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BU T T E R W O R T H

HE I N E M A N N

An Imprint of Elsevier

The Curtis Center

Independence Square West
Philadelphia, Pennsylvania 19106

CLINICAL CASES IN PHYSICAL THERAPY, 2ND EDITION 0-7506-7394-X

Copyright © 2004, Elsevier Science (USA). All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, recording, or any information storage and retrieval
system, without permission in writing from the publisher. Permissions may be sought directly from
Elsevier’s Health Sciences Rights Department in Philadelphia, PA, USA: phone: (+1) 215 238 7869,
fax: (+1) 215 238 2239, e-mail: healthpermissions@elsevier.com. You may also complete your request
on-line via the Elsevier Science homepage (http://www.elsevier.com), by selecting ‘Customer Support’
and then ‘Obtaining Permissions’.

NOTICE

Physical therapy is an ever-changing field. Standard safety precautions must be followed, but as
new research and clinical experience broaden our knowledge, changes in treatment and drug
therapy may become necessary or appropriate. Readers are advised to check the most current
product information provided by the manufacturer of each drug to be administered to verify the
recommended dose, the method and duration of administration, and contraindications. It is the
responsibility of the licensed health care provider, relying on experience and knowledge of the
patient, to determine dosages and the best treatment for each individual patient. Neither the publisher
nor the authors assume any liability for any injury and/or damage to persons or property arising
from this publication.

Previous edition copyrighted 1995

International Standard Book Number 0-7506-7394-X

Senior Acquisitions Editor: Marion Waldman

Senior Developmental Editor: Jill Rembetski
Publishing Services Manager: Patricia Tannian
Senior Project Manager: Anne Altepeter
Book Design Manager: Bill Drone

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1
To Leslee, Jeanne, Eric, Christopher, Katie, and Michael,
whose love, patience, and understanding made this
contribution possible
 Contributors

Michael B. Ashley, PT Laurie Brogan, MSPT

Ashley & Kuzma Physical Therapy and Staff Physical Therapist
Photomedicine Sports Injury Treatment Center
Erie, Pennsylvania Scranton, Pennsylvania

Angela M. Baeten, PT Kathleen M. Buccieri, PT, MS, PCS

Consultant Clinical Education Director, Physical Therapy
Abrams, Wisconsin Department
Ithaca College at University of Rochester
Amy Tremback-Ball, MSPT Campus
Assistant Professor, Physical Therapy Rochester, New York
Department
College Misericordia Christopher R. Chelius, Jr., MSPT
Dallas, Pennsylvania Lead Physical Therapist and Center
Coordinator of Clinical Education
Allison T. Behm, MSPT Manatawny Manor Nursing and Rehabilitation
Staff Physical Therapist Center
Mercy Hospital Pottstown, Pennsylvania
Scranton, Pennsylvania
Stacia M. Ciak, MSPT
Marybeth Grant Beuttler, PT, MS Hunlock Creek, Pennsylvania
Assistant Professor, Physical Therapy
Department Jason A. Craig, MCSP, DPhil
University of Scranton Assistant Professor, Physical Therapy
Scranton, Pennsylvania Department
Marymount University (Ballston Campus)
Donna Bowers, PT, MPH, PCS Arlington, Virginia
Instructor, Department of Physical Therapy
& Human Movement Science Kristina A. Dillon, MSPT
Sacred Heart University Binghamton, New York
Fairfield, Connecticut
Carolyn J. Engdahl, MSPT
Nicole A. Boyle, MSPT Mountain Top, Pennsylvania
Binghamton, New York
Andrea Falcone, MSPT
Trista L. Bratlee, MSPT Pediatric Physical Therapist with HFM
Pittston, Pennsylvania BOCES
Johnstown, New York
Mark A. Brimer, PT, PhD
Administrator, Orthopaedics
Holmes Regional Medical Center
Melbourne, Florida

vii
viii Clinical Cases in Physical Therapy

Renee M. Hakim, PT, PhD, NCS Kevin J. Lawrence, PT, MS, OCS
Assistant Professor, Physical Therapy Assistant Professor, Physical Therapy
Department Department
University of Scranton College Misericordia
Scranton, Pennsylvania Dallas, Pennsylvania

Jennifer Holmes, MSPT Holly Leaman, MSPT

Staff Physical Therapist Staff Physical Therapist
Massapequa Pain Management and Maryview Rehabilitation Hospital
Rehabilitation Portsmouth, Virginia
Massapequa, Long Island, New York
Beatriz Lizaso, MSPT
Rett Holmes, MSPT Pembroke Pines, Florida
Senior Staff Physical Therapist
Physical Therapy Plus Mark V. Lombardi, MSPT, MA, ATC
Washington, New Jersey Sports Injury Treatment Center
Scranton, Pennsylvania
Thomas Hudson, MS, PT, PCS
Assistant Professor, Physical Therapy Michelle M. Lusardi, PT, PhD
Department Associate Professor, Department of Physical
Consultant, Gannon University and Erie Therapy and Human Movement Science
Homes for Children and Adults Sacred Heart University
Erie, Pennsylvania Fairfield, Connecticut

Marianne Janssen, PT, EdD, ATC Diane E. Madras, PT, PhD

Director of Clinical Education Assistant Professor, Physical Therapy
Department of Physical Therapy Education Department
Elon University College Misericordia
Elon, North Carolina Dallas, Pennsylvania

Timothy L. Kauffman, PT, PhD Robert Marsico, PT, EdD

Kauffman-Gamber Physical Therapy Adjunct Assistant Professor, Physical Therapy
Lancaster, Pennsylvania Department
Richard Stockton College of New Jersey
Edmund M. Kosmahl, PT, EdD Pomona, New Jersey
Professor, Physical Therapy Department
University of Scranton Colleen Medlin, MSPT
Scranton, Pennsylvania Physical Therapist
HealthSouth Spine Center of Baltimore
Nicholas J Kuharcik, MSPT Baltimore, Maryland
Larksville, Pennsylvania
Keith Meyer, CP
MaryAlice Lachman, MSPT Director, Prosthetic Services
Staff Physical Therapist Keystone Prosthetics and Orthotics Inc.
NovaCare Rehabilitation Clarks Summit, Pennsylvania
Collegeville, Pennsylvania

