Carla Reyes

Hello! My name's Carla Reyes, welcome to my project, Let's Get Physical: Specialization of Physical Therapy. During my final trimester as a senior at BASIS Scottsdale, I will be able to conduct research to determine what factors impact the regimens used by physical therapists for knee and hip rehabilitation. Attending BASIS has offered amazing opportunities to explore various topics in-depth, and this project will provide an outlet to apply everything I’ve learned in a more hands-on manner.

Over the summer, I was able to shadow an oncologist/hematologist at Ironwood Cancer Research Center. While this gave me a chance to observe a more consultation and research based environment, I was curious to see other aspects of the medical field. Physical therapy interested me because of the doctor patient interaction and the flexibility which exists in the creation of treatments. The number of different types of patients and conditions treated is immense, with treatment ranging from blood sugar control diabetic patients to post-operative rehabilitation for professional athletes.

Growing up, I was always on a sports team. With constantly being on a soccer field, pool, or volleyball court came multiple injuries. Before I became aware of physical therapy offices and the restorative exercises created by PTs, I relied on naproxen and ice packs. My own stubbornness prevented me from seeking out reparative and preventative help. Since my interest in medicine has grown throughout the years, I have a fuller understanding and greater appreciation of the impact physical therapy can have on a person’s well-being.

Although I will not be able to lead appointments or have access to full patient history, by observing the physical therapists and technicians interacting with patients, I hope to be able to discover whether there exists a specific formula that physical therapists and PT technicians use to create treatments.

Week 10

Hello everyone, and welcome to the final post! With the project wrapping up and the presentation nearing, I can't help but feel like the end is a little bittersweet. I was in Pittsburgh the past week looking at a school, and was even able to talk to a professor about my project! Being able to explain my research was amazing (almost as amazing as the buildings on campus).

Since I wasn't on site at CAP, I did research regarding the average timelines of physical therapy patients with specific knee and hip injuries. I found the Mayo procedure details for ACL reconstruction and hip arthroplasty (replacement), which explain what causes the injury, what's expected from the surgery, and the steps to be taken post-operatively. Additionally, I looked at some discussion boards where physicians from different practices share their own "timelines" for recovery. Almost always the process is divided into different phases, where the times vary per surgeon. Here's a general recovery timeline provided by the Game Ready company:

Similar to this week-based timeline, many physicians break the recovery into phases from I up to VI. What I found is that for ACL reconstruction it takes 24 weeks on average until full recovery. For hip replacement it is 36 weeks and knee replacement it's 9 weeks. LCL reconstruction is 28 weeks until recovery, while the time is only 5 weeks for LCL sprains. For IT band injuries not requiring surgery, the recovery time is 6 weeks.

Additionally, for non-surgically repaired injuries the average number of days per week spent in physical therapy to fall in those recovery times is 2 days. However, for surgically repaired injuries, patients are in physical therapy on average 3 times a week until full recovery.

This quantitative research helped me to wrap up my project and finish up my presentation. I've been so happy to have been working in the "real world" the past ten weeks, researching kinesiology and physical therapy, and hunting down the perfect dog gifs. My on-site mentor, Dr. Jeschien, and all the other physical therapists and techs were beyond welcoming and always open to my questions regarding the field, and I am so thankful I was able to complete my project with them.

To really wrap up this blog and my project, here's a string of dog gifs! Thanks for reading and following my research. :)

Week 9

Hello again!

The end of my research is near, and that means there's only a limited number of dog gifs left. But don't be sad- here's a dog gif to begin this post!

My question this week: what are all the different types of patients who come in to CAP? By this I mean what are the different reasons/injuries which motivate patients to come in for physical therapy. The majority of patients who come in are geriatric patients who want to reduce day-to-day pain or athletes trying to get back to playing.

