TEAM- BASED CASE ASSIGNMENT

DAME ROBINSON AND TYLER GRAFT

 CASE DESCRIPTION FOR JENA AND KATIE:
• 31-YEAR-OLD FEMALE MOTHER OF 4 SCHOOL AGE CHILDREN (AGES 10, 8, 6, 4)
• SPINAL CORD INJURY (SCI) AT L4 AFTER REMOVAL OF BENIGN SPINAL TUMOR
• PARTNER IN THE NAVY BUT FAMILY IS SUPPORTIVE
• DEFICITS INCLUDE BALANCE, WEAKNESS IN BILATERAL FEET (PARTICULARLY IN MOVEMENT WITH GRAVITY)
• SENSORY LOSS—LIGHT AND SHARP TOUCH VARIES
• AROM WNL
• FUNCTIONAL LOSSES: DRIVING, WALKING, SIT TO STAND AND BALANCE
• NO PAIN, GRADUALLY IMPROVING SYMPTOMS
• PMH: ASTHMA
 SIMILARITIES AND DIFFERENCES
• SHELF STOCKING:
• REQUIRED MOVEMENTS:
• SIMILARITIES: PUSHING/PULLING CARTS, TRUNK ROTATION,
MULTIDIRECTIONAL REACHING AND LIFTING, SQUATTING,
POSTURAL CONTROL, STRENGTH/ENDURANCE
• DIFFERENCES: FINE MOTOR SKILLS FOR PRODUCT
PLACEMENT, CLIMBING STEP LADDER
• CONTEXTUAL NOTES ( ENVIRONMENT, SOCIAL,
EMOTIONAL AND OTHER FACTORS)
• SIMILARITIES: CUSTOMERS IN THE AREA, FLOORING, WIDTH
OF THE ISLES, CO-WORKERS, CUSTOMER MOODS,
EMOTIONS OF THE STOCKER
• DIFFERENCES: TEMPERATURE OF AREA (FROZEN VS BREAD
ISLE), HEIGHT OF SHELVES, SANITARY MEASURES, CUSTOMER
LACK OF AWARENESS,
• WAITRESSING/WAITERING:
• REQUIRED MOVEMENTS:
• SIMILARITIES: BENDING/REACHING OUTWARDS, AMBULATING IN MULTIPLE
PLANES, FINE MOTOR SKILLS, STRENGTH/ENDURANCE FOR MANIPULATING
PLATES AND DRINKS, POSTURAL CONTROL, TRUNK ROTATION
• DIFFERENCES: GRABBING AND PLACING BOOSTER SEATS, OPERATING POS
SYSTEM
• CONTEXTUAL NOTES ( ENVIRONMENT, SOCIAL, EMOTIONAL AND OTHER
FACTORS)
• SIMILARITIES: SPACING OF TABLES/BOOTHS/CHAIRS, CUSTOMERS
AMBULATING, CO-WORKERS AMBULATING, CUSTOMER INTERACTIONS, CO-
WORKER/MANAGER INTERACTIONS, UNPLEASANT CUSTOMERS MAY IMPACT
MOOD, THE NUMBER OF TABLES TO SERVE
• DIFFERENCES: FLOORING CHANGES, DROPPED FOOD/ITEMS ON THE
FLOOR, FUSSY TODDLERS AND CHILDREN MAY IMPACT MOOD, A GENEROUS
TIP FROM CUSTOMERS COULD IMPACT MOOD
CASE 1SHELF STOCKER:
THERAPEUTIC EXERCISE 1
• SIT TO STAND FOLLOWED BY
ALTERNATING BOSU LUNGES IN
PARALLEL BARS WITH A 1 SEC HOLD.
PT PROVIDES VERBAL CUES FOR
UPRIGHT POSTURE AND FORWARD
GAZE.
• EMPHASIS ON BUILDING
STRENGTH AND ENDURANCE
• DOSING: 3 SETS OF 6 WITH
EACH LEG FOR
STRENGTHENING
 CASE 1SHELF STOCKER: THERAPEUTIC EXERCISE 2
• VARIED INCLINE SQUAT + HEEL RAISE ON THE TOTAL GYM FOR LE + PF STRENGTHENING
• DOSING: DEPENDS ON INTENSITY AND INCLINE (HIGHER INCLINE, MORE RESISTANCE)
• LOWER INTENSITY WITH LOW INCLINE: 2 SETS OF 20 REPETITIONS FOR ENDURANCE
• HIGHER INTENSITY WITH HIGH INCLINE: 4 SETS OF 8 REPETITIONS FOR STRENGTH

