18CerenL – CA Work Experience Program

Day 8: Equipment

Today was a rather slow day at first. We didn’t have many patients, although most of the patients I saw were patients I have seen before. With many of them we used a lot of the tools we keep on the back wall. We have ankles weights hanging on the wall in the order of navy, white, gold, green, and black which are 1 lb, 2 lbs, 3 lbs, 4 lbs, and 5 lbs respectively. We also keep regular weights up there: lightest (1 lb) on the top to heaviest (5 lbs) on the bottom. We also keep the therabands here. We have some precut ones in the basket and uncut band on the wall. The bands also increase why tensile strength and we can cut whatever type of band and however much we need for any given patient so that they can go home and perform their exercises. In this area we also keep a multiple of other things like a goniometer which we use to measure the degrees of mobility a patient has in certain directions. In this way we can track a patient’s progress in increasing mobility. We also store a myofascial releaser in this area that can help when doing deep tissue massages. Sometimes it is difficult to get to certain muscles or the go over them we a need amount a pressure so you can use a myofascial releaser to help. We also keep a strength testing tool on the wall for dynamometeric strengths tests. This is when we test a patient’s strength (in pounds) while they perform abduction, flexion, internal rotation, and external rotation.

Day 7: Rehab Bars

Once again, we had many of the same patients today. With some of the patients, we used the rehab bars in the clinic. Typically, we use the rehab bars when working on balance exercises with the patients, and sometimes with strengthening exercises, so that patients have something to hold on to if they lose their balance. Jeffrey had a patient today that did calf raises, leg swings with weights, toe raises, and other balance work in the bars. One of the balancing exercises Jeffrey had the patient do was to stand with one foot on a less stable blue disk-shaped ball and with one foot on the ground in a sort of stagger stance. Jeffrey then held a soccer ball out at different places for the patient to reach out to and try to touch. This challenged that patient’s balance and gets the ankle working, trying to compensate for all the movement and wobbling that occurs while trying to maintain balance. Next to the bars are a lot of equipment that we tend to use with patients (depending on what they need). We keep balls, like the soccer ball Jeffrey used, on the racks there and we keep balancing tools, like the disk-shaped ball, the foam board and the bosu ball in that corner as well. Typically, we also have patients stretch their calves in the bars as well using the board seen to the left of the rehab bars in the picture below.

Day 6: The Performance Room

At this point, I have seen many of Response Physical Therapy’s patients and most of the patients I saw today, with the exception of an evaluation patient, were patients I have seen before. Today we had quite a few patients that needed to work in the performance room in the facility. Jeffrey took one patient, who had broken their tibia and fibula close to the ankle and dislocated their ankle, to the performance room so we would have more room for some of the exercises Jeffrey had planned. In the performance room, Jeffrey had the patient running, jump roping, skipping, and doing calf raises. Activities like jump roping and skipping were to help loosen the ankle and improve some flexibility while still taking on some weight. Calf raises were strengthening exercises which are necessary ass typically, after an injury, there tends to be some muscle atrophy and you want to regain all that muscle and more than that you want to build more muscle so that it can support the location of previous injury. Later in the day, Jeffrey took another patient into the performance room. The goal with this patient was to improve the strength of their hip flexors to reduce pain in the hips. Many of this patient’s exercises were strength and balance related. In the performance room there are stretchy cables attached to the floor and you can attach the other end to your waist. Jeffrey had the patient attach one end to his waist then had him walk forward until there was tension in the cable. He did many exercises with the cable were the patient would shuffle side to side or move up and back and the tension helped to work his hips. The final patient that day, a patient of Dan’s, also used the performance room. This patient was far out from an ACL surgery and was running. There were lots of hamstring, quad, and hip flexor targeting exercises for this patient to do: side-steps with a theraband, bridges while moving the feet in and out from under you, pistol squats, etc. The patient also used the sled in the performance room to push 90 lbs back and forth multiple times to continue building up strength.

Day 5: New Patients and New Knowledge

Today, we got many of the same patients that I had come to know throughout last week. Many of the patients Response Therapy gets are patients with shoulder or knee pain/injuries. There are one or two surgeons that know Response Therapy well and know that Dan is particularly specialized in shoulders and knees. Jeffrey did however explain that while Response Therapy is best at shoulders and knees, they are more than comfortable accepting patients with ailments in other areas and already readily do so. Although many of the patients today were the same, I did see a few new patients. There was an extremely sweet lady who came in whose right leg was unfortunately crippled from polio as a younger child. However, she does wear a brace and can walk around with it with the help of a walker. What brought her to us at Response Therapy was that she fell some time ago and broke the tibia in her left leg, so she could no longer support herself. Response Therapy helped with her rehab to regain the muscle lost in her left leg due to atrophy. For a long time, before her fall, she was “furniture surfing”, a term Jeffrey explained was when patients would subconsciously look for support on surround furniture or cars or other objects when trying to get around. The goal is to help curb the need for furniture surfing and to help build up strength in the left leg to where the patient can get up a sidewalk curb using just her walker. We did a long of walking in the gym with her to continue building up muscle in the left leg. So far, everything looks extremely promising and the goal seems entirely attainable!

