Interventions for outpatient ortho clinical

[ptnerd346]

I recently started my final clinical rotation at a small OP clinic. This is my final clinical, but it's my first in a traditional ortho OP setting (others were at a school for kids with developmental disabilities and acute inpatient). The sheer amount of information to review to prepare for each pt interaction can be a little overwhelming, but the thing I'm struggling the most with is coming up with good exercises to do with pts. Especially beyond a few simple ones that only target one or two muscles.

My CI expects me to have this knowledge already, and told me to review my notes from classes for intervention ideas. However, all of my class notes basically just say "strengthen this, stretch that, work balance, add return to sport activities, etc." nothing specific as far as how to actually achieve those things. I feel like I'm struggling with the rest of my interactions because I'm always stressing that I can't come up with any exercises. I'm not completely clueless, but I would like to make some solid lists to pull from on demand, to save face when I'm blanking. Does anyone have any good resources they can recommend for specific exercise interventions?

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[Bluecase]

Knowledge of anatomy and biomechanics. All you need- you'll be a better clinician using those two things than any book or someone listing some off


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[jjjDPT]

Therapeutic Exercise by Kisner and Colby. This textbook is widely used in ortho education and practice.

 

[jjjDPT]

Knowledge of anatomy and biomechanics. All you need- you'll be a better clinician using those two things than any book or someone listing some off


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Yes, very important. Although the wheel doesn't need to be reinvented 20x a day.

 

[Bluecase]

True- but I'm sure after a few weeks in outpatient ortho you can get to know bridges, squats, etc.... The fun part is being creative. Makes it so we're not robofs


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[jjjDPT]

True- but I'm sure after a few weeks in outpatient ortho you can get to know bridges, squats, etc.... The fun part is being creative. Makes it so we're not robofs


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True

 

[truthseeker]

simulate things that they want to do. squats like a linebacker not like a catcher giving signals, weightshifts in frontal and transverse planes, multi-directional lunges. single leg stance without, then with challenges in all planes. We get better at what we practice, plus it works muscle groups and systems like they need to operate in real life. works on strengthening and smartening the system at the same time which keeps the amount of time your patient's will have to commit to their HEP to a minimum thus enhancing compliance.

 

[summerX]

For most diagnoses you can stretch and strengthen around the joint that is involved. For low back also stretch the legs and give 4 way hip/squat exercises if some LE weakness. Same with neck--- stretch and then strengthen with isometrics and If arms are weak then stretch and strengthen them. If it's an overuse type injury (for example tendinitis) then don't strengthen too much or with heavy weights right away. Active assisted exercises if strengthening can't be tolerated. You can always fill in time with hot pack, massage, etc. I would memorize a handful of stretches and strengthening for each joint if I were you... Many clinicians will stretch even if the muscles aren't too tight ( the pts have to stay a certain length of time). Also memorize 3-4 balance activities. Protocols can always be used for surgical pts. Hope this helps... You could always use youtube/google/textbooks. I am sure u can pick out some useful info.

 

[jesspt]

You can always fill in time with hot pack, massage, etc.

Many clinicians will stretch even if the muscles aren't too tight ( the pts have to stay a certain length of time)

I wonder why some other health professions think we add no value?

 

[DPT_powelift]

For most diagnoses you can stretch and strengthen around the joint that is involved. For low back also stretch the legs and give 4 way hip/squat exercises if some LE weakness. Same with neck--- stretch and then strengthen with isometrics and If arms are weak then stretch and strengthen them. If it's an overuse type injury (for example tendinitis) then don't strengthen too much or with heavy weights right away. Active assisted exercises if strengthening can't be tolerated. You can always fill in time with hot pack, massage, etc. I would memorize a handful of stretches and strengthening for each joint if I were you... Many clinicians will stretch even if the muscles aren't too tight ( the pts have to stay a certain length of time). Also memorize 3-4 balance activities. Protocols can always be used for surgical pts. Hope this helps... You could always use youtube/google/textbooks. I am sure u can pick out some useful info.

A therapist who uses hot pack and massage to just fill in the time is a therapist we don't need in our profession. I wont beat around the bush here, I saw your other thread about wanting a career change and after reading your recommendations to this student, i'm happy you have chosen to switch careers.