I noticed that there are four basic categories of patients, the two aforementioned, pre-operative patients, and patients who suffer non-sports related pain. The geriatric patients tend to come in for arthritis, knee-replacements, and other age caused pain. Their number of appointments are usually longer, since they don't have time pressure to return to a previous performance capability. On the other hand, the athletes who come in for rehab do need to return to their original, pre-injury state to participate in their sport. Most of the athletes have tears in ligaments such as the ACL, Achilles, or LCL, all central to knee and ankle function. There are also less serious sports injuries treated such as soft-tissue sprains and tendinitis or other tightness in the IT band or general knee/hip area.

The pre-operative patients may also be in the geriatric/athlete category, but they are in physical therapy for preventative measures before their surgery rather than reparative. The common knee/hip surgeries that warrant pre-operative therapy are knee or hip replacements and ligament repairs. As for patients who are neither geriatric nor sports-based, the injuries treated range from general joint pain or knee/hip tightness to sprains caused from simple accidents that are outside of sports.

All these different types of patients come in for a range of time until recovery/improvement and for various times per week and hours per appointment. Next week those are the numbers I will be looking at to finish my research. See you then!

Week 8

Hello everyone!

This week was especially exciting. On Tuesday somebody brought the perfect number of bagels so everyone working the morning shift could have one, and on Thursday one of the patients brought mini cupcakes for one of the therapists and her "helpers" (aka whoever saw the box and was hungry) to enjoy. Other than the free food, I was able to interact with the patients a lot and learn more about the field.

I had a pretty simple research question: what exactly happens during a patient's first injury evaluation?

I wasn't as confused as this dog, but I wasn't 100% sure about what happened during these appointments. Luckily, I was able to sit in on my one of my site advisor's knee evals!

The patient is a dancer, who had previously been in physical therapy for Osgood-Schlatter's disease, a common, growth-related knee injury. However, this time the patient's pain was in the other knee, and came about after landing from a jump. The sharp pain was located in the back of the knee and flared during activities such as walking up the stairs. To start, Dr. Jeschien asked the patient to do a squat, but they could only bend slightly at the knee before there was discomfort and pain. After asking questions about the current and previous injuries, he asked the patient to walk back and forth (and back and forth and back and forth) in order to make observations about their gait, which is simply just how they walk. Dr. Jeschien noticed that the patient was bringing their knee in and kicking their foot out with every step, a sign of weakness in the quadriceps muscles. After making these observations, he then measured the patient's strength in both knees by bending and stretching the legs and asking the patient to resist when he pushed against either leg. This all seemed pretty straight forward as I sat in, so I sat in and watched everything, even making mental notes of my own about the patients injury.

However, as the eval went along, Dr. Jeschien was taking notes about each measurement he was taking, which would later help him to create the exercise regimen the patient would follow. Most of the notes were numbers on a scale of 1-5 or 1-10 or plus/minus signs to dictate ability, flexibility, and overall strength. By the end of the about 20 minute eval, Dr. Jeschien wrote up a short "starter" program including 4 exercises that the patient would go through that day and continue to do at home and an ice and electrical stimulation period at the end of the rehab. By the time the patient comes for a second appointment, Dr. Jeschien will write more exercises into the routine based on what he saw during the eval and any new information the patient comes back with.

This week was definitely helpful for my research on both knee injuries and how the individual rehab programs are created. See you next week!

Week 7

Hello all! Returning to my project after spring break brought a pleasantly calm week. By that I mean no patients pranking me and minimal construction work on the new building, although one of the techs did tell me I was rude when I walked in with my coffee without bringing her one. I guess what I’m saying is that working at CAP is feeling more and more normal. This comfort has allowed me to interact more knowledgeably with the patients, even answering their questions about their exercise routines and the general physical therapy. Feeling pretty accomplished, I was probably walking around the office looking like this:

Unfortunately, I walked into my first shift not knowing what my research question for the week would be. Not the most accomplished. However, after hearing one of the patients say he would be back to give his therapist a gift even though he had finished his last therapy session, I decided to focus on another patient-based question. This particular patient remembered my name after I told him once, and before he left he wished me luck on getting into the colleges we had talked about two weeks prior!

The question for this week (inspired by the very kind knee-rehab patient): just how important is a good relationship between patients and therapists/techs for the therapy process?

