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BU T T E R W O R T H
HE I N E M A N N
An Imprint of Elsevier
The Curtis Center

Independence Square West
Philadelphia, Pennsylvania 19106
CLINICAL CASES IN PHYSICAL THERAPY, 2ND EDITION 0-7506-7394-X

Copyright © 2004, Elsevier Science (USA). All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, recording, or any information storage and retrieval
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NOTICE
Physical therapy is an ever-changing field. Standard safety precautions must be followed, but as
new research and clinical experience broaden our knowledge, changes in treatment and drug
therapy may become necessary or appropriate. Readers are advised to check the most current
product information provided by the manufacturer of each drug to be administered to verify the
recommended dose, the method and duration of administration, and contraindications. It is the
responsibility of the licensed health care provider, relying on experience and knowledge of the
patient, to determine dosages and the best treatment for each individual patient. Neither the publisher
nor the authors assume any liability for any injury and/or damage to persons or property arising
from this publication.
Previous edition copyrighted 1995
International Standard Book Number 0-7506-7394-X
Senior Acquisitions Editor: Marion Waldman

Senior Developmental Editor: Jill Rembetski
Publishing Services Manager: Patricia Tannian
Senior Project Manager: Anne Altepeter
Book Design Manager: Bill Drone
Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1
To Leslee, Jeanne, Eric, Christopher, Katie, and Michael,
whose love, patience, and understanding made this
contribution possible
Contributors
Michael B. Ashley, PT Laurie Brogan, MSPT

Ashley & Kuzma Physical Therapy and Staff Physical Therapist
Photomedicine Sports Injury Treatment Center
Erie, Pennsylvania Scranton, Pennsylvania
Angela M. Baeten, PT Kathleen M. Buccieri, PT, MS, PCS

Consultant Clinical Education Director, Physical Therapy
Abrams, Wisconsin Department
Ithaca College at University of Rochester
Amy Tremback-Ball, MSPT Campus
Assistant Professor, Physical Therapy Rochester, New York
Department
College Misericordia Christopher R. Chelius, Jr., MSPT
Dallas, Pennsylvania Lead Physical Therapist and Center
Coordinator of Clinical Education
Allison T. Behm, MSPT Manatawny Manor Nursing and Rehabilitation
Staff Physical Therapist Center
Mercy Hospital Pottstown, Pennsylvania
Scranton, Pennsylvania
Stacia M. Ciak, MSPT
Marybeth Grant Beuttler, PT, MS Hunlock Creek, Pennsylvania
Assistant Professor, Physical Therapy
Department Jason A. Craig, MCSP, DPhil
University of Scranton Assistant Professor, Physical Therapy
Scranton, Pennsylvania Department
Marymount University (Ballston Campus)
Donna Bowers, PT, MPH, PCS Arlington, Virginia
Instructor, Department of Physical Therapy
& Human Movement Science Kristina A. Dillon, MSPT
Sacred Heart University Binghamton, New York
Fairfield, Connecticut
Carolyn J. Engdahl, MSPT
Nicole A. Boyle, MSPT Mountain Top, Pennsylvania
Binghamton, New York
Andrea Falcone, MSPT
Trista L. Bratlee, MSPT Pediatric Physical Therapist with HFM
Pittston, Pennsylvania BOCES
Johnstown, New York
Mark A. Brimer, PT, PhD
Administrator, Orthopaedics
Holmes Regional Medical Center
Melbourne, Florida
vii
viii Clinical Cases in Physical Therapy
Renee M. Hakim, PT, PhD, NCS Kevin J. Lawrence, PT, MS, OCS
Assistant Professor, Physical Therapy Assistant Professor, Physical Therapy
Department Department
University of Scranton College Misericordia
Scranton, Pennsylvania Dallas, Pennsylvania
Jennifer Holmes, MSPT Holly Leaman, MSPT

Staff Physical Therapist Staff Physical Therapist
Massapequa Pain Management and Maryview Rehabilitation Hospital
Rehabilitation Portsmouth, Virginia
Massapequa, Long Island, New York
Beatriz Lizaso, MSPT
Rett Holmes, MSPT Pembroke Pines, Florida
Senior Staff Physical Therapist
Physical Therapy Plus Mark V. Lombardi, MSPT, MA, ATC
Washington, New Jersey Sports Injury Treatment Center
Thomas Hudson, MS, PT, PCS
Assistant Professor, Physical Therapy Michelle M. Lusardi, PT, PhD
Department Associate Professor, Department of Physical
Consultant, Gannon University and Erie Therapy and Human Movement Science
Homes for Children and Adults Sacred Heart University
Erie, Pennsylvania Fairfield, Connecticut
Marianne Janssen, PT, EdD, ATC Diane E. Madras, PT, PhD

Director of Clinical Education Assistant Professor, Physical Therapy
Department of Physical Therapy Education Department
Elon University College Misericordia
Elon, North Carolina Dallas, Pennsylvania
Timothy L. Kauffman, PT, PhD Robert Marsico, PT, EdD

Kauffman-Gamber Physical Therapy Adjunct Assistant Professor, Physical Therapy
Lancaster, Pennsylvania Department
Richard Stockton College of New Jersey
Edmund M. Kosmahl, PT, EdD Pomona, New Jersey
Professor, Physical Therapy Department
University of Scranton Colleen Medlin, MSPT
Scranton, Pennsylvania Physical Therapist
HealthSouth Spine Center of Baltimore
Nicholas J Kuharcik, MSPT Baltimore, Maryland
Larksville, Pennsylvania
Keith Meyer, CP
MaryAlice Lachman, MSPT Director, Prosthetic Services
Staff Physical Therapist Keystone Prosthetics and Orthotics Inc.
NovaCare Rehabilitation Clarks Summit, Pennsylvania
Collegeville, Pennsylvania
Amy S. Lambert, MSPT

Lake Ariel, Pennsylvania
Contributors ix
Gerri M. Misunas, MSPT Steven D. Pheasant, PT, PhD

Staff Physical Therapist Assistant Professor, Physical Therapy
Sports Injury Treatment Center Department
Scranton, Pennsylvania College Misericordia
Dallas, Pennsylvania
Georganne N. Molnar, MSPT
Newport, Pennsylvania Kristen R. Pizzano, MSPT
Exeter, Pennsylvania
Kelley A. Moran, MSPT, DPT, ATC, CSCS
Associate Professor, Physical Therapy Pamela J. Reynolds, PT, EdD
Department Associate Professor, Physical Therapy
College Misericordia Department
Dallas, Pennsylvania Gannon University
Erie, Pennsylvania
Michael Moran, PT, ScD
Professor, Physical Therapy Department Jonathan Sakowski, MSPT
College Misericordia Adjunct Assistant Professor, Physical
Dallas, Pennsylvania Therapy Department
College Misericordia
Kristin E. Murray, MSPT Dallas, Pennsylvania
Pediatric Physical Therapist
Archway Programs Early Intervention John Sanko, PT, EdD
Atco, New Jersey Associate Professor, Physical Therapy
Department
Karen W. Nolan, PT, MS, PCS University of Scranton
Assistant Professor, Physical Therapy Scranton, Pennsylvania
Department
Ithaca College at University of Rochester Dawn M. Schaeffer, MSPT
Campus Perkasie, Pennsylvania
Rochester, New York
Eric Shamus, PT, PhD, CSCS
Patricia O’Shea, MSPT Assistant Professor, College of Osteopathic
Long Valley, New Jersey Medicine
Nova Southeastern University
Maureen Romanow Pascal, PT, MS, NCS Fort Lauderdale, Florida
Assistant Professor, Physical Therapy
Department Jennifer Shamus, PT, PhD, CSCS
College Misericordia Clinical Specialist, Administrator
Dallas, Pennsylvania Healthsouth Sports Medicine
Pembroke Pines, Florida
David Patrick, MSPT, CPO
Director, Orthotic Services Colleen Kimberly Smith, MSPT
Keystone Prosthetics and Orthotics Inc. Saylorsburg, Pennsylvania
Clarks Summit, Pennsylvania
Melissa A. Strohl, MSPT
Lehighton, Pennsylvania
x Clinical Cases in Physical Therapy
Amy L. Szumski, MSPT John Wojnarski, MSPT

Scranton, Pennsylvania Dallas, Pennsylvania
Gary Tomalis, MSPT Loraine D. Zelna, MSRT (R)(MR)(ARRT)

Wilkes-Barre, Pennsylvania Associate Professor/Clinical Coordinator,
Medical Imaging Department
Barbara Reddien Wagner, PT, MHA College Misericordia
Academic Coordinator of Clinical Education Dallas, Pennsylvania
University of Scranton
Foreword
With the first edition of Clinical Cases in cation, ethics, as well as many other areas
Physical Therapy, Mark Brimer and Mike related to physical therapist practice.
Moran set the standard for using clinical Hence, the second edition of Clinical Cases
situations to exemplify the best aspects of in Physical Therapy has evolved to demon-
our practice. These cases illustrated how strate how cases reflect the depth and scope
each patient must be approached thought- of our practice. Moreover, these cases are now
fully, and how expert clinical decisions must organized according to the practice patterns
be applied in each patient situation. This text and elements of management established in
likewise “puts a face” on physical therapist the Guide to Physical Therapist Practice,
education and practice. As students and second edition. Rather than turning these
clinicians, we are inundated with facts, con- cases into a fixed template or cookbook, this
cepts, and theories, often to the point that effort to organize and analyze according to
we begin to lose sight of what drew us to this the Guide helps point the way through each
profession in the first place. Descriptions of case in a logical and effective manner. The
clinical cases remind us that we deal with structure and organization of the second edi-
people, and that all our knowledge and skill tion of Clinical Cases in Physical Therapy
must ultimately be used to affect the life and represent an outstanding effort by Brimer
welfare of a single individual. and Moran to unite our profession and pro-
Continuing the tradition established in the vide us with a common language and strategy
first edition, the second edition of Clinical for examining the way we practice.
Cases in Physical Therapy makes excellent As physical therapists, we now recognize
use of cases as a teaching tool. We are again that case reports serve a vital role in our pro-
able to see how experienced clinicians fession. We must be comfortable with the idea
examine, evaluate, and intervene in specific that clinical cases do not just document
situations. To enhance pedagogy, learning unusual patients, but that cases represent the
objectives have been added to the beginning primary way that we communicate and teach
of each case. References to the peer-reviewed one another about the various aspects of our
literature have likewise been included in these practice. Clinical Cases in Physical Therapy,
cases. These references direct readers to addi- 2nd edition, fulfills a vital role in classroom
tional information on each topic and under- and clinical settings because it offers a com-
score the need to draw upon the growing body pendium of knowledge about our profession.
of knowledge that provides evidence for our It is rare that a single text can be applicable
decisions. The second edition also extends to all aspects of a profession as diverse as
the use of case studies to encompass diverse physical therapy, but Brimer and Moran and
aspects of physical therapist practice. We are their contributors offer some genuine pearls
now given insight into how physical therapists of wisdom to every reader. Once again,
might react to situations that do not directly Clinical Cases in Physical Therapy shows
involve patient care, but situations that are us that each patient or clinical situation
nonetheless resolved successfully with skill, requires our thoughtful and skilled approach,
knowledge, and expertise. For example, cases and this idea has been, and always will be,
are used to illustrate how therapists manage the cornerstone of our profession.
issues related to documentation, clinical edu- Charles D. Ciccone, PT, PhD
xi
Preface
The profession of physical therapy has under- the best patient care outcome. This includes
gone significant growth and development encouraging the reader to evaluate the effi-
since the first edition of Clinical Cases in cacy of intervention provided and determine
Physical Therapy was published almost if it aligns with the clinical and functional
10 years ago. Since then, the profession has goals presented.
made great strides in developing and imple- To provide a methodology for analysis and
menting the Guide to Physical Therapist learning, a matrix has been included at the
Practice, 2nd edition, the foundation for end of the text. The matrix contains group-
describing and implementing physical therapy ings under which specific practice patterns
clinical practice. The goal of this text is to can be examined. As the reader will note, the
build upon the concepts presented in the cases are also ordered by level of complexity
Guide to Physical Therapist Practice, 2nd to allow progression of learning opportu-
edition, and provide real-life examples of nities. Additionally, several cases have the
how therapists can use the Guide for patient distinction of being included in more than
care opportunities. one practice pattern, thereby reflecting the
Each case in Clinical Cases in Physical complexity of actual patient care oppor-
Therapy, 2nd edition, begins with learning tunities frequently encountered in the clinical
objectives designed to assist the reader in setting.
examining the multiple intricacies of clinical More than anything else, Clinical Cases
practice. Similar to the Guide, Clinical Cases in Physical Therapy, 2nd edition, furthers
in Physical Therapy, 2nd edition, focuses understanding of the complex role the pro-
upon enhancement of quality of care, promo- fession has in assimilating all patient care
tion of appropriate utilization of services, information with skill, knowledge, and
recognition of variations in clinical practice, expertise. The cases have been designed to
the importance of sound documentation, and provide a conceptual framework for under-
the value of professional ethics. Throughout standing how practice patterns can be used
each case the reader is provided with ques- to enhance the delivery of quality health care
tions designed to stimulate further investiga- services.
tion and enhance clinical decision making. Mark A. Brimer
Patient care outcomes are provided for most Michael L. Moran
cases. The outcomes serve to demonstrate
how patient care issues were brought to The Preferred Physical Therapist Practice
closure. Peer-reviewed and other references PatternsSM are copyright 2003 American
Physical Therapy Association and are taken
are provided at the end of each case.
from the Guide to Physical Therapist Prac-
Cases have been carefully organized tice (Guide to Physical Therapist Practice, ed 2,
according to practice patterns and elements Phys Ther 81:1, 2001), with the permission of
of care management. Attention was given to the American Physical Therapy Association.
avoiding a “cookie-cutter” case presentation All rights reserved. Preferred Physical Thera-
so that variations of clinical analysis and pist Practice PatternsSM is a trademark of the
approaches can be used by the reader to find American Physical Therapy Association.
xiii
Acknowledgments
In any complex endeavor, many individuals thanks go to Chuck Ciccone for his support
lend varying forms of assistance. We thank over the years and for writing the foreword
all of them. We would like to specifically thank to both editions. Finally, we gratefully thank
the library staff at College Misericordia for Katie Moran for her sense of humor and
their tireless and good-natured help. Also, our editorial skills.
xv
Case 1
LEARNING OBJECTIVES
The reader will be able to:
1. Describe how the physical therapy examination process is important in
establishing patient-centered goals and outcomes.
2. Identify how deficiencies in documentation can affect communication
and result in inefficient care.
The reader should know that the patient was expect such information as the patient’s level
entering his fifth week of physical therapy of education, history of therapy intervention,
intervention when he was added to the caseload. living environment (e.g., devices, environ-
mental barriers), medical history, and func-
tional status/activity level. It would also be
Examination reasonable to expect data on communication
HISTORY ability as well as on cardiovascular/pulmonary,
The patient was a 94-year-old male who lived musculoskeletal, and neuromuscular systems.
independently at home before sustaining a Tests and measures might provide baseline
fall that resulted in a displaced C-1 fracture. data in such areas as cognition, pain ratings,
The initial physician’s order was for “PT eval range of motion (especially the left knee),
and treat per plan of care.” The patient was strength, positioning, bed mobility, endurance,
retired, and his son was the primary contact. transfers, balance, and gait.
The physician documented that a cervical
collar was in place, that the patient reported
persistent neck and left knee pain, and that The Initial Examination
the patient had full use of all extremities.
Knee crepitus was recorded and documented
Documentation
as osteoarthritis. Medications included The following was a summary of the docu-
Procardia, Relafen, Darvocet, and Hytrin. mentation provided in the medical record by
Librium (25 mg t.i.d.) was discontinued. the examining physical therapist:
Nursing reported patient complaints of neck The patient was a 94-year-old male who
pain and noncompliance with the cervical lived alone in a two-bedroom home. He was
collar. The assistance of two persons was using a cane for ambulation when his left knee
needed to transfer the patient to a bedside buckled and he fell. He was found injured by
chair, and the patient’s tolerance for sitting his county home health aide. The patient was
was 10 minutes. diagnosed with a displaced fracture of C-1.
A cervical collar was in place. He exhibited
Based on the medical record review of functional mobility of all extremities except
admission information, what data might be that bilateral shoulder joint flexion and abduc-
expected in the physical therapy documen- tion was limited to 100 degrees and his left
tation after further history review, the knee lacked 15 degrees of extension. He exhib-
systems review, and the tests and measures ited fair left quad strength within his active
portion of the examination are completed? range. General strength was fair to good. He
transferred from bed to chair with a flexed
The Guide to Physical Therapist Practice posture and with moderate assistance of one.
(p. 42)1 defines patient history as “from both Goals: Short-term—
the past and the present.” Therefore, one can 1. Minimally assisted transfers.
1
2 Clinical Cases in Physical Therapy
2. Independent ambulation with assistive History information could be obtained by

