

lumbar spine disorder with associated

referred pain into the groin and hip region

or presented with a simple hip joint pathology.

Which signs suggested hip joint pathology?

The following signs suggested hip jointpathology:• Decreased ROM• Decreased muscle power at the hip joint• Pain inhibiting motion and muscle strength• Positive signs elicited by special tests

The patient was diagnosed with a second-degree groin strain of the right adductormuscles.

DiagnosisPhysical Therapist Practice Pattern 4E:Impaired Joint Mobility, Motor Function,Muscle Performance and Range of MotionAssociated with Localized Inflammation.

PrognosisIt was anticipated that the patient wouldreturn to his sport within 3 to 4 weeks offollowing an appropriate treatment protocol.The expected number of visits was betweenfour and six, spread over 4 weeks.

S H O R T - T E R M G O A L SThe patient will be able to:1. Walk and ascend stairs without pain within

2 weeks.2. Be independent in a home stretching

routine after two treatment sessions.

3. Demonstrate independent use of heat/icefor a home program by the second treat-ment session.

4. Sleep without waking from pain within 2 weeks.

L O N G - T E R M G O A L SThe patient will:1. Have full pain-free ROM by the end of the

fourth week.2. Be able to jog without pain by the end of

the sixth week.3. Be independent with a home strengthening

program and sport specific drills forbasketball by the end of the sixth week.

InterventionInitial treatment consisted of deep transversefriction to the affected muscle origins. Pulsedultrasound was applied to the affected muscleorigins to break down any cross-bridges thathad developed in the scar tissue depositedsince the time of injury. The patient was givenice massage to decrease any soreness fromtreatment and to limit any fresh inflammatoryresponse triggered by the friction massage. Astretching protocol was put in place, and thepatient was given a home exercise programconsisting of stretching and icing activities tobe carried out two to three times per day.

Once ROM was regained, stretching exer-cises were commenced, with only straight-line motion used. As time progressed and thepatient’s pain decreased, ROM increased, andstrength increased, more functional activitieswere implemented and sport-specific drillsundertaken.

OutcomeThe frictions were applied for approximately60 seconds initially, and any reaction wasrecorded. Because no adverse effects wereseen, friction massage was then applied for10 minutes. The pulsed ultrasound treatmentafforded some initial pain relief and localizedtreatment to the site of injury. Because of thedelay in seeing this patient, pulsed ultrasoundwas applied on the first day of treatment and

used throughout. Pulsed ultrasound was alsoused to assist in realignment of the fibers ofany scar tissue that had been deposited.

The ice massage decreased the sorenessproduced by the stretching and deep trans-verse friction massage. This was also incor-porated as part of the home exercise program.Passive stretching of the damaged muscletissue aided realignment of the scar tissuedeposited during the repair process. Theextensibility of the muscle tissue needed tobe increased before the patient could returnto activity. Strengthening exercises were with-held for the first week to decrease pain andattempt to regain the lost ROM. RegainingROM must be accompanied by appropriatestrengthening within the newly regained range.Before discharge, the patient had to demon-strate specific drills and exercises requiredfor a return to his previous level of activity.

ReexaminationOn reexamination after 2 weeks, it was foundthat stepping up stairs caused an immediateincrease in pain, which settled after just 1minute and registered as only 4/10 on thepain scale. Jogging still caused an immediateincrease in pain, which settled after only 3minutes and registered as 4/10. The patient’ship was still slightly stiff on waking; how-ever, it no longer awakened him when heturned in bed.

The patient’s antalgic gait had resolved, andhis ROM had improved to near-normal levels.The lumbar spine signs decreased consider-ably, with only a mild increase in symptomsoccurring at the end of the range. Some slighttenderness persisted in the adductor andpectineus muscles; however, there was nolonger any spasm associated with the deepparavertebral muscles between L2 and L5 onthe right. The Thomas test was reassessed at10 degrees of hip flexion contracture on the

right, and the Faber test was still positive forreproduction of pain on the right hip.

Having considered the initial treatment and

the long-term goals set, what would be an

appropriate course of treatment that would

continue the positive progress achieved

thus far?

An appropriate course of treatment would beto continue with deep transverse friction totreat the localized injury, and review the homeexercise program and ensure that the patientwas not overdoing it. It was found that thepatient had been attempting to push his homeexercise program too quickly, and he wasadvised of the potential risks involved withthis course of action. A new home exerciseprogram was devised that included a numberof safe sport-specific activities to give thepatient the feeling that he was returning tohis chosen sport, but in a controlled way.

D I S C H A R G EDischarge from physical therapy occurredwhen the patient had regained full active pain-free ROM in all directions and could performspecific exercise tests without developingpain or stiffness.

R E C O M M E N D E D R E A D I N G S

Starkey C, Ryan J: Evaluation of orthopedic and

athletic injuries, Philadelphia: FA Davis, 1996.Norris CM: Sports injuries: diagnosis and

management (ed 2), Oxford, UK: Butterworth-Heinnemann, 1998.

Zuluaga M, Briggs C, Carlisle J, et al (eds): Sports

physiotherapy: applied science and practice,Melbourne, Australia: Churchill Livingstone,1995.

American Physical Therapy Association: Guide tophysical therapist practice, second edition,Phys Ther 81:1, 2001.

Case 19 85

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Discuss the pathomechanics associated with pylon fractures.2. Identify and differentiate clinical signs and symptoms associated with

compartment syndrome.3. Identify and discuss potential sources of error in managing patients with

pylon fractures that may lead to complications.4. Identify appropriate referral sources for patients.5. Describe how to apply controlled forces using manual techniques,

positioning, and aquatic therapy to facilitate healing.

Background on DiagnosisPylon fractures are usually associated with ahigh-impact injury in which the calcaneusand talus are driven up like a wedge throughthe tibia and fibula, splitting the interosseusmembrane and fracturing the tibia and fibula

(Figure 20-1). Common complications asso-ciated with this type of injury include lossof limb length, abnormal function of thetalocrural and subtalar joints, compartmentsyndrome, and neurovascular changes.Arthrosis or other complications occur inabout 50% of patients with this type offracture; approximately 26% of affectedpatients will require ankle-joint fusion.1,2

The reader should know that a 39-year-old postal

worker sustained a pylon fracture of the right

lower extremity while on vacation when he fell

off an 8-foot-high wall and landed on the right

leg. The patient underwent an open reduction to

remove bony fragments. An external fixator was

applied to maintain traction through the fracture

site in an attempt to restore and maintain limb

length during healing. He was initially

prescribed Keflex (for infection), Demerol (for

pain), and coumadin (as an anticoagulant).

The surgeon recommended a short-term stay

of 3 weeks in the hospital rehabilitation unit

to ensure compliance with postoperative

restrictions. The insurance company approved

a 3-day stay with follow-up home care nursing

and one or two home visits by physical therapy.

The orthopedic surgeon was concerned about

the stability of the fracture and recommended

the patient remain non–weight-bearing for a

minimum of 5 weeks and that he not perform

any active muscle contraction or range of

motion (ROM) exercises for the first 3 weeks.

87

Case 20

F I G U R E 2 0 - 1 A pylon fracture. (From DaffnerRH: Clinical radiology: the essentials, ed 2, LippincottWilliams and Wilkins, Baltimore, 1993.)

88 Clinical Cases in Physical Therapy

The patient developed an infection 3 weeks

after surgery and was readmitted to the local

hospital for a 3-day course of intravenous

antibiotics and surgical debridement of the

infection. Radiographs at the time revealed

initial healing of the fractures but with several

areas of malunion. The ankle joint space

appeared to be maintained at this time.

The physician extended the restrictions of

no ROM and no weight bearing for an

additional 4 weeks.

The external fixator was removed at 12 weeks,

and the patient was placed in a removable

walking cast brace, but remained non–weight-

bearing. The patient was eventually referred for

outpatient physical therapy 14 weeks after the

initial surgery. The prescription read: “begin

PROM of the ankle, gait training @ 10% of body

weight through involved LE, AAROM for DF

and PF only for the first 3 weeks, and general

full body strength and conditioning program.

Avoid excessive traction or compression through

the involved extremity!”

What clinical signs and symptoms would

lead the examiner to believe a compartment

syndrome may have been developing?

ExaminationH I S T O R YThe patient was a 39-year-old male, marriedwith three children ages 3, 6, and 10 years.He was employed full time as a mail carrierand walked 5 to 8 miles per day on his route,which he described as moderately hilly. Hismail route had more than 500 stops. He wasa member of the Postal Workers Union; theUnion did not offer light duty for his position.He supplemented his income by officiatinghigh school football and track one to threetimes per week. His wife had a high schooleducation and had been staying at home withtheir youngest son. Since the initial homevisit the patient had gained 15 pounds. Hewas ambulating non–weight-bearing on theinvolved extremity and used axillary crutches,but admitted he had not been walking morethan 200 feet at a time since the injury andhad for the most part avoided stairs.

He reported pain at 6/10 (0, no pain; 10,worst pain) in the involved lower extremitywhen it was in a dependent position for morethan 10 minutes. He described the pain as ageneral ache or pressure. He expressed con-cern over the strange sensations that he hadbeen feeling in the involved leg anddescribed them as itching, burning, cold, orhot, but he was not able to associate any ofthe feelings with any particular activities orpositions. There was significant atrophythroughout the involved lower extremity. Allincisions appeared to be well healed, with nodrainage present.

Blue to reddish-purple mottling was notedwith the involved extremity in a dependentposition. When moved to a supported position,the extremity returned to a healthy pinkcolor within a few minutes.

The patient was taking Advil or Alleve forthe pain, which reportedly provided somerelief. The patient stated he was anxious toprogress with weight bearing so that he couldreturn to work. His employer could hold hiscurrent position as a mail carrier for only 2months. The patient’s and family’s under-standing of the patient’s severity of injury andthe need to adhere to restrictions appearedto be a concern.

S Y S T E M S R E V I E WThe results of a systems review wereunremarkable.

T E S T S A N D M E A S U R E SROM and strength of the uninvolved extremi-ties were within normal limits as describedin standard texts.2-5 The involved extremitywas slightly limited for knee flexion, with110/115 degrees, and extension, with –5/0degrees active/passive (A/P) range of motion.Ankle motion A/P was limited to 5 degreesof plantarflexion from neutral. There wasno dorsiflexion past neutral and no measur-able inversion or eversion. Vital signs3,4,7

were stable. Circulation3-5,7 was impaired inthe involved extremity in dependent posi-tions, with lower extremity swelling andmottling within 10 minutes of placement ina dependent position. The patient also

complained of paresthesias with the onsetof swelling and discoloration. Sensation3-5,7

was intact for the uninvolved extremity butinconsistent for the involved extremity independent versus elevated positions withlight touch. Gait with crutches was inde-pendent on level surfaces for short dis-tances, less than 200 feet, secondary toreported paresthesias in the lower leg. Thepatient required contact guard on stairs withcrutches because of difficulty coordinatingmovements at the time of the initial examina-tion.3-5 The patient was independent in per-formance of activities of daily living andIADLs.3,4

EvaluationP R O B L E M S ( F U N C T I O N A LL I M I TAT I O N S A N DI M PA I R M E N T S )1. The patient was the sole provider for his

family. He was not able to return to workuntil fully recovered. Given the type andseverity of his injury, he would be out ofwork between 4 and 8 months.3,4

2. Decreased activity level. The patient hadnot been active since the initial injury,which had resulted in decreased cardio-vascular endurance, weight gain, andmuscle atrophy.3,4

3. Potential for limited return of ROM andstrength in the involved extremity.1,2

4. Motivation. The patient was anxious toreturn to work, which would help withcompliance with the exercise program;however, he did not fully understand theneed to allow proper healing to occur.3

5. Neurovascular signs and symptoms. Thepatient needed to be monitored closelyto avoid development of complicationscommonly associated with pylon frac-tures.1-3,5,6

DiagnosisPhysical Therapist Practice Pattern 4I:Impaired Joint Mobility, Motor Function,Muscle Performance, and Range of MotionAssociated with Bony or Soft Tissue Surgery.

Compartment syndrome was ruled outbecause of the reduction of symptoms withchange of position.

Prognosis (including planof care)Over the course of 1 to 8 months, the patientwill demonstrate optimal joint mobility, motorfunction, muscle performance, and ROM andthe highest level of functioning in home,work (job/school/play), community, and leisureenvironments. The expected number of visitswas between 6 and 70.3,4

P H Y S I C A L T H E R A P Y P L A NO F C A R EThe long-term goals (2 months) of physicaltherapy were to prevent complications andrestore maximal function in the involvedextremity. Short-term goals (1 to 2 weeks)included patient and family education andfacilitation of healing through symptommanagement and initiation of therapeuticinterventions using controlled forces.

Based on the initial examination findings,

what type of activities and positions were

most beneficial for exercise?

Might this patient have benefited from

any other services?

InterventionAquatic therapy was used initially to allowthe patient to work on gait training, stretch-ing and AAROM.3,4,7,8 The principals of buoy-ancy were used to limit weight bearing(deeper water for less weight bearing) andto facilitate ROM in the hip, knee, and ankleby changing the position of the extremity inthe water.

A portion of each session was spent onpatient and family education related to healing,and the need to adhere to weight-bearing limi-tations and proper performance of exercises.3,4

Manual techniques as described by Kisnerand Colby9 and O’Sullivan and Schmitz3 wereused to facilitate (P/A/AA) ROM and stretching

Case 20 89

for the involved extremity. Exercises wereinitiated in an elevated position to aid venousreturn. By the fourth week of treatment, thepatient gained control of the muscles in theinvolved extremity. The time to onset ofparesthesias, edema, and discoloration in theinvolved extremity when in dependent posi-tions increased so the exercise positions wereprogressed to more-dependent positions.

Cardiovascular activities included the useof an upper-body ergometer initially. Thepatient was also able to swim using only armstrokes at first, progressing to straight legkicking and eventually to whip kicks. He wasprogressed to a stationary bike at approxi-mately 4 weeks as ROM improved and weightbearing increased. After 8 weeks of treatment,the patient received clearance to beginambulation on a treadmill.3,4,7,8

The patient was referred to other healthcare providers, including a social worker,psychiatrist, and vocational counselor.

OutcomeAt the time this case was reported, thepatient was 7 months postinjury and was stillreceiving physical therapy. He was ambulatingwith a cane for distances up to 1.5 miles. Hestill had significant limitations in ankle ROM

and fluctuating edema in the lower leg andfoot. He had not yet returned to work buthad entered a job-retraining program.

R E F E R E N C E S

1. Netter FH: The Ciba collection of medical

illustrations, vol 8, musculoskeletal system.

Part III: trauma, evaluation, and management,

Summit, NJ: Ciba-Geigy, 1993.2. Placzek JD, Boyce DA: Orthopedic physical

therapy secrets, Philadelphia: Hanley & Belfus,2001.

3. O’Sullivan SB, Schmitz TJ: Physical rehabili-

tation assessment and treatment (ed 4),Philadelphia: FA Davis, 2001.

4. American Physical Therapy Association: Guideto physical therapist practice, second edition,Phys Ther 81:9, 2001.

5. Evans RC: Instant access to orthopedic physical

assessment, St Louis: Mosby, 2002.6. Goodman CC, Snyder TE: Differential diag-

nosis in physical therapy (ed 3), Philadelphia:WB Saunders, 2000.

7. Bates A, Hanson N: Aquatic exercise therapy,

Philadelphia: WB Saunders, 1996.8. Ruoti RG, Morris DM, Cole AJ: Aquatic

rehabilitation, Philadelphia: Lippincott, 1997.9. Kisner C, Colby LA: Therapeutic exercise foun-

dations and techniques (ed 3), Philadelphia:FA Davis, 1996.

90 Clinical Cases in Physical Therapy

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Assess information from the interview of a patient with paresthesias inthe upper extremity and identify the most pertinent information.

2. Identify which aspects of a postural examination and upper quarterscreen are likely to provide the most pertinent information whenperforming a physical examination.

3. Decide which special tests may be most helpful in making an accuratediagnosis.

4. Decide which intervention may be most appropriate for this patient.

Examination and EvaluationH I S T O R YThe patient was a 37-year-old female with adiagnosis of right carpal tunnel syndrome. Shereported pain and intermittent paresthesiasin her right hand that developed over the pastthree months. She also reported difficultyusing her hand to perform household choresas well as in her job in a factory. She statedthat her hand easily tired and she oftendropped objects. The pain and paresthesiaswere described as being primarily in thethumb and the second and third fingers. Shestated that the pain and paresthesiasoriginally began after she used a new pieceof equipment at work that required her tofrequently turn knobs that she found difficultto turn. The patient continued to work. Sherequested to be transferred to a differentpiece of equipment at work, but her requestwas denied.

The patient reported a past medicalhistory of a motor vehicle accident 2 yearsearlier in which she injured her neck. Shewas seen by a physical therapist three timesper week for 2 months. She reported stillhaving some residual stiffness in her neck,especially in the mornings. Further, she notedhaving similar symptoms in both handsduring her last pregnancy 4 years earlier. Thosesymptoms lasted for several months after thepregnancy and then slowly dissipated. (Carpaltunnel syndrome is common during preg-

nancy.1) She reported no other significantpast medical history.

The patient wore a neutral wrist splint forthe past 2 weeks at work as directed by herphysician. The purpose of the splint was toreduce stress in the carpal tunnel.2 (The carpaltunnel is least restricted in the neutral posi-tion. Wrist extension of approximately 20degrees, as is commonly seen in a resting orcock-up splint, could produce tension on themedian nerve in the carpal tunnel.) The patientreported that wearing the splint for the last 2weeks did not change her symptoms.

The patient was prescribed Naproxen, 250mg t.i.d., but stopped taking the drug afteronly 6 days because of stomach irritation. Shereported smoking half a pack of cigarettesper day and denied any use of alcohol orrecreational drugs. The patient was a singleparent living in an apartment with two chil-dren ages 7 and 15 years. She worked in afactory that produced plumbing fixtures.

What parts of the interview were most

significant in determining the course

of the physical examination?

The pattern of paresthesias appeared to bemost closely associated with a median nervedistribution. Other possible sources of pares-thesias in the hand, such as injury to nerveroots or other peripheral nerves or diabeticneuropathy, must be ruled out.3,4 Determina-tion of the source of paresthesias should be

91

Case 21

92 Clinical Cases in Physical Therapy

clarified with sensory testing. Because of thepatient’s past medical history associated withthe motor vehicle accident, cervical spineinvolvement must be ruled out. If the mediannerve was involved, it must be determinedwhere that involvement has occurred.

What areas should be examined concerning

the type of work that the patient performed?

Further questions concerning the new pieceof equipment revealed that the patient usedthis piece of equipment most of the day. Theequipment required her to often turn a knob,with her right hand, in a counterclockwisedirection, against resistance. She also com-plained of pain and fatigue in her forearmand hand and paresthesias in her hand by theend of the day.

P H Y S I C A L E X A M I N AT I O NThe patient was 5 feet 8 inches tall andweighed 140 pounds. She presented in stand-ing with a mild forward head position and mildthoracic kyphosis. An upper-quarter screen5

revealed that cervical range of motion wasmildly limited in extension and rotation bilat-erally. There was no complaint of symptomswith either motion or pressure. All upperextremity motions were within normal limits(WNL), with no complaint of symptoms withmotion or overpressure. All resisted iso-metrics in the upper extremities were foundto be strong and painless. A dermatome scan was normal in all regions of the upperextremities, except that the patient reporteddecreased sensation on the palmar side ofthe first, second, and third fingers of theright hand. Deep tendon reflexes were foundto be normal and symmetrical for the biceps (C5), brachioradialis (C6), and triceps(C7) muscles.

What was determined from the findings

of the upper-quarter screen?

The results of the upper-quarter screenappeared to rule out the cervical spine as asource of her symptoms. No symptoms were

reproduced with cervical motion or pressureto the cervical spine. The sensory changesidentified did not appear to be in a particularnerve root pattern, such as C6 or C7, becausethere was no loss of sensation in the forearm.The sensory pattern appeared to be that ofthe median nerve.

What other tests were required to clarify

the extent of median nerve involvement

and where?

The dermatome scan was not specific enoughto enable detection of the involvement ofmuscles innervated by the median nerve,muscles innervated by other nerves, or thelocation of involvement. Careful sensorytesting and manual muscle testing wastherefore required.

More careful testing of the sensory patternconfirmed involvement of the median nerve.The patient was found to have paresthesiasin the palmar surface of the first, second, andthird fingers and the radial half of the fourthfinger, as well as on the dorsal surface of thedistal ends of the same fingers. Sensationwas normal in the rest of the hand and in theforearm. Sensory loss resulting from diabeticor alcoholic neuropathy would tend to be inmore of a “glove” pattern, involving all thefingers of the hand, and generally not in aspecific nerve pattern.3

The amount of sensory loss can beclinically measured using a static two-pointdiscrimination test, a moving two-point dis-crimination test, the Semmes-Weinsteinmonofilament test, or vibratory sensationtesting.4 The Semmes-Weinstein monofila-ment test was used for this patient. Testresults revealed that the patient’s sensoryloss was moderate in nature (she was able todetect the sensation from a 2.83 monofilament)and confined to the regions of the hand inner-vated by the median nerve.

Sensory testing confirmed median nerveinvolvement. The median nerve was deter-mined to be intact, however, because thepatient had some sensation in that nervedistribution.

How could it have best been determined

where the median nerve was involved?

Motor function of the median nerve wasassessed to determine the location of mediannerve involvement. Manual muscle testingrevealed that all muscles innervated by theulnar and radial nerves were 5/5. Results ofMMT of muscles innervated by the mediannerve were determined to be as follows:• Pronator teres, 5/5• Flexor carpi radialis, 5/5• Flexor digitorum superficialis, 5/5• Flexor digitorum profundus (to second

and third fingers), –3/5 • Flexor pollicis longus, –3/5• Abductor pollicis brevis, –3/5• Flexor pollicis brevis, –3/5

Manual muscle tests determined that themedian nerve was involved, but not all mus-cles innervated by the median nerve sustainedinvolvement. It was determined that musclesinnervated by the median nerve distal to thecarpal tunnel were involved, as were severalmuscles innervated by the median nerve proxi-mal to the wrist. This finding helped rule outthe carpal tunnel as the primary source of thepatient’s symptoms. Both the sensory loss tothe lateral three fingers and muscle weaknesswould explain why the patient reporteddropping objects and having difficulty per-forming tasks at home and work.

What special tests could have been

performed to more clearly identify the

source of the patient’s problem?

Upper limb tension tests were performed.The test using the median nerve bias repro-duced the patient’s symptoms.6 Tinel’s sign7

at the wrist and at the upper palmar forearmwas positive. (To elicit Tinel’s sign, theexaminer taps along a nerve trunk; a positiveTinel’s sign involves reproduction of pares-thesias within the sensory distribution of thenerve in question. Tinel’s sign can be positivedistal to any point along which the nerve hasbeen affected.)

What was the potential value of isometric

testing in ascertaining the source of the

patient’s problem?

Resisted isometric testing of the forearmreproduced the patient’s symptoms withrepeated resisted pronation but not repeatedsupination. The median nerve passes into theforearm between the two heads of the prona-tor teres.8 Repeated resisted pronation mayresult in hypertrophy of the pronator teres andcompression of the median nerve betweenthe two heads of that muscle. The pronatorteres, flexor carpi radialis, and flexor digi-torum superficialis are all innervated by themedian nerve proximal to the nerve travelingbetween the two heads of the pronator. Theflexor digitorum profundus to the secondand third fingers and the flexor pollicislongus are innervated distal to the mediannerve passing between the two heads of thepronator, as are the muscles of the handinnervated by the median nerve (abductor pol-licis brevis, flexor pollicis brevis, opponenspollicis, and first and second lumbricales).

The sensory pattern would be the samewhether the nerve was compressed betweenthe two heads of the pronator or in the carpaltunnel. The weakness in the hand musclesinnervated by the median nerve would also bethe same whether the nerve was compressedbetween the two heads of the pronator or inthe carpal tunnel. The main difference con-sidered in determining whether the mediannerve was being compressed in the carpal tun-nel or between the two heads of the pronatorwas the weakness found in the flexor pollicislongus and flexor digitorum profundus to thesecond and third fingers.9 The upper limbtension test confirmed that the median nervewas involved, but the Phalen’s and reversePhalen’s tests confirmed that the mediannerve was not primarily affected at the wrist.

The physical therapy diagnosis was con-firmed with an electromyogram (EMG) andnerve conduction velocity (NCV) test. TheEMG determined that all muscles in the handinnervated by the median nerve were affected,

Case 21 93

whereas the muscles innervated by the ulnarnerve were not affected. The flexor digitorumprofundus to the second and third fingersand the flexor pollicis longus were affected,and all other muscles in the forearm werenormal. The NCV test showed slowing alongthe medial nerve from a point beginning justdistal to the elbow.

What was a logical course of intervention

for this patient?

Diagnosis Physical Therapy Practice Pattern 5F: ImpairedPeripheral Nerve Integrity and Muscle Per-formance Associated with Peripheral NerveInjury.

PrognosisG O A L S1. The patient will demonstrate control of

small objects with her right hand withoutdropping them, so that she can performdressing and household tasks, within 3weeks.

2. The patient will display 5/5 muscle strengthin all muscles innervated by the mediannerve, so that she can perform all worktasks, within 4 weeks.

InterventionA key strategy to ensure a successful inter-vention was to arrange for the patient to resther right upper extremity from resistedpronation. Frequent resisted pronation causedhypertrophy of the pronator teres, resultingin compression of the median nerve as itpassed between the two heads of the muscle.Ice and pulsed ultrasound over the pronatorteres region was used to decrease inflamma-tion. The patient also benefited from gentlestretching of the pronator teres and mobiliza-tion of the median nerve.10 A gentle gliding ofthe median nerve freed up motion of themedian nerve, enhancing the nerve’s abilityto glide between the two heads of the pronator

teres muscle. Care was taken not to stretchthe nerve too aggressively. Symptoms shouldnot be exacerbated during treatment. Exces-sive tension could further damage the nerve,resulting in further disability to the patient.

The patient was instructed to ice her ante-rior forearm at home after work and gentlystretch into elbow extension, supination, andwrist flexion to glide the median nerve. Shewas instructed not to cause any reoccurrenceof paresthesias while doing her exercisesbecause this was a sign that she was stretch-ing too aggressively and possibly irritatingthe nerve.

OutcomeFinally, the patient was permitted to switchto a different piece of equipment that did notrequire her to perform resisted pronation. Asa result, she was able to continue working.On her breaks, she applied ice to her forearmjust below the elbow three times per day. Shewas also seen in a local outpatient physicaltherapy clinic three times per week for 3weeks. The patient made a full recovery,which included a return of normal sensationand strength of the right upper extremity.

R E F E R E N C E S

1. Jacobs JL: Hand and wrist. In Richardson JK, Iglarsh ZA (eds): Clinical orthopedic

physical therapy, Philadelphia: WB Saunders,1994.

2. Coppard BM, Lohman H: Introduction to

splinting: a clinical-reasoning and problem-

solving approach (ed 2), Philadelphia: Mosby,2001.

3. Emanuele NV, Emanuele MA: Diabetic neu-ropathy: therapies for peripheral and auto-nomic symptoms, Geriatrics 52:40, 1997.

4. Tan AM: Sensibility testing. In Stanley BG,Tribuzi SM: Concepts in hand rehabilitation,Philadelphia: FA Davis, 1992.

5. Hertling D, Kessler RM: The cervical-upperlimb scan examination. In Hertling D, KesslerRM (eds): Management of common muscu-

loskeletal disorders (ed 3), Philadelphia:Lippincott, 1996.

94 Clinical Cases in Physical Therapy

6. Kleinrensink GJ, Syoeckart R, Mulder PG, et al: Upper limb tension tests as tools in the diagnosis of nerve and plexus lesions:anatomical and biomechanical aspects, Clin

Biomech 15:9, 2000.7. Magee DJ: Orthopedic physical assessment

(ed 3), Philadelphia: WB Saunders, 1997.8. Rosse C, Gaddum-Rosse P: Hollenshead’s

textbook of anatomy, Philadelphia: Lippincott-Raven, 1997.

9. Gerstner DL, Omer GE: Peripheral entrap-ment neuropathies in the upper extremity.Part 1: Key differential findings, median nerveneuropathies, J Musculoskel Med 3:14, 1988.

10. Elvy RL: Treatment of arm pain associatedwith abnormal brachial plexus tension, Aust

J Physiother 32:225, 1986.

Case 21 95

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Assess the information from the interview of a patient with anterior thighand medial knee pain and identify the most pertinent information.

2. Identify which aspects of a postural examination and lower quarterscreen are likely to give the most pertinent information when performinga physical examination.

3. Decide which special tests may be most helpful in making an accuratediagnosis.

4. Decide which intervention may be most appropriate for this patient.

ExaminationH I S T O R YThe patient was a 59-year-old male who hada primary complaint of right anterior thigh andmedial knee pain. He reported that the painhad increased gradually over the past 3 monthsand had become significantly worse within thepast 2 weeks. He stated that the pain was mostsevere in the morning and gradually dissipatedthroughout the day. He had difficulty fallingasleep because the right thigh and knee pain,and occasionally low back discomfort wouldwake him at night. He was employed as a heavy-equipment operator on a construction site.

The patient reported injuring his low backon the job on several occasions in the past.The most recent injury occurred 5 yearsearlier. Immediately after each injury, he wasreferred to physical therapy. Past physicaltherapy treatment included moist heat,ultrasound, massage, and therapeutic exercise.The patient was again referred to physicaltherapy by the company physician, with adiagnosis of quadriceps strain, and was givena prescription for naproxen. The patientreported engaging in recreational bowlingtwo evenings per week, and stated that thepain was worse when he finished bowling.The patient indicated that he was 6 feet 4inches tall and weighed 275 pounds.

What were the key findings from the

interview?

Pain that is worse in the morning and relievedwith activity can be a sign of osteoarthritis.Difficulty with sleep and pain waking apatient at night can indicate pain of nonmus-culoskeletal origin.1 Night pain is much lessof a concern as long as the patient’s symp-toms can be explained with findings onphysical examination. The history of past lowback pain was significant for a possiblesource of his present symptoms. Pain in theanterior thigh may stem from pathology inthe anterior thigh, lumbar spine, or knee ormay be referred from the hip area.1 Physicalexamination should address each of thesepossibilities.

With all of those possible sources of the

patient’s symptoms, where was the best

place to begin the examination?

The examination began with a postural assess-ment and a lower quarter screen. This typeof examination helped to rule out sources ofthe patient’s symptoms.2

P H Y S I C A L E X A M I N AT I O NThe lower screen examination2 revealed thatthe patient was limited in all directions oflumbar mobility (flexion, extension, side-bending right and left, and rotation right andleft). He complained of stiffness in the lowback with each of the motions but reportedthat none of the motions reproduced his rightlower extremity pain. The motions were

97

Case 22

98 Clinical Cases in Physical Therapy

repeated with overpressure applied at theend range. Overpressure did not reproducethe symptoms in the thigh or knee. Multiplerepetitions of each motion were then per-formed, also with no reproduction of symp-toms. A dermatome scan was negative.

Resistive isometric examination2 revealedthat all muscle groups, including the quadri-ceps, were strong and pain free. Manualmuscle testing of the quadriceps revealed astrength score of 5/5. Neither palpation ofthe quadriceps muscle or tendon reproducedany pain.

The patient was unable to do a squat with-out pain and tended to lean toward the left.Hip abductors on the right were found to be4/5. Hip adductor, extensor, and flexor strengthwas found to be 5/5. Screening of lowerextremity range of motion revealed limitedmobility actively and passively in right hipflexion, abduction, internal rotation, andextension. All other lower extremity motions,including those of the right knee, were withinnormal limits and pain free. The right hipjoint was limited in a capsular pattern3 (flex-ion, abduction, internal rotation, extension)with a capsular end feel.4 These two findingswere indicative of a tight hip joint capsule.

What was concluded from the results of the

examination thus far?

The lumbar screen appeared to rule out thelumbar spine as a source of the patient’ssymptoms.2 A finding of strong and pain free,with resisted isometric testing of the quadri-ceps, was an indication that the muscle,tendon, or where the tendon attaches to the bone was not involved in the pathology.2

The patient’s inability to do a squat may beindicative of decreased mobility, pain,weakness, or a balance deficit in the lowerextremities.2

When presented with these findings,

what other special tests were then most

appropriate?

Based on the patient’s symptoms, Faber’s testwas performed. This test involves positioning

the patient supine with the knee flexed andthe foot on the opposite tibia, then passivelyflexing, abducting, and externally rotatingthe hip. The test leg falling to the level of theopposite leg indicates a negative test.5 Thetest revealed that the right leg was 4 to 5inches higher than the left leg. The patientcomplained of pain with overpressure of themovement. Restricted motion, as indicatedby the Faber test, may be indicative of tight-ness of the hip adductors, flexors, or hipjoint capsule.

A scouring test was performed. This testinvolved flexing and extending, as well asabducting and adducting, the patient’s hipwhile applying a compression force.5 Thepatient complained of pain, and the examinerfelt irregular movement at the hip joint,indicating possible degenerative changes ofthe joint surface.

A gait analysis was performed. The patientambulated with a lateral lurch to the right.He also ambulated with a slightly flexed pos-ture at the right hip. A lateral lurch may be asign of either hip abductor weakness or aresponse to hip pain.3 Manual muscle tests ofthe hip abductors produced a score of 5/5.

Further examination of the knee revealedthat it was not tender to palpation and thatrange of motion was within normal limits. All ligamentous stability tests were normaland pain free, and meniscal tests werenormal. These findings appeared to rule outthe knee as a possible source of the patient’ssymptoms.

What were the results of the clinical

examination?

The clinical examination appeared to showthat the hip joint was the cause of thepatient’s symptoms. The hip joint is knownoften to refer pain to the anterior thigh andmedial knee.5 The patient’s overall size andwork history, as well as his history ofoperating heavy equipment, may have been acontributing factor to the development of hiposteoarthritis.6

What was a logical course of intervention?

DiagnosisPhysical Therapist Practice Pattern 4D:Impaired Joint Mobility, Motor Func-tion, Muscle Performance, and Range ofMotion Associated with Connective TissueDysfunction.

Prognosis G O A L S1. The patient will be able to put on his

shoes without pain in 2 weeks.2. The patient will be able to ambulate 1000

feet without pain or gait deviation (laterallurch) in 4 weeks.

3. The patient will be able to bowl withoutpain in 6 weeks.

InterventionThe patient’s physical therapy programbegan with riding a stationary bicycle towarm the hip joint capsule and surroundingmusculature.7 After riding the exercise bicycle,the patient was manually stretched by thetherapist into hip flexion, extension, abduc-tion, and adduction to loosen the tight mus-culature surrounding the hip joint.7 The hipjoint was then mobilized, using joint capsuledistraction techniques in an attempt tostretch the joint capsule.7 The patient wasgiven a cane to use in the left hand to decreasethe compressive forces at the right hip joint.3

The patient was instructed in a program oftherapeutic exercise designed to maintainthe increased range of motion and strength.8

He was treated initially three times per weekfor 4 weeks, then two times per week for 2weeks, and finally one time per week for 2weeks. On discharge, he was instructed tocontinue with his home program permanently.He was able to discontinue the use of thecane and return to work after the first 4weeks of therapy.

The strengthening exercises were begunslowly, with minimal resistance. Resistancewas gradually increased over time. Endurancetraining was implemented to help the patientbetter tolerate a full day at work. Endurance

exercises included stationary bicycle riding,free weights, and an offsite swimmingprogram.

OutcomeThe patient reported a gradual decrease inhis pain. His gait improved until the laterallurch was no longer evident. He was thenable to discontinue the use of the cane. He waseducated about the importance of maintain-ing good strength and flexibility of his hip.He was informed that maintaining properstrength and mobility could help to slow theprogression of arthritis in his hip and helphim avoid total hip replacement surgery.9

R E F E R E N C E S

1. Goodman CC, Snyder TEK: Differential diag-

nosis in physical therapy (ed 3), Philadelphia:WB Saunders, 2000.

2. Hertling D, Kessler RM: The lumbosacral-lowerlimb scan examination. In Hertling D, KesslerRM (eds): Management of common muscu-

loskeletal disorders (ed 3), Philadelphia:Lippincott, 1996.

3. Barr AE, Backus SI: Biomechanics of gait. InNordin M, Frankel VH (eds): Basic bio-

mechanics of the musculoskeletal system,Philadelphia: Lippincott Williams & Wilkins,2001.

4. Cyriax J: Textbook of orthopaedic medicine.

Volume I: Diagnosis of soft tissue lesions (ed7), London: Bailliere Tindall, 1979.

5. Magee DJ: Orthopedic physical assessment

(ed 3), Philadelphia: WB Saunders, 1997.6. McKinnis LN: Fundamentals of radiology for

physical therapists. In Richardson KJ, IglarshZA: Clinical orthopedic physical therapy,Philadelphia: WB Saunders, 1994.

7. Kisner C, Colby LA: Therapeutic exercise:

foundations and techniques, Philadelphia: FADavis, 2002.

8. Van Baar ME, Assendelft WJ, Dekker J: Effec-tiveness of exercise therapy in patients withosteoarthritis of the hip and knee, Arthritis

Rheum 42:1361, 1999.9. Salter RB: Textbook of disorders of the

musculoskeletal system (ed 3), Baltimore:Williams & Wilkins, 1999.

Case 22 99

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Assess the information from the interview of a patient with low backpain and lower extremity paresthesias and identify the most pertinentinformation.

2. Identify which aspects of a radiological examination may be most helpfulto a physical therapist in determining accurate diagnosis.

3. Identify which aspects of a postural examination and lower-quarterscreen are likely to give the most pertinent information when performinga physical examination.

4. Decide which special tests may be most helpful in making an accuratediagnosis.

5. Decide which intervention may be most appropriate for this patient.

ExaminationH I S T O R YThe patient was a 62-year-old male with adiagnosis of lumbar strain. He reported that2 weeks earlier, after a week of fly-fishing inMontana, he began experiencing pain in hislow back and intermittent pain and pares-thesias in the right lower extremity to thefoot. The patient reported that the pain wasworse with prolonged standing and prolongedwalking but was relieved with sitting andlying in a fetal position. He denied any feel-ing of weakness in the lower extremities orany bowel or bladder changes.

The patient reported having past bouts oflow back pain in his thirties and forties butno significant bouts for at least 15 years. Hehad often felt stiff in his low back in themornings but usually felt looser as the day pro-gressed. He was employed as a tax account-ant and was concerned because his busyseason was approaching.

Radiographs were ordered by the patient’sfamily physician. Anteroposterior and lateralviews revealed moderate degenerative jointdisease and degenerative disc disease of thelumbar spine. The physician provided a prescrip-tion for Naprosyn, but the patient indicatedthat he took the medication for only 5 days andthen stopped because of stomach irritation.

The patient denied smoking and alcoholabuse. He liked to fly-fish and play cards. Hereported that he was in good health otherthan some mild high blood pressure that wascontrolled with medication. The patientrated his low back pain as 2 on a scale of 0 to10. There were no lower extremity symptomsat that time.

What were the important findings

from the interview and what could

they mean?

The patient’s lower extremity symptomswere intermittent and were consistent withactivities that involve lumbar extensionpostures. His mechanism of injury involvedrepeated lumbar extension (fly-fishing). Heattained relief with activities that involvedlumbar flexion (sitting, lying in a fetalposition). The patient’s age (62) and theradiographic findings of degenerative jointdisease and degenerative disc disease were consistent with the finding that he wasstiff in his low back in the morning and felt less stiff with activity. The adversereaction the patient had to his medication(Naprosyn) did not allow a determination if he would have obtained adequate relieffrom taking a nonsteroidal antiinflammatorymedication.

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102 Clinical Cases in Physical Therapy

P H Y S I C A L E X A M I N AT I O NWhat were the key aspects of the physical

examination?

