sample physical therapy case study

AMA 11th Edition Citation Style Guide: Sample Case Study Papers in Physical Therapy

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Marymount Library Physical Therapy Collection Repository

Physical Therapy students can access the Marymount Physical Therapy Collection Repository sample papers.

Below are two Physical Therapy Case report sample papers that exemplify best practices in writing in AMA style:

• Kinesiophobia and Joint Hypermobility Syndrome - Why Fear of Movement Should Matter to Movement Experts
• Patient Function Versus Time as a Driver for Rehab Progression Following Total Shoulder Arthroplasty
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Home > Colleges Schools and Departments > WCHP > Physical Therapy > PT Student Works > PT Student Papers > Case Report Papers

Case Report Papers

During the course of two semesters, UNE Doctor of Physical Therapy students who elect the case report track to fulfill the program’s scholarship requirement work with a faculty advisor to gather data about a patient, institution, facility, or other definable unit related to the profession of physical therapy, and write a case report manuscript following the guidelines, format, and standards for a professional journal.

Papers from 2024 2024

Implementing a Mobility Program with a Complex Patient in an Acute Care Setting: A Case Report , Marisa Carbone, Miguel Vidal, Emma Jones, Haley Yarber, Samantha Strout, Akua Obeng, and Elizabeth Cyr

Papers from 2023 2023

The Effectiveness Of The Six Minute Walk Test For Tracking Progress In Patients With Post-COVID Condition: A Case Report , Jason Angellano, Alexander M. Ferreira, Colleen McGonagle, Yurong Ren, and Michael Tran

Papers from 2021 2021

The Rehabilitation Of A 75-Year-Old Male Presenting With A Right Hip Flexor Strain Concomitant With Numerous Psychosocial Factors: A Case Report , Jillian Battista, Megan Chapski, Suma Varanasi, and Jillian Witwicki

Utilizing An Evidence-Based Practice Framework In Non-Operative ACL Rehabilitation - A Case Report , Eric Norman, Michael Madore, Kathryn Magee, Tyler Calimer, and Parker Nally

Lower Extremity Strengthening, Neuromuscular Re-Education And Graded Activity For A Runner With Distal Hamstring Tendinopathy: A Case Report , Tara Oyasato

Soft Tissue Techniques For Upper Quadrant Range Of Motion And Pain In A Breast Cancer Survivor Following Mastectomy: A Case Report , Marissa Paquette

Papers from 2020 2020

Return To Golf In A 71-Year-Old Female After A Mako Robotic-Arm-Assisted Unicompartmental Knee Arthroplasty Surgery: A Case Report , Katelyn Austin

The Creation Of An Algorithm To Assist Survivorship Clinics Identify The Rehabilitation Needs Of Cancer Survivors: An Administrative Case Report , Joseph Connor

Restoring Functional Mobility For A Patient Following A Comminuted Patella Fracture Status Post Open Reduction Internal Fixation: A Case Report , Elaina Cosentino

Graded Motor Imagery And Pain Neuroscience Education For A Middle-Aged Patient With Chronic Low Back Pain: A Case Report , Brandon Drinan

Inpatient Rehabilitation For A 75-Year-Old Female Following A Left-Sided Pontine Infarct: A Case Report , Marisa Flores

Physical Therapy Management Of Gross Function Loss Following Gunshot Wound To Left Hand: A Case Report , Matthew Freeman

Mobilizations And Strengthening For Radiating Hip And Anterior Knee Pain: A Case Report , Thai Ho

The Challenges Of Exercise Selection For A Post-Operative Patient With Severe Deconditioning And Longstanding Neurogenic Claudication: A Case Report , Madison Lostra

Physical Therapy Emphasizing Progressive Weight Bearing And Gait Training Following Chopart Amputation In A Patient With Diabetes: A Case Report , Spenser Lynass

Restoring Functional Mobility In A 51-Year-Old Male Post Intramedullary Limb Lengthening Surgery Following Helicopter Crash: A Case Report , Shawn Novella

Proprioceptive Neuromuscular Facilitation And Overground Gait Training For A Patient Following A Left Central Medullary Stroke: A Case Report , Shelby Stegemann

Physical Therapy Interventions Via Telehealth For A Child With Developmental Delay During The Covid-19 Pandemic: A Case Report , Julie Sullivan

Papers from 2019 2019

Physical Therapy Management Of Low Back Pain In A Young Female With Ankylosing Spondylitis Associated With HLA-B27 Antigen: A Case Report , Jake Adkins

Regaining Independence In Ambulation For A Visually Impaired Patient With Rhabdomyolysis: A Case Report , Brandon Bourgoin

Gait, Strength, And Balance Training For A 43-Year-Old Male Following An Acute Right Middle Cerebral Artery Stroke: A Case Report , Victoria Dwyer

Functional School-Based Physical Therapy Management For A Child With Pallister-Killian Syndrome: A Case Report , Cheryl R. Espinosa

Balance And Strength Interventions For An Older Individual With Peripheral Polyneuropathy: A Case Report , Hanna Geib

Early Mobilization And Functional Mobility Training For A Patient With Triple Vessel Coronary Artery Bypass Grafting: A Case Report , Cody Hall

Barefoot Training In The Rehabilitation Of Stage II Posterior Tibialis Tendon Dysfunction: A Case Report , Matthew Heindel

Restoring Functional Mobility For A Geriatric Patient Following Open Repair Of A Ruptured Abdominal Aortic Aneurysm: A Case Report , Grace Laughlin

Tissue Plasminogen Activator Effects On Stroke And Physical Therapy Outcomes In Acute Care: A Case Report , Lindsey Leboeuf

A Hip Strengthening Protocol For A Patient Following Achilles Repair: A Case Report , Matthew Morris

Combining A Comprehensive Physical Therapy Program And Electrocorpeal Shockwave Therapy For Plantar Fasciitis: A Case Report , Kathryn Piersiak

Treatment Of A Work-Related Superior Glenoid Labral Repair: A Case Report , Alexandra Touri

Functional Mobility In A Patient With Antiphospholipid Antibody Syndrome Following A Femoral Neck Fracture Surgical Repair: A Case Report , McKenna Young

Papers from 2018 2018

Inpatient Physical Therapy Management For A Patient With Chronic Pulmonary Complications Secondary To Multiple Lobectomies: A Case Report , Bayley Archinal

The Treatment Of Pes Anserine Syndrome Using ACL Injury Prevention Exercises: A Case Report , Stephanie Chau

Comprehensive Physical Therapy Management Of A Patient With Decreased Shoulder Function And A History Of Breast, Lung, And Oral Cancer: A Case Report , Andrew Chongaway

Functional Mobility For A Patient With Myelodysplastic Syndrome, Chronic GVHD, And Corticosteroid Use: A Case Report , Alyssa Deardorff

Restoring Functional Mobility In An Adult Patient Secondary To Subtrochanteric Femur Fracture Surgical Repair: A Case Report , Brittany Gray

A Barefoot Running Program For A College Lacrosse Player With Chronic Exertional Compartment Syndrome: A Case Report , Erica Mazzarelli

The Comprehensive PT Management Of A Patient With Chronic Low Back Pain And Lumbar Radiculopathy: A Case Report , Robin McGuire

A 6 Week Balance And Gait Training Program Using The AlterG For A Patient With Cervical Myelopathy After Spinal Decompression Surgery: A Case Report , Palak Patel

Functional Mobility For An Elderly Patient With Amyotrophic Lateral Sclerosis: A Case Report , Gianna G. Pezzano

Inpatient Rehabilitation Of A 99-Year-Old Patient Following A High-Impact Unstable Pelvic Ring Fracture: A Case Report , Julia Pratt

Relieving Low Back Pain And Improving Mobility For An Adult Patient With Progressive Multifocal Leukoencephalopathy: A Case Report , Derek Schwaiger

Mckenzie Approach To Treating Lumbar Radiculopathy With A Lateral Shift: A Case Report , Carly Theriault

The Use Of Medical Therapeutic Yoga On A Patient With Adhesive Capsulitis: A Case Report , Cameron Vallie

Subacute Physical Rehabilitation For A Young Adult With A Hypoxic Brain Injury Resulting In Severe Myoclonic Movements And Ataxia: A Case Report , Chelsea VanDriel

Conservative Management Of A Complete Rupture Of The Long Head Of The Biceps: A Case Report , Ali Woller

Papers from 2017 2017

Physical Therapy For Low Back Pain With A Focus On McKenzie Method For Diagnosis And Treatment: A Case Report , Macey N. Berube

The Use Of Therapeutic Exercises And Manual Stretching For A Patient Following A Total Knee Arthroplasty (TKA) Revision: A Case Report , Nicholas Cebula

Graston Technique Used In The Treatment Of Patellofemoral Pain In An Ultimate Frisbee Player: A Case Report , Patricia Dobrowski

High Intensity Intervals And Gait Training For A Patient With Heart Failure And Parkinson Disease In A Skilled Nursing Facility: A Case Report , Kelly Fritz

Outpatient Vestibular Rehabilitation For A Patient Three Months Post Acoustic Neuroma Resection: A Case Report , Joel Harrison

Outpatient Physical Therapy Management Of A Total Knee Arthroplasty With Severe Contralateral Knee Osteoarthritis: A Case Report , Michael Ikemura

Balance & Fall Prevention Rehabilitation Program For A 77-Year-Old Patient Following A Trimalleolar Fracture: A Case Report , Kathryn Judd

Adult Scoliosis And Chronic Low Back Pain With Land And Aquatic Based Physical Therapy: A Case Report , Thomas Kent

The Effect Of A Stability And Strengthening Program On The Oswestry Disability Index In A 14-Year-Old Patient With Spondylolisthesis: A Case Report , Hormoz Maragoul

Restoration Of Functional Mobility For A Young Adult Patient Following A Severe Motor Vehicle Accident: A Case Report , Zachary Mercier

Utilization Of Task-Oriented Training To Restore Independence In A Patient With Encephalitis In The Intensive Care Unit: A Case Report , Victoria Perez

The Role Of Physical Therapy Interventions For An Elderly Patient Following Surgical Fixation Of A Fracture Of The Femoral Shaft: A Case Report , Ashley Push

Acute Care Physical Therapy Status Post Laparoscopic Loop Sigmoid Colostomy For A Patient With Colorectal Cancer: A Case Report , Elizabeth Race

The Use Of Manual Lumbar Traction And Therapeutic Exercise In The Treatment Of A Patient With Low Back Pain: A Case Report , Kyle Rasmussen

Vestibular Rehabilitation For A Geriatric Patient With Benign Paroxysmal Positional Vertigo Treatment Failure: A Case Report , Clare Roeder

Strength And Balance Training For A 29-Year-Old Female Who Sustained A Multifocal Stroke: A Case Report , Britney Simonton

Physical Therapy On The Function Of A Patient With Stage III Parkinson’s Disease: A Case Report , Kelly Trancygier

The Physical Therapy Management Of A Patient With Chronic Shoulder Dislocations And Chronic Inflammatory Demyelinating Polyneuropathy: A Case Report , Lindsey Umapathy

A Comprehensive PT Program Utilizing An AlterG Treadmill For A Patient With Lower Extremity Fractures And Charcot-Marie-Tooth Disease: A Case Report , Mark Whitsitt

Utilization Of Postural Control Training To Improve Gait Symmetry And Walking Ability In A Patient Following A Lacunar Stroke: A Case Report , Hannah C. Wilder

Papers from 2016 2016

The Use Of Manual Therapy In The Treatment Of A Patient With Chronic Low Back Pain And Sciatica: A Case Report , Elia N. Darazi

Physical Therapy Intervention For A Patient With Temporomandibular Joint Dysfunction Caused By Two Traumatic Events: A Case Study , Elyse Detweiler

Physical Therapy Management Of A Patient With Chronic Knee Pain: A Case Report , Mohamed Elsaid

Physical Therapy Management Of A Patient With Chronic Brainstem Stroke Syndrome To Improve Functional Mobility: A Case Report , Kelley Flahaven

Therapeutic Exercise In The Treatment Of Greater Trochanteric Pain Syndrome S/P Lumbar Discectomy: A Case Report , Sean Jeffrey

Restoring Gait And Functional Mobility For A Patient With An Ischemic Stroke Through Physical Therapy: A Case Report , Colleen Kelly

