Megan Berg 0:02
All right, welcome, everybody to the very first episode of the PT edition of the resource roadmap show. This is something new we’re doing with therapy insights. And this is an offering that’s based on years of requests for members for us to provide more instruction and context on how to use our resources. So we’re super excited to be doing this. We’re going to be learning as we go. And we welcome any and all feedback as you’re listening or watching this, if there’s something that we can do better to serve your needs, just let us know you can reach us at support@therapyinsights.com. If you are subscribed to the printables feature of the access pass, you’re going to have instant access to print any and all of the resources that we are talking about today, and in the episodes in the future. And if you are not a member, you can sign up at therapyinsights.com and get instant access to everything. And if you’re wanting CEU credit, you can earn CEU credit for listening to this via podcast or watching it on video. You just need to have the CEU feature included in your access pass scription and then you’ll go to therapyinsights.com and go to access pass and click on CEUs and find this episode. This is PT episode number one, and you’ll just answer a couple quick questions and get a certificate of completion. So I’m your host for today. My name is Megan Berg. I’m the founder of therapy insights. I’m actually a speech pathologist located in western Montana. I spend most of my time on therapy insights, but I also do PRN in an inpatient rehab hospital couple days a week right now. And so your host is going to be Shweta Subramani, who I will introduce you to right now. Shweta is a PT in Arizona and she has an adorable daughter. And she is from Mumbai which is a place that has been on my list of places to travel for a really really long time. And so I can’t wait until I go have the chance to go visit but Shweta, tell us about yourself and your role as a PT
Shweta Subramani 2:13
Hello, everyone. I’m Shweta. I’m a physical therapist and currently based in Arizona, as Megan mentioned, I have been a PT for almost eight years now. And I’ve primarily practiced with the geriatric population in skilled nursing facilities. I’ve also done some acute care, some rehab hospital work. The only thing that I haven’t done is home health that I currently practice in an outpatient setting. It’s a mix of ortho and neuro. Apart from this I’m also actively involved in the APTA I am the incoming Chair for the Global Health special interest group within ebth ethics and also the secretary for APTA oncology’s balance and policy because balance is my passion. Other than that, I’ve also volunteered with ATA cardiopulmonary section and also with development of some clinical practice guidelines for osteoporosis through APTA geriatrics. So basically, it’s I just, I just love volunteering for a PTA and being more involved in my profession. On a sidenote, I also like to read I am also a lot involved in arts in the form of music and dance. That’s my passion other than physical therapy.
Megan Berg 3:35
Awesome, thank you. Then we also have Ross Eckstein with us he is a brand new dad just had a baby last week. Very exciting, and just very grateful that you’re here and I know you’re running on very little sleep. So thank you. Thank you. Just tell us a little about your role as the PT.
Ross Eckstein 3:57
So I’ve been a physical therapist since 2016. I actually graduated with Troy and I’ve been working in outpatient physical therapy since then. I live I work in a pretty rural area. So it’s kind of a combination of it’s mostly orthopedic, some cardiopulmonary and some neuro kind of sprinkled in as well, and occasional wound care. But my specialty is kind of more in orthopedic physical therapy. I’m also registered as a musculoskeletal sonographer. And so I do some musculoskeletal ultrasound as well.
Megan Berg 4:36
Thank you. And we have Troy Adam with us as well, who is a foster parent and also competes in regional curling competitions, correct?
Troy Adam 4:48
Yeah, that’s true. Yeah, yeah, I’ll I guess I’ll share a little bit about curling as well. But yeah, my name is Troy Adam. I’ve been a physical therapist since 2016. I currently working in outpatient setting as well affiliated with the University of Montana. So I work on campus. A lot of people think that means that I work primarily with sports and ortho and students and young people, but actually, I’m a board certified neurologic specialist. So I treat community members in our town of Missoula, Montana. My specialty is probably spinal cord injury more than anything else. Probably more than half of my caseload consists of individuals that have had injuries. My other half of my job is teaching in the physical therapy program. So I teach a variety of different courses and TA in a variety of different courses. I have students with me in the clinic, about half of the time that I’m treating patients, so I have a lot of student interaction. Yeah, which is great. In my spare time tonight, actually, even I have a curling match at the glacier ice rink. Where Yeah, we throw the stones down the ice and sweep and yell at each other to sweep harder and things like that. So not a fun. Yeah, get out there and try it if you haven’t yet.
Megan Berg 6:13
Awesome. Thank you. All right. So this is your PT crew for this show. And for people watching or listening, if you ever have questions, we’re going to be also adding a q&a section to this show. So feel free to reach out to us with any questions you have any clinical questions related to the resources or patients you’re working with. And you can reach us at support@therapyinsights.com. And I also just want to verbalize our disclosures really quickly, since we are offering this first the US, all of us are being paid by therapy and sites to run this show. And we are discussing therapy insights products in this show. So we have a great lineup of resources, from scar massage to neuropathic pain to Easton for wound healing. So I’m gonna go ahead and share my screen and pull up the visuals of the resources. So if you’re watching this on a podcast, you’re not going to be able to see it, but we’ll do our best to describe what you’re seeing as needed.
Megan Berg 7:38
Okay, first resource we have up is Estim in wound healing. Ross, can you tell us about this resource? Yeah.