device to be determined. interviewing the patient unless cognition
Goals: Long-term—(blank) was a problem, in which case the responsible
Rehabilitation potential—(blank) family member could be contacted. Baseline
Plan of care: 5×/week for gait training, examination data are needed to establish
general strengthening, transfer training, measurable goals.2
and left knee rehabilitation. According to Randall and McEwen,3 to
identify functional goals, it is helpful to
understand the patient’s activities as well as
Discussion of the Initial where they occur, and to establish goals that
correspond to the patient’s desired outcome.
Examination Findings In this case, the documentation does not sup-
The examining therapist did not address all port the development of functional goals that
of the expected examination areas. Some help- are specific to the patient’s needs.
ful information, such as that the patient used
a cane and lived in a two-bedroom home, was
obtained. However, many questions were Further Screening Before
unasked, including whether there were any
environmental barriers, why home health care
Intervention
was received, and what the patient’s prior The most recent physical therapy progress
functional level was. report indicated that the patient complained
The systems review portion of the examina- of headaches, received therapy b.i.d. 5×/
tion lacked baseline cardiovascular/pulmonary week, and improved ambulation with a
system data and provided only minimal walker from 20 feet × 2 with standby assis-
musculoskeletal system data pertaining to tance to 100 to 120 feet with contact guard
range-of-motion measurements and strength assistance. Transfers required minimal assis-
grades. The patient’s tolerance for activity tance for sit to stand with verbal cues to
was only minimally defined, and there was move forward in the chair and for walker
no documentation of pain or positioning. placement. No goals or contraindications to
Transfers were briefly addressed; however, treatment were described. The therapist indi-
gait and bed mobility were not assessed. It cated that the patient could return home
would be reasonable to expect such data or with support if pain decreased.
an explanation as to why they were not The physical therapy progress report lacked
obtained. a clear indication of patient management and
Despite the limited examination data avail- what skilled intervention was provided.
able, the therapist established two goals. The Nursing interviews revealed concerns regard-
ambulation goal presented appears to be a ing nutritional intake and social isolation.
long-term goal, not a short-term goal, and lacks
validity because baseline data are lacking. The Based on the available information, does
transfer goal lacks a time frame for achieve- the patient demonstrate the potential to
ment. All goals should be measurable, be func- return home independently, or is extended
tional, and have an achievement date. Use care a realistic expectation? How might one
of the Guide to Physical Therapist Practice1 proceed with care for this patient and why?
would be helpful to identify preferred prac-
tice patterns and aid in the organization of In this case, the therapist recognized a
documentation. reexamination was warranted as data were
lacking and the patient’s goals were unde-
What other information would be helpful for fined. Areas previously not addressed in
establishing goals and outcomes? And how the physical therapy documentation were
might the information be obtained? explored, and the patient, along with his
Case 1 3
representative, helped formulate the criteria lack of involvement in establishing goals and
for his return to home. After reexamination, a limited understanding of the patient’s total
the patient demonstrated a renewed interest needs may have delayed the patient’s return
in the quality of his performance. He achieved to home and hindered the transition of care
his goals within 3 weeks and returned home to another therapist.
with supportive services.
REFERENCES
Summary 1. American Physical Therapy Association: Guide
The relationship between the therapist and to physical therapist practice, second edition,
patient is important to achieving successful Phys Ther 81:1, 2001.
2. Baeten AM, Moran ML, Phillippi LM: Document-
outcomes. Effective documentation will aid
ing physical therapy: the reviewer perspective.
the exchange of information and delivery of Boston: Butterworth-Heinemann, 1999, p 14.
efficient care. Baker et al4 found that thera- 3. Randall KE, McEwen IR: Writing patient-
pists seek to involve their patients in estab- centered functional goals, Phys Ther 80:1199,
lishing goals and determining outcomes, but 2000.
do not maximize the existing potential for 4. Baker SM, Marshak HH, Rice GT, Zimmerman
this involvement. This finding would seem GJ: Patient participation in physical therapy
true in this case study, because the patient’s goal setting, Phys Ther 81:1126, 2001.
Case 2
LEARNING OBJECTIVES
1. Describe how to manage a physical therapy referral with an
inappropriate diagnosis.
2. Describe how to utilize a home exercise program with a patient with
limited physical therapy visits.
3. Identify the symptoms of coccygodynia.
The reader should know that a 34-year-old strength of the muscles of pelvic floor.1 Manual
woman whose medical diagnosis was low back muscle testing of the hip complex was normal.
pain was referred for outpatient physical
therapy.
Evaluation
At the time of referral, a physician had diag-
Examination nosed the patient with low back pain and
HISTORY recommended moist heat and ultrasound
On interview, the patient reported symptoms therapy to the lumbar and sacral spine and
including pain in the coccyx area that lumbar stabilization exercises. On physical
increased after sitting for a prolonged period therapy examination, signs and symptoms
and then arising. She also reported pain in were consistent with coccygodynia (painful
the buttocks and sacroiliac joint areas. The coccyx), which in this case resulted from
symptoms began after she gave birth to twins injury to the coccyx area from the passage of
vaginally 4 months earlier. She initially sought the fetuses through the birth canal. Based on
medical treatment 2 months after the birth. these findings, treatment of the lumbar spine
Medical intervention at that point included was not an appropriate intervention.2 The
radiographs of the pelvis that were unremark- physical therapy diagnosis was established
able, a prescription for Vioxx to relieve pain, as muscle spasm.
and a donut pillow for sitting. She continued
to experience symptoms of pain, which made
it difficult to sit to feed her twins.
Diagnosis
Practice Pattern 4D: Impaired Joint Mobility,
Motor Function, Muscle Performance, and
Systems Review Range of Motion Associated With Connective
Vital signs were normal. Tissue Dysfunction.3
How should a physical therapist proceed?

Tests and Measures What are appropriate interventions?
Observation revealed that the patient had a
sitting posture of rounded shoulders, forward
head tilt, and posterior pelvic tilt with most Prognosis (Including Plan
weight-bearing on the coccyx. Palpation
revealed trigger points over the area of the
of Care)
piriformis, gluteus maximus, and levator ani. The therapist recommended that the patient
Intravaginal palpation revealed increased be seen three times a week for 4 weeks. The
resting tone of the levator ani and 5/5 plan of care included soft tissue mobilization
5
to the buttocks and area of piriformis and

friction massage to trigger points in the levator
ani. Biofeedback was incorporated into the
plan to work on decreasing the resting tone
of the levator ani utilizing a rectal electrode.
In addition, postural training was included to
encourage the patient to sit with her weight
on the ischial tuberosities rather than the
coccyx. The therapist recommended that the
patient discontinue using the donut pillow and
instead use a coccyx cutout wedge cushion
when sitting for a prolonged period, such as
when feeding her babies.
Intervention
C O O R D I N AT I O N ,
C O M M U N I C AT I O N ,
A N D D O C U M E N TAT I O N
Unfortunately, the demand of being a mother
to 4-month-old twins limited the patient’s
ability to attend therapy three times a week. F I G U R E 2 - 1 Partner massage of the piriformis
muscle.
The therapist and patient opted for a treat-
ment program of once-weekly visits comple-
mented by a home program. The patient felt the portable biofeedback machine. The patient
that this was practical and agreed to perform adhered to the home exercise program two
the home program two to three times a week. times a week and consistently attended phys-
The physical therapist also recognized the ical therapy treatment sessions for 4 weeks.
need to communicate findings to the patient’s Symptoms of pain resolved, and the patient
physician. The therapist contacted the physi- was able to feed her twins with a 5-minute
cian via telephone and letter and detailed break in between children. The posture of
the findings from the physical therapy exami- rounded shoulders and forward head per-
nation. sisted, so the therapist discharged the patient
with a modified home exercise program to
PAT I E N T / C L I E N T- R E L AT E D include thoracic and cervical posture exer-
INSTRUCTION cises and recommendations for patient and
The therapist recommended a home exercise child positioning during feeding to decrease
program of self- or partner massage to the back strain.
piriformis, stretching of the piriformis, and
friction massage of trigger points in the
levator ani (see Figure 2-1). This was to be
Discussion
followed by a session of biofeedback for the Coccygodynia, or coccydynia, is a disorder
levator ani utilizing a portable biofeedback commonly classified under the diagnosis of
machine with an anal electrode. pelvic pain, but it may be mistakenly diag-
nosed as low back pain or sacroiliac joint
pain, because pain may refer to the sacroiliac
Outcome or lumbar areas.4 Because coccygodynia refers
The patient and her husband attended a treat- to a specific symptom (pain), it can have dif-
ment session together for instruction in self- ferent causes. It commonly results from a fall
and partner massage, as well as home use of onto the buttocks or trauma during child-
Case 2 7
birth, causing a partial dislocation of a joint priate for this patient, because it takes weight
in the coccyx or overstretching of the liga- off of the coccyx and redistributes weight to
ments and muscles attached to the coccyx.2,5 the thighs while encouraging a more appro-
Muscle spasm and pain in the tissues around priate position of the pelvis.
the coccyx may result. The symptom of pain Stretching became part of the patient’s
increases when sitting for a prolonged period home exercise program to relieve some of
or when making bed or chair transfers. There- the pain and spasm in the piriformis. The
fore, it is important to address the soft tissue piriformis may shorten and develop spasms
injury and resultant impairments in a case during pregnancy because of the altered posi-
such as this. tion of the lower extremity and an altered
Injury to the muscles, ligaments, and con- gait pattern. In this case it was contributing
nective tissue of the pelvis is common during to the patient’s pelvic pain and general
vaginal deliveries as well as during the months increase in tone of the pelvic floor muscles.
leading up to the delivery. Increased ligament
laxity, posture alterations, and increased
REFERENCES
demand on the pelvic floor to support the
viscera may lead to musculoskeletal damage. 1. Wilder E (ed): The gynecological manual,
The changes occurring during pregnancy and Alexandria, VA: American Physical Therapy
delivery must be considered when examining Association, 1997.
2. Sapsford R, Bullock-Saxton J, Markwell S
and evaluating patients in the antenatal and
(eds): Women’s health: a textbook for physio-
postnatal period. therapists, London: WB Saunders, 1998.
Massage, biofeedback, and postural train- 3. American Physical Therapy Association: Guide
ing were the treatments of choice for this to physical therapist practice, second edition,
patient to decrease muscle spasm in the piri- Phys Ther 81:1, 2001.
formis, levator ani, and gluteus maximus. The 4. Stephenson RG, O’Connor LJ: Obstetric and
donut pillow may have been exacerbating the gynecologic care in physical therapy (ed 2),
patient’s symptoms by distributing weight onto Thorofare, NJ: Slack, 2000.
the coccyx and promoting a posterior pelvic 5. Hall CM, Brody LT: Therapeutic exercise:
tilt while sitting. A wedge-shaped cushion with moving toward function, Philadelphia:
a coccyx cutout would be much more appro- Lippincott Williams & Wilkins, 1999.
Case 3
LEARNING OBJECTIVES
1. Identify the roles of the academician, clinician, and student in dealing
with difficult issues in clinical education.
2. Develop a rationale for facilitating active student participation in the
design of a remediation plan for clinical education.
The reader should know that a 22-year-old Did the student have any issues on previous
student in the final year of an entry-level affiliations? What were the concerns that
5-year Master of Science in Physical Therapy led to removal?
program was asked to leave the fourth
affiliation 4 weeks into a 6-week experience due This student had demonstrated acceptable
to patient safety concerns. Visual analog scale academic and laboratory performance on
markings and clinical instructor comments examination in individual courses in the pro-
scored the student below established grading gram. Faculty evaluation determined accept-
criteria for this level affiliation on the Clinical able readiness3 for clinical education based on
Performance Instrument (CPI).1 Primary areas completed coursework. The clinical instruc-
of deficiency were safety, professional behavior, tors evaluated clinical performance and iden-
professional demeanor, and communication tified problems in the student’s development
criteria. The student actively worked with the of appropriate professional communication
academic Director of Clinical Education (DCE) skills and demeanor on the second and third
to design and participate in a remedial plan. clinical affiliations. After each of these affili-
After completing the scheduled remediation ations, the faculty diagnosed the student’s
activities, the student returned to clinical needs and designed and directed interven-
education and successfully completed the tions in the form of remedial plans that
remaining two 6-week affiliations with entry- the student completed. Despite remediation,
level scores on the visual analog scale and similar concerns were raised with reexami-
positive comments from the clinical instructors nation of performance on subsequent clinical
on safety, professionalism, and communication education experiences.
criteria. During the fourth clinical education affil-
This case is discussed within the framework iation, the faculty planned an early site visit
of the Guide to Physical Therapist Practice 2 to examine the student’s performance. Issues
elements of patient/client management. The identified by the Clinical Instructor (CI) and
student’s ability to function as a competent Center Coordinator of Clinical Education
physical therapy practitioner is the desired (CCCE) during the visit were consistent with
outcome. The elements of the model are applied previously identified issues of communication
as follows: The student’s clinical performance on and professionalism. Studies 4,5 have revealed
affiliation is “examined,” competence is that behavior in these areas can be indicative
“evaluated,” causes of deficient performance are of success or failure in clinical education.
“diagnosed,” the student’s optimal level of The academic and clinical faculty discussed
function and the time needed to achieve that the need for change with the student and
level are “prognosed,” activities to promote emphasized the importance of these skills
improved performance are designed in providing effective patient care. After the
(intervention), clinical performance is faculty visit, the student’s performance
“reexamined,” and “outcomes” are discussed. deteriorated. A learning contract was imple-
9
mented with CI, CCCE, and DCE input to responsibility for performance and identify
clarify the level of performance that the how to improve it. This could be equated to
student needed to achieve. As examined by the diagnosis and prognosis elements of the
the clinical faculty, the student’s performance patient/client management model in the
continued to deteriorate. Five documented Guide to Physical Therapist Practice.2 The
safety incidents occurred in a 2-day period. student was asked to diagnose the cause
These incidents included failure to ascertain of deficient performance and prognose the
a weight-bearing status and proceeding with ability to be a competent physical therapist.
intervention without first reviewing medical The DCE’s role involved facilitation and
imaging reports. coordination. With time and coaching to
The site evaluated the situation and asked express individual needs, the student was
that the student be removed from the affil- able to identify areas to remediate. The DCE
iation. The student expressed an inability to and the student worked together to design a
perform and an awareness that skills were written plan to address needs (plan of care)
not improving. The academic program con- with specific activities (interventions) that
curred with the site that, given the identified included a time frame for completion (prog-
problems, this student was not safe and nosis). The DCE monitored the student’s
needed to be removed. progress (reexamination) toward fulfilling
these activities. Together, the DCE and the
Given the above-described situation, the student agreed that successful completion of
student could choose to attempt another the interventions would indicate a readiness
affiliation immediately, to remediate to participate in another affiliation.
pertinent issues and then participate in
another affil-iation, or to take some time off What specific interventions could be
and resume study next year. Which of these included to address the areas of deficient
alternatives was chosen? Why? clinical performance?
The clinical instructor provided the academic The student was able to articulate an inability
program with a “final” CPI report and copies to adopt professional behaviors and use
of the safety incident reports (evaluation). them in the clinic (evaluation). After reflect-
These reports contained specific examples ing on performance, the student realized a
of performance areas that were not accept- desire to “be everyone’s friend” and “do what
able. The student went home and was asked the CI wanted.” The student became aware
to take some time to reflect on clinical of personal actions that were an attempt to
performance, examine specific situations, mold behavior to fit what was learned in
and evaluate reasons for the poor perfor- school and what was perceived as being
mance. Based on established grading criteria, desired by the clinic. However, there was a
the CPI’s comments, and input from the CI lack of depth and a lack of what the student
and CCCE, the DCE evaluated the data and termed the necessary “thought processes”
assigned a “fail” grade for this pass/fail for the student to become a competent
course. Options were discussed, and the physical therapist (diagnosis). The student
student expressed a clear desire to become a expressed a desire to succeed and a moti-
competent physical therapist and apply vation to modify performance (prognosis).
effort to remediate the pertinent issues in a When asked to identify ways in which
timely manner. growth might occur in this area, the student
The DCE’s evaluation of the data revealed outlined a remediation plan (intervention)
that similar issues were increasing in inten- that included the following actions:
sity despite faculty-directed attempts to 1. Perform clinical observation of a practic-
improve the student’s performance. It was ing physical therapist. The student felt that
decided that the student needed to take volunteering in a physical therapy clinic
Case 3 11
would allow observation of profession- ting hypothetical treatment sessions. The