SQUAT: STANDING: HEEL RAISE:

7 Simple Squat Workouts on the Total Gym - Total Gym Pulse

(totalgymdirect.com)
 CASE 1SHELF STOCKER:
NEUROMUSCULAR RE-EDUCATION 1
• SQUAT PIVOT WITH FEET HIP DISTANCE APART WHILE
LIFTING OBJECTS FROM LOW SHELF TO HIGHER SHELF
WHILE CROSSING OVER THE MIDLINE OF BODY
• PROGRESSION TO SQUAT PIVOT IN STAGGERED STANCE
(USING THE GARY GRAY CONCEPTS)

• BALANCE, COORDINATION, TRUNK ROTATION

• DOSING: WITH A LIGHTER WEIGHTED OBJECT PERFORM 2
SETS OF 15 REACHING TO THE LEFT AND 2 SETS OF 15
REACHING TO THE RIGHT
 CASE 1SHELF STOCKER:
NEUROMUSCULAR RE-EDUCATION 2
• WEIGHT SHIFTING AND REACHING LATERALLY FOR AN OBJECT
THAT IS SLIGHTLY OUT OF REACH AND RETURNING TO NEUTRAL
AND WEIGHT SHIFTING TO OPPOSITE SIDE AND PLACING THE
OBJECT ON TABLE
• COORDINATION, BALANCE, AXIAL ROTATION AND
REACHING
• DOSING: 3 SETS OF 30 SECONDS WITH A 60 SECOND REST
BREAK TO SIMULATE UNLOADING A CART AND STOCKING
THE SAME SHELF
CASE 1SHELF STOCKER:
THERAPEUTIC ACTIVITY 1
• MIMIC PUSHING A PRODUCE
CART WITH
MULTIDIRECTIONAL REACHING AND
STEPPING AS WELL AS TURNING
• STEPPING TO DIFFERENT
SURFACES FOR SENSORY
FEEDBACK (WOOD BLOCK, SOFT
PAD, FOAM PAD, AND CARPET)

• DOSING: COMPLETE THE CIRCUIT

FORWARD + BACKWARD (TO
REACH TO THE R AND L) 5 TIMES
WITH 30 SECOND REST BETWEEN
SETS
 CASE 1SHELF STOCKER:
THERAPEUTIC ACTIVITY 2
• OVERGROUND GAIT TRAINING + OBJECT
REACHING WITH REACTIVE THERABAND PULLS TO
WORK ON REACTIVE BALANCE
• DOSING: 5 CYCLES WITH 60 SECOND REST BREAKS
BETWEEN CYCLES
• ALTERNATIVE (NOT SHOWN): MIMIC SLIPPERY
FLOOR WITH OVERHEAD HARNESS FOR SAFETY
WHILE PUSHING A CART WITH THE USE OF
FRICTION REDUCING SHEETS
 CASE 2 WAITRESS: THERAPEUTIC
EXERCISE 1
• STAGGERED STANCE WITH TIDAL TANK USING TRUNK ROTATION
IN PARALLEL BARS (ROT R, CENTER, ROT L) FOCUSING ON
STRENGTH AND ENDURANCE
• THIS RELATES TO FUNCTIONAL TASK OF DISTRIBUTING FOOD
PLATES AND FILLING WATER GLASSES AND COFFEE CUPS

• DOSING: PERFORM 4 SETS OF 30 SECONDS WITH A 30 SECOND

STANDING REST BREAK BETWEEN SETS. 2 SETS WILL HAVE THE R
LEG FORWARD AND 2 SETS WILL HAVE THE L LEG FORWARD.
• COULD INTRODUCE A METRONOME TO INVOLVE PACING OF THE
MOTION
 CASE 2 WAITRESS :
THERAPEUTIC EXERCISE 2

• 4-WAY AMBULATION (FORWARD, R LATERAL, BACKWARD, AND L

LATERAL STEPPING) AROUND TABLES IN A SQUARE PATTERN
WHILE CARRYING A WATER PITCHER
• MIMICKING NAVIGATING COUNTERS AND TABLES IN A
RESTAURANT WHILE CARRYING OBJECTS TO WORK ON
ENDURANCE

• DOSING: PERFORM 4 SETS OF 1 REPETITION (1 COMPLETE LOOP)

