Role of the PTA
Because most fractures occur unexpectedly, there is intensive patient education by PT and PTAs in effective post-fracture rehabilitation. PT evaluations and treatment planning usually begin once the patient is medically stable to progressively increase activity. In order to minimize complications and promote a successful recovery, PTs and PTAs use knowledge of physiological processes to incrementally restore integrity and function of healing tissue while instructing patients in adaptive strategies for altered weight bearing. PTs establish a plan of care based on Impairments (I), Functional Limitations (FL), and Disability (D) and PTAs select interventions in the plan of care to progress patients toward short and long term goals.
The following table provides an example of treatment planning during rehabilitation from fracture based on impairments and post-operative complications:
|
Body function and structure Participation restrictions |
Intervention |
PTA role/patient and family education |
Outcome/Method of Assessment |
|
Impaired WB status |
Gait Training |
Use of ambulation aid Use of orthosis Pt/family/staff education on precautions Instruction in gait pattern for condition |
Level of assistance with use/care for ambulation aid Demonstration of most-appropriate gait pattern for stage of healing/function Visual, Verbal and kinesthetic practice and feedback in static and dynamic environments |
|
Impaired endurance |
Therapeutic Exercise |
Progressive increase in functional mobility Progressive increase in muscle strengthening Instruction in energy conservation (pacing, planning, prioritizing, etc.) |
Level of assistance with bed mobility, transfers, balance, gait, locomotion, etc. HR/RR/%O2 sats with activity Upright tolerance in sitting, standing (PLE, BP) Demonstration of motor and activity planning for energy conservation
|
|
Need for prevention of secondary complications |
Therapeutic Exercise |
Instruction in frequent ankle pumps (dorsiflexion, plantar flexion, circles) Use and application of sequential pumps/compressive stockings during early rehab stages Instruction in incentive spirometry Instruction in diaphragmatic breathing Instruction in proper use/wear of orthoses
|
Demonstration and practice of correct technique (bed exs, breathing, brace application, etc) with and without cues Lung volume measurements consistent with expected values
|
|
Impaired skin integrity |
Wound Care |
Inspection of pin sites/surgical incisions Dressing changes Scar mobilization Positioning changes/positioning schedule |
Size/characteristics of wound Range of motion Proficiency of patient/family member(s) in skin/wound care |
|
Pain |
Therapeutic Exercise Soft Tissue Mobilization Physical Agents |
Instruction in ROM/stretching Massage techniques for secondary muscle guarding Electrical stimulation, heat, ice, US Instruction in proper use/wear of orthoses Instruction in joint/limb protection techniques
|
Pain levels at rest/with activity ROM measures Proficiency with use/application of physical agent, orthosis, etc. Proficiency with adaptive strategies during recovery phases |
|
Impaired Muscle Performance |
Therapeutic Exercise Physical Agents |
Progressive strengthening appropriate for healing stage NMES |
MMT Limb girth measurements (decreased atrophy) Ability to perform functional activities with least resistrictive/no assistive device Time/endurance measures for sustained cardiovascular activity |
|
Impaired Balance/Coordination |
Therapeutic Exercise |
Progressive activities to maintain center of gravity (COG) within base of support (BOS) in predictable and unpredictable environments Safety training in appropriate footwear and steps to minimize fall risk |
Formal balance assessment (e.g. Berg) Time in standing Functional reach testing Balance strategy appropriate to activity |
|
Impaired joint mobility |
Therapeutic Exercise |
PNF Manual stretching Instruction in self-stretching |
ROM Demonstration of correct stretching with/without cues (patient and/or family)
|
PT/PTA Team
PTAs can be the "eyes and ears" of the PT during direct patient care, family training, and interdisciplinary care meetings. PTs rely on PTAs to gather data and make comparisons so that patients are treated within the scope of PT practice safely and effectively. In some cases, a supervising PT may not be immediately available, therefore, PTAs understand signs and symptoms which require immediate medical attention. Significant adverse findings which would require immediate communication to the supervising PT/medical staff include:
- abnormal vital sign response pre- and post-activity
- changes in arousal and orientation
- swelling and signs of excessive pressure (numbness, pain, weakness) with casting or other immobilization.
- skin redness and swelling, especially in the leg and calf, which may indicate medical urgency (e.g. deep vein thrombosis)
- signs and symptoms of peripheral nerve dysfunction (numbness or sharp, shooting, electrical pain), arterial and soft tissue dysfunction
- signs, symptoms or other disclosure of physical abuse
Complications specific to fracture and fracture repair include delayed or non-union of bone tissue. PTAs often see patients successively over a period of time, and can assess if patient progress is consistent with fracture healing as measured by decreased impairments and functional limitations. PTAs develop relationships and rapport with family members and caregivers and can advise the PT on discharge readiness and planning based on safety, family training outcomes, equipment needs, and home assessments.
Patient and Family Education Considerations
The level of functional limitation and disability is influenced by general health status and psychosocial factors. PTAs play an important role in integrating effective communication, respect for individual and cultural differences, and motivation techniques into the rehabilitation process. The PT/PTA team should coordinate with family, interdisciplinary staff, and community resources to promote optimal safety, health and wellness following a fracture.
Key factors which influence outcomes include
- extent of damage to bone and soft tissue
- type of surgical procedure and surgical outcome (includes stages of healing)
- pre-fracture functional level (previous level of function (PLOF))
- health history (medication use, diseases)
- lifestyle factors (exercise and dietary habits, smoking and alcohol use)
- individual/family goals and expectations
- extent of social support (family, resources, access to transportation, etc.)
- level of motivation
- access to patient education materials in an understandable format (e.g. appropriate language level, illustrated, translated, audio-based, etc.)