Amy S. Lambert, MSPT

Lake Ariel, Pennsylvania
 Contributors ix

Gerri M. Misunas, MSPT Steven D. Pheasant, PT, PhD

Staff Physical Therapist Assistant Professor, Physical Therapy
Sports Injury Treatment Center Department
Scranton, Pennsylvania College Misericordia
Dallas, Pennsylvania
Georganne N. Molnar, MSPT
Newport, Pennsylvania Kristen R. Pizzano, MSPT
Exeter, Pennsylvania
Kelley A. Moran, MSPT, DPT, ATC, CSCS
Associate Professor, Physical Therapy Pamela J. Reynolds, PT, EdD
Department Associate Professor, Physical Therapy
College Misericordia Department
Dallas, Pennsylvania Gannon University
Erie, Pennsylvania
Michael Moran, PT, ScD
Professor, Physical Therapy Department Jonathan Sakowski, MSPT
College Misericordia Adjunct Assistant Professor, Physical
Dallas, Pennsylvania Therapy Department
College Misericordia
Kristin E. Murray, MSPT Dallas, Pennsylvania
Pediatric Physical Therapist
Archway Programs Early Intervention John Sanko, PT, EdD
Atco, New Jersey Associate Professor, Physical Therapy
Department
Karen W. Nolan, PT, MS, PCS University of Scranton
Assistant Professor, Physical Therapy Scranton, Pennsylvania
Department
Ithaca College at University of Rochester Dawn M. Schaeffer, MSPT
Campus Perkasie, Pennsylvania
Rochester, New York
Eric Shamus, PT, PhD, CSCS
Patricia O’Shea, MSPT Assistant Professor, College of Osteopathic
Long Valley, New Jersey Medicine
Nova Southeastern University
Maureen Romanow Pascal, PT, MS, NCS Fort Lauderdale, Florida
Assistant Professor, Physical Therapy
Department Jennifer Shamus, PT, PhD, CSCS
College Misericordia Clinical Specialist, Administrator
Dallas, Pennsylvania Healthsouth Sports Medicine
Pembroke Pines, Florida
David Patrick, MSPT, CPO
Director, Orthotic Services Colleen Kimberly Smith, MSPT
Keystone Prosthetics and Orthotics Inc. Saylorsburg, Pennsylvania
Clarks Summit, Pennsylvania
Melissa A. Strohl, MSPT
Lehighton, Pennsylvania
x Clinical Cases in Physical Therapy

Amy L. Szumski, MSPT John Wojnarski, MSPT

Scranton, Pennsylvania Dallas, Pennsylvania

Gary Tomalis, MSPT Loraine D. Zelna, MSRT (R)(MR)(ARRT)

Wilkes-Barre, Pennsylvania Associate Professor/Clinical Coordinator,
Medical Imaging Department
Barbara Reddien Wagner, PT, MHA College Misericordia
Academic Coordinator of Clinical Education Dallas, Pennsylvania
University of Scranton
Scranton, Pennsylvania
 Foreword

With the first edition of Clinical Cases in cation, ethics, as well as many other areas
Physical Therapy, Mark Brimer and Mike related to physical therapist practice.
Moran set the standard for using clinical Hence, the second edition of Clinical Cases
situations to exemplify the best aspects of in Physical Therapy has evolved to demon-
our practice. These cases illustrated how strate how cases reflect the depth and scope
each patient must be approached thought- of our practice. Moreover, these cases are now
fully, and how expert clinical decisions must organized according to the practice patterns
be applied in each patient situation. This text and elements of management established in
likewise “puts a face” on physical therapist the Guide to Physical Therapist Practice,
education and practice. As students and second edition. Rather than turning these
clinicians, we are inundated with facts, con- cases into a fixed template or cookbook, this
cepts, and theories, often to the point that effort to organize and analyze according to
we begin to lose sight of what drew us to this the Guide helps point the way through each
profession in the first place. Descriptions of case in a logical and effective manner. The
clinical cases remind us that we deal with structure and organization of the second edi-
people, and that all our knowledge and skill tion of Clinical Cases in Physical Therapy
must ultimately be used to affect the life and represent an outstanding effort by Brimer
welfare of a single individual. and Moran to unite our profession and pro-
Continuing the tradition established in the vide us with a common language and strategy
first edition, the second edition of Clinical for examining the way we practice.
Cases in Physical Therapy makes excellent As physical therapists, we now recognize
use of cases as a teaching tool. We are again that case reports serve a vital role in our pro-
able to see how experienced clinicians fession. We must be comfortable with the idea
examine, evaluate, and intervene in specific that clinical cases do not just document
situations. To enhance pedagogy, learning unusual patients, but that cases represent the
objectives have been added to the beginning primary way that we communicate and teach
of each case. References to the peer-reviewed one another about the various aspects of our
literature have likewise been included in these practice. Clinical Cases in Physical Therapy,
cases. These references direct readers to addi- 2nd edition, fulfills a vital role in classroom
tional information on each topic and under- and clinical settings because it offers a com-
score the need to draw upon the growing body pendium of knowledge about our profession.
of knowledge that provides evidence for our It is rare that a single text can be applicable
decisions. The second edition also extends to all aspects of a profession as diverse as
the use of case studies to encompass diverse physical therapy, but Brimer and Moran and
aspects of physical therapist practice. We are their contributors offer some genuine pearls
now given insight into how physical therapists of wisdom to every reader. Once again,
might react to situations that do not directly Clinical Cases in Physical Therapy shows
involve patient care, but situations that are us that each patient or clinical situation
nonetheless resolved successfully with skill, requires our thoughtful and skilled approach,
knowledge, and expertise. For example, cases and this idea has been, and always will be,
are used to illustrate how therapists manage the cornerstone of our profession.
issues related to documentation, clinical edu- Charles D. Ciccone, PT, PhD

