6.2

Today I tackled the fax machine for the first time. At first I watched as the office manager explained the process to me. Over the last few weeks I have started helping with the office work when there isn’t many patients in the clinic. On Tuesday and Thursday mornings one of the therapists does pool therapy in the pool downstairs which leaves the clinic with one therapist. This usually means that there is only one or two patients in the clinic and there normally isn’t very much for me to do.  Typically when I am in the office I pull all the charts for the patients the next day, between 45 and 55 charts, or go over the day sheet which is the billing from the day before and make sure that all the patients from the day before were all billed. Today however I got to fax; the clinic faxes out doctors notes and evaluations mostly. Before you fax anything there is a cover sheet that must be made. These papers are pre made and you just need to fill in the blanks. The blanks are for the name of the recipient, usually a doctor, the date, fax number, patient name and date of birth, and the current date. The patient name and doctor name are usually on the paper being faxed and the date of birth is on the intake information sheet that is in all the charts, but the fax number is the part that takes a bit more work to find. Sometimes the fax number is on the script that is in the chart or if there was any other previous evaluations are letters that had to be sent. If the number is not in any of those places the office manager looks them up online. To finish the fax you just put in the number on the machine and it does the rest. 

6.1

Since being at Bay State Physical Therapy I have seen a lot of general trends for patient care plans. For a lot of different problems many of the same techniques are used. For mostly all back problems they use a method called traction. There are a few different variations in the way traction is preformed but for the most part the leg is held at the ankle and the therapist will pull in a certain way. By doing this they are able to temporarily relieve some of the tension that is in the lower back by slightly gaping the vertebrae. The therapist can do this by either using their hands or by using a belt. The belts they use are like seatbelts that they loop under the patients bent knees and then behind their own back. When leaving back they are able to give the traction without putting their self at risk of straining anything.  They are also able to apply more force than can be done with just the hands. The types of traction that I have seen most often is either with both of the legs bent and the belt of a single leg traction with the leg straight. I was told that in my career I will probably be using the belt for the single leg traction also just because of my size.  The patients report that the traction does not cause pain and actually gives a nice relief after it is completed.  The lower back carries a lot of the body’s weight which makes this a unique technique. 

5.3

Something that I have really enjoyed about my score project and something that makes me excited about becoming a physical therapist is how personable it is. All of the therapist who work there know their patients pretty well and always are eager to learn about their lives. Every time a patient comes into the office they always know their names and always remember things they have previously said. If a patient says that they are going to New Hampshire for example over the weekend then the next visit they remember that and ask them how their trip to New Hampshire went.  Being able to relate to each and every patient is something that I really like. Another perk I have seen is that patients always are bringing in food. At least once a week someone brings in cookies, or brownies and once a patient brought a pan of fresh, homemade taquitos. Those were possibly the best thing I have ever eaten.  Also one of the therapist, Mike, is the biggest fan of the Bruins ever and on Wednesday a patient offered him and the other young therapist, Mat, tickets to the Thursday Bruins game. Not only did they get to go to a playoff game but they were actually in a luxury box with the patient and about 15 other people.  I enjoy how the therapists have such a good relationship with all of their patients but also all the other therapist. I look forward to being able to experience this after college. 

5.2

Even though I have been at Bay State Physical Therapy for about five weeks I still am seeing new things every day. However, when I see new things it just happens that I see the new thing multiple times in the same week. This week a saw a new method that uses a blood pressure cuff. I saw the blood pressure be used for a task different from the typical assignment of taking blood pressure readings. They said they were using the blood pressure cuff for something called biofeedback. Something that is very important to most injury improvements is maintaining a strong core. To do this they emphasize a using a pelvic tilt in many of the exercises. A pelvic tilt is rotating the pelvis forward and tightening the core. Biofeedback is a method used that allows the patient to see the consistency of the tilt by placing the blood pressure cuff under the lower back while the tilt is held. The pump on the cuff is set to approximately 40and then different exercises can be performed. During the exercises the patient can look at the gauge and see the change in pressure, the goal being able to not see the pressure change it the different exercises. The exercises I saw this method used with include picking up the feet one at a time or straightening the legs one at a time until they are a few inches above the table. Using this method is a good way to show patients improvement over time. When first using this method it always proves to be very hard but over time the change in pressure decreases. 

