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PTA Blog Talk

Weight Bearing

Published March 21, 2012 10:25 PM by Jason Marketti

A patient came to the nursing facility with a weight-bearing restriction of TTWB. Hospital notes indicate he walked between 25 and 50 feet while there. The day I saw the patient we were only able to gait about 10 feet before I noted the increase in weight to the involved LE.

We worked on upper-extremity exercises as well as lower-extremity strengthening in lieu of increasing gait distance. This posed a problem with everyone involved with his care. When questioned, I related what I perceived as too much weight bearing on the involved lower extremity. Stairs were impossible due to this, safety became an issue when nursing walked him to the bathroom and lack of strength and stability during activity deemed him a fall risk as well as impaired healing to the surgery site.

The push for increasing gait distance was felt throughout the therapy department. We pushed back, stating the patient is not consistent enough with the surgeon's order of TTWB. That calmed the storm for a while, but it was still brewing just outside of the parallel bars, waiting to come back at us stronger than before.

Because of the surgeon's order and our assessments of the patient and his lack of strength, he was saved from being discharged to home. Once the surgeon's order is changed to full weight bearing, the patient will most likely be sent home with inadequate follow-up care for balance, strengthening and safety. He will amble along in his home, drive his car, go shopping etc. without the benefit of continued therapy. He is a fall waiting to happen (again) because he chose the wrong insurance company.

2 comments

I agree with Toni. There's no place for TTWB in the majority of the elderly population. Actually, I'm not sure there's a place for TTWB in any population.

Unfortunate that the therapist(s) who saw this patient in acute care wasn't/weren't more observant.

I remember an elderly patient with dementia who was TTWB S/P hip repair when I worked in the nursing home. She couldn't understand why her hip hurt when she stepped on that leg. But by the very next step she'd forgotten it was going to hurt and put weight on it again anyway. We convinced the doctor to alter the order to NWB. Unfortunately, the patient didn't have the cognitive ability to understand that either, so ambulation was out of the question.  Even then, we still got some flack. But it was what it was. The patient's safety came first. We had a manager who backed us and took the heat. I'm sure your staff feels fortunate to have that kind of manager.

Jane Goude March 21, 2012 10:23 PM

I've been in the same situations many times.  Elderly patients can't do TTWB.  It needs to be NWB (which is still a challenge but they understand) or WBAT.  How much weight does that surgeon really think an elderly person is going to put through a painful extremity?  

I understand your frustration.  Of course the real loser is the patient.  He could be sent home prematurely or fall trying to do something he shouldn't.    I also wonder about the acute PTs who documented the increased distance.  Apparently no one monitored WB in the hospital setting which makes your position more difficult.

Good luck with it.  

Toni March 21, 2012 7:40 PM

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    Jason J. Marketti
    Occupation: Physical Therapist Assistant
    Setting: San Jacinto, CA
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