When recently asked to give the details of a patient success story, I struggled to decide which patient to use for my example. We have many successful results with our rehabilitation, but I wanted to use one that could also benefit other clinicians with possibly some “words of wisdom” or examples of “trial and error” that turned out for the positive.
The patient I’ve chosen is one who came in following a fall at home. She lived alone and was very independent and active. She fell down her basement stairs and sustained multiple pelvic fractures. No surgical intervention was performed; therefore, she was put on very restrictive weight-bearing for a prolonged period of time. She initially was placed on toe-touch weight-bearing status for eight weeks. Following her two month orthopedic check-up, the doctor placed her on partial weight-bearing status (25 – 50%). Then after her last check-up, he placed her on weight-bearing as tolerated. She was discharged home three days following her last orthopedic appointment.
That sounds fairly uneventful; however, our patient was quite impulsive and wanted to be very independent. She had difficulty with her weight-bearing restrictions from the start. Initially, she was in so much pain that she naturally kept the weight off of her involved extremity. However, as the pain was more controlled she began to put more and more weight on her involved extremity.
Some of the techniques we used to help her maintain her weight-bearing turned out to be successful and that is what I want to share with my fellow clinicians as weight-bearing restrictions can be difficult, especially in the elderly. The first thing addressed was strengthening. Our OT staff was performing upper extremity strengthening with emphasis on triceps for using her arms to bear the weight while using the walker. Our patient was ambulating with a rolling walker. Once the pain had decreased somewhat, she started to use the “step through” gait pattern. While this is the correct technique for a normal gait pattern, it actually caused her to increase the weight-bearing through her involved extremity. We changed her gait pattern to the “step to” pattern. She required moderate cueing at first because she was impulsive and wanted to ambulate at a quicker pace. She did, however, catch on pretty quickly and demonstrated proper weight-bearing restriction.
Once the doctor made her partial weight-bearing (25 – 50%), we had an even more difficult time as she was feeling much better and didn’t quite understand why she needed to keep the weight off of her involved lower extremity. She also had difficulty knowing what 25 – 50% weight-bearing felt like. We tried several techniques to get her to understand “partial” weight-bearing, but she still had difficulty in maintaining it. We decided to bring in a bathroom scale and have her place weight down through her foot. We were able to give her some objective feedback as to how much weight she was actually placing on her foot. This, in conjunction with emphasizing the “step to” gait pattern, helped her maintain her weight bearing status until her next doctor’s appointment. We were all very glad when he gave the okay for “weight bearing as tolerated”.
I believe that through our interventions of strengthening, modalities and mobility training we were able to successfully rehabilitate her so that she could return home independently. We were able to provide education and training to her regarding her weight-bearing status to protect and prevent further injury to the healing pelvic fractures.
Clinical Manager of the Therapy Department