Functional Training In A Patient With Middle Cerebral Artery Stroke With Multiple Comorbidities: A Case Report , Darien Lewis

Physical Therapy And Cognitive Behavioral Therapy In A Patient With Multiple Co-Morbidities – A Case Report , Jeanine Manubay

Management Of A Patient With Bronchiectasis Using Pulmonary Rehabilitation And Balance Training: A Case Report , Megan Witherow Quarles

Use Of Functional Strengthening, Balance Training, And Stretching In The Treatment Of A Patient Following A T11-L5 Spinal Fusion: A Case Report , Anna Sidloski

Papers from 2015 2015

Management Of A Patient Lumbar Spinal Stenosis and Carotid Aneurysm Using Therapeutic Exercise, Education, And Manual Therapy: A Case Report , Nicholas Adriance

Application Of A Short-Term Aquatic Physical Therapy Program For A Patient With Chronic Low Back Pain And Radiculopathy: A Case Report , Marc Asta

A Progressive Physical Therapy Plan Of Care For A Patient With Charcot-Marie-Tooth Disease Following Myocardial Infarction: A Case Report , Paige Blasco

Balance And Gait Training To Reduce Fall Risk In A Patient With Bilateral Foot And Hand Deformities Secondary To Rheumatoid Arthritis: A Case Report , Kirsten Bombardier

Body Weight Supported Treadmill Training And Overground Gait Training In The In-Patient Setting For An Individual With Chronic Stroke: A Case Report , Stephanie Bordignon

Evaluation And Treatment Of A Patient Diagnosed With Adhesive Capsulitis Classified As A Derangement Using The McKenzie Method: A Case Report , Ashley Bowser

Use Of The Lower Extremity Functional Scale (LEFS) In A Patient After A First Metatarsophalangeal Joint Implant: A Case Report , Courtney Brinckman

Use Of Core Stabilization Exercise And Medical Exercise Therapy In The Treatment Of A Patient With Chronic Post Partum Low Back Pain: A Case Report , Zachary Chaloner

Gait Training, Strength Training, And Pain Management Of A 26 Year Old Female Recovering From A Multiple Sclerosis Exacerbation: A Case Report , Ellen Cox

The Use Of Parkinson’s Disease Specific Rehabilitative Interventions To Treat A Patient With Lewy Body Dementia: A Case Report , Cassandra Dawley

The Effects Of Specific Training On Balance And Ambulation In A Patient With Stage IV Glioblastoma: A Case Report , Matt Denning

Use Of A Task-Oriented Approach In The Physical Therapy Management Of A Patient Following A Posterior Inferior Cerebellar Artery Stroke: A Case Report , Erika Derks

Treatment Of A Patient With Thoracolumbar Scoliosis Utilizing A Regional Interdependence Approach Including Components Of The Schroth Method: A Case Report , Samantha Fisk

Use Of Therapeutic Exercise, Functional Endurance, And Gait Re-training In A Deconditioned Patient With Acute Respiratory Failure: A Case Report , Ellen Forslund

Neuromuscular Strengthening Exercises Following ACL And Meniscal Repair In A 15 Year Old Female Athlete With Generalized Knee Laxity: A Case Report , Alyssa Gardner

The Use Of Manual Therapy And Strengthening Exercises To Improve Plantarflexion Strength And Mobility Following Achilles Tendon Repair: A Case Report , Jason Glikman

Using The Selective Functional Movement Assessment And Regional Interdependence Theory To Guide Treatment Of An Athlete With Back Pain: A Case Report , Gabriella Goshtigian

Neuromuscular Electrical Stimulation And Quadriceps Strength Following Patellar Fracture And Open Reduction Internal Fixation Surgery: A Case Report , Chelsea Hussey

The Role Of Physical Therapy In The Treatment And Discharge Of An Elderly Homeless Patient With Fractures Of The T12-L1 Vertebrae: A Case Report , Matthew Kraft

Restoring Functional Mobility In A Patient With Delayed Onset Of Physical Rehabilitation Following A Hemorrhagic Stroke: A Case Report , Bettie Kruger

Strength And Balance Exercises To Improve Functional Outcomes And Mobility For A Patient With Parkinson’s Disease And Co-morbidities: A Case Report , Nicholas LaSarso

Functional Mobility Management Of A Patient With Adult-Onset Hereditary Proximal Motor Neuropathy Following A Tibial Fracture: A Case Report , Timothy Lira

Use Of Manual Therapy And Sport Specific Re-training In An Adolescent Elite Sprinter With Bilateral Pedicle Stress Fractures: A Case Report , Erika Lopez

The Use Of Postural Reeducation And Strengthening Exercises In The Reversal Of Functional Scoliosis: A Case Report , Cory Marcoux

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Orthopedic Case Studies

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Author(s): Mark Dutton

• 26 Acromioclavicular (AC) Joint Separation
• 4 Ankle Pain
• 6 Avascular Necrosis of the Shoulder
• 27 Bicipital Tendinitis
• 7 Carcinoma of the Pancreas Mimicking Low Back Pain
• 8 Carpal Tunnel Syndrome
• 9 Cervical Radiculopathy
• 10 Cervical Radiculopathy
• 11 Cervical Spondylosis
• 12 Cervical Strain
• 13 Complex Regional Pain Syndrome
• 14 Costochondritis
• 28 De Quervain Tenosynovitis
• 22 Disc Herniation
• 15 Ewing Sarcoma Mimicking Left Buttock Pain
• 29 Extensor Tendon Tepair
• 16 Fibromyalgia
• 17 Glenohumeral Joint Instability
• 18 Hamstring Strain
• 2 Heel Pain
• 19 Hip Osteoarthritis
• 20 Iliotibial Band Syndrome
• 1 Intermittent Low Back Pain
• 21 Intervertebral Disc Protrusion
• 5 Knee Pain
• 24 Lateral Epicondylitis
• 25 Low Back and Leg Pain Due to Disc Prolapse
• 30 Low Back Derangement
• 31 Low Back Strain
• 32 Lumbar Disk Prolapse
• 33 Lumbosacral Metastasis
• 34 Medial Epicondylitis
• 35 Meralgia Paresthetica
• 36 Mid Humeral Fracture
• 37 Neuralgic Amyotrophy
• 38 Osgood Schlatter's Disease
• 39 Osteitis Pubis
• 45 Patellofemoral Dysfunction
• 41 Piriformis Syndrome
• 23 Radiculopathy
• 42 Raynaud's Phenomenon
• 48 Right-sided Cervical Pain
• 47 Rotator Cuff Tear
• 46 Shoulder Impingement Syndrome
• 3 Shoulder Pain
• 43 Spinal Stenosis
• 44 Thoracic Outlet Syndrome
• 40 Vascular Disease Mimicing PT Diagnosis
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Case studies in a musculoskeletal out-patients setting

