Physical Therapy Collection

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Neuromuscular electrical stimulation after one-stage total knee revision to restore quadriceps strength: a case study
Background and Purpose: Total knee arthroplasty (TKA) is one of the most successful surgeries to prolong mobility and reduce pain associated with osteoarthritis of the knee.1 However for a variety of reasons the patient may outlive their TKA prosthesis requiring a TKA revision.1 It has been shown patients rarely recover their quadriceps strength after TKA, even at the 6 and 13 year mark.2 The weakness seen within the quadriceps post-surgery is more significant than disuse atrophy; there is also neurological component which is referred to as arthrogenic muscle inhibition (AMI). The reduced motor unit output is thought to be due to altered afferent stimulus potentially due to edema, joint laxity and damaged nerves. This quadriceps inhibition has been identified as a key aspect in TKA rehabilitation. 3 Neuro muscular electrical stimulation (NMES) allows the therapist to bypass the cortical inhibition by providing stimulus directly to the muscle to evoke an action potential greater than the patient is capable of generating volitionally.3 Case Description: The patient is a 70-year-old male seen 6 weeks post-operatively for a one- stage TKA revision due to MSSA infection of the original prosthesis. Conservative treatment including debridement, antibiotics and implant retention (DAIR), failed to control the MSSA infection leading to a one-stage revision. The patient presented to an outpatient orthopedic clinic with impaired quadriceps strength (among other deficits) and was treated with a combination of NMES in conjunction with traditional physical therapy targeting strength and ROM deficits. Outcomes: Outcome measures utilized to track quadriceps strength and functional outcomes were the timed up and go (TUG), the lower extremity functional scale (LEFS), and manual muscle testing. The patient improved in all outcome measures beyond the MCID. Discussion: The patient made significant progress toward recovering quadriceps strength, improving his functional mobility, and reducing his fall risk. Neuromuscular electrical stimulation is a potential modality to attenuate quadriceps strength after a TKA revision, however additional research is required to determine the most effective protocols.
Reflections on risk management: Student perspective of total knee replacement with surgically acquired common peroneal nerve palsy
Total knee replacement (TKR) surgeries have been steadily increasing over the past two decades due, in part, to the “baby boomer” generation. Diagnostic rates of arthritis, osteoarthritis, and degenerative joint disease are rising; the stresses placed on the need for increased mobility and optimization of quality of life are rising making a TKR one of the most commonly performed surgical procedures in the United States. The management of subsequent risks and variables during the acute recovery phase affects providers and patients throughout the duration of rehabilitation. Previous research has focused on the benefits of group based exercise and early mobilization during the acute phase of recovery from TKR, however research is lacking when addressing those aspects of care along with the risk management of common peroneal nerve palsy (CPNP) and DVT prophylaxis. This paper provides a student’s reflection on the medical team management of a patient post-operative TKR with surgically acquired CPNP as well as a call to action for patient advocacy.
Abdominal Pain as an Unusual Referral to Physical Therapy: A Case Report
Background and Purpose: While gastrointestinal origins are the most common cause of moderate abdominal pain, it is estimated that 20% of cases may be caused by dysfunction in structures of the abdominal walls as opposed to being from visceral-related causes. Physical therapists are trained to address musculoskeletal and neural dysfunction, as well as to screen for more systemic causes, that may warrant patient referral back to the physician. Increasing clinical awareness of these musculoskeletal origins, that may be treated by conservative physical therapy, may help patients receive non-invasive treatment with minimal pharmaceutical intake. The purpose of this case report is to discuss the efficiency of non-invasive physical therapy interventions to improve functional movements and decrease pain and other symptoms in a 35-year-old female with complaints of abdominal pain. Case Description: The patient was a 35-year-old female complaining of abdominal pain of unknown origin. After evaluating the patient, conservative physical therapy techniques were utilized, including thoracic spine joint mobilizations, neural mobilization, therapeutic exercises and addressing the neurophysiology and neurobiology of chronic pain with the patient. Outcomes: The Oswestry disability index was administered to the patient to track her progress throughout her treatment. Sitting times were recorded throughout sessions, and subjective reports were taken regarding the ability of the patient to carry out functional activities. By the end of treatment, the patient was able to participate in her work activities and perform all functional activities with minimum to no onset of abdominal symptoms, despite not having a significant change in the outcome measure results. Discussion: Given the array of differential diagnoses for abdominal and thoracic pain coming from neural and musculoskeletal origins, it is imperative that clinical awareness of these musculoskeletal origins be made to clinicians. This case report suggests that patients with abdominal symptoms that have been cleared of gastrointestinal and cardiovascular origins should be considered for physical therapy referrals.
