In the most common sequence today, after the patient is referred to physical therapy, a physical therapist will perform an "evaluation." The evaluation procedures are described later in the chapter. All patients treated by physical therapist assistants must first be evaluated by a physical therapist, and the therapist will perform interim evaluations during the course of the treatment series, and perhaps change the treatment plan, as needed.
The patient's progress is documented in clinical notes, which are written at specified intervals, determined by the hospital or the department policy.
Frequently, a therapist will instruct the patient's family in certain procedures to hasten recovery and to prevent deformities or further disability, especially in muscles and joints.
Obviously, the director and the assistant director supervise the work of all the other staff members. In some facilities, the director's responsibilities are purely administrative, with no direct patient care. In others, he or she may be treating patients almost eight hours a day, and performing the administrative details after the department closes. In one extreme instance of this, a director was expected to work sixty hours a week, for forty hours salary.
As you read this, you will realize that direct patient service and departmental administration overlap. However, to show both aspects of the professional obligations more clearly and completely, they have been separated in the explanations that follow.
THERAPIST AND PATIENT
Some physicians will write "Evaluate and Treat" orders, allowing the physical therapist to choose the type of treatment most appropriate for the patient's problem. Other doctors will write very specific treatment orders, including the number of treatments. In most states not requiring a physician's order, the therapist must have the patient's diagnosis from a physician.
As soon as the therapist receives the requisition, he or she learns everything possible about the patient's medical history. If the therapist is not familiar with the diagnosis, he or she will review textbooks for a better understanding of the patient's problems.
If the patient is hospitalized, the therapist must decide whether it is better to perform treatment in the physical therapy department or at bedside. Usually, the only patients who receive treatments at the bedside are those who cannot be moved safely from their beds. Whenever possible, therapists bring their patients to the department because the facilities there are better, they can spend more time with the patients, the change of scenery is stimulating for the patients, and the other patients present offer a great deal of encouragement.
Aides and orderlies transfer patients from beds to carts or wheelchairs, and then transport the patients to the department. They also assist the patients in getting onto the treatment tables and in preparing them for the treatments.
Before a therapist begins any test or treatment, the patient's confidence must be won. This is a simple matter with intelligent and cooperative adults, but much more difficult with frightened children. In handling children, it is often necessary to spend as much time in the emotional preparation for treatment as in the actual treatment.
After establishing a working friendship, the therapist is ready to evaluate the patient. This may be a complex and time-consuming procedure ordered by a doctor to help in the diagnosis of a baffling problem. More frequently, it is a relatively simple assessment of the patient's abilities and limitations.
Types of Diagnostic Tests
Physical therapists perform four types of diagnostic tests: electrical muscle testing, test of voluntary muscle power, joint measurement, and functional activity tests.
The physical therapist may perform tests with electrical currents to determine whether the damage is in the brain, the spinal cord, the nerves carrying the impulse from the spinal cord to the muscle, or in the muscle itself, if a patient has had an injury that causes paralysis or if the patient develops paralysis without any apparent reason.
Where physical therapists once relied on x-rays to gather information, they can now use computed tomography to get a better image of a patient's body. Computed tomography is used in many situations. For example, it helps diagnose and treat patients with spinal stenosis-pain in the lower extremities caused by degenerative diseases that affect the joints.
One test for muscle function is the electromyograph test. A doctor or a specially trained therapist inserts a needle into a muscle. When the muscle contracts, it sends out electrical impulses that travel from the muscle through the needle and wires to a writing apparatus attached to a revolving drum. The writing arm records the pattern of the electrical output on a graph. The doctor reads the graph and learns a great deal about the condition of the muscle from the pattern of the electrical waves shown on it.
