weiner-lasher

Case Study: 65-Year-Old Male – Fall Incident During Physical Therapy

Thu, 30 Jan 2025 04:15:43 GMT

Background

A 65-year-old male, one year post-CVA (cerebrovascular accident), suffered a fall while participating in physical therapy. The incident raised concerns about the therapist’s approach to balance training and assistive device reduction.

Patient Information

Age: 65 years
Gender: Male
Medical History:
CVA (1 year ago)
Right-sided hemiparesis and foot drop secondary to CVA
Right AFO (Ankle Foot Orthosis) for foot drop
Hypertension, hyperlipidemia
Mobility:
Ambulates with a single-point cane and right AFO for support

Presenting Condition

The patient had residual right-sided weakness and foot drop, requiring an AFO and a single-point cane for mobility. His rehabilitation program included balance training, gait retraining, and lower extremity strengthening to improve independence.

Physical Therapy Program

The therapy program aimed to enhance balance, strength, and walking ability. Key components included:

Balance exercises to improve postural control and proprioception
Gait training to enhance foot clearance and weight shifting
Strengthening exercises for motor function improvement
Progressive reduction of assistive devices to encourage independent ambulation

The therapist's goal was to wean the patient off his AFO and cane to improve his mobility and functional independence.

Challenge: Fall Incident in Therapy Gym

During a balance and ambulation exercise, the therapist instructed the patient to walk without his AFO, cane, or physical assistance. While practicing weight shifting and foot clearance, the patient’s right foot caught on the floor during push-off , causing him to lose balance and fall. He sustained a right hip fracture.

Key Issues Identified:

The AFO and cane were removed simultaneously , increasing the patient's fall risk.
The therapist did not provide manual or physical support , leaving the patient vulnerable to balance loss.
The patient’s functional readiness was not adequately assessed before progressing to unsupported walking.

Solution & Results

The primary concern in this case was the therapist’s decision to advance treatment without appropriate safeguards. Best practices suggest:

✔ Gradual reduction of assistive devices rather than removing both at once.
✔ Providing hands-on support or a safety harness during balance and gait training.
✔ Assessing the patient’s readiness for unsupported ambulation with structured progression.

By following evidence-based protocols, similar incidents can be prevented, reducing the risk of falls and potential legal consequences for improper therapeutic progression.

Lessons Learned

Clinical Takeaways:

Assess functional ability before removing assistive devices.
Introduce changes gradually to ensure patient safety.
Provide manual support when reducing external aids.

Legal Implications:

The therapist may be found negligent for failing to provide necessary support.
Progressing therapy too quickly without considering fall risk can result in liability .

Expert Witness Testimony

Mon, 19 Aug 2024 11:45:07 GMT

A Physical Therapist's Perspective

Case study:

A 68-year-old female in the state of New Jersey attended her 1st physical therapy session on 2/4/22. She has a history of Falls, Peripheral Neuropathy, Diabetes Mellitus Type 2, Lumbar spine surgery at L3-L5 Laminectomy (2017), and Diabetic Foot Ulcers. This patient went to physical therapy because her balance was worsening during gait and she had some falls.

The physical therapist did an initial evaluation of her lower extremity muscle strength, hip and back range of motion, and a balance assessment. **There was no noted sensory evaluation of the patient’s lower extremities.
On the 2nd session of physical therapy, toward the end of the session the patient received a hot pack to her lower back. The physical therapy aide/technician had the patient lay on her back on top of the hot pack. After approximately 7 minutes, the patient yelled out in pain as her back/buttocks felt immense pain. The physical therapy aide/technician came back in put another towel under the patient and then left again for another 10 minutes.
The patient wound up having 2nd-degree partial thickness burns to her sacrum and buttocks.

This case did not settle and wound up going to court.

1. The therapist needs to clearly understand the matter and whether or not there was a deviation in the standard of care. Whether the therapist is testifying for the plaintiff or the defense, the therapist needs to understand the national standard of care and the practice act of the state in this matter is taking place. In this particular case study, the female patient had a history of diabetes, peripheral neuropathy, diabetic foot ulcers, and lumbar spine surgery. All of these preexisting medical conditions put the patient at risk for loss of sensation in her lower extremities. The problems identified in this matter were:

There was no sensory evaluation done in the initial evaluation to determine the patient’s sensation in her lower extremities.