Ross Eckstein 7:45
So I was actually inspired to write this resource because I had a patient who I was actually seeing for CHF kind of cardiac rehab, and he had a chronic nonhealing diabetic foot ulcer as well, when he was seeing wound specialists at a different clinic. And it had not really healed for about a year. And so I was trying to think of things outside the box for him that he could start using to help heal his wound. And so I’d remembered that we kind of touched on wound, you know, estim for wound healing in PT school, but didn’t get into a too in depth. And so I what I thought would be helpful for me would probably be helpful for other clinicians who might want to use estim for wound healing as a resource where you could look at it, and you could get all the information that you needed to apply the stem for wound healing, if you wanted to.
Ross Eckstein 8:42
So I kind of delved into the research a little bit on electrical stimulation for wound healing, I didn’t end up using estim with this patient because for one, by the time I wrote this piece, he had actually started to improve a little bit. And for another, the research seems strongest for pressure ulcers. You can use that for diabetic ulcers, but there was less research there that I could see. So that kind of goes into the different types of current that you can use for wound healing. High voltage pulse current, by far has the most research behind it, and also seems to have the largest effect sizes for healing wounds. And so I spent most time kind of going through the parameters for that, that I touched on direct current. So your high voltage pulse current is kind of, it’s an monophasic waveform. So it’s not the same thing that we typically use with our biphasic waveform so it actually delivers charge to the tissue. Typically, it’s like two twin peaks, and then you get a break and then another two twin peaks of estim. And the direct current is similar. It’s monophasic. But it’s just continuous. The disadvantage to that is you get a lot more skin irritation with that you can use alternating current, there’s not a lot of research, there didn’t seem to work as well.
Ross Eckstein 10:05
And then you can use something called degenerate wave, which, honestly, I’ve never heard before, before doing my research on this, I don’t think it’s a commonly used thing. But for the high voltage, pulsed current that kind of goes through the different parameters there that, you know, studies use, and kind of talks about the mill amps and pulse duration, frequency, and treatment durations, which range widely anywhere from two hours all the way up to as high as 37 hours per week. If you go through a lot of batteries, if you’re doing 37 hours a week, apparently, they did that in a couple of studies. So talks about how to apply the electrodes and use it and so you could easily do a step by step kind of guide on East you know, high voltage pulse current for wound healing. So, as an example, you’d start by breathing around the wound if needed, so that you can apply the electrode to a flat surface.
Ross Eckstein 11:12
Typically, you’d pack the wound with sterile gauze soaked in saline to improve the conductivity. And then you apply, you choose your polarity for the treatment sites. So typically, you want the positive polarity if you’re trying to kickstart inflammation. And the idea behind that is if you have a chronic non healing ulcer, you’re trying to create that inflammatory response, so your body starts to address it again. And then you can use negative polarity as well, which is attracts macrophages to the wound, which could be good for preventing infection, basically. And different studies, apply it in different ways, one of the more common protocols is to start with the positive polarity. And then as soon as healing stalls, switch to a negative and then just switch back and forth as soon as it stalls and a lot of protocols seem to have pretty good success with that.
Ross Eckstein 12:10
So you apply your treatment polarity, probably the positive polarity to start, you want your other electrode about at least 15 centimeters away is what most studies seem to recommend. And then typically, your frequency is about 100 pulses per second, your pulse duration, it talks about is kind of a range. So anywhere from 50 to 100 microseconds, is pretty common. And then your voltage is 50 to 200 volts, or 1.2 to 1.5 milliamps. And then you can apply that if you want it to keep it simple. You can tell the patient do this an hour a day, seven days a week, and you get your seven hours a week, which is kind of right in that evidence based dosage for using the high voltage pulse current. And then it talks about contraindications as well for using the pulse current. So I guess that’s pretty much it for that piece.
Megan Berg 13:08
Great. Thank you. We’re gonna move on to the next resource, which is understanding inferential current. And this was written by Troy.
Troy Adam 13:23
Yeah. Hey, everybody, thanks for joining us here today. So yeah, I find that honestly, electrical stimulation is, is confusing, it’s hard to understand it’s not very tangible. You know, it’s not something that we can touch very easily so, so understanding it is challenging for students, I think it’s challenging for clinicians and we tend to do what we’re most comfortable with as clinicians. So, this piece is really around understanding one of the kind of main forms of electrical stimulation which is interferential current, the other you know, the other ones being neuromuscular electrical stimulation, functional electrical stimulation tins, those would be kind of and then and then like Ross said, you know, using high high volt current for wound healing. This is meant to modulate pain. So, as we talk about interferential current, it is one of the more odd setups most of the time when we have when we’re doing electrical stimulation, we use two electrodes right. So that current is flowing from one electrode ultimately through the other going through our muscular tissue through our nerves to elicit contraction or sensation of some kind. In this case, we actually use four electrodes. And what we what we have happen is, you know, it’s like a square right or a rectangle type treatment area, you have one corner is hooked up to one line and then the opposite corner so kind of kitty corner is hooked up to the other piece of that of that. So Okay, I guess right. And then we have another line, right, that’s traveling from one from the opposite to corner. So we have this X type pattern of current flow. Now what happens with interferential? Current is right, like Ross said, you know, there’s there’s bipolar waves, right? Meaning there’s positive and negative polarity as these things travel through, and IFC or interferential, current of alternating current. So it’s biphasic. In nature, same thing that you get when you plug into the, into the wall at your house. And what they do here is they take one current, which is called our carrier frequency, it’s often pretty high, you know, probably somewhere between 2000 hertz and 4000 hertz, evidence says, doesn’t really matter, just just AC current is generally quite high, then you have what’s called your, your beat frequency.