alism, communication, and documentation student also agreed to complete a “check-
without the pressure to perform. This out” of mobility skills with a faculty mem-
would help the student identify specific ber, demonstrating skill competency and
behaviors that professionalism entails. safety in transfers, bed mobility, and gait
The student felt that 4 weeks of observa- training. Modification of interventions and
tion could provide the knowledge needed discussion of rationales for treatment
to develop appropriate “thought processes” based on changing patient scenarios would
(a term that the student used repeatedly be included.
when describing the evaluation of perfor- 5. Set clear, measurable objectives for the
mance deficits). next clinical experience. The student set
2. Read a textbook on professional commu- goals for the volunteer observation and for
nications. Based on knowledge of avail- the repeat clinical education experience.
able resources that matched the student’s
needs, the DCE proposed suggested read- What are potential outcomes demonstrating
ings to the student. After reviewing several student competency?
options, Health Professional and Patient
Interaction6 was selected. The student The student completed the remedial plan
was to read this text and incorporate the within the established time frame. The DCE
knowledge gained into the development of examined the student’s content for accuracy
personal thought processes needed to be and development (reexamination) and deter-
a physical therapist. mined the student’s apparent readiness to
3. Perform self-assessment and implement return to the clinic. A repeat affiliation was
the knowledge gained. The student and scheduled at a site that (as requested by the
DCE agreed that there were lessons to be student) was fully aware of the student’s
learned from the failed affiliation. The specific needs. The CI examined the student’s
student needed to identify behaviors that performance and evaluated his competency
had caused problems, articulate what could during the affiliation. At midterm and final
have prevented issues from occurring and CPI assessments, the CI discerned appropriate
discuss how to behave more competently. safety, professionalism, and communication
The student would define in writing 7 the performance. The DCE reexamined this per-
“thought processes” that were needed, formance in the context of previously iden-
identify and group criteria from the CPI and tified issues and awarded a grade of “pass”
the objectives for clinical education under for the affiliation. The student then progressed
each process, and write clinical actions to the fifth and final affiliation with full dis-
that would enhance effectiveness. Student closure to the CI as to the competency areas
reflection on personal professional develop- being emphasized. The student actively sought
ment8 combined with this activity led the feedback from the clinician in specific situa-
student to outline concrete steps that would tions and diligently modified his performance
be used to advance professionalism. to improve competency. At completion of the
4. Provide practical application of the knowl- final affiliation, the student earned positive
edge gained. The student expressed a comments and entry-level performance on
desire to practice new skills before return- all criteria of the CPI. The student went on to
ing to a formal clinical education experi- successfully pass the state licensing boards
ence. Working together, the student and and secure full-time employment as a physical
DCE decided that paper cases and a prac- therapist. In a follow-up interview, the student
tical skill check would be valuable. Paper concluded that taking responsibility for iden-
cases were designed to give the student tifying needs and designing the remediation
practice in designing appropriate interven- activities were effective in altering perform-
tions, setting realistic goals, and documen- ance as a clinician and achieving competency.
REFERENCES 5. Gutman SA, McCreedy P, Heisler P: Student

1. American Physical Therapy Association: Phys- level II fieldwork failure: strategies for inter-
ical therapy clinical performance instruments. vention, Am J Occup Ther 52:143, 1998.
Alexandria, VA: American Physical Therapy 6. Purtilo R, Haddad A: Health professional and
Association, 1998. patient interaction (ed 5), Philadelphia, PA:
2. American Physical Therapy Association: Guide WB Saunders, 1996.
to physical therapist practice, second edition, 7. Hobson E: Encouraging self-assessment writing
Phys Ther 81:1, 2001. as active learning. In Sutherland TE, Bonwell
3. Watson CJ, Barnes CA, Williamson JW: Deter- CC (eds): Using active learning in college
minants of clinical performance in a physical classes: a range of options for faculty, San
therapy program, J Allied Health 29:150, 2000. Francisco: Jossey-Bass, 1996, 45.
4. Hayes K, Huber G, Rogers J, Sanders B: Behav- 8. May WW, Morgan BJ, Lemke JC, Karst GM,
iors that cause clinical instructors to question Stone HL: Model for ability-based assessment
the clinical competence of physical therapist in physical therapy education, J Phys Ther Ed
students, Phys Ther 79:653, 1999. 9:3, 1995.
Case 4
LEARNING OBJECTIVES
1. Identify characteristics in this case that made an intense home exercise
program appropriate.
2. Discuss the benefits of providing therapy in the home environment.
The reader should know that an outpatient power chair for mobility in the community
physical therapist was seeing a 14-year-old and at school. The patient also had a history
female diagnosed with spastic cerebral palsy of asthma and seizures, which were con-
(CP). The patient was being seen once a month trolled with Albuterol p.r.n. and Tegretol.
for 30 minutes. The outpatient physical The patient lives in a single-parent family
therapist was frustrated with a lack of with three younger siblings. The patient’s
improvement/ progress in the patient’s mother is employed and works the second
ambulation. The patient was also being treated shift, and so is unavailable after school to
by a physical therapist at her school, who was assist the patient. In addition, the three
seeing her once a week for 30 minutes. younger siblings interfere with the patient’s
Communication between the two therapists ambulation at home and constitute a poten-
suggested that the patient’s progress in all areas tial safety hazard for ambulation.
of functioning had plateaued over the last year.
The patient, a high school freshman, would like What baseline data were necessary?
to attend her first high school social (a dance)
in approximately 4 weeks. The patient requested SYSTEMS REVIEW/TESTS
that the therapist assist her with improving her AND MEASURES
walking so that she could walk into her first The patient was initially ambulating with large
social at school. The patient and her mother also base quad cane for 10 feet on carpeted sur-
voiced a goal to increase the patient’s ability to faces with minimum to moderate assistance.
ambulate safely within her house. She was ambulating exclusively into/out of
the bathroom and with therapy at school (once
per week). She used a power wheelchair for
Examination the remainder of the day for mobility.
HISTORY Cardiovascular system. Initially, the
The patient was the sole survivor of a twin patient demonstrated a high oxygen saturation
pregnancy, delivered secondary to fetal dis- level (95% to 97%) before, during, and 1 minute
tress at 28 weeks’ gestation via cesarean after ambulating 10 feet. Immediately after
section. She spent 4 months in the neonatal ambulation, the patient demonstrated an
intensive care unit, with history of ventilation, increased breathing rate and breathing effort,
bronchial pulmonary dysplasia, intercranial with a recovery time of 2 to 3 minutes. Her
bleeding (grade IV), and severe feeding prob- heart rate increased from 89 beats per minute
lems. The patient was diagnosed with spastic (bpm) before walking to 167 bpm immedi-
diplegic CP with left hemiplegia by age 3 years. ately after ambulating 10 feet.
She underwent a dorsal rhizotomy at age 6 Musculoskeletal system. The patient
and right hip reconstruction at age 13. Before wore bilateral single-axis molded ankle foot
the right hip reconstruction surgery, the orthoses (AFOs) for medial/lateral instability
patient was a community ambulator with one at her ankle. Range-of-motion (ROM) measure-
forearm crutch; after the surgery, she used a ments were assessed with a goniometer.
13
TA B L E 4 - 1
GONIOMETRIC RANGE OF MOTION MEASURES
PREINTERVENTION POSTINTERVENTION
RANGE OF MOTION LEFT RIGHT LEFT RIGHT
Hip flexion 19° to 131° 24° to 133° 18° to 138° 28° to 142°
Hip extension –19° –24° –18° –24°
Hip abduction 0° to 35° 0° to 17° 0° to 38° 0° to 16°
Hip adduction 0° to 10° 0° to 7° 0° to 10° 0° to 8°
Knee flexion 26° to 110° 17° to 112° 19° to 121° 12° to 131°
Knee extension –26° –17° –19° –12°
Ankle dorsiflexion 0° to 3° 0° to 1° 0° to 6° 0° to 5°
Ankle plantarflexion 0° to 46° 0° to 49° 0° to 46° 0° to 50°
Generally, ROM measurements were limited –23 degrees and maximum hip flexion of
throughout both lower extremities, especially 33 degrees, a maximum knee valgus flexion
at the ends of ROM in most directions. How- of 75 degrees, and a maximum ankle flexion
ever, ROM was not felt to be limiting func- of 62 degrees of eversion and 43 degrees of
tion. Specific pretest ROM data are given in inversion.
Table 4-1. Muscle strength was assessed with The BERG Balance Scale1 was used to
a dynamometer (Nicholas Manual Muscle evaluate initial functional balance skill. The
Tester; Lafayette Instrument Company, North patient’s BERG score was initially 23/56. The
Lafayette, Indiana); pretest values are listed patient did well with sitting items, had prob-
in Table 4-2. Strength was measured three lems with standing items, and was unable to
times, and these measures were averaged. perform single-leg stance activities.
Generally, strength was significantly decreased, Behavioral assessment. The Activity-
with the right lower extremity weaker than Specific Balance Confidence (ABC) Scale2
the left lower extremity. was modified to fit the patient and used to
Neuromuscular system. A pedograph measure her confidence in her ability to
(footprint analysis) and stop-watch were function in her environment. Results of the
used to assess velocity of gait, cadence, initial ABC are reported in Table 4-4.
stride length, right and left step length, and
base of support. The stride length, step What were the primary factors limiting the
length, and base of support values reflect the patient’s ambulation?
average of three steps taken with each leg.
The results of this testing are given in Table
4-3. Generally, cadence and velocity were
Evaluation
greatly reduced, with step length shorter in After the examination and discussion with the
the right lower extremity and a large base of patient and her mother, the therapist deter-
support. mined that the major limitations to returning
In addition to the pedograph, active to household and limited community ambu-
infrared markers were placed on the patient’s lation were:
right lower extremity, and a motion analysis 1. Decreased endurance
system (CODAmpx30; Charnwood Dynamics 2. Decreased strength
Limited, Leicestershire, U.K.) was used to 3. Lack of opportunity to safely practice
determine joint angles in the right lower 4. Decreased confidence
extremity during gait. Initially, the patient 5. Lack of a home exercise/ambulation
demonstrated a maximum hip extension of program.
Case 4 15
TA B L E 4 - 2
DYNAMOMETER MEASURES IN N
IMMEDIATELY 2 WEEKS 4 WEEKS
PREINTERVENTION POSTINTERVENTION POSTINTERVENTION POSTINTERVENTION
STRENGTH (N) LEFT RIGHT LEFT RIGHT LEFT RIGHT LEFT RIGHT
Hip flexion 4.01 1.89 3.41 2.02 6.60 3.73 8.97 6.37
Hip extension 1.41 .53 1.11 .37 2.70 2.13 4.97 3.00
Hip abduction 1.74 .50 2.23 1.79 4.47 3.87 5.80 5.20
Hip adduction 3.94 3.86 5.59 4.68 10.00 9.80 9.90 8.23
Knee extension 1.23 2.52 2.41 2.58 4.43 4.10 4.37 6.20
TA B L E 4 - 3
P E D O G R A P H D ATA
STEP
STRIDE BASE OF
LENGTH (CM)
VELOCITY CADENCE LENGTH SUPPORT
PEDOGRAPH DATA (M/MIN) (STEPS/MIN) (CM) LEFT RIGHT (CM)
Preintervention 15.47 21.46 61.47 41.63 20.42 20.02