xi
 Preface

The profession of physical therapy has under- the best patient care outcome. This includes
gone significant growth and development encouraging the reader to evaluate the effi-
since the first edition of Clinical Cases in cacy of intervention provided and determine
Physical Therapy was published almost if it aligns with the clinical and functional
10 years ago. Since then, the profession has goals presented.
made great strides in developing and imple- To provide a methodology for analysis and
menting the Guide to Physical Therapist learning, a matrix has been included at the
Practice, 2nd edition, the foundation for end of the text. The matrix contains group-
describing and implementing physical therapy ings under which specific practice patterns
clinical practice. The goal of this text is to can be examined. As the reader will note, the
build upon the concepts presented in the cases are also ordered by level of complexity
Guide to Physical Therapist Practice, 2nd to allow progression of learning opportu-
edition, and provide real-life examples of nities. Additionally, several cases have the
how therapists can use the Guide for patient distinction of being included in more than
care opportunities. one practice pattern, thereby reflecting the
Each case in Clinical Cases in Physical complexity of actual patient care oppor-
Therapy, 2nd edition, begins with learning tunities frequently encountered in the clinical
objectives designed to assist the reader in setting.
examining the multiple intricacies of clinical More than anything else, Clinical Cases
practice. Similar to the Guide, Clinical Cases in Physical Therapy, 2nd edition, furthers
in Physical Therapy, 2nd edition, focuses understanding of the complex role the pro-
upon enhancement of quality of care, promo- fession has in assimilating all patient care
tion of appropriate utilization of services, information with skill, knowledge, and
recognition of variations in clinical practice, expertise. The cases have been designed to
the importance of sound documentation, and provide a conceptual framework for under-
the value of professional ethics. Throughout standing how practice patterns can be used
each case the reader is provided with ques- to enhance the delivery of quality health care
tions designed to stimulate further investiga- services.
tion and enhance clinical decision making. Mark A. Brimer
Patient care outcomes are provided for most Michael L. Moran
cases. The outcomes serve to demonstrate
how patient care issues were brought to The Preferred Physical Therapist Practice
closure. Peer-reviewed and other references PatternsSM are copyright 2003 American
Physical Therapy Association and are taken
are provided at the end of each case.
from the Guide to Physical Therapist Prac-
Cases have been carefully organized tice (Guide to Physical Therapist Practice, ed 2,
according to practice patterns and elements Phys Ther 81:1, 2001), with the permission of
of care management. Attention was given to the American Physical Therapy Association.
avoiding a “cookie-cutter” case presentation All rights reserved. Preferred Physical Thera-
so that variations of clinical analysis and pist Practice PatternsSM is a trademark of the
approaches can be used by the reader to find American Physical Therapy Association.

xiii
 Acknowledgments

In any complex endeavor, many individuals thanks go to Chuck Ciccone for his support
lend varying forms of assistance. We thank over the years and for writing the foreword
all of them. We would like to specifically thank to both editions. Finally, we gratefully thank
the library staff at College Misericordia for Katie Moran for her sense of humor and
their tireless and good-natured help. Also, our editorial skills.

xv
 Case 1
LEARNING OBJECTIVES
The reader will be able to:
1. Describe how the physical therapy examination process is important in
establishing patient-centered goals and outcomes.
2. Identify how deficiencies in documentation can affect communication
and result in inefficient care.

The reader should know that the patient was expect such information as the patient’s level
entering his fifth week of physical therapy of education, history of therapy intervention,
intervention when he was added to the caseload. living environment (e.g., devices, environ-
mental barriers), medical history, and func-
tional status/activity level. It would also be
Examination reasonable to expect data on communication
HISTORY ability as well as on cardiovascular/pulmonary,
The patient was a 94-year-old male who lived musculoskeletal, and neuromuscular systems.
independently at home before sustaining a Tests and measures might provide baseline
fall that resulted in a displaced C-1 fracture. data in such areas as cognition, pain ratings,
The initial physician’s order was for “PT eval range of motion (especially the left knee),
and treat per plan of care.” The patient was strength, positioning, bed mobility, endurance,
retired, and his son was the primary contact. transfers, balance, and gait.
The physician documented that a cervical
collar was in place, that the patient reported
persistent neck and left knee pain, and that The Initial Examination
the patient had full use of all extremities.
Knee crepitus was recorded and documented
Documentation
as osteoarthritis. Medications included The following was a summary of the docu-
Procardia, Relafen, Darvocet, and Hytrin. mentation provided in the medical record by
Librium (25 mg t.i.d.) was discontinued. the examining physical therapist:
Nursing reported patient complaints of neck The patient was a 94-year-old male who
pain and noncompliance with the cervical lived alone in a two-bedroom home. He was
collar. The assistance of two persons was using a cane for ambulation when his left knee
needed to transfer the patient to a bedside buckled and he fell. He was found injured by
chair, and the patient’s tolerance for sitting his county home health aide. The patient was
was 10 minutes. diagnosed with a displaced fracture of C-1.
A cervical collar was in place. He exhibited
Based on the medical record review of functional mobility of all extremities except
admission information, what data might be that bilateral shoulder joint flexion and abduc-
expected in the physical therapy documen- tion was limited to 100 degrees and his left
tation after further history review, the knee lacked 15 degrees of extension. He exhib-
systems review, and the tests and measures ited fair left quad strength within his active
portion of the examination are completed? range. General strength was fair to good. He
transferred from bed to chair with a flexed
The Guide to Physical Therapist Practice posture and with moderate assistance of one.
(p. 42)1 defines patient history as “from both Goals: Short-term—
the past and the present.” Therefore, one can 1. Minimally assisted transfers.