CHAPTER EIGHT Case studies in a musculoskeletal out-patients setting Adrian Schoo, Nick Taylor, Ken Niere, with a contribution from James Selfe Case study 1: Jaw Pain 217 Case study 2: Headache 218 Case study 3: Neck Pain – Case One 221 Case study 4: Neck Pain – Case Two 224 Case study 5: Thoracic Pain 226 Case study 6: Low Back Pain – Case One 228 Case study 7: Low Back Pain – Case Two 231 Case study 8: Shoulder Pain 234 Case study 9: Elbow Pain 237 Case study 10: Hand Weakness and Pain 239 Case study 11: Groin Pain 241 Case study 12: Hip and Thigh Pain 244 Case study 13: Medial Knee Pain 247 Case study 14: Anterior Knee Pain 249 Case study 15: Calf Pain 252 Case study 16: Achilles Pain 254 Case study 17: Ankle Sprain 256 Case study 18: Fibromyalgia 258 Introduction Musculoskeletal problems are very common, and can be encountered in hospital emergency departments, orthopaedics, and out-patient physiotherapy ( Carter & Rizzo 2007 ). It is not uncommon for in-patients who are admitted for another problem to be referred and treated in the ward or in the out-patient department for a musculoskeletal problem. The prevalence of specific conditions can vary between the different groups in the community. For example, sporting injuries are more likely to occur in the younger groups, whereas degenerative conditions such as osteoarthritis are more likely to occur as people progress in years. Musculoskeletal problems can result in pain and functional limitations (disability), and represent a major burden to the society due to associated health care costs and loss of productivity ( National Health Priority Action Council 2004 ). Musculoskeletal conditions, including arthritis, cause more disability than any other medical condition and affect one-third of all people with disability. Since part of the chronic disease burden is attributed to risk factors such as physical inactivity ( Bauman 2004 ) people with musculoskeletal conditions are often referred to physiotherapy out-patients for management of their conditions. As in other areas of physiotherapy practice, musculoskeletal assessment and treatment requires a systematic clinical reasoning approach ( Edwards et al 2004 ). The clinical reasoning approach used in this chapter considers: (i) differential diagnoses based on assessment and clinical presentation; (ii) intervention based on the best evidence available; (iii) constant evaluation of therapy outcomes; (iv) adjustment of intervention programme in line with diagnosis and stage of progress; and (v) referring to or working together with other disciplines to exclude and or address confounding problems. In assessing and treating common musculoskeletal conditions and measuring progress it is important to use outcome measures that are valid and reliable, and that consideration must be given to impairments of body structure and function as well as activity limitation and participation restriction, such as ability to return to work. The World Health Organization’s International Classification of Functioning, Disability and Health (ICF) provides a useful framework for physiotherapists in out-patients to assess patient functioning ( Jette 2006 ). Referral to or working with other disciplines may involve tests such as X-rays or dynamic ultrasound scans, or the provision of orthotics to improve biomechanics. In addition to specific techniques, treatment may require education, ergonomic advice and the instruction of a home exercise programme to improve outcomes on function and pain. There is an emerging and increasing body of research on the effectiveness of physiotherapy that provides the clinician in out-patients with an evidence base for their practice ( Herbert et al 2001 ). For example, there is high level evidence that therapeutic exercise can benefit clients across broad areas of physiotherapy practice ( Morris & Schoo 2004 , Taylor et al 2007 ). In prescribing exercises it can be important to know whether the exercise programme is performed correctly and adhered to by the client. Conditions such as back problems or tendinopathies may be negatively affected by incorrect activity performance. Additional problems that can affect health outcomes are incorrect belief systems and mental health problems. For instance, people with osteoarthritis may think that movement harms the joint, but by not moving they put themselves at risk of developing problems associated with physical inactivity (e.g. increased morbidity and mortality due to cardiovascular problems or falls) ( Philbin et al 1996 ). Also, people with chronic pain may be depressed and are, therefore, less likely to be interested in performing exercises, and may benefit from counselling (e.g. motivational interviewing). Screening patients for problems such as fear-avoidance behaviour and anxiety ( Andrews & Slade 2001 ), asking about past and current exercise performance, motivating them if needed (Friedrich et al 1998) and demonstrating the prescribed exercises can assist in determining the likelihood of correct and consistent programme performance (Friedrich et al 1996b, Schneiders et al 1998 ). We have selected common musculoskeletal conditions that are likely to be encountered in hospital out-patient departments. The different cases relate to younger and older people, females as well as males. A multitude of physical tests and outcome measures have been included together with clinical reasoning and evidence-based treatment options. CASE STUDY 1 Jaw pain Subjective examination Subject 34-year-old female office worker HPC Left sided headaches off and on for 3/12 Increasing pain of the left temporomandibular joint (TMJ) last 2/12 Pain at night, at rest, and when opening the mouth or chewing PMH Appendectomy Stress at work Aggravating factors Biting a big apple Chewing hard or tough food Easing factors Rest is better than chewing, although remains painful Drinking fluid Ice Night Wakes up because of pain Grinds teeth when asleep (according to partner) Daily pattern Constant pain that worsens during and directly after opening the mouth or chewing General health Using prescribed sedatives due stress at work. No other problems reported Attitude/expectations Given the symptoms she expects that it may take some time for them to settle Pain and dysfunction scores VAS current pain at rest = 3 VAS usual level of pain during chewing in the last week = 7 VAS worst level of pain during opening the mouth in the last week = 9 Objective examination Palpation Skin temperature (T sk ) normal Left TMJ painful on palpation TMJ movement and clicking can be felt when placing the index finger in the auditory canal and opening the mouth No signs of TMJ dislocation when comparing left with right Muscle length External pterygoid muscle feels tight and painful on opening of the mouth (palpation through the mouth) Functional testing, including ROM and strength Opening of the mouth is limited. It can accommodate two fingers only. Normally, the span is large enough to accommodate three fingers ( Hoppenfield 1986 ) Asymmetrical mandibular motion with severe swinging to the left when opening the mouth Questions 1. What is your provisional diagnosis? 2. What signs and symptoms lead you to this diagnosis? 3. How will you address these in your treatment plan? 4. What kind of common and less common problems need to be excluded? 5. How likely is it that the patient’s stress and teeth grinding contribute to the current complaint? 6. How will the expectations of the patient influence your treatment? 7. Is the patient likely to benefit from referral to other health professionals? CASE STUDY 2 Headache Subjective examination Subject 29-year-old male working on Help Desk in Information and Computer Technology HPC Gradual onset of headaches and cervical pain about 3/52 ago Cannot recall precipitating incident Headaches becoming more frequent (now daily) and lasting longer (up to 3 hours) Has deep ache (non-throbbing) radiating from the back of the occiput to the right frontal region. Also complaining of stiffness like pain in the right side of the cervical spine. Neck pain and headache seem related (see Figure 8.1 ) FIGURE 8.1 Body chart – Case Study 2 . PMH Car accident 10 years ago which led to cervical pain for about 3/52. No problems since apart from an occasional stiff neck Aggravating factors Prolonged work at the computer (if more than 2 hours brings on headache) Reversing the car reproduces slight cervical stiffness Easing factors Analgesia dulls the headache Night Sleep undisturbed Daily pattern Seems to depend on how long he has spent at the computer General health In good health, no weight loss No complaints of dizziness, no nausea or vomiting Assessed as being depressed, has been taking antidepressants over the last 3/12 Investigations No X-rays or other investigations at this stage Attitude/expectations At the moment headache is not affecting him a lot but wanted to get it checked out in case it is something serious Keen not to miss any work Intends to continue normal recreation of sail boarding this weekend Pain and dysfunction scores Neck Disability Index: 14% Disability VAS level of pain when headache is most severe (after working at the computer for 2 hours) = 6 Physical examination Observation Forward head posture with a slouched sitting posture Palpation Hypo-mobility of upper cervical joints on the right, with reproduction of local cervical pain Increased muscle tone in right upper trapezius and right levator scapulae Movements Active movements Right cervical rotation equals 60° with slight stiffness in neck Left cervical rotation equals 75–80° Limited cervical retraction, feels stiff Muscle function Decreased strength and endurance of the deep cervical neck flexors as determined by the cranio-cervical flexion test ( Jull et al 1999 ) Neurodynamic testing Upper limb neurodynamic/tension test (base test): In 90° shoulder abduction and full external rotation, right elbow extension lacks 40° while left lacks 30°. Reproducing local neck pain, which is eased with cervical lateral flexion towards the right Neurological tests (tests of nerve conduction) Not assessed Questions 1. What is your provisional diagnosis? 2. What signs and symptoms led to your provisional diagnosis? 3. How will you address these in your treatment plan? 4. What kind of common and less common problems need to be excluded? 5. How relevant are work details for this patient? 6. How will the expectations of the patient influence your treatment? 7. Is the patient likely to benefit from referral to other health professionals? CASE STUDY 3 Neck pain – case one Subjective examination Subject 32-year-old male accountant HPC Prolonged sitting (all day) at a conference 3/52 previously Noticed onset of left lower cervical and interscapular pain at the end of the day On waking the next morning pain had spread to the posterior aspect of the arm and forearm as far as the middle three fingers (see Figure 8.2 ) FIGURE 8.2 Body chart – Case Study 3 . Seen by doctor 1/52 ago. Doctor ordered plain X-rays including oblique views that did not show any abnormality Has not improved at all since onset of symptoms Medical history High cholesterol, overweight, sedentary lifestyle Minor neck complaints that usually settled within 2 or 3 days Aggravating factors Sitting for more than 10 minutes increases neck pain. More than 30 minutes increases arm pain Looking up or to the left increases neck and arm pain Lifting briefcase with left hand aggravates neck and interscapular pain Easing factors Neck pain relieved by lying supine Arm pain relieved by lying supine with left arm above head Night Can sleep 2–3 hours at a time before being woken by increased neck and interscapular pain Changing position helps to decrease the pain Daily pattern Increased symptoms with increased amounts of sitting, particularly if using computer Medication Was prescribed non-steroidal anti-inflammatory medication (Meloxicam) which helps take the edge off the neck pain Attitude/expectations Wants to know what the problem is, particularly as the X-rays did not show any abnormality Feels that something might be ‘out’ in his neck. If it could be ‘put back in’ the symptoms should resolve Physical examination Observation Sits with forward head posture Cervical active movements in sitting Extension reproduces pain in the neck and left arm at 30°. Movement occurs mainly in the upper and mid-cervical regions. Very little movement in the lower cervical or upper thoracic areas Right rotation produces a stretching in the left cervical region at 75° Left rotation reproduces left neck and interscapular pain at 40° Palpation Increased tone and tenderness noted in the left paraspinal muscles (cervical and upper thoracic) and left scalene muscles Local pain and left arm pain reproduced by postero-anterior (PA) pressures over the spinous processes of C6 and C7 and over the C6 and C7 articular pillars on the left Generalized stiffness noted with PA pressures in the mid and upper thoracic regions Segmental neurological examination Absent left triceps jerk Weakness in left triceps (25% of right side) Decreased sensation to light touch over the tip of the left middle finger Questions 1. What is the most likely source of the patient’s arm pain? 2. What is the most likely source of the patient’s neck and interscapular pain? 3. What are other possible symptoms sources? 4. Are there reasons to be cautious in administering physiotherapy treatment? 5. What would an appropriate initial physiotherapy treatment involve? 6. What would a longer-term management programme include? 7. What is the likely prognosis? 8. Is referral to other health professionals warranted? CASE STUDY 4 Neck pain – case two Subjective examination Subject 23-year-old female personal assistant HPC Rear end motor car accident 2/7 ago Immediate onset of cervical pain and stiffness (left and right). Both pain and stiffness have been increasing. Pain is now constant Vague headache started today (see Figure 8.3 ) FIGURE 8.3 Body chart – Case Study 4 . Seen by doctor yesterday who organised an X-ray (no abnormality detected) and referred patient to physiotherapy PMH Left knee reconstruction 3 years ago with good return of function since No past history of neck complaints Aggravating factors Turning head to either side, especially if movement is quick Travelling in car – took 20 minutes to settle after 30-minute car trip Easing factors Supine with head supported on one pillow Felt a bit easier under hot shower Night Wakes often due to discomfort Sleeps on 3 pillows Difficulty turning in bed due to pain Daily pattern Constant pain that gradually worsens during the day General health Taking non-prescription analgesics every 4 hours on advice of doctor. No other medications Not seeing the doctor for any other health problems Attitude/expectations Anxious about prognosis Worried about how much work she will have to miss as she only started in her current position 3/12 ago Pain and dysfunction scores VAS current pain at rest = 5 VAS level of pain after 30 minute car trip = 8.5 Physical examination Observation Walking slowly and all movements are guarded Removes jacket slowly and with great care Neck in slight protracted posture Palpation Generalized tenderness to light palpation of cervical spine (central, left and right) Increased muscle spasm left and right paraspinal muscles Further detailed palpation not possible because therapist wary of exacerbating symptoms Active movements Left rotation equals 30° before pain started increasing Right rotation equals 35° before pain started increasing Attempt to retract cervical spine caused increased pain No other movements tested today Questions 1. What is your provisional diagnosis? 2. Which of the signs and symptoms will you place on your priority list? 3. How will you address these in your treatment plan? 4. What kind of common and less common problems need to be excluded? 5. How relevant are work details for this patient? 6. How will the expectations of the patient influence your treatment? 7. Is the patient likely to benefit from referral to other health professionals? CASE STUDY 5 Thoracic pain Subjective examination Subject 60-year-old male lawyer Presents with bilateral lower thoracic pain with radiation of symptoms anteriorly to the lower sternal area (see Figure 8.4 ) FIGURE 8.4 Body chart – Case Study 5 . Had a similar problem 5 years previously that settled with physiotherapy which resolved after three sessions of passive mobilisation directed to the thoracic spine HPC Noticed onset of symptoms 4/52 previously after lifting pots while gardening. Pain initially felt in sternal area, then onset of thoracic pain over the course of the day Pain initially intermittent, now constant at a level of VAS 2/10 at best and VAS 7/10 at worst Medical history Noticed 5 kg of weight loss in previous 4/52 that could not be explained by other factors Had noticed intermittent, generalised, mild (VAS 1–2/10), aches and pains in trunk, arms and legs over the previous 3/12 that had worsened slightly over the previous 4/52 Aggravating factors Prolonged sitting for greater than 20 minutes at work would increase posterior and anterior chest pains to VAS 6/10 Easing factors Standing and walking for 10 minutes decreases all symptoms to VAS 2/10 Night Wakes 3–4 times each night with increased symptoms in thoracic and sternal areas. Has to get out of bed and walk around to ease pain. Tends to notice generalised aches and pains associated with increased sweating at night Daily pattern Dependent on amount of sitting during the day. More thoracic and sternal pain at end of day when sitting a lot Medication Nil Attitude/expectations Expects that physiotherapy will ease symptoms as they did for a past episode of similar pain Physical examination Observation Increased thoracic kyphosis noted while sitting. Able to actively correct sitting posture, although this increases thoracic pain slightly Thoracic active movements in sitting Extension is restricted by about 50% and reproduces posterior thoracic pain with overpressures localised to the mid/lower thoracic spine Thoracic rotation feels stiff but no pain reproduced Flexion is normal in range and reproduces a stretching feeling in the mid thoracic area Palpation Generalised stiffness noted on midline and unilateral postero-anterior (PA) pressures from T2–T10 Posterior thoracic and anterior pain reproduced with midline PA pressures over T7–T8. These pains settled quickly once the pressure was released Palpation of the ribs, inferior part of the sternum and upper part of rectus abdominis did not reveal any increased tenderness Questions 1. What are your hypotheses regarding the likely source of the thoracic and sternal pains? 2. What would an appropriate initial physiotherapy treatment involve? 3. Are there examination findings that would make you suspect a non-musculoskeletal source of the symptoms? 4. What are red flags? 5. Is referral to other health professionals warranted? CASE STUDY 6 Low back pain – case one Subjective examination Subject 44-year-old male bank manager HPC 4/7 ago bent to reach into boot of car and felt slight backache. Thought it would settle so played golf anyway. Next morning severe low back pain with aching pain radiating down the back of the right leg to just below the knee. Has no pins and needles or numbness (see Figure 8.5 ) FIGURE 8.5 Body chart – Case Study 6 . PMH Has had four or five episodes of low back pain over the last 8 years, usually settles quickly in 2 or 3 days Has not required treatment with previous episodes Aggravating factors Finds it difficult to put shoes and socks on in the morning After driving to work (about 40 minutes) found leg pain had worsened Can only sit for about 15 to 20 minutes at a time at work Has noticed that sneezing increased back and leg pain Easing factors Lying on back eventually relieves the leg pain Standing and walking seem to help a little Night Pain gradually eases after initial discomfort Is waking at night but finds can get back to sleep quite quickly when changes position Daily pattern Back stiff and aches getting out of bed first thing in the morning but eases after shower Back pain is worse by the end of the day, and leg pain is more constant by the end of the day General health Taking non-steroidal anti-inflammatories (NSAIDs) with slight improvement At recent annual review doctor advised to increase physical activity to reduce weight (BMI 26.4) and adjust diet (cholesterol 6.4). Otherwise fit and well Attitude/expectations Very keen not to miss club Stableford golf competition this weekend (in 3/7) Intending to cope with work as best he can. Very busy at work so reluctant to take time off Pain and dysfunction scores Oswestry Disability Score: 36% Disability VAS level of pain after 40 minute car trip: back = 8, leg = 6 Physical examination Observation Slight left-sided contralateral list (when observed from behind in standing shoulders are to the left relative to the hips) Changes position regularly when in sitting position Palpation Increased tone, right erector spinae in the lumbar region Central postero-anterior pressures over the lumbar spine reproduced back pain (but not leg pain) at L4 and L5 Unilateral pressures were painful on the right at L4 and L5 Movements Active movements Lumbar flexion in standing limited (2 cm below the knee) Lumbar extension in standing markedly limited Left and right rotation (assessed in sitting) both more than 60° Attempt to correct contralateral list led to increased back pain Repeated active movements Flexion in standing repeated 10 times led to increased back pain and increase of leg pain Extension in standing repeated 15 times abolished leg pain, and increased range – back pain remained Repeated correction of contralateral list (side gliding to the right) led to reduced central back pain and slightly increased range Neurodynamic tests Straight leg raise: right = 70° left = 70° Slump test not evaluated Neurological tests (tests of nerve conduction) Muscle strength in myotomes L3 to S1, left = right Sensation in dermatomes L2 to S1, left = right Reflexes (patella tendon and Achilles), brisk left = right Questions 1. What is your provisional diagnosis? 