acute care physical therapy for a patient with …

ACUTE CARE PHYSICAL THERAPY FOR A PATIENT WITH COMPLEX PELVIC

FRACTURE, TYPE III ODONTOID FRACTURE, AND VERTEBRAL ARTERY

DISSECTION

A Doctoral Project

A Comprehensive Case Analysis

Presented to the faculty of the Department of Physical Therapy

California State University, Sacramento

Submitted in partial satisfaction of

the requirements for the degree of

DOCTOR OF PHYSICAL THERAPY

by

Major Thomas Willis

SUMMER

2015

ii

© 2015

Major Thomas Willis

ALL RIGHTS RESERVED

iii



DISSECTION

A Doctoral Project

by

Major Thomas Willis

Approved by:

__________________________________, Committee Chair Dr. Bradley Stockert

__________________________________, First Reader

Dr. Katrin Mattern-Baxter

__________________________________, Second Reader

Dr. Ed Barakatt

____________________________

Date

iv

Student: Major Thomas Willis

I certify that this student has met the requirements for format contained in the University format

manual, and that this project is suitable for shelving in the Library and credit is to be awarded for

the project.

__________________________, Department Chair ___________________ Dr. Ed Barakatt Date

Department of Physical Therapy

v

Abstract

of



DISSECTION

by

Major Thomas Willis

A patient with complex pelvic fracture, odontoid fracture, and vertebral artery dissection

was seen for physical therapy for eleven treatments from July 9th, 2014 through July 14th, 2014

at an acute care hospital under the supervision of a licensed physical therapist.

The patient was evaluated at the initial encounter with manual muscle testing, goniometry,

functional activity testing, and the Functional Status Score for the Intensive Care Unit, and a plan

of care was established. Main goals for the patient were to increase strength and range of motion,

become independent in bed mobility, transfers, and ambulation on level surfaces with an assistive

device; and to ascend/descend three or more steps using an assistive device with contact-guard

assist. Main interventions used were task-specific training and an independent bed exercise

program. The patient achieved the following goals: independent in bed mobility, transfers, and

ambulation on level surfaces with a front wheel walker and supervised in stair ascent/descent

using an axillary crutch with contact-guard assist. The patient was discharged to home with

family support.

______________________________________, Committee Chair

Dr. Bradley Stockert

____________________________

Date

vi

ACKNOWLEDGEMENTS

I would like to express my thanks to my committee chair, Dr. Brad Stockert for

his dedication and many hours spent endeavoring to make this project and my didactic

education a successful and enjoyable endeavor. I would also like to thank Dr. Ed

Barakatt and Dr. Katrin Mattern-Baxter for serving as my other committee members

despite the additional workload and hardship it entails. I would especially like to express

my appreciation for my clinical instructor, David Gelber, PT, the Physical Medicine and

Rehabilitation Department, nurses, physicians, and patients at the University of

California Davis Medical Center for all of the support, encouragement, and opportunities

they provided me during my clinical externship.

A special thanks is necessary for my family. Their encouragement to always

pursue my dreams helped me to start down the path to this moment and has helped

sustain that dream along the way.

In closing I would like to express my great thanks and appreciation to my wife

Ann, and daughter Grace. They endured the worst times, and made the most sacrifices.

Without their continuous love and support I would never have been able to succeed.

Thank you.

vii

TABLE OF CONTENTS

Page

Acknowledgements ................................................................................................................. vi

List of Tables ......................................................................................................................... viii

Chapter

1. GENERAL BACKGROUND ...................................................................................... 1

2. CASE BACKGROUND DATA .................................................................................. 6

3. EXAMINATION – TESTS AND MEASURES ....................................................... 12

4. EVALUATION ......................................................................................................... 19

5. PLAN OF CARE – GOALS AND INTERVENTIONS ............................................ 21

6. OUTCOMES ............................................................................................................. 33

7. DISCUSSION ............................................................................................................ 37

References ............................................................................................................................... 41

viii

LIST OF TABLES

Tables Page

1. Medications………………………………… .............………………………………. 10

2. Examination Data………………………….… .............. ……………………………. 16

3. Evaluation and Plan of Care ....................................................................................... 21

4. Outcomes…………………………….……… .................. …………………………. 33

1

Chapter 1

General Background

Falls account for over 37.3 million injuries requiring medical attention in the

world and 3.3 million in the Americas.1 .Musculoskeletal disorders as the result of falls

are the second leading cause of unintentional injury in the United States.2 These injuries

accounted for over 860,000 years lost to disability in the United States in 2010, the 11th

of the top 30 leading diseases and injuries.2 Identification of the associated pathologies

and the use of the best interventions to treat these disorders for a successful outcome is

the role of the physical therapist in the acute care setting. Three specific categories of

injury that can occur due to falls include pelvic fractures, cervical vertebra fractures, and

vertebral artery dissection.3-5

Pelvic Fractures

Pelvic fractures are frequently classified according to the "Tile" system as type A,

B, or C depending on their characteristics.6 Type A are stable pelvic ring injuries; Type

B consist of partially stable pelvic ring injuries; and Type C describe completely unstable

fractures that allow all degrees of translational displacement, being both rotationally and

vertically unstable. Of all pelvic fractures, Type A fractures account for 40.6%, Type B

for 38.1%, and Type C for the remaining 21.3%. Of patients who have Type C fractures,

63.8% are polytraumatised.6

Most commonly, unstable or complex pelvic fractures occur from some form of

high-energy, blunt trauma including motor vehicle accidents, falls from heights, and

recreational incidents.3,7

The overall incidence of pelvic fractures is 8% of all patients of

2

trauma. These fractures are associated with chest trauma in 21.2% of patients, head

injuries in 16.9% to 25.5% of patients, and spinal injuries in 2% of patients.3,6

Incidence

rates of pelvic fracture of 0.82 per 100,000 people were reported in the United States

from 2000-2009 with the vast majority (92.4%) consisting of closed pelvic fractures.7

Incidence of pelvic fractures is highest in both males and females from 60-79

years of age.8 Males are more prone to severe trauma (68%) than females who are more

likely to sustain moderate trauma (63%).8,9

There is an increased risk of severe trauma in

20-29 year olds versus 30-39 year olds (p = 0.03) as well.8 An inverse association with

body-mass index (BMI) has been identified, with a higher BMI having a protective

effect.9 Mortality rates for patients with pelvic fractures range from 8.3% to 14.2% and

are associated with a 2.4-fold increase in the risk of death compared to patients without

pelvic fracture.3,9

Cervical Vertebra Fractures

Cervical spine injuries have a prevalence of 3.7% in trauma patients and 41.9%

are deemed to be unstable.10

Milby et al. (2008) defined unstable cervical spine injuries

as “any fracture, dislocation, or purely ligamentous injury necessitating external

stabilization and/or operative fixation.”10

Of all cervical spine fractures, 5% to 15% are

fractures of the odontoid process, also known as the dens.11

Odontoid, or dens, fractures

are generally classified by the location of the fracture within the C2 vertebrae using the

Anderson and D'Alonzo system12

:

Type I: fracture of the upper part of the odontoid/dens

Type II: fracture at the base of the odontoid/dens

3

Type III: fracture affecting the body of the axis.

