PTAE 208 NIC Originates

Let's do this...hey.

um.....

I kicked somebody out of my office,

So I could go to class

Like , I got to go! (student laughter)

Then I gotta run.

um....I gotta catch my breath.

um...

If you guys have seen

me...you would have thought

there's a fat man running in a

(Students Laughing)

Ugh, alright....

That pole

This pole right here

Is right in my view

Is that good for the camera? You guys.....

Alright, let's see

if i can get into

the computer

Then we will get started

Um..

So the quiz, i'ts posted.

Just on what we've

been covering this week

nothing more.

Just 5 questions.

There's some stuff about impairment,

on the disablement stuff

that we talked about.

There some questions

about some

examination stuff

we will talk about today

So um

It really..this quiz

isn't meant to be

terribly hard.

but more like

to get us used to

taking quizzes

and tests again.

Because you're all out of habit, right?

So...umm.....,

and then

I tried to

to move the quizzes

into the canvas

sequence so you kinda

see where they fall.

Its a little more logical

And I'm working through,

I'm in my office

going through the books

page by page

kinda getting things sequenced.

As soon I get that all done

and put together

I'll send it out to you guys.

So those of you who have the new book

verses the old

so we are all square.

And LCSC would you guys let

(pause, thinking of name)

Levi know his book is coming

in the mail?

It should be there in a couple days.

So, where are we?

Um

(student) So John,

is our syllabus off then?

Cause it says this week we are supposed

to go over chapter 5.

I think that is why we are a little confused

we just don't know which chapter we are

supposed to be reading.

(teacher) Little bit off Yes.

For this week,focus on the lecture materials

less on the book, if you would please.

I think that will, like,

You will be more successfull this week

doing it that way.

Sound fair?

The whole purpose of this week

umm

The lectures we are giving this week,

Im really trying to help you get into

the mind and thinking like a therapist.

and that is so, when I look at a patient.

When I am dissecting a patient

in my brain clinically

This is how I do it.

Alright.

And that is the whole point of this weeks

This first lecture is,

to get you guys thinking like a therapist

So you can make a decision like a therapist does.

Does that make sense?

So um,

I really encourage you guys to be asking

questions, um, as we go along.

because its through those questions

and that dialog that, that,

that the understanding comes.

It not,

I think its not necessarily intuitive all the time.

So, Umm, but I need you guys that,

that have good questions

and even questions that your like

"I'm not sure I should ask this"

I guarantee you, that if you have that

question someone else has that same question

Ok, Let me see if I can get onto Canvas now

Ummm

Alright

This is where you are normally teaching in

in this building, and today we're

teaching out of this building right here.

I dont know if you guys will see this

or if it will write on here, ugh it wont.

So normally we are here, and

today we are in this building over here

which is really close to the water.

(student laughing)

And right here, is the blackberry patch.

That in the fall you can go pick blackberries

Right here, Ummm......yeah

So I will supplement my lunch

with fresh blackberries.

Its really awesome!

And then my wife will go down there often

with the kids picking blackberries.

She probably picked 5 gallons last year

I were to guess, If I were to guess what

how many, how much, she got last year.

It was a lot!

Umm...

How are you guys doing with Neuro?

(Student) Sighs, "Confused!"

(Teacher) You ok?

(Student) "Surviving"

(Teacher) "Surviving? Umm..."

NIC? Do you have any tips?

NIC was studying as a class before.

Any recommendations?

They just had a giant study class session

(student)We just bounce things off eachother

If you do not have a study partner,

getting a study partner will help.

Please a lot of it is this stuff

to talk about and then it will make more sense

OK?

Ummm

Alright.

Let's do this.

Let's get this show on the road.

(students)Lets go for it! You've got this!

( Teacher) Alright. Ok, Where we at?

Umm

Say that again?

Student:Measurement of Functional Outcomes

Teacher:Measurement of Functional Outcomes

Alright, So, Umm, umm...

So in clinical practice, we have these

functional measurement tools.

Umm and there's

and there is as many

as there are sands of the sea.

Umm

but they are what we use to measure

the before and after stuff.

So for like when our patient is done.

Even though they say they are better.

Often times what these questionaire

are really good at teasing that out.

For example,

Umm, one functional measure that is used

for patients who have low back pain, is

the Oswestry low back pain questionaire.

And I'll write that out for you guys so

can know how to spell it.

So, Dang it! Pens not going to work!

Pen please work!

Ok

umm...

Alright, we need to use, I need to write

this down for you guys so we will.