5.1

Today I saw a different type of treatment that is not like the typical manual work or exercise routines; they used a procedure called iontophoresis. This procedure can be used for a few different problems including reducing inflammation or helping with bone spurs, when there are bony projections along the edges of bones most often resultants of wear-and –tear.  Iontophoresis uses a patch that has two gauze patches, one labeled positive and one that is negative.  To use the patch one side is filled with a negative solution, which at Bay State is a saline solution. The other side is filled with the medication, in the case it is being used for fighting inflammation normally dexamethasone is used, and for bone spurs they use acetic acid which is basically a fancy name for vinegar. Once the two solutions have been added to the patch the patch is placed over the problem area and a battery pack is attached for three minutes. The patch works similarly to a magnet and the battery helps propel the medication through the skin.  After the three minutes the battery is removed but the patch is left on for two hours. The benefit for using this method, especially for administering antinflammitories, is that the medication is more direct and there is the potential for stomach problems caused by oral medications. There is one downside which is that in order to use the patches the patient must receive a prescription for the positive side medication which depending on insurance companies can be expensive. 

4.3

Today I learned about a whole other side of the physical therapy field. When a patient came in with some shoulder problem and also a concussion I learned about the neuro side of physical therapy. First they worked on her shoulder problems and then they moved onto the symptoms of the concussion. They had her stand in front of one of the table with her fingers hovering above the table for stability and then had her do a repetition of movements. I was told they normally don’t deal with neuro-pt at Bay State but they wanted to help this girl beyond the shoulder problem. When she was standing in front of the table the first thing she had to do was close her eyes and try to stay balanced for a few seconds.  At first even this simple task through off her balance but over the process of the movements you could see improvements. The next steps including tilting the head up and down, side to side, and then putting her feet tandem, which means one in front of the other and then she did the same motions in that stance. The first time she would try any of these she would experience difficulty but by 30 seconds she would begin to have control. She then repeated the stages with her eyes closed which made her rely on her inner ear, the part that is affected by concussions. To help fix the mess up from the concussion the motions must be repeated to instill the idea. 

4.2

Today I learned two new techniques that I found pretty interesting. One was a technique called a trigger point release. This method is used to release a knot in a muscle. Knots are caused by overuse, straining, or even from sleeping in the wrong position. Essentially a knotted muscle is muscle that is in constant contraction. With a trigger point release overpressure is used to fatigue out the receptors to the point when they finally just release.  The pressure is not necessarily applied directly to the knotted or tense are but there are specific release points in different muscle that house these receptors. Today I saw this used on a patient who had lower back pain and also a high school student who had fallen off a snow mobile and was experiencing neck tightness.  

The second technique I was showed is a method I believe was called makano taping but I am not quite sure on how to spell it. The patient that I saw receive this method was experiencing knee pain. I was told that the knee cap in some people lies to laterally, or on the outside so this method would help draw the patella medially and help take away some of the rubbing the patella was creating in the joint. They used a brand of tape called leukotape which is a really strong tape. The first step was using tuf-skin which is an adhesive spray and then a cover roll is put on which is a soft tape that the stronger tape is put on. With the leukotape the therapist moved the knee cap with his hand medially and then put the tape over it with a lot of tension. The patient reported that he could feel a positive change.

4.1

Today I was given a special task which I was very excited about considering I was going to be in the clinic for six hours and any small task makes the time pass quicker than just standing and observing. The week before I had been asked to create a few different spread sheets for various things and apparently I did such a good job they had requested me to make another. The owner, Brett, asked me to make another spread sheet with the names of different doctors, their emails, phone numbers, fax numbers and mailing addresses. I have not spent that much time working with excel before this score project but most of it was easy to pick up except for the occasional problem I ran into. For this specific project today I had difficulty separating the doctors into different categories. I was asked to put the doctors in groups according to where they worked; for example there are about 16 doctors that work at Sports Medicine North, and another place would have three and so on.  I really wanted this chart to look good so I kept changing the format until I finally found a way that worked. The information I was given to put in the chart was a list of different doctor’s offices and was told to look them up on Google and fill in the chart.  For most of the offices it was fairly simple because their websites had a tab called “our specialist” and the doctors were all located. This entire process took about two hours.