Type III fractures are the second most prevalent fracture type (Type II being the most

common), accounting for 40% of odontoid fractures.13

In polytrauma patients, C2 was

the most commonly injured vertebral level (27%); of these patients, only 5% had

associated spinal cord injury.4

The frequency of odontoid fractures differs by both gender and age.13

Males

accounted for four times the number of odontoid fractures compared to females, and 25%

of odontoid fractures occurred in patients between the ages of 11-30 compared to 35% in

31-40 years old. The leading identified causes of odontoid fracture were a fall from

height (60%) followed by car accidents (25%).13

Patients with odontoid fractures present with neurological deficit on physical

examination in 12.5% of Type III cases.13

In one study, all patients achieved some

degree of improvement in fracture consolidation times using non-surgical treatment (such

as a cranial halo device). Consolidation occurred in 12 to 16 weeks in 54.5% of cases.13

Conservative treatment using a cranial halo for reduction and traction of the cervical

spine has been found to be well tolerated by patients.11

Vertebral Artery Dissection

Cervical arterial dissection has been defined as "the splitting of the arterial wall of

the carotid or vertebral artery".14

After a tear has occurred, blood can enter the muscular

portion of the vessel wall, possibly causing separation of the layers and lead to thrombus

formation and/or occlusion of the vessel lumen.14,15

To specifically identify lesion

locations, the cervical arteries are divided into four segments. Segment I runs from the

4

vessel origin to the 5th cervical vertebrae. Segment II corresponds with the region from

the 4th to 3rd cervical vertebrae. Segment III run from the 2nd vertebrae to the point the

arteries meet the dura mater (dura), while Segment IV consists of the area beyond the

dura.14

The incidence of vertebral artery dissection (VAD) has been identified as between

0.97 to 1.12 per 100,000 people.16

Of patients with head and neck trauma, 0.01% to

5.7% had VAD. Patients with VAD had a significant increase in rates of cervical spine

fracture compared to those without VAD (71% versus 11%, respectively (p <

0.0001)).5,17

A trend towards significance in the increased rates of traumatic (57%)

versus spontaneous (43%) dissections has been found. Approximately 50% of

dissections occur in Segment III and 25% in each of the 1st and 3rd segments.18

Men have been identified to have higher rates of traumatic dissection than women

(59% to 68% versus 32% to 41%).18

Recent chiropractic manipulations of the cervical

spine have been identified as a risk factor for cervical artery dissection accounting for

16% of cases of cervical artery dissection in one study.19

Of these cases, dissection was

noted more often as VAD (30%) than carotid artery dissection(6%).19

Younger patients

were also found to be more at risk of traumatic dissection.20

Excellent outcomes have been identified in 70% to 94% of people with VAD.16,19

Stroke and arterial occlusions are the most significant factors related to poor outcomes (p

< 0.05).19

Average hospital length of stay for patients with VAD is 22.2 days and 48% of

patients are discharged to home.5 Patients with VAD have a higher rate of discharge to

5

skilled nursing facilities compared to patients with head trauma without VAD (odds ratio:

2.1).5

6

Chapter 2

Case Background Data

Examination - History

This case study concerns a 29-year-old female who was admitted to the

emergency room with right flank/hip pain approximately three hours after falling an

estimated 10 feet from a rope swing onto a rocky shore. She was carried back onto a boat

by friends because she could not transfer herself due to pain. She continued to have pain

with sitting and moving. The nature of the accident and the patient's extreme pain

convinced those with her to transport her to the emergency room as quickly as possible.

Upon examination and imaging, the patient was found to have a complex pelvic fracture,

type III fracture of the dens, right VAD, and multiple abrasions and contusions as noted

by the attending physician.

The pelvic fracture was described in the medical record as a "complex pelvic

fracture with displaced fragments involving the left inferior and superior pubic rami and

left symphysis pubis, partial involvement of the left anterior column, and displaced

fracture involving the right iliac wing with extension into the sacroiliac joint." Surgical

intervention for the pelvic fracture was deemed necessary by the orthopedic team, and the

patient underwent open-reduction, internal-fixation to repair the right sacroiliac fracture

and to reduce and reposition the displaced anterior structures appropriately. The plan of

care prescribed by the orthopedic team following surgery was a six-week prophylactic

course of the anticoagulant Fragmin, physical therapy and occupational therapy, no

7

weight-bearing on the right lower extremity, and weight-bearing as tolerated on the left

lower extremity.

The patient's odontoid fracture was described in the medical record as "a type III

fracture through the base of the dens with extension into the left lateral mass of C2 and

extending into the left transverse foramen, concerning for possible vascular injury." The

description of the injury included displacement of the odontoid process both anteriorly

and to the left, as well as avulsion to both occipital condyles. Results of an angiogram of

the neck were described in the medical record as demonstrating "a long segment

narrowing involving the entire V2 segment of the right vertebral artery." This was later

determined to be a VAD. The patient was evaluated by neurosurgery for the cervical

fracture and VAD. She was placed in a halo for intervention for the fracture as well as

started on a three month course of acetylsalicylic acid (ASA) therapy to treat the VAD.

In addition, the patient underwent regular neurologic exams while admitted and was

scheduled for follow up with neurosurgery in 4-6 weeks.

Past medical history was non-contributory to the current incident, but included

significant polytrauma secondary to a motor vehicle accident roughly 10 years ago. The

only relevant ongoing pathology was minor chronic bilateral knee pain.

At the time of the accident the patient lived in a multistory condominium that

would prove extremely difficult due to her limited mobility. She subsequently planned to

temporarily move into her parents’ home upon discharge. Her parents’ home was

described as a single-level home with two steps to enter and a bedroom and bathroom

easily accessible using an assistive device (AD) as needed. The patient worked a full-

8

time job at a credit union as well as a part-time job as a server in a restaurant. During the

course of treatment she had not made any formal arrangements for work, but anticipated

that she would be able to return to her work at the credit union regardless of weight-

bearing status and use of AD. However, she was unsure of continuing her restaurant job

for the foreseeable future. Further information on the patient’s current medications can

be found in Table 1. Equipment used by the patient at evaluation and during her course

of inpatient care included a standard hospital bed, bedside commode, front-wheel walker,

axillary crutches, and a wedge pillow specifically for use with a halo.