The impact of one student's experience in a global setting for advancing a patient with gross peripheral nerve deficits and advancing local clinical practice: A Case Report
Title: The impact of one student’s experience in a global setting for advancing a patient with gross peripheral nerve deficits and advancing local clinical practice: A Case Report Background and purpose: The incorporation of international service-learning and community engagement academic experiences positively correlate with personal and professional development and improved cross-cultural competency. Since 2011, students and faculty from the Marymount University Doctor of Physical Therapy (DPT) degree program venture into Central America with a goal of advancing local physical therapist practice. In 2018, the program traveled to Masaya, Nicaragua. The purpose of this case report is to: 1) discuss the impact of one student’s international service learning experience with a complex patient presenting with gross peripheral nerve impairments; 2) postulate patient empowerment and education as tools/strategies for leading change and advancing physical therapist clinical practice in Nicaragua toward improvement in overall health and function among Nicaraguans; and 3) discuss patient empowerment through moral agency as a way to combat social injustice and health inequities/disparities. Patient Description: The patient was a 16-year-old male who sustained a fracture/dislocation of his right arm following a motorcycle accident. He was seen in a public, hospital-based outpatient rehabilitation clinic. At the time of his initial evaluation he was 5 weeks post open reduction with internal fixation of the right proximal humerus. He presented with gross sensory and motor deficits of the full upper extremity. The patient demonstrated an extinguished sense of agency and appeared resigned to the prospected poor functional outcomes. The patient and his mother both demonstrated a mistrust of the health care team that stemmed from miscommunications and delays in care previously experienced. Outcomes: The four constructs of empowerment: meaningfulness, competence, impact, and choice guided sequential construction of communication with the patient and his mother throughout treatments. As a result, the patient permitted and participated in a constructed care plan that yielded return of proximal light touch sensation and initial trace muscle activation in the right deltoid muscle. Discussion: Empowerment within each, and among the assembled team comprised of the patient, his mother and the visiting service-learning student group grew in this experience. Trust built on meaningful communications forged development of patient self-confidence to administer and take control of the prescribed treatment regimen. The patient’s mother accepted the challenge to engage and advocate on behalf of her son for a patient-centered, coordinated health care model of care (moral agency). Social responsibility in physical therapist practice requires PTs to address social injustice, reduce health disparities and health inequities situation by situation via accurate diagnosis of injustice and inclusion of an informed just response in the plan of care.