Alongside the sweet polio patient, I saw a lot of new patients that had ACL tears. Two of these patients actually had ACL and meniscus tears. I realized that the term weight-bearing came up quite frequently with these two patients and noticed that they both had crutches. This prompted me to ask Jeffrey why ACL tear patients were weight-bearing immediately whereas ACL and meniscus tear patients were not. Jeffrey explained that, in the knee, the ACL does not actually aid in supporting any weight, it has more to do with the movement of the knee anteriorly. Thus, he explained, weight would not hinder or detriment the healing process of an ACL patient, although twisting, running, jumping, cutting, etc. would affect the ACL. The reason why ACL and meniscus patients are non-weight-bearing is because of the meniscus. The meniscus is located right between the femur and the knee and serves as a sort of compression cushion when putting weight through the leg. Thus, if a patient with a meniscus injury were to put weight on their leg while the meniscus was healing, it would potentially damage the meniscus again, not allowing it to heal properly.

Day 4: Ultrasounds and How PT Works

Today, I did yet another ultrasound. Basically, when using an ultrasound on a patient, you are creating a deep heating affect in the soft tissue of the body. The waves from the ultrasound cause cells to vibrate faster on a cellular level creating that heat. The heat ultimately promotes blood flow and helps to break up knots, thus loosening and promoting healing in the targeted tissue. When performing an ultrasound, you can (and should) adjust many this according to the patient. You can first change the time, though typically we use eight minutes at Response Therapy, then you choose which sized head you will use. There is a 2 cm head for targeting smaller areas (things like tendons or ligaments) and a 5 cm head for targeting larger areas (like entire parts of a muscle). After that you choose the “duty cycle” percentage which basically controls what percent of the time the ultrasound will actually be sending waves into the body; there is 100%, 50%, 20%, and 10%. Next, you choose the frequency – either 1 MHz or 3 MHz – which determines how deep the ultrasound waves will penetrate into the soft tissue (1 MHz goes about twice as deep as 3 MHz). Finally, you adjust intensity of the waves; we typically use 1.2 or 1.5 W/cm².

Later in the day, I saw an ultrasound being performed along with e-stim. Another intern asked what that did and I realized that Dan’s response was very similar to what he had said needling with e-stim did. This prompted me to ask him about the difference between the two and when you would choose one over the other. He explained that the two processes are extremely similar in helping to break up knots and loosen the muscle, how needling is an “irritation” as he called it that also helps to reteach muscles to fire, whereas, while e-stim can help to reteach muscles to fire, it is less of an “irritant” and promotes more healing aspects. Dan explained that, in therapy, the way they help people is actually through micro-irritation. He explained that micro-irritation, like needling and other things they do at Response Therapy, helps the body. Macro-irritation is what injures the body in the first place, for example: surgery, tearing something, etc. The easiest way to think about it is which exercise. When you exercise you create micro-tears in your muscles, a form of micro-irritation, which then heal and actually promote growth of new muscles which is how working out and exercising works. However, if you push too hard you may go beyond micro-irritation into macro-irritation such as tearing a muscle which would now be an injury.

Day 3: Balancing, Dry Needling, and Body Connections

Today, I was once again mostly observing all the therapists working. I did continue cleaning tables, preparing hot and cold packs for patients, and continue preparing HEP2Go work sheets for patients and uploading them to their documents tab. There were some gaps between patients and Jeffrey helped me try a few exercises that patients commonly do when looking to improve balance. Dan and Jeffrey always express how important it is to actually do the exercises that the patients are doing from time to time to better understand how the patient is feeling. The exercises I did were all balance related as Jeffrey had me start by balancing on one leg on both sides. He then had me set a semi-hard foam under my feet and had me then try balancing on one leg again. The foam was obviously a softer and more malleable surface than the ground and thus required my ankles to work a lot harder to help me keep myself balanced and upright. The next thing Jeffrey had my stand on was an inflated circle disk that almost resembled a squished ball. Although Jeffrey asked me to try standing on it with one leg each, he explained that with patients that may need more support, they may ask that the patient have one foot on the ground and one foot on the disk then may have the patient catch and throw a ball or perhaps reach out to touch a ball placed in different locations. After the disk, Jeffrey had me balance on a Bosu Ball with one leg. All these exercises – standing on the floor, the foam, the disk, the Bosu Ball – are often combine with either throwing and catching a ball or with reaching out to touch the ball that would be placing in various locations. Finally, Jeffrey had me try to most challenging balancing method: flipping the Bosu Ball over and trying to stand on it that way. Typically, it’s extremely challenging to stand on the Bosu Ball this way and even more so with only one leg. Jeffrey explained that, for this reason, they typically had patients stand on the upside-down Bosu Ball with both legs and instead do squats.

