Session 5 Lab Guide (Student) PDF

### Learning Goal: Think Like A PT ### Course Goal \#3: Document effectively using appropriate medical terminology ### Learning Goal: Safely and Effectively Utilize Foundational Intervention Strategies When Working with Non-Complex Patients ### Course Goal \#5: Use principles of biomechanics to i...

### Learning Goal: Think Like A PT ### Course Goal \#3: Document effectively using appropriate medical terminology ### Learning Goal: Safely and Effectively Utilize Foundational Intervention Strategies When Working with Non-Complex Patients ### Course Goal \#5: Use principles of biomechanics to inform decision making in movement and injury prevention ### Course Goal \#6: Position and drape patients appropriately ### Course Goal \#7: Demonstrate proper bed mobility techniques ### Course Goal \#13: Implement effective ROM and stretching interventions for non-complex patients Part 1: ROM Application Cases ============================= - **Practice: Start with the case you were assigned. Practice it and then move on to the next case. You will probably not have time to practice all the cases but these are good things to practice outside of class.** - **Document a brief SOAP note for the case you started with (you may take artistic liberties)** 1. **Pt: Albuquerque** **DOB: 4/6/76** **PMH: Pt is day 4 s/p surgery to the R bicep. Perform appropriate range of motion and provide appropriate patient education on healing. The pt is supine at the EOB.** 2. **Pt: Baltimore** **DOB: 6/4/58** **PMH: Pt s/p R THA (posterior approach) post-op day 1. Due to pain medications the pt is having trouble remembering the hip precautions. The hospital protocol for THA calls for range of motion of the lower extremities on day 1. Pt is supine in bed when you arrive** 3. **Pt: Chattanooga** **DOB: 12/31/91** **PMH: Pt has been hospitalized with severe COVID, was ventilated and sedated for 2 weeks, and is now alert but severely deconditioned and extubated. You are instructing family today in range of motion exercises for LEs. Pt is supine in bed when you arrive** 4. **Pt: Denver** **DOB: 7/2/1950** **PMH: Pt had a R CVA resulting in L hemiplegia. He has significant weakness on L side, perform a range of motion exercise for the L arm. Pt is supine in bed.** 5. **Pt: Erie** **DOB: 1/9/83** **PMH: Pt is s/p L CVA resulting in R hemiplegia. The pt's goal is to use the R UE to bring utensils to their mouth to eat. Complete an appropriate range of motion exercise for this session. Your pt is supine in the bed.** 6. **Pt: Fairbanks** **DOB: 2/7/07** **PMH: Pt was in a car crash yesterday and sustained an SCI with paraplegia. Pt has a contusion to the R biceps. Complete an appropriate range of motion exercise for the R elbow. Pt is supine in the middle of the bed.** 7. **Pt: Gary** **DOB: 3/6/86** **PMH: Pt was in a MVA 2 days ago and sustained a SCI with paraplegia and injury to the R shoulder from the airbag deployment. Perform an appropriate range of motion exercise for the R shoulder. The pt is supine in the middle of the bed.** Practice for Later: ------------------- 8. **Pt: Hollywood** **DOB: 1/9/50** **PMH: Pt had abdominal surgery 6 weeks ago with complications and has been hospitalized since and is now severely deconditioned after a long hospital stay with B UE and LE weakness and significant hamstring tightness. Teach the pt and the family a stretch they can do for the HEP. The pt is supine in the bed.** 9. **Pt: Ithaca** **DOB: 2/3/99** **PMH: Pt s/p SCI with paraplegia. Teach the family how to help stretch the quad muscle. Pt is supine in bed when you arrive.** 10. Pt: Jackson DOB: 5/9/69 PMH: Pt is s/p L THA and is complaining of tight L gastroc. Teach the pt and family a stretch to do to relieve the tightness. Pt is supine in the center of the bed at the start of the session. Part 2: Stretching at a therapeutic exercise tool =================================================  Benefits of Stretching - Increased flexibility and ROM - General fitness - Injury prevention and reduced soreness - Enhanced performance +-----------------------------------+-----------------------------------+ | Parameters (Determinants) of | | | Stretching | | +===================================+===================================+ | Alignment | - Position so force is directed | | | to the appropriate muscle | | | group | | | | | | - Think about short-term | | | positioning | +-----------------------------------+-----------------------------------+ | Stabilization | - Fixation of a body segment | | | that has an attachment of the | | | muscle | | | | | | - Commonly manual stretching | | | stabilizes the proximal and | | | move the distal segment and | | | self-stretch often stabilizes | | | the distal | | | | | | - Watch for substitutions! | +-----------------------------------+-----------------------------------+ | Intensity of stretch | - Magnitude of the stretch | | | force applied, want low | | | intensity by a low load | +-----------------------------------+-----------------------------------+ | Duration of stretch | - Length of time force is | | | applied during a stretch | | | cycle, the shorter the single | | | stretch cycle the more | | | repetitions needed | | | | | | - **30 second hold** is the | | | median duration in most | | | literature | | | | | | - Cyclic stretching can be 5-10 | | | seconds with multiple reps to | | | be greater than 30 seconds | | | total | +-----------------------------------+-----------------------------------+ | Speed of stretch | - Rate of initial application | | | of the stretch force, | | | commonly the