The examination began with a postural exami-nation and a lower quarter screen. Those pro-cedures helped to rule out certain sources ofthe patient’s signs and symptoms. They alsoassisted the examiner to determine whatspecial tests were most appropriate to nextperform in the physical examination.1

The patient presented with a forward-flexed posture in the lumbar spine. He had amoderate thoracic kyphosis and forward headposition. Trunk forward flexion indicated hewas able to reach his mid tibia. He appearedto present with tight hamstrings judging fromthe lack of anterior pelvic rotation duringforward flexion. Hypomobility was observedthroughout his lumbar spine. He reportedstiffness and an increase in low back painwith forward flexion but no reproduction ofhis lower extremity symptoms. Extension wasmoderately restricted with a slight increasein his low back pain but no change in hislower extremity symptoms. Side-bending rightand left were both moderately restricted withcomplaints of stiffness but no increase in hislower extremity symptoms.

As a result of the findings (no reproductionof symptoms into the right lower extremity),overpressure was applied with each motion.Overpressures failed to reproduce his distalsymptoms but did cause some increase inlow back discomfort. Repeated motions werethen performed for each motion. Repeatedmotions indicated that extension and rightside-bending reproduced his lower extremitysymptoms.1 A dermatome scan was performedand indicated decreased sensation in thelateral lower leg and dorsum of the foot tothe great toe in the L5 dermatome.

Resisted isometrics were performed forhip flexors, knee extensors, knee flexors,ankle dorsiflexors, plantarflexors, and greattoe extension. All motions were strong andpainless except for ankle dorsiflexion andgreat toe extension, which were weak andpainless. Manual muscle testing of dorsiflex-ion and great toe extension revealed strength

scores of 4/5 in these two muscle groups and5/5 in all other lower extremity muscle groups.Deep tendon reflexes of the patellar tendon(L4) and calcaneal tendon (S1) were normal.

What were the results of the postural

examination and lower quarter screen?

Lumbar flexion appeared to be the patient’sposture of choice. His lumbar spine wasrestricted in all planes of motions, but singlemotions did not reproduce his distal symp-toms. Repeated lumbar extension and sidebending toward the right did reproduce hisdistal symptoms. The results of the resistedisometric testing, manual muscle testing, andsensory testing are indicative of possible L5nerve root involvement.

What additional special tests helped

clarify the meaning of the patient’s signs

and symptoms?

Passive mobility testing was performed usingposterior to anterior (PA) pressures with thepatient prone and slightly flexed over apillow. The testing revealed hypomobilitythroughout the lumbar spine but demonstratedno reproduction of lower extremity symptoms.Palpable muscle spasm was noted through-out the lumbar erector spinae musculature.

Straight-leg raising was found to be limitedto approximately 0 to 65 degrees bilaterally,with complaints of tightness of the hamstringmusculature. A lower limb tension test wasapplied to the sciatic nerve with the patientsupine by flexing the hip with the kneeextended.2 This test did not reproduce anylower extremity symptoms. Further tensionwas applied to the sciatic nerve by adductingand internally rotating the hip and finallydorsiflexing the foot. This test was also nega-tive. A lower limb tension test was applied tothe femoral nerve with the patient prone byextending the hip and flexing the knee.2 (It isimportant that the lumbar spine be kept inneutral for this test. If the lumbar spine isallowed to extend, then there may be a repro-duction of distal symptoms due to a closingof the intervertebral foramen impinging on a

nerve root and not from tension of thefemoral nerve.) This test was also negative.The patient complained of tightness in therectus femoris, but reported no paresthesias.

Gait analysis revealed that the patientambulated in a forward-flexed lumbar spineposture. When asked to ambulate with amore upright posture, he complained of rightlower extremity paresthesias after walkingapproximately 50 feet.

What information was derived from the

special tests performed?

Lower limb tension testing determined thatapplying tension to the sciatic nerve andfemoral nerve did not reproduce the patient’ssymptoms. At the time of the test, it appearedthat he did not have impingement of either ofthese nerves. He was found to have tightnessof the hamstrings and rectus femoris muscles.He ambulated with a forward-flexed lumbarposture. Ambulating in an upright, lumbar-extended posture reproduced his symptoms.It appeared that in lumbar extension, with thelumbar intervertebral foramen more closed, thepatient would experience his distal symptoms.

What could have been the potential source

of the patient’s problem?

The patient’s history of the onset of his symp-toms after fly-fishing led to the possibilitythat repeated extensions was the possiblecause of his back pain and lower extremityparesthesias. Extension also appeared to beinvolved with the patient’s complaint ofworsening of his symptoms with standingand walking and easing of the symptomswith sitting and lying in a fetal position.Radiographs showed degenerative jointdisease and degenerative disc disease. Thatfinding is often related to lateral spinalstenosis.3 Additional radiographs of a lateralview in full lumbar extension might haveshown the size of the intervertebral foramenwas significantly reduced when the lumbarspine was fully extended.

If the patient’s lower extremity paresthe-sias stemmed from inflammation of the nerve

root, then there is a strong possibility that hemay have gotten some relief from a non-steroidal antiinflammatory drug such asNaprosyn. The patient’s reported side effectof stomach irritation, however, is a commonproblem associated with nonsteroidal antiin-flammatory medications.4

Because of the patient’s history ofdegenerative joint disease and degenerativedisc disease, it was expected that he wouldhave hypomobility with passive mobility test-ing. The patient ambulated with a flexed lum-bar spine because ambulating in extensionwould have worsened his lower extremitysymptoms. The fact that the patient ambu-lated in forward flexion would cause abnormalstress on the lumbar erector spinae, possiblyleading to strain and spasm in these muscles.

Physical examination confirmed that flexionactivities worsened his lumbar pain butrelieved his paresthesias, whereas extensionactivities worsened his paresthesias. Thisfinding, along with degenerative disc diseaseand degenerative joint disease of the lumbarspine, pointed to lateral lumbar spinal steno-sis as the primary cause of the patient’s symp-toms.5 (Degenerative disc disease, resultingin loss of intervertebral disc height, causesthe size of the lumbar intervertebral foramento become smaller vertically. Degenerativedisc disease, resulting in radial bulging of thedisc, causes a decrease in the size of theintervertebral foramen from anterior toposterior. Degenerative joint disease of thelumbar zygapophyseal joints of the lumbarspine, resulting in hypertrophy of the jointcapsules, causes a decrease in the size of theintervertebral foramen from posterior toanterior. These factors, along with thedecreased size of the intervertebral foramenduring extension could result in nerve rootimpingement with lumbar extension.) Thepatient’s signs and symptoms all appeared toinvolve the right L5 nerve root.

DiagnosisPhysical Therapist Practice Patterns 4F:Impaired Joint Mobility, Motor Function,Muscle Performance, Range of Motion, and

Case 23 103

Reflex Integrity Associated with SpinalDisorders and 5F: Impaired Peripheral NerveIntegrity and Muscle Performance Associatedwith Peripheral Nerve Injury.

PrognosisG O A L S1. The patient will report decreased low

back pain and muscle spasm to 0 on ascale of 0 to 10, so that he may put on hisshoes and bend to pick small objects upoff the floor without pain in 1 week.

2. The patient will no longer experience pain orparesthesias in the right lower extremitywhile standing or walking in 3 weeks.

3. The patient will return to pain and pares-thesias-free fly-fishing in 6 weeks.

InterventionThe patient was seen for physical therapyfour times per week for 4 weeks. Interventionincluded moist heat and massage to relievethe muscle spasm in the lumbar erector spinae.Gentle flexion exercises were given to stretchthe lumbar erector spinae and open the inter-vertebral foramen. The patient was given ahome exercise program of flexion exercises,such as bringing his knees to his chest, trunkcurl abdominal strengthening, and posteriorpelvic tilt exercises. The knee-to-chest stretch-ing exercises were intended to open theintervertebral foramen and keep pressure offthe L5 nerve root. Abdominal strengtheningexercises and posterior pelvic tilts weremeant to help the patient maintain a pos-terior pelvic tilt and keep the intervertebralforamen open. The patient was also instructedto avoid forward-flexed postures to relievestress to the erector spinae and extension

postures, and to avoid impingement of lumbarnerve roots. The patient was instructed tostand and walk in a posterior pelvic tilt. Hisabdominal strengthening program was pro-gressed to an endurance program.

Once the patient’s symptoms were reduced,the patient was instructed in a program tofunction in a posterior pelvic tilt for allactivities to keep his lumbar intervertebralforamen open. This was accomplished byfirst teaching him to attain the posteriorpelvic tilt position and hold it while hechanged postures. He was then instructed inother activities, such as standing and walkingin that position.

OutcomeThe patient’s lower extremity pain and pares-thesias gradually diminished. He was left withsome residual lumbar stiffness that he wasable to control with his home exercises andby avoiding sitting for extended periods.

R E F E R E N C E S

1. Hertling D, Kessler RM: The lumbosacral-lowerlimb scan examination. In Hertling D, KesslerRM (eds): Management of common muscu-

loskeletal disorders (ed 3), Philadelphia:Lippincott, 1996.

2. McRea R: Clinical orthopaedic examination

(ed 4), New York: Churchill Livingstone, 1997.3. McKinnis LN: Fundamentals of orthopedic

radiology, Philadelphia: FA Davis, 1997.4. Ciccone CD: Pharmacology in rehabilitation

(ed 2), Philadelphia: FA Davis, 2002.5. Fritz JM, Delitto A, Welch WC, Erhard RE:

Lumbar spinal stenosis: current concepts inevaluation, management and outcome measure-ments, Arch Phys Med Rehabil 79:700, 1998.

104 Clinical Cases in Physical Therapy

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Discuss reasons to suspect reduced bone density in a selected patient.2. Identify the need for diagnostic imaging in a patient with a suspected hip

fracture.

The reader should know that a 63-year-old obese

woman with paraplegia was referred by a family

physician to a home health agency for physical

therapy. The request was due to a report by the

woman’s daughter that her mother’s right leg was

externally rotated and shortened. In addition, the

daughter stated that she felt her mother was losing

range of motion (ROM) in both lower extremities.

The family physician contacted the agency and

requested physical therapy examination and

intervention. The physician specifically requested

ROM and stretching to both lower extremities.

ExaminationH I S T O R YA review of the patient’s past and presentmedical history revealed that she was obese(5 foot 3 inches and 278 pounds reported) andhad hypertension (HTN), an irregular heartrate, congestive heart failure (CHF), nervepain, osteoporosis, incontinence, and para-plegia. The patient reported a failed spinalsurgical procedure approximately 12 yearsearlier that left her nonambulatory. In dis-cussing the spinal surgery, the patient statedthat she was nonambulatory since the surgery,which resulted in motor and sensory impair-ment in both lower extremities. She also toldthe physical therapist that it was her under-standing that she had suffered a blockage toa spinal artery. On questioning, the patientstated that she had undergone 15 weeks ofin-patient rehabilitation after the spinal surgery,with little success. At the time of history-taking, the patient was dependent on a Hoyerlift for all hospital bed-to-chair transfers.

Positioned near the bed was a TV tray, aswell as a coffee table on which the patient

kept most of her medications. Of the morethan 30 tablet bottles, 20 had been prescribedby either the family physician or psychia-trists who had attended to the patient duringa recent hospital admission for pneumonia.Among the medications were drugs for HTN(verapamil SR 180), irregular heart rate, andCHF. Pain medication included Neurontinand Tylenol 3 or Oxycodone. Additional medi-cation was identified to treat hyperlipidemia(Lipicor), a thyroid condition (Synthroid),bone demineralization (OsCal), a residualcough (Pertussin HC), and Ditropan to assistin controlling incontinence.

A discussion with both the patient and herdaughter revealed that the daughter was theprimary caregiver. The daughter revealedthat because she was employed part time,her mother was home alone approximately 4to 6 hours per day, 3 days per week. Thedaughter said that since her mother had aurinary catheter, the only time she had to bemoved was for bowel movements, for whicha bedpan was used. The daughter also saidthat her mother was moved out of bed, via aHoyer lift, two to three times a week forsponge baths, performed in the living roomwith towels on the floor.

S Y S T E M S R E V I E WVital signs were measured and found to bewithin normal limits.

What specific tests and measures were

appropriate for this patient?

T E S T S A N D M E A S U R E SMusculoskeletal assessment revealed decreasedbut functional ROM in both upper extremi-

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106 Clinical Cases in Physical Therapy

ties. ROM was mildly limited secondary topain at both shoulders and was attributed torecently diagnosed left shoulder bursitis andright shoulder impingement syndrome. Musclestrength in both upper extremities was goodto good+ throughout. The left lower extremityhad passive ROM within functional limitsthroughout. Tightness was noted in the hipflexors and hamstring musculature. The rightlower extremity appeared flexed andexternally rotated.

Passive ROM (PROM) of the left hip andknee were noted to be within functional limits.A left ankle PROM limitation was noted indorsiflexion, lacking 15 degrees from neutral.Strength testing of the left lower extremitywas poor to poor+ throughout (the patientwas able to elicit weak muscle contractionsthroughout). At the hip, the patient was unableto perform a straight leg raise, complete hipabduction, or internally rotate from a fullyexternally rotated position to neutral. At theknee, the patient was unable to completeterminal knee extension or flexion and hadincomplete active movement in both plan-tarflexion and dorsiflexion.

The right lower extremity position (at rest)was observed and recorded as follows: hipflexion approximately 20 degrees, hip externalrotation approximately 30 degrees, and kneeflexion approximately 50 degrees. The patientdenied any pain in the groin, hip, or buttockarea with palpation. She reported a greaterdegree of difficulty moving the right leg versusthe left. She also commented that the rightleg felt heavier and the hip tighter and stiff.

Sensory testing resulted in reporteddeficits throughout the right lower extremity,with no consistency in dermatomes whencompared with the left leg. The patientreiterated the presence of occasional “nervepain” in both legs and feet.

What action was appropriate for the

therapist to take?

EvaluationThe patient’s hip position, as well as her pastmedical history, were of concern to the physical

therapist. Because the list of possible prob-lems included a fractured hip, the therapistcontacted the agency nurse who had com-pleted the home care admission. That nursestated that although she had some “concerns”regarding the patient’s hip position, she keptin mind the patient’s past history and litanyof complaints, as well as the fact that thepatient had stated that the physical therapistwas scheduled to come in later that after-noon. The therapist suggested that there wasa suspicion of a hip fracture.

DiagnosisInsufficient information gathered during thephysical therapy examination to enable iden-tification of a specific practice pattern fromthe Guide to Physical Therapist Practice.

InterventionThe therapist contacted the referring physi-cian, requesting that radiographs be taken ofthe patient’s right hip. The physician statedthat although he had ordered numerousradiographs of this patient over the past 12to 15 months for “suspected” problems, hewould heed the therapist’s advice and ordera mobile radiograph.

A follow-up telephone call to the physician’soffice the next day confirmed the presenceof an oblique fracture through the surgicalneck of the right hip. It was explained thatthe physician, although surprised, wanted toextend his appreciation for the therapist’sphone call the previous day.

Outcome and DiscussionIn this case, the patient’s history was com-plex and necessitated a complete physicalexamination by the physical therapist. Giventhe position of the right lower extremity andthe patient’s history of relative immobility,the therapist wisely suspected hip pathology.Correctly, the therapist recommended diag-nostic imaging.

Having received a definitive diagnosis fromthe physician, the physical therapist discussed

the case with two orthopedic surgeons. Afterhearing specifics of the case, both of thesesurgeons agreed that the patient was not agood surgical candidate, and if they wereconsulted, they would treat the patientconservatively. Both suggested that the hipnot receive ROM or be stretched for at least4 to 6 weeks or until radiographs showedsufficient callus formation to ensure stabilityand strength of the hip.

R E C O M M E N D E D R E A D I N G S

Kottke FJ, Lehmann JF: Krusen’s handbook of

physical medicine and rehabilitation (ed 4),Philadelphia: WB Saunders, 1990.

Hertling D, Kessler RM: Management of common

musculoskeletal disorders (ed 3), Philadelphia:Lippincott, 1996.

Magee DJ: Orthopedic physical assessment

(ed 3), Philadelphia: WB Saunders, 1997.Fagerson TL: The hip handbook, Oxford, UK:

Butterworth-Heinemann, 1998.

Case 24 107

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Identify the need for referral to other health care providers.2. Recognize abnormal findings on an exercise stress test.3. Develop a plan of treatment for a patient in inpatient and outpatient

cardiac rehabilitation.4. Identify patient education issues related to cardiac surgery.

The reader should know that the patient was

a 61-year-old female referred to an outpatient

physical therapy clinic with the diagnosis of

“back pain—evaluate and treat.” She went to her

family physician with a complaint of back pain

when walking for a long time and when doing

household chores. The pain was “mainly

between the shoulder blades.”

Examination andEvaluationThe physical therapy examination was unre-markable, and symptoms were not repro-duced. The patient’s personal medical historyincluded high cholesterol levels, a cholecys-tectomy performed in 1993, postmenopausalfor 7-years, and a family history of heartdisease (her mother died at age 61 of a myocar-dial infarction [MI]). The patient did not par-ticipate in any recreational activity at the time.

Based on a lack of clinical findings, what

would be an appropriate course of action

for the therapist to take?

The patient was referred back to her familydoctor with the results of the physical therapyexamination and history. The therapistsuggested that because the patient’s pain wasnot reproduced and heart disease was acomponent of her family history, that acardiopulmonary assessment be performed.The physician ordered an exercise stress test(EST), which yielded a 3-mm ST segmentdepression in leads V5 and V6, and her systolic

blood pressure dropped 22 mm Hg at stageIII of the Bruce protocol treadmill test.

Of what significance were those EST

findings?

Back pain from the history is a sign ofcoronary artery disease (CAD). Women aretwice as likely as men to describe back painas a symptom before acute MI. The ESTyielded a 3-mm ST segment depression inleads V5 and V6, which is indicative ofischemia. Because this occurred in leads V5

and V6, the left anterior descending andcircumflex arteries should be evaluated forstenosis. In addition, the patient experienceda drop in systolic blood pressure duringexercise. This “exercise-induced hypoten-sion” (drop in systolic blood pressure withan increase in work rate) is seen in indi-viduals with CAD, valvar heart disease,cardiomyopathies, and dysrhythmias. It iscorrelated with myocardial ischemia and leftventricular dysfunction.

The patient was referred to a cardiologist,who ordered a cardiac catheterization. Basedon the findings, the cardiologist recommendedcoronary artery bypass graft (CABG) surgery.One day after the CABG, done via a mediansternotomy approach, the patient was seenby a physical therapist in the intensive careunit. She had a chest tube on her left side, atemporary pacemaker, an arterial line in herright upper extremity, and an arterial oxygensaturation monitor on her right index finger.Further, she was connected to a 12-leadelectrocardiogram (ECG) monitor. Her resting

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110 Clinical Cases in Physical Therapy

vital signs were blood pressure, 132/82 mmHg; heart rate, 88 beats per minute (bpm);and respiratory rate, 16 breaths per minute;oxygen saturation on room air was 96%. Thepatient was referred for inpatient (also knownas phase I) cardiac rehabilitation. Assumingno complications, the patient was scheduledfor discharge to home on postoperative day 5.

DiagnosisPhysical Therapist Practice Pattern 6D:Impaired Aerobic Capacity/Endurance Asso-ciated with Cardiovascular Pump Dysfunctionor Failure.

InterventionIf an assumption was made that the patient

planned to return home, what plan of pro-

gression—when to get out of bed, ambulate,

ascend/descend steps—and what type of

therapeutic exercise would be recommended?

What patient education issues existed?

The plan of care for postoperative cardiacsurgery generally follows a “step” program oran “activity classification.” Excluding anypostoperative complications, her acute carelength of stay would likely be 4 to 6 days. Itis critical that early mobilization occur. Mostof the hemodynamic monitoring lines (e.g.,Swan-Ganz catheter) were discontinued bypostoperative day 1. The patient was moni-tored either by a bedside ECG unit or bytelemetry throughout the hospital stay. Whenthe patient was hemodynamically stable,postoperative day 1 activity included beingout of bed to a chair and sitting up in the chairfor 15 to 30 minutes. She also performed activeROM (AROM) cardinal plane therapeuticexercise while seated, as well as deep-breathing exercises, incentive spirometry,and splinted coughing. On postoperative days2 and 3, the patient was progressed to out ofbed to a chair three times per day and con-tinued therapeutic exercise in sitting orstanding positions. The patient generallywalked up to 50 to 100 feet, and patienteducation focused on sternal precautions,

avoiding the Valsalva maneuver, and riskfactor modification. On postoperative days 4to 6, the patient walked more than 200 feetand ascended and descended steps. In thiscase, an exercise tolerance test was performedbefore the patient was discharged. Patienteducation focused on guidelines for a safeand effective home exercise program (HEP)and a discussion about outpatient cardiacrehabilitation.

What were some HEP considerations?

Guidelines for safe activity in the acute careprogram and the HEP will vary depending onsuch factors as medications and results ofexercise testing. In general, patients shouldbe asymptomatic, with a heart rate limited toresting rate plus <30 bpm. Clinicians oftenuse the rating of perceived exertion (RPE)scale to judge appropriate intensity, which isuseful for patients taking medication thatblunts their heart rate (e.g., beta blockers).An RPE of <13 is recommended. The HEPshould be geared toward increasing activity,with a goal of achieving 10 to 15 minutes ofcontinued ambulation. Therapeutic exerciseshould continue with cardinal plane AROMwithout resistance. Patient education shouldfocus on avoiding prolonged overhead reach-ing, which will increase stress on the healingsternum and also place additional workloadon the heart.

The patient spent 5 days in the hospitaland was then discharged to home. Six weeksafter undergoing CABG surgery, she wasreferred to outpatient cardiac rehabilitation(also known as phase II and III).

Should the physical therapist prescribe

resistance exercises? If so, what exercise

prescription—type of exercise, frequency,

intensity, repetitions/sets, and any

precautions—would be discussed with

the patient?

Resistance exercise was an integral part ofthis patient’s cardiac rehabilitation program.Light Theraband and cuff weights (1 to 3pounds) were initiated early in the outpatient

program. However, traditional strength train-ing was delayed until 3 months after thesternotomy, and the sternum was assessedfor stability by an experienced health careprovider before initiating weight training. Ingeneral, patients participate in outpatientcardiac rehabilitation focusing on increasingaerobic functional capacity for 6 weeksbefore initiating resistance training. Duringand after the 6 weeks of aerobic training, thepatient was educated on avoiding the Valsalvamaneuver and performed baseline strengthtraining, with a one-repetition maximum (1-RM) program. Resistance exercise focusedon major muscle groups (quadriceps, ham-strings, chest/back, and arms). The resistancewas set at approximately 40% of 1-RM andthe patient performed 8 to 15 repetitions in 1to 3 sets for 3 nonconsecutive days perweek. All exercises were done in a slow,controlled manner without breath holding.To adhere to RPE guidelines, the 1-RM wasreevaluated every 2 weeks, and adjustmentsto the weight load were made.

OutcomeThe patient completed 36 sessions of out-patient treatment over 3 months. On discharge,the patient was independent in recalling hercardiac risk factors and able to complete 40minutes of continuous aerobic exercise 4

days per week. She also performed a circuitweight-training program consisting of fourlower body and five upper body exercisesusing variable-resistance isotonic machinesand dumbbells. She understood the impor-tance of adding resistance, and by the end ofthe 3 months was performing 60% of her 1-RM for 2 sets of 8 to 15 repetitions for eachof the exercises on 3 nonconsecutive days.She immediately joined a local health club tocontinue the exercise program as a means ofpreventing future cardiac problems and toimprove overall health.

R E C O M M E N D E D R E A D I N G S

ACSM: Guidelines for exercise testing and

prescription (ed 6), Baltimore: Williams &Wilkins, 2000.

American Heart Association: Science advisory:resistance exercise in individuals with andwithout cardiovascular disease, Circulation

101:828, 2000.Beniamini Y, Rubenstein JJ, Faigenbaum AD, et al:

High intensity strength training of patientsenrolled in an outpatient cardiac rehabilitationprogram, J Cardiopulm Rehabil 19:8, 1999.

Hillegass EA, Sadowsky HS: Essentials of cardio-

pulmonary physical therapy (ed 2),Philadelphia: WB Saunders, 2001.

Verrill DE, Ribisl PM: Resistive exercise trainingin cardiac rehabilitation: an update, Sports

Med 21:347, 1996.

Case 25 111

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Identify the appropriate rehabilitation management strategy (physicaltherapy and prosthetic assessments, interventions, and follow-up) for achild with traumatic amputation over the continuum of his care.

2. Describe how cognitive and behavioral recovery after traumatic braininjury may affect prosthetic rehabilitation.

3. Incorporate understanding of a child and a family’s response to a life-altering traumatic event into a physical therapy plan of care.

4. In a multidisciplinary team, select the appropriate prosthetic componentsfrom among available options, and determine the effectiveness ofprosthetic fit and alignment (static and dynamic).

5. Discuss the collaborative roles of outpatient and school-based physicaltherapy in facilitating a child’s return to the educational setting aftertraumatic amputation.

ExaminationH I S T O R YThe patient was a 7-year-old boy who was 5weeks status post multiple traumatic injuriessustained in late September in a car–bicycleaccident on the street in front of his home.He suffered severe crush injuries of the distallower extremities, closed-head injury, rupturedspleen, and multiple abrasions. He was flownby medical helicopter to the regional pedi-atric trauma center, a 45-minute drive fromhis home. In the emergency room, his Glasgowcoma score was 9 (eye opening, 3 to speech;best motor response, 4 withdraws; verbalresponse, 2 incomprehensible sounds). Onfurther evaluation of his condition in theemergency room, the trauma team determinedthat amputation and splenectomy werenecessary. In the intensive care unit (ICU)after surgery, the patient’s breathing wassupported by synchronized intermittentmandatory ventilation (SIMV) for 24 hourswhile he was kept sedated. Postoperatively, acourse of intravenous broad-spectrum anti-biotics was started to reduce the risk ofinfection of his residual limbs.

After 5 days in the ICU, the patient wastransferred to the pediatric rehabilitation unit

for cognitive status assessment, functionalmobility training, and preprosthetic assess-ment. He was discharged to home with awheelchair and appropriate adaptive equip-ment in mid-October, after a 3-week hospitalstay. After discharge, he returned to the hos-pital for continued rehabilitation on an out-patient basis three times per week. His initialprostheses were fitted and delivered, andearly prosthetic training begun. He preparedto return to school in mid-November. Hecontinued with functional prosthetic trainingon an outpatient setting and was scheduledfor evaluation by the school-based physicaltherapist to facilitate reentry into school-related activities.

Before his injuries, the patient was a healthyand active 7-year-old, the oldest of threechildren in his family. His mother worked athome as a graphic artist for an advertisingagency, and his father commuted by train tohis office job in a nearby city. The patientwas in the second grade at his suburban ele-mentary school and was an active participantin the town’s soccer and baseball leagues. Healso had been active in Cub Scouts andparticularly enjoyed woodworking activities.The family lived in a two-storey home with

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bedrooms and a full bathroom upstairs. Thehome had three steps, with no railings, toenter the house from either the garage orfront door entries.

S Y S T E M S R E V I E WCognitive status. When the patient returnedhome, he was functioning at Rancho LosAmigos cognitive level 7, automatic-appro-priate, demonstrating mild distractibility,mild emotional lability with reduced toler-ance to challenging or stressful situations,mild learning/memory impairment, and somedifficulty with problem solving, planning, andorganization skills. Language comprehensionand expression were intact. Although thepatient was anxious to regain his independ-ence and walk with his prostheses, he reliedheavily on the encouragement and support ofhis parents and therapists. He often displayedanxiety about falling and quickly sought out-side assistance from his caregivers in activi-ties that he perceived to be overly challeng-ing in terms of his standing balance. Hisfrustration level fluctuated, and his desire toreturn to soccer or baseball was a motiva-tional tool at times. His emerging sense ofself when compared with classmates helpedto raise his anxiety about returning to school.He resisted the idea of using his wheelchairat school and had several outbursts relatedto this issue.

Neurologic status. The mild to moderatevestibular impairment present during thepatient’s early in-patient rehabilitationresolved. No other residual neurologic impair-ments were noted, although deep tendonreflexes at the quadriceps were brisk. Thepatient’s awareness of limb position in spaceat the hip and knee appeared to be intact.Somatosensation (pain, temperature, andtouch) was also intact, except in areas ofsplit-thickness skin grafts on the lateral thighand knee of the right residual limb. He hadmild paresthesias with some hypersensitivityadjacent to the suture line bilaterally. Hereported fairly consistent phantom sensation(deep cramping in the calf on the left, itchytoes on the right) that decreased in intensitywhen compression garments were reapplied.

Integumentary status.

The patient’s splenectomy incision was wellhealed, as were the abrasions on his face,arms, and trunk. There was a healed 2- × 4-inch split-thickness skin graft (used to closedeep abrasion) on the right lateral thigh andknee, as well as a well-healed donor site onthe left anterior thigh.

The patient had a standard-length (5-inch)posterior flap transtibial amputation on theright. In his early prosthetic training, aquarter-inch area of dehiscence (with slightserosanguinous drainage) developed at themost-medial suture line; it was held closedwith Steri-Strips. His surgical scar otherwisehealed well and was mobile, with no obviousareas of adhesion. His residual limb was wellshaped, with no redundant tissue. He had ashort (3-inch) “fish mouth” closure transtibialamputation on the left. There was a “dimple”skin fold 11⁄2 inches from the lateral edge ofhis incision. The incision healed well, wasmobile, and had no obvious areas of adhe-sion. There was an area of persistent rednessover the distal anterior residual tibia.

What types of measurable data should be

gathered?

Volume control and protection of bothresidual limbs was managed with compres-sive shrinker garments (to mid-thigh) andremovable rigid dressings (which he requiredassistance to don). Circumferential measure-ments of limbs (supine, with knee extended)were as follows:• 2 inches above the proximal border of the

patella: 14.75 inches in the left lowerextremity (LLE); 14.50 inches in the rightlower extremity (RLE)

• At the proximal border of the patella: 13.25inches in the LLE; 13.00 inches in the RLE

• At the distal border of the patella: 13.00inches in the LLE; 13.00 inches in the RLE

• At the proximal tibial tubercle: 13.25inches in the LLE; 13.00 inches in the RLE

• 2 inches below the tibial tubercle: 13.50inches in the LLE; 13.25 inches in the RLE

• 4 inches below the tibial tubercle: 13.25inches in the RLE

Strength and muscle performance.

Strength and muscle performance ratingswere as follows:• Upper extremities: 4 to 4+ throughout,

bilaterally• Trunk: gross abdominal strength 4• Hip flexion, adduction, and rotation: 4

bilaterally• Hip extension and abduction: 4– bilaterally• Knee: LLE extension 4, flexion 4–; RLE

extension 3+, flexion 3+Joint function and range of motion.

On examination, all ligaments of the LLE wereintact. Mild instability of the medial collateralligament of the RLE was noted. There wereflexion contractures (5 degrees LLE, 8 degreesRLE) with firm end feels. The patient wasable to actively flex to 120 degrees in theLLE and to 105 degrees in the RLE. Activeexcursion of straight leg raise was 95 degreesin the LLE and 85 degrees in the RLE.

Endurance. The patient described a rateof perceived exertion of 7 during ambulationactivities and 9 during stair-climbing activities.Mild deconditioning was noted with anincreased respiratory rate of 24 breaths perminute (bpm) during ambulation (baselinerate, 21 bpm at rest).

Postural control. Static postural controland anticipatory postural changes were intactin sitting in all directions. Equilibrium reac-tions and protective responses appeared tobe intact in static sitting, with occasionalloss of balance (backward) with moderatelyforceful perturbation in the long sitting orshort sitting position (without prosthesis).His forward reach distance in short sittingwas more than 10 inches, and his lateralreach in short sitting was 8 inches to the leftand 7 inches to the right.

The patient was able to stand unsupportedon his prostheses for up to 30 seconds; how-ever, he preferred at least unilateral upperextremity support to allay his anxiety aboutfalling. In the parallel bars, he was able toindependently step forward and shift hisweight between the anterior and posteriorfoot. He was hesitant to step unsupportedoutside of parallel bars, preferring bilateralLoftstrand crutches or straight canes.

How might this child access his home

environment?

Functional mobility. The patient used arented Quickie wheelchair for mobility athome. The chair was fitted with long anti-tippers to accommodate the changes in hiscenter of mass resulting from the ampu-tations. He became independent in wheelchairmobility on level surfaces and slight inclinesbut required minimal to moderate assistancefor propulsion on uneven surfaces and gradesgreater than 15 degrees. He also becameindependent in most level transfers (bed,toilet, and bath bench) and used a transferboard with minimal assistance for cartransfers. He preferred to be lifted to andfrom the floor, but was able to perform chair-to-floor transfers with verbal cues andminimal assistance.

After gait training, the patient used a four-point reciprocal gait pattern with Lofstrandcrutches, with close supervision when on leveluncarpeted surfaces for distances up to 150 feetbetween skin checks. He was able to ascendstairs step to step leading with the left leg,using a crutch and handrail and contact guardassistance. He was fearful when descending,requiring verbal encouragement, minimal assis-tance, and occasional correction of balance.

Adaptive equipment and assistive

devices. Both prostheses were fabricatedwith endoskeletal (modular) components, withflexible polyvinyl patellar tendon-bearingsockets in rigid polyethylene frames. Theyhad shuttle pin suspension mechanisms,based on an Ortho Gel (roll-on) liner (Figure26-1). To don the prosthesis, the patient stepsdown (clicks down) into the prosthesis toengage the shuttle-locking mechanism. Sus-pension was released by an external releasepositioned on the medial-distal frame of theprosthesis. Initially, he had a pair of Seattledynamic response prosthetic feet.

How might fluctuating limb volume be

accommodated?

The patient wore a five-ply cotton sock (witha hole cut for the pin) over the right Ortho

Case 26 115

Gel liner, and a five-ply wool sock (with a holecut for the pin) on the left. His mother carriedadditional one-ply cotton socks to adjust forvolume changes as his activity increased.

Bench and static alignment. To accom-modate for knee flexion contractures, thesocket was set (preflexed) at 10 degrees onthe right and 12 degrees on the left. Therewas a 5-degree lateral tilt of both sockets.His prosthetic feet were aligned a 3⁄4-inchoutset with respect to the socket. On theright, the prosthetic foot was placed in aneutral position, whereas the left prosthetic

foot was positioned slightly anterior (1⁄4 inch)to enhance knee extensor moment for stabilityat midstance. When the prostheses weredoffed after a period of quiet standing, therewas appropriate reactive hyperemia inexpected pressure-tolerant areas, althoughthere was moderate persistent redness at theright distal tibia.

Dynamic alignment. Observational gaitanalysis revealed a slightly wide step width,moderately shortened stride and step lengths,and increased double support time. Walkingvelocity was somewhat slow, apparentlyrelated to the patient’s apprehension aboutfalling. As a result, he was not effectivelyusing the dynamic response characteristicsof late stance/transition to the swing phase.With encouragement, he was able to increasestride length and velocity. He complained offeeling as if his left knee was being pushedinto extension as he moved into midstance.Toe clearance was adequate in early swing,although he tended to limit knee flexion ininitial swing phase, resulting in a slightlystiff-legged gait. With encouragement, he wasable to step over obstacles up to 3 inches inheight. When asked to identify where he feltpressure on his residual limbs when he stoodand walked, he pointed to a large area of themedial tibial flare and the distal lateralsurface of the tibia, as well as at the insertionof the patellar tendon. He indicated that thesockets felt “tight,” but there were no areasof point tenderness.

DiagnosisP R I M A R YPhysical Therapy Practice Pattern 4J: ImpairedMotor Function, Muscle Performance, Rangeof Motion, Gait, Locomotion, and BalanceAssociated with Amputation.

S E C O N D A R YPhysical Therapy Practice Pattern 5C: ImpairedMotor Function, and Sensory IntegrityAssociated with Nonprogressive Disorders ofthe Central Nervous System—Congenital inOrigin or Acquired in Infancy or Childhood.

116 Clinical Cases in Physical Therapy

F I G U R E 2 6 - 1 To don his prosthesis, the childfirst rolls the Ortho Gel liner with embedded lockingpin directly over the skin of his residual limb. He thenapplies prosthetic socks (with a distal opening forthe pin) over the liner. He sits on the edge of the chair,positions his limb in the socket, and steps down(clicks down) to engage the shuttle-locking mechanism.

(Used with permission.)

PrognosisG O A L S1. The patient will return to his elementary

school environment and participate asfully as possible in school-related activi-ties within 2 months.

2. The patient will return to valued leisureactivities, or find appropriate alternative/adaptive activities, and participate as fullyas possible within 6 months.

E X P E C T E D O U T C O M E S1. The patient and his parents will demon-

strate effective and consistent skin careand volume control strategies as hisresidual limbs mature.

2. The patient and his parents will demon-strate proper donning/doffing of prosthesis;he will wear the prostheses functionallyfor most of the day.

3. Muscle performance (strength), ROM, andpostural control and balance will improve.The patient will demonstrate full ROMand 5/5 in his lower extremities. He willperform the one-legged stance test for 30seconds without losing his balance whilewearing the prostheses on both his rightand left limbs. He will be able to maintainsemitandem and tandem Romberg positionsfor 25 seconds.

4. Cognitive function will improve and/or hewill develop appropriate adaptive strategiesnecessary for effective return to schooland leisure activities.

5. Prosthetic gait and functional mobilityskills will be safe, efficient, and functionalfor home, school, and leisure activities, asevidenced by improved scores on thedynamic gait index and gait assessmentrating scale (GARS).

6. The patient will resume full participationin his previous or adapted recreationalactivities.

D I S C H A R G E P L A NMechanisms of communication betweenoutpatient and school-based care were estab-lished. The patient was discharged fromoutpatient physical therapy when there wasconsensus among outpatient physical thera-

pists, prosthetists, parents, and the patientthat he had achieved functional goals for effec-tive community reentry (considering bothamputation/prosthetic and traumatic braininjury rehabilitation). He received school-based physical therapy for the school year,and was scheduled for reevaluation inSeptember as the next school year began todetermine whether continued school-basedphysical therapy was necessary. Based onanticipated periods of growth, the patientwas enrolled for long-term follow-up (post-discharge) at the interdisciplinary prostheticsclinic at the children’s hospital.

InterventionThe following interventions were implemented:1. Continue gait training and advanced

mobility training as an outpatient, with thegoals of improving musculoskeletal func-tion, quality of gait, functional mobilityskills, and functional endurance.

2. Pursue school-based physical therapyservices and special education services toensure appropriate reentry into school.

3. Identify strategies for periodic reevalua-tion to determine progression (and/orbarriers) toward functional goals andeffective community reentry.

4. Set up a mechanism for communication/collaboration between outpatient-basedand school-based physical therapyservices.

5. Identify current and project future needsfor adaptation of (or assistive devices) inhome, school, and leisure activities.

6. Monitor the effectiveness of the prostheticprescription; consider alternative compo-nents and transition to “permanent” pros-theses when appropriate (taking intoconsideration anticipated growth).

Outcome (3 months afterreturning to school)When the patient first returned to school, hisbehavior indicated mildly compromisedfunction in particularly complex, stimulating,

Case 26 117

active, or unpredictable environments. Therewas, however, nearly complete resolution ofmost cognitive impairments related to hishead injury in the 3 months after his returnto school. He became actively and effectivelyinvolved in classroom and playground activi-ties. Although alternative physical educationactivities were made available, he becameanxious to rejoin his buddies in regular“gym” class.

During that 3-month period, the patientmade significant progress in functionalmobility and ambulation. Currently, he walkswithout any assistive devices on level sur-faces at school and home, and keeps up withhis classmates in both distance covered andenergy cost of walking. He prefers to use asingle cane on the right side when weatherconditions make environmental surfacesslippery; other times his cane becomes a“Jedi light saber” during imaginative play. Henow manages stairs in a step-over-steppattern using one rail. He has experiencedseveral noninjurious falls during playgroundand gym activities, is able to rise independ-ently, and no longer worries about falling. Hedons his prostheses independently in themorning, wears them all day, and oftenremoves them in late afternoon to activelyplay on the floor with his sisters.