While I wasn’t trying exercises with Jeffrey, I was observing him, Dan, Parker, and Kim at work. In the morning, Kim had a patient that had stiffness and limited mobility in her neck. Kim is well-versed in dry needling and was dry needling the patients neck and using e-stim along with the needling. I have seen needling done in many other places, but I had never seen it done in the neck. It was interesting because when using the e-stim and needle to achieve a twitch, you could actually see the patients head moving with each twitch, or her shoulders (depending on where Kim was needling). Kim also explained that it’s important, when dry needling, to needle along the entire myofascial line or fascial line. A myofascial line is quite literally a line of connective tissue that runs through your body. Kim explain that it is much more effective to target an entire line than focus on the muscle in only one sections that make up only part of the line. This wasn’t the only time when connections throughout the body, and their importance, were brought to light. Another patient who comes in for back pain was being treated and the therapist told him that his tight hamstrings were a contributing factor to his back pain. It’s incredible how part of your leg is able to greatly affect another area such as your back. Most people would never think to assume that something as small as tightness in a certain area could affect so much more in your body, even when the locations are far from one another on the body.

Day 2: Using the Computer

My second day was much slower than the first day we had. There were fewer patients and one of the therapists was not there as well. Along with cleaning down tables and preparing hot and cold packs for patients, today I learned how to use the computer for different things. Parker showed me how to create a home exercise sheet for patients using HEP2go.com and Jeffrey showed me how the website OptimisPT functioned and how they used it in their day to day work.

HEP stands for home exercise program which makes sense as it creates sheets that demonstrate which exercise(s) a therapist would like a patient to perform at home. When creating a sheet, you first search up the exercise, for example: “rows”, then search for an image that best demonstrates what the exercise the patient needs. You can continue to add exercises and when you are done you click a check mark that brings up a page with all the exercises on it. On this page, HEP2go allows you to fill in information about how many repetitions and sets should be done, whether a patient needs to hold a position and for how long, and how many times a day the exercise needs to be done. The website is an extremely useful source that the therapists at Response Physical Therapy use for every patient.

Later in the day, Jeffrey showed me how they use OptimisPT. OptimisPT is the website they use for all their patient information. It has so many functions that I can’t describe them all. There is a “schedule” tab that gives you a calendar-like view of all the patients that are to come in that day. Under the “home” tab it gives a list of the patients’ names in the order they will be coming in. When you click on a patient’s name, it pulls up their profile and has a long set of pages on the left-hand side. Each page is for something else such as patient’s evaluation, additional evaluation, insurance related things, etc. All these items need to be complete for a patient on a certain day as legal documentation. It is also useful for the therapist themselves as they are able to take notes on what the patient says and can make any observations or take measurements and write these down as well. I helped type down measurements for Jeffrey has he performed an evaluation on a new patient. He would measure the force of different things such as right and left arm abduction and I would type is down for him in the “additional evaluation notes” section.

Day 1: Intro to Response Physical Therapy

For the full term of the work experience program, I will be working at Response Therapy in Cary. For my first day on the job, I was first given a brief tour of the facility. Dan Cyr, the person I am working for and with, is the owner of Response Therapy and SportHQ which are housed in the same facility. I was shown rooms for both businesses and Dan explained to me that I would be working in the clinic (the physical therapy clinic) with him, Jeffrey, Parker, and occasionally Kim and another intern. I spent most of my time during the day observing Dan and the other therapists at work as I obviously have no training in physical therapy and by no means could diagnose or treat patients. Dan and the other therapists did however take time to introduce me to each patient and explain their case and how they planned to proceed and why. It was interesting to see that there was such a range of patients. We had younger people come in for sports injuries, middle ages people in for either sports related or other injuries, we had quite a few people in for rehab after surgery of some kind, and we even had a lovely elder couple come in together. As the day went on Dan explained that in between patients I could wipe down tables, prepare pillows and while patients were in I could prepare and remove hot and cold packs when necessary. I was also able to use an ultrasound machine on one of the last patients of the day.

Some of the most interesting things I saw during the day were the use of electronic stimulus, the use of electronic stimulus along with dry needling, and the use of an ultrasound machine. Typically, when using electronic stimulus, you’re looking to help muscles fire correctly and in a way basically reteaching the muscle on how to function. This can be done by using an e-stim machine (which they have as a combined e-stim and ultrasound machine) or can be done with dry needling. To my understanding, you want to use electronic stimulus with needling to produce the same firing in muscles, but with dry needling it can also be used to break up knots and thus tightness in muscles. When I saw it in use, the patient was being dry needled in his trapeziuses/trapezii. Two needles are inserted into the muscle being worked on and cables are attached to each end so that electricity can be sent through the muscle between the two needles. You want the voltage to be turned up to a point where there is no pain but you achieve a twitch in the muscle. The electricity helps to effectively break up knots in the muscle thus allowing it to function better. This technique of using electronic stimulus with dry needling rather than just dry needling is much more effective because you can loosen larger areas of muscle with only two needles and a current passing through the muscle between the two points rather than going in with multiple needles for the same large area of focus.