Student: Can't you just write on the board?

Teacher: Yeah but they can't see the chalk

Students:We can actually see the

chalk board, I mean white board.

Teacher: But would you be able to read it?

Students: If you write it real big!

Teacher: Can you read that?

Students: Yes, "O-S"

Teacher: Oswestry

I'm still going to pull up the smart board

Ummm.

Because I just in case some of you

can't read it really well.

(Inaudible Students talking)

Teacher: Umm

So the Oswestry lower back pain

Questionaire, and you can get it in

multiple languages.

So, I had a patient who was in a car

accident. He had a lumbar radiculopathy

meaning that he had these nerve symptoms

that went down his leg, like numbness,

tingling, so you know it was suspected

that he had a disc herniation as part

of his accident that resulted in these

symptoms, and umm..

I, uh, he was native

his..his first language was Spanish.

So I administers him a Spanish

Oswestry....umm...Questionaire

So that I could make sure that I captured

his...uhh...status.

and when we first started he scored

like in the 70s-80s which is

80% disabled meaning he can't

really do anything....ummm....

and this was a patient that, ummm...

(Sound of the pen on the smartboard)

ummm

was hoping that this car accident

was his golden ticket.

ummm

ummm

His golden ticket in life. So he was

going to ride this accident out,

and get every penny he could out of this

ummm, but that Oswestry Questionaire

It's really really quite good. and umm

When I had him fill it out like ya know,

he was doing really well, doing his

exercises, his umm.....

and I had him fill out the Oswestry

and he scored an 8 on the Oswestry

which you know, ah, is almost next

to nothing, you know?

And so , he is doing really well.

when someone scores Oswestry less than

10, Often times they discharge them.

Because if they are that low, you need

to keep doing what we are doing.

and you will continue getting better on

your own, you dont need keep coming to

keep coming in to see me, otherwise,

But he told his Attorney, well I don't

want to stop therapy because I

want a bigger settlement.

But he was done with therapy.

You know, so, he stopped doing the home

exercise program and his symptoms got

worse again then he ended up getting

surgery. He insisted on surgery.

and anyways umm...but....

his case didn't go very well.

He didn't understand how the justice

system works...but...

Student: It seems like a pretty simple test.

Teacher: Yes it is a simple test,

and its very good.

And, Uh, its very effective.

The efficacy for the Oswestry

is really high.

you know, umm, and so, its something

that I use a lot with lower pack pain.

But there's tons of these functional

questionnaires...ummm...and..

functional outcome measurements that

we can use, umm...and ummm

The best ones, ummm...are the ones

that...can...help us to quantify

their impairments.

So a functional measurement tool umm..

that I like to use, umm that does

this really well is the Dynamic Gate Index

the "DGI", for example.

This would be one that I would use for

somebody who has a..uhh...

ummm

(writing on board sounds)

balance issues, and they have difficulty

like with balance as they are walking

through their house, they are falling

down, maybe difficulty you know

they are having like multiple falls

throughout their day.

The dynamic Gait Index umm

Its a series of tasks we put them through

That we can score their performance on

an object able measurable score.

Then we can repeat those same tasks again

and get another number score and we

can numerically measure their change.

umm the thing I like about the Dynamic

Gait index, is that uh...

ummm....each of the items can be

a functional measurement in and of

themselves and they can also

be your intervention list, ya know?

So let me pull it up real quick.

We will go through it just real quick.

I'll make this bigger.

Alright...So...

We will go through it right here, the top

score is going to be a 24.

So someone who is a 23/24

Those are considered people who are "safe"

Alright?

Where as if its less than 19, it is

going to be predicted of a fall.

The lower their score, the higher

their fall risk is.

And so umm....

the first umm...item on here is...

is walking straight. SO you have them

I usually do this in the hallway

I like doing it in hallways that are tile.

because tiles make a little runway.

And I can see their lateral deviation.

Umm...this is what we are looking at.

umm, seeing if their like, umm..

walking like a drunk sailor or not.

We can score them, ya know, on

their walking speed, we have their change

gait speed, walking fast or slow.

So we are looking at if they are able

to alter their gait speed.

You know, having them look left and right,

maybe some dynamic movement in there.

We are looking for stumbling or instability

looking for them to slow down,

you know when they have to move

their head or stuff.

This one is the gait, pivot, turn. umm

this is like the about face in the military

you know when they do the about face

where you turn and stop, and you look for

instability and how long it takes them to turn

and then each of things, ya know,

we go through it, umm...