Troy Adam 15:55
Now, this is something that you can actually change on your, on your, on your unit. So when you’re using this, often it’s on like a, you know, a line powered unit that plugs into the wall, you know, they’re the expensive ones that you see in the clinic that Some clinicians use a lot and some don’t use it all. But you plug this in, and the the current, or the beat frequency is set to be somewhere between 100 hertz and one hertz different from that carrier frequency. And what you see on our form here is a little bit of an image that shows how these two alternating currents are out of sync. Now, as these are Criss, as these currents are criss crossing over the top of each other, what happens is, sometimes we get the positive phase of that wave form, adding to another positive wave form and creating this this very significant wave form. And other times we have a positive aligning well with a negative and you get ultimately not a lot of of current flow through at that time. So it what it does is it it’s meant to modulate pain, right in the same way that we rub our knee or apply pressure to something that that’s hurt. And this is meant to maybe decrease our habituation or our awareness of of that pain by kind of constantly going up and down and up and down and changing a little bit with this kind of tingling type sensation that you might experience with electrical stimulation. Now that’s, that’s the main way I FC is used, you can use it with for like, enemy s as well. So for a muscular contraction, it’s not done as often most people will just use a Russian or a biphasic current. As opposed to this for quadripolar type. setup, the advantages to IFC over traditional tins would be you can treat a larger treatment area, because we’ve got this big rectangle, this big box of treatment. It’s high volt current, which there’s some evidence that suggests that the there’s less impedance through the skin and through the through the subcutaneous fat tissue there.
Troy Adam 18:24
So there’s potential that you’re just maybe able to get a little bit of a higher dose at these high volt currents. It also lets you treat over bone, that’s where I find I use it more often than not, if you put 10s over bone or NMBS over bone, it hurts, it’s often painful. So this just allows you to not place those electrodes directly over superficial bone. So I think of the knee probably more than anything else. If I wanted to, if I wanted to treat an area there or some sort of body part that’s not flat and simple, right, an elbow would be another good example a shoulder low back if I want to treat a big area on this resource. I’ll quick wrap this up. But there’s a couple of kinds of words that are going to pop up. When you plug in your unit and you’re selecting your parameters right I told you don’t worry about your carrier frequency, worry about your beat frequency set of between one and 100 is in general a pretty good idea. There’s going to be something often called Sweet. Now this is it’s something that you can select on or off. What it does is it changes that carrier frequency just pre programmed. So it stopped that maybe it even decreases habituation to the stimulation even a little bit more. The other one that you can do is called a vector scan. You’ll see these on a lot of the Chattanooga line powered units. What that does is it alternates the amplitude of the two currents.
Troy Adam 19:59
So we haven’t really talked about amplitude too much, but it changes the amplitude, which ultimately will change the location at which the summation of these two currents happens. So what you’ll hear described as is often like a swirl, like, it will feel not only like this, quick beats and slow beats, but then it will also kind of swirl around the location of the treatment area. Again, evidence for that over traditional IFC is is pretty minimal, suggesting that that’s important. But it might be something that patients would tolerate or enjoy a little bit more might allow you to treat a wider area of pain, but obviously with a little bit less kind of treatment density at that specific location. So a great resource, I hope that hope that you guys can use it in Yeah, in the clinic, or educate patients on it if they’re a little bit more interested about it, or other clinicians, because we don’t do things that we don’t know about. So hopefully, this kind of breaks down that barrier that you drew.
Megan Berg 21:05
And Ross, you wrote an article snapshot this month, about what patients would call tennis elbow, also known as lateral epicondylitis. If I’m saying that correctly, you want to talk about the clinical takeaways with that as related to estim.
Ross Eckstein 21:21
Yeah, so the high voltage pulse currents that we were talking about with wound care, it’s interesting, there’s some research, most of it’s actually coming out of Spain. And it’s very common over there. But essentially, it’s called percutaneous electrolysis, but essentially, they using ultrasound or identify the degenerated part of the tendon, put a needle into it, and then run high voltage pulse current, the same idea where you’re kind of kick starting that inflammatory process to turn a chronic non healing issue into a healing ish, you know, more of an acute injury that the body will address. And there’s some there’s kind of moderate evidence that say that there can be some benefit to it. The study that I talked about was comparing that to muscular, dry needling. And one group had kind of just regular muscular dry needling to the supinator. And the extensor carpi radialis brevis. And the other group had the percutaneous electrolysis targeting the tendon, and the percutaneous electrolysis group had a much larger, I think they defined three month clinical success as 50% improvement in symptoms. And I think that 93% of the people in the percutaneous electrolysis group achieved that at three months, whereas in the dry needling group, it was only like 40%, or something like that. And so it is something that’s kind of interesting to me, I did reach out to the company that makes these specialized electrical units that are used for percutaneous electrolysis, and they currently do not have FDA approval in the United States, unfortunately. But it’s something that, you know, since high voltage poles currently, you know, electrical STEM is in our scope of practice, Eastham is too, so I don’t see why you couldn’t apply it so long as you got the right needles, because I think that the needles that they use, apply the stem directly at the tip of the needle, rather than all along the needle, because then you’d be applying stem, you know, to the muscle and fat and everything that you’re going through towards the tendon. But I just thought it was thought provoking is a different treatment modality for tendinopathy. And something that maybe we’ll see eventually kind of catch on here in the States. And again, it’s common in Europe, but maybe eventually see more of that here. Great, thank you.