Review of major systems for the patient are noted below:

Cardiovascular/Pulmonary: Not Impaired

o HR: 86-98

o BP: (112-140)/(72-93)

o Respiration: 16

o No notable edema

Integumentary: Impaired

o Pelvis surgical site: (by RN/MD electronic medical record report) clean, dry,

intact

o Halo pin sites: dry, no erythema

o Multiple minor abrasions/contusions: no signs/symptoms of adverse healing

Musculoskeletal: Impaired

o See examination/evaluation details on page 11 and in Table 2.

9

Neuromuscular: Impaired

o See examination/evaluation details on page 11 and in Table 2.

Communication/affect/cognition: Not impaired

o Alert and oriented x4 (who, what, where, when), quietly spoken, moderately

anxious, English speaking

10

Examination - Medications

Table 1

Medications21

MEDICATION -

SCHEDULED

DOSAGE REASON PT SIDE EFFECTS

Aspirin Tablet

325mg, Oral,

QAM

Anticoagulant/Pain

Control

Nausea, vomiting, stomach

pain, heartburn

Dalteparin (FRAGMIN) Injection, 5000

Units, Daily 2100

Deep Vein Thrombosis

(DVT) Prophylaxis x6

weeks - Anticoagulant

Upset stomach, unusual

bleeding, fever,

dizziness/lightheadedness

Docusate (COLACE) Capsule 100mg,

Oral, BID

Bowel Care/Stool

Softener

Stomach or intestinal cramps,

nausea, vomiting, difficulty

breathing

Polyethylene Glycol

3350 (MIRALAX)

Oral Powder

Packet 17g, Oral,

QAM

Bowel Care/Stool

Softener

Nausea, bloating, cramping,

gas, diarrhea

Sennosides (SENOKOT) Tablet 17.2 mg,

Oral, Daily

Bedtime

Bowel Care/Laxative Stomach discomfort, nausea,

rectal bleeding

MEDICATION - PRN DOSAGE REASON PT SIDE EFFECTS

Bisacodyl

(DULCOLAX)

Suppository

10mg, Rectally,

Q24H

Bowel Care/Stimulant

Laxative

Stomach cramps, faintness,

stomach discomfort, burning in

the rectum

Diphenhydramine

(BENADRYL)

Injection 12.5-

25mg, IV, Q6H

As needed for itching Drowsiness, dizziness,

vomiting, constipation, muscle

weakness

Hydrocodone

5mg/Acetaminophen

325mg (NORCO 5)

Tablet 1-2, Oral,

Q4H

Analgesic/Pain Control Nausea, vomiting,

constipation, drowsiness,

dizziness, anxiety,

lightheadedness

Magnesium Hydroxide

(MILK OF MAGNESIA)

400 mg/5ml

Suspension 30ml,

Oral, Q12H

Bowel Care Stomach cramps, upset

stomach, vomiting, diarrhea

Morphine Injection 1-4mg, IV, Q1H Analgesic/Break

through pain

Vomiting, constipation,

drowsiness, dizziness,

lightheadedness, stomach pain

Ondansetron (ZOFRAN) Injection 4mg,

IV, Q12H

As needed for

nausea/vomiting

Diarrhea, headache,

constipation, weakness,

tiredness, dizziness

Promethazine Injection 12.5mg, As needed for Drowsiness, listlessness,

11

(PHENERGAN) IV, Q6H nausea/vomiting dizziness, blurred or double

vision, loss of coordination

mg = milligrams

g = grams

QAM = Every Morning

BID = Twice daily

Q24H = Once a day

PRN = As needed

Q6H = Every six hours

Q4H = Every four hours

ml = milliliters

Q12H = Every 12 hours

IV = Intravenous

Q1H = Every hour

12

Chapter 3

Examination - Tests and Measures

Examination of this patient covered the three domains: body structure or function

impairments, activity limitations, and participation restrictions of the International

Classification of Functioning, Disability, and Health (ICF).22

Body structure or function

impairment examinations included manual muscle testing, goniometry, and an

assessment to detect deep vein thrombosis. Activity limitations examinations included an

assessment of bed mobility, transfers, pre-gait, and ambulation. Participation restrictions

of the ICF were examined using a patient report of disablement. The procedures used for

the examination are described in detail below, and are organized by ICF domain.

Manual muscle testing (MMT) was used to assess the strength of the patient. Due

to patient pain and mobility restrictions, non-standard positions were utilized for some

testing. Strength testing using MMT has been found to have a sensitivity of 60.9% to

72.3% and a specificity of 76.7% to 100% for detecting between-side differences in

muscle force that had been identified by dynamometry.23

The diagnostic accuracy of

MMT is 77.6% at a 25% dynamometry-identified between-side difference in strength

with a positive predictive value of 81.2%.23

Inter-examiner reliability for MMT has been

found to be strong (82% to 97% agreement) as well as having very good test-retest

reliability (96% to 98% agreement) for a change of +/- one full grade.24

Reduced

strength identified using MMT is associated with the presence of symptoms (odds ratio

(OR) 4.0, 95% confidence interval (CI), 2.5-7.7).24

These findings overall lead to a test

that is moderately strong for ruling pathology in.

13

Goniometry was a body structure or function domain measure used to assess the

patient’s range of motion. During the examination, formal measurements were only

taken when the patient displayed obvious, functionally limiting deficits of range.

Goniometry has been found to be less reliable for lower extremity movements (r = 0.58)

as compared to upper extremity movements (r = 0.86).25

Intratester standard deviation for

goniometry is 4.0 degrees, therefore 95% of intratester measurements will fall within 8.0

degrees of one another.

Additionally, under the body structure or function domain, an assessment was

conducted to determine the possibility of deep vein thrombosis (DVT) using the "Wells

Rule".26

This clinical prediction rule assesses nine characteristics in three major

categories and assigns +1 point to the presence of each characteristic. An alternative

diagnosis that could explain the symptoms is given a value of -2. The categories and

characteristics are:

Medical History: Active cancer, lower extremity immobilization, recently

bedridden for greater than three days and/or major surgery in the last four weeks

Physical Exam: localized tenderness, swelling of the entire lower extremity,

greater than three centimeter swelling of the calf, pitting edema, and collateral

superficial veins.