1
2 Clinical Cases in Physical Therapy

2. Independent ambulation with assistive History information could be obtained by

device to be determined. interviewing the patient unless cognition
Goals: Long-term—(blank) was a problem, in which case the responsible
Rehabilitation potential—(blank) family member could be contacted. Baseline
Plan of care: 5×/week for gait training, examination data are needed to establish
general strengthening, transfer training, measurable goals.2
and left knee rehabilitation. According to Randall and McEwen,3 to
identify functional goals, it is helpful to
understand the patient’s activities as well as
Discussion of the Initial where they occur, and to establish goals that
correspond to the patient’s desired outcome.
Examination Findings In this case, the documentation does not sup-
The examining therapist did not address all port the development of functional goals that
of the expected examination areas. Some help- are specific to the patient’s needs.
ful information, such as that the patient used
a cane and lived in a two-bedroom home, was
obtained. However, many questions were Further Screening Before
unasked, including whether there were any
environmental barriers, why home health care
Intervention
was received, and what the patient’s prior The most recent physical therapy progress
functional level was. report indicated that the patient complained
The systems review portion of the examina- of headaches, received therapy b.i.d. 5×/
tion lacked baseline cardiovascular/pulmonary week, and improved ambulation with a
system data and provided only minimal walker from 20 feet × 2 with standby assis-
musculoskeletal system data pertaining to tance to 100 to 120 feet with contact guard
range-of-motion measurements and strength assistance. Transfers required minimal assis-
grades. The patient’s tolerance for activity tance for sit to stand with verbal cues to
was only minimally defined, and there was move forward in the chair and for walker
no documentation of pain or positioning. placement. No goals or contraindications to
Transfers were briefly addressed; however, treatment were described. The therapist indi-
gait and bed mobility were not assessed. It cated that the patient could return home
would be reasonable to expect such data or with support if pain decreased.
an explanation as to why they were not The physical therapy progress report lacked
obtained. a clear indication of patient management and
Despite the limited examination data avail- what skilled intervention was provided.
able, the therapist established two goals. The Nursing interviews revealed concerns regard-
ambulation goal presented appears to be a ing nutritional intake and social isolation.
long-term goal, not a short-term goal, and lacks
validity because baseline data are lacking. The Based on the available information, does
transfer goal lacks a time frame for achieve- the patient demonstrate the potential to
ment. All goals should be measurable, be func- return home independently, or is extended
tional, and have an achievement date. Use care a realistic expectation? How might one
of the Guide to Physical Therapist Practice1 proceed with care for this patient and why?
would be helpful to identify preferred prac-
tice patterns and aid in the organization of In this case, the therapist recognized a
documentation. reexamination was warranted as data were
lacking and the patient’s goals were unde-
What other information would be helpful for fined. Areas previously not addressed in
establishing goals and outcomes? And how the physical therapy documentation were
might the information be obtained? explored, and the patient, along with his
 Case 1 3

representative, helped formulate the criteria lack of involvement in establishing goals and
for his return to home. After reexamination, a limited understanding of the patient’s total
the patient demonstrated a renewed interest needs may have delayed the patient’s return
in the quality of his performance. He achieved to home and hindered the transition of care
his goals within 3 weeks and returned home to another therapist.
with supportive services.
REFERENCES
Summary 1. American Physical Therapy Association: Guide
The relationship between the therapist and to physical therapist practice, second edition,
patient is important to achieving successful Phys Ther 81:1, 2001.
2. Baeten AM, Moran ML, Phillippi LM: Document-
outcomes. Effective documentation will aid
ing physical therapy: the reviewer perspective.
the exchange of information and delivery of Boston: Butterworth-Heinemann, 1999, p 14.
efficient care. Baker et al4 found that thera- 3. Randall KE, McEwen IR: Writing patient-
pists seek to involve their patients in estab- centered functional goals, Phys Ther 80:1199,
lishing goals and determining outcomes, but 2000.
do not maximize the existing potential for 4. Baker SM, Marshak HH, Rice GT, Zimmerman
this involvement. This finding would seem GJ: Patient participation in physical therapy
true in this case study, because the patient’s goal setting, Phys Ther 81:1126, 2001.
 Case 2
LEARNING OBJECTIVES
The reader will be able to:
1. Describe how to manage a physical therapy referral with an
inappropriate diagnosis.
2. Describe how to utilize a home exercise program with a patient with
limited physical therapy visits.
3. Identify the symptoms of coccygodynia.

The reader should know that a 34-year-old strength of the muscles of pelvic floor.1 Manual
woman whose medical diagnosis was low back muscle testing of the hip complex was normal.
pain was referred for outpatient physical
therapy.
Evaluation
At the time of referral, a physician had diag-
Examination nosed the patient with low back pain and
HISTORY recommended moist heat and ultrasound
On interview, the patient reported symptoms therapy to the lumbar and sacral spine and
including pain in the coccyx area that lumbar stabilization exercises. On physical
increased after sitting for a prolonged period therapy examination, signs and symptoms
and then arising. She also reported pain in were consistent with coccygodynia (painful
the buttocks and sacroiliac joint areas. The coccyx), which in this case resulted from
symptoms began after she gave birth to twins injury to the coccyx area from the passage of
vaginally 4 months earlier. She initially sought the fetuses through the birth canal. Based on
medical treatment 2 months after the birth. these findings, treatment of the lumbar spine
Medical intervention at that point included was not an appropriate intervention.2 The
radiographs of the pelvis that were unremark- physical therapy diagnosis was established
able, a prescription for Vioxx to relieve pain, as muscle spasm.
and a donut pillow for sitting. She continued
to experience symptoms of pain, which made
it difficult to sit to feed her twins.
Diagnosis
Practice Pattern 4D: Impaired Joint Mobility,
Motor Function, Muscle Performance, and
Systems Review Range of Motion Associated With Connective
Vital signs were normal. Tissue Dysfunction.3

How should a physical therapist proceed?

Tests and Measures What are appropriate interventions?
Observation revealed that the patient had a
sitting posture of rounded shoulders, forward
head tilt, and posterior pelvic tilt with most Prognosis (Including Plan
weight-bearing on the coccyx. Palpation
revealed trigger points over the area of the
of Care)
piriformis, gluteus maximus, and levator ani. The therapist recommended that the patient
Intravaginal palpation revealed increased be seen three times a week for 4 weeks. The
resting tone of the levator ani and 5/5 plan of care included soft tissue mobilization

5
6 Clinical Cases in Physical Therapy

to the buttocks and area of piriformis and

friction massage to trigger points in the levator
ani. Biofeedback was incorporated into the
plan to work on decreasing the resting tone
of the levator ani utilizing a rectal electrode.
In addition, postural training was included to
encourage the patient to sit with her weight
on the ischial tuberosities rather than the
coccyx. The therapist recommended that the
patient discontinue using the donut pillow and
instead use a coccyx cutout wedge cushion
when sitting for a prolonged period, such as
when feeding her babies.

