Week 11: Twin Cities Orthopedics

August 12th, 2013

Laura Ettlin ’14 Mansfield Foundation Fellow in Physical Therapy

During my final week at Twin Cities Orthopedics I was able to pull together all the odds and ends pieces of information for my project on knee replacements as well as test my knowledge. Over the past 3 months I was able to bond with several patients and this week they became my testing material. The physical therapists quizzed me on my knowledge of anatomy, physiology, biomechanics and physical therapy massage techniques. This week I was able to take a few measurements of swelling with a tape measure and joint flexion and extension with a goniometer. Day after day I had seen the physical therapists use a goniometer and take measurements of knee flexion and extension, so I knew “how” to use the device, but I was able to really use the skill and take a few measurements.

Additionally this week, I was able to review the video analysis of several patients from the weeks prior. Using the Dartfish technology, angles and lines were drawn on the patients legs to analyze biomechanics and technique. My supervisor informed me what we were looking for, what is expected and what the outcome indicates. Next we discussed where the patient had muscle weaknesses or imbalances and what type of exercises would be prescribed to help avoid injury.

After speaking with a physical therapist, who is also a fellow runner, I learned a little about running shoes and why people of a certain foot type may benefit from a specific shoe type. For example, a patient with achilles tendon soreness would benefit from a shoe with a high heel raise rather than low drop because it reduces the stain and stretch on the tendon. This physical therapist works part-time at a running store and offers injury prevention advise related to footwear. Of course, every patient and runner is different, however I was able to learn some of the basics. This was a very neat learning experience for me to connect my academic interest of physical therapy with my personal hobby of running.

By the end of this week I felt I had learned more than any other week. I thoroughly enjoyed my time at Twin Cities Orthopedics and greatly benefited from the experience.

Week 10: Twin Cities Orthopedics

August 7th, 2013

Laura Ettlin ’14 Mansfield Foundation Fellow in Physical Therapy

As I wrap up some of my experiences at Twin Cities Orthopedics, I took the opportunity to follow my supervisor and observed him work with patients at injury prevention. There were several methods by which he tests a patient to determine where they may be at risk for injury and then prescribes the exercise program he designed to help them prevent those injuries. One of the unique and time consuming strategies is to use slow motion video analysis of biomechanics to pinpoint imbalances or weakness which could put a person at risk for injury.

The patient is tested in various jumping, balance and strength exercises where the technique informs the physical therapist about muscle imbalances and places for the patient to improve. One major example of muscle weakness that puts a contact athlete at risk is a simple box squat and slow motion stair steps. Many people are unexpectantly weak in their hips and gluteus muscles. This weakness is easy to identify when a patient is walking down stairs or walking up stairs backwards. The clue is in the medial movement of the knees and a dip in the level of the hips. After as few months working with and observing knee replacement patients, I have learned to notice this gait imbalance and recognize which exercises are necessary to increase hip strength.

The purpose of the slow motion cameras is to identify this muscles imbalances before it becomes obvious to the human eye in real time. When caught early enough, certain injuries such as ACL tears could potentially be prevented.

These last few weeks have been very intriguing to see the rehabilitation for athletes after they regain daily function. Working with the younger popular switches up the routine and allows the physical therapists to use different skills and knowledge they acquired in school.

Week 9: Twin Cities Orthopedics

July 27th, 2013

Laura Ettlin ’14 Mansfield Foundation Fellow in Physical Therapy

Twin Cities Orthopedics Physical Therapy has many patients who come and go with therapy once they have met the goals of their rehabilitation. These patients vary in age from young teen athletes to elderly who are living with arthritis. However, due to insurance coverage some patients are no longer able to afford therapy even though they still require the exercise program. For many young athletes, insurance will cover therapy until the patient meets the basic goals of walking without assistance, regain balance, and are able to climb stairs. Once these goals are met, the patient is still not ready to return to daily physical activity. Twin Cities Physical Therapy created a program called ACE which helps athletes transition from rehab to competitive training. This week I learned what this program entails and how the programs benefits the patients.