Shweta Subramani 23:54
Quick question. Ross. So since you mentioned that it like it is still within our scope of practice for wouldn’t dry needling need us to be certified. And it’s a whole nother thing. As far as you know, state practice acts are concerned.
Ross Eckstein 24:12
It can vary by your state. And of course, you want to check your you know, your local state guide, you know, guidelines. I think there are still maybe a couple of states where you can’t get maybe Washington and remember for sure, but in most states, you know, in Montana, I know that we can. And so yeah, that’s that’s a good point. It’s something that you’d want to make sure you check with your local practice act to make sure that you can do that.
Shweta Subramani 24:37
You would still need to be dry needling certified to use that time.
Ross Eckstein 24:41
In Montana, you just need training and dry needling. You don’t need like a certification to do it.
Megan Berg 24:51
We’ll move on to our third resource for this month, which is nutritional supplements and strategies for neuropathic pain. Ross, this is back to you.
Ross Eckstein 25:02
Okay, so I was inspired by this piece, I get a lot of patients who are referred for something else, but then have comorbid peripheral neuropathy. And that’s very common in our practice. And a lot of times, it can be frustrating because there’s nothing, you know, a lot of times it feels like there’s not a lot to offer for these patients, you know, they complain about it when they’re walking. But, you know, it’s not something that you can exercise away. And there’s nothing that’s really curative either, you know, they they commonly get Gabapentin and stuff like that, but, and so I’d read a little bit about nutrition and how it could potentially be helpful with some studies actually finding with anti inflammatory diets, actually, kind of similar results compared to Gabapentin. So something that’s natural, that could be recommended, is great. It’s not really meant to be prescriptive. And again, you kinda have to look at your state Practice Act, some state practice acts are, you’re completely unlimited, you can give as much nutrition advice as you want. And other ones like Montana, we have to be more careful. So it’s something that you could just give your patients they could look it over, maybe it could get them thinking and then depending on your state Practice Act, they could either talk to you about it, or you could start the conversation about maybe we should talk to get you in to see a dietitian. So it goes over some of the kind of what neuropathic pain is talks about how it can be, you know, radiculopathy, or people commonly think of it as sciatica, peripheral neuropathy or, or disorders in the central nervous system, things like spinal cord injuries as well. Sometimes they will deal with the neuropathic pain, and talks about how inflammation kind of contributes to neuropathic pain in most cases. And how kind of discusses some studies, finding that neuropathic pain can be helped with diet and talks about, you know, there’s one trial looking at people, I think it was, yeah, spinal cord injuries for 12 weeks, and having comparable benefits about a 39% decrease in sensory neuropathic pain scores, which is actually just as good or maybe even better than gabapentin, which depending on the study ranges from like 21 to 40%. And then talks about, you know, different types of diets that you can look into like whole food plant diets and Mediterranean are probably the two more commonly studied. And talks about how food intolerances can play into things. And then I touch on supplements a little bit. omega three fatty acids are probably the ones I liked the most, because we know they’re good for you, anyway. And there’s some evidence that they can actually reduce the risk of developing peripheral neuropathy to begin with. And so that could also be a good option for people. And then discusses a couple other supplements. And again, I wouldn’t do this as something where you give it to the person and say do all this, I’d say, these are some things that we can think about, talk about, follow up visit, maybe. And so a way that you could maybe come up with a goal with your patient, you know, if you were trying to implement some nutritional strategies into their plan of care, I think one way that would be pretty safe. I know that we had a dietitian come to our school when I was in physical therapy school and kind of talk about when it’s okay to discuss nutrition versus not discussed nutrition as a physical therapist, and she said, it’s typically okay to recommend things that are in practice guidelines from governmental organizations such as like the American Heart Association. So one example of a goal that I might use would be in order to decrease pain by two out of 10. On a numeric pain rating scale, patient will increase their fruit and vegetable consumption to at least five servings per day, over a weekly period as assessed by a food diary within six weeks or something like that. So it’s something where that’s what the American Heart Association recommends is a minimum of five servings of fruit and vegetables. And honestly, we probably should be getting more than that, but that’d be more achievable probably for most people. So So I think that could be a good example of a goal or you could say something like, again, the American Heart Association recommends less than 36 grams of added sugar for men less than 20 or 25 for women, something like that. So that could be another goal. You could similar verbiage but just say, you know, try to limit your added sugar intake to less than 36 grams per day. And again, you know, good for the patient and might have some benefit with their pain level as well.
Megan Berg 29:56
Yeah, that’s awesome. I mean, just the the results alone that changing the diet is comparable to Gabapentin is amazing. Because Gabapentin isn’t, I mean, it works. But it’s not great long term.
Ross Eckstein 30:06
Right? Yeah. Anything you can do to avoid drugs I see is a good thing. And it’s not like telling someone to eat more fruits and vegetables is going to be bad for them. Probably.