He is looking forward to playing “T-ball”this spring, although members of the town’srecreation department have expressed somehesitation about the appropriateness of his involvement; he is the first child withamputation who wants to be involved in theprogram.

He is now wearing 15-ply wool socks overhis suspension sleeve on both residual limbs;at his last visit to prosthetic clinic, the teambegan to discuss whether it is time to fabri-cate new prosthetic sockets. As a result ofincreasing activity and consistent stretching,he has regained full extension of both knees,which has necessitated several adjustmentsto alignment of prosthetic components. Hecurrently visits the outpatient rehabilitationdepartment once weekly; activities focus onadvanced mobility skills and leisureactivities.

R E C O M M E N D E D R E A D I N G S

Auxter D, Pyfer J, Huettig C: Principles and

methods of adapted physical education and

recreation (ed 9), New York: McGraw Hill,2001.

Berke GM: Transtibial prosthetics. In Lusardi MM,Nielsen CC (eds): Orthotics & prosthetics

in rehabilitation, Boston: Butterworth-Heinemann, 2000.

Both A: Traumatic brain injury in childhood. InTecklin JS (ed): Pediatric physical therapy

(ed 3), New York: Lippincott Williams &Wilkins, 1999.

Edelstein JE: Rehabilitation for children with limbdeficiencies. In Lusardi MM, Nielsen CC (eds):Orthotics & prosthetics in rehabilitation,

Boston: Butterworth-Heinemann, 2000.Effgen SK: The educational environment. In

Campbell SK, Vander Linden DW, Palisano RJ(eds): Physical therapy for children (ed 2),Philadelphia: WB Saunders, 2000.

Fergusen J: Prosthetic feet. In Lusardi MM,Nielsen CC (eds): Orthotics & prosthetics in

rehabilitation, Boston: Butterworth-Heinemann,2000.

Keirkering GA, Phillips W: Brain injuries:traumatic brain injuries, near-drowning, andbrain tumors. In Campbell SK, Vander LindenDW, Palisano RJ (eds): Physical therapy for

children (ed 2), Philadelphia: WB Saunders,2000.

Lunnen KY: Physical therapy in public schools. InTecklin JS (ed): Pediatric physical therapy

(ed 3), New York: Lippincott Williams &Wilkins, 1999.

Lusardi MM, Owens LF: Post-operative and pre-prosthetic care. In Lusardi MM, Nielsen CC(eds): Orthotics & prosthetics in rehabili-

tation, Boston: Butterworth-Heinemann, 2000.May BJ: Amputations and prosthetics: a case

study approach, Philadelphia: FA Davis, 1996.American Physical Therapy Association. McEwen

I (ed): Providing physical therapy servicesunder parts b & c of the Individuals withDisabilities Act (IDEA). Section on Pediatrics,2000.

Reis JD, Brewer KM: Transtibial prosthetictraining and rehabilitation. In Lusardi MM,Nielsen CC (eds): Orthotics & prosthetics in

rehabilitation, Boston: Butterworth-Heinemann,2000.

Seymour R: Prosthetics & orthotics: lower limb

and spinal, Philadelphia: Lippincott Williams& Wilkins, 2002.

118 Clinical Cases in Physical Therapy

Stanger M: Limb deficiencies and amputations. InCampbell SK, Vander Linden DW, Palisano RJ(eds): Physical therapy for children (ed 2),Philadelphia: WB Saunders, 2000.

Stanger M: Orthopedic management. In Tecklin JS(ed): Pediatric physical therapy (ed 3), NewYork: Lippincott Williams & Wilkins, 2000.

Winkler PA: Traumatic brain injuries. In UmphredDA (ed): Neurological rehabilitation (ed 4), St Louis: Mosby, 2001.

Winnick JP (ed): Adapted physical education and

sport (ed 3), Champaign, IIl, Human Kinetics,2000.

Case 26 119

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Describe how the results of medical imaging may affect a physicaltherapy plan of care.

2. Describe how psychosocial issues such as depression may affect both thephysical therapy plan of care and the patient’s long-term outcome.

3. Discuss factors one must consider when planning a treatment for apatient with multiple chronic conditions.

4. Discuss whether patients can benefit from the use of constraint-inducedmovement therapy as part of a plan of care to promote improved gait.

ExaminationH I S T O R YThe patient was a 40-year-old woman whoworked full time as a social worker in arehabilitation hospital. She had right-sidedhemiparesis caused by a left anterior cerebralartery aneurysm sustained 20 years earlier.Her right leg was more affected than her rightarm. She had spasticity in both extremitiesand had right finger flexor contractures that limited the use of her hand. She waspreviously right-hand dominant, but nowused her left hand for most functional activi-ties (e.g., writing, grooming, hygiene). Sheused her right hand functionally as an assist.She was 5 feet, 8 inches tall and weighed 190 pounds.

The patient had significant baseline gaitdeviations with a subsequent history of backand neck pain. She used a single-point canefor all gait activities; she was independent inmobility on all surfaces indoors and outdoors.She lived alone in a second-story apartment.There were five steps to enter the building,and there was no elevator.

On February 20, the patient tripped and fellin her apartment. She noted pain and swellingin her left knee. Despite the pain, she attempt-ed to continue with her daily activities. Oneweek later, she continued to have pain andswelling of the left knee. On February 27, shewas seen by her primary care physician, whodiagnosed a sprain of the right medial

collateral ligament. Because of the degree ofpain and swelling, a radiograph was ordered.Results were negative for fracture.

The physician recommended restrictedweight bearing because of pain and swelling.The physician also recommended using anace wrap to reduce swelling, and an antiinflam-matory drug for pain and swelling. Becauseof the weakness in her right arm and leg, thepatient had difficulty maintaining the partialweight-bearing restrictions. The physicianordered a physical therapy consult to addressthe problem.

What tests and measures were important

to include in the initial examination?

What recommendations could have

been made for this patient in terms of an

assistive device?

Which practice pattern(s) in the Guide

to Physical Therapist Practice would be

appropriate for this patient?

What other physical therapy

intervention(s), if any, could be

recommended?

I N I T I A L E X A M I N AT I O NDate: March 1

The physical therapist performed thefollowing tests and measures.

Pain. The patient described the pain in herknee as a 7 out of 10, worsening to a 9 out of10 at the end of the day.

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122 Clinical Cases in Physical Therapy

Peripheral nerve integrity, muscle per-

formance and sensory integrity. Sensation:

Sensation was intact throughout the left side,and decreased on the right side, with the rightleg more affected than the right arm. Proprio-ception, kinesthesia, and sharp/dull testingwere decreased in the right leg.

Strength: Because of the spasticity presenton the right side, the physical therapist didnot assign manual muscle test grades. Theleft arm was functional throughout. The lefthip and ankle had functional strength; becauseof pain, left knee strength was not tested.

The patient was able to elevate the rightarm about 45 degrees. Elbow flexion wasfunctional. She was able to fully extend herelbow in a gravity-eliminated position andextend her elbow about 30 degrees againstgravity. She had minimal motion in her rightwrist and hand. Her wrist rested in neutral,and her hand rested in a clawed position. Shewas unable to carry objects in the right hand.

The patient was able to flex the right hipagainst gravity about 20 degrees withmaximal effort. She tended to substitute byusing back extension. She was able to extendthe right hip fully against gravity but couldnot accept resistance to the movement. Whenshe attempted to abduct the hip in standing,she tended to lean toward her left side.Without leaning, she demonstrated minimalabduction against gravity. When supine, shewas able to abduct her hip about 45 degrees.She was able to extend her right knee fullyagainst gravity and could accept minimalresistance. Increased resistance causedincreased extensor tone throughout. She hadminimal movement in ankle dorsiflexion andno active ankle plantarflexion.

Range of motion. The left side was func-tional; because of pain, the left knee was nottested. The right shoulder had decreasedpassive range of motion in shoulder elevationand external rotation. The wrist and fingershad limited motion in all planes. The right legwas functional except for ankle dorsiflexionand plantarflexion, which were both limitedto 10 degrees.

Posture. The patient sat and stood with aslight posterior pelvic tilt, with more weight

on the left side. The trunk was rotatedforward on the left. The right shoulder waslower than the left. Slight forward head waspresent.

Gait, locomotion, and balance. Thepatient had been using a single-point canefor all gait. She took a short step with theright foot, because of the left knee pain.Because of weakness, she also took a smallstep with the left foot. Other gait deviationsincluded right knee extension throughout theentire gait cycle, right hip hiking and circum-duction, and decreased weight shifting ontothe right leg.

The physical therapist tested the patient’sstatic and dynamic balance using the Tinettiassessment tool and the Berg balance scale.The patient scored 18 out of a possible 28points on the Tinetti assessment tool and 33out of a possible 56 on the Berg balancescale. Both indicated that she was at risk forfuture falls. Although both scales were designedfor the elderly, the physical therapist decidedto use them to provide baseline measure-ments of the patient’s dynamic balance.

Assistive and adaptive devices. Thepatient attempted to use a large base quadcane but was unable to adequately unweighther left leg to achieve a partial weight-bearing gait. Because of the weakness in herright arm and leg, the patient was unable touse crutches.

EvaluationAfter the examination, the physical therapistrecommended a wheeled walker with a rightupper extremity platform. The decision wasbased on several factors, including the strengthavailable in the patient’s extremities and thepatient’s ability to successfully decrease theamount of weight that she put through herleft leg.

Although the patient was concerned aboutthe bulkiness of the wheeled walker, she agreedto use it. Her biggest concern was that itwould be difficult for her to get the walkerup to her second-floor apartment. She andthe therapist practiced having the patientfold the walker and carry it up the stairs. She

was able to do it but reported that theactivity was very fatiguing.

DiagnosisThe physical therapist classified this patientunder two different practice patterns, becauseof the complexity of her history. First, thephysical therapist chose Pattern 4D: ImpairedJoint Mobility, Motor Function, Muscle Per-formance, and Range of Motion Associatedwith Connective Tissue Dysfunction. Thispattern includes patients with ligamentoussprain, pain, and swelling. The expectedrange of visits for this pattern is between 3and 36.

The physical therapist also chose Pattern5D: Impaired Motor Function and SensoryIntegrity Associated with NonprogressiveDisorders of the Central Nervous System—Acquired in Adolescence or Adulthood. Thispattern includes patients who have had a cere-brovascular accident and who have impairedmotor function. It also includes difficultynegotiating terrains and inability to performwork activities, both of which were potentialproblems for the patient. The expected rangeof visits for this pattern is 10 to 60.

PrognosisBecause of the patient’s significant pastmedical history, the therapist predicted thatshe might need a longer course than usualfor rehabilitation. At the time, the physicaltherapist felt that the patient needed toconcentrate on resting her injured left leg byminimizing weight-bearing during gait. Thetherapist believed that the patient needed toimprove the strength of her right arm and legto allow her to rest her left leg.

G O A L S1. The patient will maintain partial weight-

bearing gait for the left lower extremity onall surfaces using a wheeled platformwalker independently in 2 weeks.

2. The patient will extend her right elbow 60degrees against gravity to allow improvedsupport while using a walker in 2 weeks.

3. The patient will flex her right hip 40 degreesagainst gravity to improve her ability toadvance her right leg during gait in 2 weeks.

4. The patient will demonstrate understandingof the need for compression and elevationof the left knee by the next treatmentsession.The physical therapist also provided edu-

cation about continuing to use the ace wrapfor edema reduction and education aboutelevating the leg at night or when the patientwas sitting. In addition, the physical thera-pist provided home exercises for strengthen-ing the patient’s right upper and lowerextremities. These included:1. Standing push-ups with the right upper

extremity.2. Horizontal abduction and adduction using

a yellow theraband (minimal resistance).3. Hip flexion in sitting, with instructions to

keep her hands on the edge of the chair tominimize substitution.

4. Knee extension in sitting, using a redtheraband (moderate resistance).The physical therapist scheduled the patient

to return in 1 week to evaluate progress and forany other potential problems related to mobility.

InterventionT R E AT M E N T S E S S I O N O N E Date: March 8

When the patient returned the next week,she reported pain in the neck and both shoul-ders. She believed it was related to using thewalker. The physical therapist examined thepatient’s neck and both shoulders. Thepatient had muscle spasms in both uppertrapezius muscles. She had pain with resistedshoulder flexion and adduction, as well asresisted shoulder shrugs. The patient ratedher left arm pain as 7 out of 10, and her rightshoulder pain as 6 out of 10.

How did the new symptoms change the

plan of care? What recommendations could

be made?

The physical therapist reviewed the patient’sgait with the walker. Because of the weak-

Case 27 123

ness in her right side, the patient tended touse her left arm more to push the walkerforward and to help support her right leg asshe advanced her right leg. The patient haddifficulty maintaining partial weight bearingof her left leg and again relied heavily on herleft arm. The physical therapist surmisedthat her gait pattern with the walker was thecause of the shoulder and neck pain. Althoughthe patient was using her left arm muchmore than her right, she was using her rightarm more than she was used to, and thus hadpain in both arms.

The physical therapist discussed the useof a scooter with the patient. The patient wasopposed to the idea, stating that she was notready to begin using a wheelchair or scooter.She said that she had worked very hard to beable to walk independently and was notready to face using a chair again.

The physical therapist also discussedenergy-conservation techniques with thepatient. Recommendations included havingthe patient plan her day to minimize theamount of walking she needed to do, sitting foras many activities of daily living and instru-mental activities of daily living as possible(e.g., grooming, showering, meal prepara-tion), and considering the use of a deliveryservice for her groceries. The patient agreedto all of the recommendations except using ashower seat.

Because of the pain in the patient’s rightarm, the physical therapist told the patient to discontinue the right upper extremitystrengthening exercises. The therapist reviewedher right lower extremity strengtheningprogram and instructed her to continue withit. The therapist made an appointment forthe patient to return in 2 weeks, after hernext physician visit.

T R E AT M E N T S E S S I O N T W ODate: March 22

At the next visit, the patient reported thatshe had attempted to walk without thewalker, but that the pain and swelling in herknee had increased. She brought a new orderfrom the physician for non–weight-bearinggait with the walker.

At her physician’s visit, the patient reportedthat she had a second radiograph, which wasstill negative for fractures. The physician thenordered a bone scan, which showed possibleheterotopic ossification (HO) in her left medialknee joint. The physician then decided onthe non–weight-bearing gait order.

The patient reported that the pain in hershoulders and neck was worse. She reportedconstant fatigue related to increased energycosts of gait, and difficulty sleeping at nightbecause of pain. She rated the pain in botharms as 10 out of 10. She also reported anincrease in feelings of depression.

How did this new information change the

plan of care? What new recommendations

were necessary?

At this point, the physical therapist stronglyrecommended that the patient try a scooter.The therapist told the patient that the neckand shoulder pain was likely to decrease whenshe stopped using the walker. The physicaltherapist noted that because of difficultymaintaining a non–weight-bearing gait, thepatient often returned to a partial weight-bearing gait. It was possible that this mightbe impeding healing. The physical therapistalso reminded the patient that the use of thescooter was likely to be temporary, but thatit could help prevent further HO and decreasethe neck and shoulder pain. She also dis-cussed the relationship between pain anddepression. After the discussion, the patientagreed to try a scooter. The physical therapistarranged for the patient to meet with thelocal durable medical equipment supplier thefollowing day.

The physical therapist also discussed theneed for counseling with the patient, basedon the patient’s report of feelings of depres-sion. The patient informed the physical thera-pist that she met regularly with a psychologist,with whom she had been discussing her cur-rent physical problems. The patient stated shewas worried about how long she would beable to live in her current apartment, becauseshe would be unable to get the scooter upthe stairs. She also worried about how long

124 Clinical Cases in Physical Therapy

she would be able to live independently ifher physical status continued to decline.

What was an appropriate response to the

patient’s concerns?

The physical therapist encouraged the patientto discuss these issues with her psychologist.She also reminded the patient that the use ofthe scooter might be temporary and bene-ficial in promoting healing of the left leg. Thephysical therapist did encourage the patientto begin thinking about looking for a first-floor, accessible apartment. She pointed outthe difficulties the patient had encounteredwith having to negotiate stairs with her cur-rent injury and also reminded her that itmight be possible to use the scooter at homeif she had a more accessible living situation.

At the end of the treatment session, thephysical therapist and the patient reviewedthe right lower extremity exercise program.The patient was able to perform all exerciseswithout difficulty. The physical therapistadded the following exercises:• Mini-squats for the right leg, using the

walker or a counter for support.• Hip abduction in the side-lying position

for both legs.

T R E AT M E N T S E S S I O N T H R E EDate: March 23

The following day, the patient met withthe durable medical equipment supplier andrented a scooter. The physical therapistreviewed the features of the scooter with thepatient and assessed the patient’s ability tonegotiate the scooter and transfer in and outof it. The patient was independent in scootermobility and transfers. Because of the inac-cessibility of the patient’s home, it was decidedthat the patient would use the scooter at workand use her walker at home. The physicaltherapist scheduled the patient for a follow-up visit in 1 week.

T R E AT M E N T S E S S I O N F O U R Date: March 30

The patient reported that she had under-gone a second bone scan and magnetic

resonance imaging 2 days earlier. Both testswere positive for HO in the left medial knee.The patient was placed on indomethacinfor 6 weeks to prevent further developmentof HO.

The physical therapist reviewed the patient’sstrengthening program. After consultationwith the patient’s physician, the physicaltherapist had the patient try using the exer-cise bike in the clinic. The patient was ableto transfer on and off the bike independentlyand to tolerate riding the bike for 15 minutesat a moderate pace, with appropriate vitalsign responses. The patient informed thephysical therapist that she had a stationarybicycle in her apartment. The physical thera-pist recommended that the patient add ridingthe exercise bicycle for 15 to 20 minutes perday as part of her exercise program.

The physical therapist reviewed the patient’sgait with the walker. Although her gait wasslow, the patient was able to walk 100 feetand maintain non–weight-bearing with herleft leg. It took her 6 minutes to walk 100 feetwith the walker. During the 100 hundred feet,she took three breaks of 20 seconds each.

The patient reported no problems usingthe scooter. She stated that her back and neckpain had decreased steadily over the pastweek. Her left arm pain was now 4 out of 10and her right arm pain was 3 out of 10. Thephysical therapist recommended that thepatient resume the upper extremity exercisesthat were part of her original exercise pro-gram and advised her patient to discontinuethe exercises if her pain level increased.

The physical therapist scheduled thepatient to return in 1 week to review her gaitand exercise program.

ReexaminationT R E AT M E N T S E S S I O N F I V EDate: April 6

The patient reported that the pain in bothupper extremities was unchanged from theweek before. She felt that the continued painwas related to use of the walker. Examinationof the patient’s gait revealed that the patientdemonstrated greater endurance while using

Case 27 125

the walker and was now able to walk 150 feetwhile maintaining her non–weight-bearingstatus. She was able to walk 100 feet with thewalker in 4 minutes and did not take any restbreaks while walking.

The physical therapist reviewed the patient’sexercise program. The patient was toleratingall of the exercises well, including the armexercises that she had resumed the weekearlier. The patient reported that she hadridden the stationary bicycle four times inthe past week, for 15 minutes each time.Because of the length of the patient’s currentexercise program, the physical therapistdecided not to add any new exercises at thetime. The physical therapist made the followingmodifications:• Use a red theraband (moderate resistance)

for upper extremity exercises.• Use a black theraband (maximal resist-

ance) for lower extremity exercises.• Attempt to increase the time on the sta-

tionary bicycle to 20 minutes per day, atleast 4 days per week.

T R E AT M E N T S E S S I O N S I XDate: April 13

The patient reported the pain in her leftleg had decreased. She had new orders tobegin partial weight-bearing gait with thewalker, with progression to full weight-bearing as tolerated.

How could the patient’s plan of care be

changed given that she can bear weight

on her left leg? Should she continue to use

the scooter?

The therapist began with the patient per-forming some weight-shifting exercises whilestanding with the walker, and then progressedto gait with the walker. Compared with theinitial examination, now the patient was ableto shift her weight more smoothly onto herright side and to more easily shift weightbetween her left and right legs.

The physical therapist recommended thatthe patient continue to use the scooter at

work for long distances until her left leg wascompletely healed.

T R E AT M E N T S E S S I O N S S E V E NT O T E NDates: April 20, 27, May 4, and May 11

The focus of treatment was now onimproving gait with the walker and increasingtolerance to increased weight bearing on theleft leg. Because of the patient’s past historyof back and neck pain related to her posture,the physical therapist and patient spent timeworking on the quality of gait. With practice,the patient was able to advance the right legwithout circumducting it. The physical thera-pist worked with the patient on maintainingan equal step time and length on both legs, tohelp prevent her from reverting back to herold gait patterns.

New home exercises were as follows:• Practice stepping on and off a stool

without circumducting the right leg. Thepatient used her walker during the activityand needed to make sure that her right legdid not contact the walker as she wasadvancing it onto the stool.

• While standing in the walker, roll a ballback and forth with the left leg, forstrength and balance training for the rightleg.In session nine, the patient began using

her cane instead of the walker. The physicaltherapist worked with the patient to use thecane for balance instead of leaning on itheavily to support her weight. She remindedthe patient that her right leg was strongerthan it had been, and that she should needthe cane less for support. During this ses-sion the physical therapist also began usingthe treadmill to help the patient work onweight shifting and stance time at varyingspeeds.

The patient and the physical therapistagreed that the patient could begin using hercane instead of the scooter for long distances.The physical therapist encouraged the patientto resume using the scooter if she experi-enced a return of knee, back, or neck pain.

126 Clinical Cases in Physical Therapy

Case 27 127

Outcome and DischargeT R E AT M E N T S E S S I O N E L E V E N :D I S C H A R G EDate: May 18

The physical therapist repeated the tests andmeasures used during the initial examination.

Pain. The patient no longer had pain inthe left knee or arms. She reported back painas a 3 out of 10 after walking a long distance.She said the pain was relieved with rest.

Peripheral nerve integrity, muscle per-

formance, and sensory integrity. Sensation:

Intact throughout the left side. Sensation wasdecreased on the right side; the right leg wasmore affected than the right arm. Proprio-ception, kinesthesia, and sharp/dull testingwere decreased in the right leg.

Strength: Because of the spasticity presenton the right side, the physical therapist didnot assign manual muscle test grades. Theleft arm and leg were functional throughout.The patient was able to elevate her right armoverhead 60 degrees. Elbow flexion wasfunctional. She was able to fully extend herelbow in a gravity-eliminated position. She wasable to extend her elbow 60 degrees againstgravity. The patient had minimal motion inher right wrist and hand. Her wrist rested inneutral. Her hand rested in a clawed position.The patient was able to flex her right hipagainst gravity 50 degrees without using sub-stitution. She was able to extend the righthip fully against gravity with moderate resist-ance. She was able to abduct her right hipwhen side-lying and standing 30 degrees. Thepatient was able to extend her right kneefully against gravity with moderate resistance.Increased resistance caused increased exten-sor tone throughout. The patient had minimalmovement in ankle dorsiflexion and noactive ankle plantarflexion.

Range of motion. The left side wasfunctional throughout. The right shoulderexhibited decreased passive range of motionin shoulder elevation and external rotation.Wrist and fingers had limited motion in allplanes. The right leg was functional exceptfor ankle dorsiflexion and plantarflexion,which were both limited to 10 degrees.

Posture. The patient sat and stood with aslight posterior pelvic tilt, with more weighton the left side. The patient was able to achievea neutral pelvis and equal weight-bearing onboth legs with visual cues (e.g., a mirror). Aslight forward head position was noted.

Gait, locomotion, and balance. Thepatient was using a single-point cane for allgait. Step length was nearly equal, with leftstep length slightly shorter than right.Occasional right hip hiking and circumduc-tion were noted after patient had walkedlong distances.

The patient’s Tinetti assessment tool scorewas 21/28, and her Berg balance scale scorewas 49/56. All goals established at the initialexamination had been met.

The physical therapist instructed thepatient to occasionally look in the mirrorwhile walking to help correct right hip hikingand circumduction. She recommended thatthe patient continue with her home exerciseprogram, especially riding the exercise bikeand the exercises for lower extremitystrengthening. The physical therapist told thepatient that some of her improvements ingait might be due to the need for her right legto support her weight while her left leg washealing. She described this as a form ofconstraint-induced movement therapy.

Finally, the physical therapist recommendedthat the patient come in for a reexaminationin 4 to 6 weeks, to determine the need forfurther intervention to modify and improveher gait pattern.

R E C O M M E N D E D R E A D I N G S

Berg K, Wood-Dauphinee S, Williams JI, Maki B:Measuring balance in the elderly: validation ofan instrument, Can J Public Health 83(2):S7,1992.

Blanton S, Wolf SL: An application of upper-extremity constraint-induced movement therapyin a patient with subacute stroke, Phys Ther

79:847, 1999.Davies, PM: Steps to follow: a guide to the

treatment of adult hemiplegia, New York:Springer-Verlag, 2000.

D’Lima DD, Venn-Watson EJ, Tripuraneni P,Colwell CW: Indomethacin versus radiation

therapy for heterotopic ossification after hiparthroplasty, Orthopedics 24(12):1139, 2001.

American Physical Therapy Association: Guide tophysical therapist practice, second edition,Phys Ther 81:1, 2001.

Fowler EG, Ho TW, Nwigwe AI, Dorey FJ: Theeffect of quadriceps femoris musclestrengthening exercises on spasticity in chil-dren with cerebral palsy, Phys Ther 81:1215,2001.

Hertling D, Kessler RM, Kessler D, Management

of common musculoskeletal disorders: phy-

sical therapy principles and methods (ed 3),Philadelphia: Lippincott Williams and Wilkins,1996.

McKinley WO, Gittler MS, Kirshblum SC, et al:Spinal cord injury medicine. 2 medical com-plications after spinal cord injury: identifica-tion and management, Arch Phys Med Rehabil

83(3 Suppl 1):S58, S90, 2002.O’Sullivan SB, Schmitz T: Physical rehabilitation:

assessment and treatment. (ed 4), Philadelphia:FA Davis, 2001.

Sabari JS, Kane L, Flanagan SR, Steinberg A:Constraint-induced motor relearning afterstroke: a naturalistic case report, Arch Phys

Med Rehabil 82(4):524, 2001.Shehab D, Elgazzar AH, Collier BD: Heterotopic

ossification, J Nucl Med 43(3):346, 2002.Stevenson TJ: Detecting change in patients with

stroke using the Berg Balance Scale, Aust J

Physiother 47(1):29, 2001.Taub E, Uswatte G, Pidikiti R: Constraint-induced

movement therapy: a new family of techniqueswith broad implication to physical rehabili-tation—a clinical review, J Rehabil Res Dev

36(3):237, 1999.Tinetti ME: Performance-oriented assessment of

mobility problems in the elderly, J Am Geriatr

Soc 34:119, 1986.van der Lee JH, Beckerman H, Lankhorst GJ,

Bouter LM: Constraint-induced movementtherapy, Phys Ther 80(7):711, 2000.

Whitney SL, Poole JL, Cass SP: A review ofbalance instruments for older adults, Am J

Occup Ther 52(8):666, 1998.

128 Clinical Cases in Physical Therapy

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Explain the importance of trunk strength and stability in infants andyoung children and its impact on all developmental areas.

2. Be able to develop treatment strategies that combine gross motor skillacquisition while concurrently impacting other areas (e.g., speech, finemotor skills).

3. Identify some clinical signs of trunk weakness.4. Explain the importance of developing the trunk in three planes of

movement.

ExaminationH I S T O R Y The patient was a 22-month-old male withsevere hypotonia and global developmentaldelay. He had been receiving physical therapytwo times per week from an early interventionprogram in another county and was trans-ferred to another facility when the familymoved. The new physical therapist receiveda general overall evaluation from the previousphysical therapist before the first session. Onarriving at the house, the new therapist wasable to obtain a brief history from the parents.The parents reported that the pregnancy anddelivery were unremarkable. The patient hada history of infantile spasms beginning at age3 weeks. At about 3 months, he was placedon adrenocorticotropic hormone therapy andTopomax to control the spasms. At the time ofthe initial visit, he was taking only Topomax,and no visible seizures were reported. He wasbeing followed by a neurologist and an ortho-pedist. The family’s primary physical therapygoal was for improved head control. Othergoals included holding a toy for longer periodsand continuing to work on making sounds.

T E S T S A N D M E A S U R E SAfter a brief physical examination, the physicaltherapist found passive range of motion to bewithin normal limits in all joints. When posi-tioned supine, the child kept his head turnedto the right and generally kept his extremities

in abduction and external rotation. He wasable to move them through a partial range ofmotion against gravity using small phasicbursts of movement. He was able to bringeither hand to his mouth with his head turnedto the side. He was unable to actively transi-tion in or out of any position. When rolledover onto his stomach, he would right hishead with his body. From the prone position,he was able to extend his head again usingsmall bursts (with the head laterally tilted tothe right) when given assistance to prop onhis forearms. He was rounded forward into akyphotic posture with head down into fullflexion when held in long sitting. He requiredmaximum assist to sit and keep his head upin midline. When the therapist attempted tohold him in supported standing, the therapist’shands slipped up his trunk, and the childwas unable to take weight through his feet. Itwas difficult to obtain good alignment in anyupright position.

EvaluationBased on the examination results, interventionfocused on teaching the family techniques toimprove the patient’s head, neck, and trunkcontrol. This was done through activities withthe patient in prone and supine positions onthe floor and over a ball. It also included posi-tioning while his mother was carrying him andpositioning on the floor. Over the first 2 weeks

129

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130 Clinical Cases in Physical Therapy

of treatment, the therapist continued to eval-uate the child’s functional abilities, strengths,and needs.

During intervention, the patient would tirequickly and would complain if left on hisbelly too long on the floor or over a lap.When he cried or vocalized to complain, theduration was short. When he coughed, hisentire body flexed forward in one burst andcoughed no more than once each time.Further assessment of the child’s breathingdetermined that he was primarily a diaphrag-matic breather. In his rib cage, the ribs wereflared and horizontally aligned with decreasedintercostal spaces.

DiagnosisPhysical Therapist Practice Pattern 5B:Impaired Neuromotor Development.

PrognosisG O A L SThe patient will: 1. Move his head from left to right 180

degrees and back again while in prone andsupine, in 1 year.

2. Maintain his head in an upright positionfor 30 seconds when placed in a positionof supported prone on elbows, in 1 year.

3. Maintain chin tuck while reaching in supineor while assisted playing with his feet, in 1 year.

The prognosis for achieving these goals in 1 year is fair to good. Family interest andinvolvement is likely to drive achievement ofthese goals.

What would have been appropriate

interventions at this point?

InterventionAfter gathering the information from the briefhistory and evaluation, the therapist initiallydirected treatment toward improving head,neck, and trunk control. The patient did nothave any independent movement in and outof positions and thus needed to begin to gain

some proximal stability to begin to developsome overall muscular control.

The therapist began with activities to workon trunk strengthening in prone and supineand provided suggestions to the family forpositioning. These activities were designedto work the child’s abdominal musclesprimarily in the sagittal plane. After furtherobservation and assessment, the therapistdetermined that the internal and externalobliques were not working actively. Impor-tantly, the obliques needed to be addressedfirst, because of their effect on rib cagedevelopment and thus on trunk mobility andbreathing.

Contraction of the obliques creates a down-ward pull at the bottom of the ribs, changingtheir shape and alignment. This downwardmovement increases the size of the rib space,allowing the intercostal muscles to be moreactive. The obliques work with the intercostalsand rectus abdominus to anchor the rib cageand help create a pressure gradient so thatthe diaphragm, the primary respiratory muscle,can work efficiently.

Using this knowledge, the therapist alteredthe plan of care to focus more on strengthen-ing all of the abdominal muscles in all threeplanes of movement. Such treatment strate-gies as downward vibration through the ribcage, rolling, playing while side-lying, and play-ing with feet were added. Positioning strate-gies were also adjusted using towel rolls andpillows to improve alignment and to helpopen up his intercostal spaces.

In the weeks that followed, the family beganto express their frustration with the child’sglobal developmental delay and his slowprogress. His mother stated that she wouldlike to try feeding him more textured foods, likecereal, in addition to the pureed baby foodthat he was eating. She also said that shewanted her son to be able to hold his bottle byhimself, because as he was getting bigger itwas progressively becoming more difficult tofeed him on her lap. She requested these goalsbe added to the physical therapy plan of care.

What interventions would have been

appropriate?

The physical therapist obtained consultationsfrom a speech therapist and an occupationaltherapist so that a more comprehensivetreatment plan could be implemented. Thespeech therapist recommended initiatingtherapy once weekly to address the feedingconcerns and provided the family withsuggestions for activities for oral stimulationand exploration. The occupational therapistprovided suggestions for increasing sensoryinput and awareness.

They decided to begin sessions with alotion massage to increase the child’s bodyawareness by providing tactile input. Inaddition, they decided to incorporate moremovement in various directions with thechild on the ball, to increase vestibular input.The vestibular system assists in head controland helps keep the head upright so the eyesare at a horizontal level. Movement throughdifferent planes is meant to give the childvaried movement experiences that he isunable to give himself.

After the sensory preparation, the thera-pists worked with the child side-lying onhelping him hold a teether and bring it to hismouth to provide oral stimulation. Thisposition helped the child bring both handstogether in midline while eliminating gravity.

The physical therapist also talked to thefamily about their questions regarding feedingand holding a bottle. They discussed normaldevelopment and the development of muscularstrength. They talked about how a child needsto develop a point of stability from whichskills can be built and that the trunk is thepoint of stability from which the head andthe extremities work. A lack of stabilityproximally makes it much more difficult todevelop refined skills in distal areas, such asthe arms and hands to hold a bottle, and themouth to chew and swallow textured foods.

The physical therapist and family collabo-rated on determining safe positions for feed-ing the child. The optimal position includedproviding maximal proximal support whilebringing the child out of his preferred pos-tures into capital flexion (chin tuck), bringinghis shoulders back into thoracic extension,and maintaining a midline symmetrical posture.

The mother and child had difficulty with thechange, and so two options were developedto help them adjust. The first option was asemireclining seat with rolled towels placedaround the child’s head and neck to keepthem in midline and out of hyperextensionand additional towels on each side of histrunk to keep the spine aligned. The secondoption included progression to an adaptedseat in a semireclining position with headand trunk supports. This proved the bestoption for overall alignment. The mother beganputting the child in the adapted seat for asmall snack during the day and progressedfrom one meal to three, and from a semi-reclining position to a more upright one.

OutcomeTherapy continued over the next year withcarryover at home through the family’s dailyactivities including bath, play, and mealtimes.Formal reexaminations were performedevery 6 months. The child began to developincreased head and trunk control (e.g., tomaintain head/neck extension in a proneposition on elbows), and interventions weremodified to reduce external supports. Anexample of these modifications was to reducethe number of towel rolls used to support theupper extremities and trunk.

Within the year, attention also began tofocus on the child’s transition to school whenhe turned 3 years old. The family and thera-pist worked together on seating and trans-portation issues as his birthday approached.At the appropriate time, the child entered anadapted preschool program.

DiscussionWhen treating children under age 3 years, thephysical therapist must remember that allareas of development are interrelated. In thisparticular case, the development of grossmotor skills was delayed because of thechild’s global hypotonia. This overall weak-ness led to delays in all developmental areasstemming from trunk weakness severe enoughto prohibit the child from moving independ-

Case 28 131

ently. The child’s lack of independent move-ment prevented him from exploring his bodyand environment, further affecting develop-ment of gross motor skills as well as cog-nition, fine motor skills, self-feeding, andlanguage.

The trunk plays an important role in thisdevelopment, providing a point of stabilityfrom which the head and extremities work.When the base is unstable, distal control issubsequently compensated for, which affectshow well the child can use his hands, feet,mouth, eyes, and other structures.

A child should be assessed in variouspositions, including prone, supine, and uprightpostures, enabling the therapist to evaluatethe child’s ability to move against gravity.Physical and audible clues, such as durationand loudness of vocalizations, changes invocalizations and respirations with changes inposture, quality of cough, and breathholdingduring movement, should be noted. Further

physical assessment of breathing and the ribcage—including evaluation of rib cage size,shape, and symmetry; alignment and spacingof ribs; breathing pattern; and spinalalignment—was important in this case.

The results of the assessment were used incorrelation with knowledge of normal develop-ment to devise a more comprehensive treat-ment plan. Consultations from other disci-plines can also help ensure incorporation ofall developmental areas into treatmentstrategies therefore optimizing interventionsand the child’s learning.

R E C O M M E N D E D R E A D I N G S

Stamer M: Posture and movement of the child

with cerebral palsy, San Antonio, Texas:Therapy Skill Builders, 2000.

Tecklin JS (ed): Pediatric physical therapy (ed 3),Philadelphia: Lippincott, 2000.

132 Clinical Cases in Physical Therapy

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Correlate the patient’s symptoms with objective clinical findings.2. Identify an appropriate physical therapy diagnosis and outline a plan of

care in a case with multiple areas of involvement.

The reader should know that the patient was a

33-year-old male store manager who presented

with complaints of low back pain with left

anterior hip and thigh symptoms. He also reported

symptoms that extended along the course of his

right lateral thigh and leg. He stated that his

symptoms began gradually approximately 18

months earlier. His symptoms were intermittent

in nature and aggravated with bending, lifting,

and prolonged sitting. In addition, prolonged

standing and walking both produced and

worsened his complaints. His symptoms were

less in the morning and worse as his day

progressed. He had a history of two prior

episodes of acute lumbar pain during the

previous 8 years. Each previous episode resolved

spontaneously without formal intervention 3 to

5 days after onset. The patient spent most of his

workday standing or walking, interspersed with

periods of time at his desk. His general health

was unremarkable. He enjoyed an active

lifestyle, including aerobic conditioning and

various sporting activities. Imaging studies

included lumbar radiographs that suggested

mild degenerative joint disease throughout

the L3-4, L4-5, and L5-S1 levels. He had been

referred to physical therapy with a diagnosis

of low back pain.

Based on the patient’s reports of

aggravating activities, what structures

were being stressed?

ExaminationBased on the patient’s history, symptoma-tology, and subjective reports of aggravatingactivities, the examination focused on screen-ing procedures for both the lumbar spine and

hips. The patient’s standing posture demon-strated a normal lumbar lordosis with noapparent asymmetries. His sitting posturewas poor, characterized by a moderatelyflexed lumbar spine, protracted shoulders,and forward head. Examination revealedactive range of motion (ROM) of his lumbarspine that was mildly restricted in flexionand moderately restricted in extension.Lateral bending and rotation ROM appearedto be within normal limits. Lower extremitydermatome, myotome, and reflex scans eachappeared within normal limits. Neural tensionsigns were negative for the sciatic nerve.Repeated motion testing of the lumbar spineproduced and worsened right lumbar, lateralthigh, and leg pain with flexion of the lumbarspine in standing. Lumbar spine extension instanding decreased and abolished his right lum-bar, lateral thigh, and leg symptoms. PassiveROM of his left hip revealed marked restric-tions in both internal rotation and abduction.Passive hip flexion and extension were eachmoderately restricted, whereas external rota-tion was mildly restricted on the left side.1

Resisted isometrics of the left hip were strongand painless for each of the major musclegroups. The patient’s free speed gait patternwas characterized by a lack of left hip exten-sion from midstance to preswing (toe-off).

EvaluationThe patient was demonstrating lumbar painthat extended over the course of his right L5dermatome that was produced with repeatedor sustained lumbar flexion. He also demon-strated a lack of lumbar extension ROM. Arestriction of left hip passive ROM in a

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134 Clinical Cases in Physical Therapy

capsular pattern was present. Gait deviationsconsistent with a lack of passive left hipextension ROM were also noted.

How does limited hip ROM influence

function of the lumbar spine?

A lack of passive hip flexion ROM placesgreater ROM demands on the lumbar spineand pelvis and consequently increases lumbarstress when the patient is required to for-ward flex the lumbar spine and hips fromeither the sitting or standing positions. Thesame is true when extending the lumbar spinein standing when a lack of passive hip exten-sion ROM is present. Dysfunction at one jointcan often lead to compensatory dysfunctionat an adjacent joint.