Immediately 25.83 22.95 76.78 56.03 21.34 24.23
postintervention
2 weeks 22.09 26.46 72.24 44.60 27.15 23.19
postintervention
4 weeks 26.78 25.66 73.56 52.76 28.23 23.02
postintervention
Normal range Variable 90–120 70–82 35–41 35–41 5–10
What research-based evidence could be

Diagnosis used to develop a plan of care?
Practice Pattern 5C: Impaired Motor Function
and Sensory Integrity Associated with Non- Based on research by Bower et al,3 the ther-
progressive Disorders of the Central Nervous apist planned a short period of intense inter-
System—Congenital Origin or Acquired in vention to promote functional gains in this
Infancy or Childhood.6 patient. She was seen in her home five times
during week 1, three times during week 2, two
times during week 3, and one time during week
Prognosis (including plan 4. The patient was contacted daily, either with
a home visit or via telephone. A home exercise
of care) program was developed to improve the func-
After the examination, the therapist concluded tional and impairment-level problems asso-
that this 14-year-old girl was capable of ciated with ambulation. The patient was given
increasing her ability to ambulate in her an easy-to-read chart with check-off boxes for
home and at school and to ambulate into her each part of the exercise program to help her
first high school social in 4 weeks secondary keep a written record of her progress for the
to high motivation and availability of an month-long intense intervention program.
intense home therapy program over the next Additional check-off charts were provided each
4 weeks. month after the intense intervention phase.
TA B L E 4 - 4
R E S U LT S O F A B C A S S E S S M E N T B O T H P R E A N D P O S T I N T E R V E N T I O N
How confident are you that you will not lose your balance or become Pretest Posttest
unsteady when you …
Walk around the house? 25% 60%
Bend over and pick up an object from the floor? 0% 0%
Reach for a video off a shelf at eye level? 0% 25%
Walk from the front door of your house to a car parked in the driveway? 35% 40%
Get into or out of a car? 60% 75%
Walk in a crowded place where people may bump into you? 0% 10%
Walk outside on the grass or in your yard? 0% 80%
M U S C U L O S K E L E TA L S Y S T E M
Intervention No significant changes in ROM were noted
The patient was seen in her home for a immediately postintervention (see Table 4-1).
program of walking inside and outside of the No changes in ROM were expected, because
house. The home program included pedaling the original ROM was sufficient to allow the
on a foot bike; work on weight shifting in patient to ambulate and this was not a major
standing and functional reaching; stretching focus of the home exercise program. ROM
of hamstrings, hip flexors, and knee exten- was not remeasured at the 2-week and 4-
sors; and strengthening exercises for hip week postintervention follow-ups.
flexion, abduction, and adduction and knee Strength measurement demonstrated an
extension. The home program was designed improvement immediately postintervention;
to take 15 to 20 minutes each day, based on however, these improvements continued and
the work of Schreiber et al.4 In this inter- even increased over the subsequent 4 weeks.
vention, involvement of family members was Changes in strength were found in all muscles
limited due to the mother’s work schedule assessed 4 weeks postintervention.
and the siblings’ young age. Reassessment
was planned for immediately after comple- NEUROMUSCULAR SYSTEM
tion of the intense intervention phase, and Pedograph data demonstrated an increase in
then 2 weeks and 4 weeks postintervention. ambulation velocity, cadence, stride length,
and step length (see Table 4-3). A small increase
in base of support was also demonstrated, but
Reexamination this was thought to be the result of improved
C A R D I OVA S C U L A R S Y S T E M symmetry in the lower extremity (i.e., de-
The patient’s oxygen saturation levels con- creased valgus in the right lower extremity).
tinued to remain above 95% throughout (Normal values are based on those listed in
periods of ambulation. Immediately after Magee’s Orthopedic Physical Assessment.5)
ambulation, the patient demonstrated no Changes in gait were also observed in the
increased breathing rate or increased breath- joints of the right lower extremity during
ing effort, and no recovery time was needed. ambulation. Based on the CODA movement
Heart rate was now 82 to 86 bpm before analysis system, the hip maximum range
ambulating and 91 to 100 bpm after ambu- increased to 42 degrees of flexion and –18
lating for 50 feet. These cardiovascular degrees of extension, maximum knee valgus
improvements, seen immediately postinter- decreased to 45 degrees, and maximum ankle
vention, were maintained the 2-week and motion decreased to 54 degrees of eversion
4-week postintervention reassessments. and 1 degree of inversion.
Case 4 17
The patient’s Berg balance scale score also she was about the improvements that she
increased, to 33/56 immediately postinterven- had made. The patient was given charts to
tion and then to 35/56 at 4 weeks postinter- continue her home exercise program, and
vention. Specifically, improvements were her outpatient therapist continued to follow
observed in the following areas: standing her program and update it as needed.
unsupported, performing transfers, standing
with feet together, reaching forward with
outstretched arms, retrieving an object from
Discussion
the floor, turning to look behind, and turning A home exercise program as an adjunct to
360 degrees. physical therapy intervention is important to
By the end of the first week of interven- optimize functional gains within the natural
tion in the home, the patient was independ- environment. To be effective, an exercise
ent in performing her home exercise program program must be easy to follow and become
except for needing minimum assistance to part of the daily routine. Ideally, successful
secure her feet on the foot bike. In the programs should involve family members to
second week, during one of the home visits, help motivate and guide the child. In this
the patient reported that “I am walking so case, parental involvement was limited by
much straighter and feel so much better the mother’s employment status, and it was
when I walk.” not appropriate to seek sibling assistance. A
limited intense period of physical therapy
BEHAVIORAL ASSESSMENT allowed this patient to become independent
Reassessment with the modified version of in her home exercise program, gave her an
the ABC scale demonstrated the patient’s ability to function in her natural environ-
increase in confidence in such activities as ment, and positively impacted her social
walking around the house, reaching for her interaction with her peers.
videos off her shelf in her room, walking
from her front door to a car in the driveway,
REFERENCES
getting into or out of a car, walking in a
crowded place where she could be bumped, 1. Berg KO, Wood-Dauphinee SL, Williams JI, et
and walking outside in her own yard (see al: Measuring balance in the elderly: prelimi-
Table 4-4). The ABC test was not readmin- nary development of an instrument, Physiother
Can 41:304, 1998.
istered at the 2-week or 4-week postinterven-
2. Powell LE, Myers AM: The activities-specific
tion assessment. balance confidence (ABC) scale, J Gerontol A
Biol Sci Med Sci 50:28, 1995.
Outcome 3. Bower E, McLennan DL, Arney J, Campbell MJ:
A randomized controlled trial of different
The patient improved her ability to ambulate intensities of physiotherapy and different goal-
in her home and at school (although limited setting procedures in 44 children with cerebral
by staff availability to assist and supervise), palsy, Dev Med Child Neurol 50:28, 1996.
and was able to ambulate into her first high 4. Schreiber JM, Effgen SK, Palisano RJ: Effective-
school social. The patient and her peers and ness of parental collaboration on compliance
family were able to share in her success in with a home program, Pediatr Phys Ther 7:59,
1995.
ambulating 90 feet with a quad cane and
5. Magee DJ: Orthopedic physical assessment,
standby assistance into the dance. The social Philadelphia: WB Saunders, 1997.
support experienced by the patient at this 6. American Physical Therapy Association: Guide
school event made a significant impact on to physical therapist practice, second edition,
her confidence. She stated numerous times Phys Ther 81:1, 2001.
how much stronger she felt and how excited
Case 5
LEARNING OBJECTIVES
1. Identify the clinical tests necessary to distinguish the various upper
extremity symptoms that a patient with cervical radiculopathy may
experience.
2. Describe the proper position for the body and equipment during regular
office computer use.
3. Discuss the incidence, prognosis, and typical rehabilitation of a patient
with cervical radiculopathy.
Examination Weakness was also noted in the thenar

muscles.
HISTORY
The patient was a 47-year-old single white SYSTEMS REVIEW
female accountant with a chief complaint of Integumentary system. The patient
right upper extremity symptoms of 4 months’ exhibited decreased sensation to pinprick at
duration. Her symptoms began insidiously as the tip of the right thumb. She did not
a tingling and occasionally burning sensa- complain of any recent bruising or contact
tion over the lateral forearm, hands, and discoloration from the time that symptoms
thumbs. She also complained of a tingling in developed.
the right palm, which began 2 months earlier. Musculoskeletal system
She reported that she began dropping things Gross sym-metry. The patient presented
2 weeks earlier, and this caused her to seek with a marked forward head posture and a
medical attention. prominent angle at the cervical-thoracic (CT)
The forearm and thumb symptoms were junction. The upper extremities were inter-
worse at the end of the day, after prolonged nally rotated, with visible tightness of the
sitting or computer use, or after looking up anterior cervical and both upper trapezius
for more than 5 minutes. The tingling in the muscles. There was poor muscle definition
palms awakened her after 1 hour of sleep of the posterior scapular muscles and slight
and commonly occurred after 30 minutes of atrophy of the right thenar muscles.
computer use. Palpation. Palpation of the cervical spine
The patient’s past medical history included at C5-7 on the right elicited tenderness and
a right radial head fracture at age 21 and a reproduction of right forearm symp-
a rear-end auto collision at age 35. She had toms. Accessory movements of the cervical
no ongoing complaints from either of those spine revealed hypomobility at C1-2, espe-
episodes before the onset of the current cially during right rotation. Spinal segments
symptoms. She reported jogging 3 miles per at C3-5 were assessed as hypermobile, those
day. Cervical radiographs showed moderate at C6-7 could not be assessed because of
degenerative changes at C5-6 bilaterally and irritability of the segment, and those at C7-T3
mild changes at C4-5 and C6-7. Magnetic were found to be hypomobile.
resonance imaging showed osteophyte for- There was increased muscle tightness of
mation in the region of the right C5-6 neural the right cervical paravertebral muscles and
foramen, and an electromyelography study parascapular muscles, especially the sterno-
showed mild sensory loss in the right median cleidomastoid, levator scapulae, and scalenes.
nerve distribution and the lateral forearm. There was generalized tightness bilaterally in
19
the flexor muscles of forearms, identified by particular, the cervical symptoms), which
a “ropelike” feeling. should almost always be considered irrita-
Joint range of motion. Cervical flexion ble until proved otherwise. The nature was
was limited by 50% with no reversal of cer- identified as C6 cervical radiculopathy with
vical lordosis. Cervical extension was full, potential secondary carpal tunnel syndrome,
but no motion occurred below the CT junc- caused by the restricted mobility of the right
tion. There was an increase in right forearm elbow and cervical spine secondary to earlier
symptoms with prolonged cervical extension. injuries.
Side flexion to the right was 75% full range
without an increase in symptoms and side
flexion to the left was 50% of full range but
Diagnosis
eased the symptoms. Cervical rotation to the Physical Therapist Practice Pattern 5H:
right was only 40% of full range, limited by Impaired Motor Function, Peripheral Nerve
increased symptoms in the right forearm. Integrity, and Sensory Integrity Associated
Cervical rotation to the left was 80% of normal With Nonprogressive Disorders of the Spinal
range, and the symptoms in the right forearm Cord.
decreased.
Range of motion of the shoulders and the
left elbow was within normal limits. Flexion Prognosis (including plan
of the right elbow was full, extension was –7
degrees, and pronation and supination were
of care)
both 80 degrees. Bilateral extension of the The prognosis for conservative care of the
wrists was measured at 60 degrees with the cervical radiculopathy in this patient was
fingers flexed and 45 degrees with the fingers considered fair to good, because of motor
extended. changes. The prognosis for surgical laminec-
Strength. Weakness was noted in the tomy/fusion was considered good; however,
abductor (3/5) and extensor (4/5) pollicis surgery would not be considered until con-
brevis muscles of the right thumb. No servative management had been attempted.
other weakness was observed bilaterally. The prognosis for conservative management
Cervical motion was limited by the onset of the carpal tunnel syndrome was consid-
of pain and other symptoms, but strength ered good as long as contributing factors
within the available range was within normal were eliminated or managed and if symp-
limits. toms were caught early. The prognosis for
Neurologic system. There was a dimin- surgical release of the carpal tunnel was
ished brachioradialis reflex on the right considered good.
side compared with the left side. Nerve
tension testing utilizing full tension on the SHORT-TERM GOALS
median nerve pathway reproduced all The patient will:
symptoms. 1. Have less pain and tenderness arising from
Special tests. The Adson’s, military, and the neck by the end of the second week of
hyperabduction tests were negative. Phalen’s treatment.
test and Tinel’s sign were noted as positive. 2. Have decreased tingling sensation in the
forearm and hand by the end of the first
From the foregoing information, how were week of treatment.
the severity, irritability and nature of the 3. Increase the available range of motion in
symptoms rated? the cervical region by the end of the fourth
week of treatment.
The patient’s symptoms were considered of 4. Increase strength in the right upper
moderate severity. The irritability was mod- extremity gradually over the course of the
erate because of radicular symptoms (in treatment sessions.
Case 5 21
LONG-TERM GOALS quadrant (including the upper extremities)

