What I Need to Know
Do you ever ponder on a subject for hours maybe even days? I most certainly do! Recently I have been questioning the implementation of an effective and personalized plan of care in pediatric physical therapy. A plan of care is a treatment timeline given to patients, which varies for each and may change over time. Much of my questioning was driven by my observations through interning at a pediatric physical therapy clinic. Despite all the observations I made, the one that stuck out to me was different plan of cares for the same injury. I needed to know why they were different and how each one resulted into a healed patient, so I formulated a question to aid my research: "How can I, as a Pediatric Physical Therapist, design the most personalized plan of care for my patients?" This is imperative to answer, because there is a growing importance of youth sports. Due to this, pediatricians are seeing more patients with sports related injuries and are referring them to physical therapy clinics. If I find the answers and become more knowledgable about this subject, I can inform others and bring awareness to the importance of pediatric physical therapy. In doing so, this will benefit parents, children, and me. This will be beneficiary to myself, because it will make me more aware about my plan of care a physical therapist (or doctor) assesses. By becoming aware, I can ensure that my assessments tailor to my needs and put me on track for recovery.
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What I Know Or Assume
Prior to my research, the only information I knew was based on my experience in physical therapy and information I happened to stumble upon. Based on my physical therapy experience, I knew that a plan of care consisted of an assessment following treatment sessions. The number of treatment sessions were based on if I wanted to continue physical therapy, not based on goals or positive changes. My treatments were routine-like, and my therapist only saw me as another patient on her schedule, not someone to get to know better or offer the best treatment experience. From this, I assumed that all plan of cares were similar to this experience. Though I knew in order to have the best plan of care, a therapist must not only treat their patient but treat their patient WITH CARE; it was the "How could they achieve this?" that sparked my curiosity. A few ways I assumed to achieve an excellent plan of care was to be a motivator and/or friend for your patient by establishing a connection and trust. Even though much of my assumptions and knowledge were based on my physical therapy experience, they additionally resourced from information on the internet and health magazines. The internet is full of factual and falsified information, and the downside for me was the constant questioning of the validation of my resources about physical therapy. Much of the information I gathered prior to my research resourced from websites that made readers think their articles were credible. Just because a website ends in ".org" does NOT mean it is credible! I started to fact check websites, but it was tedious. I became frustrated about the long process, so I started to believe what I read and did not fact check. For instance, I believed that patients could heal solely through exercising and not other factors.
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The Search
My search was not the easiest, but it was all worth it. Based on my research, I found credible sources I did not have to fact check. Much of these sources were found on Galileo, a search engine my school provides. My first source I used was an article, "Pediatric Sports Care is a Growing Business". This article explained the importance of pediatric sports care and why insurance companies are changing their policies. Due to the lack of pediatric care for physical therapy, “practices of over-imaging and over- treating, [which] caused the tightening up of insurance rules" (Khemlani 2). This resulted in insurance companies playing catch up and providing benefits for insurers to use towards specialty doctors. Another source I found useful was a research about knowledge translation, which was conducted by the American Physical Therapy Association (APTA). "Knowledge translation (KT) is defined as the exchange, synthesis, and ethically sound application of knowledge within a complex system of interactions among researchers and users" (APTA 1). The focus of this study was to investigate the implementations of research in a physical therapist's clinical practice. From what the APTA gathered, they concluded that the use of the KT program and integration of research lead to an increase of a physical therapist's clinical performance. Following this source, I found an article about the use of yoga. The typical use of "Yoga is purported to facilitate both a decrease in cortisol levels and stress and as well as an increase in dopamine, serotonin, and antioxidant levels, thereby warranting its role as a strong modality in fighting chronic pain conditions" (Wims 1). Although I found this source to be useful in my research, there was some bias due to research strategy. Since the funding for this study was limited, they did a voluntary survey. By doing this type of survey, responses are limited and are usually from those who strongly feel passionate about the subject. All three sources aided me into a deeper understanding of pediatric physical therapy and how a physical therapist can better their clinical practice and tailor to their patient's needs. To further my research, I went to my mentor and interviewed her. My interview consisted of questions I could have never found answers to through books or websites. Among my sources, I found the interview to be most beneficial to my research, because my mentor provided me with information based on her clinical experience. Though my mentor is credible, her answers are slightly bias since they are her own opinion and other physical therapist may disagree.