Revisiting HOAC II for Determining the Physical Therapy Course of Treatment for a Patient with Upper Extremity Paresthesia
Accountability among physical therapists is increasingly essential to ensure patients achieve optimal functional outcomes, maximize quality and efficiency of care, and establish the value of physical therapy as a profession within the spectrum of health care. The Hypothesis-Oriented Algorithm for Clinicians (HOAC) II is a decision-making tool that can enhance clinical accountability. Purpose: The purpose of this case report is to describe the retrospective application of the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II) to reflect on a student’s clinical reasoning for a patient with insidious onset upper extremity paresthesia. Discussion: This case report demonstrates that the HOAC II can be used retrospectively to outline the treatment and decision-making process which resulted in achievement of the patient’s goals. Conclusion: The HOAC II guides the clinical reasoning process to include formulating a clear intervention strategy mapped to both patient identified and clinically identified problems. To advance practice standards, clinicians must analyze the intervention effectiveness. The HOAC II establishes an ongoing treatment framework built on continuous evaluation of
Physical Therapy Following Traumatic Shoulder Dislocation and Labral Repair: A Case Report
Background: Shoulder injuries are prevalent among the athletic population.1 Multi-directional instability (MDI) is defined as instability in two or more directions and typically involves capsular laxity.2–5 Many clinicians and athletes do their best to address instability through strengthening and activity modification, however, sometimes need to turn to surgical intervention.2–7 Operative treatment is usually foregone until non-surgical management has failed.8 The purpose of surgery is to stabilize the joint.5,9–11 The post-operative physical therapy rehabilitation program is an important factor for patients to regain full use of their upper extremity.4,5,7 Soft tissue mobilization (STM), progressive resistance exercises (PRE), and proprioceptive neural facilitation (PNF) are effective in minimizing pain and improving shoulder motion.5,7,12 Purpose: The purpose of this case report was to describe the effectiveness of post-operative physical therapy for a patient with a history of multi-directional instability who underwent an arthroscopic posterior labral repair and shoulder stabilization surgery after a traumatic dislocation. Case Description: A twenty-eight year old male, five and a half weeks after left shoulder posterior labral repair and shoulder stabilization. He was previously extremely active, but has a history of multiple dislocations. Outcomes: Daily outcomes varied; however, a general positive trend was noted. The patient dramatically improved both objective ranges of motion measurements and DASH score. The case report data supports the utilization of manual therapy, PNF and PRE’s in post-surgical physical therapy rehabilitation. Discussion: Though the SLAP repair protocol was a good baseline, it should be noted that interventions should be individualized. The hypothesis that the applied interventions would be effective was accurate for this patient and can be adjusted for a similar patient population.
Physical therapy treatment for a 56-year-old female with suspected neurogenic thoracic outlet syndrome: A case study
Background and Purpose: Thoracic outlet syndrome is a rare and challenging condition to diagnose due to vague patient presentation of neck and upper extremity pain, numbness, tingling, fatigue, and weakness. nTOS is classified as a condition in which postural, anatomic, and biomechanical factors contribute to the compromise of neurovascular structures. While PT is the most common initial treatment for nTOS, effective interventions and outcomes for patients with nTOS are not well documented. The purpose of this case study was to investigate the effect of PT interventions for a 56-year-old female with suspected nTOS using ICF model to guide patient goals of participation and functional activities.Case Description: This case investigated MS, a 56-year-old female, with left arm pain and weakness that began after a resistance exercise. MS described radiating pain down the biceps to the thumb and wrist pain shooting up the elbow along the forearm. MS experienced numbness and tingling in her 4th and 5th digit, especially with overhead activity. She was limited with functional activities such as carrying groceries, driving, and opening a heavy door. PT interventions, to include manual therapy, therapeutic exercise, and modalities were initiated to improve pain and strength deficits to return MS to her prior level of function. Outcomes: After six weeks of PT management the patient had a clinically significant change in NPRS score of >2 and a significant change in the UEFI of 9 points. The patient’s tolerance to exercise also improved over time. There was a positive correlation of exercises performed in clinic and as part of the home exercise program over the six-week period. The patient was also able to return to her prior level