The patient will: alignment, and frequent stretching breaks
1. Regain full range of motion in the cervical during the workday. Exercises for the fore-
region by the end of the eighth week of arm included gentle extrinsic flexor muscle-
treatment. strengthening activities accompanied by
2. Have no lasting altered sensation in the frequent stretching breaks.
right upper extremity 3 months after treat- The patient was also given soft tissue
ment has concluded. mobilization to the right upper quadrant mus-
3. Regain full strength in the right upper cles, especially the scalenes, pectoralis minor,
extremity by the end of the eighth week of sternocleidomastoid, and upper trapezius.
treatment.
4. Develop the knowledge during the first
2 weeks of treatment that will ensure that
Outcome
she avoids situations that will lead to The patient stated that the traction initially
similar symptoms in the future. produced decreased symptoms in the neck
followed by decreased symptoms in the fore-
arm. However, she did report increased symp-
Intervention toms immediately after the traction force was
The patient was given a prescription for a removed. The force was decreased for the
nonsteroidal antiinflammatory drug and subsequent sessions such that the patient felt
referred to physical therapy by her primary symptomatic relief but did not experience
care physician. The physician discussed sur- the posttraction exacerbation. The Maitland
gical intervention with the patient, consisting mobilization techniques produced a reduction
of a decompression laminectomy or a spinal in symptoms in the neck and forearm. The
fusion. Initial treatment of the cervical radicu- patient was very compliant with her home
lopathy began with extensive patient educa- exercise program and took steps at her
tion in sitting posture, computer use with workplace to rearrange her desk and ensure
consideration of both cervical position and proper postural alignment.
hand position, sleeping posture, pillow selec-
tion, avoidance of static positions, and avoid-
ance of the closed-pack position of the right
Reexamination
cervical region. The necessity of attaining The patient was treated three times per week
and maintaining correct posture during work for the first 3 weeks and then two times per
and activities of daily living was reinforced week for the following 3 weeks. The reexami-
throughout the treatment sessions. nation was done 6 weeks after the initial
Cervical traction was used on the first day examination, at which time the patient’s cer-
of treatment, with a very gentle 5 lb of trac- vical spine mobility had improved, with for-
tion applied. Other techniques used to reduce ward flexion now 70% of normal range but
nerve root irritation included Maitland grade still without reversal of the normal lordosis.
I central vertebral pressure techniques directed Cervical extension was full, with some limited
in a posteroanterior direction. These tech- motion at the CT junction. Side flexion to the
niques were applied in 30-second bouts sepa- right was 85% of full range with no increase
rated by 1-minute rest and reevaluation in symptoms, and side flexion to the left was
periods. A total of four bouts were applied. 60% of full range with a slight decrease in
The patient was sent home with a home exer- symptoms. Rotation to the right was 60% of
cise program that included the open-pack normal range with an increase in forearm
position for symptomatic relief, modified symptoms, and rotation to the left was 90%
dorsal glides (McKenzie chin retraction exer- of normal range with an associated decrease
cises) with progression to improved mobility in symptoms. Accessory motion of the cervi-
as tolerated, stretching to correct upper cal spine was normal for the C1-2 segments,
hypermobile for the C3-5 segments, and hypo-

Discharge Summary
mobile for the C6-7 segments, and C7-T3 had This patient was progressing very well with
achieved more normalized motion. treatment up to this point and was educated
Ranges of active elbow flexion and exten- on the need for her to continue with her home
sion were full, and pronation and supination exercise program and to continue attending
were both 85 degrees actively. Wrist exten- the clinic for at least another 4 to 6 visits.
sion was 75 degrees with the fingers flexed The patient was discharged from the clinic
and 60 degrees with the fingers extended. once her maximum pain-free range of motion
The patient exhibited improved sensation was achieved at the cervical spine. Symptoms
to pinprick at the tip of the right thumb, but at the forearm and thumb persisted; however,
weakness (4/5) of the abductor and extensor the patient was advised to continue with her
pollicis brevis muscles persisted. The brachio- exercises and was reviewed every 3 months
radialis reflex was approaching normal, and for the following year.
full pressure on the median nerve pathway
(plus overpressure) reproduced symptoms in
RECOMMENDED READINGS
the right forearm. Tinel’s sign and Phalen’s
test remained positive. Cailliet R: Neck and arm pain (ed 2),
Philadelphia: FA Davis, 1991.
How was the patient’s knowledge of Maitland G, Hengeveld E, Banks K, English K:
Maitland’s vertebral manipulation (ed 6),
workplace ergonomics assessed?
Melbourne, Australia: Butterworth Heinemann,
2001.
Assessment of the patient’s knowledge of American Physical Therapy Association: Guide to
workplace ergonomics includes the following: physical therapist practice, second edition,
1. The patient was seated at a work station Phys Ther 81:1, 2001.
in the clinic.
2. She was asked to state which parts of her
posture were not in an optimal position.
3. She then demonstrated how to adjust that
work station to specifically suit her body
shape and needs.
Case 6
LEARNING OBJECTIVES
1. Define the term “scoliosis” and identify how the curves that occur in the
spinal column are classified.
2. Identify the common postural deviations that occur with idiopathic
scoliosis.
3. Discuss the common management principles utilized with patients with
idiopathic scoliosis.
4. Identify the role of the physical therapist in the management of
idiopathic scoliosis.
crests after the brace was removed. This

Examination redness resolved within 10 minutes of
HISTORY doffing the brace.
The patient, a 12-year-old white female, was Musculoskeletal system
referred to physical therapy by an orthopedic Gross symmetry. No leg length discrep-
specialist with a diagnosis of idiopathic sco- ancy was seen. Observation from the posterior
liosis. The referral requested that an exercise aspect revealed a thoracic curve with right
program be implemented in conjunction with convexity and a lumbar curve with left con-
orthotic management of the spinal curve. The vexity. The curvature was generally well
patient’s pediatrician initially detected the sco- compensated for, but the patient presented
liosis during an annual physical examination. with her head tilted to the right, her left
The presenting curve was measured radio- shoulder lowered, and her left waist fold
graphically as a 33-degree right thoracic (T5- higher. Her right ribs humped posteriorly on
11) curve and a 30-degree left lumbar (T11-L4) forward bending, and she had a more promi-
curve. The patient received a Boston brace 2 nent erector spinae muscle on the right side.
weeks before the initial physical therapy exami- Mildly winging scapulae were also apparent
nation and was advised to wear the brace 23 bilaterally. Observation from the anterior
hours each day. The patient reported some diffi- aspect revealed that the chest wall was more
culty getting used to the brace, due to the initial prominent on the left side.
discomfort associated with wearing it and gen- Palpation. No palpable muscle spasm was
erally feeling self-conscious when wearing it; noted on either side of the spinal column.
however, she also reported “no pain” in her Joint range of motion. The lower extrem-
back after wearing the brace for 2 weeks. ity active range of motion (ROM) was within
The patient was in the seventh grade and normal limits with the exception of tight
participated in gym at school but undertook hamstrings, which produced a popliteal
no other extracurricular activities. She was angle of 145 degrees bilaterally. Active ROM
generally healthy, with no previous significant testing for the trunk identified that forward
history of musculoskeletal injury. She had not flexion was decreased by 50% (i.e., the
started menses at the time of examination. fingertips reaching only the middle of the
thighs), lateral flexion to the right was
SYSTEMS REVIEW decreased by 30% (i.e., the fingertips just
Integumentary system. There was no reaching the knee), and rotation to the left
remarkable findings except for two small was decreased by 30% when compared with
slightly reddened areas noted on both iliac the opposite direction.
23
Strength. In general, the patient’s strength • More prominent erector spinae muscula-
was fair to good, with the following measure- ture on the convex side of the thoracic
ments noted: gross scores of 4/5 for the upper curve.
and lower extremities, 4/5 for the rectus • More prominent chest wall on the concave
abdominus, and 3/5 for the oblique abdomi- side of the thoracic curve.
nals, trunk extensors, and scapular muscles.
Other joints. The patient had no com-
plaints at either the hips or knees, with full
Diagnosis
pain-free ROM available, aside from the specific Physical Therapist Practice Patterns 4A:
signs and symptoms previously identified. Primary Prevention/Risk Reduction for
Special tests. Both the Thomas test and Skeletal Demineralization, and 4B: Impaired
the Ober test were positive bilaterally, although Posture.
no objective measure was taken. The patient
was independent with dressing and all
activities of daily living. She required some Prognosis (including plan
assistance to don the brace but was inde-
pendent with doffing. She was able to walk
of care)
for 10 minutes on the treadmill at 2.5 mph It was anticipated that with time, wearing the
and level grade. Conversational dyspnea brace, and a good home exercise program, the
commenced at 7 minutes with a verbal patient would gradually regain a more normal
report of fatigue. Values for heart rate and alignment of the spinal column without
respiratory rate were as given in Table 6-1. lasting significant complications. The expected
number of visits was between eight and
The patient was well compensated, with a twelve. Initially, the patient was seen for five
right convex thoracic and left convex to six appointments for instruction in the home
lumbar curve. Which asymmetries identified exercise program, which was designed to
were expected for this patient? improve flexibility and strength as well as to
establish an aerobic program. The patient
The following asymmetries were expected: and her parents jointly established a check-
• Shoulder lower on the concave side of the list to document compliance with the exer-
thoracic curve. cise program and brace use. The patient was
• Scapula farther away from the spine on followed up every 3 to 4 months to reevaluate
the concave side of the thoracic curve. and update the exercise program as needed
• Waist folds higher on the concave side of through her growing years.
the lumbar curve.
• Iliac crest higher on the concave side of SHORT-TERM GOALS
the lumbar curve. The patient will:
• Rib hump on the convex side of the 1. Become more accustomed to wearing the
thoracic curve. brace and more accomplished in donning
and doffing the brace independently
during the first week after the brace is
prescribed.
2. Undertake a home exercise program to
TA B L E 6 - 1
prevent disuse atrophy associated with
TA R G E T H E A R T R AT E : 1 5 6 T O 1 6 9
brace wear beginning during the second
RESTING PEAK COOL DOWN week of treatment and continuing while
Heart rate 78 168 84
she attends therapy.
Respiratory 18 36 24
3. Become more physically active while
rate wearing the brace to develop and improve
spinal position.
Case 6 25
LONG-TERM GOALS Outcome

The patient will: Initially, the patient was relatively noncom-
1. Develop increased strength in the trunk pliant with both wearing the brace and
muscles and continue to improve her static performing her exercise program. After some
posture by the end of the eighth week. discussion, the patient admitted that she felt
2. Increase trunk flexibility, trunk muscle very self-conscious wearing the brace and
strength, and endurance associated with had been teased in school when she wore it.
disuse muscle atrophy by the end of the
tenth week. What steps were taken to encourage the
3. Develop sufficient strength to ensure that patient to continue to wear the brace and
improvements in static posture are main- perform the exercise program?
tained during dynamic activity continuous
from the early stages of treatment until The alternative to wearing the brace—
the end of the twelfth week. surgical intervention—was discussed with
4. Gradually decrease her reliance on the both the patient and her parents. They
brace and become more independent, with agreed to try using the brace for at least 6
maintenance of normal spinal curvature months to avoid the surgical route.
beginning by the tenth week and gradually After wearing the brace and performing
working toward independence without her exercises for 3 weeks, the patient stated
the brace by the fifteenth week. that she had experienced some discomfort
when stretching the trunk muscles on the
concave aspect of her curve and also similar
Intervention discomfort when stretching her hamstrings.
Initial treatment comprised passive move- The therapist reviewed the patient’s stretch-
ments of the thoracic and lumbar spinal sec- ing technique and determined that the
tions to assess the possibility for the scoliosis patient was performing her stretching exer-
to resolve and return to a more appropriate cises correctly, but too vigorously. At this
spinal alignment. Once the curve was evalu- point, all of the strengthening exercises in
ated to be completely reversible, the patient the patient’s program were also reviewed
and her parents were educated as to what and any problems were corrected.
constitutes a “normal” spinal position. The
end point of the treatment program was iden-
tified, and a more specific exercise program
Reexamination
was devised to assist the patient in achieving On reexamination after 6 weeks, the patient
her goals. The exercises were designed such complained of some slight discomfort when
that those muscles on the convex aspect of stretching and occasional discomfort from
the curves were contracted to encourage wearing the brace but little else. In terms of
flattening of the concavity on the opposite postural dysfunction, her head no longer
side of the spine while the muscles on the tilted to the right, her left shoulder remained
concave aspect of the curvature were slightly lower, and her left waist fold was
stretched to allow the appropriate movement. now equal to her right waist fold. The right
There were a number of exercises performed rib hump, which occurred posteriorly during
independently by the patient and a number forward bending, remained. The prominent
of exercises performed by the patient with erector spinae muscles were also still visible
her parents’ assistance. Electrical stimu- on the right side. The reddening of the iliac
lation was used on the convex side of the crests was not present; however, there were
curve (at night) to alter the direction of signs of old blister scars.
deformity, decrease pressure on the concave Active ROM remained within normal limits,
side, and allow for more normal vertebral and the tightness noted in the hamstrings
growth. was decreased somewhat, with the popliteal
angles measured at 170 degrees bilaterally. The

