Table 1 Patient Cases

Patient Case #1 Part 2 (Acute Care Hospital): Knowing who and what is important (Relationship building)

Mrs. Smith’s chart identifies her husband Stan as her next of kin. With much coaxing, the patient transitions with moderate assistance to sitting at the edge of the bed. She appears nervous.

PT: “I can’t wait to tell your husband, Stan, how well you are doing today!”

Mrs. Smith: “Oh yeah?”

PT: “He will be so pleased!”

Mrs. Smith: “Oh, okay, good!” (smiles)

Mrs. Smith may not know/trust the PT, but when she hears the PT knows Stan, she becomes a bit more relaxed.

Patient Case #1 Part 3 (Acute Care Hospital): Empathic curiosity (Relationship building)

Mrs. Smith is sitting upright. Her vitals are slightly elevated but stable. She continues to appear anxious.

PT: “You are doing well.”

Mrs. Smith (anxious): “Yes. Well, I think …. Um.”

PT: “It’s hard being in a strange place, isn’t it?”

Mrs. Smith: “Yes …. It’s strange.” (smiles nervously)

PT: “We are going to get you back home.”

PT: “It will be nice to be home, won’t it?”

Mrs. Smith: “Home.” (relaxes slightly)

PT: “Thinking about home makes you relax.” (smiles)

Mrs. Smith: “Yes.” (smiles more genuinely)

PT: “Let’s take a walk, thinking about home …” .

Patient Case #2 (Community Based Rehabilitation Clinic): Reminiscence (Relationship building)

Mary has a 5-year history of Alzheimer’s Disease with moderate dementia. She lives with her husband in the community. She recently fell and her physician recommended PT for balance training.

She is reticent to engage in therapy. She is distracted and looking for her husband (who left to run an errand). The PT knows from her husband she is very proud of her long teaching career.

PT: “I understand you were a teacher for 30 years! Tell me what you loved about teaching …” .

If open-ended questions are beyond Mary’s language abilities, then interactions can be phrased for more limited (yes/no) responses or simple acknowledgement:

PT: “Did you enjoy teaching?” or “I bet the children loved you!”

To integrate into a therapeutic walking task (Motor Learning principle of task salience):

PT: “Let’s walk as though moving through rows of desks in a classroom,” or “Let’s pretend we are out at recess on the school grounds.”

Patient Case #3 Part 1 (In-Patient Rehabilitation Setting): Reality & Flexibility (Relationship)

Mr. Jones is recovering from hip fracture surgery. He has moderate dementia and presents with some confusion.

The PT may choose to help orient Mr. Jones to the reality of his situation.

PT: “Mr. Jones, you are in the hospital …. You fell and broke your hip …. Your recovery is going well.”

If Mr. Jones is asking for his sister Bess who died several years ago, the PT may respond to the perceived emotional source of the patient’s inquiry.

PT: “Are you missing your sister? Tell me about her,” which may be a more gentle and productive response than the truth, “Bess died several years ago.”

Whether an outright lie should be told (“Bess will be back shortly”) is controversial, but might be an option if Mr. Jones is perseverating on Bess and other options are failing.

Patient Case #3 Part 2 (In-Patient Rehabilitation Setting): Errorless learning & Part-whole practice (Motor Learning)

Mr. Jones is working on sit to stand from a chair to a walker. The PT identifies 3 components for safe sit to stand movement from a chair: (1) Scoot forward, (2) Push from chair to stand, (3) Hands to walker.

PT: “First, scoot forward … like this” (and demonstrates or facilitates).

The PT does not let errors occur, intervening with cues/handling in anticipation of errors.

Mr. Jones goes through several practice trials with fading demonstration and fading verbal cues (same words, just fewer). Ultimately, the PT says: “First?” and Mr. Jones scoots forward.

PT: “Now, push from the chair to stand … like this” (and demonstrates or facilitates). The PT does not let errors occur, intervening with cues/handling in anticipation of errors.

Mr. Jones goes through several practice trials with fading demonstration and fading verbal cues (same words, just fewer). If there are adjustments required (e.g., Mr. Jones needs to lean forward more for successful transition to stand), the PT facilitates the movement and may add a verbal cue.

The PT may cluster practice of steps 2 and 3, every time the patient achieves full stand successfully (step 2), the PT prompts: “Hands to the walker” (step 3) to complete the skill.

Within the PT session, the PT puts the components in context so Mr. Jones has an opportunity to practice the full sit to stand activity repeatedly.

For optimal results, the entire care team must be consistent and united in the way they cue Mr. Jones for this task; thus, this becomes his default motor program for the activity over time.

Patient Case #4 (In-Patient Rehabilitation Center) Behavior (Communication, Relationship)

John had a bout with pneumonia and became very deconditioned in the acute care hospital. The nurse reports he was agitated during morning care and has refused to get in the wheelchair to go to his morning PT session. She describes his current status as “irritable.”

The PT goes to John’s room to find him in his bed. His face and body seem tense and his manner gruff.

The PT sits across from him, unrushed, with friendly face & body language.

PT: “Hi John. I’m _________, from PT.”

John: “No, I’m not going.”

PT: “Okay, that’s fine.” Pause. “We don’t need to go anywhere.”

PT: “It must feel confusing to be here in the rehab center.” Pause.

PT: “Everything is so unfamiliar.”

John is quiet but seems to be listening.

PT: “I want to help get you home safely with your daughter, Joanne, and your dog, Lola.” Pause.

PT: “Shall we get you moving, so we can get you home?”