Harrison Ogle

8/26/2022

MSK II

Clinic Reflection

The experience I would like to reflect on and write about today involved an 18-year-old
girl s/p right ACL reconstruction. She tore her ACL during a basketball practice in February, but
did not receive reconstructive surgery until June due to the fact that her mother did not want her
to miss school. She had very poor quad activation on her right side compared to her left and this
was a focus point throughout our early stages of treatment. She also was a patient who didn’t
always show up on time and missed some sessions here and there which was concerning because
the beginning stages of therapy allow us to set the foundation that we can build on in the future. I
would ask her every session how her HEP was going and how she felt physical therapy was
going and she would always respond “It’s going well” which would further prompt more
questioning. We were progressing her exercises and getting her to do more weight bearing
strengthening activities but I was still pretty concerned about her quad activation and how it was
still poor in comparison to her other side. About 4-5 weeks in to her rehab I asked her the same
question I ask her every session, “How do you feel things are going in the clinic and do you feel
what we are doing is helping and working?” Typically, I would get a yes, I feel like what we are
doing is helping and working, but on that day, I got a completely different response.

This time, she expressed frustrations with what we were doing and said she felt like we
were working on a lot of the same things every time she came in. She also said that she
understood her quad activation wasn’t great and that her leg shakes, but she said her other leg
does as well. In preface to the last statement, about two years ago she tore her left ACL while
playing basketball, so she was familiar with the rehab process and had an idea of the things she
would be doing. She then went on to explain to me that at this point in rehab with her left ACL
she was doing single leg presses and single leg step ups and downs. At first, I was a little taken
back and started questioning myself and the things I had been doing with her. Was I limiting her
and not progressing her fast enough? Was I wrong in my assessment of her quad activation and
neuromuscular control? At the time, I was treating her one on one while my CI was seeing
another patient, so after explaining myself and my reasoning behind why we were doing certain
exercises I went to my CI for some guidance. Basically, he told me to do the exercises she wants
to do and if she can do them fine, then great. If not, then I could use that as a goal for her but
then also use it to my advantage and say, “this is why we haven’t progressed to ___ and in order
to get there we first have to master ___”. During the leg press she commented on her inability to
control terminal knee extension and when doing stairs, she noticed she wasn’t able to control a
step down going forward or backwards.

It was an eye-opening session for the both of us. She now fully understood why we were
doing what we were doing and realized that the rehab process for this knee was going to look a
little different than her previous. She was actually more motivated than ever following that
session and she now had a few goals in mind. I wouldn’t say she was disconnected before that
point, but I don’t think she was fully bought into PT at that point. I don’t think she was as
compliant with her HEP as she said she was which ultimately is on me since I was the therapist
to create and provide those exercises for her. For me, this was the first real time I had
experienced a situation like that. My CI encouraged me to set the precedent at that point and let
her fail at a few exercises that way we could both be on the same page in terms of her functional
ability. In writing this I realized that maybe there were a few cues I didn’t pick up on prior to that
situation that pointed to some of her frustrations. Was her lack of motivation due to the fact that
she felt she wasn’t being pushed hard enough? Did she feel uniformed about how she was doing
and where things were going next? When you take a step back and look at the situation from sky
view, I feel like a lot of these things start to become more apparent or show up. I feel like maybe
I didn’t do the best job at educating her or connecting what we were doing now to things down
the road. All she heard was me harping on her quad activation and neuromuscular control that
the message and reasoning behind it got lost in communication. With her being an athlete too,
maybe I should’ve pushed her a little harder than what I did and made our sessions a little more
challenging. Following that session and situation I started super setting a lot more exercises and
turned up the intensity which she responded well too. Why wasn’t I doing it before that point
though? I had another patient who was a volleyball player with a meniscal injury and I had no
problem super setting his exercises and giving him an intense workout. Yes, every situation is
different, but I feel as though I potentially wasn’t meeting the needs of our ACL patient. I
thought I was communicating well with her and making sure my treatments were patient
focused, but was I really providing that to her? I really did want to progress her to more higher-
level activity but I was cautious in doing so because I wasn’t sure if it would be safe since I
didn’t think she had the stability and control to start those. Maybe there was some implicit bias
on my part because there could have been the chance that she was able to handle it which would
mean I was limiting her. In that case, her and I would have had to restructure her rehab plan and I
would have had to do some reflection on my thought processes and clinical reasoning.

I had a lot of great discussion with my CI about her situation and how to handle similar
situations in the future and I feel like I learned a lot. Sometimes patients need a humbling
experience to help put things into perspective and keep status and prognosis realistic. I found this
really hard to do because I had never done it before and didn’t really know how to go about it.
You can’t be mean and be like “knew that wasn’t going to go well”. I think in these types of
situations you can’t sit there and harp on the things that went wrong and be a negative Nancy the
whole time. Education and explanation about why things went the way they did and driving
home the importance of completing step A before step B. It made me think of patient education
in a whole new light and I realized how powerful patient education is. It even made me question
how I was educating my other patients and wondering if any of them were in the same boat as
this girl. Education is the road that connects treatment to goals. Without education all you have is
a map with a starting point and an endpoint with a bunch of random landmarks in between the
two. I believe if I carry this way of thinking into every patient situation it will not only make me
a better physical therapist but I think it will help with my patient buy in and understanding of
their rehab journey. Having the opportunity to really hone in on my patient education skills this
semester throughout class and lab practical’s will help me be more prepared for a situation like
this in the future because inevitably it will probably happen again. Being able to practice these
skills with peers and professors will allow me to received personalized feedback on things I need
to improve or continue to do. The classroom will also allow me to integrate other aspects of the
clinic into it providing almost “trial runs” before actually doing it real time in the clinic.