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What I Discovered
Through my long research, I proved my assumptions to be wrong and discovered to design the most personalized plan of care for patients is by staying up to date on research the American Physical Therapy Association (APTA) releases, integrate different forms of exercise, and most importantly be more than a PT for your patient. From my assumptions, I thought that there was one generic plan of care for all patients and that exercising was the only considerable factor into a patient's recovery, but I proved myself wrong. Based on my research, I found that physical therapist have to tailor their plan of cares for each individual. Just because two patients have the same injury does not mean you assess them in the same way. When considering a patient's plan of care, exercises alone do not ensure a path to recovery. Therapist must use other forms of healing, such as modalities consisting of digging, soft tissue massage, cupping, and dry needling. Digging is when the therapist goes into the problematic area and digs down into the muscle until the pain turns into pressure. Soft tissue massage is softening any tissue that is left from a scar. Cupping is the use of a suction-like-cup and massage cream on the injured area to bring in blood and promote healing. Dry needing is similar to acupuncture, but instead of leaving the needle in to sit, the needle is inserted back n forth, rotated, or flicked. These modalities are used when the patient feels discomfort and pain. Besides proving myself wrong, I can say I know how to design a personalized plan of care. When designing a plan of care, one must consider research conducted by the APTA, because by staying up-to-date, therapist can apply the most advanced practice and research into their designs. Another factor I discovered into a personalized plan of care is integrating different forms of exercises. Even though patients perform five to seven minutes of cardio and stretch, it does not mean they are getting the full warm up they need. By utilizing the practice of yoga, patients can benefit by intensely stretching their muscles and improving balancing. The implantation of it can not only affect their mobilization during their treatment but also daily activities and sports. Although modalities, research, and different forms of exercises contributes to an effective plan of care, a therapist's relationship with the patient plays a key factor. Some therapists may treat their patients as another person on their schedule, and in doing so, there is no established connection causing patients to not want to be there and listen. By changing how one may approach a patient can lead to understanding patients and making treatment sessions enjoyable. For instance, I have found that if I approach patients and talk to them about their day, they become lively and want to come back for their next session. Out of all the approaches used in designing the most personalized plan of care for patients, I believe treating your patients with care is the most important factor for therapists to consider.
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Mentor Interview
This week, I interviewed my mentor and her co-workers about my research. They were best fit to answer my questions, because they have the knowledge and experience regarding pediatric physical therapy. Below is my interview with questions, answers, and reflections.
ESSENTIAL QUESTION: How can I, as a Pediatric Physical Therapist, design the most personalized plan of care for my patients?
1. What is the first thing you do when receiving patient information?
I thoroughly read everything and look for red flags. Sometimes I receive surgical protocols that are instructed my the patient's primary doctor. With this, I try to formulate a plan or diagnosis prior to their visit.
Reflection: I was expecting this answer. Prior to the interview, we spoke about what steps she takes when treating patients
2. What vital information is needed to create the most effective plan of care?
To create the most effective plan of care, I review their history, goals, and objective measures. Typically when I look at their history, I am reviewing how they got hurt or if there are any restrictions on mobilization I need to be aware of. For objective measures, this includes range of motion and strength. To calculate these, I use rulers to measure flexion (bending) in their knee or elbow and a device to measure the torque (pressure) they can generate.
Reflection: This was another answer I was expecting. I have observed many treatments and followed patient's from the start of their plan of care to the end. Without history, goals, and objective measures, patients would not recover and receive the most effective plan of care.
3. On your first appointment with your patient, what is your main focus?
My main focus is completing the evaluation and plan of care. When evaluating them, I review their strengths and mobility.
Reflection: This was no surprise to me, because she gets new patients all the time. What she told me was exactly what I have been observing with new patients.
4. Based on your clinical judgement, how do you determine a patient's prognosis and timeline of treatment?
The evaluation process aids my prognosis and timeline of treatment. But I also try to pick up on the patient's personality, because some patients show that they want to get better and do the exercises or they want to get better and not do the exercises.
Reflection: I never took into account that you have to consider a patient's personality. Looking back at a few patients, I can pick up a few personalities where their timeline of treatment has extended, because they are not completing exercises.
5. Are goals determined by your clinical judgement or patient decision? or both?
Goals are determined by both my clinical judgement and patient decision, because I want to take into consideration their feelings and thoughts on their treatment. They are more likely to work towards getting better if I get them involved.
Reflection: Prior to asking this question, I was unsure as to what the answer would be, but it makes sense that both a PT and a patient would determine goals. If a patient does not desire to work towards a certain goal, they will not be willing to do what they have been instructed.
6. If a patient is challenging to treat, how do you overcome this barrier?
I cannot force patients to complete their exercises, but if they are not complying, I must be straight forward to them or recommend them to other therapist.
Reflection: On my first day of interning, I encountered a challenging patient. This patient would always go on their phone and pretend to do the exercises. After a few treatments, my mentor told her if she does not comply and do the exercises she will never get better. The patient still did not listen to my mentor, so I tried to help my mentor by watching over the patient and ensuring they do the exercises. But still, no results were seen and the patient was referred back to the doctor and left the clinic not fully recovered.