Intervention
C O O R D I N AT I O N ,
C O M M U N I C AT I O N ,
A N D D O C U M E N TAT I O N
Unfortunately, the demand of being a mother
to 4-month-old twins limited the patient’s
ability to attend therapy three times a week. F I G U R E 2 - 1 Partner massage of the piriformis
muscle.
The therapist and patient opted for a treat-
ment program of once-weekly visits comple-
mented by a home program. The patient felt the portable biofeedback machine. The patient
that this was practical and agreed to perform adhered to the home exercise program two
the home program two to three times a week. times a week and consistently attended phys-
The physical therapist also recognized the ical therapy treatment sessions for 4 weeks.
need to communicate findings to the patient’s Symptoms of pain resolved, and the patient
physician. The therapist contacted the physi- was able to feed her twins with a 5-minute
cian via telephone and letter and detailed break in between children. The posture of
the findings from the physical therapy exami- rounded shoulders and forward head per-
nation. sisted, so the therapist discharged the patient
with a modified home exercise program to
PAT I E N T / C L I E N T- R E L AT E D include thoracic and cervical posture exer-
INSTRUCTION cises and recommendations for patient and
The therapist recommended a home exercise child positioning during feeding to decrease
program of self- or partner massage to the back strain.
piriformis, stretching of the piriformis, and
friction massage of trigger points in the
levator ani (see Figure 2-1). This was to be
Discussion
followed by a session of biofeedback for the Coccygodynia, or coccydynia, is a disorder
levator ani utilizing a portable biofeedback commonly classified under the diagnosis of
machine with an anal electrode. pelvic pain, but it may be mistakenly diag-
nosed as low back pain or sacroiliac joint
pain, because pain may refer to the sacroiliac
Outcome or lumbar areas.4 Because coccygodynia refers
The patient and her husband attended a treat- to a specific symptom (pain), it can have dif-
ment session together for instruction in self- ferent causes. It commonly results from a fall
and partner massage, as well as home use of onto the buttocks or trauma during child-
 Case 2 7

birth, causing a partial dislocation of a joint priate for this patient, because it takes weight
in the coccyx or overstretching of the liga- off of the coccyx and redistributes weight to
ments and muscles attached to the coccyx.2,5 the thighs while encouraging a more appro-
Muscle spasm and pain in the tissues around priate position of the pelvis.
the coccyx may result. The symptom of pain Stretching became part of the patient’s
increases when sitting for a prolonged period home exercise program to relieve some of
or when making bed or chair transfers. There- the pain and spasm in the piriformis. The
fore, it is important to address the soft tissue piriformis may shorten and develop spasms
injury and resultant impairments in a case during pregnancy because of the altered posi-
such as this. tion of the lower extremity and an altered
Injury to the muscles, ligaments, and con- gait pattern. In this case it was contributing
nective tissue of the pelvis is common during to the patient’s pelvic pain and general
vaginal deliveries as well as during the months increase in tone of the pelvic floor muscles.
leading up to the delivery. Increased ligament
laxity, posture alterations, and increased
REFERENCES
demand on the pelvic floor to support the
viscera may lead to musculoskeletal damage. 1. Wilder E (ed): The gynecological manual,
The changes occurring during pregnancy and Alexandria, VA: American Physical Therapy
delivery must be considered when examining Association, 1997.
2. Sapsford R, Bullock-Saxton J, Markwell S
and evaluating patients in the antenatal and
(eds): Women’s health: a textbook for physio-
postnatal period. therapists, London: WB Saunders, 1998.
Massage, biofeedback, and postural train- 3. American Physical Therapy Association: Guide
ing were the treatments of choice for this to physical therapist practice, second edition,
patient to decrease muscle spasm in the piri- Phys Ther 81:1, 2001.
formis, levator ani, and gluteus maximus. The 4. Stephenson RG, O’Connor LJ: Obstetric and
donut pillow may have been exacerbating the gynecologic care in physical therapy (ed 2),
patient’s symptoms by distributing weight onto Thorofare, NJ: Slack, 2000.
the coccyx and promoting a posterior pelvic 5. Hall CM, Brody LT: Therapeutic exercise:
tilt while sitting. A wedge-shaped cushion with moving toward function, Philadelphia:
a coccyx cutout would be much more appro- Lippincott Williams & Wilkins, 1999.
 Case 3
LEARNING OBJECTIVES
The reader will be able to:
1. Identify the roles of the academician, clinician, and student in dealing
with difficult issues in clinical education.
2. Develop a rationale for facilitating active student participation in the
design of a remediation plan for clinical education.

The reader should know that a 22-year-old Did the student have any issues on previous
student in the final year of an entry-level affiliations? What were the concerns that
5-year Master of Science in Physical Therapy led to removal?
program was asked to leave the fourth
affiliation 4 weeks into a 6-week experience due This student had demonstrated acceptable
to patient safety concerns. Visual analog scale academic and laboratory performance on
markings and clinical instructor comments examination in individual courses in the pro-
scored the student below established grading gram. Faculty evaluation determined accept-
criteria for this level affiliation on the Clinical able readiness3 for clinical education based on
Performance Instrument (CPI).1 Primary areas completed coursework. The clinical instruc-
of deficiency were safety, professional behavior, tors evaluated clinical performance and iden-
professional demeanor, and communication tified problems in the student’s development
criteria. The student actively worked with the of appropriate professional communication
academic Director of Clinical Education (DCE) skills and demeanor on the second and third
to design and participate in a remedial plan. clinical affiliations. After each of these affili-
After completing the scheduled remediation ations, the faculty diagnosed the student’s
activities, the student returned to clinical needs and designed and directed interven-
education and successfully completed the tions in the form of remedial plans that
remaining two 6-week affiliations with entry- the student completed. Despite remediation,
level scores on the visual analog scale and similar concerns were raised with reexami-
positive comments from the clinical instructors nation of performance on subsequent clinical
on safety, professionalism, and communication education experiences.
criteria. During the fourth clinical education affil-
This case is discussed within the framework iation, the faculty planned an early site visit
of the Guide to Physical Therapist Practice 2 to examine the student’s performance. Issues
elements of patient/client management. The identified by the Clinical Instructor (CI) and
student’s ability to function as a competent Center Coordinator of Clinical Education
physical therapy practitioner is the desired (CCCE) during the visit were consistent with
outcome. The elements of the model are applied previously identified issues of communication
as follows: The student’s clinical performance on and professionalism. Studies 4,5 have revealed
affiliation is “examined,” competence is that behavior in these areas can be indicative
“evaluated,” causes of deficient performance are of success or failure in clinical education.
“diagnosed,” the student’s optimal level of The academic and clinical faculty discussed
function and the time needed to achieve that the need for change with the student and
level are “prognosed,” activities to promote emphasized the importance of these skills
improved performance are designed in providing effective patient care. After the
(intervention), clinical performance is faculty visit, the student’s performance
“reexamined,” and “outcomes” are discussed. deteriorated. A learning contract was imple-