Shweta Subramani 30:18
This resource quite interesting. Sorry, not to interrupt you guys. But I do have a patient with Charcot Marie. And I was curious if something like this would be helpful for her. I mean, I know that’s, I mean, it’s not as common. I mean, the neuropathy in that condition might be a little different compared to what you might see in diabetes or something like that, but like to consider, you know, neuropathic pain. I was wondering if, you know, maybe trying something out like this.
Ross Eckstein 30:54
Could Yeah, you know, I didn’t, I didn’t see any research specifically for that. But, you know, if there’s neuropathic contributors to that, it would make sense. You know, it seemed like, the results were good. You know, when you’re looking at either chemotherapy induced neuropathy, diabetic induced neuropathy, spinal cord, you know, all these different types of neuropathic pain seem to benefit, and so I wouldn’t see why not. And again, it’s not going to it’s probably not going to hurt the patient to do some of that stuff. So yeah, it’s a good question, but I guess my answer is I’m not completely sure, but I think probably could be helpful. Yeah.
Shweta Subramani 31:30
Yeah. Sorry. It wasn’t meant to be like a question.
Ross Eckstein 31:33
No, that’s all right.
Shweta Subramani 31:36
That would be helpful, because that is something that my patient keeps complaining of, too. So maybe try this and see if it works or not. But either way, like I said, it’s not really going to cause any harm. Yeah.
Ross Eckstein 31:51
Yeah, absolutely. Yeah.
Megan Berg 31:53
For anyone working in a facility, like at a hospital, or SNF or something like that. Like, I’ve asked the dietician to join me for a session. And that’s always worked really well, because then you can have their expertise, but then also bring in, you know, the clinical expertise as well. So one idea to consider.
Megan Berg 32:17
All right. On to our fourth resource all about what is Frontotemporal dementia? And this was by Troy.
Troy Adam 32:26
Yeah, great. I just got a quick pause and say just how awesome this has been already. So far. I’m so excited for us. And for you that are listening, like mad to just just listen to Ross, talk about some of these resources just gets me excited about like, treating patients with with some of this some of these impairments. So I hope that you guys find this. Yeah, find this helpful and useful. I know that I already am. So it’s been great. But yeah, let’s move on. So frontal temporal dementia. Yeah. So this is a form of dementia, not necessarily something to get excited about a challenging diagnosis for sure. The really the handout is meant to be probably a resource, both for clinicians in terms of kind of a basic understanding of what Frontotemporal dementia is, when I, when I see that written into charts, right, I think I would be maybe a little intimidated at first, if I hadn’t encountered that before. It just sounds sounds a little intense. So ideally, right to give you a little bit, you know, get your feet underneath you in terms of some basic understanding so that you can have a good conversation with your patient that that might have been diagnosed with this. Also, I see it as a resource for someone that, you know, maybe a caregiver that has had some more questions, that is probably in a place to hear some of the information that is in this. It talks, you know, it talks about really the three different types of Frontotemporal dementia. So there’s there’s three variants, the behavioral variant, the semantic variant, and the nonfluent variant talks about morbidity associated with these as well. So I mean, it’s a heavy, it’s a heavy topic, it’s a heavy conversation. I don’t know that it’s something that I would just say, oh, here, you know, let me give you this resource on the way out the door. This is this is one that I maybe want to sit down and have a conversation with with the caregiver, or, or potentially the client at that point as well.
Troy Adam 34:37
What is frontal temporal dementia, right? It affects two lobes primarily of the brain, the frontal lobe and the temporal lobe. On the sheet, we have the frontal lobe identified. You guys know this, I’m sure but right. This is executive functioning type things. More, you know, higher order thinking, and then we have effects in the temporal lobe as well. This as can be, we can see some signs of aphasia with this warning AKIsE area if you guys are, if you remember that is located in the back of of the temporal lobe, Broca’s area, close to the frontal lobe as well. So language things can be impaired with this to progressive central nervous system disorder. In fact, I was just reading there’s a recent famous actor that was just diagnosed with Frontotemporal dementia just saw that in the headlines just this week, where they, I think, initially, they had thought that this individual had, yeah, some signs of aphasia is what it sounded like more than anything else. And now this this diagnosis has, has come out.
Troy Adam 35:46
The behavioral variant, we talked about those three variants, that’s the most common variant, it’s also got a pretty high morbidity rate, as well. But this is a tough one. So it changes the way people, their personalities, the way they act, personal experiences with patients, you know, spouses that have thought, you know, my first indication was, I thought my spouse was cheating on me, they were just acting weird. They were, you know, hiding or, you know, skirting questions and things like that, and then come to find out through further and more testing that, that they have this diagnosis of frontal temporal dementia presents, like a central nervous system, injury or disorder. So there’s, you know, effects vary widely. The behavioral variant is often associated with also musculoskeletal impairments, as well. So this might be somebody with a lot of central nervous system signs. So probably a clone is response, potentially specificity and rigidity. In some of the limbs, that wouldn’t be uncommon. In fact, I think of a patient, you know, they had the behavioral variant and couldn’t, couldn’t vocalize at this point by the time that I had, had seen them, but just simply laying my hand on their thigh, you know, in a kind of confirmatory way, would elicit a reflexive response, like a quick stretch type response. So really significant. central nervous system damage in that case, let’s see the semantic variant, often blast musculoskeletal impairments. So ADLs, they can do for often a lot longer. But they often have behavioral changes that are associated with more rigidity. So like things being on time not being flexible with schedules or things like that. And then the nonfluent variant, as you might expect, has to do with with aphasias. So we mentioned those, you know, areas of kind of speech interpretation and production. Those can obviously be impaired. Memory is often impaired with these. So, you know, recognizing loved ones, things of that nature, is often affected as well. So, yeah, there’s also just some information on the sheet in terms of how often this occurs.