Although this isn’t necessarily knee and hip injury specific, I think looking further into the patient-therapist interaction is crucial for my research about treatment specialization and individuation. One of the things I’ve noticed throughout the past weeks is how friendly all the patients are, regardless of their pain levels or anxiousness to finish their therapy. Even though some of the patients are not always in the best mood, they thank their techs and therapists and engage in conversation either with the techs or even the other patients.

I think the comfortable relationship reduces patient apprehension about their rehab. Especially for post-operative patients, the majority of their doctor’s visits aren’t necessarily as upbeat and enjoyable as the physical therapy appointments they have. Much of the effort at the office goes into ensuring that the patients will go through their rehab with minimal pain, which I think along with the interactions with the techs/therapists creates an enjoyable therapy process.

Within the final weeks, I will be seeing if I can sit in on an initial patient evaluation to see exactly how the therapy regimens for knee and hip patients are made. Until then, I will continue with my observations of patient-therapist interaction and routine specialization. See you next week!

Week 6

I took my spring break this week, so no new post!

Week 5

Hi again! Welcome back to my blog, this week there will be many more dog gifs and an answer to my newest weekly question. Since I explored the surgeon's role in rehabilitation a few weeks ago and have been researching the therapists' roles throughout my time, I decided to look further into the patients' roles as I hit the half-way point of this project.

This week I ask: how do patients influence their own therapy regimens?

Working the same days each week means that I see a lot of the same patients, and I've started to be able to recognize them (both by name and injury). I think this is in part with how much more comfortable I am at my site. Now that I'm able to help set up with heat, ice, or electrical stimulation, I've been pranked twice by patients pretending to be shocked after I place them on the lowest electric current. The first time I was definitely surprised and nervous I had burned the patient, so I looked at him kind of like this:

Other than choosing to prank the interns and PT techs, I wondered what other decisions the patients could make regarding the therapist/surgeon designed therapy routine. Obviously, the patients are ultimately in control of the intensity, number of repetitions, etc. based on their ability and pain levels. However, I wanted to know how and if they could be more in control of their therapy outside of those factors.

One of my favorite parts of this project and my observations so far is the relationship between the techs and therapists and their patients. Many of the patients will jokingly "complain" that their therapist is going hard on them during the appointment if the number of repetitions or weight is increased. While they're not truly angry, some of the patients definitely look like they would be willing to do this to their therapists:

Luckily, I haven't seen any actual altercations between patients and therapists, mostly because the patients are clearly thankful for both the techs and therapists and the treatment they are receiving.

Something I began noticing was that several of the patients were leaving the office either with handwritten notes or printed packets describing several of their usual exercises. This way, the patients would be able to go through the parts of their exercise regimens they could do at home. I thought this was a great way for the patients to take control and have an independence with their rehabilitation.

Overall, I've been focusing a lot of my energy on the relationships and individualization of treatments more generally. However, after one of the therapists said that the knee was the "step child" of the hip, I'm excited to start focusing more on knee and hip injuries for the second half of my project!

Week 4

Hello everyone!

Welcome back to my blog, I hope nobody has been missing my writing and dog gifs too desperately. Here's something to incorporate both just in case:

Since this is my fourth week working at CAP and my third in the new building, I'm starting to feel much more comfortable with the equipment, patients, and staff. As I've (slowly) gotten more familiar with everything and began to research the therapy process more closely, this week I came up with the question of how often and to what extent are the regimens altered during the patients' appointments?

Moving away from the surgical side of the rehabilitation I had been looking into the past two weeks, I decided to focus back on the more specific therapist/technician relationship with the patient. Before getting into my observations regarding my question from this week, I'll briefly explain what the general therapy process is for a patient.