9
10 Clinical Cases in Physical Therapy

mented with CI, CCCE, and DCE input to responsibility for performance and identify
clarify the level of performance that the how to improve it. This could be equated to
student needed to achieve. As examined by the diagnosis and prognosis elements of the
the clinical faculty, the student’s performance patient/client management model in the
continued to deteriorate. Five documented Guide to Physical Therapist Practice.2 The
safety incidents occurred in a 2-day period. student was asked to diagnose the cause
These incidents included failure to ascertain of deficient performance and prognose the
a weight-bearing status and proceeding with ability to be a competent physical therapist.
intervention without first reviewing medical The DCE’s role involved facilitation and
imaging reports. coordination. With time and coaching to
The site evaluated the situation and asked express individual needs, the student was
that the student be removed from the affil- able to identify areas to remediate. The DCE
iation. The student expressed an inability to and the student worked together to design a
perform and an awareness that skills were written plan to address needs (plan of care)
not improving. The academic program con- with specific activities (interventions) that
curred with the site that, given the identified included a time frame for completion (prog-
problems, this student was not safe and nosis). The DCE monitored the student’s
needed to be removed. progress (reexamination) toward fulfilling
these activities. Together, the DCE and the
Given the above-described situation, the student agreed that successful completion of
student could choose to attempt another the interventions would indicate a readiness
affiliation immediately, to remediate to participate in another affiliation.
pertinent issues and then participate in
another affil-iation, or to take some time off What specific interventions could be
and resume study next year. Which of these included to address the areas of deficient
alternatives was chosen? Why? clinical performance?

The clinical instructor provided the academic The student was able to articulate an inability
program with a “final” CPI report and copies to adopt professional behaviors and use
of the safety incident reports (evaluation). them in the clinic (evaluation). After reflect-
These reports contained specific examples ing on performance, the student realized a
of performance areas that were not accept- desire to “be everyone’s friend” and “do what
able. The student went home and was asked the CI wanted.” The student became aware
to take some time to reflect on clinical of personal actions that were an attempt to
performance, examine specific situations, mold behavior to fit what was learned in
and evaluate reasons for the poor perfor- school and what was perceived as being
mance. Based on established grading criteria, desired by the clinic. However, there was a
the CPI’s comments, and input from the CI lack of depth and a lack of what the student
and CCCE, the DCE evaluated the data and termed the necessary “thought processes”
assigned a “fail” grade for this pass/fail for the student to become a competent
course. Options were discussed, and the physical therapist (diagnosis). The student
student expressed a clear desire to become a expressed a desire to succeed and a moti-
competent physical therapist and apply vation to modify performance (prognosis).
effort to remediate the pertinent issues in a When asked to identify ways in which
timely manner. growth might occur in this area, the student
The DCE’s evaluation of the data revealed outlined a remediation plan (intervention)
that similar issues were increasing in inten- that included the following actions:
sity despite faculty-directed attempts to 1. Perform clinical observation of a practic-
improve the student’s performance. It was ing physical therapist. The student felt that
decided that the student needed to take volunteering in a physical therapy clinic
 Case 3 11

would allow observation of profession- ting hypothetical treatment sessions. The

alism, communication, and documentation student also agreed to complete a “check-
without the pressure to perform. This out” of mobility skills with a faculty mem-
would help the student identify specific ber, demonstrating skill competency and
behaviors that professionalism entails. safety in transfers, bed mobility, and gait
The student felt that 4 weeks of observa- training. Modification of interventions and
tion could provide the knowledge needed discussion of rationales for treatment
to develop appropriate “thought processes” based on changing patient scenarios would
(a term that the student used repeatedly be included.
when describing the evaluation of perfor- 5. Set clear, measurable objectives for the
mance deficits). next clinical experience. The student set
2. Read a textbook on professional commu- goals for the volunteer observation and for
nications. Based on knowledge of avail- the repeat clinical education experience.
able resources that matched the student’s
needs, the DCE proposed suggested read- What are potential outcomes demonstrating
ings to the student. After reviewing several student competency?
options, Health Professional and Patient
Interaction6 was selected. The student The student completed the remedial plan
was to read this text and incorporate the within the established time frame. The DCE
knowledge gained into the development of examined the student’s content for accuracy
personal thought processes needed to be and development (reexamination) and deter-
a physical therapist. mined the student’s apparent readiness to
3. Perform self-assessment and implement return to the clinic. A repeat affiliation was
the knowledge gained. The student and scheduled at a site that (as requested by the
DCE agreed that there were lessons to be student) was fully aware of the student’s
learned from the failed affiliation. The specific needs. The CI examined the student’s
student needed to identify behaviors that performance and evaluated his competency
had caused problems, articulate what could during the affiliation. At midterm and final
have prevented issues from occurring and CPI assessments, the CI discerned appropriate
discuss how to behave more competently. safety, professionalism, and communication
The student would define in writing 7 the performance. The DCE reexamined this per-
“thought processes” that were needed, formance in the context of previously iden-
identify and group criteria from the CPI and tified issues and awarded a grade of “pass”
the objectives for clinical education under for the affiliation. The student then progressed
each process, and write clinical actions to the fifth and final affiliation with full dis-
that would enhance effectiveness. Student closure to the CI as to the competency areas
reflection on personal professional develop- being emphasized. The student actively sought
ment8 combined with this activity led the feedback from the clinician in specific situa-
student to outline concrete steps that would tions and diligently modified his performance
be used to advance professionalism. to improve competency. At completion of the
4. Provide practical application of the knowl- final affiliation, the student earned positive
edge gained. The student expressed a comments and entry-level performance on
desire to practice new skills before return- all criteria of the CPI. The student went on to
ing to a formal clinical education experi- successfully pass the state licensing boards
ence. Working together, the student and and secure full-time employment as a physical
DCE decided that paper cases and a prac- therapist. In a follow-up interview, the student
tical skill check would be valuable. Paper concluded that taking responsibility for iden-
cases were designed to give the student tifying needs and designing the remediation
practice in designing appropriate interven- activities were effective in altering perform-
tions, setting realistic goals, and documen- ance as a clinician and achieving competency.
12 Clinical Cases in Physical Therapy