I might score them as a 15, and one

of my goals in therapy might be

to get have them get to be that 19

or set a goal, umm, or maybe set goal for

23/24....ummm...you can pull up

this gait index and now you know

what to work on.

So we are going to some activities

that require you to step over obstacles.

We are going to practice. We are going

to change the environment and we are

going to control how you set it up.

And that's how we are going to guide

what we are going to do.

Based on this objective measurement.

We have our first 5 training sessions

figured out. Just based on the results of this

And so umm.

Thats why when I say, when you really

get into therapy umm...a good evaluation

really is important umm cause you can pull

little bits of data out of that evaluation

and you can look at the goals and the

patient what they want.

Usually I put down what the patients goals

are, their functional goals. umm..you know

I want to be able to grand wish,

"I want to be able to...Whatever!"

Ya know. "I want to be able to garden

in the summer" Or

"I want to be able to...Whatever!"

So I'll break down what they want and

their impairments and functional limitations

That I'm finding, and I'm going to write

goals and treatment plans based on that.

And...Uhh...You can go back to that eval

and know where the deficits are which is

why we cover a lot of these things in

PTAE school because you need to know

what you are looking at, and know

Oh ok! I can use that and it will help

guide me in what we will be doing with

this patient.

Let's get back to it.

Alright, Uhh....

Alright, Uhh, Ok, SO

When we are trying to decide what

we are going to be doing with the patient

Really there are 5 things we are looking at

We are looking at the Patient examination.

Or eval...them...which the examination of

the patient is like the things we are doing

that are measuring. So that is our

Manual muscle tests, that our ummm...

Dynamic Gain Index, It would be Umm...

All those things, that, Its like all the

information of our history, all the

information we are gathering about this

patient into a big giant pot. We just

gather all the information we can. We

have their medical history, past medical

history, family history, previous injury

surgical list, We have their goals, their

mechanism injury,how they hurt themselves

what they were doing, what kind of

symptoms they have now, and we have

all the information we gather, and then

we evaluate that data, and umm, we

identify specific things that need to be

worked on or that are relevent, specific

problems And with that we develop

a diagnosis and there are really 2 types

of diagnosis's, there is medical diagnosis

like a rotator cup injury or there might be

a phsycial therapy diagnosis which is

usually functional based. So sometimes,

we use a medical diagnosis, but sometimes

we come up with our own.

So for example, someone who has low back

pain, if you guys, were to go through

the McKenzie Method Trade, umm, you would

put person through this evaluation process

That is part of the McKenzie Method.

and we would come up with a McKenzie

diagnosis. So someone who has low back pain

We may diagnose them with what we call

a derangement. A derangement with the

McKenzie method is something to do with

the disc that is causing a impingement

on that nerve root. So we may say that

patient has a derangment their response

mechanically to repeated extension.

We call them "Extenders" vs someone

that responds to inflection.

And then, you would use that diagnosis

after you have been trained in the McKenzie

method, and you know exactly what to do

with them.

Umm..We will talk about the Mckenzie Method

later on in this...ah...class.

Yes, We will go through the McKenzie

Method, and I'll teach you the ins

and outs of it when we get to the

lower back section.

So its not like totally comprehensive

but its enough that if you were to come

across a McKenzie evaluation you will

know what they are talking about.

Alright, So we had this diagnosis.

and then we come up with a prognosis

and a plan of care.

and ahh, the prognosis is

really really subjective.

and sometimes I feel like

ummm..

ummm...

This ability to determine a prognosis

I don't often share my prognosis with

the patient because I don't want my

biases influence their outcome.

So if I tell a patient, Yeah, I don't

think you are going to get better.

Are they going to get better?

No.

So, often times, I am optimistic and

I focus on the positives because I

like to prove myself wrong sometimes

This was a hard lesson I learned

early on in my career when I was

doing my observation hours to get

into therapy school, I was watching

a therapist work with a woman,

who had, had a couple of strokes.

This would have been her 3rd stroke, and

when he was working with her, she

couldn't even stand.

Her whole left side was essentially paralized

and I remember watching this therapist

work with this woman, day in and day out.

Thinking he is wasting both of their times

She is not going to get better.

and...I....

remember like, having really negative

thoughts about this therapist. He is just

wasting their time. This is horrible,

I can't believe he is doing this.

But you know, I'm the "student"

observing, so I'm not saying anything

obviously

But, He totally proved me wrong.

and so did she, and she was determined

andshe walked out of that skill

nursing facility, and lived at home with

her husband, with a cane. She

walked out with a cane.