Megan Berg 38:22
Yeah. And I think, therapists whether speech, occupational and physical therapists are often the ones to first see signs of dementia, especially if somebody’s admitting to a facility or in the fall with some sort of orthopedic issue or some other thing going on. And maybe they don’t have a diagnosis of dementia, yet, we can be the first ones that might make that referral to investigate that. Or people might be coming in for physical therapy, bringing a loved one in who has Frontotemporal dementia, and maybe they have the diagnosis, but just because of the way the medical system is set up right now, they don’t have a lot of support or information about what that diagnosis is. So again, I think we can play a role in continuing to provide education and support there.
Troy Adam 39:12
Yeah, I think, Megan, you bring up a great point, too, in the sense that, you know, this is this is this is a patient that’s going to be seen by all three disciplines. You know, there are some cases in here of some things that we’ve talked about, you know, that that aren’t necessarily applicable to, to all disciplines of rehabilitation, but I think this is one this handout is one that would really benefit anybody that’s that’s working with anyone with a with an A, they could come in, like you say for anything, and we could be picking up on this, but yeah, yeah.
Shweta Subramani 39:46
I was curious to know if you noticed any research of specific age groups that it’s more commonly found in or early onset dementia can also be controlled.
Troy Adam 39:59
Um, yeah, you know, I don’t know, incidence rates off the top of my head, but I do know that this is something that can affect the younger population as well. So, so not necessarily specific to, you know, geriatric physical therapy by any means.
Megan Berg 40:23
Okay, we’ll move on to the final resource, the final new resource being added to the library. And this is all about scar massage as a home program. And Troy take it away.
Troy Adam 40:37
Yeah, I’m back up. Yeah, great. So scars are something that we encounter a lot or wounds. So this resource is really meant to kind of lay the foundation for, you know, maybe you have somebody come in post op, you know, the classic example that I think of is probably someone after a total knee replacement. Let’s say they’re, you know, two weeks, they’re just starting to get their stitches out, ideally, or they’re kind of removing whatever, you know, maybe they’ve got steri strips on or something along those lines, that’s about the time to start thinking about this scar massage. Now. manual therapy is a, you know, it’s a hot topic in PT probably, evidence is variable, despite the fact that I think a lot of physical therapists use a lot of manual therapy. I won’t talk about that necessarily. But scar massage specifically has great evidence in terms of improving range of motion, associated with, with with a surgery, it doesn’t necessarily have to be surgical, but that’s often, that’s often what we’re seeing here. So, so right, my patient comes in. Ideally, the first thing that I’m going to look for is alright, what type of, you know, kind of skin fixation do you have on here, if there’s, if there’s still, you know, Staples or stitches, you’re probably pushing the limits in terms of if it’s appropriate to start scar massage. Now, as soon as they get those out, I wouldn’t even be willing to say when they still have steri strips on, if that’s closed, I think you could start some gentle scar massage.
Troy Adam 42:22
In the image, there’s, you know, there’s a variety of different kinds of pictures of of kind of techniques or things like that, in those early stages, what I would say it would be best would be, you know, to use two separate fingers compress longitudinally along the, the, kind of the long axis of that scar, since you’re trying to avoid any sort of D hisense or things like that. And then and then mobilize that in in any direction, honestly, you can do a fascial assessment to some degree to see, okay, is how much how much motion do I have superior, they are inferior, they are medial, and lateral, to try to try to find, ideally, where there’s maybe a little more adhesion, and just work in that direction. But ultimately, any direction is appropriate. That’s how I would start out with that compression. Think over time, as you’re fully confident that there’s no risk of, of dehiscence, which is, you know, obviously that’s right, where if that wound were to open back up, but you know, no bleeding after no signs of, of, you know, you impeding tissue healing, you can move to more aggressive methods. So this might be things like, skin rolling, which is a myofascial technique, where more or less you’re pinching, you’re pinching the skin and, and kind of pulling pulling the underlying fascia and subcutaneous fat up to the goal here is to just reorganize collagen fibers, right?
Troy Adam 44:00
So after an injury, collagen is laid down. And it’s in a web, right, it’s this this non uniform, non pigmented mass of tissue. Your goal with SCAR massage is to help, I mean, honestly break some of those adhesions apart potentially, and work to reorganize this structure, or that scar so that it’s more malleable and elastic, which can which can often lead to decreased risk of either pain associated with that or range of motion deficits that are that are fascial Yeah, fascial in nature. Often I hear patients asked me about, you know, can they they use lotion or things like that? Absolutely. But I would say after you’re, you’re fully confident that there’s no risk of infection with that. So, you know, maybe a month or so would be a good time to start, you know, using a vitamin E oil or something along those lines multiple times a day, multiple times a week. And really the earlier the better. This has gotten out, you know, multiple months, probably not near No, definitely not near as effective as if this was done assumed after after surgery or after injury.