WITH A 30 SECOND STANDING BREAK BETWEEN SETS.
ALTERNATE THE HAND WITH THE PITCHER AND THE ARM WITH
THE LOFSTRAND CRUTCH AFTER EACH SET.
 CASE 2 WAITRESS :
NEUROMUSCULAR RE-EDUCATION 1
• MULTI-DIRECTIONAL STEPPING TO DOTS AND REACHING
TO MOVE DINNER PLATES TO MULTIPLE SURFACES
• INCORPORATING PROPRIOCEPTION, BALANCE, POSTURAL
CONTROL, WEIGHT SHIFTING, REACHING AND
COORDINATING MULTIPLE MOVEMENTS (MULTITASKING)
• DOSING: PERFORM 4 SETS OF 30 SECONDS IN DURATION WITH
PT VERBALLY CALLING THE COLOR OF THE DOT. ALTERNATE
LOFSTRAND CRUTCH EACH SET.
 CASE 2 WAITRESS:
NEUROMUSCULAR RE-EDUCATION 2
2
• OVERGROUND GAIT TRAINING WITH PITCHER OF
WATER AND LOFSTRAND CRUTCH FOR ENDURANCE
ANTICIPATORY BALANCE AND STABILITY
• INCORPORATING MULTIPLE SURFACES TO
CHALLENGE BALANCE, POSTURAL CONTROL.
PROPRIOCEPTION, AND SOMATOSENSATION

• DOSING: COMPLETE CIRCUIT 6 TIMES WITH 30 SECOND

STANDING REST BREAKS BETWEEN SETS. PERFORM 3 SETS
WITH PITCHER IN R HAND AND 3 SETS WITH PITCHER IN L
HAND, ALTERNATING LOFSTRAND CRUTCH AS WELL.
CASE 2 WAITRESS :
THERAPEUTIC ACTIVITY 1
• SINGLE LOFTSTAND CRUTCH WITH A
TRAY DEPENDING ON PATIENT
PROGRESSION– PLACING OBJECTS ON
TABLE AND CLEARING
• DOSING: PERFORM 5 SETS OF 2 REPS
(THIS WOULD SIMULATE BRINGING 2
TRAYS OF FOOD TO 5 TABLES)
* AN ALTERNATIVE WOULD BE A
4WW (IMAGE 4) WITH ASSISTIVE
TECHNOLOGY TO ACCOMMODATE
PLATES AND CUPS.
USING A METRONOME OR MUSIC
TO ENCOURAGE SPEED
(WAITRESSING REQUIRES ACCURACY
AND COORDINATION IN A FAST-
PACED ENVIRONMENT)
 CASE 2 WAITRESS :
THERAPEUTIC ACTIVITY 2
• WEIGHT SHIFTING AND FILLING WATER GLASSES/COFFEE CUPS
• WATER GLASSES ON MULTIPLE TABLES WALKING AND WEIGHT
SHIFTING TO FILL EACH GLASS
• DOSING: PERFORM 4 TOTAL SETS WITH 30 SECOND REST BREAKS
BETWEEN SETS. THE PT COULD CALL OUT THE TABLE AND THE CUP TO
FILL. ALTERNATE THE HAND WITH THE WATER PITCHER AFTER EACH SET.
• AS PATIENT PROGRESSES THE TWO THERAPEUTIC ACTIVITIES COULD BE
COMBINED FOR A CIRCUIT
• TO ADD CHALLENGE AND TO MIMIC THE FAST-PACED RESTAURANT
ENVIRONMENT WE WOULD ADD A METRONOME OR THE BEAT OF THE
MUSIC TO IMPLEMENT EXTERNAL CUES
 RATIONALE FOR THE INTERVENTIONS
• Case 1: For Jena, we focused on exercises for strength and endurance. This correlates to multiple hours of pushing, pulling, lifting, and pivoting with store products to
properly stock isles. In addition, we focused on neuromuscular reeducation that involved training anticipatory and reactive balance which will mimic real life
scenarios.1 The use of Overground Gait Training will enhance return to function and the patient goal of returning to her job as a shelf-stocker at a grocery store.2,3

• Case 2: For Katie, we focused on exercises that would mimic the responsibilities of waitressing. In the busy lunch and dinner shifts, a waitress is constantly moving
using multidirectional stepping, trunk rotation, ankle and hip strategies, reactive and anticipatory balance all in a fast-paced environment. The emphasis on our
interventions was to enhance recovery of function to return to her waitressing job with confidence through restorative and compensatory strategies.