of function with no participation restrictions or activity limitations after the intervention period. Discussion: Individualized PT interventions such as manual therapy, therapeutic exercise, and modalities resulted in positive functional outcomes. Patient-centered care that emphasizes participation restrictions and activity limitations along with manual therapy interventions that address the health condition improved patient outcomes in this case. This suggests that clinicians may take a similar approach in treatment of patients with a comparable condition and presentation., Physical therapy, functional outcomes, manual therapy, physical therapy, therapeutic exercise, thoracic outlet sydnrome, School of Health Sciences, Degree Awarded: D.P.T. School of Health Sciences. Marymount University
The effects of an Instrument-Assisted Soft Tissue Mobilization (IASTM) protocol to improve shoulder range of motion for post-operative rotator cuff repair and debridement: a case report
Background and Purpose: It has been suggested that the use of Instrument-Assisted Soft Tissue Mobilization (IASTM) can be utilized to remove scar tissue, improve blood flow, promote tissue healing, and increase range of motion (ROM). Improvements in ROM from the administration of IASTM were stated to be from the results of removing tissue adhesions and increasing muscle extensibility. However, there is a lack of literature examining the effects of IASTM on patients with a post-surgical status. The purpose of this case report is to evaluate the effects of IASTM on shoulder ROM in a patient with a post-operative rotator cuff repair and debridement. Case Description: IASTM was initiated on the 14th therapy session for a duration of eight weeks due continuously limited ROM, pain, diminished strength, and decreased left shoulder function. A protocol involving a warm up, IASTM, manual therapy, stretching, strengthening, and cryotherapy were initiated in that order to combat the deficits. Manual muscle testing (MMT), ROM measured by goniometry, Numeric Pain Rating Scale (NPRS), and the Upper Extremity Functional Index (UEFI) were collected prior to the IASTM protocol, on the 14th, 17th, 20th, and 23rd treatment session to asses for improvements in shoulder function. Outcomes: The patient reported and demonstrated improvements in all objective measures at the end of an eight week treatment. NPRS improved from 3/10 to 0/10. Shoulder flexion (flex) MMT from 3-/5 to 4-/5, shoulder abduction (abd) from 3-/5 to 4-/5, shoulder internal rotation (IR) from 3+/5 to 4+/5, shoulder external rotation (ER) from 3-/5 to 4-/5, and shoulder extension (ext) of 4+/5 to 5/5. Active shoulder flex increased from 109 degrees to 135 degrees, shoulder abd from 60 degrees to 102 degrees, IR from 38 degrees to 75 degrees, and ER from 20 degrees to 44 degrees. The UEFI raised a total of 13 points from 57/80 to 70/80 at the end of the protocol. Discussion: The IASTM protocol as an intervention to increase shoulder mobility has already been demonstrated in other studies. However, the literature lacked evidence to support the use of IASTM for patients with a post-surgical status. The protocol implemented with IASTM may provide beneficial gains for pain, strength, shoulder active range of motion (AROM), and functional use of the shoulder for patients that are restricted in those areas as a result of a post-operative status.
Instrument Assisted Soft Tissue Mobilization – A Novel Tool for the Physical Therapy Treatment of Plantar Fasciitis: A Case Report
Background and Purpose: Plantar fasciitis is the most common foot condition in the U.S. yet consensus has never been reached on the best treatment interventions. Instrument assisted soft tissue mobilization (IASTM) is a novel intervention that applies general soft tissue mobilization principles with the use of a tool. Favorable responses have been achieved in a number of other conditions. However, only one other case series regarding the treatment of PF with IASTM exists. The purpose of this case report is to describe the effectiveness of IASTM, in conjunction with an exercise program, as an intervention for the treatment of a 48-year-old male with plantar fasciitis who had not responded to any prior interventions. Case Description: The patient was a 48-year-old male and an active duty Coast Guardsman. He presented to physical therapy with a 3-month history of plantar fasciitis after trying numerous other interventions, including 4 sessions of physical therapy, without success. Outcomes: The patient was treated with IASTM to the plantar surface of the foot along with a therapeutic exercise program for 11 visits. He achieved immediate pain relief in one session and by discharge, subjective pain reports, self-reported functional ability, Foot and Ankle Ability Measure scores had all improved significantly. Discussion: The combined use of IASTM and a therapeutic exercise program was effective in improving the patient’s functional status and pain levels. Future research is necessary on a larger scale to confirm these findings and address the current gap in the literature. However, these findings are consistent with what little research is currently available.