Alternative Diagnosis: Possible more likely alternative diagnosis to DVT

This clinical prediction rule has been found to have a positive likelihood ratio of 6.62 for

a high pretest score, 1.0 for a moderate pretest score, and less than 1.0 for a low pretest

score.26

Negative predictive values for a low pretest score has been calculated as 96%

14

with a positive predictive value of approximately 75% in a high pretest score. As a result

the assessment is most useful in identifying patients without DVT, and less conclusive in

ruling in DVT .26

Pain is another factor that falls in the body function/structure domain and was

assessed with this patient. Because pain is a subjective experience, patient report is a

valid method of assessment. The numeric pain rating scale (NPRS) was used to measure

the patient's subjective experience of pain. The patient was asked to rate their pain on an

eleven point range from zero to ten, with zero indicating no pain, and ten indicating the

worst pain imaginable. In post-operative patients a percentage change has been found to

be more clinically meaningful than raw score changes.27

Minimal clinically meaningful

changes have been calculated at 35%, 67%, 70%, and 94% to correlate with minimal,

moderate, much, and complete relief respectively.27

Within the activity limitation domain, many common functional mobility

activities were examined that are frequently divided into four broad categories of bed

mobility, transfers, pre-gait, and ambulation:

Bed Mobility: rolling, scooting,

Transfers: supine/side-lying to sit, sit to stand, stand to sit, sit to chair/commode

Pre-gait: Standing

Ambulation: Ambulation on level ground, stair/curb ascent/descent

Five of these activities (rolling in bed, supine to sit, unsupported sitting, sit to stand, and

ambulation) are combined to form the Functional Status Score for the Intensive Care Unit

(FSS-ICU).28,29

Each activity is scored from zero to seven according to the level of

15

assistance needed for task completion. A zero indicates that the patient is unable to

complete a task; a seven indicates that the patient is independent in the task. In between

these levels of ability, the range includes dependent, maximum, moderate, minimal,

contact guard, and supervised. The scores for each of the five activities are combined for

a total score with a range of zero to 35.

The FSS-ICU score has been determined to detect significant change from

admission scores of a median inter-quartile range (IQR) of 9 (3-17) to a score of 14 (5-

24) at discharge (z= -6.11, P < 0.001).28

In addition, all five categories assessed detected

change from admission to discharge individually (P < 0.001 for each category).

Secondly, significant differences in the FSS-ICU score were found between each of the

five discharge settings (P < 0.001) of home, inpatient rehabilitation facility, skilled

nursing facility, long-term care/hospice/expired, and transfer to short stay hospital.28

Participation, the last of the ICF domains, was addressed by a patient report of

disablement. Further details of participation restrictions and examination details at all

levels of ICF domains are found in Table 2.

16

Table 2

Examination Data Table

BODY FUNCTION OR STRUCTURE IMPAIRMENTS

Measurement Category Test/Measure Used Test/Measure Results

Strength MMT BUE: 5/5 Grossly- Further evaluation

performed by Occupational Therapy

LLE:

Hip Flexion = 4/5 (pain limited)

Knee Flexion = 5/5

Knee Extension = 5/5

Ankle/Foot = All 5/5

RLE:

Hip = not tested secondary to NWB

precautions

Knee Flexion = 3/5 (pain limited)

Knee Extension = 3/5 (pain limited)

Ankle/Foot = All 5/5

Active Range of

Motion (AROM)

Goniometry BUE: Within practical limits for functional

mobility - Further evaluation performed by

Occupational Therapy

LLE:

Hip Flexion: WFL (Pain limited)

Hip Extension: NT

Knee Flexion: WNL

Knee Extension: WNL

Ankle Dorsiflexion: WNL

Ankle Plantarflexion: WNL

RLE:

Hip Flexion: 45° (Pain limited)

Hip Extension: NT

Knee Flexion: 60° (Pain limited)

Knee Extension: -30° (Pain limited)



Passive Range of

Motion (PROM)

Goniometry BUE: Within practical limits for functional

mobility - Further evaluation performed by

Occupational Therapy

17

LLE:

Hip Flexion: WNL

Hip Extension, Abduction, Adduction, Internal

and External Rotation: NT

Knee Flexion: WNL

Knee Extension: WNL



RLE:

Hip Flexion: 90° (Pain limited)

Hip Extension, Abduction, Adduction, Internal

and External Rotation: NT

Knee Flexion: WNL

Knee Extension: WNL



Pain Numeric Pain Rating Scale Posterior Head: 6/10

Right Hip/Pelvis: 8/10

ACTIVITY LIMITATIONS


Bed Mobility Functional Testing Rolling: Maximum Assist x1

Supine scooting: Maximum Assist x1

Side-lying to Sit (aka Logroll): Maximum

Assist x2

Transfers Functional Testing Sit to Stand: Maximum Assist x2 using Hand-

hold Assist x2 maintaining non-weight-bearing

right lower extremity

Stand to sit: Maximum Assist x2 using Hand-

hold Assist x2 maintaining non-weight-bearing


Bed to chair: Maximum Assist x2 maintaining

non-weight-bearing right lower extremity

using Hand-hold Assist x2 utilizing Stand-

pivot transfer technique maintaining non-

weight-bearing right lower extremity

Pre-gait Functional Testing Standing: Moderate Assist x2 using hand-hold

assist x2 maintaining non-weight-bearing right

lower extremity for approximately 30 seconds.

18

Ambulation Functional Testing

10 meter walk test (10MWT)

Six minute walk test (6MWT)

Unable to ambulate at initial evaluation.

Plan to include 10MWT and 6 MWT as patient

ability progresses.

FSS-ICU (Rolling, Supine-to-

sit, Unsupported sitting, Sit-

to-stand, Ambulation)

Rolling: 2

Supine to sit: 2

Unsupported sitting: 7

Sit to stand: 2

Ambulation: 0

FSS-ICU Total: 13/35

PARTICIPATION RESTRICTIONS


Self Care Patient Report Maximum Assist required leading to patient

perception impaired self-image

Recreation -

Independent Exercise

Routine

Patient Report Completely unable leading to patient

perception impaired self-image

BUE = Bilateral upper extremity

LLE = Left lower extremity

RLE = Right lower extremity

WNL = Within normal limits

WFL = Within functional limits

NT = Not tested

FSS-ICU = Functional Status Score for the Intensive Care Unit

19

Chapter 4

Evaluation

Evaluation Summary

At the time of the initial evaluation the patient was a 29 year old female that

presented with impaired functional abilities for bed mobility, transfers, ambulation, and

self-care consistent with medical diagnosis of polytrauma including complex pelvic

fracture, cervical fracture, and VAD.

Diagnostic Impression

Impaired mobility secondary to polytrauma and NWB status for RLE

necessitating use of AD, and increased difficulty due to halo.

