Written by: Yaffa Liebermann, PT, GCS,CEO
1989-1991 Riverview Hospital, Red Bank, NJ:
I took a job at the River View Hospital in Red Bank NJ. I loved it ~ it was a great team of therapists who were very dedicated to the job. We helped each other constantly and we shared information that we gained through professional courses we attended.
In our department, we had two rehab aides. They understood that I grew up in a different country, talked with an accent but have the same idioms and, of course, the same feelings. We would compare English to Hebrew and always found the correct sentence in both languages, followed with a great deal of laughter. The department manager had also majored in English, prior to getting a Master in PT, and was always willing to help me phrase things correctly in English when I struggled.
Everyone Wants to Have an Assignment and Be Proud of Achieving It:
One of the aides had worked in the department for years. One of his duties was to disinfect the Hubbert Tank and the Whirlpools. At lunch time they shined. I watched him and figured out that my job is to treat patients and to see them progressed in each session. That achievement made me proud. His job was to disinfect the Hubbert Tank and the whirlpools, and this duty made him proud.
Learning experience: If you want a productive and happy team – divide the tasks to individuals and make them accountable for their performance. They will do their best to achieve their goal as each one of us wants to shine in something. As a supervisor, you need to find duties which will allow them to experience a sense of pride.
Physical Therapy Month Celebration:
In the USA, October is PT month. I was in charge of organizing the exhibit in the PT department. With the team’s help, it was a beautiful day. We gave out APTA t-shirts and welcomed visitors with a big smile. We served delicious food and shared the secrets of healing patients through strengthening. Later, when I left to take another job, the supervisor thanked me for organizing that day and making it successful. His gratitude made me feel that I am unique as well as a good therapist.
Learning experience: We all are good therapists but, sometimes we need to step out of our comfort zones, and volunteer to create something different for our department in order to get more interest and create excitement among our peers.
Looking at X-Rays:
The X-ray department was located nearby the PT department. Sometimes while waiting for a patient or at lunch time I would sneak into the x- ray department and look at my patients’ x rays. I read the written result and compared it to the x-ray in order to teach myself. It was very helpful to get a clear picture of the patient outside and inside.
One day I looked at x-rays of a patient with bone cancer but I did not know how to read it correctly so I asked the radiologist for an explanation. He looked at the x-rays and said: “This woman should not walk on her legs. She does not have bones, her legs are all cavities. If she would walk, her legs will break”.
I shared this information with her medical doctor however, he gave me the ok to walk with her. She surprised me and, in a few days, got stronger and was able to walk out of the hospital on discharge day. Patients did surprise me through the years as sometimes their will is the deciding factor despite the x ray results.
Treating A Baby with Torticollis:
One of our staff members became a grandmother to a beautiful, baby girl. She saw that the baby’s neck is short on one side but her son, the baby’s father, did not seem concerned and said it would be ok. The daughter in law listened to the grandmother and came to us to get treatment. I did not treat babies at that time but I have four children of my own. I started the session holding the baby close to my heart and walked with her in the department slowly to allow her to get comfortable with me. Then the mother would hold the body while I would hold the head in order to gently stretch the Sternocleidomastoid muscle.
The mother told me that she hurt her arm in a car accident three years prior to the baby delivery and when the baby arrived she held the baby only with her stronger right arm. I advised her to hold the baby equally with both arms, so the child would turn her head to both sides to see the mother and the world and not only gaze to one side. The mother then felt her pattern of holding her daughter led to the torticollis, but with a great deal of support during our sessions, she no longer blamed herself. We made good progress – the muscle stretched and the baby gained full movement to both sides. I remember this little baby as a great achievement for the mother and me.
The father summarized the treatment with: “It would be ok without PT treatment- time could have healed her”. No argument here. She would be ok but would live her life with a crooked neck. PT is not an emergency treatment. We do not save lives, we just make them better when injury happens.
There was also a medical mastectomy program in the hospital. Our physical therapy department was involved with assisting in the recovery process. I would like to share my knowledge and experience regarding being a part of this process. The following information was part of a presentation we provided to a group of women who underwent mastectomy as it not only improved their range of motion but their morale as well.
Carcinoma (cancer) of the breast generally occurs in middle-aged women. It begins in the mammary gland, spreads to the skin, fascia, and muscles in the chest. Later, the lymph glands themselves may become diseased. Lymphatic spread is rapid and more remote parts of the body may also become involved.
Surgical treatment: The operation consists of removal of the mammary gland, with part of the pectoralis major and of the skin and fascia of the chest. Either to avoid further lymphatic spread of the disease, or because they are already involved, the axillary glands on the affected side are also removed.