A hot pack was used over an area that was not tested for sensory loss.

The patient was supine on the hot pack which facilitated her burn.

A physical therapy technician applied the hot pack to the patient and also determined that the hot pack would stay on the patient even after the patient complained of immense pain.

2. The therapist needs to be able to have a jury understand the matter that occurred and the laws in that state, that made the therapeutic act permissible or not. The therapist needs to be able to understand the details of the matter so that it can be explained more easily to the jury. In this particular case, the therapist would need to be able to explain to the jury the contraindications that exist with Diabetes Mellitus, Peripheral Neuropathy and Spinal Surgery. The therapist would also need to explain the New Jersey Physical Therapy Practice Act to the Jury in which physical therapy aides/technicians are not permitted to administer, apply, or remove any modalities and make patient care decisions.

3. The therapist needs to rely on evidence-based research and solid data points when taking the stand. Being able to point out solid evidence-based research and medical data points during the trial testimony is very important to make a case. In this particular case, bringing and speaking about peer-reviewed journal articles would be very helpful to show the contraindications that exist with heat and Diabetes Mellitus. This is an example of a research article that could be discussed during trial testimony and explained to the jury: The Factors Associated with Contact Burns from Therapeutic Modalities , https://www.ncbi.nlm.nih.gov/pmc/articles/PMC(917) 301-1672/ . This peer-reviewed article from the National Institute of Health, also explains how peripheral neuropathy can occur from Diabetes Mellitus or Spinal Surgery and the effects that it has on the nerves ( https://www.ninds.nih.gov/health-information/disorders/peripheral-neuropathy .)

The Role of Occupational Therapy and Physical Therapy in Legal Cases

Mon, 19 Aug 2024 11:40:46 GMT

When being assigned a new legal matter as a Physical Therapy or Occupational Therapy expert witness there are a few things to consider as a medical expert.

Understanding the Clinical Setting where the matter occurred

Medical malpractice matters and personal injury matters occur in a variety of settings. In my clinical physical therapy and occupational therapy practice, I have worked with inpatient and outpatient orthopedic and neurological populations including both adults and pediatrics. It is very important that the expert therapist understands the in’s and out’s of the setting the incident occurred in (e.g acute inpatient hospital, outpatient clinic, skilled nursing facility, and school.).

Analyze the Complaint

The expert therapist is responsible to understand the accusations in the case. Whether the expert is working with the plaintiff or defense the therapist needs to understand the allegations and where to focus the review. Having a complaint when initiating a review is helpful and also assists in saving the therapist time during the review so they can focus on the issue at hand.

Reviewing Therapy Records and Understanding Medical Jargon

While reviewing documents for the legal matter, therapists are responsible to interpret for the attorney and understand the medical jargon that is documented. These are examples of common therapy terms that are often seen during medical chart reviews that are important and that are often discussed with the attorney:

CGA during transfers- Contact Guard Assistance -therapist hands are very close and occasionally on the patient; < 25% assistance from the therapist.
Min assist during transfers- Minimal assistance - therapist hands are on the patient and the therapist is offering between 25-50% of the assist during the transfer/movement.
Dyspraxia - difficulty in performing coordinated movements, often associated with a neurodevelopmental condition in children (developmental coordination disorder).
ORIF -Open Reduction Internal Fixation- occurs usually with a displaced bone fracture and a pin is placed in the fractured area to ascertain anatomical alignment.
THA -Total Hip Arthroplasty -otherwise known as total hip replacement. It is important for the therapist to understand the surgical approach that the surgeon used whether it was an anterior approach or a posterior approach as the approach determines the continuance of care.

Review past Medical Records and History (Surgeon or MD)

It is imperative that the therapist understands the past medical history of either the plaintiff or defendant in the matter. Past medical history allows the therapist to better understand the plaintiff or defendant and enables the therapist to determine if their past medical history or surgical history influenced the current matter.

Keeping in mind the Practice Act of the State and APTA/AOTA Code of Ethics

It is the expert therapist’s responsibility to understand the practice act of the state where the matter took place. Different states hold different responsibilities for physical therapists/assistants, occupational therapists/assistants, and the expert needs to be guided by that state act. The code of ethics is a national set of ethics set for physical therapists and occupational therapists separately.