Megan Berg 45:30
And what I like about this handout is it’s very easy to read, there’s clear illustrations, or how people can do this at home. Yeah, I think it’s a great accessible resource that you could hand to someone at the end of possession, and they could take home with them and be able to do it themselves, which is great.
Troy Adam 45:48
Right. It’s not rocket science stuff. It’s, it’s, it’s important for you to know that this works, that it’s effective, but it’s something you shouldn’t be doing something that I would definitely not, I would probably wouldn’t feel comfortable just handing them the resource without having done it in the clinic once or twice. But this isn’t something that often, you know, unless unless you are really concerned about some some other risks, this is something that I would feel comfortable handing off to my patient in terms of their treatment and say, Alright, this is on you. Now, I’ve shown you how to do this, maybe we’ll advance maybe I’ll show him some skin rolling techniques or something like that later on down the road. But this is something that I feel comfortable educating my patient on, or again, a caregiver on potentially, to be implemented as a home program. So a great resource for them to come back to and say, Wait, how was I supposed to do this again? What was this about? Yeah.
Megan Berg 46:41
Great. Thank you. Okay, we’re gonna move on to our case study. So these case studies are a chance for us to have conversations about clinical ideas and perspectives. I think we all have different ways to approach challenges and problems. And then we also will be talking about resources that we would pull from the access paths library that we could use to apply to this case study. So this month, we’re talking about a 65 year old male with a total knee replacement, who lives with his son, in an apartment on the second level with no elevator access, he has to navigate two flights of stairs to get to appointments, his son works during the day. So the patient is alone during the day with very limited support. So what we’re going to do is just kind of go around the table, and everyone’s going to talk about a resource that they would use from the access paths library. And then also any thoughts or perspectives as to how you would approach this case study. And Shweta, was this the resource that you selected that right? Yeah,
Shweta Subramani 47:52
The case study was kind of loosely based on a patient that I was seeing. And this was the issue with the patient later. Right after surgery, this patient did not have any access to home health apparent either. Insurance covers no home health, and the surgeon was very comfortable with the patient going up and down stairs right away after surgery right after they were discharged from acute care to get to outpatient appointments. So I was, it was quite interesting, because usually, like you see that they discharge patients with either a home health referral, depending on their how they’re doing or you know, like if they are in a ground level apartment or ground level house, and it’s easier for them to get to appointments again and make it outpatient physical therapy. But anyway, so this patient had to do, like go up and down stairs, anyway, because he has to get to outpatient PT appointments. So I felt comfortable giving the Navigating standard assistive device resource to this patient. So it’s easier for them to understand because if he has go up and down two flights of stairs multiple times in a day, he’s going to need to understand early on how to navigate stairs, they’re likely because with that kind of excruciating pain right after any replacement, it’s harder to do stairs, but it’s like if your situation is such that you have to have your surgeon still feel comfortable with that and doing it the right way. Yeah, and
Megan Berg 49:27
This handout like you said, it’s called navigating stairs with an assistive device and it provides basically step by step instructions for how to do it safely. And I think in this scenario, it would work well to for his son to have access to this if the son’s not present for like initial PT sessions for caregiver training. So yeah, easy to read, easy to access.
Megan Berg 49:54
All right. The next resource I believe that Ross picked out is how to squat with good technique.
Ross Eckstein 50:02
Yeah. So, yeah, typically after a total knee replacement, especially when you’re talking about stairs, the three things that are most important in our good technique is spread the talked about and then having the range of motion to do it, and then also having the quad strength to do it. And so this kind of addresses the quad strength aspect of that. And so a squat is something that we commonly prescribed to people, especially early on after a total knee just because a lot of times they can’t tolerate a lot of higher intensity exercises, at least right away. And so, the squats nice, because you can load it, you know, they can put as much weight to the leg as they can take and, and you can kind of tweak the technique based on how much you want to load the quad. So this handout just kind of goes through how to squat with good technique, either a quarter squat, which was probably what you’d start with, and then talking about how to, you would probably, you wouldn’t do the full squat, but you’d start with probably a quarter squat. And it kind of goes through how to do that with good technique, you’d be surprised how often you get someone doing something in the clinic, it looks great. And then the next time you come in, you ask them to do something, and it’s pretty wonky. So this could be something nice that they could look at at home. And you could also write your sets, reps and how often you want to do it on there. So it’s kind of convenient that it also saves you some time that you don’t have to go run into the office, get on your home exercise software and try to type something up, if you’re giving them this, you can just talk through how to do the squat. Some of it might not be applicable, you know, the talks about using a barbell. But again, you know, you could talk through the parts that are applicable to this patient, and then prescribe your sets reps and send him home with it. So it’s it’s a simple resource, but it’s really practical and very applicable for this type of patient.
Megan Berg 51:59
Great, thank you. And the last resource that we’re pulling from the library to use for this case study is called stiffness after total knee replacement. And Troy, why did you pick this resource?
