Session 4 Lab Guide (Student) PDF

Session 4 Lab Guide =================== Learning Goal: Safely and effectively utilize foundational intervention strategies when working with non-complex patients #### Course Goal 12: Implement effective **therapeutic exercise** interventions for non-complex patients #### Course Goal 18: Consider...

Session 4 Lab Guide =================== Learning Goal: Safely and effectively utilize foundational intervention strategies when working with non-complex patients #### Course Goal 12: Implement effective **therapeutic exercise** interventions for non-complex patients #### Course Goal 18: Consider the stages of **tissue healing** in developing therapeutic plans of care #### Course Goal 13: Implement effective range of motion Part 1: The Impacts of the Stages of Tissue Healing on Ther Ex ============================================================== - Choosing the Best Therapeutic Exercise: 1. - 2. - - 3. **Today you are covering for a PT in the outpatient clinic.** **You have 3 patients on your caseload today.** For each patient **choose the appropriate exercise plan of care.** The SubPar Outpatient Clinic provides the same basic HEP for all LE injuries, you however graduated from GWPT and you know that it is important to tailor and personalize your exercises. Choose which, if any, of the exerises on the HEP are appropriate and modify them as needed for your patient. Your Patients: - **May** is 18 y.o., she fell yesterday during a flag football game and sustained a sprain on her MCL and ACL on the R. She is in 5/10 pain with movement. - **June** is 65 y.o., she underwent a R TKA 2 weeks ago, she reports 3/10 pain with walking with her rolling walker. - **July** is 47 y.o., she underwent a meniscectomy 16 weeks ago on her R knee. She has no pain with movement. +-----------------------+-----------------------+-----------------------+ | | | | +-----------------------+-----------------------+-----------------------+ |  | | | +-----------------------+-----------------------+-----------------------+ **Patient: May** ------------------- **Patient: June** **Patient: July** Just a Reminder! To document your exercise, you need to be **specific and clear**! Think about the components of the exercise that are necessary to meet the goals and document these **3 components of the activity**: Part 2: Range of Motion as a Therapeutic Exercise Tool ======================================================  **Benefits of Therapeutic ROM:** - **Maintain joint and soft tissue mobility** - **Minimize loss of soft tissue flexibility and contracture formation** - **Improved healing of tissues** - **DOES NOT improve ROM or flexibility! This is not a stretch!** Old Key with solid fill**ROM as a Therapeutic Exercise** -------------------------------------------------------- - **PREPARE:** - **Know what segment(s) you are treating and what movement you want** - **POSITION:** - **PT:** - **Hand placement** - **Body mechanics** - **PATIENT:** - **Positioning for access, movement, and comfort** - **Draping** - **PERFORM:** - **Explain and demonstrate** - **Control the movement proximal and distal to the joint as needed** - **Support as needed to maintain pain free range** - **Smooth rhythmic movements** - **Monitor for potential compensations and substitutions** - **Use of manual and mechanical equipment as needed and as appropriate** - Guarding and Safety Considerations: Monitor patient's tolerance, ask during and after how they are tolerating it, adhere to the guidelines of tissue healing - **PROM** -------- - Keys to PROM: - Remember the pt must be relaxed! - Establish rapport and drape - Patient's often do not understand PROM - Start with small amplitude movements before advancing ROM excursion - Allow your patients to get comfortable with you holding their arm and moving it so they can allow YOU to move them (aka relax) - Never move your patient into full ROM until they are comfortable and trust you - **Place your patient in a position where you can see their face -- watch for non-verbal\'s!!! If they are prone, use constant communication with your folks in this position.** - **Learn how to say "relax" about 18 different ways (or languages).** - Research has shown that CPMs may not be beneficial but you will need to use your clinical reasoning there are times that it is warranted so you as the PT may need to train in proper fit and usage - **PROM Dosage** - **Can be repetitions or time** - **At least 5-10 repetitions** - **AROM** -------- - Keys to AROM: - A pt with \< 3/5 will need assistance with a movement against gravity - As the pt transitions from PROM AAROM AROM you may need to modify position to control for the effect of gravity - Have your hands in a position to help if needed - Watch for: - pain - fatigue - changes in quality of performance - changes in vital signs (can be an indication of increased pain) - **AAROM/ AROM Dosage** - **20-30 repetitions, 2-5 times a day** Straight Plane Practice ----------------------- - PROM - Manual: Elbow Flexion- Extension - Manual: Knee Flexion-Extension - AAROM - Mechanically-Assisted: Shoulder Flexion - Self-Assisted: Shoulder Abduction-Adduction - Manual: Ankle Dorsiflexion-Platarflexion - AROM - Ankle Inversion-Eversion - Against Gravity: Hip Abduction-Adduction Diagonal ROM Practice --------------------- ------------------ ---------------------------------------------- -------------------------------------------- **PNF Label** **Starting Position of the Upper Extremity** **Ending Position of the Upper Extremity** **D1 Flexion** **Extension -- Abduction - IR** **Flexion -- Adduction -- ER** **D1 Extension** **Flexion -- Adduction -- ER** **Extension -- Abduction - IR** **D2 Flexion** **Extension -- Adduction -- IR** **Flexion -- Abduction -- ER** **D2 Extension** **Flexion -- Abduction -- ER** **Extension -- Adduction -- IR** ------------------ ---------------------------------------------- --------------------------------------------  Applying ROM as Exercise Concepts to Patient Care ================================================= **Case study \#1** Marge is a 35-year-old who reports having difficulty putting on her jacket\'s sleeve and reaching towards the back seat of her car to attend to her baby. 1. The pain came on suddenly yesterday when she reached behind to give her kids a toy. What stage of tissue healing is she in and how does this impact your plan of care? 2. It has been a month since the initial onset of pain but it is still painful. How would you change your plan of care? 3. How will you focus your intervention? Choose 2 motions that are likely to be the most limited. 