Physical Therapy Guide Practice Pattern

Pattern 4G: Impaired Joint Mobility, Muscle Performance, and Range of Motion

Associated with Fracture

Pattern4I: Impaired Joint Mobility, Muscle Performance, and Range of Motion

Associated with Bony or Soft Tissue Surgery

Pattern 4C: Impaired Muscle Performance

G-Code/s Current Goal

Changing + Maintaining Body Position G8981 - CL G8982 - CH

Mobility: Walking + Moving around G8978 - CN G8979 - CH

Self Care G8987 - CL G8988 - CH

20

Modifiers were selected based on the patient's scores on the FSS-ICU.

Percentages were calculated based on the component subscales of the measure and

applied to the appropriate functional limitation. The rolling and supine to sit components

had a total of 4/14 points or 29%. If subtracted from 100% this justifies a 71% limitation

restriction warranting a CL modifier for changing + maintaining body position.

Ambulation was 100% limited at the initial evaluation with and FSS-ICU score of 0/7

warranting the CN modifier for Mobility: walking + moving around. Finally, the

modifier for self-care was selected based on the total FSS-ICU score since self care

required all components of the measure. The total score of 13/35 equals 38%, which

when subtracted yields a 62% impairment and justifies the CL modifier.

21

Chapter 5

Plan of Care - Goals and Interventions

Table 3

Evaluation and Plan of Care

PROBLEM PLAN OF CARE

Short Term Goals

(Anticipated Goals)

2-3 Days

Long Term Goals

(Expected Outcomes)

By Discharge

Planned Interventions

Interventions are Direct or

Procedural unless they are

marked:

(C) = Coordination of care

intervention

(E) = Educational

intervention


Impaired Strength Increase strength to at

least 4/5 globally

No further gains of

strength expected

within this course of

care.

(C) Strength limitations that

are due to pain will be

addressed with better

pharmaceutical pain control

provided by MD/RN.

Desensitization and reduced

fear-avoidance behaviors by

including bed exercises to

promote moving BLE into

end range. Bed exercises to

be performed 3-5/day, 10

repetitions each including

ankle pumps, heel slides,

quad sets, and glut sets.

Impaired Active

Range of Motion

(AROM)

LLE: No changes

expected at this time.

RLE:

Hip Flexion: 60°

Hip Extension: 10°

Knee Flexion: 90°

Knee Extension: -15°

LLE:

Hip Flexion: WNL

Hip Extension: WNL

RLE:

Hip Flexion: 90°

Hip Extension: 20°

Knee Flexion: ≥100°

Knee Extension: 0°

(C) ROM limitations that are

due to pain will be addressed

in part with better

pharmaceutical pain control

provided by MD/RN and

timing of interventions to

coincide with best analgesic

windows.

(E) Bed exercise program as

22

above.

AROM to BLE in all

restricted motions following

demonstration of bed

exercises as warm-up at

beginning of each treatment

session.

Impaired Passive

Range of Motion

(PROM)

RLE: No changes

expected at this time.

RLE:

Hip Flexion: WNL (or

limited as directed by

MD)

Hip Extension: WNL

(or limited as directed

by MD)

(E) Bed exercise program as

above.

(E) Passive stretching of BLE

instruction to mother of

patient in all restricted

motions. 30 second holds x3

for each restriction, 2-3/day

as patient tolerance and

caregiver schedule permits.

Pain Posterior Head:

4/10

Right Hip/Pelvis:

6/10

Posterior Head:

1/10

Right Hip/Pelvis:

2/10

Pharmaceutical pain

control/coordination provided

by MD/RN

Desensitization and reduced

fear-avoidance behaviors

through mobility training and

education


Bed Mobility Rolling: Moderate-

Minimum Assist x1 or

independent with use

of hospital bed

features

Supine scooting:

Moderate-Minimum

Assist x1 or


of hospital bed

features

Rolling: Independent in

flattened bed without

use of bedrails

Supine scooting:

Independent in flattened

bed without use of

bedrails

Task specific training

progressing from logrolling

with maximum assist

provided and use of bed

features to progressively

decreasing assist levels and

reduced use of bed features


progressing from maximum

assist provided and use of bed



reduced use of bed features

23

Side-lying to Sit (aka

Logroll): Moderate-

Minimum Assist x1 or


of hospital bed

features

Side-lying to Sit (aka

Logroll): Independent

in flattened bed without

use of bedrails






reduced use of bed features.

Transfers Sit ↔ Stand: Moderate

Assist x1 using FWW

maintaining non-

weight-bearing right

lower

Bed to chair: Moderate

Assist x1 using FWW

maintaining non-


lower

Sit ↔ Stand:

Independent with FWW

maintaining non-


lower

Bed to chair:

Independent with FWW

maintaining non-


lower




features and assistive devices

to progressively decreasing

assist levels.

Verbal and Manual cueing

performing ≥ 5 Sit ↔ Stands

per session.




features and assistive devices

to progressively decreasing

assist levels.

Begin with squat/stand pivot

transfers with hand hold

assist, progress to stand pivot

transfers using FWW,

progressing to short bouts of

ambulation with turns to

mobilize to more distant

chairs/toilet/etc.

Pre-gait Standing:

Contact guard assist

(CGA) to Stand-by

assist (SBA) using

FWW maintaining

non-weight-bearing on


for ≥ 2 minutes.

Standing:

SBA to supervised

assist using FWW

maintaining non-


lower extremity for ≥ 5

minutes.


progressing from standing

using FWW with CGA for

balance for 3x30sec bouts (or

as patient tolerates) with goal

of adding 30-60sec/day with

reduced level of assist.

Ambulation Level surface:

Pt will ambulate ≥ 15

Level surface:

Pt will ambulate ≥ 50

Task specific training using

FWW with assist as needed

24

feet with CGA to SBA

using FWW

maintaining non-


lower extremity

Stair Ascent/Descent:

No progress expected

at this time.

feet with CGA to SBA

using FWW

maintaining non-


lower extremity


3+ stairs using axillary

crutches with CGA to

SBA.

initially for success

progressing to decreasing

level of assist as patient

safety allows. Progress

distance of ambulation as

patient tolerance permits.

Task specific training using

axillary crutches with assist

as needed initially when

deemed safe by clinical

judgment. Begin with single

platform step, progress to

multiple steps as patient

tolerance permits.


Self Care leading to

patient perception

impaired self-image

Pt will be able to

independently perform

personal hygiene

tasks, feeding, and

peri-care in

bed/bedside commode.

Pt will be able to

independently perform

personal hygiene tasks

and peri-care in

bathroom .