The ACE program focuses on balance, stability, and strength. Patients are initially tested with balance, jump and strengthening tests typically comparing the surgical from non-surgical limb. The program is 8 weeks, once a week for an hour. Physical therapists create a unique program for each patient because each patient struggles in one area more than others. The exercises in the ACE program are more advanced than regular physical therapy but the goals remain very similar; focusing mostly on stability, balance, and strength of muscles that are typically weak. ACE is designed to makes athletes feel confident that they will not get re-injured or favor one side when they return to the court of the field.

Spending my time this week with the physical therapists that are in charge of the ACE program allowed me to see the sports side of physical therapy and yet another possible career path once I obtain my degree.

Week 8: Twin Cities Orthopedics

July 20th, 2013

Laura Ettlin ’14 Mansfield Foundation Fellow in Physical Therapy

With only a few more weeks at Twin Cities Orthopedics I am finishing up my experiences and opportunities. This week I was able to view some x-rays of ankle replacement, ankle fusion as well as a tibia plateau fracture stabilization. A few of the physical therapists explained how the surgeons stabilize the injured areas and how the implanted hardware can limit motion. In an ankle fusion, for example, a metal plate is placed anteriorly and screws are used to attach the tibia and talus to the plate. A second example of x-rays images I viewed was of an ankle replacement which is similar to a knee replacement. The distal end of the tibia and the proximal end of the talus is smoothed out and replaced with a metal piece that mimics the ankle joint. Again screws are put in place to keep the parts stable. The x-ray images provide an insight look to the anatomical features of the patients surgical site. This may also explain certain range of motion restrictions for a patient.

This week I also sat in on several evaluations for new patients. When a new patient comes in to receive physical therapy they first go through an evaluation with a PT. Paperwork from doctors (who likely referred the patient to PT) is reviewed and the patient explains their injury and symptoms. By the end of the session the PT prescribes a home exercise program for the patient and the patient sets up more sessions for the future. After the evaluation the physical therapist must fill out paperwork which is all done behind the scenes. There is an online program which is connected to all doctors and surgeons that work at Twin Cities Orthopedics. There is a lot of information that is filled out regarding the patient’s injury and symptoms as well as the physical therapists plan for their rehab. The evaluation includes goals, both short term and long term. For patients with routine surgeries such as knee or hip replacements the evaluations are relatively standard and may include specific goals such as “patient wishes to return to ice skating in the winter”. Even tough the paperwork is not the most enjoyable part of the job it is certainly important. The paperwork is reviewed by insurance companies to grant the patient more PT sessions or to charge medicare for the services the patient receives.

This week I was able to see the big picture of what happens behind the scenes, including the paperwork submitted by the physical therapists. I have seen almost every aspect of what a career in physical therapy entails. Only a short time left at TCO, and I look forward to absorbing as much knowledge as possible and wrap up my observations of patient’s progress with knee replacements.

Week 7:Twin Cities Orthopedics

July 15th, 2013

Laura Ettlin ’14 Mansfield Foundation Fellow in Physical Therapy

Twin Cities Orthopedics physical therapy has a lot of patients each with a story of their own. According to a study done by the University of Iowa Carver College of Medicine, the number of knee replacements in the year 2030 is expected to reach 3.5 million. Each individual who receives a knee replacement will be unique. After seven weeks of working in a physical therapy office I have not encountered two knee replacement patients who had the same rehab progress and required identical exercises. As explaining in a previous update, the progress of an individual patient can be a direct effect of the knee replacement parts.

Continuing with the rehabilitation progression after a knee replacement, weeks 2 through 5 focus on progressive function. This includes static and dynamic balance, stationary bicycle, wall slides and increasing the functionality of the new knee. Body weight activities including gentle semi-squats, which focus on eccentric control of the quadriceps. Flexibility and motion are also keys to regaining function as it was before the replacement. There are two popular machines at the physical therapy office that are known as the “torture” machines (as the patients call them). The flexinator and the extensinator help with passive motion of the knee, providing a deep stretch either in the flexed or extended position. The machines have measurements on them to record progress from week to week. Some patients need more strengthening in the hips while others require more strength exercises for their quads and hamstrings. The goals for each patient are usually very similar however the plan of action to achieve those goals vary between patients.

This week I was exposed to an ankle replacement, which is a similar surgery to a knee replacement; similar in the sense that the articulating joints replaced with metal and plastic to mimic the natural motion of the joint. Every week at Twin Cities Orthopedics I am exposed to new procedures and diagnosis as well as methods to guide the patient through rehab to regain normal function and reduce pain.