goal is slowly | | | applied stretching unless | | | ballistic or high-velocity | | | stretching | +-----------------------------------+-----------------------------------+ | Frequency of stretch | - Number of stretch sessions | | | per day or week, recommended | | | **2 to 5 sessions per week, | | | daily 1-3 session** | +-----------------------------------+-----------------------------------+ | Mode of stretch | - Form or manner: | | | | | | - in which the stretch is | | | applied (static, | | | ballistic, or cyclic), | | | | | | - degree of pt | | | participation (passive, | | | assisted, or active), | | | | | | - or the source of the | | | stretch (manual, | | | mechanical, or self) | +-----------------------------------+-----------------------------------+ Old Key with solid fill**[Considerations for Stretching:]** - Prepare - Know what you want to do based on the pt and goals - Warm-up tissues - Position - Position for safety, comfort, access - Explain and help pt relax - Perform - Move through the available range using proximal stabilization and moving the distal segment, if multi-joint stretch 1 joint at a time - Apply low-load in the opposite direction to the line of pull of the range limiting muscle - Ask pt if they feel it and where - Gradually release the force - Post - Implement active exercises to use the new available range - Guarding and Safety Considerations: Monitor patient's tolerance, ask during and after how they are tolerating it Old Key with solid fill**DOSAGE** - 30-60 second duration (can be broken up into multiple reps) - 1-3 sessions per day, 2-5 days a week PRACTICE STRETCHING ------------------- Practice the different modes of stretching. Be sure to watch for substitutions/compensations and cue appropriately. Remember your anatomy! Stretching is all about understanding the origin and insertion and the direction of muscle pull. TYPE OF STRETCH MUSCLE STRETCHED DOCUMENT YOUR STRETCH (include dosage) ----------------- ------------------ ---------------------------------------- Gastrocnemius Towel stretch sitting Quadriceps Adductor Triceps Soleus Hamstrings Hamstrings Applying The Principles of Stretching to Patient Care ----------------------------------------------------- 1. Your patient, DJ, just moved from the ICU to the general floor of the hospital (he was in the ICU for 7 days). His doctor has requested a consult by PT, because the patient is demonstrating possible contractures at his hips and knees. He is in a hospital gown. Be sure to think of ST positioning and draping as appropriate. a. What 2 lower extremity muscle groups are mostly likely affected? b. Demonstrate cyclic stretching of one of your chosen muscle groups for your patient. c. Demonstrate static progressive stretching of the other chosen muscle group. d. Which upper body muscle groups could potentially show signs of positional shortening? e. Demonstrate static, progressive stretching of one of the upper body muscle groups. f. When you go in to evaluate DJ, what would be three things that would lead you to say that stretching is contraindicated? g. What type of contracture does DJ most likely have? 2. Your patient, MJ, is a professional dancer for the Washington Ballet. She is in the chronic stage of healing for Achilles Tendinitis. She tells you that she's noticed that she's noticed decreased flexibility with hip abduction, since her injury. Be sure to think of ST positioning and draping as appropriate. h. What muscles are limiting her ankle dorsiflexion? i. What muscles are limiting her hip abduction? j. Demonstrate a Hold-Relax technique (for the soleus) k. Demonstrate a Contract-Relax technique (for the gastrocnemius) l. Demonstrate a ballistic stretch (for the adductor magnus and longus) m. What signs/symptoms would you be expecting the patient to have in this phase of healing prior to initiating these stretches? n. In the case of a dancer who may be hypermobile, what would it be important NOT to do in areas outside of her complaints, and why? Summary Review For Stretching ============================= 1. When is stretching recommended for a patient after a tissue injury? 2. What is the difference between PROM and stretching? Prom is in a comfortable range 3. What is the difference between the treatment for a myostatic contracture and a fibrotic contracture? No pathology for myostatic contracture, so we can do more. Fibrotic has tissue changed so surgery will likely be needed to fix this type of contracture 4. What are some of the contraindications for stretching? Inflammation, hypermobility, boney infill/limitation, fracture (in healing stage), soft tissue is providing stability to a joint where there might be weakness 5. What occurs in a grade III injury? 6. What is the general recommendation (ie. Dosage) for stretching for changing tissue length in your patients? 7. When would you use ballistic stretching? 8. If your patient has a lot of muscle guarding and is fearful of stretching what technique could you use to encourage the patient to actively do the stretch themselves? 9. What is the difference in performance of hold-relax vs. contract-relax stretch? 10. When thinking about the sequencing of exercises during your PT session, what is important to consider with stretching? Think about what should come before and after stretching. 11. Your patient is 3 months post elbow fracture and has a myostatic contracture of the bicep muscle. What would be the best home stretch to teach your patient? 12. If your patient now has full PROM and AROM what is your plan for the next session? Where would you document that in the SOAP note?