therapy treatment this afternoon. However, when it is time for afternoon therapy, she once again declines. What is likely interfering with therapy in this case? This patient is showing many signs of depression: She is very tired and does not want to participate, despite good pain control and education in the importance of her participation in therapy. Regular exercise is a good treatment for mild to moderate depression, yet this patient declines. An appropriate step to take in this case is to speak to the physician about this patient’s lack of desire to participate in therapy. This patient has a history of depression, and is likely to be on medication for it already. She may need an increase in her dosage or she may need to see a psychotherapist to work through her feelings of depression. It is estimated that 50 percent of orthopedic patients will have depression symptoms after surgery. Depression is statistically more common in women and in individuals who have a history of depression (Nickinson, Board & Kay, 2009). It is appropriate to be on the lookout for the signs and symptoms of depression during therapy sessions, as a patient with depression is less likely to have optimal outcomes from the surgery. Look for a patient who is persistently sad or anxious, has appetite and/ or weight changes, experiences a loss of interest in hobbies, decreased energy, difficulty concentrating, changes in sleep patterns, thoughts of death or suicide, irritability, or persistent physical symptoms. It can be difficult to distinguish the symptoms of depression from the expected changes after surgery, but recognizing depression symptoms can make the difference between a patient making progress in therapy or not. In the previous example, once the depression has been dealt with, the standard priorities in therapy can be addressed. The patient can then focus on gait, transfers, weight bearing activities and strength training with the goal of returning to her PLOF, including ambulation. The patient is much more likely to participate in therapy and make progress after the depression has been treated appropriately. normally “as sharp as a tack.” During the evaluation, the patient transfers supine to sit with minimum assist, but tries to cross his legs in the process. The patient then transfers sit to stand with min/CGA and ambulates with a roller walker; however, the patient is impulsive and requires min assist for safety. The therapist is unable to formally assess ROM and strength secondary to this patient’s impulsiveness and difficulty with following simple commands. In this example, encouraging ambulation will not be difficult. Safe ambulation, however, will be a challenge for this patient. He has mixed delirium that can interfere with treatment. It is estimated that between 9 percent and 87 percent of elderly patients will experience some form of delirium after a major surgery, depending on the patient population and the degree of operative stress (Robinson & Eiseman, 2008). There are three types of delirium: Hyperactive, hypoactive and mixed delirium. The most common form (in 79 percent of delirium cases) is hypoactive delirium and presents with lethargy and decreased alertness. Hyperactive delirium is rare, but will present with agitation, combativeness, and restlessness. Mixed delirium is present nearly 21 percent of the time. According to Robinson & Eisemen, patients with mixed delirium can have characteristics of both hyperactivity and hypoactivity. This will obviously impair this patient’s safety with ambulation and transfers which will delay the ability for this patient to return home. The physical therapist has an important role in identifying delirium as a problem and also in treating it. There are many different approaches in addressing it. Specific to therapy, the options include daily ambulation and ROM performed at a regular time each day, as well as regular orientation to person, time and place (Robinson & Eiseman, 2008). In this case study, the patient’s family is present. An important part of therapy will be educating the
strength is impaired right now and it is unlikely that she will be able to tolerate resistance training at this time. She will need to focus on AROM of the knee against gravity and AAROM of the hip, in either the standing or in the supine positions. If the therapist is able to spend 60 minutes each day completing this patient’s treatment (including all of the above elements), the likelihood of this patient returning to her prior level of function increases significantly. It is unlikely, though, that this patient will be able to regain all of her function during an acute stay. An inpatient rehab or skilled nursing facility may be able to provide her with the additional time and therapy needed for her to return home. It is important to discuss these discharge options with the patient during therapy, to help her understand that these inpatient rehab facilities can help her to reach her goal of returning home. Contrast the previous example with the following study that illustrates another common malady that often interferes with physical therapy: A 78 year old woman is on the acute unit 1 day s/p ORIF of the left hip. This patient is from a nursing home and has multiple comorbidities including diabetes, GERD, oxygen dependent congestive heart failure, obesity, as well as a history of depression. During the subjective exam, the patient states that she was walking before the fracture with the use of a walker and with the assistance of an aide. The patient participated in a “walk and dine program” - an aide assisted her to all meals. The patient participates in the evaluation and is mod assist to transfer supine to sit, and mod assist to transfer sit to stand. The patient declines ambulation because she “just doesn’t feel like it.” The patient rates pain 3/10 after pain medication, but complains of being very tired. The next day, the patient also states she is very tired and doesn’t want to do therapy. She says there isn’t much point in walking as she “can’t walk right anyway.” After education about the importance of therapy, she agrees to bed level activities. She states that she will walk in her Total hip replacement Although most of the time a hip fracture will be repaired with an ORIF, a surgeon will occasionally choose to perform a total hip replacement. This can present additional challenges, as a hip replacement will also have certain precautions that can limit mobility. A total hip replacement done with the anterior approach will have virtually no precautions; however, it is estimated that only 20 percent of surgeons use this approach (Koeppel, 2015). A hip replacement done with the posterior approach will limit hip adduction, internal rotation, and hip flexion beyond 90 degrees. These precautions will necessitate the use of higher seats and higher toilet seats, as well as avoiding crossing legs. If seats are unable to be raised, the patient will be required to sleep with a pillow between his or her legs and may make sleep more difficult. Consider how this can complicate a rehab process: An 88 year old man has been admitted to the hospital after a fall at home. It is found that he had an intertrochanteric fracture, and the surgeon performed a total hip replacement via the posterior approach. Orders were received in the physical therapy department to begin therapy the next morning with standard posterior hip precautions and WBAT. The patient is very sleepy during the subjective exam, but the patient’s wife is present in the room and is able to answer several of the therapist’s questions. The patient lives with his wife. His adult daughter comes over for a couple of hours each day to assist with meals, laundry, and housekeeping. The patient has been walking independently in the house with a roller walker, but has had difficulty with stairs. The family recently installed a ramp for the patient to get into the home. The patient is somewhat alert and is oriented to his name, but is not oriented to time or place. He denies pain. He is showing signs of confusion, thinking he is at a friend’s house and is referring to the therapist as his “daughter.” His wife states that this is unusual for him, as he is
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