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Toni Talks about PT Today

Expectations Make a Difference

Published May 11, 2010 10:05 AM by Toni Patt

Last weekend I worked at another rehab facility. I've been there before and like going there. The staff is very nice and the patients have been challenging but not overly difficult. This time it was different. Included in my caseload was a stroke patient. Comparing what he did for me to what he'd done previously would be like comparing night and day.

He was a max-assist transfer that required two people and was unable to stand. I was able to transfer him by myself and progress him to standing with mod assist within an hour of treatment. I wish I could say the difference was my skill. While that might be a factor, it wasn't the cause. My expectations for the patient were different from those of his regular therapist. I'm used to working by myself. I rarely have help. Most of the patients I see on the stroke level are just as involved or worse than that patient. My expectation was that I could perform the treatment myself and I would progress his standing ability because that is what I normally do. It never occurred to me that I would need a second person. Nor did it cross my mind that I couldn't do it.

Help is readily available in that facility. The normal caseload is heavily orthopedic. Before the patient was evaluated, the expectation must have been that he would be difficult to mobilize and require two people. Because they expected him to be hard to move, he was. He didn't make much progress because no one thought he would. From what I read in the notes they were standing him but it was difficult and labor-intensive. In all fairness, a dense hemiplegic like this would be unusual for them.

I noticed something else. Prior to working in standing, I worked on the mat with him. I inhibited a flexion synergy of the trunk and flexor tone of the leg. I didn't even try to stand him until I was ready. From what I read in the notes they did supine exercises and went right to standing. That would have made him much more difficult to manage. If the leg flexor tone prevented weight-bearing, he would not have been able to stand. Seeing it might have been enough to make someone think standing was impossible.

Therapist expectations weren't the only limiting factor. So were the expectations on the therapist. Where I normally work, I'm expected to get patients up and mobilized as soon as possible. If I don't, I need an explanation. We're very aggressive. This facility is just the opposite. There was no pressure or expectation to mobilize anyone. Getting patients out of bed is as far as they go with that. Making sure the patient receives three hours of therapy is adequate. The conclusion is to give our patients a chance. Appearances can be deceiving. Instead of telling ourselves we can't do something, we need to be open to the possibilities. I got more out of the patient because I expected to get more.

3 comments

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May 12, 2010 1:40 PM

Christi and Toni,

You both make me proud to be a PT! You are so right. Appreciating spine alignment and relaxation of the body before doing functional activities takes more time, but it is time well spent. Gold star to both of you for your patience and perception! -Marian

Marian, geriatrics - staff P.T., SFN unit May 11, 2010 7:39 PM
York SC

Toni,

I certainly don't have your extensive neuro background, but I did work in a medical surgical setting as a split shift for years.  I agree with you completely.  I recall one patient in particular because not only did he have hemipelgia, but he also recently had a CABG.  He was getting out of bed with the nursing staff...but he was basically being "dragged" out of bed.  Three people came in all the time for this "difficult" transfer.  I took my time, made sure his posture was correct, did what little NDT skills I had and made sure he was READY to stand.  Guess what, this supposedly max assist x 3 transfer turned into a min/mod of one.

Certainly, I don't expect nursing staff to have the same skill level I do, but I think they essentially set a patient up for the expectation that he was "difficult."  When he realized he could do much more than that, he began to cry.  He was a preacher, and prayed hard to accept what had happened, but he was over joyed to learn his expectations underestimated what he could do.  I'll never forget him.

Christie ,, May 11, 2010 11:45 AM

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