3.3

When I first got to the office today I was amazed by how many people were there. All of the therapists were there as well as a college student intern; and every bed was filled plus two patients were in chairs. I was shocked at how easily the therapists were able to handle this massive number of patients. They altered their normal course of treatment so that some patients were getting manual work for their neck before going on the table like normal. At one point a patient was done with her icing the aid helped take off the ice and the patient up while I started wiping down the table for the next patient. After my first hour there the clinic had drastically changed and there was suddenly only one patient there.

At that point I went to go help at the front desk because I wasn’t needed in the clinic. First I pulled all the files for tomorrow’s patients which seemed to be a lot easier today because I had started to know the patients names and was getting better at the whole alphabetical order thing. Once I had stacked and recorded all the patients and their co-pays I had to pull another pile of files for patients that would be going in tomorrow for pool therapy. On Tuesday’s and Thursday’s one of the therapists ,Mike, has pool therapy for four hours and during this time he shows patients exercises they can do in the water that are less strenuous then on land. I also learned how to fax stuff today. 

3.2

Today the office wasn’t very busy because most of the therapists were at a meeting so I got to help the office manager instead. She had to run to the bank to drop off the weekly deposit she asked me to pull all the patient files for tomorrow. To do this I had to write down all the names of the patients for tomorrow on a special sheet in order as I saw them in the schedule book. Once I wrote all 52 of these names down I went through the list and took each file out of the cabinet. There are two drawers to the cabinet with the first holding the first half of the alphabet and the second holding the rest. There is also a section in the bottom drawer that has held patients who taking a break from coming but are not discharged yet. On the other side of the office is a bigger filing cabinet that has all the discharged files dating back to January 2012; everything before that is stored in a different location. After I took each file out I had to open in and write down on the name sheet what their co-pay was. A majority of the patients don’t have co-pays because their insurance has a deductable and they are billed directly to their house and the rest range from $10 up to around $40. I put all the files in order and stacked them in their designated spot, helped clean up a few tables and went home for the day. 

3.1

Bay State Physical Therapy sells Aline insoles at their office. These are a type of insoles for shoes that is a higher level than the inserts available at drug stores and one step down from fully customized orthotics. They are a good alternative and cost only $100 compared to $300 custom orthotics. Today I learned a lot about these because the owner was teaching one of the aids at the office how to screen people for them. In the future Bay State plans to occasionally set up a station in the downstairs lobby to show them to the general public of the YMCA. When the owner was explaining them to the aid I also got to listen in and get my foot fitted and evaluated. To fit people to the insoles they use a piece of equipment that the foot rests on that has two metal poles near the ankle on each side of the foot. The first thing they ask you to do is to do a few squats and they watch to see if your ankle gets closer to either pole while you do so. They observed that mine tended to role medially (towards the middle) they then turned on a laser that was positioned to line up your ankle and knee and then the repetition of squats was repeated. Using the laser showed how even if the ankle isn’t moving sometimes the knee is compensating. They then put the insole under my foot and when I repeated the squats my leg was a lot more inline. 

2.3

On Saturdays I work for six hours which is my longest day but they are also my favorite days.  With only one therapist working and no office manager I get the opportunity to help out a bit more than usual. I get to answer the phone and help patients with heat/ice and some exercises. This Saturday the YMCA hosted a healthy living event at the teen center adjacent from the YMCA. There were a bunch of businesses that were able to set up booths to teach children about healthier lifestyle. Bay State had a booth but Bret (the owner) wouldn't be able to make it until the time it started so he had given me a list of things to bring over and set up before the event started. This gave me the opportunity to walk around a little and was fun.

I also learned that physical therapists have to be very flexible because patients often cancel at last minute or just don’t show up. Today an patient that was coming for an evaluation, a one hour appointment, never showed up so the therapist, Mike, I was with taught me how to crack backs. He taught me three different methods; one of which the patient was on their back with your hand under them, one where they were on their  back and one where you twisted there lower body. First he explained all of the ways and did them to me and then he gave me the chance to try them on him. He said he’ll let me try more in the future.

