Going into college, I was fortunate in that I already knew what I wanted to be - a physical therapist. With my career path chosen, I elected to enter into the 6-year PT program at my school. While I knew I wanted to be a physical therapist, the only experience I had in the field was as a patient at an outpatient ortho clinic and volunteering at a VA. I had no idea what physical therapy entailed in the hospital setting.

    Following my freshman year of undergrad, I was fortunate to acquire a job as a physical therapy aide at a hospital near my hometown. Being in a hospital setting and handling patients regularly was definitely a nerve-wracking experience at that age. I remember going into the ICU my first couple weeks terrified of touching the patient or any of the cords! Over time I became more comfortable working with various patients. As I became more experienced, I became more and more familiar with medical terminology, transferring patients, and the hospital setting in general. When it came to courses focused on the inpatient setting, it definitely made the material easier, but probably the most beneficial aspect of the position was an alternative perspective gained from working in that setting. The way we are taught in school is not always the way techniques are performed in the clinic! For example, while it is essentially universally understood that there should always be two practitioners present while performing stairs, my school was different in that it taught us the therapist should stand behind the patient on the stairs. I realize this is almost unheard of with other practitioners. One of my teachers reinforced it in me specifically by having me try to guard her, while standing in front on the stairs. She purposely had her legs give out and slid down several stairs! The point is working with therapists outside my classroom setting has made me realize why some practitioners prefer their methods. Bringing in multiple perspectives can really help to develop your own style of care.

    The early exposure to inpatient care also had an impact on my first inpatient acute care rotation. With having observed or performed many techniques over the prior 4 years, I had little hesitation in treating patients. While I recognize that inpatient PT does not require extensive utilization of specific techniques, it definitely has a high-level of clinical reasoning required. Knowing how to pick out the important material in a chart review, which lines you can disconnect, developing discharge plans and more can only become more efficient through experience.

    I think what's important to take away from this is to always keep an eye or ear out for advice from PTs in all settings. You never can hear too many opinions or methods on how they choose to practice. That is one of the reasons we started this website. While going on our initial clinicals, we were encountering examination procedures and treatment styles not exposed to us in school. If we can continue to develop lines of communication through various schools and parts of the country, we can all benefit. Hopefully, it will lead to research that enables physical therapists to become more highly-skilled practitioners at a higher rate!

Well I'm down to 23 ribs...

     In 2010, my entire right arm started to swell. I went to the Doctor and initially was prescribed antibiotics for MRSA. I had been paint-balling 2 days prior to the incident and had a few open wounds that were potentially infected. The Doctor said to follow up in a few days if I did not improve. My arm continued to swell and became even worse with activity. At the second visit, I was told to go to the hospital to get a venous doppler for a suspect DVT. 
     The doppler revealed a ~4 inch blood clot in my subclavian vein. I was immediately admitted to the ER, placed on blood thinners, and underwent a surgical procedure to remove the clot. Following a 3 days hospital stay, I was diagnosed with Thoracic Outlet Syndrome (TOS) and sent to a specialist at Barnes-Jewish in St. Louis. Fortunately the vascular surgeon I met with, Dr. Thompson, is one of the national leaders in TOS. After a long discussion on the pathology, we discussed treatment options. Due to the severe fibrosis of my subclavian vein, Dr. Thompson highly recommended a first rib resection to open the thoracic outlet space. Additionally, he would perform a vein graft on my subclavian vein.* Other treatment options would have been conservative and severely limited my activity level in the future. Although my case did not allow for this, other treatments include a pectoralis minor release or scalene release.

So why did this happen to me?
Growing up I was always involved in athletics, specifically sports that involved overhead activities (mainly swimming and water polo). In addition to practice, I would supplement my training in the weight room. With only limited knowledge of training at the time, I excessively worked my mirror muscles (pectoralis major, biceps, rectus abdominus). This rounded shoulder posture coupled with overhead motion, significantly reduced the space in my thoracic outlet, specifically between my clavicle and first rib. 

Things to consider with future patients?
Thoracic outlet syndrome can be a compromise of any portion of the neurovascular bundle in the thoracic outlet. I should note that I was completely asymptomatic prior to the day when my arm swelled up. While I presented with Venous TOS, >95% of cases are neurogenic. For vascular TOS, common initial symptoms can include a loss of pulse, arm swelling,  cyanosis, and a "cool limb." With neurogenic TOS, patients will complain of paresthesias in the entire hand. This may vary depending on the exact location of compression. Common examination tests include: Roos Test, Costoclavicular brace test, and the Hyperabduction test (Check out our TOS tests page for more information).

If anyone has any comments or questions, feel free to write below or email me at jheafner@slu.edu. 

                    -Jim 

*Previously vein grafts were taken from another vein in your body (often the saphenous-- the vein had to be double sutured over to size appropriately as the subclavian), but Barnes-Jewish had a "vein bank" where they harvested veins from stem cells. 
**The fistula rerouted my artery and vein at my distal forearm to circulate the blood ~10 faster back to my heart to reduce the risk of a subsequent clot. Ten weeks after this surgery, I had a second small procedure to reverse the fistula and return normal blood flow. 