Post-operative condition: The removal of the axillary glands destroys most of the channels by which the lymph returns from the arm. There is, therefore, an intense lymphatic congestion which causes the arm to be edematous, hard, tender, and painful. The joints are stiff, and movement is difficult. There may also be swelling over the front of the chest and the back of the shoulder. The edema persists until the lymph has forced new channels for itself through the axilla to the subclavian glands or, if these have also been removed, to the thoracic or right lymphatic duct.
Support: Post-operatively, the arm may be kept bandaged to the side, supported on a pillow, or slung in elevation, depending on the views of the surgeon.
Physical Treatment: The start of this also depends on the surgeon’s views. Some allow no physical treatment for 10 to 14 days at least, in order to allow the wound to heal. Others allow gentle massage and movements at once. The aim of treatment is to force on the lymph, thereby relieving congestion in the arm and assisting in the formation of new drainage paths by raising the pressure in the lymphatic vessels. The methods of treatment are the same, whether it is begun at once or later in convalescence.
Position of Patient: The patient should lie down, with the arm in elevation so that gravity may assist the lymphatic flow. The arm should be comfortably supported by pillows and, as in varicose conditions, it is a good plan for the patient to lie with the arm thus raised for 15 to 20 minutes before treatment.
Massage: The most important manipulation is slow, deep effleurage. This should first be given to the proximal upper part of the arm, so as to empty the lymphatics in that area. The part immediately below this should next be treated, to press the lymph on into the vessels above, which have already been cleared, after which a return should be made to this upper region. The PT should continue working on this principle until the whole length of the arm has been treated. The arm should be considerably reduced in size by the end of the treatment. The PT must not be disappointed to find it is as bad as ever the next day.
Passive and Active Movements: should follow the massage to assist the venous and lymphatic flow and prevent permanent stiffness in the joints. Abduction, elev:ation, and external rotation are especially important. Treatment might continue for many weeks after the operation.
Pumping Exercises: The most important exercises in decreasing edema. It is full flexion of every joint in the upper extremity followed by full extension. Can be done to all directions.
The following are some suggestions to protect your arm:
- If you cut, burn, or pierce your skin, wash and use an antiseptic and apply a bandage.
- If your arm becomes red, warm, unusually hard or swollen, this may be an indication of infection and you should call your doctor.
- If there is swelling without redness, increased warmth or hardness, positioning in conjunction with the “pumping exercise” can help decrease the swelling. Position the hand higher than your elbow, elbow higher than shoulder and shoulder higher than your heart. Keep the arm in this position as long as possible. Notify your doctor if the swelling does not increase in 24 hours.
- Keep your arms clean. Wash often if you perspire, but always dry your skin well so moisture doesn’t remain in skin folds or between fingers.
- Protect your fingers, hands and arms from punctures. Use your unaffected arm if you have blood drawn, your blood pressure taken or need injections.
- Trim your fingernails carefully. Don’t cut or tear the cuticles.
- Wear gloves when you’re working outside to avoid punctures from thorns and tools.
- Use an electric shaver under your arms. The skin is less likely to become injured.
Muscle Strain: Use your affected arm as normally as possible, but avoid heavy lifting and vigorous pushing, pulling or scrubbing. Ask your doctor, nurse or physical therapist about the best exercise program.
Burns: Always wear protective clothing and sunscreen with an SPF 15 or higher. If possible, stay out of the sun from 10 a.m. to 3 p.m. Avoid hot baths, saunas and dishwater. Wear oven mitts when cooking or baking.
Constriction: Avoid anything that constrains your hands or arms, such as tight sleeves or cuffs, watch bands or jewelry. Make sure your bra fits properly so the straps don’t dig into your shoulders. With proper education and care, you can recognize lymphedema’s symptoms and seek treatment early.
Helpful hints when exercising: You should feel a pulling sensation around your incision. As you repeat each exercise, you should find it easier to move.
- Always allow enough time for your exercises.
- Do each exercise slowly and completely.
- Do each exercise as many times as you are instructed.
- It is important to use flow and steady breathing while exercising.
- It is most beneficial to do the exercises three times a day and exercise at the same time every day.
- The exercises you do in the first months following surgery determine the degree of strength, movement and the use you will have of your arm.
For persistent lymphedema, treatment on an outpatient basis may be necessary in order to decrease the swelling and prevent further complications. Your doctor may prescribe physical therapy, based on your individual needs. Treatment would include, but not be limited to: Exercise, Massage, Compression, Glove-Isotonic, Education.
Please keep in touch with your doctor for any problems or concerns.