REFERENCES 5. Gutman SA, McCreedy P, Heisler P: Student

1. American Physical Therapy Association: Phys- level II fieldwork failure: strategies for inter-
ical therapy clinical performance instruments. vention, Am J Occup Ther 52:143, 1998.
Alexandria, VA: American Physical Therapy 6. Purtilo R, Haddad A: Health professional and
Association, 1998. patient interaction (ed 5), Philadelphia, PA:
2. American Physical Therapy Association: Guide WB Saunders, 1996.
to physical therapist practice, second edition, 7. Hobson E: Encouraging self-assessment writing
Phys Ther 81:1, 2001. as active learning. In Sutherland TE, Bonwell
3. Watson CJ, Barnes CA, Williamson JW: Deter- CC (eds): Using active learning in college
minants of clinical performance in a physical classes: a range of options for faculty, San
therapy program, J Allied Health 29:150, 2000. Francisco: Jossey-Bass, 1996, 45.
4. Hayes K, Huber G, Rogers J, Sanders B: Behav- 8. May WW, Morgan BJ, Lemke JC, Karst GM,
iors that cause clinical instructors to question Stone HL: Model for ability-based assessment
the clinical competence of physical therapist in physical therapy education, J Phys Ther Ed
students, Phys Ther 79:653, 1999. 9:3, 1995.
 Case 4
LEARNING OBJECTIVES
The reader will be able to:
1. Identify characteristics in this case that made an intense home exercise
program appropriate.
2. Discuss the benefits of providing therapy in the home environment.

The reader should know that an outpatient power chair for mobility in the community
physical therapist was seeing a 14-year-old and at school. The patient also had a history
female diagnosed with spastic cerebral palsy of asthma and seizures, which were con-
(CP). The patient was being seen once a month trolled with Albuterol p.r.n. and Tegretol.
for 30 minutes. The outpatient physical The patient lives in a single-parent family
therapist was frustrated with a lack of with three younger siblings. The patient’s
improvement/ progress in the patient’s mother is employed and works the second
ambulation. The patient was also being treated shift, and so is unavailable after school to
by a physical therapist at her school, who was assist the patient. In addition, the three
seeing her once a week for 30 minutes. younger siblings interfere with the patient’s
Communication between the two therapists ambulation at home and constitute a poten-
suggested that the patient’s progress in all areas tial safety hazard for ambulation.
of functioning had plateaued over the last year.
The patient, a high school freshman, would like What baseline data were necessary?
to attend her first high school social (a dance)
in approximately 4 weeks. The patient requested SYSTEMS REVIEW/TESTS
that the therapist assist her with improving her AND MEASURES
walking so that she could walk into her first The patient was initially ambulating with large
social at school. The patient and her mother also base quad cane for 10 feet on carpeted sur-
voiced a goal to increase the patient’s ability to faces with minimum to moderate assistance.
ambulate safely within her house. She was ambulating exclusively into/out of
the bathroom and with therapy at school (once
per week). She used a power wheelchair for
Examination the remainder of the day for mobility.
HISTORY Cardiovascular system. Initially, the
The patient was the sole survivor of a twin patient demonstrated a high oxygen saturation
pregnancy, delivered secondary to fetal dis- level (95% to 97%) before, during, and 1 minute
tress at 28 weeks’ gestation via cesarean after ambulating 10 feet. Immediately after
section. She spent 4 months in the neonatal ambulation, the patient demonstrated an
intensive care unit, with history of ventilation, increased breathing rate and breathing effort,
bronchial pulmonary dysplasia, intercranial with a recovery time of 2 to 3 minutes. Her
bleeding (grade IV), and severe feeding prob- heart rate increased from 89 beats per minute
lems. The patient was diagnosed with spastic (bpm) before walking to 167 bpm immedi-
diplegic CP with left hemiplegia by age 3 years. ately after ambulating 10 feet.
She underwent a dorsal rhizotomy at age 6 Musculoskeletal system. The patient
and right hip reconstruction at age 13. Before wore bilateral single-axis molded ankle foot
the right hip reconstruction surgery, the orthoses (AFOs) for medial/lateral instability
patient was a community ambulator with one at her ankle. Range-of-motion (ROM) measure-
forearm crutch; after the surgery, she used a ments were assessed with a goniometer.

13
14 Clinical Cases in Physical Therapy

TA B L E 4 - 1
GONIOMETRIC RANGE OF MOTION MEASURES
PREINTERVENTION POSTINTERVENTION
RANGE OF MOTION LEFT RIGHT LEFT RIGHT

Hip flexion 19° to 131° 24° to 133° 18° to 138° 28° to 142°
Hip extension –19° –24° –18° –24°
Hip abduction 0° to 35° 0° to 17° 0° to 38° 0° to 16°
Hip adduction 0° to 10° 0° to 7° 0° to 10° 0° to 8°
Knee flexion 26° to 110° 17° to 112° 19° to 121° 12° to 131°
Knee extension –26° –17° –19° –12°
Ankle dorsiflexion 0° to 3° 0° to 1° 0° to 6° 0° to 5°
Ankle plantarflexion 0° to 46° 0° to 49° 0° to 46° 0° to 50°

