Received a referral from an orthopod for home physical therapy to see a client who had fallen at home. She had both hips replaced in the last few years. The referral said “Left Hip Pain. Eval and Treat.” I figured I was walking into a situation of someone who had a painful left hip…possible hip contusion…probably would need a home safety assessment, some ice/heat, massage, gentle stretching and move toward more aggressive strengthening and fall prevention strategies.
When I saw her, she could hardly move and was in a lot of pain from the most recent fall that occurred the night before. Pain not from her hip but instead her back and left rib area because of the latest fall. She could hardly move from the pain. I arranged for an x-ray for possible rib or spinal fractures. The x-ray did show left side rib fractures.
But things still just didn’t add up. Her motor recruitment or muscle contractions were diminished generally…she couldn’t move as well as I would have expected. She had a scissoring gait pattern…walked kind of pigeon toed, slight resting tremor or shake on right forearm that was worse when stressed. When her physicians asked about it she told them “doctors make me nervous” and her dad had it too. Awgh! Essential tremor…maybe. But the dulled emotional tone on her face…she didn’t laugh outwardly at my amazing jokes….bad sign! …and the akinesia…all those light postural adjustments and lack of head rotation to track me as I moved around the room as we continued our conversation. Hmm….
So, I prodded a little deeper. Reviewed her medications again…hmm…depakote, clonazepam… and about ten other meds including a narcotic for the pain. That explains it…or does it?
Time to call her primary care doctor. I hate this! Get put on hold, get screened, someone tries to decide if my information is worth putting “the man” on the phone with me. I’ve done this before and learned the hard way. Don’t assume you know the “new and unknown diagnosis that will save the day!” Just ask questions and state your observations and concerns. Anticipate what they will ask you and have your responses ready. State objectively your findings, then ask a few questions of your own. Why is this sweet woman falling so often? Why is her motor pattern and response the way it is? Have you seen her get up in the office and walk across the room, moved her arms and felt her tone?…why no right arm swing when she walks at normal speed? Why no little postural adjustments that we all usually make all the time? Why does she not rotate her head and follow me as I move around her apartment?
It is very easy to get “tunnel visioned” into seeing what the referral script says…left hip pain. But do I see the tree and miss the forest. A tree can tell you a lot, but step back and look at the forest…you may be surprised at the view.
This is one reason I love working as a home health physical therapist. I can make time to look at the tree and even step back and view the forest.