In another group of electrical tests, the therapist places an active electrode fastened to a pencil-like applicator on the myoneural junction or motor point, the place where the nerve enters the muscle. By observing whether the muscle responds, how it responds, and the amount of time necessary for the contraction, the therapist can determine whether there is damage to the brain, to the peripheral nerve trunks, or to the muscles. After repeated tests, the therapist knows whether a nerve is healing or dying. This description is, of course, an oversimplification of a difficult and time-consuming procedure.
The most common test of a patient's ability to move is the manual muscle test, or the test of voluntary muscle power. Manual muscle testing requires patience, practice, and experience, as well as a thorough knowledge of muscle function and substitute motions. In this test, when the patient attempts to perform a certain movement, the therapist observes whether the muscle can take normal resistance to the motion, move the part against gravity, move the part with gravity eliminated, or contract the muscle only without producing any movement. The patient repeats the motion several times so that the therapist can observe the endurance of the muscles.
Muscles can contract strongly and permanently in cases of damage to certain areas of the brain or spinal cord. If a muscle is not able to relax when the opposite muscle contracts, the condition is called spasticity. In testing for a spastic muscle, the therapist moves the muscle through the motion to observe whether the muscle jerks, remains contracted, or relaxes.
Muscle testing in the legs usually includes gait analysis. By observing alignment of a patient's bones, in standing and walking, a therapist can confirm findings in other tests for weakness and spasticity. The position of the weak and spastic muscles, the areas of weight bearing in the feet, and the manner in which a patient walks all combine to help the doctor and the therapist decide whether a patient needs braces, lifts, or specific exercises.
Testing procedures are not limited to specific muscles. Many patients receiving physical therapy suffer from brain damage at birth or in old age. These people may have lost their ability to move, their sensation, or their sense of position. Some may have lost part of their vision, while others lose their hearing, and a few lose both. Many older adults who are paralyzed on the side of the dominant hand lose their speech or their understanding of words. Before therapists can begin a program to restore function in the affected arm and leg, they must know the extent of the brain damage. They learn this by observing the patient's performance.
Goniometry is the measurement of joint motion. This is another important part of the testing procedure. The therapist uses a goniometer, an adaptation of the common protractor, to measure how many degrees a joint moves. The therapist repeats the measurement at regular intervals, to gauge how rapidly the patient is recovering function-or possibly to conclude that the patient won't recover any motion at all in the joint.
Activities of Daily Living (ADL)
Besides determining the source and extent of paralysis and the limitation of joint motion, the therapist must also know how well a patient can function with whatever motion is left after a disease or injury. The therapist tests the performance of Activities of Daily Living (ADL) by observing how patients feed, bathe, and dress themselves; how they write or use a computer, handle a telephone, and maneuver a wheelchair.
After determining the extent of a disability, the therapist plans an exercise program to build strength and increase motion. Planning such a program to restore the patient to a productive life is the most stimulating and rewarding responsibility of a physical therapist.
Traditional Therapeutic Program
A therapeutic exercise program is much different from the calisthenics in a physical education class. Sometimes treatment begins with passive motion, in which the therapist moves a body part for the patient, to make the patient aware of the sensation of motion. Knowledge of the sensation is fundamental to all voluntary movement. The next step is passive assistive motion, in which the therapist moves the body part, with the patient helping a little. The third step is active assistance exercise, in which the patient moves, with the therapist offering some assistance. Next, the patient moves without any assistance. Last, the patient moves against resistance offered by a therapist or by weights attached to the arms or legs. Those who have practiced weight lifting know that muscles gain strength more quickly when they move against resistance than by moving more frequently without resistance. This pattern of exercise has been the conventional and traditional program for more than fifty years.
Advances in Recent Years
During the past sixty years, however, there have been exciting advances in therapeutic exercise. Several groups of scientists in different parts of the United States and Great Britain studied reflexes and the normal progression of motor skills in infants and young children. Through their research, physicians and physical therapists have learned that:
- Certain sensations, such as cold, tapping, brushing, or rubbing will cause a muscle to contract when the usual progression of the conventional exercise program fails to produce motion.