Troy Adam 52:13
Yeah, great. Honestly, this is this one’s not a necessarily a simple resource. This one is rich, I think with with great information, probably best suited for maybe the clinician, or again, the really interested and the, you know, the patient that wants to be well informed of some risks associated with with a total knee replacement. So right, this document talks about more or less stiffness or range of motion deficits, which are super common after a total knee injury, if somebody is not going to do well, after a total knee injury, it would be my guess that this is this is the reason why your lack of range of motion is one of the biggest reasons why we would say, you know, hey, you got to go back, you got to get a revision, or something’s got to get a change here. So it outlines range of motion kind of goals associated with different activities that are important to your patient. So ideally, right, we often think of about 110 degrees of flexion is something that’s good. But you know, what do you need to be able to just sit comfortably? What do you need to be able to climb stairs, things like that. So that you have some benchmarks, maybe when it comes to goal writing, specifically, or again, education to your patient, Hey, you want to be able to get down to the basement to be able to do your laundry? Well, guess what, we got to work on this. And we got to get it to this. This point. It talks a little bit about treatment options for the physical therapist as well, that’s having trouble improving range of motion. Yeah, and some risk factors associated with not having or with potential to kind of develop a stiff, stiff knee or stiffness after surgery. So just a good a good kind of base piece of literature to give your patient right off the get go get them excited about about their range of motion. Hey, great, you know, you’re able to achieve 70 degrees of flexion. Today, Oh, great. Now you’re able to achieve 90 degrees of flexion. This is what this means. So they maybe they can have a little bit of buy in and kind of follow along with the treatment process. So.
Megan Berg 54:28
Great, thank you.
Megan Berg 54:31
And do you guys have any thoughts as far as how you would counsel this person? Like, should they be going home? Should they be going out and doing things in the community? Right after a total knee replacement? If they’re going to do it anyway, even against somebody’s advice, like how would you be talking to them or counsel them through this?
Ross Eckstein 54:53
I think it would depend for me a lot on their functional status, you know, and how they were doing and then also So, sometimes compliance with your assistive device instructions as well complained to that, you know, a lot of times people can get around pretty good and do more walking, if they are willing to use a walker, something that unweighted a little bit. And then a lot of times the people that insist on not using a walker and they’re just grunting and limping through pain, then they end up with a really swollen angry knee. And so I guess it depends, I guess, depending on how, how the patient presented and and how the knee was doing, I guess it’d be a lot of times I talked about pacing, you know, it’s like, you know, maybe if you got really sore, you know, walking 500 feet next time, try maybe just limiting yourself a little bit more and see, see how you do and then kind of gauge it on that and hopefully progress it with time.
Troy Adam 55:50
Yeah, I love and hate Ross’s answer, which is like the classic PT. School everybody knows it. And I’m sure other professions as well. Other therapies that it depends answer, right? So you got to use your clinical judgment, you got to see, okay, what’s, what’s their fall risk? How good are they with their assistive device? What’s their pain level, things like that, in general, we’re going to push towards, towards as much community involvement as we can classically, people do better with that. But if it’s not safe, it’s not safe.
Shweta Subramani 56:23
Honestly, other than what both of you mentioned, I would say that I actually learned something very interesting recently, which was motivational interviewing, I feel that when I get patients were like, very non compliant, very persistent, that they’re going to be unsafe, but they still want to get the rehab that they deserve. I try. Like, I wouldn’t say I’m an expert in motivational interviewing. That’s something that I’m still looking into. But I feel like I’ve tried a little bit applying the strategies, the ones that I know of at least trying to, like, question them further about like, Okay, why is that? If they’re denying using an assistive device? Why is that they feel that way? What are the pros and cons? What would happen and kind of weigh the risk versus benefits for them and see if they’re able to make an informed decision at that point?
Megan Berg 57:17
Yeah, absolutely.
Megan Berg 57:19
And at the end of the day, it’s it’s always personal choice. And I think all we can do is recommend and be supportive, but then also honor that it’s the choice that they get to make for their own lives. And that’s 100%. Okay. All right. Before we wrap up, I just wanted to mention, each month will mention any resources that were created by the other teams in therapy insights that might apply to your clinical practice. So this was the resource created by the OT team that’s now available. And it’s all about gate control theory of pain in practice. So that can be used as a handout for your patients. And then the OTA team also developed a handout about growth mindset. So trying to shift from a fixed mindset of like, I can’t give up toward the growth mindset of I’m still learning, I’ll keep trying, this is going to take time and efforts. So that can be a helpful conversation, if you’re working with patients who tend to live in that fixed mindset realm, helping them shift that so they’re able to reach the goals that they’re trying to accomplish.
Megan Berg 58:33
Yeah, so those are all of our resources, you can find them at therapyinsights.com. All of the links to the resources that we’re talking about will be in the show notes, if you want to just find them very quickly. And if you have any questions, you can reach us at support@therapyinsights.com. Thank you for joining us for this last hour, we’re going to be back in one month, with a whole new episode all about our new resources that we’re releasing in April. And we’ll have a new case study that we’ll be discussing then as well. And if you are an Access Pass member, be sure to vote in our upcoming survey about which resources that we create Next, we absolutely listen to all requests as well. If you’re looking for a specific resource that you need for your clinical practice, you can type that into the survey and we take those and those are often the resources that we create next. So thank you to all the therapists out there for making therapy informed and empowering in person centered and we will see you next time. Thanks. Thanks, everybody.
Troy Adam 59:39
Thank you guys enjoyed it.