Sarah: 2.2

Today during SCORE I continued to observe the therapists at Bay State Physical Therapy. One of the patients I was observing was recovering from a knee replacement on the right knee. I am not quite sure how long ago the surgery was but she was on the strengthening phase of recovery. After surgery the first phase is just letting everything heal and then things like scar tissue needs to be worked. If you begin strengthening too early you risk re-injuring the operated area, and because you cannot strengthen during this time a lot of the muscle tone begins to go away and it is necessary to build everything back up. This patient did a series of strait leg lift on her back, as well as ball clamps (when a ball is placed between bent legs and the patient squeezes the ball to work the inner quad muscle), and bridges.  Another part of the recovering from a knee replacement is working to gain back degrees of flexion and extension. Flexion is decreases the angle and extension makes the degree between the two parts greater. This is a slow process where normally only a few degrees are gained a week but has a greater chance of improving with the hands on help of the therapists. The therapists are able to stretch the patient in a controlled way that the patient often cannot do on their own without risking pushing it too far. Even though I am not allowed to do anything hands on I have enjoyed watching all the therapists.

2.1

The Beverly Bay State Office is located inside the Sterling YMCA right off of the gym. I think this is a really unique opportunity for the clinic because it allows them to have the use of many different machines that most clinics lack. They have access to bikes, treadmills, a variety of weight machines and many more.  Something I have learned about this individual office is that they try to focus on manual work such as soft tissue massages and then teach the important strengthening exercises for the patients to work on by themselves. Other physical therapists tend to do a repetition of exercises during a visit but mostly they are things they can do on their own were as manual stuff requires a therapist. I was also informed that most of the patients that go to Bay State are also members of the YMCA so if they are taught machine exercises they are able to come in on their own time to continue working.

Today I spent a lot of my time in the gym with one of the student therapist who is also a certified personal trainer.  She was sent out with patients after they had been with their therapist and after the therapist had told the assistant what they wanted to be done in the gym. I saw a lot of strengthening of the shoulders and back with use of the weight machines as well as some resistance pullies. As a side note I also so someone who had blacked-out on a treadmill and who was taken off by the ambulance unconscious. 

1.3

Today I was at my score for six hours. On Saturdays there is only one therapist and no secretary. This gave me the opportunity to try out answering the phone and handling some of the scheduling. I rescheduled one patient who wanted to make her next appointment earlier and then I canceled an appointment for that day because someone had received Red Sox tickets for the same day. With only one therapist in the office it gave me a lot more opportunity to do a lot more to help out the therapist such as getting kettle balls from the gym, getting heat packs and ice packs, bringing patients back from the waiting room, and checking a patient out who wanted to buy a role of kinesio-tape for the Boston marathon this Monday.  I was also able to give a new patient paperwork to fill out as well as making a copy of her insurance card.

I also got to hear all about how the boss and the therapist I worked with today are going down to Boston on Monday to help with the marathon. At the end of the race there are fifty first aid tents and for every five tents there is a physical therapist, a physical therapist student, a nurse, a doctor. Last year the boss ran the marathon and they said they were excited to get to go this year to get the offices name out there.  They were also excited that it is not supposed to be as hot as it was during last year’s Boston marathon. 

1.2

On my second day at the clinic I got to work with my score advisor who is also the owner of the clinic as well as one of the therapists I worked with on my first day. I was also introduced to a college student who is doing a weekly internship as part of her physical therapy schooling. She is able to help patients do some of the basic exercises under the supervision of the licensed therapists. After the pre-work rush I listened to the boss and the intern have a conversation about different colleges and how they have contracts with different physical therapy offices and that is how people get internships. I had never previously thought about this and it was an interesting thought considering my supervisor is already filing paper work for his next year’s interns. I was given a bit more responsibility today and was asked to bring patients from the front room back to the tables. This was an opportunity for me to talk to the patients and also gave the therapists time to finish up with other patients or look over charts. Another thing that I learned about Bay State is how they take their notes of patients which are completely done on computers the only part that goes into their physical chart is their evaluations, and re-evaluations.  So far I am still finding my way around the clinic and meeting all the people who work there, I hope to get to shadow each of the therapists at some time. 