- Adults and children learn to walk more easily if they have learned to do all the things that normal infants and children do before walking. If a patient can roll over, crouch, crawl, and kneel upright, walking is less difficult.
- Motor reflexes, certain involuntary movements over which a patient at first has no control, can be used as a foundation for teaching willed and voluntary motion.
Some therapists use one system exclusively, while others take parts from all the systems to achieve results. For anyone interested in research, investigation into the vast field of motor development would be challenging to the therapist engaged in research and beneficial to all the therapists practicing in clinics.
In general hospitals, therapists frequently teach patients to walk with crutches, without placing any weight on an injured leg or by placing partial weight on a weak or painful leg. The therapist must fit the crutches to the patient, then decide which of the five crutch gaits is best for the patient. As soon as the patient can walk independently, the therapist will instruct the patient how to sit down, rise from a chair, and climb and descend stairs. Not all patients can use crutches; some never pass beyond the walker stage, while others advance quickly to a cane. Sometimes after a patient learns to walk, a therapist may teach her or him to run, skip, and perform some ballroom, folk, and modern dance movements.
Physical therapists also assist with treatment of lung diseases. British therapists have long been aware of the value of pulmonary care for patients suffering from lung congestion. In this exercise system, the patient lies in a certain position to drain the fluid from a specific lobe of the lung. While the patient is tilted, the therapist claps and vibrates (two massage techniques) over the lobe being drained. The patients also learn breathing exercises that emphasize breathing out and coughing.
Many obstetrical patients learn groups of abdominal exercises before and after the delivery of a baby. Sometimes the therapist teaches these in classes, but more frequently he or she instructs each patient independently.
In every general hospital department, therapists teach posture correction exercises to patients who have pain resulting from poor body mechanics and to youngsters who are developing bad postural habits that might produce serious deformities.
Orthopedic physical therapy is a rapidly expanding specialty. Therapists who use this treatment must learn the techniques of mobilization and manipulation used in osteopathy. The therapists who use mobilization and manipulation of joints to increase the range of motion must take many advanced courses, and they must continue to study independently and to practice constantly. This therapy requires specialized technique and knowledge, and special skill in working with the patients to create an atmosphere conducive to their complete cooperation and relaxation during the procedures. Manual therapy, as it is called in physical therapy, can increase range and relieve pain dramatically and rapidly, in the situations where it is indicated. Although many therapists have learned to mobilize, some have had difficulty in timing the manipulation thrust. Another technique in the same category is a form of osteopathy called "Strain and Counter Strain," which combines pressure with position to relieve pain.
Craniosacral therapy is another osteopathic technique to relieve pain. It, too, requires intensive postgraduate studies.
Although most of a therapist's time is spent in teaching patients to move, sometimes a therapist must teach a patient who is very tense and nervous how to relax.
Every physical therapy department has exercise equipment that a patient may use independently before or after a session with the therapist. The weights, wands, stall bars, wrist rolls, shoulder wheels, pulleys, and bicycles all emphasize the need for the patient to assume the responsibility for her or his own exercise program. The patient must not depend totally upon the therapist for improvement. Sometimes yoga positions and dance patterns are included in the exercise program.
A physical therapist uses different exercises for different disabilities, but exercises are beneficial for many conditions, including polio, cerebral palsy, hemiplegia, spinal cord injury, multiple sclerosis, muscular dystrophy, Parkinson's disease, emphysema, bronchiectasis, cystic fibrosis, arthritis, burns, nerve and muscle lacerations, poor posture, mental illness, and the post-operative care of amputees. These exercises are also used by patients who have had corrective bone, joint, and muscle surgery.
Often, the exercise program begins in a pool or in a large tank of water. The buoyancy of the water makes movement easier, and a weak muscle can develop strength and co-ordination more rapidly. Sometimes patients begin walking in pools or in specially designed tanks.