With only a few weeks remaining in my fellowship, I have made arrangements to meet with a few physical therapists to discuss details regarding the grad school programs they attended. My hope is to gain insight on the important features to look for when applying to a grad school program. I am also looking into career paths and how to specialize in the field of physical therapy such as sports injury prevention like my supervisor.

Week 6: Twin Cities Orthopedics

July 5th, 2013

Laura Ettlin ’14, Mansfield Foundation Fellow in Physical Therapy

The rehabilitation process after a knee replacement is quite taxing on the individual. There is a lot of work that must go in the first week or two following the surgery. This week at Twin Cities Orthopedics I was able to meet with a patient who was only three days post- operation from a total knee replacement. The patient was very conversational and gave me some insightful information to the initial stages of recovery. Not only did I learn the initial goals of rehab but I also received specific protocols directed by the surgeon.

The first phase of rehab is to regain early function. The goals of phase one rehabilitation are: control post-operative pain, reduce inflammation, provide passive motion in a specific plane of movement, and protect the healing repair or tissue. This is accomplished by building up the patient’s confidence and key components to motion such as balance and ambulation with assistant devices. The majority of motion of the knee is passive early on. A continuous passive motion (CPM) device is used to guide the patient into a light passive stretch without the requirement of the therapist. With the help of a CPM a patient aims to be able to extend the knee to 0° and flex the knee to 100° hopefully by the end of rehab.

A statistical analysis by a hospital in Minneapolis showed that the average knee flexion of patients one year after a knee replacement was 116°. Some patients that I have seen are right on track with this statistic while other patients achieve 120° or more within the first three weeks. A study conducted at Queen Margaret University College indicated that 110° of flexion is a suitable goal for total knee rehab and would not limit daily activity for the patient.

The range of motion that is achieved is influenced by a number of factors including how much time and effort the patient puts into their rehab as well as how well the parts of the new knee fit together. After speaking with several physical therapists, I learned that the more knee flexion does not necessarily mean better results because this could indicate the parts of the new knee are too small and therefore are not as supportive as it could be.

Throughout my time at Twin Cities Orthopedics, I am constantly learning about how intricate and amazing the human body truly is. I am very excited to attend graduate school and have made some great connections as well as some insightful information regarding programs I may apply to.

Week 5: Twin Cities Orthopedics

July 1st, 2013

Laura Ettlin ’14 Mansfield Foundation Fellow in Physical Therapy

This past week at Twin Cities Orthopedics has provided me with some valuable information and details for my personal project. Several weeks ago I began observing a patient who had a knee replacement and over the many visits have learned the specific reasons for changes in her rehab program.

One of the major goals of knee replacement rehab is to strengthen the muscles that cross over the knee joint. There are noticeable changes in the patient’s gait when these muscles are weak versus when the muscles are strong. As my supervisor and I watched the patient walk he pointed out, not only the weakness in the patient’s quad and hamstring muscles, but also a weakness in her hips. This weakness in her hips is causing her hips to dip and twist a certain way. This type of walking pattern is a classic example of a Trendelenburg gait which describes a weakness in the hip, thigh, and gluteal muscles.

Due to this hip weakness my supervisor gave the patient some hip exercises as a home exercise program which will help allow the patient to regain a more natural gait pattern. The body is all connected and a weakness in the hips could affect the knee which could affect the ankle joint as well.

My fellowship at Twin Cities Orthopedics has not only allowed me to network with healthcare professionals, but opened my eyes to various career routes within physical therapy. I attended a seminar and listened to surgeons present insightful information on anatomy and typical injuries of the shoulder, hip and knee. The next portion of the seminar was led by several physical therapists. They discussed different realms of rehab that I not aware of. There are 5 types of physical therapy including Pediatric, Cardiovascular, Neurological, Geriatric, and Orthopedic Physical Therapy (which is what I am most familiar with). I have heard of these types of physical therapy and I am interested in looking into these types for potential career paths.