Asking a future doctor of physical therapy to memorize a few of balance activities is irresponsible.. also saying that for most diagnoses you can simply stretch and strengthen is exactly why our profession is thought of by the masses as khaki pants/polo technicians who simple stretch and strengthen everything under the sun. For every person you think you need to "stretch" there likely another similar diagnoses that doesn't need any stretching at all, this is skilled pt service not technical work.


I wish there was a way to make sure "experienced" PT's with this sort of mentality could never be CI to a student like myself.

sign DPT student

 

[summerX]

Lol take a deep breath... I can tell you are a student. I am trying to help the student. The reason his notes are saying stretch/strengthen/return to sport ( functional activities) is because this is the focus of outpatient. He says he can only think of a couple exercises for each jt so he should memorize more. Same with balance exercises... He needs to memorize some. If he can't keep the pts for a certain length of time in the clinic his CI will probably fail him or be frustrated with him and outpatient clinics won't keep you. I have worked in outpatient for 5 yrs, have my ocs, and have been offered jobs teaching classes in physical therapy programs. I believe this is a good place for him to start. I also believe that as therapists we shouldn't be afraid of trying new fields. We can grow in these fields and help people in other fields as well.

 

[jesspt]

Lol take a deep breath... I can tell you are a student. I am trying to help the student. The reason his notes are saying stretch/strengthen/return to sport ( functional activities) is because this is the focus of outpatient. He says he can only think of a couple exercises for each jt so he should memorize more. Same with balance exercises... He needs to memorize some. If he can't keep the pts for a certain length of time in the clinic his CI will probably fail him or be frustrated with him and outpatient clinics won't keep you. I have worked in outpatient for 5 yrs, have my ocs, and have been offered jobs teaching classes in physical therapy programs. I believe this is a good place for him to start. I also believe that as therapists we shouldn't be afraid of trying new fields. We can grow in these fields and help people in other fields as well.

ACCE: So, what's your justification for failing the student?
CI: Well, he doesn't keep the patient in the clinic long enough, so my employer can't charge as many units per visit as they would like. I recommended that they take up time with hot pack or massage, or possibly stretch muscles that don't need it.
ACCE: That sounds like you want to bill for non-skilled care, also known as fraud.
CI: Uh.....so can I still fail the student?

 

[callmecrazy]

Lol take a deep breath... I can tell you are a student. I am trying to help the student. The reason his notes are saying stretch/strengthen/return to sport ( functional activities) is because this is the focus of outpatient. He says he can only think of a couple exercises for each jt so he should memorize more. Same with balance exercises... He needs to memorize some. If he can't keep the pts for a certain length of time in the clinic his CI will probably fail him or be frustrated with him and outpatient clinics won't keep you. I have worked in outpatient for 5 yrs, have my ocs, and have been offered jobs teaching classes in physical therapy programs. I believe this is a good place for him to start. I also believe that as therapists we shouldn't be afraid of trying new fields. We can grow in these fields and help people in other fields as well.

Your attempt at justification is no better than your previous response. Recommending hot packs, massage, and stretching just to fill time is just bad advice. It's irresponsible, to say the least. Recommending a student do anything without a direct line of clinical reasoning and evidence is not helpful. There is just so much wrong with all of this.

As for the OP, here's my suggestion. Sit down with your CI and discuss planning a day ahead. You'll be able to establish a well thought plan much better ahead of time/overnight/without your CI and patient staring at you than you will in the moment. Then come in with a Plan A, B, and C so you're not stuck when something just doesn't work. Also, remember that you don't have to recreate the wheel every visit. Your plan should have a logical progression from the previous session with only strategic changes (i.e. Discontinue or add interventions with purpose, add reps/weight/etc methodically, etc). It doesn't need to be all new all the time. If your facility doesn't use a documentation system that gives a clear visual of this, you may want to initiate a sort of chart or flow sheet for your own planning purposes. With specific challenges, don't be afraid to ask classmates or other PTs for ideas either. It shows initiative and it's not like anyone keeps their methods a secret. Lastly, the more experience you get, the more you'll start to make connections, see patterns, and build your "toolbox". Good luck.