DiagnosisPhysical Therapist Practice Patterns 4F:Impaired Joint Mobility, Motor Function,Muscle Performance, Range of Motion andReflex Integrity Associated with Spinal Disor-ders and 4D: Impaired Joint Mobility, MotorFunction, Muscle Performance, Range ofMotion Associated with Capsular Restriction.

PrognosisG O A L SThe patient will:1. Exhibit restoration of full lumbar exten-

sion ROM and abolished right lowerextremity referred symptoms in 3 weeks.

2. Demonstrate improved passive ROM of theleft hip to mild restrictions with internalrotation and abduction, with full restora-tion of hip flexion and extension passiveROM in 8 weeks.

3. Resolve associated left lower extremityreferred symptoms in 8 weeks.

4. Normalize free-speed gait pattern as hipextension ROM is restored.

InterventionThe patient’s lumbar symptoms were addressedusing therapeutic exercises based on McKenzie

principles for lumbar derangement includingextension in prone lying, which was performedevery waking 2 hours.2 The patient was alsoencouraged to avoid periods in high-stressspinal postures, particularly prolonged sittingand bending from the waist. A lumbar rollwas issued for use during the times when hewas required to sit. His left hip capsularrestriction was addressed with stretchingexercises for hip abduction, internal rotation,flexion, and extension to be performed for aminimum of 2 minutes in each direction, fourtimes per day.

OutcomeThe patient was reexamined at 3 weeks, atwhich time he demonstrated full lumbarextension and a complete resolution of hislumbar and right lower extremity referredsymptoms. However, he continued to expe-rience significant restrictions in his left hipROM and the onset of left anterior hip andthigh symptoms after extended periods ofweight bearing. The patient was referredback to his primary care physician becauseof a lack of meaningful progress with his left hip condition. His primary care physi-cian in turn ordered further imaging studies.A radiograph of his left hip suggested end-stage degenerative changes. Subsequentmagnetic resonance imaging suggestedfemoral head avascular necrosis. The patientcontinued to perform his left hip stretch-ing exercises on a home basis before under-going a cementless total hip arthroplasty 24months later.3

R E F E R E N C E S

1. Hertling D, Kessler R: Management of common

musculoskeletal disorders: physical therapy

principles and methods (ed 3), Philadelphia:Lippincott, 1996.

2. McKenzie RA: The lumbar spine: mechanical

diagnosis and therapy, Waikanae, NewZealand: Spinal Publications, 1981.

3. Hellman EJ, Capello WN, Feinberg JR: Omnifitcementless total hip arthroplasty: a 10-yearaverage followup, Clin Orthop 364:164, 1999.

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Describe the pathophysiology of psoriasis.2. Differentiate psoriatic arthritis from other joint dysfunctions.3. Display knowledge of the psychosocial issues associated with psoriasis.4. Recognize common impairments and functional limitations of a person

with psoriasis.5. Identify pertinent examination and evaluation elements for a person with

psoriasis.6. Describe the benefits of phototherapy and photochemotherapy

interventions in the treatment of psoriasis.7. Identify risk factors of phototherapy and photochemotherapy.8. State specific phototherapy goals for this patient.

The reader should know that the patient was a

38-year-old white male with ongoing psoriasis.

He worked as an accountant at a local firm.

He began seeing scattered spots of psoriasis

when he was 19 or 20 years old. In the past 10

to 12 years, his psoriasis became progressively

worse. He reported that, from increased

job-related stresses and at certain times of the

year, his psoriasis would flare up.

What are the etiology, incidence, risk factors,

pathogenesis, clinical manifestations,

and prognosis of psoriasis?

Psoriasis is a noncontagious, chronic, inflam-matory dermatosis characterized by elevatederythematous plaques covered with dry,silvery scales. Its cause is unknown. Hereditycontributes to development of psoriasis inabout one third of the cases, but the role ofgenetic factors is not clear. Current researchindicates that there is an immune-mediateddysfunction in families with psoriasis. Thenormal life cycle of a skin cell is 28 days;however, the turnover time of psoriatic skinis 3 to 4 days. Psoriasis is represented equallyin both genders and is most common inyoung adults, with a mean onset at age 27. Itaffects about 1% to 2% of Caucasians and isuncommon in African-Americans. Flare-ups areunpredictable, but may be related to systemic

and/or environmental factors. Trauma, infec-tion (especially hemolytic streptococci),pregnancy, and endocrinologic changes arefrequent precipitating systemic factors. Coldweather and emotional stress or severe anxietymay also exacerbate psoriasis. Psoriasis canbe physically disfiguring and emotionallydisabling, and can have a distressing effecton the lives of both the individual and his orher family.1-6

Examination and EvaluationThe patient’s most recent flare-up of psoriasisfollowed a severe strep throat infection. Whenthe patient presented to the dermatologist,he had 55% to 65% body coverage of moderatelythick plaques that were thicker and larger onhis knees and elbows. Occasional plaques onthe palmar surfaces of his hands and plantarsurfaces of his feet were painful and limitedhis ability to perform some activities of dailyliving. Ambulation for more than short dis-tances was also difficult. The dermatologistconfirmed the diagnosis of psoriasis with apunch skin biopsy and prescribed severalincreasingly stronger topical corticosteroids.

The patient saw the dermatologist every 3to 4 weeks for 6 months, but despite this medi-cal intervention, his psoriasis became progres-sively worse. He also received two courses

135

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136 Clinical Cases in Physical Therapy

of antibiotic therapy during that time secondaryto topical skin infections. The dermatologistdecided to try phototherapy and referred thepatient to the light therapy center in the physi-cal therapy department at his local hospital.

How should a person with psoriasis be

examined and evaluated?

Elements of examination and evaluationinclude history of previous skin treatment,including topical applications, light therapy,photosensitizing medication, and radiationtherapy. Initial skin assessment includes skintyping, description of extent and type of skinlesion, duration, factors causing flares andremissions, itching, history of “cold sores,”observation of skin scalp and nails, and iden-tification of any other discomforts. A bodydiagram is helpful for documenting the extentof lesions and progression of healing. Addi-tional essential data to collect include con-comitant medical problems, family history ofskin disease, and any other medications thatthe patient may be taking. Several commonmedications, including tetracycline, thiazidediuretics, and oral contraceptives, can increasephotosensitivity.7

The patient’s general health was good, andhe had few other medical problems. His fatherhad severe psoriasis, and his grandfather hada skin disorder of unknown origin. The patientexercised two to three times per week andwas involved in occasional social activities.However, he usually avoided outdoor activitieswhere he might need to wear short-sleevedshirts or shorts. He enjoyed playing golf, butplayed only during the early spring or latefall when the temperatures were cool enoughthat he could comfortably wear a long-sleevedjersey and long pants.

The patient had never received any type ofphototherapy or radiation therapy, and hewas not taking any medications. Through hisself-reported erythema and pigment responseto natural sunlight, he was classified as skintype II (always burns, sometimes tans). A bodydiagram was completed, noting the type andextent of his skin lesions (Figure 30-1). Hisrange of motion, muscle strength, and sensa-

tion were all within normal limits at the timeof the examination. He was given a minimal

erythema dose (MED) test on his arm to deter-mine his sensitivity to ultraviolet light. (TheMED is the smallest dose of ultraviolet radia-tion that yields erythema that is just detectableby eye after 8 to 24 hours of exposure.) Indi-viduals may also be classified according totheir self-reported erythema and pigmentaryresponse to natural sunlight exposure.7,8

DiagnosisPhysical Therapy Practice Pattern 7C: ImpairedIntegumentary Integrity Associated withPartial-Thickness Skin Involvement and ScarFormation.

PrognosisAt the end of the plan of care, the patientwas expected to have 80% to 90% clearing ofhis disease. The dermatologist and physicaltherapist had biweekly meetings in which theamount and extent of disease was diagrammedand reviewed to reassess and determine thebest course of therapeutic intervention forthe patient.

InterventionThe patient was taught about the etiology ofpsoriasis and how ultraviolet radiation slowsthe overproduction of skin cells and mildlystrengthens the immune system. Phototherapyor ultraviolet B light band (UVB) therapywas initiated at 20% below the patient’s MED,or at 35 mjoules. (Broad-band UVB has beenan accepted treatment for psoriasis fordecades and works for about two thirds ofpatients. UVB is considered when topical treat-ments, such as ointments and corticosteroids,are not effective.) The UVB dose was increasedby 20% to 30% per treatment as tolerated.The patient was seen three times a week for6 weeks. He was reevaluated at the beginningof each session and asked to report his ery-thema at approximately 6 to 8 hours after thesession. This information was then used todetermine the next UVB dose.

Case 30 137

LIGHT THERAPY CENTER ASSESSMENT

Previous Patient:

Name:

Age:

Address:

Insurance:

Daytime Phone #:

Occupation:

Previous Skin Treatment:

Topical:

Light Therapy:

Photosensitizing Meds:

Radiation Therapy:

Skin Assessment at First Treatment:

Subjective:

Skin Type:

Extent:

Duration:

Factors Causing:

Flare

Remission

Itching:

Discomfort:

History of “Cold Sores”:

Objective:

Lesion Type:

Hair/Scalp:

Nails:

Date: Time:

Physician:

Diagnosis:

Add’l Med. Problems:

Medications:

Previous Light Rx:

Goal of Therapy: Clearance of Skin Disease

Family History of Skin Disease:

Therapist:

F I G U R E 3 0 - 1 Sample body diagram (©Michael B. Ashley, PT, Ashley & Kuzma Physical Therapy andPhotomedicine, Erie, Penn. Used with permission.)

Continued

138 Clinical Cases in Physical Therapy

F I G U R E 3 0 - 1 , c o n t ’d For legend see p. 137.

Light Therapy Review Rx #:

Response:

Compliance:

Complications:

UVA/UVB Dosage:

Medications:

Clearing/Maint. Rx/wk:

Changes:

Reviewer:

Date:

Physical Findings:

Light Therapy Review Rx #:

Response:

Compliance:

Complications:

UVA/UVB Dosage:

Medications:

Clearing/Maint. Rx/wk:

Changes:

Reviewer:

Date:

Physical Findings:

Light Therapy Review Rx #:

Response:

Compliance:

Complications:

UVA/UVB Dosage:

Medications:

Clearing/Maint. Rx/wk:

Changes:

Reviewer:

Addressograph

Date:

Physical Findings:

Monthly Phototherapy Progress Notes

Three weeks after beginning phototherapy,the patient reported increased pain in his rightelbow and hands after a weekend during whichhe played three rounds of golf, because theweather was finally comfortable enough forhim to wear long sleeves and pants.

What are the incidence, etiology, and clinical

manifestations of psoriatic arthritis?

The possibility of psoriatic arthritis shouldbe considered for all persons known to havepsoriasis and exhibit any type of joint dys-function. Approximately 10% to 30% of personswith psoriasis develop psoriatic arthritis. Itcommonly affects one or more joints of thefingers or toes and has a predilection for thedistal interphalangeal joints of the hands.There may be nail changes including separa-tion from the nail bed and/or pitting that mimicsfungal infections. Usually, psoriatic arthritistends to develop slowly, with mild symptomsand less joint tenderness, leading to misdiag-nosis and/or underestimation of its severity.5,6

ReexaminationThe pain in the patient’s elbow resolved in 3to 4 days, but it took about 10 days for the painin his hands to go away. Because this appearedto be an isolated and justifiable incident ofjoint pain, the dermatologist and physicaltherapist decided to just monitor his joints.

The patient tolerated phototherapy welland had very few episodes of pinkness orsoreness. Generally, he was increased 20% to30% per treatment up to a dose of 450 mjoules.However, after 15 treatments, the patientdemonstrated only a fair response, or abouta 30% reduction in plaques. It was determinedthat the broad-band UVB was not as effectivefor this patient, and after consultation withthe dermatologist, PUVA therapy (consistingof psoralen, an oral medication drug thatincreases photosensitivity, and ultraviolet Alight band [UVA] phototherapy) was recom-mended. PUVA is typically considered forpersons who have moderate to severe pso-riasis and who have been resistant to othertypes of treatments.2,8,9

What risk factors and safeguards are

associated with UVB and PUVA treatment

interventions?

The main side effect of UVB is severe erythemacausing blistering and subsequent peeling ofskin. Despite the fact that sun exposure is amajor risk factor in the development of skincancer, no additional risk from UVB photo-therapy has been reported.

Although PUVA treatments have beenassociated with an increased risk of skincancer (particularly of nonaggressive forms,such as squamous cell and basal cell car-cinoma), this risk has also been shown to bedose dependent.2,8 Stern et al10 reported aslightly increased risk of melanoma skincancer in patients who had undergone long-term, high-dose PUVA (11 cases in 1380 sub-jects followed for 21 years). Current PUVArisks are minimized through sophisticatedmeasuring devices and protection of sensi-tive areas (e.g., wearing protective eyeglassesfor 12 to 24 hours, applying sunscreen touninvolved areas, shielding male genitalia,and avoiding sunlight for 24 hours afteringesting psoralen).2

InterventionThe patient was taught about PUVA therapyand how to protect his skin and eyes whiletaking photosensitizing medications. Thepatient was advised to put on sunglasses andapply a sunscreen immediately after swal-lowing his medication. Between 11⁄2 and 2hours after receiving his oral medication of30 mg of oxsralen-ultra (a psoralen-type drug),he received 1.0 joule of UVA; this amountwas increased by 0.5 joule each treatmentsession per protocol. (Note that the UVBphototherapy standard of administration isin mjoules and that of UVA is in joules.) Anew body diagram was made. At the begin-ning of each subsequent treatment session,the patient was reexamined and asked toreport any erythema he may have experiencedapproximately 24 to 48 hours after the lasttreatment session. He was scheduled threetimes a week for treatment, and provided

Case 30 139

that he did turn pink or report soreness, hisdosage was increased according to protocol.

OutcomeAfter nine treatments, the patient was showingclinical clearing of disease. At the twenty-fourth treatment, he had significant (90%+)clearing of disease, with only mild discolorationon his trunk and lower legs and a few thinspots on his elbows. Extra exposure on armsand legs was instituted by having the patientwear a gown for part of the treatment so thatthose areas could be exposed to UVA longer.By the twenty-sixth treatment, the patient wascompletely clear. After discussion with thedermatologist, he was placed on a weaningprogram two times per week for 2 weeks andthen once a week for 2 weeks. Eventually hewas tapered down to once per month. Hewas then discharged from photochemotherapyand monitored by his dermatologist.

After several months, the patient beganhaving recurrences, indicating the need for along-term maintenance program for his pso-riasis. It was decided that the patient wouldobtain a home UVB unit. The physical thera-pist helped him obtain approval from theinsurance company and a UVB unit delivered.The physical therapist made a home visit tocalibrate the unit and instruct the patient inits use. After the home visit, the patient wasmonitored through several telephone calls tomake sure he understood how to use it andwas safely tolerating it. The patient nowtreats himself once every 10 to 14 days witha very small dose of UVB light and has beenkeeping his skin clear of psoriasis withoutthe use of topical corticosteroids or oralmedications. Currently, his skin has beenclear for 8 months. He will continue with thisregimen. During the summer, he will take abreak from his phototherapy to get morenatural sunlight exposure. He now enjoysplaying golf throughout the summer.

Discussion The patient in this case study needs to con-tinue phototherapy treatments through the

fall and winter, treating his skin every 7 to 10days to keep the psoriasis under control. Hislong-term prognosis is that he will more thanlikely have a flare-up every 6 to 18 monthsthat may require more aggressive treatmentat times. The nature of psoriasis is highlyindividualized and unpredictable, because itis closely linked to the immune system. Thereis no known cure for psoriasis, only controlmeasures to treat it.1-3

R E F E R E N C E S

1. Goodman CC, Boissonnault WG: Pathology:

implications for the physical therapist,Philadelphia: WB Saunders, 1998.

2. National Psoriasis Foundation: PUVA, Portland,Oregon: National Psoriasis Foundation, 1999.

3. Psoriasis. In Miller-Keane encyclopedic dic-

tionary of medicine, nursing and allied

health, Philadelphia: WB Saunders, 1997.4. National Psoriasis Foundation: Psoriasis:

questions and answers, Portland, Oregon:National Psoriasis Foundation, 2000.

5. Goodman CC, Boissonnault WG: Pathology:

implications for the physical therapist,Philadelphia: WB Saunders, 1998.

6. National Psoriasis Foundation: Psoriatic

arthritis, Portland, Oregon: National PsoriasisFoundation, 1999.

7. Davis JM: Ultraviolet therapy. In Prentice WE(ed): Therapeutic modalities for physical

therapists, New York: McGraw-Hill, 2002.8. Diffey B, Farr P: Ultraviolet therapy. In Kitchen

S, Bazin S (eds): Electrotherapy: evidence-based

practice, Philadelphia: Churchill Livingstone,2001.

9. Shelk J, Morgan P: Narrow-band UVB: a prac-tical approach, Dermatol Nurs 12:407, 2000.

10. Stern RS, Nichols KT, Vakeva LH: Malignantmelanoma in patients treated for psoriasiswith methoxalen (psoralen) and ultraviolet Bradiation (PUVA), New Engl J Med 336:1041,1997.

R E S O U R C EPersons with psoriasis, their families, andfriends founded and continue to direct theNational Psoriasis Foundation. They arecommitted through education, advocacy, and

140 Clinical Cases in Physical Therapy

research to improve the quality of life forpeople who have psoriasis. They welcomerequests for information and are a past reci-pient of the American Academy of Derma-tology’s Excellence in Education Award.

National Psoriasis Foundation6600 SW 92nd Avenue, Suite 300Portland OR 97223-7195800-723-9166 or 503-244-7404Fax: 503-245-0626E-mail: [email protected]: www.psoriasis.org

Case 30 141

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Describe the signs and symptoms of chronic obstructive pulmonarydisease (COPD).

2. Describe how the disease affects the functional capacity and quality oflife of an individual with COPD.

3. Explain how to accurately and safely prescribe activity levels for patientswith COPD.

4. Determine the appropriate use of oxygen therapy for the patient withCOPD.

ExaminationH I S T O R YThe patient was a 65-year-old retired busdriver. He had been married for 42 years, andhad a 66-pack-year history of cigarette smok-ing. His wife encouraged him to stop smokingever since she had quit 13 years ago aftersustaining a myocardial infarction. The couplehas two grown children and three grandchil-dren, but they do not visit very often because“grandpa” quickly becomes short of breathand tires easily. After years of progressivelyworsening bouts of shortness of breath, he wasdiagnosed with emphysema at age 59. Shortlyafter the COPD diagnosis was made, he wasforced to take early retirement. He continuedto be socially active in his community, however.

What signs and symptoms would be typical

for a patient with emphysema?

Chest radiographs done at the time revealedhyperinflated lungs, flattened diaphragm, anda moderately enlarged heart. Subsequent test-ing demonstrated a slow, but continuous pro-gression of the disease process. During the pastyear, the patient was hospitalized several timesfor acute respiratory infections. Three monthsago he was hospitalized for 2 weeks withsevere chest pain, which turned out to be pneu-mococcal pneumonia and pleurisy. Duringthat hospital stay, the patient was placed onantibiotics and received chest physical therapy

and respiratory therapy. The pneumonia lefthim very weak, with a dramatically decreasedfunctional capacity to perform activities ofdaily living (ADL). His physician referredhim to physical therapy as an outpatient inthe pulmonary rehabilitation program.

S Y S T E M S R E V I E WThe patient had no significant neurologic orintegumentary system findings, and his ortho-pedic examination was unremarkable exceptfor muscle weakness of the lower extremities.He averaged a strength grade of 3/5 for themajor muscle groups of the upper and lowerextremities. His other signs and symptomswere limited to the pulmonary and cardio-vascular systems.

The patient’s predicted maximal oxygencapacity, based on gender, age, and activitylevel, was 28.8 mL/kg/minute (or 8.2 metabolicequivalents [METS]). (1 MET = 3.5 L oxygen/kgof body weight.) He attained a level of 10.5mL/kg/minute (3 METS) on a graded exercisestress test using the Balke-Ware protocol.Therefore, he had a functional aerobic impair-ment (FAI) of 63.5%, which is consideredmarked impairment of aerobic capacity. (FAI= predicted maximal oxygen consumption –observed maximal oxygen consumption/pre-dicted oxygen consumption × 100.)

Arterial blood gas (ABG) values are listedin Table 31-1, and pulmonary function test(PFT) values are given in Table 31-2.

143

Case 31

144 Clinical Cases in Physical Therapy

How could the 6-minute walk have been

used to assess the patient’s functional

capacity?

The patient performed the 6-minute walk andwas able to cover 320 meters, but had to stopseveral times due to dyspnea. At rest hereported a dyspnea level of 2/4, but whilewalking, his dyspnea level rose to 3/4, and itreached 4/4 when he was forced to stop andrest. (The dyspnea scale is as follows: 1, mild,noticeable to patient, not to observer; 2, somedifficulty, noticeable to observer; 3, moderatedifficulty, but can continue; 4, severe difficultycannot continue.)

His oxygen saturation level, as measuredby pulse oximetry, was 88% at rest, and itdropped to as low as 82% during portions ofthe 6-minute walk.

DiagnosisPhysical Therapist Practice Pattern 6C:Impaired Ventilation, Respiration/Gas Exchange,and Aerobic Capacity/Endurance Associatedwith Airway Clearance Dysfunction.

Prognosis G O A L SAll of the following goals were expected tobe accomplished during a 12-week pulmonaryrehabilitation program in which the patientexercised three to five times per week for 30to 45 minutes per session:1. Improve aerobic capacity to 14.0 mL/kg/

minute (4 METS).2. Improve muscle strength so that he is at a

MMT grade of at least 4/5 in all the majormuscle groups of the upper and lowerextremities and the trunk.

3. Improve the ABG profile so that restingPaCO2 level drops within the normal rangeof 35 to 45 mm Hg and PaO2 improves toat least 70 mm Hg, as measured with apulse oximeter.

4. Reduce smoking and stop completely bythe end of the 12-week pulmonary reha-bilitation program.

5. Avoid recurrence of acute respiratoryinfection for 1 year.

E X P E C T E D O U T C O M EAll of the expected outcomes will be attainedby the end of the 12-week pulmonary reha-bilitation program:1. The patient’s 6-minute walk distance will

increase without decreasing his oxygensaturation and increasing his RPE andperception of dyspnea.

2. The patient will perform ADL and self-care activities with less dyspnea.

3. The patient will increase to a level of 4/5or greater for the major muscle groups ofthe upper and lower extremities.

4. The patient’s increased mobility andpulmonary function will result in fewerrespiratory infections.

5. The patient will stop smoking cigarettes.

InterventionWhat is the benefit of long-term oxygen

therapy for COPD patients?

It was determined that long-term (at least 19hours per day) oxygen therapy was indicated.Long-term oxygen therapy has been shown

TA B L E 3 1 - 1A R T E R I A L B L O O D G A S VA L U E S

OBSERVED VALUES NORMAL

pH 7.33 7.35-7.45PaCO2 46 mm Hg 35-45 mm HgPaO2 58 mm Hg >80 mm HgHCO3 29 mEq/L 22-28 mEq/LO2 Sat 88% >90%

TA B L E 3 1 - 2P U L M O N A R Y F U N C T I O N T E S T D ATA

PULMONARYFUNCTION TEST OBSERVED PREDICTED

FEV1 78% >90%FVC 2.75 L 4.11 LFEV1/FVC (%) 46% 70%TLC 7.00 L 6.98 L

to improve the quality of life for COPDpatients by improving their psychologicaloutlook, enhancing exercise performance,and improving skeletal-muscle metabolism.Long-term oxygen therapy is the only treat-ment known to increase the longevity ofindividuals with COPD.

Why was selecting the correct oxygen

delivery device important?

An oxygen concentrator capable of fillingportable containers was the device of choice,because it would provide the patient with aneconomical oxygen source at home, allowhim to move about and remain socially active,and perform his ADL. Because Medicare paidfor one device, it was important that the mostappropriate device for this particular patientbe selected. A pulse oximeter was also pur-chased so that the patient could monitor hisoxygen saturation level and adjust the oxygenflow rate in response to his activity levels.

What were some areas of patient education

appropriate for this patient?

The patient completed a 12-week pulmonaryrehabilitation program. A significant portionof the program was dedicated to patient andfamily education. He was taught to monitorhis own pulse rate, perception of dyspnea, andrate of perceived exertion (RPE). In addition,he and his wife were instructed in the use ofthe oxygen concentrator and pulse oximeter.

During the stress test, the patient was ableto perform at a level of 3 METs, or 10.5 mL/kg/minute at a heart rate of 144 beats per minutebefore stopping the test because of dyspnea.

The physical therapist developed an exer-cise prescription with an intensity, duration,and frequency appropriate for the patient’scondition and current functional status. Thepatient combined the stationary bicycle witha walking program, exercised 3 days a weekat the clinic, and continued the walking pro-gram at home on his off days. The therapisttaught him the proper way to warm up andcool down, breathing exercises, and a low-intensity weight-training program. The patient

enjoyed relaxation training and attendedsmoking cessation classes.

Discharge PlanThe patient was discharged from pulmonaryrehabilitation when he was able to perform ADLand self-care activities at a level of 3 to 4 METsusing his oxygen delivery system and oximeterat a dyspnea level no greater than 2/4.

What are some activities within the

patient’s MET range?

MET values for some common activities areas follows: • Eating 1.5• Dressing 2.5• Bathing 2.0• Showering 4.0• Driving car 2.0• Light play with children 2.5 to 2.8• Pumping gasoline 2.5• Light housecleaning 2.5 to 3.5• Fishing (sitting in boat) 2.5

OutcomeThe patient was able to walk 440 meters (anincrease of 25%) in 6 minutes with severalrests and only mild dyspnea. His ABG andPFT profiles improved slightly (Tables 31-3and 31-4). His muscle strength increased toan average of 4/5 in the major muscle groupsof the extremities. He could not stop smok-ing completely, but was able to cut downfrom 11⁄2 packs a day to 1⁄2 pack a day andcontinued to attend the smoking cessationprogram in hopes of completely quitting.

The patient was able to properly use hisoxygen delivery and monitoring system. Hismaximal oxygen consumption increased to13.5 mL/kg/min (3.86 METS), which decreasedhis FAI to 53% and classified his impairmentas moderate rather than marked.

DiscussionEmphysema is a progressive disease that cannotbe cured. However, with proper management,

Case 31 145

an individual can improve his or her qualityof life despite the disease. Without propermanagement, an affected individual’s qualityof life and longevity will rapidly deteriorate.What is the most important thing this patientcan do to manage his disease? Stoppingsmoking would do more to help this patientthan any other intervention.

Patient education is very important, becausethere are many misconceptions about COPD.Exercise, done properly, helped this patient.But exercise done improperly could havemade him more dyspneic, anxious, and frus-

trated in his effort to improve his physicalcondition. Finally, educating the COPD patienton the use of oxygen is essential. The oxygensupply must match the physiologic demands.Too much oxygen can depress respiratorydrive in a COPD patient. Dyspnea and RPEcan be used to subjectively assess the amountof exertion and therefore the demand, where-as the pulse oximeter is a relatively economicaland objective means of assessing oxygendemand. Initially, however, the oximeter shouldbe correlated with the ABG values, becauseit is the PaCO2 level, not oxygen saturation,that “plays tricks” on the respiratory centerin the brainstem.

R E C O M M E N D E D R E A D I N G S

ACSM: Guidelines for exercise testing and

prescription (ed 6), Philadelphia: LippincottWilliams & Wilkins, 2000.

ACSM: Resource manual for guidelines for

exercise testing and prescription (ed 4),Philadelphia: Lippincott Williams & Wilkins,2001.

Carter R, Brooke N, Tucker JV: Courage and

information for life with chronic obstructive

disease, Onset, Mass: New Technology Publishing,1999.

Hodgkin JE, Celli BR, Connors GL: Pulmonary

rehabilitation: guidelines to success, Philadelphia:Lippincott Williams & Wilkins, 2000.

Weg JG, Hass CF: Long-term oxygen therapy forCOPD: improving longevity and quality of lifein hypoxemic patients, Postgrad Med 103:147,1998.

American Physical Therapy Association: Guide tophysical therapist practice, second edition,Phys Ther 81:1, 2001.

146 Clinical Cases in Physical Therapy

TA B L E 3 1 - 3A R T E R I A L B L O O D G A S VA L U E SF O L L O W I N G I N T E R V E N T I O N

ARTERIAL BLOOD GAS VALUES

pH 7.37P2CO2 42 mm HgP2O2 60 mm HgHCO3 28 mEq/LO2 Sat 92%

TA B L E 3 1 - 4P U L M O N A R Y F U N C T I O N T E S TF O L L O W I N G I N T E R V E N T I O N

OBSERVED

FEV1 80%FVC 2.76LFEV1/FVC (%) 46%TLC 7.05 L

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Describe the elements of a musculoskeletal examination of the knee.2. List and describe the signs, symptoms, and clinical patterns for the

presence of a giant cell tumor.3. Explain the importance of referring individuals to the appropriate

specialist when there is any indication that the problem may be beyondthe scope and expertise of the physical therapist.

4. Describe the appropriate interventions for an individual after bone andsoft tissue surgery of the knee.

ExaminationH I S T O R YDuring a brisk 2-mile walk on her lunch break,a 27-year-old woman began to experiencepain along the medial aspect of her left knee.She completed the walk and returned to workin her office for the remainder of the after-noon. Still feeling the pain in her left knee,she drove home from work in noticeable dis-comfort. Shortly after the woman got home,a neighbor dropped off the woman’s 4-year-old daughter from daycare. The woman’shusband, a self-employed building contractor,did not get home until 7 P.M. that evening.Meanwhile, she continued to ambulate andbear weight on the painful extremity whileshe prepared dinner for her family and caredfor her daughter. She took two Tylenol for thepain, which was now a dull throbbing ache.

When her husband got home, the womanwas finally able to get off her feet, sit down,and elevate her leg. The painful area wasnow visibly swollen. She decided to take ahot bath. The bath relaxed her and made herfeel slightly better, but increased the swellingaround her left knee and further restrictedher active range of motion. She went to bedearly, but the throbbing made it difficult tofall asleep, and she did not sleep well.

The next morning, the woman got up anddecided to wrap her knee with an ace band-age. She took two more Tylenol and left forwork. The pain didn’t seem as bad as it did

the night before. She managed to get aroundthe office by favoring her left leg and stoppingto elevate her leg whenever possible. Thispattern continued for several days before shefinally decided to call her family physician.

The woman saw her doctor, who said sheprobably twisted her knee while walking. Thedoctor told her to stay off her feet as muchas possible and gave her a prescription forAnaprox (a nonsteroidal antiinflammatorydrug), which she took for the next 10 days.She felt better the next morning and continuedher busy work and home schedule. A fewdays after her prescription ran out, the painreturned, and it progressively worsened overthe next several days. She called her physi-cian, who suggested that she see a physicaltherapist. The referral slip said, “mild sprainof the medial collateral ligament. Evaluateand treat.”

S Y S T E M S R E V I E WThe physical therapist took a complete his-tory, including the nature, onset, and locationof the pain. The patient had no other pertinentmedical history. An examination of cognitive,cardiovascular, pulmonary, neurologic, andintegumentary systems was unremarkable.

The patient had an obvious limp as shewalked and favored her left leg when sheambulated or stood still. This caused her tolean slightly to the right. Strength and jointrange of motion were evaluated; the results aregiven in Table 32-1. The end feel for passive

147

Case 32

148 Clinical Cases in Physical Therapy

range of motion (ROM) of the left knee wassoft with pain in those movements demon-strating a limitation. Resistance during amanual muscle test (MMT) for flexion andextension of the involved knee also elicited apainful response. Tests for the integrity of thecollateral and cruciate ligaments, and menisciwere all negative.

The patient rated her pain on a visual analogscale as 5/10 in the morning and 8/10 at theend of a typical workday. Most nights it wasintense enough (7/10) to disrupt her sleep.

Why did the physical therapist rule out

the diagnosis of sprained medial collateral

ligament?

Sensation, skin temperature, color, andperipheral pulses all appeared normal. Thephysical therapist noted that the patient hadpoint tenderness over the medial tibial plateauand discovered a palpable soft mass on themedial aspect of the patient’s left knee. Thetherapist explained the findings to the patient

and recommended that she be examined byan orthopedic surgeon. Her medical insuranceplan required that she obtain a referral fromher primary care physician. The therapistcalled the family physician and explained thefindings, and an appointment was scheduledwith the orthopedic surgeon.

To make the patient more comfortable, thephysical therapist instructed her to continueto wrap the knee with an ace bandage, applyan ice pack, elevate her leg as much as pos-sible, and use crutches. The therapist recom-mended that it would be prudent for the patientto ambulate non–weight-bearing until seenby the orthopedic specialist.

The orthopedic specialist’s examinationproduced the same results that the physicaltherapist had observed, most notably, the pres-ence of a soft palpable mass. The patient wassent for magnetic resonance imaging, whichdemonstrated the presence of a 3 × 2 × 2 cmlesion in the left medial tibial plateau andextending outside the bone. The mass wascausing the medial collateral ligament to bulgeoutward. A preliminary diagnosis of osteoclas-tomas, also known as giant cell tumor, wasmade at that time.

What allowed the orthopedic specialist

to make the diagnosis of giant cell tumor

so quickly?

Giant cell tumors are the most common bonetumor found in individuals between age 25and 40. They are more common in femalesand usually found in the distal femur, proxi-mal tibia and distal radius. Pain and swellingbegin when the lesion begins to destroy thecortex of the bone and irritate the periosteum.About 85% of giant cell tumors are benign,but benign giant cell tumors can metasta-size to the lungs. Treatment involves curet-tage of the tumor and bone graft replace-ment, or bone chip packing of the cavity leftby removal of the tumor. A recurrence rateof 40% to 60% is seen in the first 2 years aftersurgery.

A lung scan and bone scan were performedto identify any other lesions; both were nega-tive. The patient was discharged the day after

TA B L E 3 2 - 1S T R E N G T H / R A N G E O F M O T I O ND ATA

(R) (R) (L) (L)PROM MMT PROM MMT

Hip

Flexion 0-120 5/5 0-120 4/5Extension 0-30 5/5 0-30 4/5Abduction 0-45 5/5 0-45 5/5Adduction 0-30 5/5 0-30 5/5Medial 0-45 5/5 0-45 4/5

rotationLateral 0-45 5/5 0-45 4/5

rotation

Knee

Flexion 0-135 5/5 10-100 3/5Extension 0-10 5/5 10 3/5

Ankle

Dorsiflex 0-20 5/5 0-20 4/5Plantarflex 0-50 5/5 0-50 5/5

L, Left; R, right; MMT, manual muscle test; PROM, passive rangeof motion.

surgery after being seen by the physical thera-pist in the hospital. She already had crutchesand knew how to ambulate non–weight-bearing. Because of the bone loss from thelesion, a cast was applied, and the patientremained non–weight-bearing for 6 weeks.After 6 weeks, a radiograph was taken. The cast was removed and replaced with alightweight brace for support. The patientwas allowed to walk with crutches (partialweight bearing) for another month. When thecast was removed, the orthopedic surgeonreferred the patient to the physical therapistonce again.

DiagnosisPhysical Therapist Practice Pattern 4I: ImpairedJoint Mobility, Motor Function, Muscle Per-formance, and Range of Motion Associatedwith Bony or Soft Tissue Surgery.

What was an appropriate physical therapy

plan of care for this patient?

Prognosis G O A L SThe patient will:1. Increase her aerobic capacity to 42 mL/kg/

minute, which is above the 80th percentilefor her age and gender, over a period of 4to 6 weeks.

2. Increase her lower extremity musclestrength to 5/5 in the involved knee over aperiod of 4 to 6 weeks of exercise threetimes per week along with a daily homeexercise program.

3. Increase her ROM for right knee flexion to0 to 135 degrees and extension to 0 degreesduring the same time frame required formuscle strengthening.

E X P E C T E D O U T C O M EThe expected outcome will be attained during4 to 6 weeks of outpatient physical therapythree times a week accompanied by a dailyhome exercise program. The patient’s aerobiccapacity will improve and muscle perform-ance (strength, power and endurance) will

increase. The patient will regain the ability toperform activities related to home manage-ment, work, and leisure.

D I S C H A R G E P L A NThe patient will be discharged from physicaltherapy when she had full passive and activeROM in the involved knee, muscle strengthequal to the contralateral leg, and the abilityto perform all activities of daily living at herprevious level.

InterventionAfter the physical therapist’s reexamination,the patient was encouraged to perform gentleactive range of motion exercises along withquadriceps and hamstring setting. When sub-sequent radiographs demonstrated completebone healing, a more aggressive program formuscle strengthening and joint ROM wasinstituted.

She performed cardiovascular/pulmonaryexercises on a bicycle ergometer, UBE, andwalking at an appropriate intensity, beginningat 60% of the age-predicted maximum heartrate and progressing toward 90% as her fitnesslevel increased. The program also includedisometric, isokinetic, and isotonic exercises;heat application; and aquatic therapy.

OutcomeThe patient increased her maximum aerobiccapacity from 37 mL/kg/minute to 42 mL/kg/minute, as measured by bicycle ergometry. Inaddition, she increased strength in the involvedextremity to 5/5. The giant cell tumor wasremoved with no recurrence. The pathologywas corrected, and the patient had a fullrecovery with no residual impairments, dis-abilities, or handicaps.

DiscussionGiant cell tumors are common in women ofthis patient’s age group. Most are discoveredaccidentally when patients are seen by ahealth care specialist for what appears to bea common musculoskeletal injury. If these

Case 32 149

patients are not seen, diagnosed, and treatedpromptly, the bone that has been weakenedby the tumor will eventually fracture. As com-monly seen, this patient had family and workresponsibilities that caused her to delayseeking prompt treatment.

Because the physical therapist followedthe Guide to Physical Therapist Practice

and performed a thorough examination, thetumor was detected and the appropriatereferral was made. Subsequently, the correcttreatment was provided and the patient had a positive outcome. Had the physicaltherapist not detected the tumor, the patientlikely would have received inappropriatecare and delayed the appropriate interventionuntil she fractured her tibia and radiographsrevealed the tumor. This case underscores

the importance of a thorough and accurateexamination.

R E C O M M E N D E D R E A D I N G S

Dorfman HD, Czerniak B: Bone tumors, St Louis:Mosby, 1998.

Schubach GD, Wallis JW: Diagnosis: giant celltumor, available at http://www.gamma.wvstl.edu/bs047tel143.html

ViaHealth: Bone disorders: giant cell tumor,available at http://www.viahealth.org/disease/bone-disorders/giant.html.

ACSM: Guidelines for exercise testing and

prescription (ed 6), Philadelphia: LippincottWilliams & Wilkins, 2000.

American Physical Therapy Association: Guide tophysical therapist practice, second edition,Phys Ther 81:1, 2001.

150 Clinical Cases in Physical Therapy

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Identify the preferred practice pattern for a patient who has undergoneopen reduction, internal fixation surgery on the hip.

2. Identify signs and symptoms indicating a lack of expected response tonitroglycerine medication.

ExaminationA home health physical therapist was treatinga 72-year-old man who was recovering froman open reduction internal fixation of a righthip fracture. The man had a history of anginaand had non–insulin-dependent diabetes. Hewas ambulatory with the use of a walker and50% weight bearing; he ambulated about hishome without difficulty. The improvement instrength and ambulation the patient demon-strated indicated that he had been performinghis exercises as directed.

DiagnosisPhysical Therapist Practice Pattern 4I:Impaired Joint Mobility, Motor Function,Muscle Performance, and Range of MotionAssociated with Bony or Soft Tissue Surgery.