4. What position would you place Marge in to complete your intervention? **Case Study \#2** Edna is a 65-year-old who has osteoarthritis in her knees. She works as a teacher part-time and was having difficulty negotiating stairs. She underwent an arthroscope 2 weeks ago to clear out some of the debris in the joint. 1. What stage of tissue healing is she in? 2. What motion(s) are limited in her mentioned activities? 3. How would you position Edna to perform your intervention? 4. What type of motion (passive, active, self-assisted or active-assisted range of motion) would you choose to use considering her age and report of osteoarthritis? **Case Study \#3** Bart is a 16 year old who endured and ankle fracture in a skateboarding accident. He was casted for 6 weeks and is coming to you for outpatient rehabilitation. Bart denies pain but reports having difficulty with walking since his cast was removed. His chief complaint is stiffness. 1. What ankle motions are required to achieve a normal walking pattern? 2. What plane of motion is most important for Bart to achieve his goal of walking? 3. What type of range of motion would be most beneficial for Bart at this time? **Case Study \#4** Homer is a 36-year-old male who is s/p MVA resulting in a traumatic brain injury is currently in the ICU on a ventilator and in a medically induced coma. Homer is being closely medically monitored at this time. You review his chart and notice there are no red flags and you proceed with your physical therapy session. 1. Can you perform range of motion exercises? If so, which technique (AROM, AAROM, Self-assisted or PROM) would you choose? 2. Provide your rationale for choosing to proceed with or without range of motion. 3. How would you educate the patient, staff or family to optimize functional outcomes? Summary: ======== - Range of motion is a **prerequisite to movement and function** - ROM affects muscles, joint surfaces, capsules, ligaments, fascia, vessels, and nerves - PROM, AAROM, AROM, self-assisted ROM, PNF and diagonal ROM can help **minimize the effects of immobility** - ROM typically progresses from **PROM to AAROM to AROM** - The type of ROM and position you choose for performing ROM will depend on the **patient's health condition, stage of healing and strength** - **End feels** can help you differentiate between normal and pathological joint structures - **ROM is not stretching;** ROM occurs within the **pain free range** available to your patient. Summary Questions for Ther Ex, Tissue Healing, and ROM ====================================================== 1. What are some signs of inflammation? 2. What are the goals of management in the acute stage? 3. What are the goals of the subacute stage? 4. What is happening in the subacute stage? 5. At what point is a scar unable to be changed? 6. When is it appropriate to begin stretching? 7. When is it appropriate to do resisted eccentric exercises with high load? 8. A pt is 4 weeks after injury and has begun running when they note pain and swelling that lasts for more than a day. What is the best course of treatment at this point? 9. What are some potential ways to progress active exercises in the chronic phase? 10. What are the components that need to be included when documenting a therapeutic exercise? 11. What do you need to consider when choosing the best therapeutic exercise? 12. When do we do PROM? 13. When do we do AAROM? 14. How do we know when it is ok to move to AROM? 15. If your goal was to increase strength which type of ROM would you choose? 16. A pt is 4 days s/p TKA. The most beneficial treatment at this time would be: a. Rest and no exercise during the inflammatory phase b. **Gentle PROM of the knee** c. Gentle resisted ROM of the knee d. Stretching of the hamstring to prevent contracture development 17. The goal of the intervention is to increase biceps strength to help with carrying groceries s/p prolonged immobilization in a cast. What is the best treatment option? e. PROM of the elbow in supine f. AAROM of elbow extension in prone g. **Resisted elbow flexion ROM in sitting** h. Shoulder flexion with a 2lb cuff weight 18. A pt is 2 weeks s/p severe contusion to the thigh from a football tackle. The pt is able to contract his quad muscle actively but cannot fully extend the knee in supine. What is the best option for intervention at this time? i. **AAROM in supine with foot on a slippery sheet and therapist assisting** j. Daily use of a CPM for 15 minutes k. LAQ seated in a chair l. Quad setting exercise 19. Is ROM is synonymous with stretching? Why or why not? 20. In order to prepare for a ROM intervention place the following statements in correct order: m. Access the region and drape appropriately n. Position to allow for alignment and stabilization o. Explain to the patient what you plan to do and what methods you will use to achieve the goal p. Position yourself to maintain good body mechanics 21. ROM must be completely pain free q. **True** r. False