The Effect of a Hybrid Learning Model on Burden of Care and Functional Mobility in a Patient with Cognitive Impairments and Encephalopathy: A Theory to Practice Case Report
Background: Errorless learning, error learning and hybrid learning are methods applied in rehabilitative services to enhance functional capacity. Each model has specific applications and cognitive impairments are primarily being addressed with the errorless model. However, hybrid learning has been inferred to improve metacognition and carryover of task. Purpose: The purpose of this case study is to analyze the effect of hybrid learning on burden of care and functional mobility tasks in a 77-year-old patient with cognitive impairments and encephalopathy in a skilled nursing facility Patient Description: A 77-year-old Caucasian male presenting to a skilled nursing facility (SNF) following a fall and unknown down time. The patient was diagnosed with acute pulmonary embolism, acute encephalopathy, dehydration, hypernatremia, and non-traumatic rhabdomyolysis. Physical therapy evaluation revealed significant decline in functional mobility with decreased balance and strength as well as impairments to cognitive ability Outcome and Discussion: The patient showed significant improvements from evaluation to discharge in functional mobility and metacognition throughout motor output. It is unclear whether the errorless learning model or hybrid learning made the greatest impact.
Case report: Contextual implications of an evidence-based falls intervention in a sub-acute setting for a frail, elderly patient with rhabdomyolysis
Background and Purpose: Falls in elderly can result in rhabdomyolysis from muscle damage. The Otago Exercise Program (OEP) is an evidence-based falls program that helps frail elderly over the age of 80 regain balance, strength, and walking. Subacute settings have a high falls risk population and skilled therapy. The purpose of this theory to practice case report is to expand on the contextual factors of a subacute setting that limit fidelity to an evidence-based falls intervention while postulating the benefits of a sustainable falls prevention network. Case Description: The patient was an 86-year-old community dwelling adult who met the criteria for the OEP after she fell and was diagnosed with rhabdomyolysis and subsequent exacerbation of chronic obstructive pulmonary disease. She was admitted to a sub-acute setting for therapy due to deficits in mobility. She had previously been independent with ambulation. Outcomes: The OEP protocols were not followed. Though her Six Minute Walk Test, Timed Up and Go, 30 second Chair Stand Test and Four Stage Balance Test had clinically significant improvements, she was discharged to an assisted living facility. Discussion: The fidelity to the OEP was not maintained. Function drove the exercise prescription. The focus on profit in subacute facilities appears to impact delivery of evidence-based falls programs. An opportunity exists for these facilities to be part of a unique healthcare delivery model for falls prevention. A falls prevention network could facilitate this and serve as a repository of programs, promote collaboration amongst healthcare professionals, and facilitate patient transitions
Effectiveness of Perturbation Balance Training in Future Falls Incidence and Falls Risk Reduction in a Frail Older Adult Residing in a Skilled Nursing Facility: A Case Report
ABSTRACT Background Falls incidents and falls-related mortalities and morbidities among older adults in the U.S have raised global concerns. Perturbation Balance Training (PBT) is considered a task-specific balance training that has shown to be effective in decreasing fall incidents among older adults. Purpose The purpose of this case study was to evaluate the effectiveness of PBT in improvement of future fall incidents and falls risk reduction in a frail older adult residing in a Skilled Nursing Facility (SNF). Case Description J.B was an 89-year- old male with stage III laryngeal cancer residing in a SNF, with two recent episodes of falls. J.B’s level of function was decreased secondary to fear of future fall incidents. J.B performed overall 15 sessions of PBT as well as conventional physical therapy treatments for five weeks. Fall incidents and falls-related outcome measure scores compared pre and post training to determine the effectiveness of PBT in overall future fall risk reduction. Outcomes No falls occurred during and two weeks after the completion of the intervention. Mini-BESTest pre to post training scores was noticeable. (13/28 to 19/28, MDC: 3.5), also, improvement made in Berg Balance Scale, Timed Up & Go and Activities-specific Balance Confidence Scale after five weeks of treatment. Discussion PBT can be considered as an effective balance training program to decrease future fall incidents in older adult population by improving reactionary stepping strategies in response to postural perturbations.

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