2. What is the likely source of the right leg pain? 3. Which of the signs and symptoms will you place on your priority list? 4. How will you address these in your treatment plan? 5. What kind of common and less common problems need to be excluded? 6. How relevant are work details for this patient? 7. How will the expectations of the patient influence your treatment? 8. Is the patient likely to benefit from referral to other health professionals? CASE STUDY 7 Low back pain – case two Subjective examination Subject 49-year-female assembly worker at automotive manufacturer HPC Complaining of increasing back pain over the last 14/12. Back pain is in the central low back region and radiates into both gluteal regions – no leg pain (see Figure 8.6 ). Has been off work for the last 6/12 with no improvement in pain FIGURE 8.6 Body chart – Case Study 7 . Injured back when installing car upholstery 14/12 ago. Initially had 3/7 off work and experienced some slow improvement over the first 3/12 Has had manipulative physiotherapy involving manipulation, mobilisation and traction with no benefit. Also tried chiropractic without benefit PMH 15-year history of intermittent low back pain usually no more than a few days off work Cholecystectomy 6 years ago Aggravating factors Prolonged walking or standing (more than 15 minutes) increases ache Prolonged sitting (more than 15 minutes) increases ache Unable to do weekly shopping or housework as these activities aggravate the ache Easing factors Lying down but only for about 30 minutes, as gets stiff when lying in one position for too long Night Finds it difficult to get comfortable, wakes when turning Not getting good-quality sleep any more Daily pattern Gradually worse by the end of the day General health Has gained weight over the last 14/12 (about 6 kg) Assessed as being depressed, has been taking antidepressants over the last 3/12 Investigations X-ray shows mild bilateral degeneration of the L4–5 facets CT scan shows a minor disc bulge at L4–5 and L5–S1 with no nerve root involvement Attitude/expectations Has reduced activity level to avoid aggravating back Believes that if she can find the right practitioner then they will fix her Very concerned with the CT scan report and the diagnosis of disc pathology Has been more short-tempered with family and friends since her back problem began Her spouse has been very supportive and has willingly taken over tasks such as housework and shopping Pain and dysfunction scores Oswestry Disability Score: 72% Disability VAS level of pain after 15 minutes of standing or sitting = 7.5 Physical examination Observation Exhibits pain behaviours including grimacing, and placing hand on back Changes position regularly when sitting and standing Walking pattern is slow and guarded Palpation Central palpation of the lumbar spine at L1, L2, L3, L4 and L5 painful Unilateral pressures are painful left and right at L1, L2, L3, L4 and L5 Movements Active movements Lumbar flexion in standing limited (2 cm above the knee) Lumbar extension in standing moderately limited (estimated half of expected range) Left and right rotation (assessed in sitting) both about 40° Neural mobility tests Straight leg raise on right = 50° left = 50° Able to fully extend knee in upright sitting Slump test not evaluated Neurological tests (tests of nerve conduction) • Normal no abnormality detected Questions 1. What is your provisional diagnosis? 2. How do you interpret the X-ray and CT scan reports? 3. Which of the signs and symptoms will you place on your priority list? 4. How will you address these in your treatment plan? 5. What kind of common and less common problems need to be excluded? 6. How relevant are work details for this patient? 7. What are yellow flags and how are they relevant for this patient? 8. Is the patient likely to benefit from referral to other health professionals? CASE STUDY 8 Shoulder pain Subjective examination Subject 47-year-old female factory worker Right arm dominant HPC Right shoulder pain which started 1/52 ago when dragging a heavy item onto the conveyor belt. Routinely she has to pull, lift, and reach overhead PMH Low back pain episodes since work-related lifting injury Asthma and frequent coughing Aggravating factors At work: Overhead work, lifting and carrying boxes In transit: Driving car, riding a bike with wide handlebars. At home: Preparing meals, working at the computer, knitting Easing factors Rest Avoiding overhead work or holding elbows out when lifting or carrying items Night Wakes frequently because of pain, particularly when sleeping on the painful shoulder Daily pattern Constant nagging pain that worsens during activities as mentioned above (see aggravating factors ) General health Asthma attacks. Smokes. Using bronchodilatators as needed Attitude/expectations Is afraid that she may need to look for another job due to experiencing increasing shoulder problems at work Wants better duties within the factory as some of her colleagues have managed to do Pain and dysfunction scores VAS current pain at rest = 3 VAS usual level of pain during aggravating activity in the last week = 7 VAS worst level of pain in the last week = 9 Shoulder Pain and Disability Index (SPADI): Pain score = 60%, Disability score = 45%, Total score = 50.8% ( Roach et al 1991 ) Objective examination Standing with arms relaxed Shoulders protracted and depressed (right > left) Right shoulder abducted and elbow flexed Hyper kyphosis Shortness of breath with upper chest breathing Palpation Skin temperature (T sk ) normal Tenderness of subscapularis, supraspinatus and serratus posterior superior with palpable trigger points Painful insertion of subscapularis and supraspinatus on the humerus Palpable click on shoulder abduction Muscle length and strength Tightness of the subscapularis, pectoralis minor Weakness of rhomboids, supraspinatus Functional and other testing, including ROM Painful arc when abducting arm (90–115° abduction) with audible click (VAS rises to 6 during this impingement) Hawkins and Kennedy impingement test (compressing the subacromial tissues by internal rotation in 90° shoulder flexion) was positive ( Ginn 2003 ) and VAS rises to 8 Apprehension test for shoulder stability and SLAP lesion tests were negative, indicating integrity of joint capsule, labrum and ligaments ( Brukner et al 2001e , Ginn 2003 , Hoppenfield 1986 ) Shoulder elevation reduced by 10° with early scapular movement when comparing with left shoulder (VAS rises to 5) Pain on resistance against external rotation and abduction (VAS rises to 8) Reduced internal rotation and adduction strength when pushing palm of the hand on the table when sitting at the table (VAS rises to 7) Difficulty placing right hand behind back. Positive Gerbers’ test (resisting against hand when patient is pushing hand away from the spine (VAS rises to 8) Questions 1. What is your provisional diagnosis? 2. What signs and symptoms lead you to this diagnosis? 3. Describe the mechanism that can leads to this condition. 4. How will you address these signs and symptoms in your treatment plan? 5. What kind of common and less common problems need to be excluded? 6. Can patient’s asthma and hyper kyphosis contribute to the shoulder complaint? 7. How will the expectation of the patient influence your treatment? 8. Is it possible that outcome measures do not reflect the severity of pain and disability experienced by the patient? 9. Is the patient likely to benefit from referral to other health professionals? CASE STUDY 9 Elbow pain Subjective examination Subject 39-year-old male carpenter Right hand dominant HPC Right lateral elbow pain off and on for at least 5/12. Insidious onset Worsened 4/52 ago when his nail gun broke down and he was forced to use a hammer all day Severe pain and reduced strength, particularly when using his arm during activities such as gripping, holding and lifting. Pain radiates into forearm No history of locking PMH Fractured ribs 3 years ago due to fall at work. Landed on his right side, and elbow was pushed into the ribs. No elbow symptoms until 5/12 ago Never experienced any symptoms of the cervical or thoracic spine Minor injuries such as an ankle sprain, mainly due to sport Aggravating factors Firm gripping (e.g. pliers) Hammering Screw driving Using a jackhammer Driving (car has no power steering) Closing a tap Knocking the elbow Easing factors Rest Ice Night Constant ache. Lying on elbow or pulling up the blanket makes it worse Daily pattern Constant pain that worsens during and directly after activity General health No other health problems reported. Not using any medication or receiving any other medical care Attitude/expectations Is disappointed that his elbow problem hasn’t improved over time as his other injuries did Experiencing increasing problems at work. Is afraid that he will lose his job One of his colleagues experienced major improvement after physiotherapy treatment and he hopes that it will help him too Expects that it may take some time since he wants to stay at work Pain and dysfunction scores VAS current pain at rest = 4 VAS usual level of pain during activity in the last week = 8 VAS worst level of pain in the last week = 9–10 Upper Extremity Functional Index (UEFI) 35/80 ( Stanford et al 2001 ) Objective examination Arm at rest while standing Elbow flexed (right > left) Wrist flexed (right > left) Forearm supinated (right > left) Palpation Skin temperature (T sk ) normal Lateral epicondyle extremely painful with some palpable swelling Tenderness extensor carpi radialis brevis and longus Thickening in extensor carpi radialis brevis (ECRB) Difficult to palpate for tenderness of capitellum radii due to surrounding tissue swelling and pain Muscle length ECRB – tight (flexion and ulnar deviation of the wrist, pronation of the forearm, and slight extension of elbow) Extensor carpi radialis longus – tight (flexion and ulnar deviation of the wrist, pronation of the forearm, and complete extension of elbow) Functional testing, including ROM and strength Elbow extension showed pain in at end of ROM (VAS rises to 6) Forearm pronation/supination showed full ROM (VAS rises to 5) Reduced grip strength (VAS rises from 4 to 9 during firm gripping) Difficulty opening pushing door handle and opening door (VAS rises to 7) Difficulty lifting an object with palm of hand facing down (VAS rises to 8) Resistance against dorsiflexion in a dorsiflexed position of the wrist, with fist closed, caused severe pain on the lateral side of the elbow Questions 1. What is your provisional diagnosis? 2. What signs and symptoms lead you to this diagnosis? 3. Describe the mechanism that can lead to the condition 4. What will you include in your treatment plan? 5. What kind of common and less common problems need to be excluded? 6. How likely does the patient’s previous fall contribute to the current complaint? 7. How will the expectations of the patient influence your treatment? 8. Is the patient likely to benefit from referral to other health professionals? CASE STUDY 10 Hand weakness and pain Subjective examination Subject 56-year-old woman who works part-time as a kindergarten assistant Right hand dominant HPC Pain, numbness and tingling noticed in right hand (particularly in the thumb, index and middle fingers) over the last 6/52, especially at night. Insidious onset Has started to have difficulty using right hand for gripping and it is starting to affect work as a kindergarten assistant and tennis Feels it is getting worse, because pain is now extending up the forearm. Is now waking her during the night PMH Diagnosed with non-insulin-dependent diabetes 5 years ago, currently well controlled with diet and exercise (walks for 45 minutes three times a week and plays social tennis twice a week) Knee arthroscopy with partial left medial menisectomy 12 years ago after tennis injury, recovered well Aggravating factors Gripping (tennis racquet after 1 set, a feeling of weakness) Opening jars Packing up play equipment at kindergarten Sleeping Easing factors Gets a little relief from changing position and shaking out wrist Aspirin (started aspirin 2/52 ago on advice of GP), may have helped a little Night Now waking every night (once only) with right wrist pain and numbness Daily pattern Symptoms are dependent on activity. Finds it is painful at end of shift at the kindergarten and after tennis. Otherwise not troubling too much during the day Attitude/expectations Enjoys her regular exercise (especially tennis) so is keen to get the problem fixed She has friends who had surgery for something that sounded similar so is not sure why she was referred to physiotherapy or how it might help Pain and dysfunction scores VAS current pain at rest = 1.5 VAS worst level of pain in the last week = 7 Levine symptom severity scale = 1.9/5.0 Levine functional status scale = 1.4/5.0 Physical examination Observation No abnormality detected No wasting of right thenar eminence Palpation Slight reduction to light touch on the palmar surface of the right thumb and 1st and 2nd finger Movement (right side) Wrist flexion = 60°, no pain Wrist extension = 55°, no pain Wrist supination = 90° from mid-prone, no pain Wrist pronation = 90° from mid-prone, no pain Finger IP flexion OK, no pain Finger MCP flexion OK, no pain Thumb flexion, abduction and opposition OK, no pain Functional testing, including ROM and strength Grip strength assessed on Jamar dynamometer (right = 27 kg with VAS = 3, left = 35 kg) Phalen’s test (sustained bilateral wrist flexion) reproduced numbness on palmar surface of index and middle after 45 seconds Upper limb tension test with a median nerve bias: reproduced right hand symptoms which eased on release of shoulder depression ( Butler 2000 ) Questions 1. What is your provisional diagnosis? 2. What are the anatomical relationships that explain your provisional diagnosis and the patient’s symptoms and signs? 3. Explain the significance of the night symptoms and the positive Phalen’s sign. 4. Are there other assessment techniques that could be used to confirm the provisional diagnosis? 5. Find out what items the Levine symptom severity and functional status scales assesses ( Levine et al 1993 ) and then discuss how this patient rates. 6. Which of the symptoms and signs will you place on your priority list? 7. How will you address these in your physiotherapy treatment plan? 8. Are there other problems that could be contributing to the symptoms? 9. The patient has some friends who had surgery for something similar. What is the role of surgery for this condition? CASE STUDY 11 Groin pain Subjective examination Subject 17-year-old male student Playing in high-level senior soccer team with training three times a week in addition to a match on the weekend Plays as midfielder Right foot dominant HPC About 4/12 ago noticed slight stiffness in groin the morning after a strenuous match. Insidious onset Gradually got worse until about 2/12 ago could not train or play without right-sided groin pain. Performance was also waning with a loss of power and acceleration On advice of team trainer rested from all training and playing for 6/52, but on resumption of training 2/52 ago groin pain returned immediately. Seen by GP who ordered X-rays and a bone scan, and referred him to physiotherapy PMH Well-controlled asthma. Uses one puff of a preventer daily (Flixitide). Rarely needs to use reliever (Ventolin) Episode of Osgood–Schlatters syndrome when 14 years old after joining soccer development squad. Resolved after 1 year through modification of activity Otherwise well and not seeing the doctor for any other condition Aggravating factors Running, especially when sprinting and when cutting (changing direction) Kicking, especially when taking a corner No pain on sneezing or coughing Easing factors Avoidance of aggravating activities Night Sleep unaffected Daily pattern Symptoms are dependent on activity. Now affecting whenever tries to run or kick a ball Notices in morning, takes 10 to 15 minutes to ease Attitude/expectations Concerned that the problem appears to be getting worse. Had thought it would just go away Receives payment for playing in soccer team which he had planned to continue to help support his studies at university Pain and dysfunction scores VAS current pain at rest = 0 VAS worst level of pain in the last week = 9 (kicking across from a corner) VAS worst level of pain in the last week = 8 (when attempting to sprint) Physical examination Observation In standing, no obvious wasting or pelvic asymmetry With walking, observed excessive pelvic tilting (obliquity) in the frontal plane Palpation Tender to palpation at tendon attaching to right medial inferior pubic ramus Trigger point tenderness to muscle belly distal to medial inferior pubic ramus Tender at right side of pubic symphysis Movement Right hip flexion = 130°, no pain = left Right hip extension = 25°, no pain = left Right hip abduction = 45°, pain (VAS = 3), left = 55° Right hip internal/external rotation = left Functional testing Squeeze test (patient supine with hip flexed 45°, examiner places fist between patient knees, and asks patient to bilaterally adduct) reproduced right groin pain (VAS = 4) Resisted straight-leg right hip adduction reproduced right groin pain (VAS = 4) Right hip quadrant (passive hip flexion, adduction and internal rotation) only very slight pain, similar to discomfort when tested on the left side Thomas test (slight restriction on right compared to left with only slight reproduction of pain (VAS = 0.5) when hip flexion resisted) Abdominal muscle testing: 1. global muscles, only slight pain (VAS = 1) on resisted abdominal flexion 2. stabilising muscles, assessed in supine with a pressure cuff biofeedback unit placed in the small of the back. He could increase the pressure in the cuff from 40 to 43 mmHg for 3 seconds 4 times before unwanted activity from global muscles was observed Standing on one leg (Trendelenburg test), only slight drop of pelvis observed, within normal limits (<10°) Investigations (completed 1/52 ago) X-ray: no abnormality detected Bone scan: indicated some increased uptake in the right inferior pubic region Questions 1. What is your provisional diagnosis? 2. What are the key findings from your examination that led to your provisional diagnosis? 3. What other common causes of groin pain did you consider in making your diagnosis? 4. What are some less common causes of groin pain that you need to consider when examining this patient? Briefly explain why these are considered unlikely at this stage. 5. What is Osgood–Schlatter’s disease and what is its relevance to the current condition? 6. What are the significance of the bone scan findings and the assessment of the abdominal stabilising muscles, and do these findings tie in with the other assessment findings? 7. Which of the symptoms and signs will you place on your priority list? 8. How will you address these in your physiotherapy treatment plan? CASE STUDY 12 Hip and thigh pain Subjective examination Subject 38-year-old female Right leg dominant HPC Right lateral hip and thigh pain that can radiate to knee Started approximately 1/12 ago Woke up with pain after a long shopping day PMH Overweight (BMI ≥27) Neck pain and headaches Aggravating factors Walking Sleeping on right side Sleeping on a hard mattress Easing factors Rest and ice Night Wakes up frequently, particularly when lying on right side, or on left side with right hip in adduction and knee resting on the mattress Daily pattern Pain during and after prolonged standing and walking General health Overweight. No other problems reported. Not using any medication Attitude/expectations Is not sure whether treatment will provide immediate relief, but hopes that at least she will be able to sleep better. Between pain experienced at night and her youngest child waking up and demanding attention she does not get much sleep and feels fatigued Pain and dysfunction scores VAS current pain at rest before activity = 2 VAS usual level of pain when waking up at night = 8 VAS usual level of pain during and after activity in the last week = 7 VAS worst level of pain in the last week = 9 Lower Extremity Functional Scale 48/80 ( Binkley et al 1999 ) Objective examination Standing Visibly overweight Wide hips, but knees are touching each other Valgus position of knees and ankles Pronated feet with reasonable longitudinal arches Palpation Although skin temperature (T sk ) around hip and along the thigh appeared normal, that of the posterior aspect of the trochanter may have been a little elevated Tenderness of the iliotibial tract and the bony posterior aspect of the greater trochanter, with a boggy feeling around the location of the bursa ( Hoppenfield 1986 )