Discharge Statement
Thomas and Ober tests were still assessed as Discharge from physical therapy did not
slightly positive bilaterally. ROM of the trunk officially take place; however, after 6 weeks
had improved with forward flexion from a of treatment the patient was given a revised
decrease of 50% to one of 25%; lateral flexion home exercise program, and a return appoint-
to the right improved from a decrease of 30% to ment was scheduled for 6 months from that
one of 15%; and rotation to the left improved date. The patient was advised to adhere to her
from a decrease of 30% to one of 15%. exercise program and to contact the therapist
Strength measures had apparently improved if anything untoward occurred before her
slightly, but not in all areas. The oblique next appointment.
abdominals, trunk extensors and scapular mus-
cles all improved to 4/5, whereas the upper
extremities, lower extremities, and rectus
abdominus remained at 4/5. Calliet R: Scoliosis: diagnosis and management,
The patient was now independent with Philadelphia: FA Davis, 1985.
dressing and activities of daily living, including Campbell SK: Physical therapy for children.
Philadelphia: WB Saunders, 1994.
independent donning and doffing of the brace.
Tachdjian MO: Pediatric orthopedics, vol 3,
Her endurance increased to 20 minutes on the
Philadelphia: WB Saunders, 1990.
treadmill at 2.5 mph on a level grade. Conver- American Physical Therapy Association: Guide to
sational dyspnea commenced at 12 minutes physical therapist practice, second edition,
with report of fatigue. There were no signifi- Phys Ther 81:1, 2001.
cant changes in heart rate or respiratory rate.
Case 7
LEARNING OBJECTIVES
1. Identify pertinent information to support a physical therapy diagnosis of
inefficient/ineffective movement patterns resulting in greater energy
demand to perform tasks.
2. Explore approaches to address energy-conserving devices and movement
patterns.
3. Discuss aerobic activity benefits for those who have fatigue as an
impediment to quality of life.
The reader should know the patient participated had a Kurtzke expanded disability status
in an outpatient education program for people scale (EDSS) score (i.e., disability index) of
with multiple sclerosis (MS) and their stage 2, meaning that she had minimal dis-
significant others. Each participant was ability, with slight weakness or stiffness,
encouraged to bring questions, concerns, and minor gait disturbances, or mild motor dis-
activity goals to the medical team. The team turbances. She was married, lived with a
assessed the patient’s physical capabilities and supportive husband, and had two grown
interests, then formulated an activity program daughters who lived in a neighboring state.
congruent with the patient’s goals and abilities.
According to the Guide for Physical What home modifications may have helped
Therapist Practice,1 the potential functional this patient to conserve her energy and help
limitations or disabilities displayed by patients create a safe environment for her to work
with MS include deconditioning from a cardio- and live in?
vascular, neuromuscular, or musculoskeletal
deficit that could lead to impaired endurance The patient’s house was equipped with an
and progressive loss of function. Neuromuscular office so that she could perform her work
difficulties resulting from this patient’s duties at home without having to go outside.
disorder included difficulty in coordinating She lived in a three-bedroom, two-bathroom,
movement related to gait on home, work, or single-level home. On the outside of the house,
community terrains. This impaired motor there were three steps to both the front and
function and impaired sensory integrity back doors. Handrails were installed on both
impeded the patient’s ability to perform her sets of steps. She was able to go up and
employment duties as a software technician down the steep basement steps, but did so
because her hands were involved, and she only when absolutely necessary.
complained of decreased fine motor skills The patient enjoyed generally good health,
interfering with her ability at the keyboard. although she experienced numbness in her
hands and fatigue that required rest. She
walked around the house without any assis-
Examination tive devices, but used a straight cane or a cane
GENERAL DEMOGRAPHICS with a folding seat for outings. She was able
The patient, a 5-foot, 5-inch, 55-year-old to manage her household with her husband’s
female software technician who weighed 149 help. At times, she had difficulty managing
pounds with a body mass index (BMI) of multiple tasks requiring short-term memory.
24.4, had an 11-year diagnosis of MS (although She participated in physical activity about
her symptoms began 16 years earlier). She three days per week, including stretching for
27
15 minutes and cycling for 10 minutes. In the score on the Tinetti balance assessment was
summer months, she also swam for 1 hour 25/28, indicating a low risk of falls.8
three times a week. The only medications that
she took were Avonex (an interferon used to What modifications may enable someone
slow disease progression),2 Evista (for osteo- with sensory and cognitive loss (problems
porosis prevention),3 and aspirin for preven- with multiprocessing with short-term
tion of heart disease and stroke. memory) to perform their computer
technical support duties at work?
What examination procedures could be
included for a patient with MS at Kurtzke The patient worked as a software consultant
stage 2? from her home office, where she used an
exercise ball as a chair during work. She tried
TESTS AND MEASURES to be as active as possible with cooking,
The patient’s EDSS score was 3.5.4 Testing of cleaning, gardening, and other activities, but
her aerobic capacity on a Schwinn Airdyne she was limited by her energy levels. She
cycle ergometer yielded the results given in learned to pace herself and to sit with proper
Table 7-1. posture. At work, she kept a detailed diary of
Significant weakness was found in right conversations with customers. She stated
shoulder abduction, external rotation, and that others in her position might not need to
elbow flexion (4/5) and in left shoulder flex- do this, but that it helped her focus on one
ion and external rotation (4-/5). In the left problem at a time.
leg, strength was assessed at 4/5 in straight-
knee hip flexion, 4/5 in hip external rotation,
4-/5 in hip extension, and 3/5 in hip extension.
Evaluation
In the right leg, strength was 4/5 in bent-knee The patient presented as a very functional,
hip flexion, hip external rotation, and knee well-adjusted woman with minimal physical
flexion. Strength in trunk flexion was 3/5.6 A dysfunction, although she stated she felt
hip flexion contracture of 5 degrees on the “wobbly” on her feet and thus used a straight
left was also noted.7 cane for balance and reassurance. Her
The patient was hyperreflexic in both lower weight was within a healthy range, and her
extremities and the left upper extremity, but balance and gait skills were good. She had
exhibited no clonus or nystagmus. Her vibra- weakness in her hips and trunk flexors,
tory sense and stereognosis were intact which may have contributed to her feeling of
bilaterally, although blunted on the left side. insecurity while ambulating on level and
On ambulation, the patient exhibited a unlevel surfaces. She had good exercise
forward head, anterior pelvic tilt, and mild tolerance, and was in need of education
ataxia. She was able to walk 25 feet in 6.3 regarding safe levels of aerobic exercise and
seconds (the average of two trials), and her daily activity.
TA B L E 7 - 1
A E R O B I C C A PAC I T Y T E S T I N G
RESTING PEAK COMMENTS
Heart rate 79 142 Resting ECG showed nonspecific ST changes

Blood pressure 144/90 160/92 Test duration: 6 min
Peak RPE 7 (1-10 Borg scale)5
ECG, Electrocardiogram; RPE, rate of perceived exertion.

Case 7 29
Diagnosis • Aerobic: Stationary bike, four to five days

Physical Therapist Practice Patterns 5A: per week at a rating of perceived exertion
Primary Prevention/Risk Reduction for Loss of 3 to 4 (on a scale of 1 to 10), moderate
of Balance and Falling, and 5E: Impaired to somewhat hard for 6 minutes. Include
Motor Function and Sensory Integrity Asso- warm-up and cool down periods. Increase
ciated with Progressive Disorders of the duration by no more than 10% per week,
Central Nervous System. as tolerated, to 20 minutes.
• Balance and coordination: Swiss ball, pool,
or counter exercises, two to three days
Prognosis per week.
Few factors that could prolong the need for • Strength: Abdominal and lower extremity
continued intervention were present in this strengthening exercises, two to three days
case. The patient had a consistently supportive per week.
husband and employer. Her work setting was
adjusted to allow continued employment with- What strategies could be suggested to improve
out interruption resulting from her disorder. the endurance of a patient complaining of
She had no comorbidities, she maintained fatigue after walking with a standard cane
adequate nutrition, and her disorder had not for 3 minutes at a moderate speed?
progressed markedly over the past 11 years.
She enthusiastically embraced the exercise The patient’s cane height was adjusted and
recommendations. the hand position altered for thumb and
wrist safety (Figure 7-1).
Intervention
C O O R D I N AT I O N , Reexamination
C O M M U N I C AT I O N , The patient was given a home exercise
A N D D O C U M E N TAT I O N program and ideas of how to integrate the
As part of a multidisciplinary approach, the suggested activities into her life. She was
patient was given a binder in which to place supplied with a log sheet to fill in as she
lecture notes and exercise recommendations, continued her activities. She was to return
as well as any questions that arose during the the completed sheet with her subjective
class times, to maintain a record of what she comments to have the exercise prescription
learned and to help her review material after modified accordingly.
returning home. The exercise prescription
was practiced throughout the educational
program, and was provided to the patient in
Outcome
both audiotape and written formats on the The patient was very aware of her activities
last day of the program. during the day and stated that she had a hard
time stopping before she became overtired.
Which interventions for decreasing muscle She improved in monitoring her activities
tone are efficacious for patients with MS? (including rest periods and prioritizing tasks)
and was learning to pace herself by keeping
The exercise program included the following a diary of her activities and how she felt. As
activities: she controlled her life better, she found that
• Flexibility: Daily stretching with empha- she had more energy and focused on partici-
sis on the lower back and lower pating in activities that she enjoyed and was
extremities. able to enjoy them even more.
A B
F I G U R E 7 - 1 Hand placement on the cane. A, Correct hand placement. B, Incorrect hand

placement.
REFERENCES 5. Stuifbergen AK: Physical activity and perceived

1. American Physical Therapy Association: Guide health status in persons with multiple scle-
to physical therapist practice, second edition, rosis, J Neurosci Nurs 29:238, 1997.
Phys Ther 81:9, 2001. 6. Kendall FP, McCreary EK: Muscle testing and
2. Rudick RA, Goodkin DE, Jacobs LD, et al: function (ed 3), Baltimore: Williams & Wilkins,
Impact of interferon beta-1a on neurologic 1983.
disability in relapsing multiple sclerosis, 7. Hislop HJ, Montgomery J, Connelly, B: Daniels
Neurology 57(12 Suppl 5):S25, 2001. and Worthingham’s muscle testing: Techniques
3. Barrett-Connor E: Raloxifene: Risks and of manual examination (ed 6), Philadelphia:
benefits, Ann N Y Acad Sci 949:295, 2001. WB Saunders, 1995.
4. Kurtzke J: Rating neurological impairment 8. Berg KO, Maki BE, Williams JI, et al: Clinical
in multiple sclerosis: an expanded disability and laboratory measures of postural balance in
status scale (EDSS), Neurology 33:1444, an elderly population, Arch Phys Med Rehab
1983. 73:1073, 1992.
Case 8
LEARNING OBJECTIVES
1. Classify a patient with Bell’s palsy according to preferred practice
pattern, diagnostic classification, and ICD-9-CM codes.
2. Determine appropriate examination process, including tests and
measures.
3. Evaluate to determine the appropriate diagnosis, prognosis, and
interventions.
The reader should know that the patient was following components: muscle strength,
a 32-year-old male who was otherwise healthy. power, and endurance during functional
On awakening, he noticed drooping of the right activities; electroneuromyography; strength-
corner of his mouth and an inability to duration testing; and reaction to degeneration
completely close his right eye. He later noted an testing.
inability to keep food in the mouth when eating.
Later that day, he visited his physician, who
made the diagnosis of Bell’s palsy. The physician
Examination
prescribed oral corticosteroids for 1 week HISTORY
(with gradual discontinuation during the The patient, a high school English teacher,
second week) and an eye patch and referred the reported several bouts of low back pain in
patient for physical therapy. The patient arrived the past that had resolved with modification
for the first physical therapy visit 1 day after of activities for several days. He reported no
onset with a referral that read “Bell’s palsy— significant health problems. He did not use
right. Evaluate and treat.” tobacco, and he consumed alcohol only
occasionally.
What components should the physical
therapist incorporate into the examination SYSTEMS REVIEW
process (including tests and measures)? The systems review yielded no signs of
undetected health problems.
The referring physician gave the diagnosis as
Bell’s palsy. The physical therapist should TESTS AND MEASURES
complete a patient history and systems review The patient was unable to voluntarily contract
to learn about issues that may influence the any of the muscles innervated by the right
plan of care. For example, a history of cardiac cranial nerve VII. He could not close the
arrhythmias may preclude the use of electric right eye voluntarily, and saliva drooled from
stimulation devices as an intervention. The the right corner of his mouth. The therapist
therapist uses the information obtained from was able to produce strong twitch and
the history and systems review to screen for tetanic contractions in the muscles inner-
undiagnosed problems that may require vated by the right cranial nerve VII using
further evaluation by the referring physician pulsatile current. The stimulation parameters
or other health care practitioner. were biphasic, asymmetric, balanced pulses;
For a patient with Bell’s palsy, the thera- 300 μsec initial negative phase duration and
pist should conduct a detailed examination 1200 μsec positive phase duration; no interval
of facial musculature and cranial nerve VII between phases; 30 Hz and amplitude 1.5 mA
function. This examination might include the (Figure 8-1). Contractions of similar quality
31
What is the expected natural course of

