We need diversity of thought in the world to face the new challenges
– Tim Berners-Lee
In the clinic we come upon challenges of all magnitudes on a daily basis. I have come to believe that our attitude about each challenge is generally a strong predictor of our outcomes, especially when we stretch slightly out of our comfort zone. Recently I had the good fortune of treating a patient who was referred to me by a friend who also happens to be a physician. The plot thickens because the patient was himself a retired surgeon. The challenge as the physical therapist in this situation lies within the context of how the surgeon viewed his body and his circumstances which initially was in moderate contrast to the conservative treatment and management paradigm rendered in physical therapy.
The pleasant patient was a male in his 60’s and presented for physical therapy evaluation with report of right anterior and lateral hip pain. Interestingly, the patient had undergone total hip arthroplasty five years prior and had enjoyed two years of pain free physical activity. He was diagnosed with prostate cancer somewhere around two years after hip surgery, and underwent an abdominal surgery with DaVinci robotic assist. Soon after that, he underwent left total knee arthroplasty as well. His right hip slowly and insidiously became painful after all of this surgery, and the left knee had recently become painful as well. At the time of evaluation he was unable to lift his right leg off the table independently for manual muscle testing of the hip flexor, and all attempts at this were painful. Further muscle testing revealed poor gluteal, abdominal, and hip abduction strength. Gait observation revealed mild trendelenburg pattern with limited hip extension, internal rotation throughout the gait cycle of the right lower extremity, and no transverse trunk rotation. Soft tissue palpation revealed trigger points in the right gluteus medius, and in bilateral psoas muscles with the right psoas more restricted than the left.
And here is where the case becomes more interesting. DaVinci robotic assisted abdominal surgery utilizes five portal incisions in the abdomen. One 1-1.5 inch incision in the linea alba usually approximately three inches superior to the umbilicus, two small portal incisions in the right aspect of the abdominals, and one small portal incision in the left aspect of the abdominals. These portal incisions transverse through all four layers of abdominals, and depending on the patient’s genetics and activity level, they can lead to significant adhesions following surgery. This particular patient presented with significant scar tissue formation in the abdominals. On the Vancouver Scar Scale he presented with score of 11/13. Suffice it to say that the limitations in trunk rotation during ambulation and poor abdominal strength were most likely impacted by these severely contracted scars.
When documenting my findings, I find bestPT evaluation forms to be exquisite in capability to include details of subjective, objective, surgical, and imaging data. Preparation of the evaluation is quick, and allows for inclusion of multiple involved body parts, which was particularly important in this case as the patient had report of simultaneous right hip and left knee pain. Selection of appropriate anatomy is made with quick and easy clicks, and allowance for free type to document what the patient reports during history taking.
A screenshot of the subjective portion of the evaluation. (Click to enlarge it)
As previously noted, the patient had undergone three surgeries in 5 years, and had undergone repeat imaging to determine the integrity of the right hip arthroplasty after it became painful. I was able to document radiograph film findings under the imaging reports section. Similarly there is an option to include operation reports in the initial evaluation as well.
A screenshot of the radiographic imaging report. (Click to enlarge it)
Discussing post surgical scarring and adhesions and the impact on biomechanics and overall functional capability to a surgeon can require tact. Depending on the perspective of the surgeon, this subject matter maybe well understood, but conversely it may be foreign and result in defensive dialogue from the patient. Additionally, there seems to be a general propensity for each of us a health care providers to examine our own impairments and illness based upon the lens of our area of expertise. This particular patient explained to me during history taking that he would have simply had the joint surgically manipulated but thought he might try physical therapy first at the recommendation of his wife. In an effort to clarify subjective information I try to sum up what the patient has said and ask for clarity if I have missed the intended message. The true meaning of his statement was that he indeed had considered surgery first, and physical therapy was an afterthought. Understanding this concept allowed me to communicate in a collaborative way to inform him of the role that physical therapy has in improving joint pain, reducing post-surgical adhesions, and improving overall functional capabilities for patients. I explained to him my assessment of how the three surgeries were interacting together to produce aberrant gait and biomechanical patterns with subsequent pain.
He responded extremely well to a regimented program of manual therapy to address limitations in the right hip, scarring and abdominal adhesions. With practice he learned to isolate the transverse abdominus and later to co-contract the deep abdominals with the glutes for enhanced core stability which lead to normalization of his gait pattern and decreased pain.
The importance of clear documentation in this case was evident. Not only was the patient a retired physician who would scrupulously read his own documents, but they were sent to a referral source who was fairly new to our practice. Documentation acts as an impression of quality of care, and it is important to make a good impression in order to maintain referral sources. As physical therapists we always want our work to speak for itself, and the best way to convey that to referring physicians is with easy to read and easy to sign documented plan of care and evaluation forms. This case was an excellent opportunity to grow in communication skills and build relationships with physicians in my community. In the end, the patient gained a new perspective on body mechanics and his ability to address impairments without a scalpel.
Disclaimer: For HIPAA compliance, all characters appearing in this post are fictitious. Any resemblance to actual persons or actual events is purely coincidental.
-Amanda Olson, DPT