A Look Below the Surface

While I was in physical therapy school, we were taught that it all hinges on the bones. Our curriculum began with human anatomy and a functional anatomy class. In other words, learning the muscles and bones and how they move. During my career in physical therapy so far, I have worked in a variety of settings. These include pediatrics (1 year old to 17 years old), outpatient orthopedic,  some prosthetic (new legs) and neurological (after stroke, nerve damage, and traumatic brain injury), acute care (hospital), orphanage, summer camp for children with physical disabilities, and tent on dock with Mercy Ships (plastics/burn contracture releases).  Many of the settings, I have not had much guidance or learned on the fly. Tricks of the trade and gaining knowledge from other therapists always carry over to the next setting. Due to working in a variety of settings, I am not a specialist in any one setting.  Often when I am not sure where to begin with a patient, however, I go back to the anatomy and functional anatomy I learned in school.

Yes there are specialties within physical therapy. Some I mentioned above. Within each area of physical therapy there are specialties and techniques of treatment.  At the root ,it is my experience that it all builds on the foundation of orthopedics. With pediatrics or after a stroke, for example,  if the muscle tone is too little or too much (a neurological component), the bones are unable to be moved as easily to roll, sit up, crawl, walk. If the tone is atypical, it effects the alignment of the bones and the developing strength of the bone. If there is nerve damage no matter the cause, the muscles are not told how to move. Therefore, the bones do not move. The brain and the body will adjust as they are able often leading to compensation patterns for walking, reaching, transitioning sit to stand, etc. The compensation patterns themselves over time can cause further damage or create additional issues. This is where surgeries, orthotics, braces, special suits, prosthetic legs,wheelchair designs and components and the like come in to play. These are all used maintain proper postural alignment as much as possible and facilitate movement pattern as close to correct as possible.

Mercy Ships was definitely another unique experience and setting. As mention in earlier blogs, I mostly worked with children and adults after burn contracture releases and skin grafts. At first, I was unsure how to exactly work with these patients. It did not take long to realize that one of the primary goals for these patients was to attain as much range of motion as possible to provide function. Strength in the new range of motion is necessary to keep the new gains. So, at the foundation, it is similar to orthopedics. It is just wrapped in a different wrapper...skin grafts. Keeping in mind that some of these joint have been in atypical positions for years, the surrounding ligaments, tendons, nerves, and bone alignment may hinder achieving perfect movement patterns. Surgery is the first important step for these patients. It gets the bones and tissues as close as possible to the proper place. It is after the surgery the long road of rehabilitation begins. 

 There were a few instances when I was glad I had some experience in looking below the surface. All the different therapists on the Rehab team have varied experiences. This works out well as we play to each others strengths and truly work as a team. One time I was asked to work with a middle age female who had burns on her arm, hand, face and neck. She was slowly gaining more bend in her elbow and hand. One day, she reported that she had pain in her elbow that was different. Upon further questioning through the translator, it became clear it was pain related to a nerve being pinched somewhere. After a brief exam of her neck, it became clear that the nerve was being impinged in her neck or anterior shoulder area. I showed her the difference posture made on the position of her shoulder and neck. Amazingly, simply by sitting upright with her shoulder blades in neutral position and head and neck in line, the pain turned off. I used a special tape (the type you see in the Olympics) to cue her muscles to maintain neutral position of her shoulder blades. While the tape was on, we trained the muscles that support and move the shoulder blade and neck. She left with no pain that day and was able to sleep with little bit of elbow pain. During the next several sessions, some time was spent on continuing to train the postural and shoulder muscles as well as continuing to gain range of motion in her elbow and hand. The "different" pain went away for good. Now we could continue to bend her elbow aggressively without the nerve pain. This was the first time I realized how things below the surface matter more than we think.

Another time the orthopedic viewpoint came into play was with a middle school age boy who had surgery on his foot several months ago. He had made great progress with strength and range of motion. He was able to walk without a AFO/brace better than with one. He, however, continued to have pain in his midfoot. One of the therapist asked if I could look at his foot. After performing some joint mobilizations and foot alignment assessment and gait, it was apparent that his foot remained in supination (his big toe never made contact with the ground) throughout the whole gait cycle. After some joint mobilizations, his pain abolished. I brainstromed about putting corkboard on the outside sole of his foot to tip his foot flat. By doing this, he was able to walk with increased muscle activation in the arch of his foot and in his big toe allowing him to walk with improved mechanics and no pain. We attached the corkboard in his too big shoe with velcro to keep it from moving in his shoe. He walked with it for a week with no foot pain. 

Well, now that you have had your lesson physical therapy and the importance of anatomy and functional anatomy, you may appreciate what is below the surface more. The complexity of the human body has amazed me from a young age. The bones, muscles, nerves, digestive, respiratory, skin, biochemistry of hormones, neurotransmitters, etc. It is truly amazing that it ever works correctly. Truly astounding how all interconnected it is and how it functions well so much of the time. I agree with God, "It is good."