(C) Coordinate treatment

sessions with Occupational

Therapy(OT) to allow work

on self care tasks during

mobility training to/from

bathroom, while up in

bedside chair, and as

requested by OT.

Recreation - Pt wants

to return to exercise

routine to validate

perception of self-

image

Home/Bed exercise

program

Possible return to

restricted use of gym at

discharge

Home exercise program

to include strengthening

and ROM activities

(E) Instruction on a

Bed/Home exercise program

for the patient while in

hospital and that the patient

will be able to maintain and

progress at discharge until

follow-up with outpatient

physical therapy. Evaluation

of needs and program plan to

be made at discharge.

BLE = Bilateral lower extremities




FWW = Front wheeled walker

25

Prognostic Considerations

The patient of this case study had a number of attributes that led to a positive

prognosis for good recovery of function at discharge, decreased length of stay in the

hospital, and decreased risk of mortality. Some of these factors included: 1) additional

and more intensive physical therapy than is typically given to patients in the acute

inpatient setting; 2) receiving early mobilization following the patient's trauma; 3) the

patient's age; and 4) certain characteristics of the patient's presentation.

Additional physical therapy treatments, whether occurring as an extra day a week

or more intensive multiple sessions each day, have been shown to lead to higher

functional independence at discharge.30-32

This patient was seen seven days a week, and

was seen twice a day on more than 50% of the days she was under physical therapy care.

The additional physical therapy improved the prospect of increased function at the time

of discharge. Additional physical therapy has also shown a trend to decreased hospital

length of stay (see PICO question).

Early mobilization was a factor that contributed to the increased likelihood of

good recovery for this patient. Although the patient had a significant vascular trauma,

this type of major vascular injury has been determined to generally present no restriction

on early mobility.33

In addition, the patient received operative fixation of her pelvic

fracture which allowed for earlier mobilization than external fixation.33

Early mobility

has been shown to be significantly associated with increased functional ability, as well as

reduced risk of mortality.11

26

Although the patient of this study sustained serious traumatic injuries, some of

which have significant mortality rates, this patient presented with characteristics that

reduced her likelihood of pre-mature death.3 She survived past the median time of death

for patients who die due to pelvic fracture (6.22 hours). She was admitted with a

Glasgow Coma Scale rating of 15/15, without hypotension (systolic blood pressure < 90

mm Hg), and being of younger age. All of these factors are associated with decreased

mortality.3 Additionally, decreased mortality rates have been shown in patients with

pelvic fractures that are closed and in females.7

Other factors related to the VAD that contributed to this patient's good prognosis

included the fact that the patient did not present with any adverse ischemic events or

neurological deficits which are both considered predictors of poor outcomes.19,34

In

addition, clinical outcomes for patients with cervical artery dissection are good for 92%

of patients with a low recurrence rate of 0.3% per year.16

Less quantifiable considerations that led to a good prognosis for the patient

included the patient's prior level of moderately good fitness, a perceived good attitude

toward therapy and recovery, and the effort the patient put forth during therapy sessions.

In addition the patient had strong family and social support including regular visits in the

hospital by family and friends as well as a supportive environment in which to be

discharged.

27

Plan of Care- Interventions

See Table 3

Overall Approach

In a 2009 study on management of patients in the acute care setting, Jette et al.

found that 95.7% of patients with primarily orthopedic conditions were treated using

interventions related to functional ability.35

As the patient of this case study fit this

category the primary approach used for treatment was a focus on task-specific functional

training of mobility skills. Patient and family education as well as a bed exercise

program provided a means to allow the patient to continue to train and progress between

treatment sessions.

To determine how much to challenge the patient, the patient and therapist agreed

on pre-determined levels of effort and pain that would establish cut-offs for an activity.

The one to ten Borg scale of perceived exertion was used to measure the level of effort

for activities with the patient agreeing to maintain an effort level less than or equal to six,

which would equal a moderate effort level. This was done in order to prevent undue

fatigue. Pain cut-offs utilized a zero to ten numeric pain rating scale in which the patient

indicated she would be willing to push herself up to a pain level of six before wanting to

stop the activity. Fatigue was utilized as an indicator to cease the activity when the

patient or therapist no longer felt the activity could be maintained safely, and/or when the

level of assist needed to conduct the activity increased more than one level (i.e. from

minimum to maximum assist).

28

With all patients, but with patients of polytrauma in particular, the level of

function may fluctuate to a high degree from treatment session to treatment session, or

even within an individual treatment session. For this reason each treatment session

needed to be approached with goals that could be adjusted for how the patient presented

at that time. Pain control also required coordination with the patient's nurse prior to and

in anticipation of needs during treatment sessions. Each treatment session was planned to

address all of the main functional mobility activities of an independent exercise program

(e.g. bed mobility, transfers, and pre-gait or ambulation) as the patient could tolerate at

that time and progress them as able. Progression was expected to vary from treatment to

treatment. The planned progression of each general ability is described below with

decreasing levels of assist as the patient progressed.

Bed Exercises:

o Supine: ankle pumps, heel slides, "Quad and Glut" sets - All x10 to bilateral

lower extremities (BLE), 3-5x/day

o Seated at edge of bed (EOB): long arc quad sets x10 BLE, seated marching

x60secs - both 2-3x/day

Bed Mobility: reduce use of bed features as patient ability progresses

o Propping into long-sitting with flat spin to EOB and reverse - 5x or to

tolerance

o Rolling to side-lying using bed features as needed to elbow propping to short-

sitting at EOB and reverse - 5x or to tolerance

o Scooting: Via bridging with unaffected lower extremity

29

Transfers:

o Sit ↔Stand: hand hold assist(HHA) progressing to FWW with assist to

independent with FWW - at least 5x/session as tolerated

o To bedside commode/chair: squat pivot transfer with HHA progressing to

stand pivot with HHA to pivot transfer using FWW with minimal ambulation

- 3-5x/session as tolerated

Pre-gait:

o Sustained standing: with HHA progressing to FWW. Begin with baseline

time for patient and attempt to progress by 50%/day - 3 bouts/session

Ambulation:

o Level surface: Three bouts/session

Using FWW with progressively decreasing level of assist

Progress distance of ambulation as patient tolerates

o Stairs: begin when patient strength allows, decreasing level of assist as

tolerated

Progress from single platform step using FWW to stairs using axillary

crutch on unaffected side

3 steps up/down x2 sets as tolerated

Wheelchair transport to stairs to prevent fatigue.

30

PICO question

In patients with polytrauma (P), does an increased amount of inpatient physical

therapy (I) as compared to usual care (C) lead to improved functional mobility, decreased

length of stay (LOS), and/or increased quality of life (QoL) (O)?

