I shadowed at the front desk this morning, and since it was a pretty busy day, they had a lot to do. They had a lot of calls, appointment check-ins/check-outs, and referrals to take care of. After that, I observed treatment on patients with shoulder and knee injuries. The entire staff at BreakThrough Physical Therapy then had a meeting from 1PM-2PM during their lunch break. After the meeting, they were back on a full schedule. I shadowed multiple patients with glute, back and neck injuries. Kenny discussed the reasons behind why his was having pain and tenderness in certain areas, emphasizing that he didn’t have enough blood flow to these muscles that are attached to the rib. I was also able to observe dry needling done in these areas. He explained to me that the longer needles were used in areas around the pelvis, while the shorter needles were used in more shallow muscles such as the neck. Since a woman’s pelvic muscles are convex around the pelvis, they need even longer needles than those used on men in order to reach the deeper muscles.
Today was my last day at Duke Physical Therapy and Sports Medicine, and it was the longest. I started my morning at 8:00am with Ashley and saw around 4 patients. 3 of the patients were in the Joint Health Program (JHP). The program was created by the Department of Orthopaedic Surgery and the Department of Physical Therapy and Occupational Therapy to try and find a better way to treat osteoarthritis and osteoporosis, which is hard to treat and comes with a lot of pain in the joints. Ashley is the only one in the clinic who does JHP, so she sees a number of patients in the program. It focuses on education about pain management, nutrition, sleep, stress management, exercise, and general lifestyle changes that can be made to better manage the pain. One big focus is making a change from overexerting yourself by doing a bunch of an activity until you’re in pain, and then taking a prolonged break. It’s better to break an activity into manageable time chunks and take breaks in between, and it makes you more productive since there will be less rest time overall due to pain. I saw a couple patients with Tyler today, one of which had a period of time in college where she was aspiring to become a doctor. Tyler took the opportunity to start quizzing me, one of the college interns, and the patient about anatomy. Needless to say, we have some brushing up to do on our anatomy knowledge. The rest of the day was just spent seeing more patients and observing various exercises until 5:45. I’ve had a great 7 days at Duke Physical Therapy!
This morning, I shadowed Kenny treating a patient with a back injury. He used techniques such as dry needling, massage, and use of a lacrosse ball to target the trigger point areas and promote muscle relaxation. Afterwards, he had two more patients with back injuries in similar ways. Back and pelvic injuries seem to be the most common issues here at BreakThrough Cary. I then watched treatment done on the people with neck, hip, and foot injuries. I was able to shadow Kenny in the morning, but his hours are 6am-12:30pm on Wednesdays, so it’s a bit odd in that sense. Around 1pm, I was able to partake in a therapeutic yoga class with Rachel Gorman (CA alum). Some of the people in her class had cancelled, so since there was only one other person she invited me to participate. I really enjoyed it!
I was able to observe treatment and exercise guidance done on people with back, ankle, and kneecap injuries. I was also able to watch some dry needling and shadow some of the front desk work. After extensive viewing of dry needling, I have learned about the science behind it. The muscle tightness can be determined by how far in the needle goes into the muscle. If the needle goes all the way down to its base, the muscle isn’t super tight. However, if the needle only goes in up to a certain point, that means that the muscle must be tense and needs to relax, which will be aided by the dry needling process. Kenny explained the differences to me between how the Medicare and normal appointments work. At the front desk, they sometimes receive fraudulent phone calls that call to book appointments, but the way they deal with this is by checking the caller ID to see if it matches the name of the person given. During my time at the front, I continued watching their scheduling and appointment organizations. They gave me the task of peeling the excess labeling off of their sign-in sheets. Later, I observed one of the physical therapists treating a patient with an ankle injury. She informed him that she had been doing her at-home exercises consistently. He then told her that he already knew this not only because of the significant strength improvement, but also because she was coming in with new symptoms. These changing symptoms are a sign that she had been doing her exercises because there was a significant change every time.