For new patients, they are either referred by their surgeons (in post-operative cases) or come in on their own. Prior to beginning the actual rehabilitative regimen, the patients meet with one of the physical therapists for an evaluation, in which the patients' injury, range of motion, symptoms, and other abilities are assessed. The "eval" will help the therapist to write up the exercise regimen based on what is observed regarding the injury. Following this, the new patients go through the exercises written on their charts, closely observed by their therapist and guided by a tech. For patients who have already had their evaluations, when they enter the facility, they are either given heat before beginning their exercises, or immediately go into the regimen depending on their pain levels. After following the therapist-written work-out, the patients go to get ice or electrical stimulation (the game ready unit) and meet with their therapist again to discuss their progress and receive a massage. Most days the inside part of the office looks a little like this:

BUT on Wednesday, I actually saw a patient receiving suction cup therapy, which is used to loosen connective tissue and reduce pain. While this is unusual, I think it's interesting that it is offered and used for certain patients! After meeting with the therapist and receiving ice, the patient is free to go.

Alright back to my question: how often and to what extent are patients' exercise regimens changed while the appointment is in session? One of the days I was working alongside a tech, the patient was flying through one of the exercises for her ankle rehabilitation. After talking with the therapist, they decided to add weight to her squat work-out, and with a little ASU-level skill (# in innovation!) I was able to help by fastening two 5-pound ankle weights onto either end of a PVC pipe so that the bar she was lifting was a little lighter than the metal one usually used as she struggled squatting that. While it wasn't changed on the original notation, the tech wrote in the specific column and row for that day and that exercise that weight was added for the squats.

I think that this flexibility with adding/subtracting weight, increasing/decreasing repetitions, and other minor alterations helps to specify each patients' rehabilitation as they progress and their ability changes and improves. Further, this really shows the understanding and trust between the therapists/techs and the patients.

Next week, I will continue to look into what else is a factor in the individual and specified nature of physical therapy and find more dog gifs to add to my blog! Thanks for reading :)

Week 3

Hi there! With my third week of the project and second week in the new building down (I've finally stopped pushing the pull doors), I've learned so much about physical therapy and the unique interactions within the field. Last week, I was noticing that surgeons had an invisible role for the post-operative patients, and I decided to research the surgeon-therapist-patient relationship further this week. My question for this week: how often/do the surgeons determine the rehabilitation protocol for ACL, general knee, and hip reconstruction patients?

After doing a quick search for the specific ACL treatment protocol for the Mayo Clinic (one of the surgery locations patients come from for therapy), I found that physical therapy is required for ACL injuries and patients can choose to use a brace and/or crutches for stability. Many of the ACL reconstruction patients who come in do wear a brace, which can be unlocked for certain therapeutic exercises.

Fortunately, those with the knee braces also use crutches to walk around and don't end up looking like this clumsy pup. Based on a frequently asked questions page from Columbia University Shoulder, Elbow and Sports Medicine Service, patients must wear the brace for 4 weeks following their surgery.

Many hospitals and surgeons have similar timelines for when patients can stop using their brace, participate in sports again, and even begin driving after their operation. Normally, the first post-op follow-up appointment occurs within the first two weeks, with following appointments being decided by the doctor (often every month). However, my on-site mentor informed me that many of the surgeons CAP works with do not provide set protocols when they refer their patients for physical therapy. Those who do (about 1/4 of the post-operative cases) might meet with the therapist regarding what is expected. Dr. Jeschien also told me he prefers when surgeons don't include the protocols as much of the rehab process is dependent on individual progress and ability rather than set weekly or monthly deadlines to be reached.

I found this especially interesting. There isn't a definitive 6 month or year time in which a patient's therapy will be done, but the recovery is based on the therapist (and surgeon) opinion of how well the recovery is progressing and what they are able to complete.

As I've started to understand more about the surgeon-therapist-patient interaction, I'm anxious to begin research on other factors that impact the specialization of rehab!

Week 2

Hello again!

To start, I will include my question I used to guide my second week of research: what role does the surgeon play in the formation of post-operative patients' rehabilitation?

This week was the first week in the new location. While there is still some construction occurring on the second level, the downstairs is completely finished and functional. Unlike what I had previously expected, there is still the same "inside"/"outside" divide between the facilities, with the treatment tables inside and the work-out equipment outside. A new addition is the courts which are used by club teams, but the patients definitely use them for specific exercises such as lunges and running. Here is a (fairly low quality) picture of the new site!