One morning, the therapist arrived to find the patient in bed and in moderatedistress. The patient indicated that he wokeat about 4 A.M. with tightness in the chest andperiodic chest pains. He reported havingslight difficulty with respiration. The patient’spulse rate was 96 beats per minute and bloodpressure was 150/100 mm Hg, both measuredwith the patient supine. The patient indi-cated that he had taken his medication for diabetes and that his blood sugar levelwas within acceptable limits. Informationgathered during the initial evaluation severalweeks earlier indicated the patient also usednitroglycerin. The patient indicated he had taken nitroglycerin twice since 4 A.M.,but that it had made no difference in hischest discomfort.

EvaluationWhat was the immediate concern

regarding the reported ineffectiveness

of the medication?

Nitroglycerin is a fast-acting medication.Normally, a patient would notice some reliefof chest discomfort almost immediately ontaking the medication. The therapist examinedthe label on the medication bottle and foundthat the nitroglycerin prescription was 2 yearsbeyond the indicated expiration date. Mean-while, the patient became diaphoretic andexhibited increased difficulty breathing. Hetook another nitroglycerin tablet, but themedication failed to produce any change insymptoms.

What was the most appropriate course

of action?

InterventionThis patient presented all the symptoms ofan acute cardiac event. The therapist contactedemergency medical services, which thentransferred the patient to the local hospital.During transport, the ambulance crewadministered additional nitroglycerin. Withinmoments, the patient indicated that his chestpain had subsided substantially and he couldbreathe more easily.

OutcomesAfter the patient’s discharge from the hospital,it was determined that the nitroglycerin that

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he had been taking was old and ineffective. Atherapist providing home health services needsto know the location of any medication thatthe patient is taking, so he or she can helpprovide that medication in the event of dis-tress. In this case, the therapist’s knowledgeof the patient’s home environment and thenormally fast-acting nature of nitroglycerinwas essential enabled the therapist to recog-nize a cardiac distress situation and initiateaction. When the patient returned home, he wasprovided with a new supply of nitroglycerintablets. He was also instructed by his physi-cian to call for a new supply every 6 months.

DiscussionThe therapist attempted to monitor thesituation and contacted emergency medicalservices when all conservative measures hadfailed. The steps taken were appropriate forthe situation. The important point in this caseis the failure of the nitroglycerin to relievesymptoms. Nitroglycerin relaxes vascularsmooth muscle, producing a general vasodi-lation effect throughout the body. The adminis-tration of nitroglycerin has been shown toreduce blood pressure in some patients. Phar-macists commonly suggest that nitroglycerinpills older than 6 months be discarded.

R E C O M M E N D E D R E A D I N G S

Baumann BM, Perrone J, Hornig SE, et al:Randomized, double-blind, placebo-controlledtrial of diazepam, nitroglycerin, or both fortreatment of patients with potential cocaine-associated acute coronary syndromes, Acad

Emerg Med 7:878, 2000.Cooper A, Hodgkinson DW, Oliver RM: Chest pain

in the emergency department, Hosp Med

61:178, 2000.Engelberg S, Singer AJ, Moldashel J, et al: Effects

of prehospital nitroglycerin on hemodynamicsand chest pain intensity, Prehosp Emerg Care

4:290, 2000.Everts B, Karlson B, Wahrbog P, et al: Pain

recollection after chest pain of cardiac origin,Cardiology 92:115, 1999.

Kimble LP, Kunik CL: Knowledge and use ofsublingual nitroglycerin and cardiac-relatedquality of life in patients with chronic stableangina, J Pain Symptom Manage 19:109, 2000.

Mahmarian JJ, Moye LA, Chinoy DA, et al:Transdermal nitroglycerin patch therapyimproves left ventricular function and preventsremodeling after acute myocardial infarction:results of a multicenter prospective random-ized, double-blind, placebo-controlled trial,Circulation 97:2017, 1999.

Purvis GM, Weiss SJ, Gaffney FA: PrehospitalECG monitoring of chest pain patients, Am J

Emerg Med 17:604, 1999.

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Describe potential risks of personal contamination when performingwound debridement procedures.

2. Describe ways to reduce risks of personal contamination whileperforming wound debridement procedures.

ExaminationH I S T O R YTwo physical therapists were assigned to workin the hydrotherapy department of an acutecare hospital. For the past 2 weeks one of theirinterventions consisted of providing hydrother-apy to a very ill patient who was positive forhuman immunodeficiency virus (HIV) and hepa-titis C and had open wounds. A large portionof the area receiving debridement was verypainful and frequently bled into the whirlpool.

DiagnosisPhysical Therapist Practice Pattern 7D:Impaired Integumentary Integrity Associatedwith Full-Thickness Skin Involvement andScar Formation.

The patient generally tolerated wounddebridement well. In one particular instance,however, as a wound was being cleaned, thepatient suddenly moved because of pain. Thesudden movement, although completely acci-dental, splashed water into one therapist’sface and directly into her eye. The therapistimmediately dropped her debridement toolsand jumped back, requesting a towel. Thetherapist did not suffer any puncture woundsfrom the sharp instruments she was holdingat the time of the incident.

What was the best response in this situation?

Intervention The first therapist calmed the patient andquickly came to the assistance of the therapist

who had been splashed with the contami-nated water. She helped wipe the therapist’sface and then used an eye irrigation systemavailable within the department to cleanseand irrigate the eye. Although no water hadentered the therapist’s mouth, the first ther-apist helped rinse the splashed therapist’smouth with 10% hydrogen peroxide. Thesplashed therapist was taken to the emer-gency department, where her eye was irri-gated again and blood samples were taken toestablish a baseline by which to monitorexposure to HIV.

OutcomeThe accident was documented with an inci-dent report. Since the splash incident,departmental policies and procedures havechanged. The entire department wasinstructed in the proper mechanisms to usein the event of a similar incident. Anyonenow working in the hydrotherapy depart-ment must wear a face shield to preventanother such event. To date, additional testshave been negative for the presence of HIV,and the therapist continues to work in thesame hydrotherapy area. All health careworkers exposed to any blood-borne pathogenshould be baseline tested immediately afterexposure.

DiscussionWhat health care concerns should therapists

have when providing sharp instrument

debridement?

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Although there are no documented instancesof a therapist contracting HIV throughhydrotherapy, exposure safety precautionsmust be followed. Besides wearing properclothing, it is important to add chemical dis-infectants to the water to lessen the proba-bility of exposure should a splash occur. In thisinstance, the water had been treated withchemical disinfectants before the initiationof debridement.

HIV is not the only transmissible virus ofconcern to healthcare providers. Hepatitis C,a viral disease primarily affecting the liver,has infected more than 4 million people inthe United States. Worldwide, it affects anestimated 3% of the population. It has beenprojected that up to 10,000 people in the UnitedStates will die each year from the disease,and that this death toll may triple by the year2010. The primary transmission route forhepatitis C is through the blood. The risk tohealth care workers for contracting hepatitisC by needle stick is between 1.2% and 10%,compared with 0.3% for HIV. Appropriatesafety procedures must always be taken bytherapists during hydrotherapy to avoidpuncture wounds with sharp and potentiallycontaminated instruments.

R E C O M M E N D E D R E A D I N G S

Beekmann SE, Vaughn TE, McCoy KD, et al:Hospital bloodborne pathogens programs:program characteristics and blood and bodyfluid exposure rates, Infect Control Hosp

Epidemiol 22:73, 2001.

Berrouane YF, McNutt LA, Buschelman BJ, et al:Outbreak of severe Pseudomonas aeruginosa

infections caused by a contaminated drain in awhirlpool bathtub, Clin Infect Dis 31:1331,2000.

Burke DT, Ho CH, Saucier MA, Stewart G: Effectsof hydrotherapy on pressure ulcer healing, Am

J Phys Med Rehabil 77:394, 1998.Dillman CM: Hepatitis C: a danger to healthcare

workers, Nurs Forum 34:23, 1999.Ganju SA, Goel A: Prevalence of HBV and HCV

infection among health care workers (HCWs),J Commum Dis 32:228, 2000.

Gogi PP: Physical therapy modalities for woundmanagement, Ostomy Wound Manage 42:46,50, 54, 1996.

Hollyoak V, Boyd P, Freeman R: Whirlpool bathsin nursing homes: use, maintenance, andcontamination with Pseudomonas aeruginosa,

Commun Dis Rep CDR Rev 23:102, 1995.Juve Meeker B: Whirlpool therapy on post-

operative pain and surgical wound healing: anexploration, Patient Educ Couns 33:39, 1998.

Madan AK, Rentz DE, Wahle MJ, Flint LM:Noncompliance of health care workers withuniversal precautions during trauma resus-citations, South Med J 94:277, 2001.

Moloughney BW: Transmission and postexposuremanagement of bloodborne virus infections inthe health care setting: where are we now?CMAJ 165:445, 2001.

Pearson T: The wearing of facial protection inhigh-risk environments, Br J Perioper Nurs

10:163, 2000.Stevens AB, Coyle PV: Hepatitis C virus: an

important occupational hazard? Occup Med

(Lond) 50:377, 2000.

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Define the “terrible triad” injury.2. Discuss a possible cause for a joint infection.3. Describe signs and symptoms of a joint infection.

The reader should know that a 23-year-old man

had been referred to physical therapy after

sustaining an injury to his right knee while

playing intramural basketball 1 week earlier.

The patient was initially treated in a hospital

emergency department and referred to an

orthopedic surgeon for specialist care. The

patient was seen the next day by an orthopedic

surgeon, who aspirated about 20 mL of blood

from the knee. The injury was sustained when

the patient was rebounding and felt the knee

give way when he came down with the ball.

The physician suspected the “terrible triad”

injury, to the medical collateral ligament,

medial meniscus, and the anterior cruciate

ligament. The patient desired to attempt physical

therapy for a period of time before agreeing to

arthroscopic surgery or any form of reconstruction.

On examination, the therapist found the patient

bearing partial weight on the leg while using

crutches. The knee was very warm and sensitive

to light touch, and range of motion was painful,

with flexion to only 70 degrees and extension

limited to –15 degrees. The patient indicated

he had been running a low-grade fever of

99 degrees and that he generally was not feeling

well. The physician requested a physical

therapist initiate range of motion (ROM) and

progress weight-bearing as tolerated. The first

intervention (consisting of gentle ROM) did not

go well, because the patient was experiencing

severe pain. The patient made no discernible

progress in obtaining additional ROM.

ExaminationH I S T O R YThe patient was a physically well-condi-tioned young man who had been running and

working out in a gym regularly. He indicatedthat he weighed 225 pounds and was capableof bench-pressing 300 pounds and squat-lifting 400 pounds. He reported that he playedcollege football and had sustained injuries inthe past but none to this degree. None of theprevious injuries involved the lower extremi-ties. Medications included a nonsteroidalantiinflammatory drug and a mild pain reliever.He took pain medication before attending thefirst physical therapy session. He believed hehad good pain tolerance. He stated that hehad been accepted to law school and wasplanning to begin school in 8 months.

S Y S T E M S R E V I E WThe patient presented with no known cardiacor pulmonary problems. His heart rate waswithin normal limits. Blood pressure was150/90 mm Hg, measured in the left upperextremity while seated. The patient indicatedthat his blood pressure was usually muchlower, and he believed that it was high becausethe pain in his leg had kept him awake thenight before.

T E S T S A N D M E A S U R E SSensation was intact throughout the lowerextremity. ROM and strength were withinnormal limits in the involved hip and ankle.The knee was visibly swollen and warm to thetouch. Palpation to the soft tissues aroundthe knee elicited a very painful response. Thepatient indicated he had been applying iceonce an hour for 20 minutes, but that the knee“just heats right back up.” There was noreported calf discomfort or pain on palpation.

What type of problem was suspected?

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EvaluationThe therapist recognized the problem aspossibly related to an infection in the kneejoint. The knee was warm and sensitive tolight touch. The patient indicated he had agood pain tolerance and had been applyingice to the area as recommended. The calfpresented no tenderness upon palpation.

DiagnosisPhysical Therapist Practice Pattern 4E:Impaired Joint Mobility, Motor Function,Muscle Performance, and Range of MotionAssociated with Localized Inflammation.

What was an appropriate course of action?

InterventionThe physician’s office was immediately con-tacted and apprised of the patient’s symp-toms. The patient was seen by the physicianlater that same day and subsequently admit-ted to the hospital. The next day the patientunderwent arthroscopic surgery for kneeirrigation and was given intravenous anti-biotics for 7 days. It was suspected thepatient may have contracted a staphylo-coccal infection of the knee during needleaspiration of the joint.

OutcomeOnce the infection was under control, thepatient resumed physical therapy. The primarygoal of rehabilitation was to restore ROMand ambulation. Because of the presence ofthe infection, no attempt was made by thesurgeon to make internal derangement repairs

to the knee. Repairs were performed at a laterdate once there was convincing evidencethat the infection had subsided. The patientresumed ambulation without gait abnormali-ties and began law school. His conditioningprogram now included a low-weight, high-repetition program for the involved extremity.

R E C O M M E N D E D R E A D I N G S

Dubost JJ, Soubrier M, Sauvezie B: Pyogenicarthritis in adults, Joint Bone Spine 67:11,2000.

Holder-Powell HM, DiMatteo G, Rutherford OM:Do knee injuries have long-term consequencesfor isometric and dynamic muscle strength?Eur J Appl Physiol 85:310, 2001.

Hurley MV: The effects of joint damage on musclefunction, proprioception and rehabilitation,Man Ther 2:11, 1997.

Le Dantec L, Maury F, Flipo RM, et al: Peripheralpyogenic arthritis: a study of one hundredseventy-nine cases. Rev Rhum Engl Ed 63:103,1996.

Nair SP, Williams RJ, Henderson B: Advances inour understanding of the bone and jointpathology caused by Staphylococcus aureus

infection, Rheumatology (Oxford) 39:821, 2000.Regev A, Weinberger M, Fishman M, et al:

Necrotizing fasciitis caused by Staphylococcus

aureus, Eur J Clin Microbiol Infect Dis

17:101, 1998.Smerdelj M, Pecina M, Hasp M: Surgical treatment

of infected knee contracture after war injury,Acta Med Croatica 54:151, 2000.

Solomom DH, Simel DL, Bates DW, et al: Does thispatient have a torn meniscus or ligament of theknee? Value of the physical examination,JAMA 286:1610, 2001.

Swain R: An unusual cause of knee pain in anadolescent basketball player, Clin J Sport Med

10:142, 2000.

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Discuss the importance of history taking as an ongoing process.2. Describe appropriate procedures to follow when spontaneous bleeding

occurs during physical therapy (whirlpool) intervention.

ExaminationA therapist was assigned to hydrotherapy tofill in for another therapist who had to attendan unscheduled mandatory meeting in anotherarea of the hospital. That therapist indicatedthat the patient had a full-thickness third-degreeburn involving the anterior compartment ofthe left lower extremity. The extremity alsohad an infection with Staphyloccocus aureus

that was seriously affecting the healing of arecent surgical skin graft. To fully irrigate thewound, the patient had to lie semireclined ina full-body whirlpool. Sterile technique wasto be followed throughout the course of thetreatment. The patient’s entire medical recordand rehabilitative service records were avail-able for review before initiating intervention.The patient received hydrotherapy twice daily.

The patient sustained the burn as a resultof falling asleep in bed while smoking. He hadbeen to surgery on two occasions. The firstsurgery was after admission to the hospitalfor wound debridement. The second surgicalintervention occurred 12 days after the firstoperation once the wound was ready for graft-ing. During that surgery 5 days earlier, graftswere taken from donor sites on both thighs.

The patient was receiving intravenous (IV)antibiotics, intramuscular (IM) morphine forpain relief, and coumadin (an anticoagulant)because of concerns regarding potentialphlebitis. The IV site, located in the right fore-arm, had required replacement twice becausethe patient exposed the arm to the whirlpoolwater, loosening the tape and partially remov-ing the needle. The patient’s most pressinghealth care concern was, however, the poten-tial loss of the grafts as a result of infection.

The patient was a 61-year-old man whowas a heavy smoker (41 years of two packsper day) and had little formal education. Helived alone and indicated he had no interestin stopping smoking. He was cooperative butseldom understood complex medical termsand concepts. A review of the chart indicatedthat he had signed all consent forms by markingan “X” in areas for signature.

The patient’s physician requested aggres-sive cleansing of the wound. Small superficialpockets of purulent drainage were present,and the patient had a low-grade fever of101° F. Additionally, to enhance wound heal-ing, the physician requested that staples withovergrowing skin be removed.

EvaluationThe patient was a suitable candidate forphysical therapy intervention. He receivedwhirlpool twice daily and was receiving the first of two scheduled sessions. Thirtyminutes before the whirlpool treatment, hereceived intramuscularly administered painmedication. Without this medication, thepatient could not tolerate treatment inter-vention and became impatient and agitated.Timing whirlpool sessions in conjunctionwith the administration of pain medicationwas critical to providing effective whirlpoolinterventions.

DiagnosisPhysical Therapist Practice Pattern 7D:Impaired Integumentary Integrity Associatedwith Full-Thickness Skin Involvement andScar Formation.

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InterventionWhile cleaning the wound, the therapistcame across a staple near the surface of theskin that was particularly difficult to remove.When removed, blood suddenly began pul-sating from the leg while the extremity wasunder water.

What was the proper response to the

bleeding?

The patient in this case had been receivingphysical therapy since his hospital admission.Before initiating an intervention with thispatient, the therapist had thoroughly reviewedthe patient’s chart. Part of this reviewincluded reading earlier therapy notes, nurs-ing notes, and notes on the surgeries that hadbeen performed. The therapist also spoke indepth with the patient regarding his responseto intervention and how he believed he wasprogressing. Because of the patient’s inabilityto ambulate, his physician had become con-cerned regarding the potential for phlebitisin the lower extremities and had initiatedcoumadin therapy 4 days earlier. The therapistinformed the patient of the importance ofanticoagulant medication and its potentialimpact on intervention. Rehabilitative servicessupport staff directly involved in providingcare to the patient were apprised of thepotential change in the patient’s health carestatus and the new medication. Because of thepatient’s fever, the therapist informed supportstaff that the typical duration of whirlpooltherapy may have to be decreased if thepatient indicates that he is not feeling well.

Staple removal must always be done withcaution. It is not uncommon for small arte-rioles to bleed as a result of stress caused bywound care in adjacent areas. Clotting abilitymay be reduced with the addition of coumadin.Arterial bleeding near the surface of the skinis often best controlled with direct pressure.In this case, the correct response was to leavethe patient in the whirlpool. The combina-tion of pressure of the water in the whirlpooland direct pressure applied with a gauzebandage controlled the bleeding. Keeping thepatient in the whirlpool and applying pressure

to the wound allowed others to make arrange-ments to transfer the patient to a stretcherfor rapid transport, if needed. In this case thewound stopped bleeding, and the sessionwas safely concluded.

Based on the occurrence of bleeding in the

first whirlpool session, was it appropriate

to cancel the second scheduled session?

The therapist decided to proceed with theafternoon session of whirlpool intervention,but did not proceed as aggressively withdebridement. The session went well, and thepatient tolerated the intervention withminimal bleeding.

OutcomesThe preferred method to control severebleeding is the application of direct pressure.In the absence of a compress, a gloved handor fingers may be used, but only until a com-press pad can be applied. Blood clots shouldnot be disturbed once they have formed. Ifblood soaks through the entire pad withoutclotting, then the pad should not be removed;instead, additional thick layers of dressingshould be added and direct pressure con-tinued. If pressure firmly applied to the areadoes not assist in the control of bleeding, thenthe extremity should be elevated and pres-sure also applied to the artery supplying theinvolved area. In this case, direct pressurewas applied to the site with gauze while theextremity remained in the whirlpool. The woundstopped bleeding within 2 minutes of pres-sure application without harm to the patient.

DiscussionBeyond the issues regarding successful woundcare management, this case presents issuesconcerning the proper steps to take whenfollowing previous health care interventionsand providers. A patient with a third-degreeburn grafting and infection may demonstratechanges in health care status between therapyinterventions. In this case the therapist notonly reviewed the patient’s chart but also

spent significant time gaining an under-standing of how the diagnosis and previousinterventions may have changed since the lastwhirlpool session. Because of the therapist’sinterest in understanding the current healthstatus of the patient, there was no surprisewhen the prescribed medication increased thelikelihood of bleeding. Providing whirlpoolintervention as a follow-up to other health careinterventions requires the therapist to collectand sort new data that can identify potentialproblems and improve outcome potential.

What was a reasonable health care “team

approach” concerning patient education?

Fires started by cigarettes are the mostcommon source of fatal house fires. Approxi-mately 29% of fire deaths in the United Statesare caused in a manner similar to how thispatient was burned. With limited ambulationability and a refusal to stop smoking, thispatient was at risk for further injury. Thefocus of the patient education effort becameone of involving social services, the physi-cian, and the physical therapist in an educa-tional effort to assist the patient in lifestylemodification. The physical therapy programincluded improving the patient’s overall con-ditioning. Social services focused on encour-aging the patient to attend a local smokingcessation program. The physician emphasized

to the patient the need to stop smoking tomaintain good oxygenation levels in order topromote proper wound healing. Over thenext several months, the patient was able toreduce his smoking significantly and achievedgood wound healing.

R E C O M M E N D E D R E A D I N G S

Barillo DJ, Brigham PA, Kayden DA, et al: The fire-safe cigarette: a burn-prevention tool, J Burn

Care Rehabil 21:162, 2000.Fritsch DE, Coffee TL, Yowler CJ: Characteristics

of burn patients developing pressure ulcers, J Burn Care Rehabil 22:293, 2001.

Ho WS, Ying SY, Chan HH: A study of burn injuriesin the elderly in a regional burn center, Burns

27:382, 2001.Muller MJ, Pegg SP, Rile MR: Determinants of

death following burn injury, Br J Surg 88:583,2001.

Stassen NA, Lukan JK, Mizuguchi NN, et al: Thermalinjury in the elderly: when is comfort care theright choice? Am Surg 67:704, 2001.

Stiles NJ, Bratcher D, Ramsbottom-Lucier M, HunterG: Evaluating fire safety in older personsthrough home visits, J Ky Med Assoc 99:105,2001.

Treharne LJ, Kay AR: The initial management ofacute burns, J R Army Med Corps 147:198,2001.

Wibbenmeyer LA, Amelon MJ, Morgan LJ, et al:Predicting survival in an elderly patientpopulation, Burns 27:583, 2001.

Case 36 159

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Identify and recommend creative switch placement for use of assistivetechnology for children/consumers whose physical disabilities limit theuse of more conventional switch solutions.

2. Differentiate between criteria/candidacy for contemporary spasticitymanagement alternatives.

ExaminationH I S T O R YThe patient was an 11-year-old white malewith choreoathetotic and spastic cerebralpalsy, who was significantly compromised inmovement and physical interactions with hisenvironment. Electronic devices (i.e., for com-munication and mobility) had the potentialto improve his participation in home and schoolenvironments. Evolution of assistive tech-nology switch choices, including type and place-ment, to facilitate interaction with his envi-ronment, had been slow and frustrating forthe child, his parents, and his younger sibling.

This child first demonstrated atypicalmotor skill development at age 4 months. Heexhibited significant limitations in movement,mobility, and access to his environmentbecause of his athetoid movements, spas-ticity, and muscle spasms. The child found itdifficult to maintain a seated position becauseof hypertonicity, and he began to arch andslide, requiring frequent assistance withrepositioning. Furthermore, spasms were aproblem during the day and night, and hissleep was frequently disrupted because ofapparent discomfort.

S Y S T E M S R E V I E WInitial observation showed a thin child in noapparent distress. Musculoskeletal examinationrevealed limited flexibility in the hamstringsbilaterally. This child reported lower extremitypain, specifically in the left hip on passive oractive movement, and his position of comfortwas with the left hip in flexion, adduction,

and internal rotation, accompanied by kneeflexion. Other findings included hypertonicityin the extremities and athetoid movements inthe upper extremities and oral-motor muscu-lature. Neuromuscular examination revealedthat the child had a floor mobility strategyusing side-to-side rolling. He maintainedshort sitting when placed and provided withmaximal adult assistance at the trunk. Herequired adult assistance for all transfer andpositioning tasks.

The child’s cognitive skill level was closeto age level, and he attended school in thecommunity in which he lived. He had expe-rienced significant limitations in movement,access, and mobility because of his athetoidmovements, spasticity, and muscle spasms.He made several verbal utterances (“yeah,”for example), but otherwise communicatedusing a DynaMyte augmentative communi-cation device (Dynavox Systems, SunriseMedical, Pittsburgh, Pennsylvania), using anautomatic scan setting. With that setting, thedevice scrolled through categories of topics,from which the user actively selected. Withinthe categories, the device had preprogrammedsentences, phrases, words, or responses. Theindividual waited for the device to advanceto the desired response. (This child requiredswitch access for both his augmentativecommunication device and his power wheel-chair.) Since the child’s preschool years, along progression of switches had been imple-mented and abandoned, including a simplepad switch (or “jellybean”) and toggle switches.Placement had also varied over the years,

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including upper extremity, lower extremity,head, and chin. All had been unsuccessful forlong-term use.

T E S T S A N D M E A S U R E SHamstring flexibility was measured with thehip positioned in 90 degrees of flexion andneutral rotation. The right knee lacked 30degrees of extension, and the left knee lacked45 degrees. Limitations of range of motionwere noted, specifically hip extension on theleft at –35 degrees (with discomfort), hipabduction on the right at 0 to 15 degrees, andhip abduction on the left at 0 to 5 degrees.

Muscle tone was evaluated using a modi-fied Ashworth scale,1 which provides specificcriteria with which to evaluate spasticity.Muscle tone was graded on an ordinal scaleof 0, 1, 1+, 2, 3, and 4, with 0 indicating noincrease in muscle tone on imposition ofquick stretch, 1 indicating a slight increase inmuscle tone with a quick catch and releasepalpated (with catch defined as the initialresistance to motion in the muscle and release

defined as subsequent muscle relaxationthat permits motion), 1+ indicating a slightincrease in muscle tone with a quick catchand release palpated and minimal resistancepalpated through the remainder of the rangeof motion after the catch, 2 indicating moremarked increase in muscle tone through muchof the range of motion but with the affectedpart easily moved, 3 indicating considerableincrease in muscle tone with passive movementdifficult, and 4 indicating rigidity of flexionor extension in the affected part. Upperextremity tone was scored as 2 in the bicepsand 3-4 in the triceps brachii; lower extremitymuscle tone, as 3-4 in the adductors andhamstring muscles and 2 in the gastrosoleuscomplex. Variable muscle tone was reported,representing the range of findings in thedescribed muscles during the physicalexamination.

The child’s functional skill level wasassessed using the Gross Motor FunctionalClassification System (GMFCS).2 This ordinalclassification scale measures a child’s per-formance based on self-initiated movement. It

is a five-level system, with distinctions betweenlevels based on functional limitations and theindividual’s use of assistive technology, includ-ing a broad range of assistive and mobilitydevices. Level I describes motor function ofthose most mildly involved children, andlevel V represents motor function of childrenwith severe limitations in self-mobility. Thissystem is appropriate in evaluating individualsup to age 12. The patient in this case met thecriteria for level V. Given the problems withselection of switch type and placement, thechild’s self-mobility was severely limitedeven with the use of assistive technology.

EvaluationThis child needed a switch that would usehis most available motor strategy to activatethe mobility and communication devices.The optimal placement for a switch wouldallow him to use movements over which hehas the greatest control.

What considerations were incorporated into

decisions regarding switch access for this

individual?

A second major issue for this child centeredon optimal management of spasticity. Hisspasticity influenced ease of positioning, easeof care, function, and comfort, which ofcourse hindered his ability to participatemaximally in his home, school, and commu-nity environments. Therapy with diazepam(Valium) had been used with some minimalappreciable effect. Because of the general-ized distribution of his spasticity, the patientdid not appear to be an appropriate candi-date for botulinum toxin type A injections.Botulinum toxin type A has been describedin the literature as producing the best effectswhen spasticity is focal versus generalized.3

The patient also did not meet the criteria forselective dorsal rhizotomy.4

What were appropriate spasticity

management options for discussion and

potential trial?

DiagnosisPhysical Therapist Practice Pattern 5C:Impaired Motor Function and SensoryIntegrity Associated with NonprogressiveDisorders of the Central Nervous System—Congenital Origin or Acquired in Infancy orChildhood.

PrognosisGiven appropriate switch placement andeffective interface with mobility and commu-nication systems, this child’s prognosis pre-dicted independent mobility in his school,home, and community environments (althoughhe would continue to require adult assistancefor transfers). Additionally, he was expectedto attain an improved level of autonomy incommunication because of the use of theswitch (although this is outside of a physicaltherapist’s scope of practice).

Intrathecal baclofen therapy was recom-mended by the spasticity management evalua-tion team. In this approach to reducing spas-ticity, the drug baclofen is introduced intothe subarachnoid space through a catheter,which is attached to a computer-controlledpump.5,6 This pump contains a reservoir forthe drug and is refilled periodically. After asuccessful trial (using a bolus dose ofbaclofen, injected intrathecally), an intrathecalbaclofen pump was implanted subcutaneouslyin the anterior abdominal wall. The child wasexpected to experience reduced spasticityand improved ease of positioning, with thebenefits of a reduced burden of care for hiscaregivers and an improved ability to worktoward independent sitting. Reduced pain andpositional discomfort were also predicted.

After baclofen administration, what

components of the physical therapy plan

of care were considered?

The recommended plan of care includedflexibility exercises, balance and postureawareness training, neuromotor develop-ment, strength training, intrathecal baclofentrial, and alternative switch trials. This child’sschool-based physical therapy program was

provided three times per week, and statusand outcomes were reevaluated at the end ofthe school year.

G O A L SShort-term goals included:1. Improve hip abduction range of motion by

10 degrees to improve seated base ofsupport, in 3 months.

2. Improve abdominal and erector spinaestrength, for improved upright posture insitting, measured at grade 3+, in 3 months.

3. Demonstrate success with powered mobilityusing appropriate switch, 80% of trials, in6 months.

4. Demonstrate success with DynaMyteusing appropriate switch, 80% of trials, in6 months.

5. Demonstrate success with independenttransfers between devices using appro-priate switch, 80% of trials, evaluated in 6months.

Long-term goals were as follows:1. Maintain independent sitting, when on a

firm surface, with close supervision, up to5 minutes, in 6 months.

2. Demonstrate independent powered mobilityin 100% of trials, in all environments, in 1 year.

3. Demonstrate independent communicationusing DynaMyte 100% of trials, in all envi-ronments, in 1 year.

How was evidence applied to guide

selection of appropriate interventions?

InterventionAfter numerous trials with prototypes usingthe creative input and suggestions of manyteam members and vendors, one long-term,useful solution for this child involved aninfrared switch. This switch was mounted toa head set, an arrangement that finallyprovided the child with significantly greaterconsistency of switch access to his powerwheelchair and DynaMyte augmentative com-munication device. The child used an oral-motor point of access (his area of greatestmotor control) by interrupting the infrared

Case 37 163

beam with his tongue. He used this switchwith considerable success, and continued towork on his accuracy and control using theswitch with his wheelchair. Through problem-solving efforts of his assistive technologyservice providers, this one-of-a-kind prototypewas created.

After a trial of oral baclofen and a trial bolusdose of baclofen intrathecally (both were suc-cessful), this child underwent an intrathecalbaclofen pump insertion. He received thisseveral months after his eleventh birthday.

Left hip radiograph findings indicatedvalgus positioning of the femoral neck-shaftrelationship, with mild uncovering, but revealednothing acute. The left femoral head was lessdeveloped than the right, but no significantsigns of any displacement were noted. Non-steroidal antiinflammatory drugs were recom-mended6 to reduce the child’s discomfortrelated to any soft tissue or joint surfacemicrotrauma and/or inflammation.

ReexaminationThe child recently experienced switch failure,noted when the switch stopped functioning,because of suspected problems with exces-sive moisture (i.e., saliva). The switch wasreplaced. As a result of the switch failure,investigation into alternative switches usingsimilar access is under way.

During evaluation after the baclofen pumpimplantation surgery, the child was noted tosit apparently quite comfortably in hiswheelchair, with his right leg casually flexed,abducted, and crossed over the left. Evalua-tion of spasticity in the lower extremities(i.e., hip and knee musculature) using themodified Ashworth scale showed a reductionin scores ranging from 3 to 4 before pumpimplantation to 2 to 3 after pump implanta-tion. When positioned in sitting on the edgeof the examination table, the child maintainedan upright position for several minutes withmoderate trunk support. He showed no arch-ing or sliding while maintaining this position.

OutcomeThe patient’s family reports that the patientis doing well, exhibiting a general reductionin muscle tone and pain. The family notes thissubjectively, from their observations whileassisting the child with activities of daily living.Reduced spasticity has also been noted onclinical examination. Functionally, the childshows improved participation in sitting,requiring less assistance and with greaterrelative comfort.

The child continues to work on consistencywith independent mobility and maneuver-ability over greater distances, in the schoolsetting, at this time. Efforts continue tofabricate a switch for the child that will havegreater durability over time.

Although the child continues to complainabout the left hip pain, before the pump hewas frequently reported to hurt “everywhere.”As the child experiences less discomfort, hewill have greater attention and energy fortasks and challenges facing him daily.

R E F E R E N C E S

1. Bohannon RW, Smith MB: Interrater reliabilityof a modified Ashworth scale of musclespasticity, Phys Ther 67:206, 1987.

2. Palisano R, Rosenbaum P, Walter S, et al:Development and reliability of a system toclassify gross motor function of children withcerebral palsy, Dev Med Child Neurol 39:214,1997.

3. Russman BS, Tilton A, Gormley ME: Cerebralpalsy: a rational approach to a treatmentprotocol, and the role of botulinum toxin intreatment, Muscle Nerve Suppl 6:S181, 1997.

4. McLaughlin JF, Bjornson KF, Astley SJ, et al:Selective dorsal rhizotomy: efficacy and safetyin an investigator-masked randomized clinicaltrial, Dev Med Child Neurol 40:220, 1998.

5. Campbell SK, Almeida GL, Penn RD, CorcosDM: The effects of intrathecally administeredbaclofen on function in patients with spasticity,Phys Ther 75:352, 1995.

6. Ciccone CD: Pharmacology in rehabilitation

(ed 3), Philadelphia: FA Davis, 2001.

164 Clinical Cases in Physical Therapy

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Identify a reason why a patient may have anterior thigh pain after totalhip arthroplasty surgery.

2. Discuss examination procedures to help identify the source of pain in apatient who has undergone total hip arthroplasty.

3. Formulate a recommendation for a patient status post–total hiparthroplasty with a residual leg length difference.

ExaminationH I S T O R YThe patient, a 67-year-old man, requested aphysical therapy examination of his right hip6 months after undergoing total hip arthro-plasty surgery. The patient indicated that hecontinued to experience leg pain, primarilyin the anterior mid-thigh. According to thepatient, he received extensive postsurgicalphysical therapy at a rehabilitation center for1 month. That center provided him with anexcellent home program, which he continuedto perform with little or no difficulty. With hisphysician’s approval, the patient progressedto working out three times a week at a localfitness center.

During the physical therapy examination,the patient ambulated with no assistive devicesbut exhibited a slight limp involving the rightlower extremity. The patient reported thatpain increased with prolonged ambulation andthat the limp worsened the more he ambulated.He exhibited good passive and active hiprange of motion. Strength in the right lowerextremity was not equal to that in the leftlower extremity, but there was no evidenceof a Trendelenburg deviation that wouldcontribute to the limp. The patient had onlyminimal soreness on palpation of the involvedright hip and thigh. There were no reports oflow back pain, and the knee and ankle pre-sented full pain-free range of motion. At theconclusion of the examination the patientbecame frustrated and asked, “I’m returningto my doctor next week. Is there anything I

should point out that might be helpful inaddressing this problem?”

The patient was active in a number of out-door recreational pursuits, and enjoyed camp-ing, hiking, and swimming. Five years ago hehad a lumbar fusion at L5-S1. He completed 6weeks of physical therapy after the lumbarsurgery. He indicated that he had one alco-holic beverage per day, usually with dinner.He reported no other significant surgeries,and his last physical examination, before thesurgery, gave him a “clean bill of health.”

S Y S T E M S R E V I E WThe patient presented with no cardiac or res-piratory problems. His blood pressure wasmedication-controlled and within normallimits. Sensation was intact throughout.

T E S T S A N D M E A S U R E SRecently completed postoperative bloodwork ordered by the physician demonstratedall values within normal limits. Radiographreports indicated good postoperative posi-tioning of the prosthesis. The patient deniedany history of hip dislocations.

What was another area of examination

considered by the therapist?

Pain continued in the involved extremity andthere was no possibility of a fracture; thus thetherapist examined the patient for possibledifferences in leg length. In this case, thepatient presented a difference of approximately

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1⁄2 inch (12.7 mm), with the right leg shorterthan the left. When questioned, the patientreplied he had no idea that such a differencein length existed. The therapist who had pro-vided the initial intervention apparently hadnot informed the patient of the leg lengthdifference.

DiagnosisPhysical Therapist Practice Pattern 4H:Impaired Joint Mobility, Motor Function,Muscle Performance, and Range of MotionAssociated With Joint Arthroplasty.

InterventionIf a true leg length difference is present, thetherapist can recommend that the patient usea shoe lift or insert to correct the problem.Once the device fits properly, additionaltherapy is seldom required.

What was the therapist’s recommendation

to the patient’s surgeon?

OutcomeDespite the efforts of every orthopedic sur-geon to ensure leg length equality, obtainingequal leg lengths can be difficult. Surgeonsoften inform their patients that every effortwill be made to ensure equal length, but thatsteps can be taken after the operation if adifference is present. Many surgeons assessfor the presence of a difference in leg lengthonly after several weeks of ambulation. Thereason that surgeons prefer to wait is that asmall difference in leg length may pose noproblems to the patient.

In this case the therapist sent a note to thephysician asking that consideration be givento providing an insert to see if the problemwith pain during ambulation could be elimi-nated. The surgeon agreed with the recom-

mendation, and the patient was providedwith an insert. Within 2 weeks, the patientwas ambulating pain free. The patient sub-sequently had all of his shoes adjusted withpermanent 1⁄2-inch lifts, and reported nofurther difficulties.

R E C O M M E N D E D R E A D I N G S

Chaudhuri S, Aruin AS: The effect of shoe lifts onstatic and dynamic postural control in indi-viduals with hemiparesis, Arch Phys Med

Rehabil 81:1498, 2000.Chiu HC, Chern JY, Chen SH, Chang JK: Physical

functioning and health-related quality of life:before and after total hip replacement,Kaohsiung J Med Sci 16:285, 2000.

Chiu HC, Mau LW, Hsu YC, Chang JK: Postopera-tive 6-month and 1-year evaluation of health-related quality of life in total hip replacementpatients, J Formos Med Assoc 100:461, 2001.

Garellick G, Malchau H, Herberts P, et al: Lifeexpectancy and cost utility after total hipreplacement, Clin Orthop 346:141, 1998.

Jones CA, Voaklander DC, Johnston DW, Suarez-Almazor ME: The effect of age on pain, func-tion, and quality of life after total hip and kneearthroplasty, Arch Intern Med 161:454, 2001.

Knutsson S, Engberg IB: An evaluation of patients’quality of life before, 6 weeks and 6 monthsafter total hip replacement, J Adv Nurs

30:1349, 1999.March LM, Cross MJ, Lapsley H, et al: Outcomes

after hip or knee replacement surgery forosteoarthritis: a prospective cohort study com-paring patients’ quality of life before and aftersurgery with age-related population norms,Med J Aust 171:235, 1999.

Ranawat CS, Rao RR, Rodriguez JA, Bhende HS:Correction of limb-length during total hiparthroplasty, J Arthroplasty 16:715, 2001.

Shields RK, Enloe LJ, Leo KC: Health-relatedquality of life in patients with total hip or kneereplacement, Arch Phys Med Rehabil 80:572,1999.

Towheed TE, Hochberg MC: Health-related qualityof life after total hip replacement, Semin

Arthritis Rheum 26:483, 1996.

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Describe the relationship between cast immobilization and possibleperipheral nerve compression.