Three studies were identified that support the use of increased physical therapy

for patients in the ICU and/or acute inpatient care. Two of the studies were randomized

control trials (RCTs) addressing specific means of increasing the level of therapy, one in

which an additional Saturday session was added to the patient's regular plan of care,31

and

the second of which included an additional two treatment sessions per day during the

standard care.32

A systematic review of RCTs (level of evidence: 1a - systematic review

with meta-analysis) that evaluated the effects of extra physical therapy on patient

outcomes was also found that addressed this topic along with the limitations and

difficulties of providing extra physical therapy.30

Improvement of functional ability of the patient is one of the top priorities of

acute care physical therapy in order to prepare a patient for discharge. In the case of the

study that looked at the effects of an additional Saturday physical therapy treatment

(PEDRO score 8/10), the intervention group had a higher level of functional

independence than their counterparts upon discharge as measured by the functional

independence measure (mean difference (MD) 2.3, 95% CI, 0.5-4.1, P = 0.01).31

In a

second study of increased physical therapy treatments (PEDRO score 6/10), researchers

added two additional treatment sessions per day.32

An increase in functional mobility

was identified at days three and five after admission as measured by the modified Iowa

31

Level of Assistance scale (mILOA) (Day 3: median 7 points vs. 10 points, p = 0.02) (Day

5: median 7.5 vs. 16pts, p = 0.04) as compared to the group receiving standard care.32

Finally, a systematic review specifically looked at the effects of extra physical therapy on

LoS, QoL, and functional outcomes in patients with acute conditions.30

The review

found 16 RCTs that included 1699 patients with a range of PEDRO scores from four to

eight. Application of extra PT was achieved by different methods but in all trials the

experimental group received more PT than the control group with a weighted mean of 19

additional minutes per day. The review concluded that extra physical therapy

significantly improved walking ability (standard mean difference (SMD) 0.37, 95% CI,

0.05-0.69, P = 0.02) as well as having a small but significant effect on improving activity

levels (SMD=0.22, 95% CI, 0.07-0.37, P = 0.005).30

These studies all support that the

addition of extra physical therapy will likely result in improved functional ability of

patients in acute care.

Another aspect of care that is of concern for physical therapists is to try and

decrease patient LOS. Both of the RCTs found that in their studies the additional care

resulted in a trend toward decreased LOS but without statistical significance 31,32

A small

but significant decrease in LOS was found in the systematic review (SMD= -0.22, 95%

CI, -0.39 to -0.05, p = 0.01) with a decrease of one day in acute settings where the

average LOS was seven days.30

Once again the findings of the studies support the use of

additional physical therapy, in this case to help reduce LOS.

A third aspect of patient care that may be influenced by additional therapy is the

patient's perception on their QoL. While QoL is not measured in all studies of additional

32

therapy, some have found that on discharge patients did have higher health related QoL

(measured by the EQ-5D) compared to the control group (MD 0.04, 95% CI, 0.01-0.07, p

= 0.009).31

They were 18% more likely to achieve the MCD95 (RR 1.18, 1.04-1.34) with

12 patients needed to treated for one additional significant improvement to occur that

would not have occurred without the addition of the Saturday treatment (NNT=12, 95%

CI, 7-45).31,32

Likewise, the authors of the systematic review discussed above also found

a significant improvement in QoL in patients receiving additional therapy (SMD= 0.48,

95% CI, 0.29-0.68, p = < 0.0001).30

All of this evidence strongly supported the use of additional physical therapy for

this patient in order to more rapidly improve her functional abilities, decrease her hospital

length of stay, and improve her quality of life. Although it may not always be possible to

provide additional therapy for a variety of reasons (e.g. patient pain or fatigue, procedures

and scheduling with other medical practitioners, availability of therapists, and financial

burden of providing extra care), it is clear that every effort should be made to provide the

patient with as much additional therapy as possible. This evidence supported the plan of

care for this patient to include twice a day treatments rather than the normally scheduled

once a day, as well as treatment on both Saturday and Sunday for as long as the patient

was admitted and under the care of physical therapy services.

33

Chapter 6

Outcomes

Table 4

Outcomes

OUTCOMES


Outcome Initial Follow-up Change Goal

Met

(Y/N)

Strength -MMT LLE:

Hip Flexion = 4/5 (pain

limited)

RLE:

Hip = not tested secondary

to NWB precautions

Knee Flexion = 3-/5 (pain

limited)

Knee Extension = 3-/5

(pain limited)

LLE:

Hip Flexion: 5/5

RLE:

Hip = not tested secondary

to NWB precautions

Knee Flexion = 4-/5

Knee Extension = 4-/5

One grade

One grade

One grade

Yes

AROM LLE:

Hip Flexion: WFL

(Painful)

RLE:

Hip Flexion: 45° (Pain

limited)

Hip Extension: NT

Knee Flexion: 60°


LLE:

Hip Flexion: WFL (No

Pain)

RLE:


limited)

Hip Extension: 20° (in

standing)

Knee Flexion: 90°


↓ Pain (not

quantified)

45°

Unknown,

not

previously

tested

30°

25°

Yes

No

Yes

No

No

PROM RLE: RLE:

34


limited)

Hip Flexion: 100° (Onset

of pain and feeling of

pulling at surgical site)

10° No

Pain Posterior Head: 6/10


Posterior Head: 0/10


6 pts (100%)

6 pts (75%)

Yes

Yes



Met

(Y/N)

Bed Mobility Rolling: Maximum Assist

x1

Scooting: Maximum Assist

x1

Side-lying to Sit:

Maximum Assist x2

Rolling: Independent

Scooting: Independent

Side-lying to Sit:

Independent

Decreased

assist

Decreased

assist

Decreased

assist

Yes

Yes

Yes

Transfers Sit to Stand: Maximum

Assist x2 using Hand-hold

Assist x2

Stand to sit: Maximum


Assist x2

Bed to chair: Maximum


Assist x2 utilizing Stand-

pivot

Sit to Stand: Independent

using FWW

Stand to sit: Independent

using FWW

Bed to chair: Independent

using FWW

Decreased

assist

Decreased

assist

Decreased

assist

Yes

Yes

Yes

Pre-Gait Standing: Moderate Assist

x2 using hand-hold assist

x2 for approximately 30

seconds.

Standing: Independent

using FWW for occasional

balance for > 5 minutes at

sink performing self-care.

Decreased

assist

Yes

Ambulation Unable to ambulate at

initial evaluation.


Completely unable

Ambulation: 60ft on level

surface using FWW with

standby assist.