Out of site on the right hand side are where the treatment tables are. Again, this is where patients can receive restorative treatments. One of the most used is the game ready, a sort of localized ice bath, where a control unit and body wrap (either shoulder, knee, or ankle) are used to activate air compression and cooling in order to draw heat away from the injury and stimulate healing. While most of the patients receive some type of ice packs, I did notice that a large number of the Anterior Cruciate Ligament (ACL) repair patients used the game ready instead.

With my second week, I was beginning to understand what was happening at my site more. The physical therapists' shorthand for specific exercises on patient charts were actually interpretable and I felt like I knew my way around both the "inside" and "outside" facilities. Because of this, my new question was slightly more specific. I noticed many of the patients were in PT for hip or knee surgeries, and I began wondering how the surgeon-therapist interaction impacted the therapist-patient one. After seeing some charts for ACL and hip surgery patients, I saw that a few had several extra pages stapled to the back from the surgery office with deadlines and goals to meet post-operation. I also picked up a sheet that had a basic description of post-opertive knee exercises. After seeing these two things I felt pretty accomplished, and a little like this:

While the relationship the surgeon has with the rehabilitation protocol isn't as direct as the physical therapist and techs', there is definitely a large influence on how the therapy should be executed and on what schedule. For knee and hip injuries, this definitely seems to limit the individuation at the expense of time efficiency, but the PTs still have flexibility to add extra work-outs or reparative treatments they believe will benefit the patients most based on their age, mobility, etc.

I'm very excited for the upcoming week and what else I will be able to discover about knee/hip injuries and the therapist-patient relationship!

Week 1

Hello all and welcome back to my blog!

This week I started interning at my on-site location, Center for Athletic Performance and Physical Therapy. While my first day meant filling out paper work regarding patient confidentiality and interaction limitation, I was extremely excited to begin observing appointments to learn more about doctor-patient interaction. One of the most important things I learned about this site in particular are the different areas. The "inside" is made up of treatment tables, where patients can receive ice/heat packs, stretch, or get isolated muscular massages. On the other side, the "outside" is structured more like a gym, with work out equipment throughout for patients to go through their rehabilitative exercises. However, starting next week the inside/outside split will be a downstairs/upstairs division, since the entire facility will be moving location to a larger building! Luckily the staff and patients will remain the same and I will be able to continue my research.

Another interesting division is within the staff. The physical therapists are those with their doctorates and primarily work with patients "inside", performing fire cupping massages, kinesio tape wrapping, and other restorative treatments. The PT techs are either physical therapy school or undergrad students, who guide patients through their exercise programs "outside" or other stretches "inside". As an intern, I'm able to move between the two areas, primarily reading charts and observing regimens during down time "outside" and helping with laundry "inside" during busier hours.

For each week, my on-site adviser asked that I have a question to guide my research. The first week brought a more general question: what level of independency do the patients take with their exercise programs? After watching several outside exercise programs, I noticed that several patients ask the PT tech to explain each exercise and watch their form. However, others who have had more appointments only require the occasional check-in to confirm the number of repetitions or weight amount their therapist wants for them. Some patients ask to do their hardest exercises first and finish with the easier ones, showing that there is a certain flexibility. One of the common requirements for almost all of the knee and hip patients is the "alter g" which is an anti-gravity treadmill to reduce pain upon movement and leaves you looking a little like this:

So far, other than the alter g, there seems to be some similarities between the majority of knee/hip exercise regimens such as squats, lunges, and other quadricep stretches. The specialization seems to occur both within the "outside" workouts and the "inside" treatments, and depending on the patient's fatigue or pain level, certain parts of the program may be skipped or new steps may be added.

I can't wait to see what else I will be able to discover about how the regimens are created and how the doctor-patient interactions are unique for each injury, especially in the new building! Stay tuned for more observations on the physical therapy field and dog gifs next week.