2. Discuss reasons why a patient may refuse gait training.

The reader should know that a therapist was

asked to instruct a patient at bedside in crutch

ambulation before the patient was discharged

from the hospital. The patient was a 17-year-old

male who sustained a right nondisplaced tibial

plateau fracture the night before while playing

a high school football game. The patient was

struck slightly below the knee between the fibula

and tibia. Most of the force was inflicted by a

football helmet striking the tibia and the soft

tissue area between the tibia and fibula.

Radiographs were negative for a fibula fracture.

The tibia fracture did not appear to have disrupted

the growth plate. There was, however, a very

strong possibility that he sustained internal

derangement of the right knee. The patient was

known as a top college running back prospect

and was informed by his physician that he would

not be able to play for the rest of the season.

Throughout the night, the patient made

continual requests for pain medication. He was

also very difficult for the orthopedic nursing

staff to manage. The patient was angry over

his situation and did not want to be bothered.

His orthopedic physician had not seen him

since applying a full leg cast in the emergency

department at 11 P.M.

The patient was in significant pain and

subsequently had refused to ambulate. Overnight,

the leg had been elevated and externally rotated

on two pillows with an ice pack applied to the

site of the fracture. The foot was swollen, and

the patient reported numbness over the dorsum

of the foot. The patient was requested by the

therapist to flex and extend his toes. The patient

responded by flexing the toes, but toe extension

could not be seen or palpated. The patient abruptly

responded, “I’ve had enough, I’m not getting up,

it hurts too much. Please just leave me alone!”

ExaminationH I S T O R YThe patient was from a very poor socioeco-nomic background. According to the attendingorthopedic nurse, the patient’s family andhome situation was known to be very diffi-cult. The parents were not present during theinitial physical therapy examination but wereexpected to arrive at the hospital 2 to 3 hourslater to take their son home.

S Y S T E M S R E V I E WThe patient presented with no cardiac orpulmonary problems. His heart rate, bloodpressure, and respiratory rate were withinnormal limits. Range of motion of the unin-volved lower extremity was within normallimits. The involved knee was casted toapproximately 40 degrees flexion. Strengthin the upper and the noninvolved lowerextremities was within normal limits. Sensa-tion in the areas above the cast, where palpa-tion could be performed, was within normallimits. Sensation on the plantar surface ofthe toes was intact.

T E S T S A N D M E A S U R E SActive toe flexion was within normal limits.There was no evidence of active toe extensiondespite repeated attempts to elicit voluntarymovement. Toe position sense was present,but sensation was markedly decreased onthe dorsum of all toes.

EvaluationWas it appropriate to consider the presence

of an anterior compartment syndrome?

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A compartment syndrome occurs when thecirculation and function of muscle within aclosed fascia space are compromised byincreased pressure within that space. Blunttrauma can produce an acute compartmentsyndrome. Rapid clinical diagnosis and treat-ment is crucial to the prevention of compli-cations associated with the condition.

Proximal-third tibia fractures account for5% to 11% of all tibial shaft injuries. Treat-ment is typically more challenging, and therate of compartment syndrome is higher, indistal tibia fractures. If an acute compartmentsyndrome is present, then fasciotomy isgenerally required to relieve the pressure andrestore neurologic function. Although a possibleconcern, the likelihood of an acute compart-ment syndrome was very low in this case.

What would be the next area to examine

with this patient?

The therapist in this situation examined thecast to check whether it had been fitted tootightly. Because the patient had a full leg cast,only an attempt could be made to palpate thearea around the toes on the dorsal andplantar surfaces of the foot. Noting that thespace between the cast and skin was mini-mal at best, the therapist recommended thephysician be informed of the possibility thatthe cast was too tight. Neurologic symptomsconsistent with loss of motor function in theanterior compartment indicated possibleincreased pressure to the peroneal nervewhere it comes over the neck of the fibula.

DiagnosisPhysical Therapist Practice Patterns 4G:Impaired Joint Mobility, Muscle Perform-ance, and Range of Motion Associated withFracture and 5F: Impaired Peripheral NerveIntegrity and Muscle Performance Associatedwith Peripheral Nerve Injury.

What was the correct response to the

patient’s refusal to attempt ambulation?

InterventionThe therapist contacted the physician, whoimmediately ordered that the cast be win-dowed laterally to relieve pressure from theperoneal nerve over the neck of the fibula.The physician also requested that she becontacted immediately after the windowingof the cast to be apprised of the sensory andmotor aspects of the patient’s condition.

Once cast pressure was relieved, the numb-ness on the dorsum of the foot dissipated,and sensory function was restored. Within 30minutes, sensory and motor function returnedto the toes. Had sensory and motor functionnot returned quickly, it would have beenappropriate to again consider the presenceof a compartment syndrome.

OutcomeLater that day, the patient was refitted with anew long-leg cast. He was then able to toleratecrutch training and ambulation. The patientwas discharged from the hospital withinstructions to keep the extremity elevatedand to remain non–weight-bearing for 6weeks. He experienced no additional motoror sensory problems.

R E C O M M E N D E D R E A D I N G S

Bae DS, Kadiyala RK, Waters PM: Acute compart-ment syndrome in children: contemporarydiagnosis, treatment, and outcome, J Pediatr

Orthop 21:680, 2001.Bono CM, Levine RG, Rao JP, Behrens FF:

Nonarticular proximal tibia fractures: treat-ment options and decision making, J Am Acad

Orthop Surg 9:176, 2001.Mubarak SJ, Hargens AR, Karkal SS: Coping with

the diagnostic complexities of the compart-ment syndrome, Emerg Med Rep 9:185, 1998.

Perron AD, Brady WJ, Keats TE: Acute compart-ment syndrome, Am J Emerg Med 19:413,2001.

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Describe a possible mechanism of injury resulting in a torn quadricepstendon.

2. List examination strategies to help determine if a quadriceps tendon istorn.

3. Discuss alternative interventions for a patient with a torn quadricepstendon.

The reader should know that an 80-year-old

man with arthritis was referred to physical

therapy for postsurgical rehabilitation of a right

total knee arthroplasty. The patient arrived at a

therapist’s office in a wheelchair from home

after having been discharged 2 days earlier

from a rehabilitation hospital. He required

moderate assistance to get out of the car and

into the wheelchair. During the transfer, the

patient indicated that he had considerable

difficulty maintaining knee extension and that

he could not place much weight on the extremity

without feeling as though it were going to

collapse. The patient first noticed he was having

problems with weight bearing and keeping the

knee straight after attempting a pivot transfer

into his car after discharge from the

rehabilitation hospital.

The knee exhibited swelling not uncommon

for a recent total knee arthroplasty. Active-

assisted flexion was 100 degrees, and full

extension could be obtained only passively while

the patient was in the long sitting position.

The patient ambulated with a walker, a knee

immobilizer, and with a very short-stride gait.

It appeared that he was placing minimal weight

on the right lower extremity. He was unable to

perform a straight-leg raise and demonstrated

a very weak quadriceps contraction that

was palpable only in the mid-quadriceps.

No significant patellar movement was noted

on attempts to actively elicit a quadriceps

contraction.

During the next two visits to the clinic,

attempts to improve the patient’s gait pattern

and lessen the extension lag were unsuccessful.

There was decreased flexibility in the hamstring

muscles. The patient reported that he was not

making progress with his home program.

ExaminationH I S T O R YThe patient was a well-educated man whoexpressed his opinion that he sustained aninjury to the knee at the time of transfer. Heindicated he felt a “pop and a sharp pain” atthe time he was being assisted from thewheelchair to the car. He indicated that hementioned the problem to the staff at therehabilitation center during the transfer. The staff indicated that he should not beconcerned.

S Y S T E M S R E V I E WThe patient had a history of high blood pres-sure controlled by daily medication. Hereported no other significant past medicalhistory. There were no reports of low backpain or discomfort. He reported no plans tohave further total joint surgeries because ofthe difficulties experienced with his firstreplacement.

T E S T S A N D M E A S U R E SStrength in the uninvolved lower extremitywas within normal limits. Sensation wasintact throughout.

EvaluationWhat problem was suspected?

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It was surmised that at some point during thetransfer into the car at the rehabilitation hos-pital, the patient sustained a tear of thequadriceps tendon at its insertion. The tearwas identified visually and by palpation byrequesting the patient to perform a short-arcquadriceps exercise. Although there wasvirtually no pain while the patient attemptedthe short arc, very little or no movementcould be seen or palpated.

What was the most appropriate next step?

DiagnosisPhysical Therapist Practice Pattern 4H:Impaired Joint Mobility, Motor Function,Muscle Performance, and Range of MotionAssociated with Joint Arthroplasty.

InterventionUpon recommendation of the therapist, thepatient was immediately seen by his orthopedicsurgeon. The surgeon advised the patient ofthe torn tendon and indicated that if a repairwere to be made, it would have to be per-formed within the next several days. If notrepaired soon, the tendon would retract tothe point where reattachment would be diffi-cult or impossible. It was the physician’sopinion that rehabilitation would begin aftera long period of immobilization. The kneewould have to be in full extension for at least4 weeks.

OutcomeA quadriceps tear is considered rare aftertotal knee arthroplasty. If present, it isusually associated with trauma. When a tearhas occurred, repair is best done immediately.After reattachment, the knee frequently mustbe maintained in full extension for severalweeks. Regaining range of motion after theserepairs may be difficult. In this instance, thepatient decided not to have the repair. Hepreferred wearing a brace rather than endur-ing another operation and rehabilitation.

What was the focus of subsequent therapy

visits and the home program?

Therapy focused on general conditioning,ambulation, and the use of a knee brace tohelp control knee flexion. The therapist andpatient worked toward the goal of independ-ence in ambulation and activities of dailyliving in the home environment. After 3 weeksof daily physical therapy, the patient wasdischarged as independent with the use of awalker.

R E C O M M E N D E D R E A D I N G S

Bedor M: Quadriceps protects the anterior cruciateligament, J Orthop Res 19:629, 2001.

Campbell R, Evans M, Tucker M, et al: Why don’tpatients do their exercises? Understandingnon-compliance with physiology in patientswith osteoarthritis of the knee, J Epidemiol

Community Health 55:132, 2001.Cole BJ, Harner CD: Degenerative arthritis of the

knee in active patients: evaluation and manage-ment, J Am Acad Orthop Surg 7:389, 1999.

Enad JG: Patellar tendon ruptures, South Med J

92:563, 1999.Hansen L, Larsen S, Laulund T: Traumatic bilateral

tendon rupture, J Orthop Sci 6:187, 2001.Kelly BM, Rao N, Louis SS, et al: Bilateral, simul-

taneous, spontaneous rupture of quadricepstendons without trauma in an obese patient: acase report, Arch Phys Med Rehabil 82:415, 2001.

Konrath GA, Chen D, Lock T, et al: Outcomes fol-lowing repair of quadriceps tendon ruptures, J Orthop Trauma 12:273, 1998.

Labib SA, Hage WD: A simple technique fortranspatellar fixation of quadriceps tendonrupture, Orthopedics 24:743, 2001.

Miller ME, Rejeski WJ, Messier SP, Loeser RF:Modifiers of change in physical functioning inolder adults with knee pain: the observationalarthritis study in seniors (OASIS), Arthritis

Rheum 45:331, 2001.Rejeski WJ, Miller ME, Foy C, et al: Self-efficacy

and the progression of functional limitationsand self-reported disability in older adults withknee pain, J Gerontol B Psychol Sci Soc Sci

56:S261, 2001.Rougraff BT, Reeck CC, Essenmacher J: Complete

quadriceps tendon ruptures, Orthopedics

19:509, 1996.

Scranton PE: Management of knee pain and stiffnessafter total knee arthroplasty, J Arthroplasty

16:428, 2001.Shelbourne KD, Darmelio MP, Klootwyk TE:

Patellar tendon rupture repair using Dall-Milescable, Am J Knee Surg 14:17, 2001.

Yilmaz C, Binnet MS, Narman S: Tendon lengthen-ing repair and early mobilization in treatmentof neglected bilateral simultaneous traumaticrupture of the quadriceps tendon, Knee Surg

Sports Traumatol Arthrosc 9:163, 2001.

Case 40 171

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Describe how diagnostic testing may influence a physical therapy plan ofcare.

2. Discuss how a patient’s clinical progression may be influenced by aphysician’s medical choices.

ExaminationH I S T O R YA 46-year-old female arrived at a physicaltherapy clinic after sustaining a left proximalhumeral fracture. That fracture had occurred6 weeks earlier when she tripped over a babystroller and landed on her left arm. The patienthad her arm in a sling until 1 week earlier.She was referred for physical therapy by herfamily physician.

What additional information was needed

from this patient’s history?

The patient was the primary caretaker forher 1-year-old granddaughter. She was alsogoing to school part time and working parttime as a legal aide. The patient was right-handdominant. She had no significant medicalhistory except intermittent chronic low backpain. The only medication she took was regular-strength Tylenol for shoulder pain, as needed.She rated her pain at rest as a 5 on scale of 0to 10, and 8 with any movement of the arm.

What tests and measures were appropriate

for this patient?

T E S T S A N D M E A S U R E SWith the patient supine, her left shoulder activerange of motion (ROM) was measured as 10degrees of flexion, extension, and abduction.External and internal rotation could not bemeasured because of the patient’s pain andguarding. Shoulder passive ROM was 30degrees of flexion, 10 degrees of extension,and 30 degrees of abduction.

Manual muscle testing of the shoulderflexors and abductors produced scores of–2/5. The patient’s shoulder end feel in alldirections was empty secondary to guarding.No significant swelling was seen, but moderatetenderness was noted on the anterior aspectof the shoulder.

Were there any other important items to

address in the examination?

Instrumental activities of daily living werereviewed. The patient had moderate difficultydonning and doffing her shirt.

DiagnosisPhysical Therapist Preferred Practice Pattern4G: Impaired Joint Mobility, Muscle Perform-ance, and Range of Motion Associated withFracture.

PrognosisThe prognosis for this patient was judged asfair because she had a moderate loss of func-tion. There were also the complicating butmotivating factors of childcare, work, andschool. Overall, the patient was in good physicalhealth; therefore, prolonged impairments wereinitially expected to be minimal to none.

InterventionThe plan of care for this patient included moistheat, passive ROM, active/active-assistedROM, ice, and a home exercise program. In thefirst month, the patient showed an increase

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in shoulder ROM, but no reduction in pain.After the second month, the patient’s ROMreached a plateau, and her pain levelsincreased.

What was an appropriate course of action

for the therapist to take?

The physical therapist contacted the familyphysician and recommended diagnostic imag-ing (specifically, magnetic resonance imaging[MRI]), because of lack of progression andincrease in pain. The physician felt that MRIwas not needed, and changed the diagnosisto “frozen shoulder.” A request was made tocontinue with “aggressive physical therapy.”

The patient returned to the clinic, where thetherapist added aggressive ROM exercises andelectrical stimulation to help with pain control.The patient did not tolerate aggressive ROM;therefore, the range was done to her tolerance.After a few sessions, the patient’s pain wasnoted to have increased with no significantincrease in ROM.

Finally, after a month, the family physicianagreed to order MRI and consultation withan orthopedist. Two weeks later, the patientreturned to continue with physical therapyafter undergoing a manipulation under anes-thesia. A referral slip from the family physicianread “continue physical therapy.”

What information was appropriate for the

therapist to review before resuming

intervention?

The physical therapist requested the MRIresults, which showed inferior subluxation

of the humeral head, a torn glenoid labrumposteriorly, an osseous fragment, and prob-able partial tear of the supraspinatus andinfraspinatus tendons. After reexamination, a call was placed to the family physicianregarding the results of the MRI. The physi-cian wanted to continue rehabilitation at thetherapist’s discretion. The physical therapistthen contacted the orthopedist to schedule afollow-up appointment. Subsequently, anarthroscopic surgical repair was performed.

OutcomeThe patient returned to physical therapy andregained full functional ROM and strengthwith intermittent pain. She was dischargedfrom therapy to continue with a home exer-cise program, and was able to return to workwithout difficulty.

DiscussionIn this case the physical therapist used goodprofessional judgment and facilitated acorrect referral. The patient benefited fromprompt surgical intervention and follow-upphysical therapy intervention.

R E C O M M E N D E D R E A D I N G S

Magee DJ: Orthopedic physical assessment (ed 3),Philadelphia: WB Saunders, 1997.

Goodman CC, Snyder TE: Differential diagnosis

in physical therapy (ed 3), Philadelphia: WBSaunders, 2000.

McKinnis LN: Fundamentals of orthopedic

radiology, Philadelphia: FA Davis, 1997.

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Discuss the physical therapy needs of the patient with multiple trauma.2. Discuss what clinical factors may need to be considered when

recommending electrodiagnostic studies.3. Describe at what point physical therapy should be discontinued when no

progress is made toward set goals or when progress has plateaued.

ExaminationH I S T O R YA 4-year-old girl was mistakenly run over byher mother while on a riding lawn mower.The patient sustained an open fracture to theright femur, tibia, and multiple bones of thefoot. She also had extensive soft tissue, vas-cular, and nerve damage. She underwent 23surgeries, including external fixators of thefemur, tibia, and fibula; multiple skin grafts;and revascularization by surgically attachingher legs together. The patient presented at aphysical therapy clinic at age 5 with her mother.

What other information from the patient’s

history was needed?

The patient was in kindergarten and lived athome with both parents and four siblings. Shewas very active, had no other health problems,and liked to do physical activities. She wantedto be able to roller-skate and ice skate. Thepatient was 6 weeks status post surgery ofgrafting the wounds from separating the legsand reattachment of the quadriceps tendon.

What tests and measures were appropriate

for this patient?

The patient had extensive bound scarring onthe entire right anterior leg, with loss of allsensation. She had a full-thickness woundalong the incision site on the thigh.

She ambulated with knee-ankle-foot ortho-sis (KAFO) with a ratchet lock, non–weight-bearing, and used a walker. She had a leg length

discrepancy of 1.25 inches and foot length dis-crepancy of 1 inch on the right. Additionally,according to diagnostic imaging reports, shehad no growth plates left in the knee or anklejoints. Her knee was in a flexion contractureof 30 degrees, and manually she demonstrated–25 degrees of full extension. The end feelhad some give, but was not hard. At the time,there was trace quadriceps, hamstring, anteriortibialis, and gastrocsoleous muscle activity.

Ankle passive range of motion (ROM) wasminimal. The contralateral leg and bilateralupper extremities demonstrated normalstrength, ROM, and function.

DiagnosisThis patient’s case was very complex, asreflected by the choice of four PhysicalTherapist Preferred Practice Patterns:• 4G: Impaired Joint Mobility, Muscle Per-

formance, and Range of Motion Associatedwith Fracture.

• 4I: Impaired Joint Mobility, Motor Function,Muscle Performance, and Range of MotionAssociated with Bony or Soft Tissue Injury.

• 5F: Impaired Peripheral Nerve Integrityand Muscle Performance Associated withPeripheral Nerve Injury.

• 7E: Impaired Integumentary Integrity Asso-ciated with Skin Involvement Extending intoFascia, Muscle, or Bone and Scar Formation.

PrognosisThe referring orthopedist believed that thepatient’s overall prognosis was poor. That

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physician believed that unless the patient’sROM and quadriceps strength increased,amputation would be necessary.

What would a physical therapy plan of care

entail? What factors need to be considered?

InterventionThe patient was seen three times per weekfor 3 months after school. The patient’s motherwas always present at the treatment sessionsand because she had no childcare, she alwaysbrought the patient’s 6-year-old sister.

The plan of care included active, active-assisted, and passive ROM exercises; strengthen-ing exercises; gait training; scar mobilization;electric stimulation for muscle reeducation;balance training; and dynamic splinting.

OutcomeAfter 3 months, the patient was able toambulate without the KAFO but continued touse a walker, weight bearing as tolerated on theright lower extremity. There was no increasein strength, ROM, or scar mobility. The patientalso began to complain of severe pain in her

involved leg. The physical therapist contactedthe referring physician to inform him of thepatient’s status. The therapist also discussedthe possibility of sending the patient for elec-trodiagnostic testing (electromyography andnerve conduction studies) to check innervationof the right lower extremity. Those studiesdemonstrated a lack of innervation of thequadriceps and dorsiflexor muscles. Thephysical therapy was stopped. Because ofintractable pain and poor functional gains,the patient had a knee disarticulation ampu-tation approximately 1 month later.

R E C O M M E N D E D R E A D I N G S

Aitken ME, Jaffe KM, DiScala C, Rivara FP:Functional outcome in children with multipletrauma without significant head injury, Arch

Phys Med Rehabil 80:889, 1999.National Pediatric Trauma Registry, Research and

Training Center on Rehabilitation andChildhood Trauma: The National PediatricTrauma Registry: Injuries among children,Pediatr Phys Ther 7:24, 1995.

Haley SM, Baryza MJ, Webster HC: Pediatricrehabilitation and recovery of children withtraumatic injuries, Pediatr Phys Ther 4:24,1992.

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Discuss the clinical signs and symptoms associated with Meniere’sdisease.

2. Identify and differentiate clinical signs and symptoms associated withmedications commonly used to treat Meniere’s disease.

3. Discuss what impairments may be permanent and how they might becompensated for.

4. Identify appropriate referral sources for a patient with Meniere’s disease.5. Discuss how to apply the principals of neurological treatment theories in

developing intervention strategies for a high-level functioning patientwith Meniere’s disease.

Background On DiagnosisMeniere’s disease is associated with overpro-duction of endolymph or fluid in the ears,which affects auditory and vestibular function.Common precipitating factors include viralinfections or trauma. Clinical signs and symp-toms include reports of transient but severeattacks of dizziness or vertigo that incapaci-tate the individual. Nausea, vomiting, abnormaleye movement (nystagmus), and sensorineuralhearing loss (tinnitus) are also commonfindings. Acute attacks may last a few minutesto several hours, with residual affects reportedweeks to months later. Medical treatmentincludes the use of central nervous systemsuppressant, diuretic, or antiemetic medica-tions. Individuals with Meniere’s disease areadvised to decrease consumption of salt, caf-feine, alcohol, and tobacco. Physical therapyhas also proven beneficial.1-3,5

The reader should know that a 26-year-old female

was diagnosed with Meniere’s disease after an

episode of vertigo. She was originally unable to sit,

stand, or walk without episodes of severe nausea

and vomiting, which lasted for 10 days. At the

time of the initial physical therapy examination,

she was able to do all of the above, but reported

feeling very unsteady. She reported that she had

begun to identify what she referred to as “triggers”

for attacks as being repetitive vertical patterns,

moving or flashing lights, unsteady floors

(elevators, docks, escalators), or busy floor and wall

patterns. She reported that during attacks she

noticed things spinning from right to left and she

had a tendency to fall to the right when experiencing

attacks. She was taking meclizine (Antivert)

four times per day and trimethobenzamide

(Tigan) as needed to control the vomiting.

She also had a history of lupus erythematosus.

ExaminationH I S T O R YThe patient, a 26-year-old single female,reported experiencing a sudden onset ofvertigo after an intense aerobic workout 4months earlier. She was treated and releasedfrom the emergency room with intravenousfluids, meclizine, and antibiotics for a possibleear infection. The symptoms persisted off andon for approximately 2 weeks but did notinterfere with her normal activities. She expe-rienced a second attack approximately 6weeks later while at work. She saw her familyphysician and received a new prescription ofmeclizine. The symptoms lasted for approxi-mately 2 weeks, and she again was able toresume all normal activities.

When the most recent attack occurred, thepatient decided to follow up with her familyphysician and a neurologist. The symptomshad persisted for more than 2 weeks, and she

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was not able to work or function even aroundthe house for more than a few minutes.Magnetic resonance imaging of the headrevealed inflammation around the eighthcranial nerve. Blood work showed slightlyelevated sedimentation rates, but no differentthan her previous levels. The patient saw aneurologist, who offered options of surgicalrhizotomy, continuing medication therapy,and a trial of physical therapy.

The patient reported a history of systemiclupus erythematosus, which was managedthrough diet and exercise. She reported hermain symptoms from the lupus as fluctuatingweight, facial and upper torso skin rash, andperiodic joint and muscle pain and weakness.Before the recent attacks she had been active,playing field hockey 2 or 3 days per week fora competitive club team and lifting weightsand running 4 or 5 days per week. Since theattack, she was happy to be able to stand andwalk for short distances. She reported shewas able to sit for 15 to 20 minutes and standand walk for 5 to 10 minutes before symptomsincreased to the point at which she wouldneed to lie down. She was not able to work,drive, or use the telephone on the right side.She reported the medication was causingblurred vision, and consequently she haddifficulty reading. She had noticed that if shecould find external focal points, she couldusually keep attacks from becoming fullblown, although admitted she was not alwayssuccessful and still experienced two or threebouts of nausea and vomiting a day. She alsosaid that she was walking much more slowlythan normal and preferred to stay close towalls or railings when possible.

The patient was employed as an outpatientphysical therapist in a very busy clinic, buthad been on sick leave and using vacation timesince the most recent attack. She lived in athird-floor apartment with her sister and wasrelying on friends and family to transport herto appointments.

S Y S T E M S R E V I E WIntegumentary system. Discoid lesionswere noted on the patient’s face and uppertorso consistent in appearance to those

commonly associated with lupus erythe-matosus. Otherwise, the integumentary systemwas intact.

Cardiopulmonary system. The patient’scardiopulmonary system was intact.

Musculoskeletal system. The patient’smusculoskeletal system was intact, with novisible atrophy or edema at time of initialexamination.

Neuromuscular system. The neuro-muscular system was the main focus ofexamination.

T E S T S A N D M E A S U R E SThe following test results were obtained:• Loss of gaze stability with the head thrust

test as described previously.2

• Positive Romberg’s test: able to stand for10 seconds with eyes open; immediateloss of balance with eyes closed.1,2

• Positive single-leg stance: immediate lossof balance with eyes open, not attemptedwith eyes closed.1

Gait disturbance was noted, with decreasedstep and stride length, decreased speed, widebase of support and no trunk rotation or armswing. The patient was constantly reachingfor objects to steady herself and was unableto turn her head while walking without lossof balance. Transfers were independent butslow, and the patient needed to pause for 1to 2 minutes for dizziness and nausea to passand for gaze to stabilize.

EvaluationBased on the initial examination findings,

which impairments are temporary and can

be remedied?

How much improvement can be expected

and how soon will it occur?

The patient’s problems (functional limitationsand impairments) were characterized as follows:• Unable to sit for more than 15 to 20

minutes.• Unable to stand for more than 5 to 10

minutes.• Ambulation unstable.

• Unable to drive.• Unable to use telephone on right side.• Unable to work.• Unable to work out or participate in social

activities.

DiagnosisPhysical Therapist Preferred Practice Pattern5F: Impaired Peripheral Nerve Integrity andMuscle Performance Associated with PeripheralNerve Injury.

PrognosisOver the course of 4 to 8 months, the patientshould demonstrate optimal peripheral nerveintegrity and muscle performance and thehighest level of functioning in home, work (job/school/play), community, and leisure environ-ments, within the context of the impairments,functional limitations, and disabilities. Theexpected number of visits is between 12 and 56.4

G O A L SThe long-term (2 months) goals for thispatient were to return to normal work, social,and recreational activities. The short-term (1to 2 weeks) goals included independent sitting,standing, and ambulation for 300 feet toreturn to normal work, social, recreational,and therapeutic activities.

InterventionsGaze-retraining exercises were used to helpreestablish positional sense. Exercises wereperformed in a variety of positions (e.g.,supine, prone, semirecumbent) with headposition changes, as the patient was able toprogress.1-3,5

Exercises and activities were used topromote habituation. This was accomplishedthrough repeated exposure to noxious stimulias identified by the patient. As the patientregained control of her ability to focus morerapidly, modifications were made to theenvironment, including altering the surfaceon which she was located and increasing

the number of distractors within the envi-ronment.1-3,5

Balance-retraining activities were alsoincluded in the program. Besides the Romberg,tandem Romberg, and single-leg stanceactivities, these included such activities asriding on an elevator with eyes open andeyes closed, sitting or laying on a phys-ioball with eyes open and eyes closed, andsitting on a rolling stool and moving thestool in all directions and rotating in bothdirections.1-3,5

Might this patient have benefited from any

other services?

The patient was referred to an otolaryngologistand an audiologist for the hearing deficitsand reports of tinnitus.

Which impairments are permanent and

must be compensated for?

OutcomeAfter completing 8 weeks of three times perweek outpatient therapy, the patient reportedexperiencing only two attacks in the pre-ceding month. She was able to regain hersense of equilibrium within a minute or twoboth times. She had returned to work fulltime and was able to drive without difficulty.She was still experiencing dizziness whenriding elevators or escalators, but had beenpracticing with eyes open and closed whenable. She had resumed running 1 to 2 milesthree to four times a week and weightliftingthree times a week. She had not yet resumedplaying field hockey, because she still feltunsteady if she repeatedly bent forward andstood up. She also reported no longer evenattempting to use the telephone on her rightside because of the persistent tinnitus. Shereported difficulty riding a jet ski, in that she kept tipping over to the right and thoughtthe equipment was faulty, but then sherealized that this was a higher-level skill thatshe had not yet mastered. She also reportedreluctance to attempt to ride roller coastersbecause of the quick directional changes.

Case 43 179

She was scheduled to have her hearingtested every 6 months.

If this patient were to return to physical

therapy at this stage, what type of

activities would likely be included in

the intervention?

The activities described as difficult, aside fromthe use of a telephone, all appeared to requirethe ability to balance without the normal pro-prioceptive input from the lower extremitieswhile weight bearing. During all of the aboveactivities the patient was exposed to quickchanges in direction and required to stabilizein multiple planes simultaneously. The patientwould also be exposed to rapidly changingvisual input. This patient did return for a shortcourse of physical therapy (eight visits), duringwhich aquatic therapy activities were used tosimulate the multiplanar forces encounteredin such activities. Various flotation deviceswere used along with manual perturbationsand water turbulence to increase or decrease

the intensity of the balance activities. Activitieswere performed first with eyes open and laterwith eyes closed. After the short course oftherapy, the patient had again resumed ridingroller coasters and jet skis, and playing fieldhockey. She also reported feeling more steadywhen riding elevators or escalators.

R E F E R E N C E S

1. Goodman CC, Boissonnault WG: Pathology

implications for the physical therapist,Philadelphia: WB Saunders, 1998.

2. O’Sullivan SB, Schmitz TJ: Physical rehabili-

tation assessment and treatment (ed 4),Philadelphia: FA Davis, 2001.

3. Umphred DA: Neurological rehabilitation (ed4), Philadelphia: Mosby, 2001.

4. American Physical Therapy Association: Guideto physical therapist practice, second edition,Phys Ther 81:9, 2001.

5. Gonzalez EG, Meyers SJ, Edelstein JE, et al:Downey and Darling’s physiological basis of

rehabilitation medicine (ed 3), Boston:Butterworth Heinemann, 2001.

180 Clinical Cases in Physical Therapy

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Discuss indications for a molded ankle-foot orthosis and for itsreimbursement.

2. Describe basic principles of the prospective payment system (PPS) inskilled nursing facilities.

3. Differentiate PPS and Medicare Part B.4. Identify the modifications needed in a physical therapy plan of care for a

patient living in a retirement community.

The reader should know that an 81-year-old

female with degenerative joint disease of the

right knee underwent a total knee arthroplasty.

Six days after her surgery, she was placed in a

skilled nursing facility (SNF) for rehabilitation

before returning to her apartment, where she

lived alone. Her apartment was part of an

independent-living retirement community.

She was used to an independent lifestyle in her

apartment, but in the SNF she received 24-hour

nursing care. The apartment was on one floor,

had wall-to-wall carpeting except for tiled floors

in the kitchen and bathroom, and a full-sized

bathtub. She needed to demonstrate the ability

to independently perform all activities of daily

living before returning to her apartment.

There was full handicap access throughout

the community, and all meals were provided

(although there was a kitchen in each unit if

the residents desired to cook). The housekeeping

department also cleaned all bathrooms weekly,

but the residents were responsible for their

own laundry and general upkeep of the rest

of their apartment. The patient had 94 PPS

days remaining.

ExaminationH I S T O R YThe patient’s past medical history was sig-nificant for type 1 diabetes with mild distallower extremity neuropathies (affecting onlysensation on the distal dorsal and plantarsurfaces of her feet), and a left total kneearthroplasty done 2 years earlier.

S Y S T E M S R E V I E WThe patient presented with no history of car-diac or pulmonary problems. Seated/restingvital signs were heart rate, 72 beats perminute; blood pressure, 116/76 mm Hg; andrespirations, 18 breaths per minute. She wasallowed weight bearing as tolerated throughthe right lower extremity. She was unable totolerate narcotics for pain control becausethey made her nauseous. She received insulininjections to control her diabetes.

T E S T S A N D M E A S U R E SOn examination, active range of motion (ROM)of the right knee was –16 degrees extensionand 30 degrees flexion. Passive ROM of theright knee was –13 degrees extension and 75degrees flexion. Strength of the right kneewas 3–/5 for flexion and extension.

The patient experienced a right foot droppostoperatively and had been provided withan off-the-shelf molded ankle-foot orthosis(MAFO) by the acute-care hospital. Her rightankle dorsiflexors presented as flaccid, andsensation to light touch, pinprick, and tem-perature were diminished on the anteriorand lateral surfaces of the right lower leg anddorsal right foot. Skin inspection of thelower extremities was unremarkable exceptfor a 9-inch clean incision on the right kneethat was healing well.

Midpatellar girth measurements of theright and left knees were 49 and 42.8 cm,respectively. Pain levels were 8 out of 10 withROM and 10 out of 10 with weight bearing on

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the affected leg. All transfers were per-formed with minimal assistance of one, andthe patient ambulated 15 feet with a standardwalker and minimal assistance of one. Shecomplained of severe discomfort with theMAFO, and on closer examination, it wasdetermined that her heel was too wide for it.The MAFO was also causing her to invertand plantar-flex her right foot whenever shebore weight through the right lower extremity.

DiagnosisPhysical Therapist Practice Pattern 4H:Impaired Joint Mobility, Motor Function,Muscle Performance, and Range of MotionAssociated with Joint Arthroplasty.

EvaluationHow could the positioning of her right

foot in the off-the-shelf MAFO affect

the right knee?

It was never determined exactly, per the ortho-pedic surgeon, why this patient developed aright foot drop. The inclination was that afterthe leg became edematous postoperatively,the increased pressure around the kneecompromised the common peroneal nerve.Unfortunately, no follow-up testing was per-formed to make an exact determination.

The acute-care hospital staff gave thepatient the off-the-shelf MAFO versus acustom-fitted one because they believed thatthe foot drop would resolve rather quickly.They also did not correlate the increased kneepain with the ill-fitting MAFO. Her invertedand plantar-flexed foot was causing a signifi-cant increase in varus force at the right knee,which appeared to be the chief cause of theincreased pain. She was able to ambulatesafely without the MAFO but demonstrated asevere steppage gait because of the right footdrop. This was causing her excessive rightknee flexion during the swing phase of gait, which resulted in increased pain andswelling, delaying healing. Therefore, toavoid causing a chronic inflammation in herknee, it was decided to consult an orthotist

to fabricate a custom-fitted MAFO for thepatient’s right foot.

What were some of the indications and

concerns surrounding a custom-fitted MAFO

for this patient?

Despite the diagnosis of diabetes (along withperipheral neuropathy causing altered sensa-tion), the patient was determined to be reliableto examine her foot after wearing the off-the-shelf orthosis for signs of skin breakdown.As opposed to the first orthosis, the custom-fabricated MAFO normalized forces andstresses transferring through the foot andankle, decreasing the risk of skin ulceration.The new MAFO also allowed the patient toassume a more normal gait pattern. Her paindecreased to 5 out of 10 within 2 days, andthe edema decreased by 3 cm within a week.In turn, active and passive ROM improved.Because pressure around the knee was reduced,nerve recovery could begin, as evidenced bythe return of sensation and trace contractionsin the right dorsiflexors.

How was the MAFO reimbursed and how

did the PPS apply?

Medicare is divided into two separate systemsto provide coverage to those who qualify toreceive its benefits. Part A (also known asPPS) is the hospital and subacute coverage,which can last for up to 100 days. The require-ment for a patient to continue coverage as aPart A is the classification as “skilled.” Thismeans that the patient receives a service thatis performed under the supervision of skillednursing or rehabilitation personnel. Skillednursing must be provided daily 7 days a week;therapy services must be provided 5 days perweek. There are also nursing issues that can“skill” a resident who does not receive reha-bilitation services. Examples include patientswith open wounds, intravenous treatments,insulin-dependent diabetics, feeding tubes,dialysis, chemotherapy, and a myriad ofother reasons. However, depending on thecomplexity of these nursing issues, theamount of reimbursement can vary.

Because the patient was an admission underthe Medicare Part A (or PPS), the MAFO wasnot directly reimbursed by Medicare. Theregulations required that the SNF provideequipment and supplies for patients asneeded, and the funding for those suppliescame out of the money prospectively paid byMedicare. This means that the SNF received thesame funding regardless whether the MAFOwas purchased. It was then an expense fromthe facility’s budget, not Medicare’s budget.

Part B is considered Medicare’s outpatientinsurance, though someone living in a skillednursing facility can receive Part B services ifhe or she does not qualify for Part A. Part Bis a more traditional fee-for-services systemand covers 80% of the services provided. Theremaining 20% is covered by a secondaryinsurance, or must be privately paid. There isno set number of days or minutes that mustbe achieved to qualify for reimbursement,though the Centers for Medicare and Medi-caid Services has its own fee schedule fortreatments, modalities, etc. (i.e. currently $65for a physical therapy evaluation). Part B willpay for 80% of most durable medical equip-ment, and also orthotics and prosthetics.Therefore, with this case, the patient hadPart A benefits and the MAFO’s cost had tobe subtracted out of the prospective payment.However, under Part B, the MAFO would havebeen 80% directly reimbursed and at no costto the facility.

Intervention/OutcomeOccupational therapy’s main goal with thispatient revolved around lower extremitydressing, because she found this task mostdifficult. Their treatment sessions incorporateddonning and doffing the MAFO, allowingphysical therapy to focus on gait, transfers,strengthening, ROM and edema reduction.Also, occupational therapy purchased a tubbench for the patient’s bathroom and workedwith her to increase safety with homemakingskills. Four weeks after admission, thepatient was able to return to her apartmentand previous lifestyle.

R E C O M M E N D E D R E A D I N G S

Atherly A: Supplemental insurance: Medicare’saccidental stepchild, Med Care Res Rev 58:131,2001.

Federal Register 58:60789, 1993.Gardner J: Groups support PPS for skilled-nursing

care, Mod Healthcare 25:38, 1995.Green MF, Aliabadi Z, Green BT: Diabetic foot:

evaluation and management, South Med J

95:95, 2002.Papagelopoulos PJ, Sim FH: Limited range of

motion after total knee arthroplasty: etiology,treatment, and prognosis, Orthopedics 20:1061,1997.

Vance TN: Medicare guidelines explained for the

physical therapist: a practical guide for

physical therapy service delivery, Reston, Va:St. Anthony’s Publishing, 1998.

Case 44 183

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. List forms of diagnostic imaging used to identify deep vein thrombosisand pulmonary embolus.

2. Describe signs and symptoms of a pulmonary embolism.

ExaminationH I S T O R Y The patient, a 72-year-old retired female, wasadmitted to an acute care hospital throughthe emergency room with left-sided weakness,headache, and nausea. She was diagnosedwith evolving left cerebral vascular accident(CVA) and was immediately placed on anantithrombolytic TPA (tissue plasminogenactivator) drug.

During the course of her acute-care stay,she developed warmth, pain, and swelling inher right calf. Homan’s sign was positive.Doppler scan was positive for deep veinthrombosis (DVT). She was placed on bedrest for 3 days, with intravenous heparinfollowed by oral administration of coumadinand TEDS to be worn at all times whenallowed out of bed. After an acute care stayof 3 weeks, the patient was transferred to arehabilitation facility.