Today was a bit of a shorter day due to Ashley having meetings in the morning and mid-day, but I still got to observe four appointments (30 min is the normal length of an appointment) and talk some things over with her. The first patient was very active and only came in for occasional check-ins about every 4-6 weeks. She used Graston tools on him to loosen the muscles and tissues in his back/shoulder. The second patient was an older who had a mini-stroke earlier, and is now working on balancing. Ashley talked through the 3 systems the body uses to balance and how each exercise challenged a system. She walked over and balanced on foam, which provided a different surface and challenged the tactile system. Balancing on uneven surfaces is much harder than a flat surface, and is something most people come across. The next system is visual. Ashley had the patient hold a weighted ball and raise it up and down while looking up and down. This gets rid of the ability to spot a point. Sometimes they’ll also have patients close their eyes. The last one is the “inner ear” which is what creates your body’s spatial awareness and helps with movement and balancing. The third patient was a dancer who had a “pump bump” aka Haglund’s deformity , which is a bony bump on the heel caused by the soft tissue near the Achilles being irritated and becoming inflamed, which can lead to bursitis. The last patient was having neck/shoulder tension and had dry needling done.
Today Dr. Ashley Lake was back! The first patient we saw had dry needling done which was cool to see again, and Ashley used a different device for the electric current. The next patient didn’t want an extra observer, so Ashley had me read the post-op report of another patient coming in 5 days post-op who had surgery to repair his ACL. Although it was very confusing and had a lot of new terms, it was interesting to read and I got a vague sense of the procedure that was done. I then talked it over with Ashley to more fully understand what to expect. Another patient that came in was a young (middle school age) dancer, and it was cool to see Ashley giving her some of the same exercises she gave me when I got treated by her.
Room where ice and heat pack supplies are stored with washing machines.
Today, I watched various physical therapists perform treatment on people with back, shoulder, glute, ankle, and back injuries. One of the key important phrases that is widely used in the BTPT Cary facility is “Motion is Lotion”. This was a really cool funny phrase that reminds patients that they need to have a lot of movement and physical activity incorporated into their daily lifestyle in order to produce more lubrication for their joints, which in turn aids in faster recovery and healing for certain injuries. They also stress to their patients the importance of R&R (rest and recovery) in the healing process, however. Our bodies need time to recuperate before jumping back into the active lifestyle that we may have had before our injury. One therapist saw his patient looking down at her phone for a long period of time while she was waiting to be treated, and he made it clear that doing such actions has a negative impact on the body and causes muscles in the back and spine to tighten. Today I mainly helped out with creating an ice pack as soon as I walked in the door, throwing away and retrieving supplies, and collecting a patients’ waiver for dry needling. I was also able to observe an internal pelvic floor release done by a physical therapist that specializes in pelvic health. This was really interesting and different from anything else I had observed over the past week. It was very interesting to me because as a dancer (outside of school) I learn a lot about the pelvic floor muscles and she was able to teach me a lot about this particular topic that isn’t very commonly discussed. When observing a dry needling session of the back, Kenny noted that repetition of symptoms is something that is looked for when needling. If the same symptoms appear when dry needling as in the patients’ daily life, that means that the PT found the correct spot. It was a very different experience to not only observe him dry needle the back muscles, but also the neck muscles both in the posterior and anterior. The anterior neck muscles were right next to the throat, so I was on edge watching this particular session of dry needling in fear that something might go wrong, but of course everything went smoothly because he is very experienced.
A new day, a new PT to shadow. With more appointment cancellations and schedule differences, I ended up shadowing 4 physical therapists today. I started with Zach who was working with a runner trying to regain strength. The patient ran on the treadmill for a while, and then did some isolations and strength building exercises. This was the first patient I’ve worked with who actually had the strength to do cardio and run. I also shadowed Ann Marie for the first time today while she did an ankle evaluation on a patient who came in after going to an Orthopedic Urgent Care. I got to see how she assessed the injury first, and then gave strengthening exercises. This particular patient was already in the habit of doing high intensity workouts regularly, so she would likely have a faster healing time due to her built up strength. I was also back with Tyler for a couple appointments today, and got to see one of the patients again from earlier this week.
One of the most interesting cases of the day was with Kristina. A patient came in 3 days post-op after getting 2 screws taken out of the front of his knee. He had been a regular patient before, and had other sugeries done in the past. Since he was only 3 days out, Kristina had to do a dressing change, and it was cool to see the sutures and how it’s healing. We worked mainly on strength building, since his mobility was still very good, likely due to the fact that he was a young adult and the placement of the incision at the front of the knee and not directly over the kneecap. I also got to see the Alter-G (anti-gravity) treadmill being used for the first time!
Throughout this week I’ve noticed that the majority of patients come in with either shoulder or knee mobility issues. I’ve seen patient after patient doing the same arm strengthening exercise or balancing exercise, and they’re all based around strength building and gaining mobility.
Mobile Vault System! Moves back and forth smoothly when spoke handle is turned.