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Home > Communities > School of Medicine & Health Sciences > PT > PT-GRAD > 668

Physical Therapy Scholarly Projects

A Case Report: Adhesive Capsulitis and Physical Therapy Intervention

Haley Brenner , University of North Dakota

Date of Award

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Scholarly Project

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Doctor of Physical Therapy (DPT)

Physical Therapy

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Bursitis -- therapy; Case Reports

Background and Purpose The purpose of this case report is to describe the physical therapy interventions for a patient with adhesive capsulitis.

Case Description The patient was a 68-year-old right-handed male who presented with left shoulder pain and limited range of motion (ROM) following a fall 7 months prior. The patient had a past medical history of type II diabetes mellitus. The diagnosis of adhesive capsulitis was determined following radiographs, mechanism of injury, past medical history, and physical therapy examination and evaluation.

Intervention The patient was seen for a total of 8 physical therapy sessions over the span of 6 weeks. Interventions included a home exercise program, instruction in heat/ice use, mobilizations, therapeutic exercises, ROM, stretching, and upper body ergometer use. Outcome measures included ROM measurements, pain ratings, strength tests, the Shoulder Pain and Disability Index (SPADI), and the Patient Specific Functional Scale (PSFS).

Outcomes Following 6 weeks of physical therapy intervention and home exercise program, the patient demonstrated increased shoulder ROM, decreased pain, and improved function based on the improved SPADI and PSFS scores

Discussion Rationale for treatment was based on textbook information for shoulder interventions and research articles. The treatment was altered based on patient's response.

Conclusion This case report is in concordance with the current research that shows strengthening, mobilizations, a home exercise program and stretching are appropriate combinations of interventions for individuals with adhesive capsulitis. This patient returned to his prior level of function following the above treatment regimen.

Recommended Citation

Brenner, Haley, "A Case Report: Adhesive Capsulitis and Physical Therapy Intervention" (2019). Physical Therapy Scholarly Projects . 668. https://commons.und.edu/pt-grad/668

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Constrained Physical Therapist Practice: An Ethical Case Analysis of Recommending Discharge Placement From the Acute Care Setting

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Ernest Nalette, Constrained Physical Therapist Practice: An Ethical Case Analysis of Recommending Discharge Placement From the Acute Care Setting, Physical Therapy , Volume 90, Issue 6, 1 June 2010, Pages 939–952, https://doi.org/10.2522/ptj.20050399

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Constrained practice is routinely encountered by physical therapists and may limit the physical therapist's primary moral responsibility—which is to help the patient to become well again. Ethical practice under such conditions requires a certain moral character of the practitioner. The purposes of this article are: (1) to provide an ethical analysis of a typical patient case of constrained clinical practice, (2) to discuss the moral implications of constrained clinical practice, and (3) to identify key moral principles and virtues fostering ethical physical therapist practice.

The case represents a common scenario of discharge planning in acute care health facilities in the northeastern United States.

An applied ethics approach was used for case analysis.

The decision following analysis of the dilemma was to provide the needed care to the patient as required by compassion, professional ethical standards, and organizational mission.

Constrained clinical practice creates a moral dilemma for physical therapists. Being responsive to the patient's needs moves the physical therapist's practice toward the professional ideal of helping vulnerable patients become well again. Meeting the patient's needs is a professional requirement of the physical therapist as moral agent. Acting otherwise requires an alternative position be ethically justified based on systematic analysis of a particular case. Skepticism of status quo practices is required to modify conventional individual, organizational, and societal practices toward meeting the patient's best interest.

Constrained physical therapist practice is encountered when the clinician understands the patient's legitimate needs and, while acting to meet those needs, may be compelled to provide less than the necessary care. 1 – 3 The process for determining legitimate patient needs is defined by the profession. 4 Acting to meet patients' needs requires sufficient assets such as the expertise 5 and moral courage 6 of the physical therapist, sufficient financial resources, and supportive laws, regulations, and institutional culture. 7 As an example, care may be constrained if a physical therapist determines a patient needs a particular intervention but a third-party payer does not reimburse for physical therapy or only reimburses for a different intervention. In this situation, if the physical therapist chooses to provide less than the needed patient service, the physical therapist's actions may be unethical.

The physical therapist is in a helping relationship, with the primary moral responsibility “to stand alongside” the patient. 8 This manner of relating is crucial, as the patient is vulnerable and needs the help of the physical therapist to become well again. 9 Due to this vulnerability, patient need carries a moral obligation for the physical therapist to act. 10 Chronically constrained physical therapist practice erodes this helping relationship, moving the physical therapist toward moral disengagement 11 and a loss of the commitment to stand alongside the patient.

The causes of constrained clinical practice may be internal or external, and the effects of constrained care may be weak or strong. A physical therapist's clinical practice is internally constrained when he or she possesses less than sufficient moral intent, expertise, or moral courage to help meet the individual patient's needs. Laws and regulations may be a source of external constraint on the physical therapist's practice. When professionals follow just laws, they contribute to a well-ordered society. 12 However, professionals must be vigilant and not follow unjust laws or regulations not in the patient's best interest. 13 The effect of constrained clinical practice on the patient varies from weak to strong. Weak constraint may have no discernable effect on a patient's care, whereas strong constraint always results in harm to the patient.

