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Raising the Bar in Rehab

Great Expectations for Physical Therapy

Published December 23, 2010 9:10 AM by

As I was leaving for vacation last week my Dad called to let me know my grandmother had fallen (while taking out the recycling) and had broken her hip. She had also badly injured her shoulder when she fell, although it wasn't broken. It sounded like she was doing well, but I thought about her many times while I was gone. 

After I returned home I learned grandma had an ORIF and was discharged from the hospital to a subacute rehab facility as she was non-weight bearing for approximately 6 weeks. I called my Dad and told him I would drive to visit her and watch one of her therapy sessions.

The day I visited her was 11 days post-injury and 7 days post-admission to the rehab facility. As I have worked with many hip ORIF patients in the past, and knowing my grandmother was completely independent prior to her injury, I walked into the therapy session with some general expectations of what her mobility should look like. 

She was supervision or light min assist for bed mobility. She was able to boost herself to the edge of the bed by weight-bearing in both arms, but at times needed light assist due to weakness and pain in her left leg. She and the therapist did a standing pivot transfer to a w/c (supervision level, while maintaining her NWB status), and then she was taken to the therapy gym.

Her entire therapy session for PT was supine therex. The therapist cued her through the line of exercises -- hip abduction, adduction, straight leg raises, ankle pumps, heel slides etc. Her therapist was a very kind woman who had obviously developed great rapport with my grandparents. She was calm and very patient, taking notes and offering rest breaks when the pain became overwhelming for my grandmother. Meanwhile, my grandfather and dad are sitting in the gym cheering her on and both impressed with the progress she had made. 

I was livid, as I had expected much more out of her therapy than mat exercises. I had to confront the therapist, but in a manner that was calm and would not disrupt my grandparents' relationship with the facility.  "Have you been doing any gait training?" I asked. The therapist responded that it was difficult to do so with her sore shoulder and NWB status. 

I agreed, but pointed out that the shoulder was able to boost with bed mobility, and therefore would also do well with weight-bearing through a walker. It is the therapist's responsibility to teach patients how to maintain NWB status, not to avoid ambulation out of fear or because it is easier. Furthermore, supine therex is very rarely skilled therapy. Supine therex should be homework the patient does outside of therapy sessions. 

I brought my grandmother's walker back to the therapy gym, where we walked 6 feet x 2 trials. She maintained the NWB status and said her shoulder didn't bother her at all. "I just have to think about not stepping on my foot," she said. I nodded to my Dad and suggested that her therapy should include more walking. He agreed, but like most of our patients' families, he did not know what to expect.

I expect all therapists, especially those working with my family, to get more into a 45-minute session than a few exercises. I would hope all therapists can defend their reasoning for choosing certain interventions over others, and would target all activities towards maximizing progress. 

*I suppose I should disclaim here, that my feelings are obviously magnified by the fact that I am related to the patient. Secondly, I don't know all the details of her case -- I have not read her chart. Finally, I don't know the details about the facility she is at, their policies or relationship with physicians. I am writing my perspective as I see it, regardless of my biases or pieces I may be missing.



You are right, more needs to be done to call mat exercises skilled therapy.  For a quick warm up yes, then get to the gait training/functional mobility that a person needs to get back home.  I am glad you spoke up, I wish more families would.

jason Marketti December 24, 2010 1:01 AM

Lisa - I totally agree with Dean. I always have told my students "Treat every patient like they were your mother". That perspective will always drive you in the right direction - not too easy to be non-constructive and certainly not too hard to cause any harm or unecessary discomfort. As I get closer to retirement, I keep thinking that a good part-time job would be a Medicare auditor to keep routine, repetitive, non-skilled exercises from draining the health system. Don't ever shy from asking questions of other PT's, but do respect their experience. Maybe they were burned once or twice by the enthusiasm you feel. I pray for full recovery for your grandmother and keep up the excellent writing - Al D.

Al DiMicco December 23, 2010 8:31 PM

Lisa, it is fascinating to watch you grow as a professional. Kudos to you for maintaining a professional air when dealing with the other PT. Even more Kudos for speaking up for your grandmother.

You have learned an important lesson by watching your father and grandfather. Even with a PT in the family, they don't know what to expect, what questions to ask, or how to appropriately engage health providers. Imagine how many patients and families out there don't have someone like you, and what happens as a result of that!

The points you raised were completely appropriate. Well done!

I hope your grandmother has a quick and thorough recovery.

Cheers, Dean

Dean Metz December 23, 2010 2:20 PM

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