A word used frequently in physical therapy jargon is "modalities." Physical therapists use this word to refer to many treatments requiring large pieces of electrical equipment. The term is frowned upon by many school faculty members and many of the profession's leaders, but the clinicians working in the field continue to use it. Usually, the assistant's activities and responsibilities include these treatment procedures. If a department has no assistants, the physical therapist will administer the treatments.
Hydrotherapy is the use of water in treatment. The water is warm, usually slightly above body temperature. The water is caused to whirl by a jet of air forced from a turbine that looks like an outboard motor but that, of course, has no rotor blades. Immediately following severe trauma (accident), however, patients including athletes involved in sports-related injuries, are treated in very cold water.
The combination of heat and the water massage helps to relieve pain and to increase circulation. It is also beneficial in cleansing an arm or leg after a cast, splint, or dressing has been removed or when a large area of tissue has been severely burned, frostbitten, or ulcerated.
A popular and easy form of home treatment that therapists often teach patients suffering from arthritis of the hands and feet is the contrast bath, the alternating use of hot and cold water in a specific time sequence.
Paraffin baths-the use of paraffin and mineral oil mixed together and heated to temperatures between 123 and 132 degrees Fahrenheit-provide an effective relief from the pain of arthritis and inflammation of the tendons of the hands and feet. They are also one of the mainstays of physical therapy treatment for patients with leprosy. The patient dips her or his hands into the wax about seven times, then continues to soak the hands in the wax or wraps the paraffin-coated hands in a towel for twenty to thirty minutes.
Hot packs-pads containing a mixture of silicon, gelatin, and chemicals-retain heat for relatively long periods and effectively reduce pain. A thermostatically controlled cabinet keeps the packs hot until the therapist wraps them in towels and applies them to a patient.
Elastogel Packs can be heated in an oven or microwave, or frozen in a freezer, as a convenient method of conductive heat or cold.
There is some controversy regarding the relative efficacy of dry and moist heat.
Heat from an infrared lamp often precedes other procedures such as massage or exercise. Both infrared and ultraviolet rays are forms of radiant heat, but they are at opposite ends of the color spectrum, so the effects are totally different. Ultraviolet produces no heat but has instead a chemical effect upon the skin. The patient notices a mild sunburn several hours after the exposure, just as you notice a sunburn after you return from the beach. Ultraviolet is successful in the treatment of skin diseases and is especially beneficial in promoting the healing of pressure sores.
Diathermy is a form of heat produced by the resistance of the tissues to the short waves of an electrical current. Because the heat is a milder dosage of the same inductotherm used to melt metal in the steel mills, the diathermy cannot be used on patients who have metal implanted in their bones. Diathermy that penetrates from one-and-a-half to two inches brings great comfort to patients with aches and pains in muscles and joints.
Ultrasound has proven to be an extremely effective measure in reducing pain, especially after sudden injuries such as sprains and strains. There are many other conditions that respond to sound, such as arthritis, bursitis, tendinitis, and muscular pains. More recently, sound has been successful in the treatment of warts on the sole of the foot and around nail beds of the fingers and toes.
Ultrasound waves are faster than waves in the range of human hearing, but not faster than sound; that is why they are called "ultrasound waves." Ultrasound is produced by a current of electricity passing through a transducer, or sound head that looks something like an old pistol. Inside the transducer the current passes through a quartz crystal that changes the current into ultrasound. The physical therapist applies ultrasound by moving the transducer over the painful area. Hands and feet, which have irregular contours, may be treated underwater.
You read earlier of the use of electrical current in testing muscles and nerves. These currents are also used in treatment. In one type of treatment, called iontophoresis or ion transfer, the current deposits chemicals or medicines on wounds or ulcers to hasten healing. The electrical current used to stimulate muscle contractions teaches the muscle to move again when it has forgotten to move or when it is too weak to move voluntarily.