On admission to the rehabilitation facility,the patient was 5 feet 2 inches tall andweighed 200 pounds. She reported a seden-tary lifestyle, with hobbies of knitting anddoing crossword puzzles. She was of Polishdescent and liked to prepare and eat ethnicspecialty foods, such as kielbasi, pierogies,and potato pancakes. She had smoked for 40years but quit 10 years earlier secondary toproblems with asthma. She resided in a two-story house that had 12 stairs with tworailings between the first and second floorsand three stairs with two railings to enter thehome from outside. She lived with her hus-band of 50 years and before admission wasindependent in all activities of daily living(ADL) and instrumental ADLs.

The patient’s past medical history includedhypertension, diabetes mellitus (adult onset),asthma, degenerative joint disease, choles-terolemia (excessive amounts of cholesterolin the blood), and osteoporosis with a historyof compression fracture of T8.

Her medications included lisinopril (Zestril)20 mg twice a day for hypertension, glyburide(DiaBeta) 5 mg four times a day for diabetes,albuterol (Proventil) 2 puffs twice a day forasthma, celecoxib (Celebrex) 20 mg/day fordegenerative joint disease, and atorvastatin(Lipitor) 10 mg/day for cholesterolemia.

R E V I E W O F S Y S T E M S• Vital signs: Blood pressure 130/84 mm Hg,

heart rate 76 beats per minute (bpm), res-pirations 18 breaths per minute

• Range of motion/joint mobility: Flaccidright upper extremity, spastic right lowerextremity

• Gait, locomotion, balance: Bed mobility,moderate assistance of 1 to roll right to left;transfers, supine → sit moderate assistanceof 1; sit ⇔ stand, maximum assistance of1; stand → pivot maximum assistance of1; gait, nonambulatory at the time

• Reflexes: Positive Babinski’s sign andclonus in the right lower extremity

• Balance: Sitting balance unsupported fairminus

• Endurance: Fair• Communication: Global aphasia

T E S T S A N D M E A S U R E M E N T SMagnetic resonance imaging was positive fora left CVA, and a Doppler study was positivefor a previous DVT, now resolved.

185

Case 45

186 Clinical Cases in Physical Therapy

EvaluationWhat are the possible areas of occlusion

that may have lead to this patient’s

symptoms?

Lesions are most often large, involving theperisylvian area of the frontal, temporal, andparietal lobes. An occlusion of the internalcarotid area or the middle cerebral artery atits origin was the most common location. Withthis particular patient, injury had occurredon the left side of the brain. The frontal lobeof the brain is the site of Broca’s area, whichprovides the motor aspects of speech. Thetemporal/parietal region is the area thathouses the sensory aspects of speech (per-ception and interpretation of language)known as Wernicke’s area.

The patient was alert and oriented toperson and place but demonstrated difficultywith time accuracy. She presented withglobal aphasia, allowing her to respond toyes/no questions correctly approximately40% of the time.

What are the characteristics of global

aphasia?

Global aphasia is the most common and mostsevere form of aphasia. It is characterized byspontaneous speech that is either absent orreduced to a few stereotyped words orsounds. Comprehension is reduced or absent.Repetition, reading, and writing are impairedto the same level as spontaneous speech.

Examination findings were consistentwith left CVA. Impairments included toneabnormalities, decreased endurance, decreasedcognitive and communication skills, decreasedbalance, and decreased functional mobility.

DiagnosisPhysical Therapist Practice Pattern 5D:Impaired Motor Function and SensoryIntegrity Associated with NonprogressiveDisorders of the Central Nervous System—Acquired in Adolescence or Adulthood.

PrognosisThe patient will achieve optimal functionwithin 12 months, with expected dischargein 3 to 4 weeks.

InterventionThis patient was treated by a multidiscipli-nary approach comprising speech therapy, toaddress communication and comprehen-sion; occupational therapy, for training inADL and self-care activities; and physicaltherapy, including activities to improvebalance, coordination, postural stability, andstrength and endurance, including gait train-ing, general mobility, and neuromuscularreeducation.

One week after admission to the rehabili-tation facility, while lying on the mat table,the patient began to exhibit signs of anxiety,including rapid breathing, sweating, andrapid extraneous hand movements includingholding her chest. She was unable to verbalizeher complaints and her response to yes/noquestions was more inconsistent than usual.Vital signs were measured and found to beblood pressure, 100/50 mm Hg; heart rate,100 bpm and weak; and respirations 24 perminute and labored.

What could be the cause of this behavior

and how should a therapist respond

given the patient’s past medical history

of DVT, CVA, osteoporosis, and compression

fracture?

There could be numerous explanations forthis type of behavior. Because this patienthad been pleasant and cooperative in the pastand never exhibited this type of behaviorbefore, it was reasonable to assume that sometype of physical event was contributing to heractions. Although she was unable to verballyexpress her symptoms, her hand motionsappeared to indicate chest discomfort. Shehad a rapid and weak pulse, low blood pres-sure, dyspnea, and sweating, all of which canbe indicators of pulmonary embolism.

Pulmonary embolism can be a life-threatening condition that can lead to deathif not treated immediately. It is typically theresult of a venous thrombus that occludes apulmonary artery. Factors that contribute toincreased risk of venous thrombosis alsocontribute to the risk of pulmonary embolism.These factors include prolonged bed rest orimmobilization, especially with concomitantlimb paralysis and obesity. Although physicaltherapists are trained to monitor for DVT inpostsurgical and immobile patients, manypatients will not have physical complaints orobvious clinical signs. It is important not onlyto be aware of symptoms of DVT (i.e., edema,dull achiness, color/temperature changes ofthe extremity, pain, warmth, redness, espe-cially in the calf), but also to stay alert forsigns of pulmonary embolus (PE), includingsudden anxiety or restlessness, rapid andshallow respirations, tachycardia, chest pain,diaphoresis, and cyanosis. Such changes in apatient’s presentation should be reported toa physician immediately.

What diagnostic imaging studies can

identify DVT or PE?

To identify a DVT, the gold standard is lowerlimb venography (a contrast medium isinjected and radiographs taken to visualizethe veins). This procedure is used to helprule out a DVT. Another technique is venousultrasound with or without Doppler waveformanalysis. Pulmonary angiography or lungperfusion imaging (requiring a radiopharma-ceutical injection and a camera to obtainlung images) are often used to detect PE.

What is the standard treatment for DVT

or PE?

Treatment usually includes thrombolyticagents. Physical therapy management isimportant when the patient is again stableand the threat of further emboli is resolved.

Treatment can then include deep-breathingexercises, positioning, and mobilization withprogressive activity to improve cardiopulmonaryfunction.

OutcomeBecause this was a behavior uncharacteristicof this patient and her motions and vital signsindicated some type of a cardiopulmonaryevent, the nursing staff and physician wereimmediately notified. The patient’s symptomsappeared to indicate the need for immediatemedical attention. This patient was transferredimmediately to her wheelchair and escortedby professional personnel (physical therapist/nurse) back to her nursing unit. She was read-mitted to the acute-care facility and treatedfor a PE. Following recovery from the PE, thispatient was brought back to the rehabilita-tion center to finish her rehabilitation. Shewas discharged from that facility 1 monthlater to her home with family support.

R E C O M M E N D E D R E A D I N G S

American College of Radiology: Appropriatenesscriteria, 1999, available at http:www.acr.org.

Bruckner M: Circulatory system. In Ballinger P,Frank E (eds): Merrill’s atlas of radiographic

positions and radiologic procedures, St Louis:Mosby, 1999.

Maxey L, Magnusson J: Rehabilitation of the

postsurgical orthopedic patient, St Louis:Mosby, 2001.

Nunnelee J: Minimize the risk of DVT, RN December1995; 28, 1995.

Rothstein JM, Roy SH, Wolf SL: Communicationdisorder. In Rothstein JM (ed): The rehabili-

tation specialist handbook, Philadelphia: FADavis, 1998.

Tortorici M, Apfel P: Pulmonary angiography:

advanced radiographic and angiographic

procedures, Philadelphia: FA Davis 1995.Watchie J: Cardiopulmonary physical therapy,

Philadelphia: WB Saunders, 1995.

Case 45 187

L E A R N I N G O B J E C T I V E SThe reader will be able to:

1. Discuss the reasons for performing a physical examination on ahomebound patient even though she had been examined in the hospitalemergency room.

2. Identify the need for diagnostic imaging in a patient who has already hadroentgenograph examination.

3. Discuss the importance of corroborating clinical findings with medicaldocumentation.

The reader should know that an 80-year-old

female was referred by her family physician to

a home health agency for physical therapy.

The patient experienced multiple falls and was

having increased difficulty maintaining her

independence in her home. Her most recent fall

occurred 6 weeks earlier and necessitated her

relocation into a new apartment 1 week earlier.

ExaminationH I S T O R YThe patient presented with a complex medicalhistory including a left hip fracture 13 monthsearlier and a right total hip replacement 7 yearsearlier. She also had a history of myocardialinfarction, degenerative joint disease (especiallyin the weight-bearing joints of the lowerextremities), osteoporosis with compressionfractures, dorsal kyphosis, and intermittentswelling in both lower extremities. Additionally,she had a congenital short left foot.

S Y S T E M S R E V I E WVision, hearing, and communication skillswere all normal. Pulse was steady at 72 beatsper minute at rest.

Upper extremity range of motion (ROM)was essentially within functional limits bilat-erally. Left lower extremity ROM was alsowithin functional limits but was longer byapproximately 3 cm. The right lower extremitypresented with severe pain, which increasedwith attempts to move. The right knee wasrestricted to 30 degrees of flexion, and exten-

sion lacked 10 degrees. The right hip wasalso painful with limitations in motion of 80degrees flexion, 0 degrees extension, and 25degrees abduction.

Assessing strength was difficult becauseof the patient’s pain, especially in the lowerextremities. On a manual muscle test, strengthwas estimated as 3–/5 in the right lowerextremity and 3+/5 in the upper extremities.

The patient exhibited decreased sensationto light touch in the lower extremities bilat-erally. Her balance was fair with the use of awalker and poor without the use of a walker.She was independent with bed mobility,although she did have moderate difficulty asa result of her pain. She ambulated with anunsafe hop-to gait with both lower extremities.Because of her pain and poor endurance, shewas able to ambulate only 10 feet. She pre-sented with independent wheelchair mobility.

T E S T S A N D M E A S U R E SRight knee ligamentous testing for the medialcollateral and lateral collateral ligaments aswell as the anterior drawer sign was painfuland lax.

EvaluationThe patient was now in a new apartment andhighly motivated to remain independent. Sheappeared to have good potential for rehabili-tation with goals to improve the distance ofambulation, decrease her pain and improvethe overall safety of her mobility.

189

Case 46

190 Clinical Cases in Physical Therapy

DiagnosisPhysical Therapist Practice Patterns 5A:Primary Prevention/Risk Reduction for Lossof Balance and Falling; 4D: Impaired JointMobility, Motor Function, Muscle Perform-ance, and Range of Motion Associated withConnective Tissue Dysfunction; and 4B:Impaired Posture.

InterventionA comprehensive home treatment programwas started that involved therapeutic exer-cises for improving her ROM and strength,and therapeutic activities to improve herbalance, safety of ambulation, and overalltolerance for exertion.

After approximately 4 weeks of home physi-cal therapy, she was referred to a local medicalcenter for orthopedic assessment of hercontinuing right lower extremity pain. Herformer orthopedist suggested that she mayhave had a loosening of the right hip pros-thesis. There was no orthopedic decision con-cerning her right hip, but the knee diagnosiswas bursitis, which was treated with acortisone injection.

The patient made excellent progress overthe next 5 weeks of intervention in herhome. Her ambulation improved so that shewas able to walk with one hand assist andwith a minimal limp. She could also ascendand descend one flight of steps with twohandrails and minimal assistance. Her ambu-latory endurance was approximately 15 meters.Her right knee flexion had improved to 90degrees without pain. Plans were being madeto discharge the patient from physical therapycare to a home exercise program.

However, while the treating therapist wasaway, the patient was sitting outside in herwheelchair when a strong gust of wind blewher over backward and she fell out of herwheelchair and off of a curb. This occurredeven though the wheelchair was locked. Shewas evaluated at the hospital’s EmergencyRoom. Radiographs were negative. She wasreturned to her home.

The treating therapist was scheduled for avacation; therefore, a colleague was the first

physical therapist to see the patient after thefall from the wheelchair. The colleague’sreport indicated that the patient felt pain fromher right buttock to her toes when attemptingto move her right lower extremity. Her painlimited accurate ROM measurements but shewas limited to approximately 10 degrees inter-nal rotation and 15 degrees external rotation,and other hip and knee motions were essen-tially within functional limits. She was able tostand up independently but used a toe-touchto partial weight-bearing gait for only 10 feetwith the use of her walker. Because of pain,the patient’s mobility and exercise weremarkedly limited.

The emergency room diagnosis after

radiographs was deep muscle bruising.

What else could have been considered?

Six days after the most recent fall, the treat-ing physical therapist returned for continuedhome physical therapy. The discharge papersfrom the emergency room were reviewed andindicated no fracture. However, the patientcomplained of severe pain that she rated at a10 on a 0 to 10 pain scale, with marked limi-tation in right ankle ROM at –10 degrees dor-siflexion, 30 degrees plantarflexion, 5 degreesinversion, and 10 degrees eversion. Swellingwas present in the lateral ankle, and moderateto severe tenderness was noted over the lateralmalleolus and distal fibula. The strength ofplantarflexion, inversion, and eversion wereall scored as 1/5. Ambulation was a hop-togait using a walker.

What course of action could be taken?

OutcomeThe clinical findings suggested that thepatient may have sustained an injury to theright ankle. The inability to bear weight in con-nection with the swelling, tenderness, and painwere all indicative of a possible fracture.

The therapist contacted the home healthagency to report the foregoing findings. Also,the emergency room records were reviewedto confirm the exact site that had been

radiographed at the time of the fall. Theemergency room discharge papers did notindicate which body part or parts had beenexamined. Until the possible injury to theinvolved ankle was clarified, no further weightbearing, ROM, or strengthening exerciseswere attempted for the lower extremities.

DiscussionAfter communication with the hospital’sradiology department, it was learned thatonly the hip and knee were radiographed inthe emergency room. The coordinator of homehealth services for the home health agencycommunicated that information to the familyphysician, who ordered a radiograph of theankle. A courtesy telephone call had alreadybeen placed to the referring orthopedic physi-cian. The new radiographs revealed a fractureof the fibula with displacement of the distalfragment.

Physical therapy was continued in thehome. At the request of the family physician,

the patient was given a knee immobilizer forthe right fibular fracture and an elastic wrapto reduce swelling. When the elastic wrap wasremoved, the skin was damp and remainedcompressed for more than 40 minutes. Again,contact was made with the home healthagency to coordinate care.

Finally, 1 week after the fracture, thepatient was seen by an orthopedist, who putan air cast on the fracture site and approvedambulation with a walker.

R E C O M M E N D E D R E A D I N G S

Brimer M, Moran M: Clinical cases in physical

therapy, Boston: Butterworth-Heinemann,1995.

American Physical Therapy Association: Guide tophysical therapist practice, second edition,Phys Ther 81:1, 2001.

Kauffman T: Geriatric rehabilitation manual,Philadelphia: Churchill Livingstone, 1999.

McRae R: Practical fracture treatment (ed 3),Philadelphia: Churchill Livingstone, 1994.

Case 46 191

The Preferred Physical Therapist PracticePatternsSM are copyright 2003 AmericanPhysical Therapy Association and are takenfrom the Guide to Physical Therapist Prac-

tice (Guide to Physical Therapist Practice, ed2, Phys Ther 81:1, 2001), with the permissionof the American Physical Therapy Association.All rights reserved. Preferred PhysicalTherapist Practice PatternsSM is a trademark ofthe American Physical Therapy Association.

Addressing Issues or Information OutsideDesignated Practice Pattern(s).

Cases: 24, 1, 3

Practice Pattern 4A: Primary Prevention/RiskReduction for Skeletal Demineralization.

Case: 6

Practice Pattern 4B: Impaired PostureCases: 46, 6

Practice Pattern 4D: Impaired Joint Mobility,Motor Function, Muscle Performance, andRange of Motion Associated with ConnectiveTissue Dysfunction.

Cases: 29, 46, 22, 2, 27, 18

Practice Pattern 4E: Impaired Joint Mobility,Motor Function, Muscle Performance, andRange of Motion Associated with LocalizedInflammation.

Cases: 35, 11, 19, 9

Practice Pattern 4F: Impaired Joint Mobility,Motor Function, Muscle Performance, Rangeof Motion, and Reflex Integrity Associatedwith Spinal Disorders.

Cases: 29, 23

Practice Pattern 4G: Impaired Joint Mobility,Muscle Performance, and Range of MotionAssociated with Fracture.

Cases: 39, 41, 42

Practice Pattern 4H: Impaired Joint Mobility,Motor Function, Muscle Performance, andRange of Motion Associated with JointArthroplasty.

Cases: 38, 40, 44

Practice Pattern 4I: Impaired Joint Mobility,Motor Function, Muscle Performance, andRange of Motion Associated with Bony or SoftTissue Surgery.

Cases: 33, 42, 32, 20

Practice Pattern 4J: Impaired Motor Function,Muscle Performance, Range of Motion, Gait,Locomotion, and Balance Associated withAmputation.

Case: 26

Practice Pattern 5A: Primary Prevention/RiskReduction for Loss of Balance and Falling.

Cases: 46, 7, 17, 13

Practice Pattern 5B: Impaired NeuromotorDevelopment.

Case: 28

Practice Pattern 5C: Impaired Motor Func-tion and Sensory Integrity Associated withNonprogressive Disorders of the CentralNervous System—Congenital Origin orAcquired in Infancy or Childhood.

Cases: 4, 37, 12, 26

193

Appendix

C A S E P R A C T I C E PAT T E R N D E S I G N AT I O N A N D C A S EC O M P L E X I T Y — L O W E S T T O H I G H E S T

194 Clinical Cases in Physical Therapy

Practice Pattern 5D: Impaired Motor Func-tion and Sensory Integrity Associated withNonprogressive Disorders of the CentralNervous System—Acquired in Adolescenceor Adulthood.

Cases: 8, 45, 27

Practice Pattern 5E: Impaired Motor Functionand Sensory Integrity Associated with Progres-sive Disorders of the Central Nervous System.

Case: 7

Practice Pattern 5F: Impaired Peripheral NerveIntegrity and Muscle Performance Associatedwith Peripheral Nerve Injury.

Cases: 39, 42, 21, 23, 43

Practice Pattern 5H: Impaired Motor Func-tion, Peripheral Nerve Integrity, and SensoryIntegrity Associated with NonprogressiveDisorders of the Spinal Cord.

Cases: 16, 15, 5, 14

Practice Pattern 6C: Impaired Ventilation,Respiration/Gas Exchange, and AerobicCapacity/Endurance Associated with AirwayClearance Dysfunction.

Case: 31

Practice Pattern 6D: Impaired AerobicCapacity/Endurance Associated with Cardio-vascular Pump Dysfunction or Failure.

Case: 25

Practice Pattern 7C: Impaired IntegumentaryIntegrity Associated with Partial-ThicknessSkin Involvement and Scar Formation.

Case: 30

Practice Pattern 7D: Impaired IntegumentaryIntegrity Associated with Full-Thickness SkinInvolvement and Scar Formation.

Cases: 34, 36

Practice Pattern 7E: Impaired IntegumentaryIntegrity Associated with Skin InvolvementExtending into Fascia, Muscle, or Bone andScar Formation.

Case: 42

Guide to Practice: Procedural Interventions,Page s108: Functional Training in Work (job/school/play), Community, and Leisure Integra-tion or Reintegration (including instrumentalactivities of daily living, work hardening, andwork conditioning).

Case: 10

R E F E R E N C E S

American Physical Therapy Association: Guide tophysical therapist practice, second edition,Phys Ther 81:1, 2001.

Aerobic conditioning, 133Aerobic exercise, 29Aerobic program, establishment, 24AFOs. See Ankle foot orthosesAggravating activities. See PatientsAggressive ROM, 174Agility drills, 44Albuterol. See ProventilAlbuterol, usage, 13Alcoholic neuropathy, 92Aleve, usage, 76, 88Alternative activities, discovery, 117Ambien, usage, 60, 63Ambulation, 78. See also Crutches;

Independent ambulation;Non-weight bearing

attempt, patient refusal, 168demonstration, 28goal, 2instability, 179program, lack, 14skills, 72, 99

American Academy of Dermatology,Excellence in Education Award,141

American Physical Therapy Association,77

American Spinal Injury Association(ASIA) impairment scale, 59t, 67t

Anaprox, usage, 147Ankle foot orthoses (AFOs), 13Ankles

angle, 40dorsiflexion, 127inversion, 37motion, 16passive ROM, 175PROM, 88swelling. See Lateral ankle

Antalgic gait, 77, 79Anterior cervical, visible tightness, 19Anterior compartment syndrome,

consideration, 168Anterior pelvic rotation, lack, 102Anterior pelvic tilt, 28Anterior thigh, pain. See Right anterior

thighAntiemetic medications, usage, 177Antivert. See MeclizineA/P. See Active/passiveAphasia, 186. See also Global aphasiaA/PROM, 44Aqua jogger

time increase, goal, 37usage, 37

Aquatic therapy, 149, 180Arch height, 35AROM. See Active ROMArterial bleeding, 158Arterial blood gas (ABG)

profile, improvement, 144values, 144f, 146f

A

AAROM, 88, 89ABC. See Activity-Specific Balance

ConfidenceAbdomen muscles performance, tests/

measures, 78-79Abdominal binder, wearing, 67Abdominal muscle

strengthening exercises, 81weakening, 79

Abdominal spinae strength,improvement, 163

Abdominal surgery, 76Abductor pollicis brevis, 93Abductors, stretching, 81ABG. See Arterial blood gasActive dorsiflexion, 72Active hip abduction, 83Active ROM (AROM), 25, 110, 133.

See also Lower extremitiesusage, 173, 176

Active/active-assisted ROM, 173Active-assisted flexion, 169Active-assisted movements, 69Active-assisted ROM, 176Active/passive (A/P) range of motion, 88Activity

classification, 110level, 75

decrease, 89Activity of daily living (ADL), 185

ability, 80. See also Homeindependence, 75performance, 144-145

functional capacity, 143training, 186

Activity-Specific Balance Confidence(ABC)

assessment results. See Post-intervention; Pre-intervention

Scale, 14, 17completion, 53-54

Acute compartment syndrome, 168Acute respiratory infection, 143

avoidance, 144Acute-care facility, 187ADA, 39Adaptive activities, discovery, 117Adaptive devices, 122Adaptive equipment, 115-116Adductors, muscle strength, 80Adhesions. See Pelvic floor

decrease. See Episiotomy scarADL. See Activity of daily livingAdmission information, medical record

review, 1Adrenocorticotropic hormone therapy,

129Advil, usage, 76, 88Aerobic capacity

improvement, 144, 149increase, 149

Arthritis, 169. See also Neck; Psoriasisproblem, suspicion, 169-170

Arthroscopic surgery, 155, 156Ashworth scale, 162, 164ASIA. See American Spinal Injury

AssociationASIS, 79Assistive devices, 115-116, 122

recommendations, 121-123usage. See Home activities; Leisure

activities; School activitiesAssistive technology, evolution, 161Assistive walking device, usage

(feasibility), 73Asymmetric pulse, 32fAsymmetrical gait, 47Ataxia, 28Athetoid movements, 161Atorvastatin. See LipitorAuscultation, 68Autonomic dysfunction, 61Autonomous neurogenic bowel/bladder,

64Axillary crutches, usage, 88

B

Babinski’s sign, 185Baby weight, losing, 75Back

discomfort, 102height, 40muscles performance, tests/measures,

78-79Back pain, 23, 75

decrease, 80reporting, 104

diagnosis. See Low back painevaluation/treatment, 109radiation, 79

Baclofen administration, 163Balance, 122, 185. See also Single-leg;

Sittingactivities, 180control, 72decrease, 186disorders, 53findings, 35loss

avoidance, 117closed eyes, impact, 178

practice, 29retraining activities, 179skills, quantification, 72tests/measures, 78training. See Left leg

Balanced pulse, 32fBalke-Ware protocol, 143Ball

rolling, left leg (usage), 126throwing test, 49

BAPD board, 37Basketball

195

Index

Basketball—cont’dright knee, injury, 155sport specific drills, independence, 84

Bath bench, 115Bathing, METS range, 145Bed mobility, 64, 185

difficulty, 67improvement, 68

Behavioral assessmentreexamination, 17review/test/measure, 14

Bell’s palsy, 31-32treatment, efficacy, 33

Bench alignment, 116BERG Balance Scale, 14, 122, 127

score, 17Biceps, deep tendon reflexes, 92Bicycle

accidentproblems, 60response, 59-60

ergometry, 149usage, time increase (goal), 37

Bilateral calf, restrictions, 36Bilateral compression stockings, usage,

63Bilateral hip movements, 68Bilateral PRAFO, 59, 67Bilateral tasks, 50Biofeedback

intervention, 81usage, 6, 7

Biomechanical findings, 35Biomechanics, 38

analysis, 39Bipartite sesamoid, 43f

definition, 43radiographs, 43

Biphasic pulse, 32fBlack theraband, usage. See Lower

extremitiesBladder

diary, 78infections, 76irritants, questions/answers, 80training, questions/answers, 80

Bleedingoccurrence. See Whirlpool sessionsresponse, 158

Blister scars, 25Blocks, stacking. See One-inch blocksBlood

aspiration. See Kneeflow, increase, 44sugar level, 151

Blood pressure, 40, 60, 68, 155, 185borderline, 76control, 165drop. See Systolic blood pressurerange, 167, 181, 186

Blurred vision, 178BMI. See Body mass indexBody

diagram, 137f-138fmechanics, 80

awareness, 79temperature, control, 61

Body mass index (BMI), 27Bone

chip packing, 148cortex, 148graft replacement, 148healing, radiographs, 149loss, 149

Bone scaneffectiveness, 43plain film radiograph, advantages, 37

Bony fragments, removal, 87Botulinum toxin type A, 162Bowel

habits, 64incontinence, physical therapy

sessions (efficiency), 64Bowling ability, demonstration, 99Brace, wearing, 24

encouragement, steps, 25Brachioradialis, deep tendon reflexes,

92Breathing

difficulty, 151exercises, 145

Breech position, 45Broad-band UVB, effectiveness, 139Broca’s area, 186Bronchial pulmonary dysplasia, 13Bulbocavernosus reflex, 64Burn grafting. See Third-degree burn

graftingBursitis, 190Buttocks, pain, 5

C

C7-T1 ASIA level B quadriparesis, 67C7-T1 fracture dislocation, 59CABG surgery, 110CAD. See Coronary artery diseaseCalf

bilateral stretching, 44deep cramping, 114discomfort, 155restrictions. See Bilateral calftenderness, 156

Canehand placement, 30fusage. See Tip-weighted pistol-grip

cane; Weighted pistol-grip caneCapital flexion, 131Cardiac arrhythmias, history, 31Cardiac rehabilitation, 110-111Cardiovascular activities, 90Cardiovascular endurance, decrease, 89Cardiovascular history, 76Cardiovascular improvements, 16Cardiovascular systems

reexamination, 16review, 13, 77, 178test/measure, 13

Cards, pickup (test), 49Care plan. See Physical therapy care

plan; Prognosisacceptance, 73-74change, 126

information, impact, 124-125symptoms, impact, 123-124

compliance, demonstration, 72physical therapy

appropriateness, 149components, considerations, 163

Carpal tunnelmedian nerve, 91stress, reduction, 91

Carpal tunnel syndrome. See Rightcarpal tunnel syndrome;Secondary carpal tunnelsyndrome

CCCE. See Center Coordinator ofClinical Education

Celebrex (celecoxib), 185

Center Coordinator of ClinicalEducation (CCCE), 9-10

Center of gravityalteration, 73maintenance, 54

Central nervous system (CNS)depressant, usage, 177nonprogressive disorders, 15

recovery, natural course, 32Cerebellar atrophy, 71Cerebral artery aneurysm. See Left

anterior cerebral artery aneurysmCerebral palsy, 48f. See also Spastic CP;

Spastic diplegic CPswitch access, 162

Cerebral vascular accident (CVA), 185medical history, 186

Cervical (C1-2) hypomobility, 19Cervical (C3-5) hypermobility, 19, 22Cervical (C5-6) degenerative changes, 19Cervical (C5-7) palpation, 19Cervical (C6) radiculopathy, 20Cervical (C6-7) hypermobility, 22Cervical collar, placement/

noncompliance, 1Cervical extension, 20Cervical flexion, 20Cervical motion, limitation, 20Cervical orthosis, 68Cervical radiographs, 19Cervical region

closed-pack position, avoidance.See Right cervical region

ROM increase, 20, 21Cervical rotation, 20Cervical spine

accessory motion, 21hypomobility, 19mobility, improvement, 21

Cervical traction, usage, 21Cervical-thoracic (CT) junction, 19

movement, 20, 21Chair-to-floor transfers, 115Cheerios

pickup test, 49spoon transfer test, 49

Chemotherapy, 182CHF. See Congestive heart failureChildren

access. See Home environmentlight play, METS range, 145motor function, 162self-mobility, 162

Chin tuck, maintenance, 130Cholesterol, levels, 109Cholesterolemia, 185Chronic obstructive pulmonary disease

(COPD)diagnosis, 143misconceptions, 146patients, long-term oxygen therapy

(benefit), 144-145CI. See Clinical InstructorCigarettes

fires, 159smoking, reduction, 144

CIMT. See Constraint-induced movementtherapy

Client-related instruction, 6Clinical examination, results, 98Clinical findings, therapist (action), 109Clinical Instructor (CI), 9-11Clinical observation, performing, 10-11Clinical Performance Instrument (CPI),

9

196 Clinical Cases in Physical Therapy

Clinical Performance Instrument(CPI)—cont’d

assessments, 11group criteria, 11report, 10

Clinical tests, 76Clonus. See Right lower extremityClosed chain supination/pronation, 37Closed fascia space, 168Closed-head injury, 113Clotting ability, 158Clubbing, 60, 68Clutter, elimination, 56CNS. See Central nervous systemCoccydynia, 6-7Coccygodynia, 5-7Coccyx area

pain, 5weight bearing, 5

Coccyx cutout wedge cushion, usage, 6CODA, 14

movement, 16Cognition, systems review, 77Cognitive function, improvement, 117Cognitive impairment, 53Cognitive loss, modifications.

See Computer technical supportduties

Cognitive screening examinations, 55-56Cognitive skills, reduction, 186Cognitive status

assessment, 113systems review, 53-54, 71-72, 114

Colace, usage, 60, 63Cold, response, 60Color/temperature changes, 187Communication, 185

resource. See Professionalcommunications

skills, 186systems review, 77

Community-dwelling older adult,fall risk

identification, screening type, 53-54reduction/prevention, intervention

development, 54Comorbidities, 29Compartment syndrome, clinical signs/

symptoms, 88Comprehension, reduction, 186Compression

force, application, 98fracture, 189. See also T8

medical history, 186stockings, 59, 67

usage. See Bilateral compressionstockings

understanding, demonstration.See Left knee

Computed tomography, 67Computer technical support duties,

sensory/cognitive lossmodifications, 28

Condition/complaint, 76-77Confidence, decrease, 14Congestive heart failure (CHF), 105Constraint-induced movement therapy

(CIMT), 47effectiveness, 47-48inclusion criteria, 48intervention, 48

Constraint-induced movement therapy(CIMT) intervention

improvement, 48process, 48-49

Constraint-induced movement therapy(CIMT) intervention—cont’d

technique, usefulness, 47-49usage, 47-48

Contractual obligationsguidelines, components, 39information sources, 39

Contralateral leg, muscle strength, 149Conus medullaris, 64Conversational dyspnea, 24, 26Cool-down exercises, 55Coordination, practice, 29COPD. See Chronic obstructive

pulmonary diseaseCoronary artery disease (CAD), 109Coumadin

oral administration, 185prescription, 87

Counter exercises, 29CPI. See Clinical Performance InstrumentCranactin, usage, 76Cranial nerve

examination, 31VII

impact. See Right cranial nerve VIIischemia, 32

Cross-country running, progressiveintervention, 36-37

Cross-training, 36Crutches

ambulation, 167usage. See Axillary crutches

CT. See Cervical-thoracicCustom-fitted MAFO, 182Cutaneous blood flow, control, 60CVA. See Cerebral vascular accidentCyanosis, 60, 68

D

D1F patterns, 68Darvocet, usage, 1DCE. See Director of Clinical EducationDe Quervain’s thyroiditis, 76Debridement. See Infection

health care concerns. See Sharpinstrument debridement

tools, 153Deep muscle bruising, radiographs, 190Deep paravertebral muscles, 83, 85Deep tendon reflexes. See Biceps;

Brachioradialis; Patellar tendon;Quadriceps; Triceps

Deep vein thrombosis (DVT), 60, 185identification, diagnostic imaging, 187medical history, 186standard treatment, 187

Degeneration testing, reaction, 31Degenerative disc disease, 103Degenerative joint disease, 101, 103,

185, 189. See also Hips; Knees;Lumbar zygapophyseal joints

Demerol, prescription, 87Demographics, 75Denervation, signs, 32-33Depressant, usage. See Central nervous

systemDermatologic compromise, 60Dermatome scan, 98, 102Desk workstation setup, considerations,

39-40DiaBeta (glyburide), 185Diabetes, 185. See also Non-insulin-

dependent diabetesmellitus, 185

Diabetic neuropathy, 91, 92Diagnosis

background, 177procedures, 5

Diagnostic imaging, 174. See also Deepvein thrombosis; Pulmonaryembolus

reports, 175Dialysis, 182Diaphragmatic breather, 130Diazepam. See ValiumDidronel, usage, 60, 68Dilantin, usage, 71Director of Clinical Education (DCE),

9-11Disability index, 27Discharge

plan, 80, 117, 145, 149summary, 22

Discoloration, 89onset, 90

Displaced C-1 fracture, 1Distal anterior residual tibia, redness,

114Distal control, 132Distal femur, 148Distal lower extremities, crush injuries,

113Distal radius, 148Disuse atrophy, prevention, 24Ditropan, usage, 105Diuretic, usage, 177. See also Thiazide

diureticsDocumentation. See Initial examination;

Physical therapyDonut pillow, usage. See SittingDoppler scan, 185Doppler waveform analysis, 187Dorsal glides/distraction, 44Dorsal kyphosis, 189Dorsal rhizotomy, 13, 162Dorsalis pedis pulsations, 60, 68Dorsiflexion. See AnklesDorsiflexors, 182

muscles, innervation, lack, 176Dressing, METS range, 145Driving, inability, 179Dulcolax, usage, 63, 68Duty restrictions, levels (description), 40DVT. See Deep vein thrombosisDynamic alignment, 116Dynamic gait index, improved scores,

117Dynamometer

measures, 15tusage. See Grip strength evaluation;

Pincher strength evaluationDynaMyte

augmentative communication device,161, 163

success, demonstration, 163usage. See Independent communication

Dysplasia. See Bronchial pulmonarydysplasia

Dyspnea. See Conversational dyspneadecrease, 144perception, increase, 144

E

Eating, METS range, 145EBP. See Evidence-based practiceECG. See ElectrocardiogramEdema, 60, 68, 187

onset, 90

Index 197

EDSS. See Expanded disability statusscale

Elbowsactive flexion, 22extension, 94flexion, 127supported prone, 130

Electrical stimulation, 25Electrocardiogram (ECG), 109, 110Electrodiagnostic testing, 32Electromyelography study, 19Electromyogram (EMG), 93Electroneuromyography, 31Elementary school environment, return/

participation, 117Elevated work, 40Elevation (understanding),

demonstration. See Left kneeEmbedded locking pin, usage, 116fEmergency room diagnosis, 190EMG. See ElectromyogramEmphysema

functional capacity, assessment(walking, usage), 144

progression, 145-146signs/symptoms, 143

Endocrine history, 76Endocrinologic changes, 135Endurance, 31, 115, 185. See also

Functional activitiesdecrease, 14improvement strategies. See Fatiguemaintenance, 36training, 99

Energyconservation

home modifications. See Patientstechniques, 124

levels, 28Episiotomy, 76

scar, adhesions (decrease), 80Erector spinae

muscle, 23musculature, prominence, 24strength, improvement, 163

Ergonomic contract, establishment, 39EST. See Exercise stress testEvidence-based practice (EBP), 75, 78

search, 80studies, 82

Examinationbeginnings, decision, 97documentation. See Initial examinationfindings, discussion, 2procedures. See Multiple sclerosisprocess, components (incorporation),

31results. See Clinical examination;

Postural examinationconclusions, 98

Exercise stress test (EST)findings, significance, 109-110order, 109

Exercise-induced hypotension, 109Exercises

activities/positions, usefulness, 89frequency, 110-111independence, demonstration, 80intensity, 110-111precautions, 110-111prescription, 110-111program

encouragement, steps, 25independence, demonstration.