Day 1 (4/9/13)

Today was my first day at Bay State Physical Therapy in the Sterling YMCA in Beverly. When I arrived there was only one therapist there who I had never met. As soon as I got there he was seeing his first patient. I got to watch him treat this patient and I got to learn about kinesio-tape which is a type of tape used to help with stability but still give patients a full range of mobility. I was taught the process of applying it which requires using a spray called tuf-skin which helps with the adhesion. Throughout my day I saw this method used on an ankle that had an avulsion fracture (when a section of bone dethatches from the whole bone usually due to a tendon injury), and also a patient who was experiencing knee pain due to a partially torn calf muscle. I was also told how when massaging edema (swelling) how you want to massage towards the heart so that the blood and fluids get reprocessed which is a concept that I have never considered.  Besides observing a few patients I was also showed around the office and was told how they schedule appointments and how and where they store their files. For their scheduling I learned about the different marks they put for patients who show up to their appointments, cancel, reschedule, or do not show up.  I learned a lot about how they operate their office. I look forward to returning and working with the different therapists and being able to compare their styles.

Sergeanr's Outline

Sarah Sergeant

March 11, 2013

Score Thesis & Outline

Thesis: Females are more susceptible to tearing the anterior cruciate ligament of the knee due to differences in the physical structures in their legs as well as hips, along with differences in muscle strengths and flexibility compared to the male knee.

Body 1: The knee is a fairly simple hinge joint that is constructed by three bones, as well as a number of ligaments, muscles and tendons.

·         The three bones: the femur, patella, and the tibia.

o   The patella (knee cap) is normally what we associate with knee but the other two bones are the bones on either side of the knee.

·         There are four ligaments which connect bone-to bone.

o   Anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), lateral collateral ligament (LCL).

o   The ACL is responsible for the rotational movement and the forward movement of the tibia.

·         A variety of muscles move the knee including the quadriceps on the upper thigh, hamstrings, and the plantar flexors, dorsiflexors and the soleus.

·         Each of these muscles is attached with tendons to the bone.

Body 2: The hips play a crucial role in the alignment of the knee, and position of the leg.  

·         The hip or pelvic girdle is made of three bones that are fused together (the illium, ishium, and pubis.

·         The sacrum or the final segment of the spinal column is also located along side the pelvis.

·         There are variations in heights and widths of this bone.

·         The femur or leg attaches into a ball and socket joint

Body 3: The lower portion of the body differs in both males and females, especially in the hips.

·         The pelvic girdle of a female is wider and shallower.

·         The hips are also more flexible and allow for more rotation.

·         The femur is angled forward and towards the knee at the top.

·         Less developed thigh muscles. (Quadriceps)

·         The knee joint is more flexible and can hyperextend

·          A narrower notch in the femur where the ACL attaches.

·         The hips of a female are straighter which makes the angle of the leg lean more inwards.

·         Women have a lower center of gravity.

·         Women have more flexibility in their muscle tissue.

Body 4: Women have less stability in the knee due to weakness of the muscles, and hormones.

·         Female leg muscles are often more lax.

·         The ACL is required to stabilize more because of the muscles laxness.

·         Hormonal levels at certain times during the menstrual cycle make the ACL more lax.

·         Flexibility helps prevent injury because the parts can absorb more shock before damage.

Body 5: ACL injuries can range in severity and also can be caused by a variety of different movements.

·         Most of these injuries are seen in athletes.

·         Tears can range from a small injury to a complete tear.

·         If all surrounding ligaments are loose then more stress is put on the ACL.

·         ACL injuries can be caused by many things:

o   Overstretching.

o   Extending knee past normal resting position (hyperextension)

o   Impact when the leg is firmly planted.

o   Sharp changes in movement and abrupt stops during high speed movements.

·         Ligaments have a low blood supply which causes slow healing and they cannot completely regenerate by themselves.

Body 6: Many severe tears in ACL’s require surgical repair due to the lack of a blood supply to the ligament.

·         In the occurance of a tear the ACL cannot be mended or reattached so normally a graft is done.

·         Most of the time grafts are taken from tendons, not ligaments in places like the hamstring, or quadriceps.

