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Toni Talks about PT Today

Acute Frustration

Published December 23, 2008 11:16 AM by Toni Patt
Even though I enjoy it, working in acute care can be frustrating.  It has its own unique limitations. Unlike any other setting, I only see my patients for a few visits. With the exception of orthopedic patients, no one is in a hospital to get therapy. Patients are in the hospital because they are sick. Frequently I'm faced with having to accomplish a lot therapy-wise in a short period of time. Patients are stabilized and moved out. This is particularly challenging when working on a neuro unit. I have to get those patients as mobile and safe as possible because they are almost as likely to go home as to another setting. I have to do treatments that address mobility while treating the neurologic deficit. Getting that done can be very frustrating.

Therapy becomes a compromise of neurological rehab and gait training.  For some reason, as soon as I get the patient's feet on the floor the patient becomes focused on walking. I try to incorporate fundamental basics such as trunk control, facilitation of motor return, weight shifting and midline postures because those are basic pieces of movement. Patients want to walk. Frustration arises when a patient is so focused on walking I can't get him to work on anything else. I can talk all I want but it falls on deaf ears. These patients will go through the motions but there will be little carry over to the functional activity. They become unreceptive to anything else.  They don't hear me explain that one is necessary for the other.

Gait can't happen unless all the pieces are in place and working smoothly as a unit. Sometimes a substitution such as an AFO is necessary. Other times a substitution such as an assistive device makes things worse.  A walker allows mobility but the gait pattern is poor. With an RW a patient will attempt to move forward using whatever muscle group is working.  To a patient an RW could be seen as a simple solution to a complex problem. Once a patient has one, they can be reluctant to try something else. I don't like to use RWs initially.  I want to get a sense of the gait pattern and associated deficits. I can't see those with an RW. If someone focused solely on gait gets a walker my job gets 10 times worse.

That happened to me twice this week. The first time it was a 40-something-year-old woman admitted with a CHI after a seizure. When we started she couldn't sit EOB without assist. Eventually we progressed to standing. I wanted to stop there and develop additional trunk control and initiate further ground work for gait. Somewhere along the way she got it into her head that she could go home if she could walk. Forget the pre-gait. I got her walking with mod assist of me, min assist of another person, a RW and a piece of theraband. We never got any further. In her mind she was walking. She could go home. Even though she was approved for inpatient rehab she refused and went home.  This bothers me because she is so young and had the potential to possibly become deficit free.  By going home she practically ensure she'll be using that walker for a long time because there is no one to push her forward.

The second patient was an older woman admitted with an evolving CVA. She had some cognitive deficits but could follow one-step commands. She was able to take a step but her gait pattern was terrible and she couldn't keep her eyes open. I worked on weight shift, trunk activation and weight bearing on the involved limb. We did so much standing knee extension I lost count. Since I was by myself, I gave her an RW for gait. That was a mistake. As soon as she had it in her hands she took off as fast as she could go dragging me and the IV pole behind, totally deaf to what I was saying.  She made it about 10 feet.  The only way I could slow her down was to put my stool in front of her which worked as a braking system but limited my hand placement. I ended up on my stool behind her with my hands on her knee to facilitate extension, my shoulder on her bottom for stability and one foot wrapped around the front of the RW for a braking mechanism. I think the floor nurses are still laughing. The whole time she kept repeating "I can walk. I go home." I never got her any further.

I get frustrated because I could do so much more with these patients. With a lot of work and some facilitation their gaits can be safer with fewer deviations. I understand these people want to go home. I can see how tunnel vision can develop. I see patients who have the potential to do so much more.  The patients seem to see a means to the end. The focus on gait becomes a self limiting barrier for them.  I hope they find themselves back in therapy at some point.  I tell them what's hard now may be next to impossible later.  A bad habit is a terrible thing to break and sometimes not possible.

posted by Toni Patt


Gait is a fundamental movement and can always be worked on in a SNF or Home Health.  The major thing is that acute patients are up and moving, quality should not be an issue, it is the quantity that counts.

The agruement is that if they start a deviation it will stay, however, behaviours and deviations can be facilitated to change.

A pick up walker may help, it slows the person down, however, gait is a basic mobility tool that every patient needs.  

You are facilitating weight bearing, trunk control, balance, etc with gait, why worry about the quality - the SNF therapists can do that.  

In acute a PT/PTA will see a patient 3-5 days, realistically how much patient education and carry over will you see? There are so many more things going on in the hospital that the patient hardly listens to the MD - think about what is said and what the patient interprets.  

What I have found is that we can educate and instruct and do therapy within the time frame allowed and let other skilled therapists continue with what we started.  We should be thankful a patient is even up and moving in acute care.  

If you want to see long term results and throughly educate and follow up with progression you should be in a SNF not acute care. One reason there are PT/PTA's in acute care is that no one else is going to take the time to get the patients up and moving.

Karen December 27, 2008 10:47 AM

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