On Fridays, the entire staff finishes with their appointments by 3pm, so the they close early. For a change of scenery, I was behind the front desk for the entirety of the morning after watching therapy done on the upper back. Lori Glass gave me a tour of the space, which consists of a small cubicle and vault in the back part, and a desk facing the lobby in the front. In the administration, I was shown exactly how the scheduling works: checking in and out, inputting and cancelling appointments, and blocking out the therapists’ schedules. The system they use is RevFlow, which easily allows them to do all of their scheduling and keeping track of payments. A fun fact that I learned is that Breakthrough Physical Therapy is one branch of many under a national company called Confluent Health, which owns many different PT companies throughout the nation. Something that I’ve had to get used to while working over the past couple of days is the no-phone policy. We aren’t allowed to have our phones out in the central gym area and lobby to maintain professionalism, so instead of keeping it in my pocket throughout the day, I leave it in the PT office and only check it during breaks. This is definitely something that is practiced in a wide variety of offices and workplaces, so it’s been a good experience to have to get used to because it’s different than usual. The administrators had quite a bit of work to do wrapping up and completing a stats deadline since it is the last day of the month. However, they had no problem with this because they distribute their workload throughout the month. They have an established system worked out for patient check-in by placing a sticker on a personal card for each therapist and delivering it when a patient is arrived and ready. This change in view has allowed for me to observe and note a lot of the front desk’s interaction with the patients–greeting, casual conversation, and customer service. The customer service is very notable here at the front; Lori told me that she never answers a call when she is talking to a customer face-to-face, and doesn’t put a call on hold when she gets another incoming call. She says she also makes sure to greet each customer on their way in and out. Since they were running low on business cards for some of the doctors, she had to order more so she showed me how she designed and sent out the proofs. I also learned a lot about insurance: it plays a big role in healthcare facilities. There is a lot of paperwork and computerized inputting involved with getting people’s insurances approved. The two admin at work take alternating lunch breaks so that there is always someone available at the desk. They are constantly being given new tasks to complete on top of what they are already doing which can be very overwhelming, and it can be easy to get behind on certain tasks that need to be completed. For this reason, they complete tasks as soon as they receive them so that they can complete everything fully and accurately. They are definitely very busy people and don’t have nearly any down time aside from their one lunch break, which is why I believe that they are pretty much the powerhouse of the Breakthrough Cary functions to keep everything running smoothly. In the afternoon, I observed massage and exercise guidance done on people with shoulder and hip injuries. I was able to get supplies for the therapists as well as make an ice pack.
Today I worked mainly with Kristina, but her 10am appointment cancelled, so I got to work with TJ for the first time. He had a really interesting case with a teen who recently had a femur lengthening surgery on his right femur. TJ had never treated this patient before, so the hour long session was focused on testing flexibility and improving mobility. I actually got to help stretch the quads and it was surprising just how tight it was post-surgery. I had to hold his ankle still just so his knee flexion could be measured without any slipping since he couldn’t hold it in place himself yet. I also got to see just how far he had come, as he showed TJ that right after the surgery he could barely hang his leg off a table because the tendons in his knee were so tight, and today he got well past 90 degrees.
I also did a few sessions with Tyler again, and even got to see a returning patient from earlier this week. It was interesting to see how much improvement there was in just a few days because this patient was dedicated to doing his at home excersizes. When I saw the patient earlier this week, he came in on crutches, but today he was able to walk in the boot and put some weight on the injured foot without the boot. Tyler used a blood flow restriction machine on this patient, and many others, to make simple exercises harder. When a patient has limited mobility but still needs to build strength, the machine can be used to allow the patient to keep getting stronger while doing the same exercises.
The blood flow restriction machine.
One really cool thing I happened to get to see was dry needling. I had never seen it before, and by chance I was with Kristina in a room when she noticed that one of the staff members was about to have dry needling done. He had 4 acupuncture needles placed in his hamstrings and then the needles were connected to an electrical current. It was intetesting to see his reactions when the needle hit a certain spot in the muscle, and how his muscle would twitch due to the electric current.
With Kristina, I got to see patients on complete opposite ends of the compliency spectrum. Two of her patients were well educated in athletics and how to take care of their bodies. Another two were known for missing appointments and not doing their at home exercises. One huge part of PT is patient compliency. They need to actually do exercises at home to get better. She told me that they do what they can in the clinic to help, but if the patient is known to be non-complient, there isn’t much more they can do, especially with older patients. While it would be nice to get really good patients all day, part of the job is definitely learning how to handle challenging patients.