Direct current, called galvanic current, has been successful in reducing pain. For many years, high voltage was in vogue, but since 1985, the application of micro-amperage currents proved to be more successful in sports medicine and other types of trauma, as well as podiatry.
Transcutaneous Electrical Nerve Stimulation
TENS, a low volt galvanic application, is a battery-operated device with electrodes placed upon the patient in the area of pain, or on the acupoints applicable to the pain. TENS units are worn by patients who suffer from constant, chronic pain. Therapists instruct the patient in the points of application and periods of time to be used, in order to obtain relief from pain. This is primarily a "home care" modality, and rarely used in a clinical setting, except for testing its efficacy and for instruction.
During World War II, when physical therapy began to gain momentum, almost every order for treatment read, "heat, massage, and exercise."
Physiologists are still uncertain about the reason why ice is an effective method of reducing pain and spasticity. Therapists have observed that ice produces gratifying results. Patients experience almost immediate relief from pain and also an increase in motion. The therapist may apply crushed ice in a plastic or rubber bag or may massage the patient with a large chunk of ice, applying it directly to the skin until the area becomes numb. Usually, the patient receives additional instruction in the use of ice at home. Patients who are spastic because they suffer from multiple sclerosis are often submerged in a tub of ice water for four minutes. The cold water relieves the spasticity for many hours.
Many patients who suffer from pain in the low back, neck, or head receive relief from traction. The traction can be steady or intermittent. The patient may be lying down or sitting up. The traction can be applied to the lower back or to the neck with a pelvic belt or a head halter. Traction will stretch the muscles and increase circulation and often results in the correction of joint dysfunction.
Some patients have a great deal of swelling in their arms and legs from a variety of causes. They are helped by means of a device called the Intermittent Pressure unit, which forces the fluid from the extremities by pressure within a sleeve or stocking. The treatments last for varying periods of time, ranging from three to twenty-four hours a day. When the edema or swelling has gone, the therapist measures the arm or leg with special tapes, at points an inch and a half apart, for custom-made, pressure-gradient supports to give the circulatory system some help.
For centuries, in all parts of the world, massage has been a method of relieving pain, inducing relaxation, and increasing circulation. In recent years, researchers debunked some of the old theories about its results, but it remains an effective method of treatment.
Physical therapists massage to increase circulation, to relieve pain, and to stretch tight muscles. In more recent years, stretching of the fascia has become an important method of relieving areas of tissue tension. This is called Myofascial Release, and it can be a very painful procedure, but extremely effective.
Currently, therapists use massage techniques in the treatment of specific muscular or fascial problems. It is rare for a physical therapist to administer a complete body massage for relaxation, or "just because it feels so great."
The Chinese began developing acupuncture treatments four thousand years ago by inserting needles into various parts of the body. The Japanese used the same concept, but used pressure and called it Shiatsu.
Western allopathic medicine has looked askance at this therapy for many decades, but recent research is recognizing that 70 percent of the acupoints are the myoneural junctions, and that there is a relationship of the points to the body's electrophysiology, and to the release of the endorphins and enkephalins in the brain.
The philosophy is much too complicated to detail here, but in the practice of acu-therapy, physical therapists apply an electrical current or pressure, a cold laser, or a cold spray to the acupoints. In the United States, physical therapists may not insert needles, although this is permitted in other countries. In the United States, physical therapists may use acu-therapy to relieve pain only, but not to treat disease entities.
Therapists interested in this approach to treating pain must attend continuing education courses, because it is not a part of the curriculum in the academic courses.
And Many Other Duties
During a typical day, a therapist or an assistant will do many more things than those just described. You may consult with a physician to decide the best type of brace for a patient or the height of a lift on a shoe. You might teach a patient how to put on an artificial arm or leg and how to use the prosthesis effectively. You might put dressings over wounds. In some of the large hospitals, which have burn units, physical therapists debride necrotic tissue-that is, they scrub, scrape, and cut away skin so badly burned that it is dead.