1.5
ma recovery for this patient?
300 ␮s 1200 ␮s Prognosis (including plan

of care)
FIGURE 8 - 1 Biphasic, asymmetric, balanced
pulse. If the patient had sustained a first-degree
injury, then conduction distal to the injury
site would be preserved, and recovery would
be expected within a few weeks of onset. If
and strength could be produced on the left he had sustained a second-degree injury, then
(unaffected) side using the same pulse the prognosis for recovery would remain good.
characteristics. Axon regeneration would be expected to
A 1-cm-diameter handheld electrode was occur at a rate of about 1 to 2 mm per day.1
used to apply current to the seventh cranial Electrodiagnostic testing (i.e., nerve con-
nerve and the involved muscles, and a 10-cm duction velocity testing) may aid in formu-
× 10-cm electrode was applied to the right lating a more accurate prognosis. If Wallerian
arm. The therapist was able to produce twitch degeneration had occurred, then signs of
contractions in the muscles innervated by gradual denervation would become evident
cranial nerve VII bilaterally using direct during the 21-day period after the initial
current. Twitch contractions were observed onset of symptoms. Signs of denervation that
when the cathode was applied to the muscle the therapist could elicit would include
motor points and when the tap-key of the decreasing response to increasing amplitudes
hand-held electrode was closed. of pulsatile current and a slow, wormlike
response to direct current.
Evaluation SHORT-TERM GOALS
The ability to induce tetanic contractions Goals for this patient included restoring
with pulsed current and twitch contractions muscle performance (i.e., strength, power,
with sudden-onset cathodal direct current endurance) and the ability to perform physical
indicated that Wallerian degeneration had not actions, tasks, and activities related to self-
taken place. Because there was no trauma, care.3 The timeline for achieving these goals
and considering the medical diagnosis (Bell’s was 8 weeks. The plan included five visits
palsy), it seemed likely that the patient had during the first week, then reevaluation of
sustained either a first-degree (neurapraxia) visit frequency at the beginning of the second
or second-degree injury to cranial nerve VII.1 week. Based on the identified preferred
Presumably, Bell’s palsy is due to compres- practice pattern, ICD-9-CM code 351.0 was
sion and ischemia of cranial nerve VII as it selected for billing purposes.
courses through the temporal bone. This may
be due to swelling associated with immune
or viral disease.2
Intervention
Pulsatile current, with pulse characteristics
as noted earlier, was used daily for the first
Diagnosis week of treatment. A total of 20 contractions
Physical Therapist Practice Pattern 5D: were elicited in each of the affected muscles.
Impaired Motor Function and Sensory The patient was taught how to perform
Integrity Associated With Nonprogressive massage to the affected muscles and how to
Disorders of the Central Nervous System— attempt voluntary muscle contractions using
Acquired in Adolescence or Adulthood. a mirror for feedback.4 At 1 week after onset,
Case 8 33
obvious signs of denervation were present, with acoustic neuroma excision, and con-
and the therapist added direct current to the cluded that long-term electrical stimulation
treatment regimen. At 3 weeks after onset, may facilitate partial reinnervation. It is
the therapist could no longer elicit contrac- worthwhile to note that stimulation was kept
tions using pulsatile current. Direct current at submotor levels for this study. Jaweed1
was continued, and the patient was instructed has indicated that excessive physical or
in the use of a home stimulator. The patient electrical activity during reinnervation may
returned for reevaluation weekly. have deleterious effects.
Given the ambiguity of the evidence, it
seemed prudent to use motor-level electric
Outcome stimulation in an attempt to maintain muscle
At 4 weeks after onset, contractions of contractibility while denervation, and then
minimal strength could be elicited by maxi- reinnervation occurred. The therapist chose
mum voluntary effort in some of the affected to induce 20 contractions of moderate strength
muscles. During the next three weekly visits, daily, hoping that this regimen would not
the patient exhibited increasingly stronger constitute excessive activity. Massage was
voluntary contractions in increasingly more used to maintain flexibility and perhaps
of the affected muscles. By 8 weeks after increase circulation in the affected muscles.
onset, muscle strength improved to “fair” (i.e., The therapist believed that voluntary effort
complete range of motion against gravity), with mirror feedback served to promote
and electric stimulation was discontinued. muscle reeducation.
The patient was able to consistently close his
right eye and no longer experienced drooling
REFERENCES
from the right corner of his mouth. Because
the goals had been met, physical therapy was 1. Jaweed MM: Peripheral nerve regeneration. In
discontinued. A follow-up visit was scheduled Downey JA et al (eds): The physiological basis
for 6 months after onset. At the 6-month of rehabilitation medicine (ed 2), Boston:
Butterworth-Heinemann, 1994.
follow-up visit, muscle strength had improved
2. Beers M, Berkow R (eds): The Merck manual
to “normal” (i.e., complete range of motion of diagnosis and therapy (ed 17), Whitehouse
against strong pressure). The patient was Station, NJ: Merck & Co, 1999.
satisfied with the outcome and noted no con- 3. American Physical Therapy Association: Guide
tinuing impairments, functional limitations, to physical therapist practice, second edition,
or disabilities. Phys Ther 81:9, 2001.
4. Ross B, Nedzelski JM, McLean A: Efficacy of
feedback training in long-standing facial nerve
Discussion paresis, Laryngoscope 101:744, 1991.
Evidence for the efficacy of electric stimula- 5. Ysunza A, Inigo F, Oritz-Monasterio F, et al:
tion in treating Bell’s palsy is ambiguous. Recovery of congenital facial palsy in patients
with hemifacial mocrosomia subjected to sural
Ysunza et al5 studied the use of electric
to facial nerve grafts is enhanced by electric
stimulation in patients who underwent nerve field stimulation. Arch Med Res 27:7, 1996.
grafting after facial palsy and concluded that 6. Targan RS, Alon G, Kay SL: Effect of long-term
electric stimulation induced improvement. electrical stimulation on motor recovery and
Targan et al6 studied the effect of electric improvement of clinical residuals in patients
stimulation on two groups of patients with with unresolved facial nerve palsy, Otolaryngol
chronic facial nerve palsy, one group with Head Neck Surg 122:246, 2000.
idiopathic Bell’s palsy and the other group
Case 9
LEARNING OBJECTIVES
1. Analyze the importance of a training schedule.
2. Differentiate between a bone scan and a radiograph.
3. Compare the physiological effects produced by aquatic, closed-chain, and
open-chain exercises.
The reader should know that a young woman any heat or ice to the area of injury. She also
arrived at an outpatient facility. As the therapist denied any changes in her menstrual cycle.
reviewed the intake form, it was noted that the
patient was 15 years old, and it was evident
that her parents or coach were not present. Examination and
She reported that a friend drove her to the
appointment. Because parental consent was
Evaluation
required for the therapist to examine and treat Physical examination revealed the following
a minor, the appointment was rescheduled for findings:
the next evening. • Strength MMT: Right quadriceps, 4/5; right
When the parents were present, the therapist adductor and hamstring, 4+/5; right hip
inquired if they had brought a prescription. external rotators, 4/5; right hip abductors,
The patient replied that she did not have one, 3+/5; all of the foregoing for the left side,
that her coach had referred her to the clinic. 5/5.
The patient’s father added that it was extremely • Sensation: Intact to light touch bilateral
important that his daughter be able to return to lower extremities.
competition as soon as possible, because they • Posture: Increased lumbar lordosis, genu
were hopeful that she would receive a college recurvatum.
cross-country scholarship. • Balance: Unilateral stance with eyes open:
The patient reported that her hip pain started right decreased compared with left
about 21⁄2 weeks earlier. She described the pain secondary to pain.
as “sharp” and “shooting,” in the right anterior • Squat test: Patient weight shifted to left
thigh. Initially, it occurred after a few miles of during the flexion component of the squat.
running, but worsened to the point of hurting Single leg squat: right, 20 degrees of knee
when walking or climbing steps. flexion; left, 60 degrees of knee flexion.
The patient reported that cross-country • Gait analysis: Positive Trendelenberg’s
season had started 4 weeks earlier, and that sign, hyperpronation right greater than
she had done no training in the off-season. left at midstance.
The team ran 6 days a week; the runners did • Biomechanical: Right Q-angle 20 degrees,
not stretch before or after running and did no Left Q-angle 18 degrees; leg lengths even;
supplemental weight training. The coach had moderate forefoot varus, R>L; bilateral
them performing walking lunges around the increased external tibia torsion
track at school. She had not recently changed • Arch height: Normal non–weight bearing,
her footwear for running. The team trained on decreased in weight bearing.
a combination of sidewalks and roadways. • Range of motion: Spine and lower
The patient denied any relevant past medical extremity WFL
history except for exercise-induced asthma. • Special tests: Negative Thomas, Faber,
She was taking no medications nor applying and Ober tests.
35
• Lumbar spine: Negative for SLR and abnormal biomechanics and weakness of the
slump test. hip, knee, or ankle musculature. This is a
• Flexibility: Moderate restrictions bilateral sport-specific skill that is needed during the
calf, quadricep, hamstring, and piriformis. shock-absorption phase of running.
• Palpation: No palpable tenderness in the
hip or lumbar spine. What features should the patient’s running
• Running shoes: More than 1 year old, slip shoes have had, based on her foot type?
last, semicurved shoe with worn-out heel
counter. The desired shoe features for a patient who
pronates are a straight last, board construc-
tion, and a strong heel counter with less than
Diagnosis 300 miles of wear.
Physical Therapist Practice Pattern 4E:
Impaired Joint Mobility, Motor Function, What type of progressive intervention
Muscle Performance, and Range of Motion could be used to return this patient to
Associated With Localized Inflammation. cross-country running?
What information did the squat test The early stages concentrated on cross-
provide? training to maintain endurance. This was
accomplished with a bicycle and aqua jogger.
The unilateral squat test demonstrated the Improving lower extremity flexibility was
patient’s ability to eccentrically control knee also important. Non–weight-bearing exercises
flexion (Figure 9-1). It can demonstrate were progressed to weight-bearing strengthen-
A B
F I G U R E 9 - 1 Single-leg squat. A, Front view. B, Side view.

Case 9 37
ing, focusing on the eccentric gluteus medius, What was the goal of increasing the time on
piriformis, quadriceps, and posterior tibialis. the bike or the aqua jogger?
Closed-chain exercises, (e.g., step-downs and
squats) were then progressed to jumping in a The goal of increasing the time on the bike
step-jump-hop progression. Once this was or aqua jogger was to improve and maintain
accomplished, an interval-jogging program the patient’s cardiovascular fitness.
was instituted.
WEEKS 4 TO 7
Physical therapy was continued with a
Intervention non–weight-bearing program, increasing the
WEEK 1 time on the bike and adding a home exercise
The patient was referred to medical imaging; program with an aqua jogger. At the end of
plain film radiographs were negative. The the fourth week, the patient’s pain on walking
patient began her physical therapy treatment resolved.
with a 10-minute warm-up on an exercise
bike, followed by stretching of the piriformis, WEEKS 8 TO 11
quadriceps, hamstring, and calves. Application Weight-bearing exercises were gradually
of ice concluded the treatment. The therapist added, with a slow progression of the
noted a decrease in Trendelenburg’s sign with following: wall sits, step-ups, single-leg
the warm-up, but the patient still reported balance, leg press, BAPS board, closed chain
pain on ambulation. supination/pronation in ankle plantar flex-
ion, lower extremity exercises, step-downs,
WEEK 2 plyo-ball toss, and resisted gait. At the end of
The patient began by continuing with the pre- the eleventh week, Trendelenburg’s sign
vious treatment, then added non–weight- resolved.
bearing strengthening exercises, including four-
way straight-leg raises, prone hamstring curls,
external hip rotation with tubing for resist-
Outcome
ance, and ankle inversion with a theraband. A running analysis revealed a greater amount
The patient reported decreased pain after of pronation than during ambulation. The
exercising, but no change in the symptoms at patient was advised to purchase Spenco
school. She was referred to an orthopedic over-the-counter orthotics. A return to a
physician with a recommendation to use running program was initiated. This includ-
crutches to ambulate and a request for a ed a bike warm-up, stretching, and mini-
bone scan. trampoline jogging every other day,
increasing the time from 5, to 7, to 9, to
What were the advantages of a bone scan 11 minutes.
versus a plain film radiograph in this case? The patient progressed to a treadmill for a
2-minute walk, a 5-minute run, and a 2-minute
The main advantages of a bone scan are the walk. She continued with the walk-run-walk
early detection of and increased sensitivity combination every other day, progressing to
for detecting bone fractures. 5-, 7-, 7-, 10-, 10-, 14-, 14-, 20-, and 20-minute
runs. The patient was discharged at the 10-
WEEK 3 minute run and was to continue the program
The bone scan revealed periostitis of the on her own. At that time, the cross-country
femur. The physician wanted to continue season was over.
physical therapy with a non–weight-bearing
program with increased time on the exercise What was the benefit of having the patient
bike and the addition of a home aquatic exer- jog on the mini-trampoline before running
cise program with the aqua jogger. on the treadmill or sidewalk?
The main benefit of jogging on the mini- Steele PM: Management of acute fractures around
trampoline was the decreased impact forces. the knee, ankle and foot, Clin Fam Pract
In this case the athlete had an overuse injury 2:661, 2000
with weight bearing. Alonso JE, Lee J, Burgess AR et al: The
management of complex orthopedic injuries,
Surg Clin North Am 76:879, 1996.
Why did the therapist wait until the twelfth
Eiff PM, Hatch RL, Walter CL: Fracture
week to start the patient jogging? management for primary care, Philadelphia:
WB Saunders, 1998.
Certain progressive criteria needed to be met Greenspan A: Orthopedic radiology (ed 2), New
before the patient could return to sports York: Raven Press, 1992.
activities. The patient needed to demonstrate Kaufman D, Leung J: Evaluation of the patient
pain-free ambulation, a 45-degree unilateral with extremity trauma: An evidence-based
squat with good biomechanics, and the approach, Emerg Med Clin North Am 17:77, 1999.
ability to perform 25 unilateral heel raises. Shamus E, Shamus J: Sports injury prevention
and rehabilitation, New York: McGraw-Hill,
2001.
O’Kane JW: Anterior hip pain, Am Fam Physician
60:1687, 1999.
Case 10
LEARNING OBJECTIVES
1. Differentiate between work hardening and work conditioning.
2. Compare the different levels of duty and lifting restrictions.
3. Apply biomechanical factors to designing a desk workstation.
4. Define the Occupational Safety and Health Administration (OSHA) and
Americans With Disability Act (ADA) guidelines.
The reader should know that a physical that are causing or likely to cause death or
therapist established a new ergonomic contract physical harm.
with a large electronics production facility. ADA: Main guidelines for developing job
The facility had more than 200 employees with descriptions; requisite skills; essential job func-
many different job descriptions and physical tions, and manner by which job is performed.
demands. Some employees needed to carry After reviewing all of the guidelines, the
boxes, whereas others had desk jobs. therapist performed a job/work risk analysis
The therapist was to develop an injury for one of the stock employees. The work
prevention program, a prescreening program, analysis consisted of analyzing the employee’s
and education classes. In addition, the chief job duties by observing the employee per-
executive officer (CEO) wanted her workstation forming the essential duties of the job func-
assessed. tion. This analysis included, but was not
limited to, posture, biomechanics, forces,
temperature, vibration, repetitions, and pacing.
Diagnosis It was important to also look at the floor,
Guide to Physical Therapist Practice, Proce- equipment, workstation, and office environ-
dural Interventions, p. S108: Functional Train- ment. During the analysis, the therapist
ing in Work (Job/School/Play), Community, and noticed that the employee had to repetitively
Leisure Integration or Reintegration (Includ- lift 40-pound boxes to a height of 4 feet, and
ing Instrumental Activities of Daily Living, that the employee did not have good lifting
Work Hardening, and Work Conditioning). mechanics. The recommendation to the
supervisor was to train the employee in lift-
ing mechanics and also to provide the
Intervention employee with a hydraulic lift.
What were important sources of information This process was repeated for all of the
that the therapist used to help fulfill employees. Adapting the tasks, workstation,
contractual obligations? tools and equipment reduced physical stresses,
which helped decrease musculoskeletal
The physical therapist obtained copies of disorders.
OSHA and ADA guidelines for review. The next step was to design the CEO’s
workstation. The CEO spent most of her day
What was the main component of each sitting behind the desk working on the
guideline? computer.
OSHA: Each employer must furnish employees What were important areas to consider
employment free from recognized hazards when setting up a desk workstation?
39
These areas included seat height, seat back The employee who sustained a back injury
angle, knee and ankle angle, back height and was referred to the therapist for rehabili-
support, elbow alignment, wrist angle, table tation. The referring physician requested
height, knee clearance, keyboard height, physical therapy intervention, specifically
screen height, viewing angle and distance, work-hardening and work-conditioning
keyboard and mouse design, screen glare, programs.
and room lighting. One factor that required
changing was the oversized leather chair. It What is the difference between work
was not suitable for proper body support hardening and work conditioning?
while working on the computer, so a new
ergonomic computer chair was ordered. Work conditioning usually involves one or
two disciplines, comprises primarily exercise
What were the benefits of physical therapy and education, takes 2 to 4 hours per day, and
intervention to the workers and the usually lasts up to 6 weeks. Work hardening
company? is a more complex program that involves at
least several disciplines, uses work simula-
When all of the jobs were analyzed, proper tion as a primary source of treatment in
equipment was obtained, and the setup was conjunction with exercise and education,
corrected, it was time to complete the injury takes 2 to 8 hours per day, and typically lasts
prevention program. All employees received for 6 to 8 weeks. Once the employee com-
education in biomechanics of lifting and pleted the work-conditioning and then the
fitness evaluations of strength, flexibility, work-hardening programs, the employer
and cardiac condition based on their job wanted to know whether the employee was
duties. Individualized programs were estab- ready to return to full duty. To make this deter-
lished. Educational classes were also imple- mination, the therapist decided to perform a
mented for nutrition, walking, flexibility, functional capacity examination (FCE).
body mechanics, and other topics as needed.
Many companies have realized decreased What is an FCE?
medical costs and decreased lost time from
work by implementing various types of The therapist reviewed what was already done
wellness programs. via the work-hardening/work-conditioning
Before the therapist secured the contract programs. Next, the therapist compared the
with the company, one employee working in employee’s physical abilities with the physical
the packaging area sustained a back injury demands of the job as specified by the U.S.
and was placed on light duty. Department of Labor in the U.S. Department
of Transportation (DOT). The FCE was then
What are the different levels of duty and performed using visual and objective measure-
lifting restrictions? ments, as well as physiological measurements
of heart rate and blood pressure. Some of the
According to the Department of Labor and categories performed during the FCE were
the Social Security Administration, all jobs lift, carry, push/pull, elevated work, lowered
fit into one of five levels of exertion: seden- or forward work, unweighted rotation, crawl,
tary work, light work, medium work, heavy kneel, sustained crouch, repetitive squat, stair
work, or very heavy work. Jobs are also clas- ambulation, balance and stabilization, sitting,
sified into one of three skill levels: unskilled, and upper extremity coordination. The em-
semiskilled, and skilled. The National ployee’s self-reported assessments (e.g., pain,
Institute for Occupational Safety and Health fatigue) were also obtained. It is important to
has published guidelines for ergonomic remember that prevention of injury to the
manual lifting. employee (i.e., safety) was the first concern.
Case 10 41
Outcome Association for Worksite Health Promotion, US