She walked out with a cane and

I ate my thoughts, ya know?

That really taught me, a really

important lesson, is not to decide

what's going to happen with the patient

because ya know, she wanted to get better

and she worked her tail off and she got

better. and....umm....So

the plan and care is a couple of things

I think we talked about it more

So we will get into the plan and care more.

Umm, and then so the therapist will

develop a plan of care and you guys will

follow the plan of care or implement it

And that kinda where you fall in on

this chart, is the implementation of that

plan and care.

That's your job.

Ummm.......So.....

The examination begins....ummm....

with that patient referral.

Umm....

and this is really something that happens

throughout the treatment episode.

Ok? So that

I do the therapist does initial evaluation

but you guys are collecting data along the way.

When I'm doing home health with the patient

and i'm doing time up and go test.

As ....a .....uh....

functional measurement of progress.

You know, I really appreciate it when the

PTAE, periodic does that time up and go

and I can go back when I'm doing my..my

maybe I'm doing a progress note after

30 days, reviewing the discharge summary.

When I'm writing it, I can go back, and I

can say, You know What? Yeah I can show

his steady progress throughout their plan

and care.

Um, because you guys were collecting

some of that examination data.

and we work together to do that.

and....so....ummm...but...

This examination is where is where we're

pulling information,from as many places

and sources as we can get, and we're

just trying to get as much information as

we can get, so we can have all the information

we need so we know we are doing the right

thing.

ummm....so.....the ah....

So the difference between examination and

Evaluation is in your SOAP note.

So in your SOAP note, you have you "S"

which is your subjective information

Your "O" is which your objective information.

which is our examination information.

Then our "A" is our Assessment

which allowed us to evaluation.

That evaluation is where we synthasize

all this information, and we put it all

together, and we make a judgement

or make a decision.

Its, its, what is the human element of

this whole process.

and....umm....

that's what the evaluation is.

ok?

and ummm......

For the examination really 3 like basic

important components.

You have the patient history, which comes

from multiple stake holders sometimes.

It might be a child we're talking to a parent

or talk to his teachers, ummm it may be

an older adult where we are talking to the

children getting data from the children

It might be getting information from other

umm...medical professionals. I might be

reviewing a medical chart or I'm looking

at a surgical report.

I'm looking at, ya know, their notes from

their last doctor visit. I might be

looking at maybe notes from OT.

I might be looking at lots of different

information and I'm putting it all together

I'm doing a system's review, where we

go through systematically.

Umm, So we are going to be looking at.

ya know,

subcutaneous system, their neouro muscular system

We're looking at their cardiovascular system

looking at all their major body systems.

and just as a general evaluation

umm...

and as a PT, its at my discretion to skip

stuff, ya know?....So....

I might be having like a young 12 yr old

soccer player, that umm...ya know

twisted their ankle, and its sprained.

and i might like really quickly just gloss

over their cardiovascular system.

because you know this person spent

they, they don't have the cardiovascular

history, you know, I may not do like a lot

of cardiovascular intervention or assessment

for that person because it isn't necessary.

Where as if I have a new patient

who is older and they have had

3 heart attacks and they have you know

congestive heart failure, and they've got

peripheral vascular disease,

already had 2 strokes,

they've had a pulmonary embolism

I'd probably do a really thorough

cardiovascular check on them.

As part of my evaluation....so

You may see a lot of like variance

from one eval to the other,

based on the patient.

Ok, and that's my digression.

And then we have all the tests & messures.

Those are all the things

all the data, all the info that I collect

that I gathered.

(Student ?) So....the evaluation is based on

the examination.... Jon: exactly

The evaluation is based on the examination.

(clears throat)......yes.

They..we call it a funnel......

like this whole process is

funneling down to what's key.

We start out with that first examination,

Where we're the circle is really big,

and then as we go through

the evaluation process,

We are honing in on

what's the core problem.

What's the thing that we need to do.

And personally when I'm treating a patient,

I'll always try to hone in on what's

that one exercise that I can give you,

that can make you feel better.

I try to find that one thing.

So I can say to my patient,

if you'll do this ONE thing,

you'll get better.

You HAVE to do this thing.

You NEED to do this thing,

and this is why.

Then I'll have them do it.

I'm like, and don't you feel better,

and their like yah it feels better now.

You just need to do this ONE thing.

So I try to hone it down as much as I can

to like, THIS is the thing that you

NEED to do.