The therapist may frequently saw off canes, take photographs of unusual conditions, make splints of plaster of paris or other materials, and make permanent records of deformities of hands and feet by using finger paint and felt marking pens.
Then there are the days when the therapist mops part of the floor or changes a diaper.
THE PHYSICAL THERAPIST AS AN ADMINISTRATOR
In the early years of physical therapy, the therapist, like the doctor of earlier times, had a one-on-one relationship with patients. It was the great personal contact of "laying on of hands" and the resulting gratitude from patients that brought many people into the field in its earlier days.
Today, the average physical therapist in the United States consults with many other professionals: physicians, dentists, nurses, occupational therapists, speech-language pathologists, and audiologists. The comparatively rapid shift from the therapist's responsibility for the total care of the patient to the current role of administrator and teacher has resulted from the population explosion, the increased public demands for better health care, and expanded physical therapy treatments.
In the average hospital, a patient's physical therapy treatment requires one hour; in a rehabilitation center, the aver-age treatment is two-and-a-half hours long. No matter how intensely the physical therapist may want to cling to the role of practicing clinician, he or she must often abandon it to become an administrator and teacher.
The Department Director
Whether by choice or by chance, the director of a department is in a position that demands great professional and personal dedication. Directors are very special kinds of leaders. They have two responsibilities: one to the hospital administration and one to their own staffs. But they must be primarily concerned with the development of the staff and with the constant improvement of the department's service.
Department directors often play many roles. They are guides, planners, overseers, evaluators, interpreters, reporters, teachers, and, sometimes, counselors, confessors, and peacemakers. In each role, they are expected to excel!
The concrete and tangible responsibilities are many and varied. They may assist in designing a desirable floor plan for a new department or decide on the new equipment that the hospital or center requires to meet the needs of the community.
Department directors co-operate with the administration, the controller, and the accounting departments in establishing a budget and working within that budget. They assist in establishing an equitable fee scale based on actual cost. They assist in preparing forms for referrals, records, billing, and inventory. They also prepare statistics and periodic reports of department activity.
They work closely with the personnel department to prepare job descriptions, personnel policies, and a just salary scale. They help to recruit and select the staff. The search for a professional physical therapy staff is relentless, because the current competition for new graduates is high. The pressure of offering continuing education opportunities and maintaining morale is constant because the turnover is steady no matter how ideal the working conditions may be.
Department directors represent the hospital administration to the physical therapy department staff and the staff to the administration. Directors attend department head meetings and relay the important information learned there. They must always insist that their staff comply with all the hospital or institution rules. On the other hand, they have an obligation to their employees to communicate unusual problems to the administration and to back just demands. This sounds as though department heads are walking a tightrope-and it often seems that way!
The director or chief therapist will attend medical staff meetings where physical therapy patients are studied and will review patients' progress for the doctors. In some hospitals, the director accompanies the doctors on ward rounds.
Teaching and Student Supervision
If a hospital has a school of nursing, the director of physical therapy may teach as a guest lecturer in such areas as body mechanics, transfer techniques, massage, crutch walking, orthopedics, and the care of the patient who has had a stroke.
In a hospital or rehabilitation center serving as an affiliating center for physical therapy students in the final phase of their professional education preparation, the department director, assistant director, or clinical supervisor supervises the students clinical experience, criticizes, counsels, and consoles them-and prepares extensive reports on their performances. As a member of the clinical faculty of a physical therapy school, the director or a delegate will attend many of the regular faculty meetings.
In large departments, where the staff may include as many as twenty-five professional physical therapists and a greater number of sub professional and nonprofessional workers, the director will serve only as an administrator and coordinator. The director will give no individual patient treatment and will probably designate a qualified staff member to be responsible for teaching programs. In medium-sized departments, the director may or may not give treatment; may perform only tests and certain evaluative procedures, or treat very difficult patients.
In a private practice, or in a small department, the director may be the one-person show, administering all treatments.