Reference: 
Sanders RJ, Hammond SL, Rao NM. Thoracic outlet syndrome: a review. The neurologist. Nov 2008;14(6):365-373

      I became a CSCS in August 2011 but my interest in strength and conditioning principles started back in high school.  As a competitive high school and club soccer player I quickly learned the value of sports performance training.  Competing in some of the top soccer tournaments around the country made me realize how important building my speed and strength were to be successful.  I trained in multiple speed programs, agility and jumping programs, and “injury prevention” programs, all while lifting weights.  Looking back on it, none of the programs had any structure to them.  Luckily I had a gym teacher my senior year that was a CSCS/ATC who taught me the principles and got me interested in becoming a strength and conditioning specialist. 

      How has my CSCS helped me?  First and foremost, I really enjoy sports performance training and I pursued the CSCS to have the opportunity to train high-level athletes.  I have structured evaluations, performance enhancement programs (speed, agility, plyometrics, power), and taught proper weight training techniques for multiple athletes at both the collegiate and high school levels.  It has been a very rewarding experience working with these high level athletes and I continue to learn more about strength and conditioning everyday.  From a physical therapy aspect, I have benefited tremendously.  During my clinical rotations I have never failed to give more challenging exercises to my patients.  I think the biggest benefit is understanding how and when to effectively change the intensity of the rehabilitation program.  Unfortunately, physical therapy curriculum is so dense that it’s almost impossible to teach all the different types of exercises out there and how to effectively change intensity (sets, reps, type of contraction, speed of reps, rest time, etc) in a program.  

      Overall, my experience as a CSCS has been wonderful from both a physical therapy and strength & conditioning aspect.  I can confidently say that I understand dosage and exercise prescription better than most of my peers because of the additional knowledge I’ve gained.  If you are interested in pursuing a strength and conditioning job on the side from physical therapy, the CSCS certification is the one to start with.  Right or wrong, it is still considered the “gold standard” in the industry (although there are some definite gaps in the CSCS test).  For those who aren’t interested in becoming a CSCS but would like to learn the principles, the Essentials of Strength and Conditioning book is a must read starting point (I don’t agree with all of their principles-namely the periodization principles but for beginners it’s a great resource!). 

      Please leave a comment if you would like any additional posts on anything to do with the CSCS, whether its study tips for the exam, any other strength and conditioning certifications, or just general questions!  

                                                                                  -Brian

    I just finished up a clinical rotation in Montgomery, Alabama. The patient population I saw was a mix of workers comp, outpatient ortho, and sports. My CI happened to have the contract with two local universities. Each year, at the beginning of the fall semester, the athletes at those schools are required to have physicals to ensure their health before their respective seasons begin. To speed up the process, various stations were set up: height/weight, vision, general medical, and ortho. I worked with some orthopedic surgeons, performing ortho screens, to assess for any orthopedic impairments and pathologies.

    Due to the large amount of student-athletes, we had to perform the ortho screens as fast as possible, while still testing the athletes' musculoskeletal system to ensure safety. We first obtained an ortho history from each individual, so we could perform a more extensive examination of the affected area. Our general screen usually included a cervical clearing test (along with mytomal/dermatomal assessment), AROM of the shoulder followed by resisted muscle testing, spinal flexion/extension overpressure, single leg hopping, deep squat with either a "duck-walk" or twisting the hips on stable ankles (clears the ankles and stresses the rest of the lower extremity as well!), and push-ups to check the elbows and shoulders for apprehension.

    It was a great experience working with the ortho surgeons! I was able to look into their reasoning behind using one test versus another when examining a joint. I highly recommend being involved with the physicals of an athletic organization or school if given the opportunity.

                                                                               -Chris

      Currently I am on an inpatient clinical rotation in Kansas City. This past Tuesday morning I had the opportunity to observe 5 surgeries, 4 of which were total joints. Two of the surgeries were total hip replacements, 1 total knee, and 1 unicompartmental knee replacement (partial knee replacement). 
      
     The afternoon following the surgery, I performed a physical therapy evaluation with each of the patients. Each day I worked with them until they discharged from the hospital today (Friday). Seeing the entire process from start to finish really pieced together the entire rehabilitation process for me.

      Being able to observe surgeries and interact with the surgeon empowered me to more fully understand the patient's pain. It allowed me to answer their questions more appropriately and gain a better understanding of exactly what structures were involved in the surgery.
      
      Additionally, the hospital I am working at has a well developed joint center. (Recently named the best joint center in the region). Each day, for a total of 3 days, all of the total hips and knees would gather together for a 1.5 hour morning therapy session and a 1.5 hour afternoon session. Each session would include basic therapeutic exercise, precautions guidelines (for the hippies), and ADL training with both PT and OT. The patients were extremely happy with the group therapy sessions. Seeing other people go through the same pains and process as them seemed to make the rehab process easier.

     In conclusion, I highly recommend observing any surgeries that you have the opportunity to see. It allows you to appreciate the integrity of the human body, understand more fully what your patient is experiencing, and ultimately be a better therapist.

                                                                                - Jim 

  We set up this website for physical therapy students and physical therapists across the country to discuss what we have been learning and practicing. This blog is intended to be educational and informational, reviewing some of the key concepts of anatomy, kinesiology, and pathophysiology and discussing new evidenced based research in the field of physical therapy. Please feel free to leave a comment!