See Home exercise program

Exercises—cont’dprogression, decision making, 80repetition/sets, 110-111types, 110-111

Exertion, levels, 40Expanded disability status scale

(EDSS), 27score, 28

Extension lag, decrease, 169Extension passive ROM, 134External fixator. See Femur; Fibula;

Tibiaapplication, 87removal, 88

External hip rotation, 37Extremity movements, 55Eyes

abnormal movement, nystagmus, 177closure, 178

inability. See Right eyecontact, avoidance, 71irrigation system, 153

F

Faber test, 36Facial musculature, examination, 31FAI. See Functional aerobic impairmentFall risk

elimination, 55follow-up, tracking, 55

factors, 53-56knowledge, 54reduction/elimination, 56t

identification, screening type.See Community-dwelling older adult

reduction, 55follow-up, tracking, 55program, 55

reduction/prevention, interventiondevelopment. See Community-dwelling older adult

scores, 56t, 73Falls

history, 53reported number, decrease, 72

Family history, 75-76Fascia space. See Closed fascia spaceFatigue

endurance improvement strategies, 29verbal report, 24

FCE. See Functional capacityexamination

Feedingproblems, 13tubes, 182

Feet, open fracture, 175Femoral head avascular necrosis, 134Femur, external fixators, 175Fibula

external fixators, 175fracture, 167

Fifteen-ply wool socks, 118Fishing, METS range, 145Five-ply cotton socks, 115Flexibility

evaluation, 40findings, 36practice, 29

Flexion. See Active-assisted flexion;Cervical flexion; Right hip

restoration. See Hip flexionrigidity, 162ROM increase. See Right knee

Flexor carpi radialis, 93

Flexor digitorum profundus, 93, 94Flexor digitorum superficialis, 93Flexor pollicis brevis, 93, 94Fluctuating limb volume,

accommodation, 115-116Fly-fishing, 101

demonstration, 104symptoms, 103

Follow-up, tracking, 55Food, pickup, 49, 50Footprint analysis (pedograph), 14

data, 15tForearms

flexor muscles, bilateral tightness,19-20

tingling, reduction, 20Forefoot varus, 35Fork/spoon, usage, 49, 50Forward head, 28Forward-flexed lumbar posture, 103Four-way straight-leg raises, 37Fractures. See L1 burst fracture; Left

proximal humeral fracture; Rightnondisplaced tibial plateaufracture

detection, radiograph usage, 43healing, 88medical history. See Compressionrecovery, open reduction internal

fixation. See Right hipFree-speed gait pattern, normalization,

134Friction massage. See Trigger pointFull lumbar extension ROM, restoration,

134Full-body whirlpool, 157Functional activities, 121

endurance, 31Functional aerobic impairment (FAI),

143, 145Functional capacity examination (FCE),

explanation, 40Functional endurance, improvement, 117Functional intervention, 49Functional limitations/impairments, 89Functional mobility, 115

decrease, 186skills

improvement, 117safety, 117

Functional ROM, 105Functional status, 75Functions performance, inability, 79

G

Gait, 122, 185. See also Antalgic gait;Asymmetrical gait; Non-weightbearing; Resisted gait; Short-stridegait

analysis, 35, 98, 103assessment, 64, 72characteristic. See Trendelenberg’s

gaitdeviation, 99disorders, 53disturbance, 178index. See Dynamic gait indexmaintenance. See Left lower extremitypattern

improvement, 169normalization. See Free-speed gait

patternquality, 63

improvement, 117

198 Clinical Cases in Physical Therapy

Gait—cont’dskills, 28

safety. See Prosthetic gaittests/measures, 78training, 88, 186

continuation, 117velocity, assessment, 14

Gait assessment rating scale (GARS),improved scores, 117

GARS. See Gait assessment rating scaleGasoline (pumping), METS range, 145Gastrointestinal history, 76Gaze stability, loss, 178Gaze-retraining exercises, 179Genitourinary history, 76Genu recurvatum, increase, 35Giant cell tumor

curettage, 148orthopedic specialist, diagnosis,

148-149Glasgow coma score, 113Global aphasia, 185

characteristics, 186Global development delay, 129Glove pattern, 92Gluteus maximus, palpation, 5Glyburide. See DiaBetaGMFCS. See Gross Motor Functional

Classification SystemGravida, 76Grip strength evaluation, dynamometer

usage, 49Groin pain, 84. See also Right intermittent

inner groin painGross Motor Functional Classification

System (GMFCS), 162Gross range of motion (ROM), 77Gross sitting balance, 77Gross strength, 77Gross symmetry, 19, 23systems review, 77, 83Group home, unassisted walking, 72Guide to Physical Therapist Practice

definitions. See Patientspatient/client management, discussion,

9practice patterns, usage, 121, 123procedural interventions, 39usage, 27, 150. See also Practice

patternsGuide to Practice, 78Gunning Fox index, 55Gynecologic history, 76Gynecological Manual, 77, 78

H

Hairbrushing, 50combing, 49

Hamstringbilateral stretching, 44curls. See Prone hamstring curlsmuscles flexibility, decrease, 169restrictions, 36setting, 149stretching, 16, 25tightness, 23

Handicap access, 181Handrails, installation, 27Hands

placement. See Canetingling/burning, 19

Head. See Forward headextension, 131

Head. See Forward head—cont’dfracture. See Right radial head

fracturemovement, 130thrust test, 178upright position, maintenance, 130

Health habits/status, 75Heart rate, 167, 185. See also Target

heart ratemeasurements, 40

Heat, independent use, 84Hemodynamic monitoring lines, 110Hemolytic streptococci, 135HEP. See Home exercise programHepatitis C, 153-154Heterotropic ossification (HO), 60, 124Hip abduction, 122. See also Active hip

abductionrange of motion (ROM), improvement,

163side-lying position, 125strength/muscle performance ratings,

115Hip arthroplasty surgery, 165

therapist, recommendation, 166Hip extension

ROM, restoration, 134strength/muscle performance ratings,

115Hip flexion, 28. See also Right hip;

Sittingcontracture, 84restoration, 134strengthening exercises, 16strength/muscle performance ratings,

115Hip flexor

muscle strength, 80stretches, 16stretching, intervention, 81tightness, 79

Hip joint, 98muscle power, decrease, 84musculature, 99pathology, usage, 84

Hip range of motion (ROM), 79influence. See Lumbar spine

Hipsadduction/rotation, strength/muscle

performance ratings, 115degenerative joint disease, 71motion, ROM, 80movements. See Bilateral hip

movementspain, 35pathology, suspicion, 106-107region, pain, 84replacement. See Right total hip

replacementrotation. See External hip rotation;

Internal hip rotationweakness, 36

History review, 1History/systems screen, tests/measures

(appropriateness), 77HIV. See Human immunodeficiency virusHO. See Heterotropic ossificationHome

activities, assistive devices (usage),117

ADL, 80ability, 80

IADLS, ability, 80modifications. See Patientsprogram, focus, 170

Home—cont’dstrengthening program, independence,

84stretching routine, independence, 84therapy program, 15

Home care nursing, 87Home environment

child access, 115modifications, 54

Home exercise program (HEP), 149, 173considerations, 110independence, demonstration, 80lack, 14performance, 17referral, 55undertaking, 24

Home health agencyphysical therapy, referral, 105referral, 189

Home health services, 152Hop-to-gait ambulation, 189Horizontal abduction/adduction, 123Housecleaning, METS range, 145Household chores, pain, 109HTN. See HypertensionHuman immunodeficiency virus (HIV),

153-154Hydraulic lift, providing, 39Hydrotherapy, complications (response),

153Hyperpronation, 35Hypertension (HTN), 105, 185

medical history, 67Hypomobility, 103. See also Lumbar

spineHypotonia, 129Hytrin, usage, 1

I

IADLs. See Instrumental ADLsIbuprofen, usage, 68ICD-9-CM code (351.0), usage, 32Ice

inclusion, 173independent use, 84

Idiopathic scoliosis, 23Iliac crest, 24IM. See IntramuscularImmune-mediated dysfunction, 135Impairments

permanence, 179-180remedies, 178-179

Incontinence, symptoms, 76Independence, maintenance, 189

action, 190-191Independent ambulation, 2Independent communication

(demonstration), DynaMyte(usage), 163

Independent sitting, maintenance, 163Independent-living retirement

community, 181Infantile spasms, 129Infection, 135. See also Post-surgery

infectionprevention, 63surgical debridement, 88

Inflammation, decrease, 44Initial examination, 121-122

documentation, 1-2tests/measures, 121-122

Initial treatment, consideration, 85Innervation, lack. See Dorsiflexor

muscles; Quadriceps

Index 199

Insomnia, 60, 63Instrumental ADLs (IADLs), 185

ability, 80. See also HomeInsulin injections, 181Integumentary history, 76Integumentary status, 114Integumentary systems, review, 19, 23,

77, 83, 178Intensive care unit (ICU), 113. See also

Neonatal ICUIntercostals, 130Intercourse, pain (reporting), 80Intercranial bleeding, 13Interdisciplinary prosthetics clinic, 117Internal derangement repairs. See KneesInternal hip rotation, 77Internal rotation/abduction, restrictions,

134Intervention. See Cross-country running

ABC assessment results. See

Postinterventionappropriateness, 130-131benefits. See Physical therapycoordination/communication/

documentation, 6, 29development. See Community-dwelling

older adultlogical course, 98-99. See also Patientsselection guidance, evidence

application, 163-164therapy, 50tusage. See Screeningweeks 1 to 11, 37

Intervertebral foramen (size), decrease,103

Interviewcomponents, significance. See

Physical examinationfindings, 97, 101

Intramuscular (IM) morphine, 157Intrathecal baclofen

pump insertion, 164therapy, 163

Intravenous (IV) antibiotics, 88, 157Intravenous (IV) treatments, 182Ischial tuberosities, 6Isokinetic exercises, 149Isometrics. See Resisted isometrics

examination. See Resistive isometricexamination

exercises, 149testing, value. See Patient problems

Isotonic exercises, 149IV. See Intravenous

J

Jellybean, 161Job-related stresses, increase, 135Jogging

ability, 84benefit, 38timing usage, 38

Joint range of motion (ROM), 19, 23,72, 115

evaluation, 147-148results, 148tsystems review, 83

Joints, 24deformities, 60dysfunction, 134function, 115integrity/mobility, tests/measures, 78mobility, range, 185needle aspiration, 156

Joints—cont’dpathology, usage. See Hip jointsurgeries, 169systems review, 84tenderness, 139

K

KAFO. See Knee-ankle-foot orthosisKeflex, prescription, 87Knee-ankle-foot orthosis (KAFO), 175Knees

action. See Right kneeangle, 40arthroplasty, postsurgical rehabilitation.

See Right total knee arthroplastyblood, aspiration, 155clearance, 40compression/elevation. See Left kneedegenerative joint disease, 71diagnosis, 190disarticulation amputation, 176extension, 123

maintenance, 169strengthening exercises, 16

extensorsmovement, 116stretching, 16

flexion, 116ROM increase. See Right knee

immobilizer, 169internal derangement. See Right knee

repairs, 156pain. See Medial knee pain

persistence. See Left kneestaphylococcal infection, 156strength/muscle performance ratings,

115striking, examination, 168swelling, 169wrapping, ace bandage (usage),

147, 148Kurtzke stage 2, examination procedures.

See Multiple sclerosisKyphotic pressure, 129

L

L1 burst fracture, 63L5 myotome, weakness, 77L5 nerve root, 103

pressure, 104L5-S1 lumbar fusion, 165L5-S1 segmental innervations, 64Lateral ankle, swelling, 190Lateral bending, 133Lateral forearm, tingling/burning, 19Left anterior cerebral artery aneurysm,

121Left arm splint, 67Left convex lumbar curve, compensation,

24Left hip

flexion, 161internal rotation, 161passive ROM, 133

improvement, demonstration, 134radiograph, 134

Left kneecompression/elevation, understanding/

demonstration, 123pain, persistence, 1PROM, 147-148

Left legstrength, assessment, 28usage. See Ball

Left leg—cont’dweight bearing, 126

Left lower extremity (LLE)measurement, 114-115partial weight-bearing gait,

maintenance, 123referred symptoms, resolution, 134ROM, 189

Left proximal humeral fracture, 173action, 174care, physical therapy plan, 176examination, 273intervention, information, 174patient history, 173tests/measures, 173

Left shoulder flexion, 28Legs

cast, application, 167elevation/external rotation, 167length, 83

equality, 166raise, performance. See Straight leg

raisestance. See Single-leg stance

Leisure activities, 79-80assistive devices, usage, 117return, 117

Levator ani, palpation, 5Librium, usage, 1Life activities

independent functioning, 80return, 80

Lift patterns, 68Lifting restrictions, levels, 40Ligamentous laxity, 60Light therapy, 135

center assessment, 137f-138fLimbs

circumferential measurements, 114volume, accommodation. See

Fluctuating limb volumeLipitor (atorvastatin), 185Lisinopril. See ZestrilLLE. See Left lower extremityLocomotion, 122, 185

tests/measures, 78Long-term goals, 21, 25, 84, 163

set, consideration, 85Long-term oxygen therapy, benefit.

See Chronic obstructive pulmonarydisease

Lovenox, usage, 60, 68Low back pain, 173

diagnosis, 5, 133Lower abdominals, strength (increase),

80Lower extremities. See Noninvolved

lower extremitiesactive ROM, 23black theraband, usage, 126dysfunction, 53muscle

groups, increase, 144strength, increase, 149

ROM. See Uninvolved lower extremitystretching, 105

Lower quarter screen, results, 102Low-intensity weight training program,

145Lumbar curve, 24

compensation. See Left convex lumbarcurve

Lumbar extension ROM, 133-134restoration. See Full lumbar extension

ROM

200 Clinical Cases in Physical Therapy

Lumbar flexion, 102Lumbar lordosis, increase, 35Lumbar mobility, 97Lumbar screen, 98Lumbar spine

disorder, 84extension, 133findings, 36hip ROM, influence, 134hypomobility, 102ROM, decrease, 79

Lumbar, ultrasound therapy, 5Lumbar zygapophyseal joints,

degenerative joint disease, 103Lupus erythematosus, 177

M

MAFO. See Molded ankle-foot orthosisMagnetic resonance imaging (MRI),

19, 76, 148, 174Maitland grade I central vertebral

pressure techniques, 21Maitland mobilization. See

Metacarpophalangeal jointMalunion areas, 88Manual muscle test (MMT), 93, 98, 102.

See also Strengthgrade, 144usage, 148, 189

McKenzie chin retraction exercises, 21MDRT. See Multi-directional reach testMeasurable data types, gathering, 114Meclizine (Antivert), 177MED. See Minimal erythema doseMedial collateral ligament, mild sprain,

147Medial knee pain, 97Medial tibial plateau, tenderness, 148Median nerve. See Carpal tunnel

compression, 94distribution. See Right median nerve

distributionimpact. See Musclesinvolvement

determination process, 93extent, tests/clarification, 92

Medical history, 76Medicare

Part A, 183Part B, 183payments, 145

Medications, 76Meniere’s disease, 177Meniscal tests, 98Menses, 23Mental retardation patient, physical

therapy services (refusal), 74Metabolic equivalents (METS), 143

measurement, 144range, 145

Metacarpophalangeal joint (MPJ),43, 44t

Maitland mobilization, 44METS. See Metabolic equivalentsMI. See Myocardial infarctionMiami-J collar, wearing, 59Midline, crossing, 72Minimal erythema dose (MED), 136Mini-squats, walker/counter support.

See Right legMini-trampoline jogging, benefit.

See Sidewalk running; Treadmillrunning

Miscarriages, 76

MMT. See Manual muscle testMobility. See Bed mobility

decrease, 98increase, 21, 144skills, 11training, continuation, 117

Modified dorsal glides, 21Molded ankle-foot orthosis (MAFO),

181-182. See also Custom-fittedMAFO

impact. See Right kneereimbursement, 182-183

Motionanalysis system, 14inhibition, pain, 84measures, goniometric range, 14trange, 122, 185. See also Joint range

of motionMotivation, 89Motor function. See Pelvic floor

impairment, recovery (naturalcourse), 32

Motor log, usage (test), 49Motor strength, 68Motor vehicle accident (spinal cord

injury), 59functional limitation, response, 67response, 63

Movement, functional patterns(development), 68

MPJ. See Metacarpophalangeal jointMRI. See Magnetic resonance imagingMS. See Multiple sclerosisMulti-directional reach test (MDRT), 54Multidisciplinary approach, 29Multiple falls, 189

action, 190-191Multiple sclerosis (MS)

diagnosis, 27Kurtzke stage 2, examination

procedures, 28muscle tone decrease, interventions,

29Multiple skin grafts, 175Multiprocessing problems. See Short-

term memoryMuscle strength, 14, 31. See also

Adductors; Hip flexors; Pelvicfloor; Piriformis

5/5, ability, 94improvement, 33, 144inhibition, pain, 84

Musclesatrophy, 89bruising, radiographs. See Deep

muscle bruisingcontraction

active performance, 87strength, 81

flexibility, decrease. See Hamstringgroups, increase. See Lower

extremities; Upper extremitiesinnervation, median nerve (impact),

94performance, 89, 115, 122

improvement, 117tests/measures. See Abdomen

muscles performance; Back;Pelvic floor muscles

power, decrease. See Hip jointspasm, 5, 161strengthening, 149tests, 63-64. See also Manual muscle

testtone, 162

Muscles—cont’ddecrease, interventions. See Multiple

sclerosistraining. See Pelvic floor muscles

Musculoskeletal damage, 7Musculoskeletal examination, 161Musculoskeletal function, improvement,

117Musculoskeletal history, 76Musculoskeletal injury, history, 23Musculoskeletal screening, 54

examination, 55-56Musculoskeletal systems

reexamination, 16review, 13-14, 19-20, 23-24, 77, 178test/measure, 13-14

Myocardial infarction (MI), 76, 109,143, 189

Myofascial release, 81

N

Naproxen, usage, 91, 97National Psoriasis Foundation (NPF),

140-141Nausea, 177NCV. See Nerve conduction velocityNeck

arthritis, 75extension, 131stiffness, 91

Neck pain, 123persistence, 1reduction, 20

Neonatal ICU (NICU), 13, 47Nerve conduction velocity (NCV) test,

93-94Nerve integrity. See Peripheral nerve

integrityNerve root. See L5 nerve root

irritation, reduction, 21pattern, 92

Nerve trunk, tapping, 93Neurologic status, 72, 114Neurologic system, review, 20Neuromuscular history, 76Neuromuscular screening, 54

examination, 55-56Neuromuscular systems

reexamination, 16-17review, 14, 77, 178test/measure, 14

Neurontin, usage, 71, 105Neuropathy. See Alcoholic neuropathy;

Diabetic neuropathyNeurovascular signs/symptoms, 89Nicholas Manual Muscle Tester, 14NICO. See Neonatal ICUNitroglycerin

ineffectiveness, 151-152usage, 151

Nocturia, 76Non-insulin-dependent diabetes, 151Noninvolved lower extremities, 167Nonsteroidal antiinflammatory drug,

prescription, 21, 147, 155Nonsteroidal antiinflammatory

medication, 101side effects, 103

Non-weight bearing, 35, 149, 168. See also

Patientsambulation, 148exercises, 37gait, 124strengthening exercises, addition, 37

Index 201

Non-weight bearing—cont’dusage, 175

NPF. See National Psoriasis FoundationNumbness, 64Nystagmus. See Eyes

O

Ober test, 36Oblique abdominals, improvement, 26Oblique fracture, presence, 106Obliques, contraction, 130Obstetric history, 76Obturator musculature, trigger point

tenderness (decrease), 80Occlusion, areas, 186Occupational therapist, usage, 130-131Occupational therapy, 186One-inch blocks, stacking (test), 49One-legged stance test, 117Open fracture. See Feet; Right femur;

Tibiapatient information, 175tests/measures, 175

Open reduction, 87internal fixation. See Right hip

Open wounds, 182Open-pack position. See Symptomatic

reliefOral baclofen, trial, 164Oral contraceptives, usage, 136Oral corticosteriods, prescription, 31Oral-motor musculature, 161Ortho Gel liner, usage, 115, 116fOrthopedic specialist, diagnosis.

See Giant cell tumorOrthotics, usage, 37OsCal, usage, 105OSHA, 39Osteophyte formation, 19Osteoporosis, 185, 189

medical history, 186Outpatient physical therapy, 88

clinic, 109Overpressure, 98, 102Oxycodone, usage, 105Oxygen

consumption, 143delivery device selection, importance,

145saturation levels, 16, 144therapy, benefit. See Chronic

obstructive pulmonary disease

P

PA. See Posterior to anteriorP/A/AA ROM, 89Pacing, 39PaCO2, resting level (decrease), 144Pain, 121. See also Hips; Palpation;

Pelvic floordecrease, 44. See also Pelvic floor;

Pelvic painexperience, 104inhibition. See Muscle strengthlevels, 81medication, requests, 167nonmusculoskeletal origin, 97radiation. See Back painreduction, 163relief, 68symptom, increase, 7tests/measures, 79

Pain-free ROM, 84, 165Palmar surfaces, plaques, 135

Palpation, 19-20, 23findings, 36pain, 155systems review, 83

Paraplegia, 105Paravertebral muscles. See Deep

paravertebral musclesParesthesias, 92. See also Right lower

extremitycomplaints, 89experience, 104onset, 90, 91reoccurrence, 94

Partial weight-bearing gait, maintenance.See Left lower extremity

Passive mobility testing, 103Passive ROM (PROM), 43, 44t, 60, 106.

See also Ankles; Extensionpassive ROM; Left knee

exercises, 176improvement demonstration.

See Left hipinclusion, 129, 173

Patella, proximal border/distal border,114

Patellar tendondeep tendon reflexes, 102insertion, 116

Patient problemsidentification, tests (performing), 93source, 103

isometric testing, value, 93-94Patient-related instruction, 6Patients

aggravating activities, 133-134benefit, 179complaints, cause, 78concerns, response, 125education

health care team approach, 159intervention, 81issues, 110, 145

energy conservation, homemodifications, 27-28

history. See Left proximal humeralfractureGuide to Physical Therapist

Practice, definition, 1intervention, course, 94non-weight bearing, 87, 88physical therapy. See Outpatient

physical therapysole provider, 89symptoms, sources, 97

PE. See Pulmonary embolusPediatric Evaluation of Disability

Inventory (PEDI), 49Pediatric rehabilitation unit, 113Pedograph. See Footprint analysisPelvic floor

impact. See Tone increasemotor function, 78pain, decrease, 80resting activity, decrease, 80resting tone, demonstration, 80scar adhesion/pain, 79strength

exhibition, 80increase, 80

strengthening, 81tone, reduction, 81weakness, 79

Pelvic floor musclesperformance, tests/measures, 78-79strength, 5

Pelvic floor muscles—cont’dtraining, 82

Pelvic paindecrease, 80relief, 77

Pelvic tilt. See Anterior pelvic tilt;Posterior pelvic tilt

Pelvis, radiographs, 5Percocet, usage, 63Percussion, 68Perforated colon, 76Perineal body, self-massage, 81Perineum integument, tests/measures,

78Periosteum, irritation, 148Peripheral nerve integrity, 122Permanent prostheses, transition, 117Pertussin HC, usage, 105PFT. See Pulmonary function testPhalen’s test, 22Phenobarbital, usage, 71Photosensitivity, increase, 136Phototherapy, usage, 136, 139Physical activity, participation, 28Physical dysfunction, 28Physical examination

aspects, 102interview components, significance,

91Physical fitness, maintenance, 54Physical therapy

analysis. See Sprained medialcollateral ligament diagnosis

appropriateness. See Care plancare plan, 89continuation, 174documentation, 1examination, 165, 167intervention

benefits, 40recommendation, 121, 123

program. See School-based physicaltherapy

referral. See Home health agencyrefusal. See Mental retardation patientreturn, 180services, pursuance. See School-based

physical therapysessions

efficiency. See Bowel incontinenceparticipation, 64

Pillows, selection, 21Pincher strength evaluation, dynamometer

usage, 49Piriformis

musclesbilateral stretching, 44strength, 80

palpation, 5restrictions, 36stretching, 81tightness, 79trigger point. See Right piriformis

tenderness, decrease, 80Pivot transfer, attempt, 169Plyo-ball toss, 37PNF, 68Poikilothermia, 60Positioning

strategies, 130tasks, 161

Posterior pelvic tilt, 122Posterior to anterior (PA) pressures, 102Posteroanterior central vertebral

pressures, 84

202 Clinical Cases in Physical Therapy

Postintervention, ABC assessmentresults, 16t

Post-surgery infection, 88Postsurgical physical therapy, 165Posttraction exacerbation, 21Postural control, 115Postural deviation, 79Postural examination, results, 102Postural stability, 186Postural training, 6Posture, 122

analysis, 39attaining/maintenance, 21findings, 35patient awareness, 79questions/answers, 80skills, 72tests/measures. See Sitting; Standing;

WalkingPower, 31Powered mobility, success

(demonstration), 163PPS, application, 182-183Practice patterns (identification),

Guide to Physical Therapist

Practice (usage), 2PRAFO. See Pressure-relief ankle-foot

orthosesPre-intervention, ABC assessment

results, 16tPressure-relief ankle-foot orthoses

(PRAFO), 59. See also BilateralPRAFO

Prevention/wellness program, planning,56-57

Primary diagnosis, 116Problems, 89

list, 79Procardia, usage, 1Professional communications, resource,

11Progression plan, recommendation, 110Progressive intervention. See Cross-

country runningPROM. See Passive ROMPronator teres, 93, 94Prone hamstring curls, 37Prosthesis, 115

donning, 116fdemonstration, 117

transition. See Permanent prosthesesProsthetic gait skills, safety, 117Prosthetic prescription (effectiveness),

monitoring, 117Prosthetic socks, applications, 116fProsthetic training, 113Prosthetics clinic. See Interdisciplinary

prosthetics clinicProtective helmet, usage consideration,

73Proventil (albuterol), 185Proximal stability, 130Proximal tibia, 148Proximal tibial tubercle, measurement,

114Proximal-third tibia fractures, 168PSIS, 79Psoralen, usage, 139Psoriasis

arthritisclinical manifestations, 139incidence/etiology, 139

clinical manifestations, 135etiology/incidence, 135examination/evaluation, 136

Psoriasis—cont’dpathogenesis, 135prognosis, 135risk factors, 135

Psychological history, 76Psychotropic medications, usage, 53PT evaluation/treatment, 1Pubic symphysis, 77Pulmonary embolism, 187Pulmonary embolus (PE)

diagnostic imaging, 187standard treatment, 187

Pulmonary function test (PFT), 143profiles, 145values, 144f, 146f

Pulmonary history, 76Pulmonary rehabilitation program, 144Pulmonary systems review, 77Pulsatile current, usage, 33Pulse oximeter, usage, 145Pulse oximetry, usage, 144Pulsed ultrasound, application, 44Punch skin biopsy, 135Puncture wounds, 153Push/pull, 40PUVA treatment interventions, risk

factors/safeguards, 139Pylon fracture, 87f. See also Right lower

extremitycomplications, avoidance, 89

Q

Quadricepscontraction, 169deep tendon reflexes, 114innervation, lack, 176restrictions, 36setting, 149strain, diagnosis, 97strength, 176tear, 170

Quarters (pickup), test, 49

R

Radial head fracture. See Right radialhead fracture

Radiograph. See Bipartite sesamoid;Cervical radiographs; Deepmuscle bruising; Pelvis

advantages. See Bone scanlateral views, 103order, 191usage, 101, 124. See also Fractures

Radiography, usage, 76Rancho Los Amigos cognitive level 7, 114Range of motion (ROM). See Active

ROM; Active/passive range ofmotion; Gross range of motion;Hip ROM; Joint range of motion;Passive ROM

active performance, 87changes, 16decrease, 84. See also Lumbar spinedemonstration, 117findings, 36improvement, 117, 190. See also Hip

abduction; Trunkincrease, 99. See also Cervical region;

Right kneeinitiation, 155limited return, potential, 89loss, 85, 105

tests/measures, appropriateness,105-106

Range of motion (ROM)—cont’dtherapist, action, 106

measurements, 13-14, 190restoration, 84, 156. See also Full lumbar

extension ROM; Hip extensionrestrictions, extension, 88

Ratchet lock, 175Rate of perceived exertion (RPE), 145

increase, 144usage, 146

Reaching down ability, demonstration, 72Rear-end auto collision, 19Reconstruction, form, 155Recreational activities, resumption, 117Rectus abdominus, 130Red theraband, usage. See Upper

extremitiesRedness, resolution, 23Reflexes, 185

integrity, tests/measures, 79Rehabilitation

hospital, discharge, 169potential, 2

Rehabilitative services, 158Relafen, usage, 1Repeated motions, 102Repetitive squat, 40Repetitive vertical patterns, 177Residual limbs, maturation, 117Resistance

exercises, prescription(considerations), 110-111

training, 111Resisted gait, 37Resisted isometrics, 102, 133Resistive isometric examination, 98Respiratory infection

avoidance. See Acute respiratoryinfection

reduction, 144Respiratory rate, range, 167Rest periods, 29Resting activity, decrease. See Pelvic floorResting tone, demonstration. See Pelvic

floorRetirement community. See Independent-

living retirement communityRevascularization, 175Reverse-chop patterns, 68Rib hump, 24Right adductor muscles, second-degree

groin strain, 84Right anterior thigh, pain, 35, 97Right carpal tunnel syndrome, 91Right cervical region, closed-pack

position (avoidance), 21Right convex thoracic, compensation, 24Right convexity, 23Right cranial nerve VII, impact, 31-32Right elbow, extension, 123Right eye, closure (inability), 31Right femur, open fracture, 175Right hip

examination, considerations, 165-166flexion, 123flexors, 84fracture

action, 151recovery, open reduction internal

fixation, 151reconstruction surgery, 13

Right ilium, forward rotation, 79Right intermittent inner groin pain, 83Right knee

action, 156

Index 203

Right knee—cont’dextension, 122flexion, 182, 190

ROM increase, 149injury. See Basketballinternal derangement, 167MAFO, impact, 182problem, suspicion, 155-156

Right legcircumducting, 126external rotation/shortening, 105mini-squats, walker/counter support,

125strength/balance training, 126tests/measures, appropriateness,

105-106therapist, action, 106

Right lower extremity (RLE). See SpasticRLE

clonus, 185joint angles, determination, 14measurement, 114-115paresthesias, 103pylon fracture, 87referred symptoms, abolishment, 134weight, placement, 169

Right median nerve distribution, 19Right nondisplaced tibial plateau

fracture, 167Right obturator internus, trigger point,

79Right palm, tingling, 19Right piriformis, trigger point, 79Right radial head fracture, 19Right total hip replacement, 189Right total knee arthroplasty, postsurgical

rehabilitation, 169Right upper extremity, 185

altered sensation, 21strength, increase, 20strengthening exercises, 124symptoms, 19

severity/irritability/nature ratings, 20Right upper quadrant muscles, soft tissue

mobilization, 21Risk factors. See Fall riskRLE. See Right lower extremityRobitussin, usage, 60Rocephin, usage, 63ROM. See Range of motionRomberg position, maintenance.

See Semitandem Rombergposition; Tandem Rombergposition

Romberg’s test, 178RPE. See Rate of perceived exertionRunning

mini-trampoline jogging, benefit.See Sidewalk running; Treadmillrunning

shoesage, 36features/usage, 36

S

Sacral sparing, 68Sacral spine, ultrasound therapy, 5Sacroiliac joint (SIJ)

area, pain, 5misalignment, 77mobility, 78

Sagittal plane, 130Scapulae. See Winging scapulaeScapular muscles, improvement, 26

Scar adhesion. See Pelvic floorabsence, demonstration, 80

Scar massage, 81School activities

assistive devices, usage, 117return, 117

School-based physical therapyprogram, 163services, pursuance, 117

Scoliosis. See Idiopathic scoliosisScooter usage (considerations), 126Screen height, 40Screening, intervention usage, 2-3Seat height/back angle, 40Seattle dynamic response prosthetic

feet, 115Secondary carpal tunnel syndrome, 20Secondary diagnosis, 116Second-degree groin strain. See Right

adductor musclesSecond-degree injury, sustaining, 32Seizure disorder, 71Self-assessment, performing, 11Self-care activities, 186

performance, 144Self-mobility. See ChildrenSelf-reported assessments, 40Semitandem Romberg position,

maintenance, 117Semmes-Weinstein monofilament test,

92Senekot, usage, 68Sensation, findings, 35Sensorineural hearing loss (tinnitus),

177Sensory integrity, 122

impairment, recovery (natural course),32

tests/measures, 79Sensory loss, modifications.

See Computer technical supportduties

Sensory testing, 92, 106Sesamoid bones, roles, 43Sharp instrument debridement, health

care concerns, 153-154Shoes (painless usage), demonstration,

99, 104Short-stride gait, 169Short-term goals, 20, 24, 32, 84, 163Short-term memory, multiprocessing

problems, 28Short-term stay, 87Shoulders

blades, pain, 109pain, 123ROM, 20, 174

Showering, METS range, 145Shuttle-locking mechanism, engaging,

116fSide flexion, 21Side-bending, 102Side-lying position, 130. See also Hip

abductionSidewalk running, mini-trampoline

jogging (benefit), 38SIJ mobility, decrease, 79SIMV. See Synchronized intermittent

mandatory ventilationSingle-leg

balance, 37, 44stance, 178

Sittingbalance, 67, 185. See also Gross sitting

balance

Sitting—cont’ddonut pillow, usage, 5hip flexion, 123inability, 178maintenance. See Independent sittingpatient tolerance, 1posture, tests/measures, 79upright posture, improvement, 163

Skeletal-muscle metabolism,improvement, 145

Skilled nursing facility (SNF)placement, 181regulations, 183

Skinbiopsy. See Punch skin biopsycare, demonstration, 117grafts, 175. See also Multiple skin

grafts; Split-thickness skin graftsrash, 178scalp, observation, 136

Sleepingpattern

disruption, 79pain, 84

posture, 21trouble, 75

Sling, usage, 50tSLR, 36Slump test, 36Small objects (control), demonstration,

94, 104Smoking

cessation program, 14level, 91reduction. See Cigarettes

SNF. See Skilled nursing facilitySocial activities

independent functioning, 80participation, inability, 179return, 80

Social ADL, 80Social habits, 75Social history, 75Socks. See Fifteen-ply wool socks;

Five-ply cotton socksSoft tissue

intervention, 81mobilization. See Right upper quadrant

musclesSomatosensation, 114Spastic CP, 13Spastic diplegic CP, 13Spastic RLE, 185Spasticity, 122, 161

increase, evidence, 60management options, 162-163reduction, 164

Special education services, pursuance,117

Special tests, 20, 24, 83findings, 36performance, information derivation,

103positive signs, 84types/usage, appropriateness, 98,

102-103Speech therapist, usage, 130-131Spinal cord injury, response. See Motor

vehicle accidentSpinal curvature, maintenance, 25Spinal position, 25

improvement, 24Spinal segments, hypermobility, 19Split-thickness skin grafts, 114

204 Clinical Cases in Physical Therapy

Spoontransfer test. See Cheeriosusage. See Fork/spoon

Sport specific drills, independence.See Basketball

Sprained medial collateral ligamentdiagnosis, physical therapistanalysis, 148

Squat. See Repetitive squatperformance, inability, 98

Squat test, 35information, 36

Stabilization (surgical procedure), 59Stairs, walking/ascension, 84Standing

inability, 178posture, tests/measures, 79push-ups, 123

Staphylococcal infection. See KneesStaphylococcus aureus, 157Static alignment, 116Static positions, avoidance, 21Static two-point discrimination test, 92Stationary bicycle usage, increase, 126Step-downs, 37Step-ups, 37Steri-Strips, usage, 114Stomach irritation, 91, 103Stool, step on/off, 126Straight leg raise, 84, 102. See also

Four-way straight-leg raisesperformance, 169

Strength, 20, 24, 72. See also Grossstrength

assessment, 189decrease, 14evaluation, 40exhibition. See Pelvic floorimprovement, 117. See Erector spinaeincrease. See Lower abdominals;

Pelvic floorMMT, 35performance, 115results, 148tsystems review, 83testing, 106training. See Left leg

Strength-duration testing, 31Strengthening

intervention, 81program, independence. See Home

Stress, reduction. See Carpal tunnelStretching, 89-90. See also Abductors;

Hip flexor; Lower extremities;Piriformis

breaks, 21routine, independence. See Home

Structures, stress, 133-134Student competency, outcomes

demonstration, 11Subluxations, 60Supine/side-lying, rolling (facilitation),

68Surgical debridement. See InfectionSurgical history, 76Surgical rhizotomy, 178Swan-Ganz catheter, 110Sweating, regulation, 60Swelling, 60, 121

increase, 147onset, 89

Swiss ball, usage, 29Switch

access. See Cerebral palsyusage, 163

Symptomatic relief, open-pack position,21

Synchronized intermittent mandatoryventilation (SIMV), 113

Synthroid, usage, 105Systemic lupus erythematosus, 178Systolic blood pressure, drop, 109

T

T8, compression fracture, 185Table height, 40Tai chi exercises, 55, 56Tampon insertion, pain (reporting), 80Tandem Romberg position, maintenance,

117Target heart rate, 24tTEDS, 185Teeth, brushing, 49, 50Tegretol, usage, 13Telephone usage, inability, 179Tendon

reflexes. See Biceps; Brachioradialis;Patellar tendon; Quadriceps; Triceps

retraction, 170Terrible triad injury, 155Tetanic contractions (induction),

inability, 32Tetracycline, usage, 136Thenar muscles, weakness, 19Theraband, usage, 37. See also Lower

extremities; Upper extremitiesTherapeutic exercise, recommendation,

110Therapy visits, focus, 170Thermoregulatory changes, 60Thiazide diuretics, usage, 136Thigh, pain, 83. See also Right anterior

thighThird-degree burn grafting, 158Thomas test, 36, 79, 84Thoracic

compensation. See Right convexthoracic

curve, 23, 24Thumbs

sensation, improvement, 22tingling/burning, 19

Tibiaexternal fixators, 175open fracture, 175torsion, 35

Tibial tubercle, measurement, 114.See also Proximal tibial tubercle

Tigan. See TrimethobenzamideTimed up-and-go (TUG) test, 54Tinel’s sign, 22, 93Tinetti assessment tool, 122, 127Tinetti balance assessment, 28, 72Tinnitus, 179. See also Sensorineural

hearing lossTip-weighted pistol-grip cane, usage, 73Tissue plasminogen activator (TPA), 185TLSO clamshell brace, 63Toes

clearance, 64, 116extension, 102, 167pain, 43palpation, 168position, 167

Tone increase, pelvic floor (impact), 79Topomax, usage, 129Towel rolls, 131Toys, usage, 49TPA. See Tissue plasminogen activator

Traction maintenance, external fixator(application), 87

Transcendental meditation, usage, 76Transfers

dysfunctionality, 79performance, 17

Trauma, 135, 177Treadmill running, mini-trampoline

jogging (benefit), 38Treatment sessions, 123-127Trendelenberg deviation, 165Trendelenberg’s gait, characteristic, 64Trendelenberg’s sign, 35

resolution, 37Triceps, deep tendon reflexes, 92Trigger point. See Right obturator

internus; Right piriformisfriction massage, 6location, 78revealing, 5tenderness, decrease. See Obturator

musculature; PiriformisTriggers, identification, 177Trimethobenzamide (Tigan), 177Trunk

control, 131extensors, improvement, 26flexibility, improvement, 25flexion, strength, 28forward flexion, 102movements, 55muscle strength, improvement, 25musculature, 68ROM, improvement, 26strength/muscle performance ratings,

115TUG. See Timed up-and-goTumor, curretage. See Giant cell tumorTwo-point discrimination test. See Static

two-point discrimination testTylenol

3, usage, 105usage, 147, 173

U

Ultrasonography, 45Ultrasound

application. See Pulsed ultrasoundtherapy. See Lumbar; Sacral spineusage, 97

Ultraviolet A (UVA)exposure, 140light, 139treatment interventions, risk factors/

safeguards. See PUVAUltraviolet B (UVB)

effectiveness. See Broad-band UVBexposure, 140light, 136treatment interventions, risk factors/

safeguards, 139Uninvolved lower extremity, ROM, 167Uninvolved upper extremity, reliance, 48Upper extremities

coordination, 40exercises, red theraband (usage), 126joint ROM, gross screen, 72muscle groups, increase, 144reliance. See Uninvolved upper

extremitystrength/muscle performance ratings,

115Upper trapezius muscles

muscle spasms, 123

Index 205

Upper trapezius muscles—cont’dvisible tightness, 19

Upper-quarter screen, findings(determination), 92

Upright posture, improvement.See Sitting

Urinary accidentsdecrease, 80increase, 76

Urination frequency, 79Urine, leaking, 79UVA. See Ultraviolet AUVB. See Ultraviolet B

V

Vaginal tenderness, 79Valium (diazepam), 162Vasodilation, response, 60Vehicle

accident. See Motor vehicle accidentdriving

inability, 79METS range, 145

Ventilation, history, 13Verbal cues, 115

need, 50Vertebral growth, 25Vertigo, 177Vestibular system, 131Vibration, analysis, 39Vibratory sensation testing, 92Viewing angle/distance, 40Vioxx, usage, 5Viral infections, 177Visual analog scale markings, 9Visual impairment, 53Vital signs, 185

Vocalizations, loudness, 132Voiding interval, increase, 80Voiding pattern, normalization, 81Volume control strategies, demonstration,

117Vomiting, 177

W

Walker, usage, 151, 175, 190Walking

observation, 73pain, complaint, 109posture, tests/measures, 79program, 145skills, quantification, 72usage. See Emphysema

Wall sits, 37Warm-up exercises, 55WBAT, 67Wedge-shaped cushion, usage, 7Weight

gain, 89lifting, 178shifting, 55training, 35

program. See Low-intensity weighttraining program

Weight bearing, 79gait, 190

maintenance. See Left lowerextremity

strengthening, 37tolerance, 155

Weighted pistol-grip cane, usage, 72.See also Tip-weighted pistol-gripcane

Well-being (sense), improvement, 54

Wellness program, planning.See Prevention/wellness program

Wernicke’s area, 186WFL, 36Wheelchair

assistance, 169mobility, 67, 189

Wheeled platform walker, usage, 123Whip kicks, 90Whirlpool. See Full-body whirlpool

intervention, 158-159sessions, bleeding occurrence, 158treatment, 157

Window shopping, 76Winging scapulae, 23Within normal limits (WNL), 92WNL. See Within normal limitsWork. See Elevated work

activitiesindependent functioning, 80return, 80

hardening/conditioning, contrast, 40inability, 179loss, 89return, 89type, examination, 92

Workstation, analysis, 39Wrists

angle, 40bilateral extension, 20cuff weights, 68

Z

Zestril (lisinopril), 185Zosyn, usage, 60

206 Clinical Cases in Physical Therapy