Evidence of constrained physical therapist clinical practice was identified by Guccione 1 and Treizenberg, 2 indicating physical therapists may not have sufficient resources to meet patients' needs. Greenfield and colleagues' qualitative study of 7 novice physical therapists also reported constraints on practice, including barriers to caring and the culture of the practice setting. 14 Purtilo 3 declared scarce resources to be an ongoing reality of the physical therapist practice environment. The medical profession is debating how to ensure patients' needs are met in an environment of constrained practice that attempts to limit professional autonomy. 15 – 18 Morreim 19 proposed deceptive documentation, so-called “gaming,” as a justifiable response. In the physical therapy profession, Nalette 20 reported a case of a physical therapist gaming third-party payers to ensure patients received needed care and later reported anecdotal information from graduate student physical therapists who were involved in gaming. 21

Jette et al 22 proposed a clinical decision-making model used by occupational therapists and physical therapists for recommending placement of patients being discharged from an acute care setting. In the model, a clinician's initial discharge recommendation may be constrained by various regulations. This routine constraint of practice seemed to be recognized by these occupational therapists and physical therapists as a practice reality and an accepted condition for altering an individual's professional judgment. Moral concerns were not expressed about the acceptance of this routine constraint.

The processes used by physical therapists to make good moral decisions regarding a patient's legitimate needs are described in the physical therapy literature 23 – 27 and are interwoven into expert clinical practice. 28 The physical therapy profession defines this moral intent through its code of ethics. The American Physical Therapy Association's (APTA) Code of Ethics (Code) “[p]rovide standards of behavior and performance that form the basis of professional accountability to the public.” 29 This public professing of a moral intent creates a normative foundation from which physical therapists ought to assess their moral actions. As an example, the physical therapy profession recognizes that third parties may attempt to constrain the physical therapist's ability to meet patient needs. However, its Code obligates physical therapists to “be accountable for making sound professional judgments” ( Fig. 1 , principle 3) while acting in “the best interests of patients/clients” ( Fig. 1 , principle 2A) and being “responsible stewards of health care resources and shall avoid overutilization or underutilization of physical therapy services” ( Fig. 1 , principle 8C). The physical therapist is morally obligated for meeting patients' needs.

Selected ethical principles from the Code of Ethics . 10 Column A indicates principles supporting choice 1 in the moral brief. Column B indicates principles supporting choice 2 in the moral brief. Reprinted from [ http://www.apta.org/AM/Template.cfm?Section=Ethics_and_Legal_Issues1&Template=/CM/ContentDisplay.cfm&ContentID=63686 ], with permission of the American Physical Therapy Association.] This material is copyrighted, and any further reproduction or distribution is prohibited.

When all is calm, the physical therapist understands a patient's needs and is able to meet those needs. This moral calmness ought to be interrupted when the physical therapist is unable to meet patient needs. Under conditions of constraint, the physical therapist is not fulfilling the profession's moral ideal, may not be fulfilling his or her personal moral intent, and may be practicing unethically as a physical therapist. During professional (entry-level) education, student physical therapists are taught to meet patients' needs and to do so in an ethical manner. 30 At entry to clinical practice, the physical therapist is competent to meet patients' needs, is capable of assessing the ethics of practice, and is legally bound by the state jurisdiction to practice within ethical boundaries. A physical therapist then is professionally obligated to apply an ethics comprised of the agent's “personal philosophies, metaphysical beliefs, the virtues, communities, narratives, rules, principles, circumstances, consequences, feelings, intuitions, codes of ethics training and workplace norms” to the resolution of specific cases 31(p147) to ensure morally good actions on behalf of patients. Ethical analysis, what Purtilo referred to as “tools for developing ‘habits of thought' for reflection,” 32(p1114) and moral action then are required when the physical therapist encounters a situation of constrained practice. After all, as Frankena stated, “being without doing, like faith without works, is dead.” 33(p66)

Constrained physical therapist practice is routinely encountered by physical therapists. Swisher 34 stated there is a paucity of literature on ethical issues routinely encountered by physical therapists. The purposes of this article are: (1) to provide an ethical analysis of a typical patient case of constrained clinical practice, (2) to discuss the moral implications of constrained clinical practice, and (3) to identify key ethical principles and virtues that may foster ethical practice within a culture of constrained practice.

An applied ethics approach was used to analyze a patient case. Applied ethics is a systematic approach of applying ethical concepts to actual cases involving 2 or more goods in conflict, resulting in a justifiable decision. 35 A systematic approach implies “a whole composed of parts in orderly arrangement according to some scheme or plan.” 36 A systematic approach to ethics for physical therapists is: (1) pluralistic and accessible, (2) fostering of moral agency, and (3) comprehensive.

A pluralistic and accessible approach to ethics supports various philosophical perspectives 37 , 38 and various levels of moral development. 39 Physical therapists, like the general public, possess differing mixes of moral philosophies such as deontology, utilitarianism, or virtue ethics. 37 As an example, a physical therapist's moral philosophy of practice may derive from a set of moral rules and principles with a focus on the consequences of actions. Alternatively, practice may be conceptualized from a nonconsequentialist perspective, a belief that certain actions are intrinsically good and morally obligatory regardless of consequences. A pluralistic approach to ethics is open to these and other moral philosophies. Physical therapists, again mirroring the general public, vary in level of moral development. The moral abilities of a specific physical therapist allow the individual to function at a particular level of moral agency. 40 An accessible approach to ethics will have utility for physical therapists functioning at varying levels of moral agency.

A systematic approach to ethics for physical therapists fosters moral agency. Physical therapists profess to be autonomous practitioners, 10 thereby claiming the liberty and personal freedom to follow their own will and act as moral agents. As moral agents, physical therapists use their moral beliefs to guide actions in relationship with patients 41 under particular circumstances, 40 , 42 ensuring their actions are in the patient's best interest. Through this process of moral deliberation, the physical therapist as moral agent recognizes the responsibility for making good moral decisions and acting on those decisions.

Finally, an approach to physical therapy ethics is comprehensive by encouraging reflection on the 3 realms of ethics. 7 The primary focus of the physical therapist clinician's practice is the individual patient and the inherent moral nature of the helping relationship. To lose this focus on the individual patient as the primary unit of care for the physical therapy profession would foretell its doom. However, in addition to this individual realm of practice, there also are organizational and societal realms of practice. Doing ethics without an awareness of all 3 realms of ethics would be naive. A comprehensive approach to ethics provides guidance in these 3 realms.

A number of systematic applied ethics methods that meet the above criteria appear in the literature. 31 , 41 , 43 , 44 Each approach utilizes a set of questions intended to expose the morally relevant components of a particular case and facilitate the moral agent's arrival at an ethically justifiable decision. I am unaware of a published analysis of applied ethics methods indicating the efficacy of one approach over another. Nash's approach 31 meets the above criteria of a systematic ethics approach for physical therapists and was selected for the analysis. Nash's moral brief framework is presented in Figure 2 .

Nash's moral brief framework. 31(pp194–206)

The case ( Fig. 3 ) and institutional mission statement ( Fig. 4 ) were presented to the author by an experienced physical therapist with expertise in acute care. The case represents a common discharge planning scenario at several acute care health facilities in the northeastern United States. The case was accepted for analysis by the author and was not altered. No personal or organizational identifiers were present in the case. The central moral concern of the case is the patient-practitioner relationship, which is primarily nested in the individual ethical realm. 7

Case study presenting a moral dilemma.

Institution's mission statement.

I reviewed the case and institutional mission statement and consulted with the therapist who provided the case to ensure a common understanding of these materials. I then responded to the moral brief ( Fig. 2 ) as the physical therapist treating the patient might have responded.

All physical therapists are responsible to act as moral agents with their patients. Ethical analysis requires that the moral agent apply general moral concepts to a particular case, arrive at a decision, and take an ethically justifiable action. 31 , 34 , 42 The moral agent's approach to a particular case emanates from life experiences and from the moral wherewithal that is accessible to the particular agent at the time of the analysis. This moral wherewithal is an accumulation of an agent's “personal philosophies, metaphysical beliefs, the virtues, communities, narratives, rules, principles, circumstances, consequences, feelings, intuitions, codes of ethics, training and workplaces norms.” 31(p147) I assumed the role of moral agent in the analysis and brought to this analysis a narrative encompassing more than 3 decades of clinical and academic physical therapist practice, respect for ethical principles, the APTA Code of Ethics , and a primary disposition toward virtue ethics, 8 , 42 , 45 of which relationship ethics is a subset. 46 – 48

The results of the case analysis are summarized in the following moral brief. The subheadings are the questions that make up the moral brief.

What Are the Central Moral Issues of Your Dilemma?

I do wish we could treat every patient who could benefit from physical therapy, but we don't have enough staff. Mr Smith's needs can be met by physical therapy in [the rehabilitation facility]. Will he really gain that much more benefit from a few days of therapy here? Patients can't possibly understand the pressures. Health care is expensive, and we get pressure from all of the administrators to contain costs. If we were to meet all the patients' needs, health care would be even more expensive.

Mary and her colleagues recognized about a decade ago that they no longer had sufficient personnel to carry out their professional responsibilities. The administrators were informed of the lack of sufficient staff to meet patient needs, responding, “You'll have to learn to do more with less.” Due to these externally imposed constraints, the physical therapists developed and instituted the current unwritten rationing procedure.

My colleagues and I need to look out for each other. If I help Mr Smith, will I be turning my back on my colleagues? I have friends who practice at other acute care centers. They didn't get necessary staff either and worked to the point of exhaustion. A number of those physical therapists got injured or left the practice, and then patients got even less help. By following our procedure, we are responding to all patient referrals in the same way and not playing favorites. If I do not follow the procedure, we will be back in the same chaos we were in before we worked out our procedure. Previously, we were making choices based on political pressure or arbitrary information. That was clearly not right.

Mary recalls a time in the past when resources were not so tightly constrained and the therapists made decisions about how much therapy a patient needed in the acute setting. In the past, the question about good patient care was, “Did you help the patient reach the needed level of function?” The new question about patient care is, “Can we afford to offer that service?”

What Are the Conflicts in Your Case That Make It an Ethical Dilemma?

The classic moral concern is the dilemma. A moral dilemma occurs when “an agent has a moral obligation or requirement to do each of two acts but cannot do both.” 49(p508) If, at this early point in the analysis, the choice was between a good act or an evil act, no further analysis is indicated. The practitioner acts on the good. 33 Mary's moral dilemma is to choose between 2 good acts. From her knowledge of the case, she sees 2 choices: (1) to follow the rationing procedure and refer Mr Smith to the rehabilitation facility without providing care by the physical therapists in the acute setting or (2) to provide Mr Smith with physical therapy services during his stay in the acute care setting. Mary does not have the resources to carry out both choices. There is a tragedy inherent in an ethical dilemma in that a moral good will be left undone.

Choice 1 produces a good for the group of patients referred to the physical therapy practice. They are treated justly 12 ; all individual patients enter the practice under the same guidelines and receive, or do not receive, interventions based on the results of an evaluation. Therefore, benefits and burdens are fairly distributed among all patients based on defined patient needs. 12 Delaying an intervention for Mr Smith seems to Mary to be a relatively small burden under chronic conditions of insufficient resources. Selecting choice 1 means Mary will maintain the status quo.

Choice 2 also produces a good in that Mr Smith will receive a beneficial service in a timely fashion. Mary could choose to help Mr Smith and keep her choice to herself; she would only need to speak with the case manager with whom she has already consulted. Mary could quietly shift her resource of time from one patient to another. Choice 2 means Mary will disrupt the status quo.

Who Are the Major Stakeholders in Your Dilemma?

Mary: The physical therapist who is the moral agent and who is accountable for the decision.

Mr Smith: The patient who has come to Mary seeking her help. He may influence the decision if Mary is responsive to his input. Regardless of the decision, the outcome of the decision will have a direct bearing on his care.

Mr Smith's family: Given that Mr Smith is competent, the family may not have a direct influence on the decision; however, the family will be affected by the decision.

Colleagues: Mary's colleagues and the organizational leadership will be influenced if Mary selects choice 2.

What Are Some Foreseeable Consequences of the Possible Choices in Your Dilemma?

If Mary selects choice 1, the status quo is maintained and no further action will be necessary. Mr Smith will leave for the rehabilitation facility in a few days, and the “problem” will appear to be resolved. However, with this upheaval of thought, Mary's conscience may remain unsettled.