• With Jena and Katie showing signs of recovery and zones of partial preservation at 3 weeks with an L4 incomplete SCI, we wanted to capitalize on the initial 6
months of SCI rehabilitation by offering functional and challenging activities that would enhance neuroplasticity and return to function.4 Exercise after SCI may elicit
biochemical changes. Sandrow-Feinberg and Houlé found that after exercise, there was a rise in the mRNA level of Brain Derived Neurotropic Factor (BDNF), Glial
Cell-line Derived Neurotropic Factor(GDNF) and Neurotropin-4 (NT-4).4

• We also considered the biopsychosocial factors present for Katie and Jenna as working mothers of four school-aged children with a supportive family to assist their
recovery and return to the things they enjoy. Both Jena and Katie are motivated and determined to return to work and the responsibilities of their life. Sullivan et al
writes, “The psychological impact of SCI can be just as great as the physical impact.” 5 (p855) Therefore, by drawing in functional interventions, saliency and patient
goals we are considering recovery beyond the physical impairments.

• The focus of our selected interventions was a return to function. Sullivan et al. write, “Recovery of function refers to restoration of the neuromuscular system so that the
motor task is performed in a similar manner as it was before the SCI.” 5 (p876)

• An emphasis for our interventions was to incorporate patient goals and return to function as well as evidence on SCI rehabilitation in order to foster confidence,
independence and return to function.4-8
 SUMMARY OF CLINICAL REASONING PEARLS
• We learned how many resources we have available to us from looking at present and past course materials, evidenced-based
research to observing individuals in the community to hone our skills of seeing movement in real time and creating interventions that
are patient-centered. The resources and the specific patient cases were the foundation for our interventions. Within these
parameters we were able to use creativity to generate activities that were patient-centered and functional.
• Incorporating patient goals and saliency fueled dialogue and creative problem solving.
• Observing individuals in the community encouraged us to really look at the necessary movements and activities essential for a
particular task/profession. Through this activity, we realized that this is how we can connect with our patients, by researching and
observing the activities they want to return to for more authentic and personalized interventions.
• Adding layers of complexity to our initial observations added dimension and difficultly to our team-based assignment.
• We learned the importance of sharing ideas with each other for the benefit of the patient.
• The act of executing our interventions allowed us to tweak and necessary make changes.
• Working together we were able share ideas and learn so much from this team-based assignment to enhance our consolidation of
the course material and the material throughout our physical therapy didactic experience.
 REFERENCES
1. Unger J, Chan K, Scovil CY, et al. Intensive Balance Training for Adults With Incomplete Spinal Cord Injuries: Protocol for an Assessor-
Blinded Randomized Clinical Trial. Phys Ther. 2019;99(4):420-427. doi:10.1093/ptj/pzy153.
2. Hornby TG, Reisman DS, Ward IG, et al. Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke,
Incomplete Spinal Cord Injury, and Brain Injury. J Neurol Phys Ther. 2020;44(1):49-100. doi:10.1097/NPT.0000000000000303.
3. VanHiel L. Spinal Cord Injury and Gait Training. Model Systems Translation Center website. https://msktc.org/sci/factsheets/spinal-
cord-injury-and-gait-training. Accessed June 12, 2023.
4. Sandrow-Feinberg HR, Houlé JD. Exercise after spinal cord injury as an agent for neuroprotection, regeneration and
rehabilitation. Brain Res. 2015;1619:12-21. doi:10.1016/j.brainres.2015.03.052.
5. O’Sullivan SB, Schmitz TJ, Fulk GD. Physical Rehabilitation. 7th ed. Philadelphia, PA: FA Davis Co.; 2014.
6. Sullivan SB, SchMitz TJ. Improving Functional Outcomes in Physical Rehabilitation. 2nd ED. Philadelphia, PA: FA Davis Co.; 2016.
7. Harvey LA. Physiotherapy rehabilitation for people with spinal cord injuries. J Physiother. 2016;62(1):4-11.
doi:10.1016/j.jphys.2015.11.004.
8. Zbogar D, Eng JJ, Miller WC, Krassioukov AV, Verrier MC. Movement repetitions in physical and occupational therapy during spinal
cord injury rehabilitation. Spinal Cord. 2017;55(2):172-179. doi:10.1038/sc.2016.129.