·         The majority of the surgery is completed with arthroscopic techniques through two small incisions.

·         A larger incision is made to take the graph from chosen location.

·         The recommended time for surgery is 3-6 weeks after the injury to allow for all swelling to die down.

·         6-9 months is the typical recovery time for surgery.

·         Physical therapy is prescribed after surgery to help regain strength, range of motion, and propioception (awareness of your bodies position)

Body 7: Awareness of movement can help in preventing an ACL injury by knowing what types of movements can put the knee at risk.

·         Females tend to not flex their legs when landing from a jump.

·         Focusing on landing on two legs after jumping instead of one takes away some of the chance of putting too much pressure on one leg.

·         Work on balance.

·         Be aware of position:

o   Chest high and above knees.

o   Have a sports stance with knees bent coming from hips.

o   Toes facing forward to prevent from rotational problems.

Body 8: Having strong leg muscles such as the quadriceps and a strong core help in preventing ACL injuries, especially in women who generally have weaker muscles.

·         When the muscles are lax the ACL is at a greater risk for tearing.

·         Quadricep strength and hamstring strength help in stabilizing the knee.

·         Core strength.

·         Practice key movements repetitively and with good form so they become second nature.

Works Cited

Carlson, Karen J., Stephanie A. Eisenstat, and Terra Diane Ziporyn. The New Harvard Guide to Women's Health. Cambridge, MA: Harvard UP, 2004. Print.

• This book is specified for the female body and has a variety of useful sections one of which is a section on knee pain. This is none specified to the ACL and will allow for general knee information.

Chiaia, Theresa, and Polly De Mille. "ACL Injury Prevention Tips and Exercises: Stay Off the Sidelines!" Hospital for Special Surgery. N.p., 24 Mar. 2009. Web. 13 Mar. 2013.

• I will being using this source to get information about how to prevent ACL injuries by proper strength training and what types of movements you should look for.

Haverbush. "ACL Injuries in Women." Online Orthopaedics. N.p., n.d. Web. 13 Mar. 2013.

Ireland, Mary L. "ACL Injuries." ACL Injuries. N.p., n.d. Web. 13 Mar. 2013.

• This source goes into a lot of depth on differences in the knee ACL specifically. One unique part of it is the section where it talks about hormone changes and how this plays a role on when your knee is weaker.

"Ligament Injuries to the Knee." Ligament Injuries to the Knee. N.p., n.d. Web. 13 Mar. 2013.

McAlindon, Robert. "ACL Injuries in Women." ACL Injuries in Women. N.p., n.d. Web. 13 Mar. 2013.

• This goes into more depth about the differences in the female knee, ligament injuries specifically and the lack of muscle strength. A large portion of it is about muscle and ligament looseness.

Schenck, Robert C. Athletic Training and Sports Medicine. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1999. Print.

• This book talks about general anatomy of the body and specifically the muscular and skeletal systems. This is also a complete section specific to knee injuries. The part about the ACL talks about stability. Also they talk about the reconstruction of the tibia after a tear.

Scott, W. Norman., Carol Colman, and Robert S. Gotlin. Dr. Scott's Knee Book: Symptoms, Diagnosis, and Treatment of Knee Problems, Including--torn Cartilage, Ligament Damage, Arthritis, Tendinitis, Arthroscopic Surgery, and Total Knee Replacement. New York: Simon & Schuster, 1996. Print.

• This entire book is about knees and there are sections that include different types of recovery surgeries, and there are different types of ways to test the amount of damage to the ACL.

Stein, Alvin. "Why Ligaments Do Not Heal On Their Own | GetProlo.com." GetProlocom. N.p., n.d. Web. 13 Mar. 2013.

• The website talks about the body’s ability to repair ligaments and how it isn’t very capable of this because of the lack of blood supply directly to ligaments. It also includes a section about the prolotherapy which is a way of repairing smaller ligament injuries non evasively.

Wickiewicz, Thomas L. "Anterior Cruciate Ligament (ACL) Tears." Hospital for Special Surgery. N.p., 14 Jan. 2003. Web. 13 Mar. 2013.

• This website talks about what exactly happens in the event of an ACL tear. It talks about the different severities and conditions. 

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