Week 4: Twin Cities Orthopedics

June 24th, 2013

Laura Ettlin ’14 Mansfield Foundation Fellow in Physical Therapy

After about a month with Twin Cities Orthopedics I have become very comfortable with the physical therapists, patients, as well as completing my responsibilities. For the most part I am seeing patients 2-3 times each week. I am beginning to notice that each session for the patients is different even though the goals are about the same for each visit. For example, a patient recovering from a knee replacement may have difficulty regaining mobility of the knee joint. Rather than working on mobility and range of motion for each physical therapy session, the patient may receive a home exercise program that has several exercises to help the patient regain range of motion on their own. As the patient progresses from visit to visit, the physical therapists are very good at thinking ahead and challenging the patient. The patient never seems to master an exercise before the rehab progresses. This allows the patient to work on these skills on their own, while at the same time working towards the rehabilitation goals during their physical therapy visits.

This week I followed a PT and his patient who had a shoulder injury. I learned a bit about the shoulder joint and the typical range of motion in the joint. The PT allowed me to use the goniometer to measure the range of motion in degrees of the shoulder. There are several specific exercises that isolate muscles of the shoulder around the scapula or shoulder blade. These exercises help strengthen the shoulder and immobilize the humerus bone to help prevent injury to the joint. After taking with the PT, I learned that many swimmers actually have weak muscles in the shoulders, but compensate by using muscles of the back which can result in injury.

There is so much to learn and so many subtle differences between patients which makes each patient a new learning opportunity. I look forward to attending an injury prevention seminar next week which will also relate to my personal interests as a runner.

A device used by many physical therapists to measure the range of motion in degrees of a joint. This measurement is used to chart a patients progress.

A goniometer is a device used by many physical therapists to measure the range of motion in degrees of a joint. This measurement is used to chart a patients progress.

Week 3: Twin Cities Orthopedics

June 16th, 2013

Laura Ettlin ’14 Mansfield Foundation Fellow in Physical Therapy

Week three at Twin Cities Orthopedics consisted of many private sessions with a patient and physical therapist. Up until this point, I have spent most of my time in the general gym area where multiple physical therapists lead their patient through the rehab exercises. However this week I sat in on several longer sessions of deep tissue massage in which I learned a lot about scar tissue and the purpose of a massage. I sat in on several patients who had knee replacement surgeries and complained of knee joint pain and stiffness even 5-8 weeks out of surgery. Scar tissue is a result of a healing process that replaces damaged tissue with very fibrous, grainy tissue. This scar tissue greatly restricts motion and can cause pain. Deep tissue massage can help break up abnormal tissue and loosen up a joint and increase motion of the joint.

After the physical therapists massaged specific tight and tender regions of the joint and surrounding muscles, the patient continued to finish their rehab exercises. For the most part, the patients reported a reduction in pain after the massage even though they were in pain during the massage. Some patients require deep tissue massage while others do not, depending on the type of injury and symptoms after surgery.

It was interesting to learn about scar tissue and how deep tissue massage works, while also hearing the patient’s input. As always I look forward to continue to follow patients through their rehab and watch as they improve and eventually graduate from physical therapy.

Week 2: Twin Cities Orthopedics

June 8th, 2013

Laura Ettlin ’14 Mansfield Foundation Fellow in Physical Therapy

Week two of my fellowship consisted of my usual housekeeping type responsibilities and learning from the physical therapists. I received my name badge which allows me to access to staff only areas of the main floor. I was introduced to staff outside of the physical therapist rehab setting and am getting more familiar with my way around.

On Friday I followed my supervisor and his patient to learn some new information about human balance. I expanded on my previous knowledge of proprioceptors in joint capsules and their role in balance. I also learned how to challenge the mind and body to work together to improve a patient’s balance by manipulating the method by which the body finds balances. This week I was also introduced to a few more injuries that I have never heard of before. For example, I learned about adhesive capsulitis also known as frozen shoulder. After following several patients who struggle with the pain from scar tissue, I was better able to understand the symptoms and rehab for a patient with frozen shoulder (which is a build up of scar tissue in the shoulder joint and restricting movement).

I have started to see patients session after session and am seeing how patients progress from week to week. I am looking forward to next week to continue observing patients who are recovering from knee replacements. So far I have seen patients in the middle of their rehab (6-8 weeks), and I am excited to observe their state of mobility and strength as they graduate from their physical therapy rehab program.

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