If Mary selects choice 2, the results may be disruptive. First, this choice commits Mary to providing the needed intervention to Mr Smith, placing additional demands on her. Second, justice considerations 12 then would require that Mary reconsider the rationing procedure. She would need to make adjustments in the practice that would allow future patients like Mr Smith to receive needed services in a similar manner. Otherwise, choice 2 and the rationing procedure would become arbitrary and capricious. Third, breaking with convention may result in negative consequences for Mary if she appears to be disloyal to her colleagues and is no longer following the procedure that is intended to provide justice for the patient population at large. 50

What Are Some Foreseeable Principles Involved in Each Decision?

Choice 1: to follow the established routine defined by the rationing procedure and refer mr smith to the rehabilitation center.

Justice is the principle that Mary views to be most supportive of choice 1. Justice refers to the “fair, equitable, and appropriate treatment in light of what is due or owed to persons.” 38(p327) The principle of justice is invoked in health care due to conditions of finitude. 3 Limited resources may be distributed based a number of material principles of justice, including “equal share, need, effort, contribution, merit, and free market exchange.” 38(p330) Of these principles, need is used as the material principle for resource distribution, as meeting patients' needs has a moral obligation in this analysis.

Autonomy is another relevant principle. Autonomy is used here in the sense of self-governance, including capacities such “as understanding, reasoning, deliberating, and independent choice.” 38(p121) Mary understands that fairly implementing the rationing procedure requires skillful data collection and clinical reasoning. Additionally, she must possess sufficient autonomy to implement her independent choice. 16 To date, she and her colleagues have not acted with sufficient autonomy to effect organizational change. She does recognize she has sufficient autonomy to implement her choice with Mr Smith, if she is morally silent, in that no one is in a position to stop her from making and implementing either of the choices available as an outcome of this analysis. This awareness is a heightened level of moral consciousness for Mary.

Two additional principles— nonmaleficence , the obligation to knowingly not inflict harm, and beneficence , the active provision of benefits 38 —are presumed in Mary's everyday practice. She is not aware of any literature stating that delaying Mr Smith's intervention by a physical therapist for less than a week will have harmful effects on his outcome. In addition, Mary believes that referring Mr Smith to the rehabilitation facility will be of benefit to him, as he will receive needed services. The past results of the rationing procedure seem to benefit patients referred to the rehabilitation center.

Choice 2: Not following the established routine defined by the rationing procedure; treat Mr Smith and forgo the rehabilitation center referral

Autonomy also is a principle that Mary views as being supportive of choice 2. However, viewing this case from the perspective of choice 2 guides her not exclusively to professional autonomy, but also to respect for patient autonomy. 51 Acting on the principle of respect for autonomy encourages her to actively facilitate Mr Smith's autonomous actions. If Mary had involved Mr Smith in the original decision-making process, the current ethical dilemma may have been averted.

The moral principle of nonmaleficence calls on health care practitioners to first do no harm. 38 Avoiding physical harm is crucial and is a primary concern in every patient-professional relationship. Potential harms to Mr Smith by his physical therapist are not limited to physical harms. Mr Smith's autonomy has certainly been ignored and thereby harmed. Although nonmaleficence, in its broadest sense, is a necessary ethical principle of a physical therapist's practice, it is not sufficient. Beneficence, the moral obligation to create benefit for others, 38 also is a moral requirement of practice. Dividing these principles may be problematic in health care. Frankena's formulation of beneficence—(1) one ought not to inflict evil or harm, (2) one ought to prevent evil or harm, (3) one ought to remove evil, and (4) one ought to do or promote good 33 —sets a clearer moral ideal in health care practice. This formulation of the principle continuously calls on the practitioner to avoid harm and provide benefit.

What Are Some Viable Alternatives to Ethical Courses of Action in Your Dilemma?

Mary remembers a number of past alternatives and reflects on those possible options prior to making a decision in this case.

Alternative 1: Misrepresent select patient populations in the medical record and on billing forms to enhance reimbursement and improve the possibility of improved staffing

A colleague from a different practice setting offered the possibility of misrepresenting patient populations in the medical records and on billing forms. He explained how his practice altered documentation in select populations, resulting in enhanced income and additional staffing. The good was that patients received additional services and the staff were under less pressure and able to be more helpful to patients. For Mary, however, choosing to lie 52 in her documentation or billing forms is not a viable alternative. The good choice is to maintain her honesty and, therefore, her moral integrity.

Alternative 2: Accept referrals on a preferential basis

The goods of this alternative offer additional perspectives on justice. Accepting all patient referrals on an equal basis means each patient ought to receive the same type, frequency, and duration of treatment. This egalitarian approach (material principle of equal share), 38 although attractive, applies only when patients' needs are equal. 12 Preferential treatment of select patients or patient populations is justifiable only when, under conditions of constrained resources, preference is given to the most vulnerable groups within the larger population, such as poor people, children, or those who are discriminated against. 12 Mary knows the premise of equal need is not true in her practice and, therefore, rejects this alternative.

Alternative 3: Accept referrals only when sufficient staff are available to meet patient needs

Limiting acceptance of referrals 53 based on available staffing seems to have merit. The effect might be to shift the responsibility for responding to referrals back to those (referring agents, institutional leadership) who have the authority to make a change in staffing. 7 Mary presumes this decision will have a significant effect on the status quo. More pressure might be generated to change the status quo, with a resultant good of additional needed help for patients. Although this alternative may be beneficial for future consideration, the choice will not be helpful in addressing the case of Mr Smith within the necessary time frame.

What Are Some Important Background Beliefs You Should Consider in Your Dilemma?

Ethical background beliefs are personal stories that help guide us in life, including within our professional relationships with patients, colleagues, and others. 31 Mary's background beliefs emanate from her rural, small-town, Roman Catholic upbringing. She grew up drawing her moral authority from her parents, teachers, and exemplars such as Jesus, Gandhi, Martin Luther King, and Nelson Mandela. Based on this background, Mary aspires to be inclusive, fair, compassionate, persevering, nonviolent, and just. Although these beliefs are private and rarely discussed, Mary sees every human being as unique and imbued with dignity. Her professional purpose supports human dignity by helping others—relieving suffering and assisting her patients' return to health. Mary feels that in Mr Smith's case, and potentially with other patients, she is not living up to her own deeply held beliefs. Specifically, she feels Mr Smith has not been fairly treated and that she has added to his suffering in the name of justice. She wonders if her compassion was too thin to respond in this case.

What Are Some of Your Initial Intuitions and Feelings About This Dilemma?

Intuitively, that is, based on her life experiences, 54 Mary now wonders whether she made a good decision. She feels badly about not facing Mr Smith and offering him help. Emotionally, Mary feels something is wrong in this situation. Mr Smith reminds her of her father; she would be very upset if her father's needs were deferred by a health care practitioner without an adequate explanation. Mary is now hesitant about her initial decision and feels uncomfortable.

What Choices Would You Make if You Were to Act in Character in Your Ethical Dilemma?

Acting in character means Mary will think and act in a manner that is consistent with who she is and who she hopes to become, respecting her background beliefs, personal narrative, intuitions, and emotions. For Mary, acting in character means she would be responsive to Mr Smith and provide the needed care. She realizes she has not been acting fully in character. As Neoptolemus wrote, “Everything is discomfort, when someone leaves (her) own character and does what is not fitting.” 55

The reflections being discussed in the responses to the prior few questions may be so intensely personal and private that an external perspective on the analysis may be beneficial. Mary now turns to her professional code of ethics for an objective perspective.

What Does Your Profession's Code of Ethics Say Regarding the Relevant Moral Issues in Your Dilemma?

Consideration of the profession's Code brings the accumulated wisdom of the profession in a recently updated document 56 into Mary's thinking. The Code “provides standards of behavior and performance that form the basis of professional accountability to the public” 10 and “specific guidance to inform ethical decision making in their interactions with patients and clients, colleagues, other health care professionals, employers, and organizations.” 57 Mary's responsibility at this step in the brief is to apply the general guidelines from the Code to Mr Smith's particular case and discern which of her 2 choices can be best justified. Mary first reviews the Code with the particulars of Mr Smith's case in mind, seeking justification for choice 1, and finds guidance in principles 1 and 3 ( Fig. 1 ).

Principle 1 guides Mary to reflect on the concepts of dignity and rights. She believes Mr Smith has the right to an intervention that will help him meet his needs but that deferring this intervention does not seem to infringe on his rights and will result in compassionate care. Mary recognizes her professional responsibility for making sound professional judgments ( Fig. 1 , principle 3) and views her assessment and evaluation of Mr Smith as being within her scope of practice ( Fig. 1 , principle 3C).

Next, seeking justification for choice 2, Mary views the Code through a prism of compassion and reflects on principles 1, 2, 3, 4, 5, and 7 ( Fig. 1 ). She now views principle 1 with different shading. Patient rights have continued importance, but patient dignity and practitioner compassion take on a more central meaning based on Mr Smith's reaction to the decision to transfer him to another facility and his belief that he deserved services immediately was not given sufficient respect in the deliberations leading to the transfer decision. From the perspective of her reflections on patient rights, dignity, and practitioner compassion ( Fig. 1 , principle 2), Mary reconsiders her approach to patient evaluation and assessment. Mary realizes she was not mindful 58 of Mr Smith's needs when making her decision to defer intervention. Mr Smith met Mary and entrusted his health to her. He is vulnerable in this relationship due to his inability to help himself. The decision to refer Mr Smith to the rehabilitation facility may be an exploitation ( Fig. 1 , principle 4B) of this vulnerability.

The manner in which the procedure was executed certainly did not encourage trustworthiness from Mr Smith ( Fig. 1 , principle 2), nor was Mary's manner collaborative ( Fig. 1 , principle 2D) in nature. Given this new reflective context, Mary reconsiders principle 3 in a different light. In reconsidering this principle, Mary has a heightened sense of compassion and patient autonomy. She is concerned that her professional judgments may not have been in the patient's best interest ( Fig. 1 , principle 3A).

Principle 7 ( Fig. 1 ) highlights the necessity of involving the organization in resolving the current practice conundrum. According to the organizational mission statement, the mission of the institution is “to serve patients compassionately and effectively by providing personalized, excellent care” ( Fig. 4 ). In Mr Smith's case, Mary is not implementing the organizational mission. The Code provides guidance for reforming the current process. A revised process shall include a “collaborative process” ( Fig. 1 , principle 2D) with patients in “a practice environment supportive of autonomous and accountable professional judgments” ( Fig. 1 , principle 7A) while providing services in a “compassionate and caring” manner ( Fig. 1 , principle 2B). The current process does not foster this morally patient-centered manner of caring. Disallowing such patient involvement does not support moral practice on behalf of the patients, therefore, making the current procedure, at minimum, morally suspect.

Based on these reflections, Mary now faces the responsibility of discerning which of the 2 choices considered during this analysis best matches with her professional role and character.

What Is Your Decision in the Dilemma, and Do You Have Any Afterthoughts?

Mary decides to change her original position by selecting choice 2—to provide Mr Smith with physical therapy services during his stay in the acute setting. Acting on this decision means Mary will directly follow up with Mr Smith, first to acknowledge to herself that she broke her relationship with Mr Smith, ask his forgiveness for not honoring his point of view, 59 invite his input to the plan of care, and initiate the intervention plan. Next, she will communicate her reasoning to her colleagues and enlist their support in reconsidering the rationing procedure. Additionally, Mary will recommend implementing alternative 3 from question 5 of the above moral brief (ie, making the moral commitment to new patients only when sufficient staff resources are available). 53 Lastly, she will follow through with the organizational authorities and inform them of the change in the procedure to accept new referrals only when sufficient staff are available to meet the patient's needs.

Mary proposes to her colleagues that a revised policy be developed, printed, posted, and used in open dialogue with patients. The new policy will include the parameters under which patients will be accepted into the practice—that patients will be actively encouraged to participate in the treatment planning process (including discharge) and that they will be educated regarding the results of the treatment and recommended follow-up. She also recommends they post the APTA Code of Ethics in a prominent location in the clinic as an educational tool for patients and a reminder of ethical responsibilities to herself and her colleagues.

As Mary recommits herself to a more collaborative approach to patient care, she desires to extend this collaborative character to her organizational relationships. Mary intends this interaction with organizational leadership to follow the precepts of the moral conversation 60 wherein she seeks conversation and not contestation, with a focus on introducing narrative through questioning, respectfulness, and understanding. Her hope is for a better organizational understanding of ethical and legal physical therapist practice and a better understanding on her part of the organizational resource constraints.