 

[Azimuthal]

For most diagnoses you can stretch and strengthen around the joint that is involved. For low back also stretch the legs and give 4 way hip/squat exercises if some LE weakness. Same with neck--- stretch and then strengthen with isometrics and If arms are weak then stretch and strengthen them. If it's an overuse type injury (for example tendinitis) then don't strengthen too much or with heavy weights right away. Active assisted exercises if strengthening can't be tolerated. You can always fill in time with hot pack, massage, etc. I would memorize a handful of stretches and strengthening for each joint if I were you... Many clinicians will stretch even if the muscles aren't too tight ( the pts have to stay a certain length of time). Also memorize 3-4 balance activities. Protocols can always be used for surgical pts. Hope this helps... You could always use youtube/google/textbooks. I am sure u can pick out some useful info.

Yeah...OP don't get in this mindset. In fact, pretend the post above never happened.

 

[PTMattI]

Your knowledge of TE will come with experience I think...observe other PTs, read various blogs, check out this site: https://www.hep2go.com/

But ultimately remember to make sure that the interventions you choose target an impairment that your patient has which is related to their functional limitation. And whatever you do, try not to fall into the trap of just picking exercises to "fill time" that can certainly be an easy trap to fall into in a busy OP ortho, but that is not good PT.

 

[noyceguy]

Your knowledge of TE will come with experience I think...observe other PTs, read various blogs, check out this site: https://www.hep2go.com/

But ultimately remember to make sure that the interventions you choose target an impairment that your patient has which is related to their functional limitation. And whatever you do, try not to fall into the trap of just picking exercises to "fill time" that can certainly be an easy trap to fall into in a busy OP ortho, but that is not good PT.

So one way to look at TE is to apply some general exercises and then some individualized exercises. For example for a stiffness dominant shoulder patient you could spend a unit with high rep low load sidelying flexion/abduction/scaption to available end range, then some light band work for chest and shoulder pressing, then some rowing. This serves to warm the patient up, increases endurance, lets you assess pain and neuromm. control, etc. Then follow with a unit of more specific ther ex targeting the impairments you found in the eval...prolonged stretching, some heavier resistance training, maybe some mobs with movement, contract/relax, etc...whatever this particular patients needs. There are many ways to approach ther ex, but in general I like to operate by the thought that there are some exercises every one needs and then some this patient in particular needs.

 

[DesertPT]

You can always fill in time with hot pack, massage, etc....

Many clinicians will stretch even if the muscles aren't too tight ( the pts have to stay a certain length of time)....

memorize 3-4 balance activities....

Protocols can always be used for surgical pts....

This list of sage pieces of wisdom reminded me of another great list I saw recently

http://physicaltherapyfitnessandnut...16/01/dinosaurs-in-physical-therapy-will.html

 

[DPT_powelift]

probably a good person, who meant well, but is to far into the dinosaur practice.

 

[NJ DPT HOPEFUL]

I'm not starting PT school until the end of May, so take my advice with a grain of salt.

I currently work as an exercise physiologist, and it seems like your problem is more with exercise prescription than with anatomy/biomechanics. You seem to know that you need to stretch/strengthen and why but just simple don't know enough exercises. i'd recommend an exercise prescription text as that will show you many ways of how too stretch and strengthen.

Also using a hot pack to waste time? that's a real shame. Don't do that, you (and hopefully most therapists) are better than that.

 

[jesspt]

probably a good person, who meant well, but is to far into the dinosaur practice.

They've been practicing for all of 5 years. Aren't they a bit young to be a dinosaur? Also, they haven't returned. Wouldn't they, if they had anything of substance to support their position?

 

[josierita]

What worked for me during clinicals was to look at my CIs exercise plans for patients with similar diagnoses as well as other therapists' exercise plans for patients with similar diagnoses. If I had any questions I would ask the PT what the rationale was, why they used it instead of x,y,z exercises, have them teach me the technique and appropriate cueing etc. That way I could cherry pick the exercises I felt I was comfortable teaching and made sense to me and then pare down what I thought was most effective/applicable for each patient. I always tried to spend a week or two during a clinical working with other therapists for this exact reason because your CI may not/will not treat exactly the way you do so it gives you a chance to come up with your own style. A good CI will let you change up what you want as long as you can back it up and have a good rationale for what you're doing.