Department of Health and Human Services,
The employee was able to perform all of her William M. Mercer, Inc: 1999 national worksite
job duties without complaints and with health promotion survey, Northbrook, Illinois:
proper body mechanics. She returned to full- Association for Worksite Health Promotion
time duty without restrictions. and William M. Mercer, Inc, 2000.
Woo M, Yap AK, Oh TG, Long FY: The relationship
between stress and absenteeism, Singapore
RECOMMENDED READINGS Med J 40:1, 1999.
U.S. Department of Labor, Bureau of Labor Lechner L, deVries H, Adriaansen S, Drabbels L:
Statistics: News release: Lost work-time injuries Effects of an employee fitness program on
and illnesses; characteristics and resulting time reduced absenteeism, J Occup Environ Med
away from work, 1998. April 20, 2000. 39:827, 1997.
National Institute for Occupational Safety and Mobley EM, Linz DH, Shukla R, et al: Disability
Health: Work practices guide for manual case management: an impact assessment in an
lifting (pub 81-122), Cincinnati, Ohio: US automotive manufacturing organization,
Public Health Service, 1981. J Occup Environ Med 42:597, 2000.
Bunn III W: Health, safety, and productivity in a Rubens AJ, Oleckno WA, Papaeliou L: Estab-
manufacturing environment, J Occup Environ lishing guidelines for the identification of
Med 43:47, 2001. occupational injuries: a systematic appraisal, J
King PM: A critical review of functional capacity Occup Environ Med 37:151, 1995.
evaluations, Phys Ther 78:852, 1998. Wyman DO: Evaluating patients for return to
Harten JA: Functional capacity evaluation, Occup work, Am Fam Physician 59:844, 1999.
Med 13:209, 1998. US Department of Labor, Bureau of Labor
Isernhagen SJ: Work injury, Gaithersburg, Statistics: Workplace injuries and illnesses in
Maryland: Aspen, 1988. 1995 (pub 97-76), Washington, DC: US
Towers Perrin: Regaining control of workers’ Government Printing Office, 1997.
compensation costs: the second biennial National Safety Council: Accident facts, Itasca,
Towers Perrin survey report, New York: Illinois: National Safety Council, 1997.
Towers Perrin, 1994. Schibanoff J (ed): Workers’ compensation: health
care management guidelines, vol 7,
Washington, DC: Milliman and Robertson,
1998.
Case 11
LEARNING OBJECTIVES
1. Analyze the role of the sesamoid and flexor hallicus longus (FHL)
muscles.
2. Analyze the progression of return to sport activities.
3. Explain the biomechanical role of the foot intrinsic muscles.
The reader should know that a 19-year-old male

college football player presented with complaints
of pain in the right great toe with walking.
He had stopped playing football a year earlier
because of the inability to run and cut. Sesamoid
He remembered injuring the toe last football bones
season but did not receive any formal treatment
at that time. He applied ice for a few days and
had hoped the pain would go away once football
season was over. Football practice was scheduled
to restart in 1 month, and he was frustrated
that the right great toe pain persisted.
The patient denied any previous lower
extremity injuries, and there was nothing
significant in the past medical history. He had
recently visited a podiatrist, who examined the
foot. Radiographs were negative for fracture
of bipartite sesamoids. The patient was referred
to physical therapy with a diagnosis of
sesamoiditis. The physician was optimistic
that no surgery would be required. The patient
was not taking any medication currently.
F I G U R E 1 1 - 1 Bipartite sesamoid.
What are the roles of the sesamoid bones?
The sesamoids act as mechanical “pulleys” to A radiograph will not always detect a frac-
allow for force generation. They allow for ture. Depending on the view and osteoblast
distribution of force and provide a mechanical calcification, a bone scan may be more
advantage. Another example of a sesamoid is effective.
the patella.
What is a bipartite sesamoid?

Examination and Evaluation
PA S S I V E R A N G E O F M O T I O N
A sesamoid is called bipartite if the bone did Mobility testing (Table 11-1) revealed capsular
not completely ossify and there can be two tightness in the first metacarpophalangeal
pieces instead of one (Figure 11-1). joint (MPJ) and decreased sesamoid mobility
along with decreased flexibility in ham-
Will a radiograph always detect a fracture? strings and piriformis bilaterally, and the
43
sion (30 repetitions), towel crunches with a

TA B L E 1 1 - 1
2-pound weight, and isometric first MPJ
M O B I L I T Y / S T R E N G T H D ATA
flexion (10 × 10 seconds), with no flexion of
DEGREES R L the interphalangeal joint permitted. Ankle
Dorsiflexion 3 12 eversion strengthening was progressed to
Plantarflexion 50 50 theraband therapy. Proprioception exercises
First MPJ extension 35 85 included single-leg balance with eyes closed,
MANUAL MUSCLE TEST gait training for extension and first meta-
tarsal stabilization, and resisted gait in all
R L planes with single-leg balance at the end posi-
DF 5 5 tion. After exercise, ice and electric stimu-
INV 5 5 lation were used to decrease pain and inflam-
EV 4+ 5 mation.
First MPJ extension 4+ 5
As range of motion and strength were
Hip and knee 5 5
restored, the patient was progressed to sport-
MPJ, Metacarpophalangeal joint. specific running and agility drills.
right gastrocnemius. Gait analysis revealed

decreased heel raise and push off on the
Outcome
right foot. The patient had an excellent outcome. He
Single-leg balance on the right extremity was able to increase his 40-yard dash time by
was 30 seconds with the patient’s eyes open 4/10 of a second and return to playing foot-
and 3 seconds with the eyes closed. Arch ball. The patient continues with ongoing intrin-
heights, both weight bearing and non-weight sic stabilization and strengthening of the FHL
bearing, were normal. muscle.
Diagnosis REFERENCES
Guide to Physical Therapist Practice Pattern 1. Adelaar RS: Disorders of the great toe.
4E: Impaired Joint Mobility, Motor Function, Rosemont, Illinois: American Academy of
Muscle Performance, and Range of Motion Orthopedic Surgeons, 1997.
Associated With Localized Inflammation. 2. Aper RL, Saltzman CL, Brown TD: The effect
of hallux sesamoid excision on the flexor
hallucis longus moment arm, Clin Orthop
Intervention 325:209, 1996.
3. Aper RL, Saltzman CL, Brown TD: The effect
The patient began with 7 minutes on the exer- of hallux sesamoid resection on the effective
cise bike to begin to increase blood flow and moment of the flexor hallucis brevis, Foot
pliability of the musculature and soft tissue. Ankle Int 15:462, 1994.
This was followed by bilateral stretching of 4. Aseyo D, Nathan H: Hallux sesamoid bones:
the calf, hamstring, and piriformis muscles anatomical observations with special reference
for 3 × 30 seconds. Pulsed ultrasound was to osteoarthritis and hallux valgus, Int Orthop
applied to the plantar aspect of the great toe, 8:67, 1984.
followed by first MPJ Maitland mobilization 5. Baechle TR (ed): Essentials of strength train-
ing and conditioning, ed 2, Champaign, Illinois,
grade III and IV dorsal glides/distraction and
2001, Human Kinetics.
sesamoid grade III mobilization superior and 6. Battista J: Pro football Testaverde may start
inferior to decrease pain and inflammation against Giants despite toe injury. New York
and increase A/PROM, joint mobility, and Times August, 17:1, 2000.
flexibility. As A/PROM increased, neuromus- 7. Boissonnault W, Donatelli R: The influence of
cular retraining and strengthening was initi- hallux extension on the foot during ambula-
ated, with seated heel raises for toe exten- tion, J Orthop Sports Phys Ther 5:240, 1984.
Case 11 45
8. Camasta CA: Hallux limitus and hallux rigidus: 14. Coker TP, Arnold JA. Weber DL: Traumatic
clinical examination, radiographic findings lesions of the metatarsophalangeal joint of
and natural history, Clin Podiatr Med Surg the great toe in athletes, Am J Sports Med
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Instant Ebooks Textbook Clinical Cases in Physical Therapy 2nd Edition Mark A. Brimer PHD PT Download All Chapters

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Physical Therapy of the Shoulder 5th Edition Clinics in

Expertise in Physical Therapy Practice Second Edition

Clinical Management Notes and Case Histories in

Neurologic Interventions for Physical Therapy 2nd

DNA Repair in Cancer Therapy Molecular Targets and

Physical Therapy of the Shoulder 4th Edition Clinics in

Management in physical therapy practices 2nd Edition

Core Clinical Cases in Psychiatry A problem solving

The Curtis Center

CLINICAL CASES IN PHYSICAL THERAPY, 2ND EDITION 0-7506-7394-X

Previous edition copyrighted 1995

International Standard Book Number 0-7506-7394-X

Senior Acquisitions Editor: Marion Waldman

Printed in the United States of America

Michael B. Ashley, PT Laurie Brogan, MSPT

Angela M. Baeten, PT Kathleen M. Buccieri, PT, MS, PCS

Jennifer Holmes, MSPT Holly Leaman, MSPT

Marianne Janssen, PT, EdD, ATC Diane E. Madras, PT, PhD

Timothy L. Kauffman, PT, PhD Robert Marsico, PT, EdD

Amy S. Lambert, MSPT

Gerri M. Misunas, MSPT Steven D. Pheasant, PT, PhD

Amy L. Szumski, MSPT John Wojnarski, MSPT

Gary Tomalis, MSPT Loraine D. Zelna, MSRT (R)(MR)(ARRT)

2. Independent ambulation with assistive History information could be obtained by

How should a physical therapist proceed?

to the buttocks and area of piriformis and

would allow observation of profession- ting hypothetical treatment sessions. The

REFERENCES 5. Gutman SA, McCreedy P, Heisler P: Student

Preintervention 15.47 21.46 61.47 41.63 20.42 20.02

What research-based evidence could be

Examination Weakness was also noted in the thenar

LONG-TERM GOALS quadrant (including the upper extremities)

hypermobile for the C3-5 segments, and hypo-

crests after the brace was removed. This

LONG-TERM GOALS Outcome

angles measured at 170 degrees bilaterally. The

Heart rate 79 142 Resting ECG showed nonspecific ST changes

ECG, Electrocardiogram; RPE, rate of perceived exertion.

Diagnosis • Aerobic: Stationary bike, four to five days

F I G U R E 7 - 1 Hand placement on the cane. A, Correct hand placement. B, Incorrect hand

REFERENCES 5. Stuifbergen AK: Physical activity and perceived

What is the expected natural course of

300 ␮s 1200 ␮s Prognosis (including plan

F I G U R E 9 - 1 Single-leg squat. A, Front view. B, Side view.

Outcome Association for Worksite Health Promotion, US

The reader should know that a 19-year-old male

What is a bipartite sesamoid?

sion (30 repetitions), towel crunches with a

right gastrocnemius. Gait analysis revealed

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