Mary has a number of afterthoughts beyond the specific actions she will take regarding this case. First, although she was quite nervous about her analysis, she feels good that she was willing to take a personal risk in the decisions that she made related to this case. Second, she is amazed how the status quo of the routine practice of not meeting patient needs seduced her into moral silence. Third, she remembers that her professionalism is grounded in providing help to patients and that without this relationship her profession is useless. She also vows to regularly revisit the Code. Fourth, Mary has realized a new integration of self and professional practice. She is moving toward being the same compassionate person in her practice as she is in her personal life.

Swisher 34 stated that practitioners in today's managed care environment are being asked to balance their fidelity to their patients with fiscal accountability to their employer. Balancing these interests is a moral good presuming the resources are sufficient for meeting patients' needs, health care organization vitality, and society's health. 7 The current “balance” within health care in the United States is ineffective. 61 – 63 As a society, the World Health Organization ranks the United States 29th in its years of healthy living measure and ranks the US health care system 37th. 64 This poor performance of the health care system is not due to lack of financial resources. In 2001, the United States spent 75% more dollars per capita on health care than Canada; however, Canadians live 2.7 years longer than US citizens. 58 Rather than an insufficient financial investment in the country's health care system, there is an unjust distribution of those financial resources. 60 There is sufficient evidence of systemic dysfunction of the health care system that skepticism of conventional practices is warranted, especially when cost containment is the proposed justification. 65

The analysis in this article demonstrates a micro-ethics of resource redistribution grounded in virtue ethics and the virtuous practice of meeting individual patient needs, while providing a method for the practitioner seeking a balance between the patient's need for help and the employer's need for organizational vitality. Fundamental concepts key to this analysis include: (1) the moral nature of human relationships, specifically the relationship between a patient and a physical therapist; (2) the finitude of health care resources and the ethics of constraint; and (3) the practitioner's adjunctive responsibilities in relationship to the organizational and societal realms of ethics.

The moral nature of human relationships is based on mutual respectfulness, helpfulness, truthfulness, and keeping promises and secrets 8 and “is concerned with relations between people and how, ultimately, they can best live in peace and harmony.” 41(p8) In addition to these shared humane expectations, the physical therapist is called to help others in a relationship 48 become well again—to stand alongside the patient. Helping others is a mindful practice 57 wherein the practitioner learns the patient's story. The better the patient story is understood, the more the patient's humanity is respected and sustained in the heart of the practitioner. Humanity is nearly synonymous with compassion 66(p111) ; therefore, the moral physical therapist knows the patient's humanity, and his or her practice is grounded in compassion. In our case, Mary's conventional practice is disrupted when confronted by Mr Smith's personal narrative, by what Nussbaum referred to as an “upheaval of thought.” 55(p1) Mary recognizes her “father” in Mr Smith (see question 7) and through her more “attentive openness, solicitude, patience, and listening” 66 becomes more mindful of “the ordinary, the obvious and the present” 57 in the situation. Mr Smith's humanity becomes known to Mary, thereby awakening her compassion.

The importance of emotions in physical therapist practice is commonly misunderstood as being irrational or lacking in objectivity. Rather, our emotions need to be fully developed to enter into moral discourse, 67 and positive examples of the emotions in physical therapist practice are available in the physical therapy literature. 25 , 41 , 68 , 69 The compassionate physical therapist knows the patient's narrative and is emotionally moved to “do what (he or she) must” 66 to relieve the patient's suffering.

In our case, Mary expresses some mixture of emotion, 70 the moral virtues (prudence, justice, fortitude, and temperance), 71 and theological virtues (faith, hope, and love). Additional virtues such as gentleness, generosity, and courage 66 have relevance to this case. I am proposing that Mary adopted, or readopted, compassion as a cardinal virtue, which, when well practiced, fosters a continual focus on the professional's fundamental responsibility for being responsive to the patient's best interest. Aristotle 42 would remind us, as in any consideration of virtue, to avoid both a deficient and an excessive compassion. A deficient compassion, or “arrogant harshness,” 55 lacks sufficient moral engagement for understanding the patient's narrative and providing the type of help needed by the patient. An excessive compassion, or sentimentality, may not relieve suffering but may add to the total suffering in a particular situation, what Buddhists call “idiot compassion.” 72 Nussbaum 55 counseled that the practitioner be compassionate and take an emotional position that allows practical reasoning on behalf of the other. Mary, then, is of a certain moral character, and the case analysis reflects on what sort of person she is in her relationship with Mr Smith—what Hursthouse called “a claim that goes all the way down.” 37(p12) At this individual realm of ethics, Mary is compassionate and stands alongside Mr Smith, helping meet his needs.

The second fundamental concept in this ethical analysis is the finitude of health care and the ethics of constraint. The above analysis accepts Purtilo's premise that health care resources are finite. 3 This societal condition has imposed itself on the organizational level of patient care and is routinely experienced by physical therapists in their relationship with individual patients. Over time, financial resources were incrementally constrained by the organizational leadership. The consequence of this action was an insufficient number of available physical therapists within the organization for meeting patients' needs. However, the organization did not limit the number of patients admitted to the acute care hospital who were in need of the care of physical therapists. This organizational constraint resulted in patients receiving less than needed care from their physical therapist.

Incremental organizational constraint on physical therapist resources results in diminishing benefits to the patient and, eventually, in patient harm. Diminishing benefit may come in shades of delaying care and rationing care. Delay in care implies a patient queue due to limited resources. Delays result from various causes, 73 and care may be delayed without criteria. Rationing of care may involve delay in care, but with some procedural or distributive criteria. 3 Retrospectively identifying exactly when the resources were no longer sufficient, or when diminishing benefit becomes harm, probably is not possible. 74

Over a number of years, Mary and her colleagues internalized a series of external constraints that negatively affected their responsibility to make sound clinical judgments (see question 1). Once constraints on practice are internalized, the practitioner conspires in the constraint of practice, and the patient harm becomes part of the practice culture. It is difficult for physical therapists to sustain moral agency in a culture of constrained practice and be “impervious to the social realities in which they are enmeshed.” 11(p102) Moral conscience diminishes, individuals become morally disengaged, and moral agency fails. Practitioners then find themselves in an ethically untenable position, unable to stand with all of the referred patients and help them become well again. A moral corrective is required.

Mary breaks from the culture of constraint, 75 and a moral corrective begins when she chooses her compassionate self and her professional role over her employee role. As Bruckner 76 discussed, when a physical therapist chooses the employee role, responsiveness to professional responsibilities diminishes; the physical therapist becomes more receptive to organizational needs and less receptive to patient needs. This decision is morally critical; Mary recognizes her potential double agency, choosing her professional role over her employee role. The ethics of constraint demonstrate that, at some point along the continuum of diminishing resources, a balance between the professional role and the organizational role is no longer feasible. The ethical physical therapist chooses the professional role and chooses to stand next to the patient. Moral agency is strengthened.

Therefore, being an ethical physical therapist in the context of constrained practice means the practitioner is receptive to the needs of the unique patient; is accountable 77 to an array of normative standards such as the Code, state practice acts, and health care regulations; and is practicing in harmony with his or her own moral character. Mary takes the time to know and become morally engaged with all of her patients and to comprehensively apply professional standards for patient care/management ( Fig. 1 , principle 4.1.E). Mary is integrating her knowledge, clinical reasoning, and understanding of movement with her virtuous character disposition toward expert practice. 5 As Mary takes action based on the decision from her ethical analysis, she demonstrates a recapturing of her professional autonomy. She now understands her professional autonomy is nested with the individual realm of ethics and is functioning every time she accepts a new patient referral. This re-found autonomy means that Mary treats fewer total patients and that some patients she would have “treated” previously may not receive help. This reality is troubling to Mary. The residual moral tragedy of this analysis is those patients who are in need of physical therapy care but do not receive this needed care.

The third fundamental concept in this ethical analysis contemplates Mary's responsibilities in relationship to the organizational and societal realms of ethics. Our analysis, as with every true ethical dilemma, involves a moral tragedy: the patients whose needs are not met as a result of this analysis. This unmet need is beyond the authority and, therefore, the responsibility of Mary and her colleagues. The ethical responsibility for organizational vitality, while executing its publicly professed mission, resides with the organizational leadership ( Fig. 4 ).

Achieving and maintaining organizational vitality ought to occur while not harming, or being harmed by, its individual components 7 , 12 —in our case, the physical therapists' practice. Based on the organization's mission statement ( Fig. 4 ), Mary and her colleagues ought to provide “compassionate care,” while not harming the organization by wasting its resources. In the past, when Mary became morally silent about unmet patient needs, the organizational leadership may not have had the necessary feedback to change the organization's resource allocation. The organization ought not to admit patients needing physical therapist services who cannot be provided that care, or the leadership ought to change the staffing to meet the patients' needs.

Re-establishing this ethical behavior of the physical therapists begins to form a future organizational relationship that should allow “all (individual members of the organization) to justify their conduct to everyone else (when their conduct is justifiable) without self-defeating or other disturbing consequences.” 12(p582) Mary ought to be able to practice within the organization without putting her professional integrity at risk.

Mary's efforts with Mr Smith and her evolving moral practice help with improving the individual realm of ethics and may begin to influence organizational ethics. However, private virtue 78 and organizational realms of ethics should not be expected to positively affect problems at the societal level 7 without further specific action. Mary is seeking a societal identity 32 to help her form a vision of an ethical health care system to help guide her individual and organizational ethics actions. She adopts 3 societal health care system concepts she believes support an ethical health care system: a unified system, nonprofit financing, and universal coverage. 65 She hopes to express herself in public policy discussions in a manner that is supportive of these principles and that will be extensions of her personal philosophy and professional practice.

Limitations

Case analysis has a long history as a method of teaching ethics 7 , 31 , 38 and of providing normative guidance on matters of ethics. 35 However, the process of “doing ethics” by analyzing a written case is inherently different from “doing ethics” within the environment in which the case occurs. The case used in this article does not directly represent reality but is a facsimile thereof. 79 , 80 Also, the ethical case analysis was completed outside the clinical environment, and I was not constrained by the culture of a specific clinical environment. I did not face the patient, a peer group, or organizational leadership during or following this analysis and had no responsibility to act on the decision. Moral courage 6 was not required. Whether I would have come to the same decision had I completed the ethical analysis within the actual clinical setting is unknown.

Nash's approach to case analysis may be limiting because it is comprehensive, theory rich, and may not address concerns of the third realm of ethics. Adequately completing an ethical analysis similar to that demonstrated in this article may be viewed as time prohibitive in the typical clinical environment. Additionally, this approach is rich in philosophical theory, and the average physical therapist may not have the philosophical background required to take full advantage of this approach. As an example, Nash's use of background beliefs may require more training to be accessible to many physical therapists. Also, the concerns of the third realm of ethics may not be well addressed if the moral agent is without sufficient background in the theoretical underpinnings of the concept of stakeholders (see question 3).

The lack of clinical data in the case provided for analysis did not allow me to gauge the influence various physical therapist interventions 81 may have on the analysis. Cases including rich clinical information ought to be considered for future publication.

In this article, I offer an ethical analysis of a common patient case set in the context of constrained clinical practice. Constrained care is routinely encountered by physical therapists, and when resources are not sufficient to meet patients' needs, ethical dilemmas result. The primary moral roles of the physical therapist are to be in relationship with the patient and to advocate for that patient's best interest—to stand next to the patient and offer help. A culture of constrained physical therapist practice emphasizes the patient-physical therapist relationship, resulting in the patient receiving less care than is needed. Providing less care than is needed by the patient is unethical practice, unless a moral alternative can be explicitly justified through systematic ethical analysis. Being mindful of the patient narrative morally engages the physical therapist with the patient and fosters the physical therapist's compassion, the profession's cardinal virtue, thereby moving the practitioner to help relieve the suffering of the patient and countering the effects of constrained care.

The primary moral role of the physical therapist is in the individual realm of ethics. Although this realm is central, the physical therapist also is responsible to actively influence the organizational and societal realms of ethics. Effectiveness in these realms requires moral imagination and a passion for social justice. Skepticism is necessary when reflecting on personal practice patterns, organizational policies and procedures, and societal culture norms that may not be beneficial to meeting patients' needs.

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