7. A patient has a goal date, but when the date comes around, it is not met. What actions are take to evaluate this failure?
When goals are not met, I reassess my patients and make the goals more attainable. I may modify their goals and explain why I have to reassess them.
Reflection: This answer was no surprise to me. Sometimes patients have goals that will not be met until months into treatment, so their goals may have to be reevaluated. This does not meant they are never going to recover; rather so they are recovering at a slower pace.
8. You are treating two patients, with a dislocated shoulder, but they play different sports with similar mobilization. How does their plan of care differ from one another?
The first few visits are general and similar to one another. Depending on their sport and position, I later incorporate sport exercises
Reflection: Before asking this, I thought patients are secluded to exercises relating to their sport, but it turns out they are not. It makes sense that in the first few treatments, exercises will be similar, and once the road to recovery has almost ended, they start incorporating sport-specific exercises.
9. A patient has come in due to hip pain, but they later have a tibial fracture (broken leg). Do you stop hip treatment and treat both injuries or do you work around the fracture?
For this situation, I can continue treating them for the hip and modify their plan of care or treat both and do a reevaluation. It depends on what the patient wants to do.
Reflection: For the patients sake, I figured that it would be recommend that treatment be stopped until mobilization is active in both injuries, but it depends what the patient wants to do and how the plan of care is modified. If I were the patient, I would continue treatment for my hip and work around my new injury.
10. If a patient wants a certain treatment, but their parents does not consent, what measures are taken to ensure that the patient will receive the best plan of care?
If my patient is a minor, I have to get parent consent. If their parents do not consent, there is nothing I can do besides treat them a different way.
Reflection: This answer was a surprise, because prior to treatment, parents sign a consent form that it is okay for their child to receive treatment. I figured with that consent form, their child could receive any type of treatment without additional consents. An example of an additional consent is dry needling. Dry needling is similar to acupuncture, but this modality -- way of treating -- is focusing on trigger points and releasing muscle tension, causing simulations and twitches of the muscle or other muscles connected to it. The procedure requires a thin, hallow needle, which can sit in the trigger point or be moved in and out. This type of modality is intensive and requires additional consent because of the needle.
11. What is your favorite type of modality to use on patients?
Dry needling is considered a modality, so I would say dry needling for sure!
Reflection: When my mentor treats patients, she always offers dry needling, so this was no surprise.
12. Are there age restrictions when it comes to using different types of modalities (not relating to parent consent)?
No there is not an age limit for using modalities, however each modality has contraindications. For example, a contraindication to using ultrasound is using it over open growth plates, so therefore since we work with mostly growing bodies, I do not necessarily use ultrasound a lot on my kids. And then, you already know that we (here at CHOA) seek parental consent for Dry Needling as well as patient consent, only if the patient is under age (under 18 years old).
Reflection: Since the start of my internship, I have never observed an ultrasound, so I never knew what it was. Once she explained why it is not used on many of their patients, I understood why I have never observed it.
13. How do you get parents involved in their child's plan of care?
Parents are usually at the evaluation, and I try to give them my assessment of their child and the injury/issue, as well as my plan of care and the home exercise program. I encourage parents to feel free to email me or call me with any questions. I also try to speak to the parents after treatment sessions to give them an update on their child’s progress so that they feel included and informed.
Reflection: Looking as to how my mentor ends a treatment session, I knew she would speak to the patient's parent(s) to follow up on their child's progress, but I never knew they were able to personally contact her with any questions or concerns.
14. How are the implications of ultra sounding and cupping different from one another and how does one greater benefit from one?
You can choose to use modalities for a variety of reasons including but not limited to pain, muscle tightness, tendinopathies, muscle strains, ligament sprains, etc. and we use our clinical judgement skills based on the patient’s age, injury, symptoms, tolerance level, body part being treated, etc to help you decide which modality to select. I would not say that one modality overall is better than the other, but one may be more APPROPRIATE to select based on the situation or patient.
Reflection: From her previous answer to no. 12, it partially answered this question. Though it was great insight when she furthered her explanation about how modalities may be more appropriate based on the situation or patient.
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WORK CITED
KHEMLANI, ALEE. "Pediatric Sports Care Is Growing Business." NJBIZ, vol. 28, no. 49, 14 Dec. 2015, p.
18.NJA.
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Schreiber, Joseph, et al. “Knowledge Translation and Implementation Special Series. The Use of a
Knowledge Translation Program to Increase Use of Standardized Outcome Measures in an Outpatient
Pediatric Physical Therapy Clinic: Administrative Case Report.” Vol. 95, no. 4, Apr. 2015, pp. 613–629.
Wims, Mary E., et al. “The Use of Yoga by Physical Therapists in the United States."
International Journal of Yoga Therapy, vol. 27, no. 1, pp. 69–79.