Ascend/Descend 3 steps

Decreased

assist

Decreased

assist

Yes

Yes

35



NWB = Non weight bearing


FWW = Front wheeled walker

10 meter walk test

(10MWT): Unable to test

using single axillary crutch

in left arm with contact

guard assist.

10MWT: Not tested

NA

NA

Functional Status

Score for the

Intensive Care Unit

(FSS-ICU)

Rolling: 2

Supine to sit: 2


Sit to stand: 2

Ambulation: 0


Rolling: 7

Supine to sit: 7


Sit to stand: 7

Ambulation: 5


20 pts Yes



Met

(Y/N)

Self-Care:

Independent

performance of

personal hygiene

tasks, feeding,

dressing, and peri-

care in bathroom to

fulfill the patient's

self-image.

Maximum Assist required

Independent Decreased

assist

Yes

Recreation -

Independent

exercise routine to

include progressive

strength training

and aerobic

exercises to fulfill

the patient's self-

image.

Completely unable

Variable: Independent to

Assist for setup

Decreased

assist

Yes

36

Discharge Statement

The patient was seen for a total of 11 treatments over six consecutive days with

the initial evaluation occurring on the third day following her accident and one day after

her halo placement and pelvic open reduction internal fixation procedure. For the entire

course of treatment the patient remained in the halo device for treatment of her cervical

fracture, continued pharmaceutical treatment for her VAD, and remained on a non-weight

bearing status for her right lower extremity. At the time of discharge the patient had

attained independence in bed mobility in a flattened bed without the use of bedrails,

independence in transfers using a front wheeled walker (FWW), and independence in

ambulation on a level surface for 50+ feet using a FWW. Additionally, she was able to

ascend and descend 3 normal stairs using an axillary crutch with her left upper extremity

and the handrail with her right upper extremity with contact guard assist. The patient was

instructed in an independent exercise program focused on the right lower extremity to be

performed three times a day until strength and range of motion were equal to her

unaffected lower extremity. She was also instructed to ambulate using her AD as much

as she could tolerate daily with an agreed upon goal of 10 minutes of continuous

ambulation before needing to rest. She was discharged to her parents’ home where one

or more family members would be available for assistance with mobility and activities of

daily living as needed 24 hours a day. Follow-up appointments were scheduled with her

neurosurgeon in 2-4 weeks for reassessment of her cervical and vascular pathologies and

with her orthopedic surgeon in six weeks. After clearance from these physicians she was

expected to be referred for a course of outpatient physical therapy.

37

Chapter 7

Discussion

The patient’s response to treatment is one measure of the effectiveness of the

treatments used by the physical therapist. By this measure the treatment of this patient

was very effective with good progression of functional mobility and fairly rapid

discharge from inpatient care. Overall, the patient made rapid gains in almost all

functional abilities with only ambulation progressing more slowly than expected at the

initial evaluation. She remained motivated throughout her course of treatment and

regularly challenged herself to increase her level of function.

Many aspects of the treatment of this patient were conducted in an exemplary

fashion as noted at the time by the patient and her family, her primary nurse, as well as

the supervising physical therapist. First and foremost, a good rapport was established

with the patient and her family facilitating communication on the goals and plan of care.

A second aspect that assisted in quality care was good coordination of care with the rest

of the patient's medical team, primarily her primary nurse, daily nurse and occupational

therapist (OT). Coordination of pain medication, timing with other procedures, and

working in conjunction with the treating OT facilitated the entire team in progressing the

patient. Another factor contributing to the high quality care the patient received was

application of the current evidence by providing this patient additional treatment beyond

what was standard for the facility in which she was treated. The additional treatment

gave the patient far more task-specific training with skilled professional care and

38

appeared to benefit her psychologically by having more frequent interaction with hospital

staff.

In future patients with a similar presentation, a more in depth assessment will be

performed of the bilateral upper extremities rather than leaving this to the OT.

Additionally, more effort will be made to work with the patient during the goal setting

process to get a more collaborative attempt at making goals and progress rather than

simply laying out a fairly straight-forward goal progression that was determined by the

treating therapist. Although in this case the less collaborative goal setting approach was

successful, it is possible that better and/or faster progress could have been made using a

more collaborative approach. This approach may or may not be successful with a

majority of patients. More effort will be made during the intervention stage of care to

customize the intervention for a particular patient and seek his or her input and feedback.

Overall, a more collaborative effort in developing a plan of care by seeking the patient's

impressions as well as the therapist's professional judgment on what the priorities should

be for each day’s intervention could prove to be a more successful approach.

This patient presented with both typical as well as atypical features for a patient

with polytrauma. As mentioned earlier, both VAD and odontoid fractures are very

uncommon injuries. Once cleared by neurosurgery for treatment, there are no

contraindications to mobilization due to VAD or for the patient utilizing a halo external

fixation for cervical fracture. The halo device does present with added challenges for

patient mobility and comfort, but the external fixation makes typical mobility precautions

for fractures of the cervical spine unnecessary.

39

Pelvic fractures are injuries commonly encountered in a level one trauma center

and regularly treated by acute care physical therapists. As in this case, patients with

polytrauma typically have significant pain as well as non or partial weight-bearing status

of one or more extremities necessitating the use of assistive devices for functional

mobility. Typical of a patient with extensive polytrauma, this patient presented initially

with timidity and apprehension with movement for fear of exacerbating her pain. This

patient continued to have significant pain but as she became familiar with which

movements and positions caused her the most difficulty and discomfort, she was able to

adapt and her functional mobility increased dramatically.

An aspect of the physical therapy plan of care that should be examined is the use

of evidence based diagnostic measures, outcome measures, and interventions. Many

diagnostic measures that are common to physical therapy practice are rarely used and

frequently impractical for the acute care setting. Medical diagnoses are provided by the

medical team assigned to the patient before the patient is ever evaluated by the physical

therapist. As a result the diagnostic information is already found in the patient chart.

Additionally, many diagnostic tests for impairments, such as balance and/or gait, are

either impossible for a patient to perform or can be guaranteed to be positive for

impairment without even testing the patient.

At the facility in which the patient was seen, few outcome measures were

regularly used in acute care physical therapy. The tool used for assessment of this

patient, the FSS-ICU, performed well in assisting to quantify functional mobility which is

normally only rated subjectively. The FSS-ICU is a good tool for patients of polytrauma

40

to quantify progress and perform discharge planning. For patients anticipated to achieve

independence in the five categories of the measure, the physical therapist should consider

other outcome measures assessing higher functional levels. The 10 meter walk test, 6

minute walk test, and/or the Performance Oriented Mobility Assessment (i.e. Tinetti test)

would all be appropriate for this patient if she was anticipated to continue her stay or for

other, higher functioning patients with polytrauma.

41

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