AOTA 2020 Occupational Therapy Code of Ethics

APTA Code of Ethics for the Physical Therapist

Ensuring a Successful Process for a Physical Therapy or Occupational Expert Review

Mon, 19 Aug 2024 11:37:34 GMT

Every plaintiff or defense legal matter is different but there are basic concepts that are typically analyzed by the reviewing therapist:

Practice Act for Physical Therapy and Occupational Therapy
Every state has its own Physical and Occupational Therapy Practice Act which is a statute defining the scope and practice of physical therapy within the jurisdiction, outlining licensing requirements for Physical Therapists and Physical Therapist Assistants, and establishing penalties for violations of the law. The expert reviewer needs to be aware of the state’s individual practice act as different states have different allowances for the scope of practice.

Code of Ethics
The American Physical Therapy Association (APTA) and the American Occupational Therapy Association (AOTA) both have guides to serve physical therapists and occupational therapists in interpreting the code of ethics in matters of professional conduct. The expert reviewer will use these guides to help to interpret matters of professional misconduct.

Past Medical History
Reviewing a person’s past medical history and medication history in the documents is critical. A person’s past medical history may determine if there were pre-existing issues that could have affected the way a person was presenting and was subsequently treated in therapy.

Communication
The expert reviewer needs to understand the typical communication pattern that occurs in a specific rehabilitation setting amongst interdisciplinary staff members (acute hospital, outpatient setting, skilled nursing facility etc.) The expert reviewer will determine if adequate communication (e.g., safety protocol, orthopedic protocol, fall risk protocol, vitals protocol) occurred whether it was written verbal or written during the time frame of the incident.

Documentation
The expert reviewer needs to determine if proper documentation occurred by the treating physical/occupational therapist to ensure viable information was communicated and implemented during therapy. The expert reviewer also needs to determine if proper precautions and protocols were implemented and documented by the patient’s team.

Ethics in Physical Therapy Expert Witness

Tue, 19 Mar 2024 11:48:27 GMT

How to LOSE A Physical Therapy Negligence Case

When practicing clinically and when reviewing legal matters as an expert, the reviewer/physical therapist needs to always keep the Code of Ethics in mind. There is a Code of Ethics for occupational therapists as well. This blog will focus on one aspect of the Code of Ethics for Physical Therapy.

The Code of Ethics for Physical Therapy “delineates the ethical obligations of all physical therapists as determined by the House of Delegates of the American Physical Therapy Association”(APTA) ( https://www.apta.org/siteassets/pdfs/policies/codeofethicshods(917) 301-1672.pdf . ) Principle #3 states that Physical Therapists shall be accountable for making sound judgments. Under this principle, there is subsection 3C which states: Physical Therapists shall make judgments within their scope of practice and level of expertise and shall communicate with, collaborate with, or refer to peers or other health care professionals when needed.

This is an example of a case that I reviewed where the physical therapist did not abide by the code of ethics.

A 65-year-old woman had come into a physical therapy outpatient clinic with a diagnosis of left thigh and lower back pain from her primary care doctor. The physical therapist evaluated the patient and concluded that she was experiencing radicular pain from an injured disc or nerve at the level of L5-S1. The physical therapist proceeded to treat this patient for 14 visits. On the 14th visit there with no change in her pain level or any sign that the pain was lessening. There was no indication that the pain was improving. The patient then began complaining of sleepless nights due to the pain, diaphoresis in the middle of the night and stated that the pain was constant and not exacerbated by certain movements. These complaints that the patient made with no decrease in her pain level, constant pain not based on mechanical movements, disturbed sleep and acute diaphoresis during sleep are red flags that warrant the patient to be referred out to an MD who can do further testing. This physical therapist did not refer the patient out. Instead, he continued to treat her and changed the treatment plan around to include other modalities. After 10 additional visits, the patient called the physical therapist. She explained to him that she had intense searing pain in her buttock and she could not walk and that her husband was taking her to the emergency room. During her emergency room visit, it was found via imaging that the patient had a large malignant tumor on her pelvis which caused a pathological fracture to her left acetabulum.

The physical therapist had an ethical duty to refer this patient out to a medical doctor so she could have been properly diagnosed when these red flags appeared during therapy. The physical therapist deviated from the standard of care and did not appropriately refer this patient out to get diagnosed in a timely manner.