Generally, ROM measurements were limited –23 degrees and maximum hip flexion of
throughout both lower extremities, especially 33 degrees, a maximum knee valgus flexion
at the ends of ROM in most directions. How- of 75 degrees, and a maximum ankle flexion
ever, ROM was not felt to be limiting func- of 62 degrees of eversion and 43 degrees of
tion. Specific pretest ROM data are given in inversion.
Table 4-1. Muscle strength was assessed with The BERG Balance Scale1 was used to
a dynamometer (Nicholas Manual Muscle evaluate initial functional balance skill. The
Tester; Lafayette Instrument Company, North patient’s BERG score was initially 23/56. The
Lafayette, Indiana); pretest values are listed patient did well with sitting items, had prob-
in Table 4-2. Strength was measured three lems with standing items, and was unable to
times, and these measures were averaged. perform single-leg stance activities.
Generally, strength was significantly decreased, Behavioral assessment. The Activity-
with the right lower extremity weaker than Specific Balance Confidence (ABC) Scale2
the left lower extremity. was modified to fit the patient and used to
Neuromuscular system. A pedograph measure her confidence in her ability to
(footprint analysis) and stop-watch were function in her environment. Results of the
used to assess velocity of gait, cadence, initial ABC are reported in Table 4-4.
stride length, right and left step length, and
base of support. The stride length, step What were the primary factors limiting the
length, and base of support values reflect the patient’s ambulation?
average of three steps taken with each leg.
The results of this testing are given in Table
4-3. Generally, cadence and velocity were
Evaluation
greatly reduced, with step length shorter in After the examination and discussion with the
the right lower extremity and a large base of patient and her mother, the therapist deter-
support. mined that the major limitations to returning
In addition to the pedograph, active to household and limited community ambu-
infrared markers were placed on the patient’s lation were:
right lower extremity, and a motion analysis 1. Decreased endurance
system (CODAmpx30; Charnwood Dynamics 2. Decreased strength
Limited, Leicestershire, U.K.) was used to 3. Lack of opportunity to safely practice
determine joint angles in the right lower 4. Decreased confidence
extremity during gait. Initially, the patient 5. Lack of a home exercise/ambulation
demonstrated a maximum hip extension of program.
 Case 4 15

TA B L E 4 - 2
DYNAMOMETER MEASURES IN N
IMMEDIATELY 2 WEEKS 4 WEEKS
PREINTERVENTION POSTINTERVENTION POSTINTERVENTION POSTINTERVENTION
STRENGTH (N) LEFT RIGHT LEFT RIGHT LEFT RIGHT LEFT RIGHT

Hip flexion 4.01 1.89 3.41 2.02 6.60 3.73 8.97 6.37
Hip extension 1.41 .53 1.11 .37 2.70 2.13 4.97 3.00
Hip abduction 1.74 .50 2.23 1.79 4.47 3.87 5.80 5.20
Hip adduction 3.94 3.86 5.59 4.68 10.00 9.80 9.90 8.23
Knee extension 1.23 2.52 2.41 2.58 4.43 4.10 4.37 6.20

TA B L E 4 - 3
P E D O G R A P H D ATA
STEP
STRIDE BASE OF
LENGTH (CM)
VELOCITY CADENCE LENGTH SUPPORT
PEDOGRAPH DATA (M/MIN) (STEPS/MIN) (CM) LEFT RIGHT (CM)

Preintervention 15.47 21.46 61.47 41.63 20.42 20.02

Immediately 25.83 22.95 76.78 56.03 21.34 24.23
postintervention
2 weeks 22.09 26.46 72.24 44.60 27.15 23.19
postintervention
4 weeks 26.78 25.66 73.56 52.76 28.23 23.02
postintervention
Normal range Variable 90–120 70–82 35–41 35–41 5–10

What research-based evidence could be

Diagnosis used to develop a plan of care?
Practice Pattern 5C: Impaired Motor Function
and Sensory Integrity Associated with Non- Based on research by Bower et al,3 the ther-
progressive Disorders of the Central Nervous apist planned a short period of intense inter-
System—Congenital Origin or Acquired in vention to promote functional gains in this
Infancy or Childhood.6 patient. She was seen in her home five times
during week 1, three times during week 2, two
times during week 3, and one time during week
Prognosis (including plan 4. The patient was contacted daily, either with
a home visit or via telephone. A home exercise
of care) program was developed to improve the func-
After the examination, the therapist concluded tional and impairment-level problems asso-
that this 14-year-old girl was capable of ciated with ambulation. The patient was given
increasing her ability to ambulate in her an easy-to-read chart with check-off boxes for
home and at school and to ambulate into her each part of the exercise program to help her
first high school social in 4 weeks secondary keep a written record of her progress for the
to high motivation and availability of an month-long intense intervention program.
intense home therapy program over the next Additional check-off charts were provided each
4 weeks. month after the intense intervention phase.
16 Clinical Cases in Physical Therapy

TA B L E 4 - 4
R E S U LT S O F A B C A S S E S S M E N T B O T H P R E A N D P O S T I N T E R V E N T I O N
How confident are you that you will not lose your balance or become Pretest Posttest
unsteady when you …
Walk around the house? 25% 60%
Bend over and pick up an object from the floor? 0% 0%
Reach for a video off a shelf at eye level? 0% 25%
Walk from the front door of your house to a car parked in the driveway? 35% 40%
Get into or out of a car? 60% 75%
Walk in a crowded place where people may bump into you? 0% 10%
Walk outside on the grass or in your yard? 0% 80%

M U S C U L O S K E L E TA L S Y S T E M
Intervention No significant changes in ROM were noted
The patient was seen in her home for a immediately postintervention (see Table 4-1).
program of walking inside and outside of the No changes in ROM were expected, because
house. The home program included pedaling the original ROM was sufficient to allow the
on a foot bike; work on weight shifting in patient to ambulate and this was not a major
standing and functional reaching; stretching focus of the home exercise program. ROM
of hamstrings, hip flexors, and knee exten- was not remeasured at the 2-week and 4-
sors; and strengthening exercises for hip week postintervention follow-ups.
flexion, abduction, and adduction and knee Strength measurement demonstrated an
extension. The home program was designed improvement immediately postintervention;
to take 15 to 20 minutes each day, based on however, these improvements continued and
the work of Schreiber et al.4 In this inter- even increased over the subsequent 4 weeks.
vention, involvement of family members was Changes in strength were found in all muscles
limited due to the mother’s work schedule assessed 4 weeks postintervention.
and the siblings’ young age. Reassessment
was planned for immediately after comple- NEUROMUSCULAR SYSTEM
tion of the intense intervention phase, and Pedograph data demonstrated an increase in
then 2 weeks and 4 weeks postintervention. ambulation velocity, cadence, stride length,
and step length (see Table 4-3). A small increase
in base of support was also demonstrated, but
Reexamination this was thought to be the result of improved
C A R D I OVA S C U L A R S Y S T E M symmetry in the lower extremity (i.e., de-
The patient’s oxygen saturation levels con- creased valgus in the right lower extremity).
tinued to remain above 95% throughout (Normal values are based on those listed in
periods of ambulation. Immediately after Magee’s Orthopedic Physical Assessment.5)
ambulation, the patient demonstrated no Changes in gait were also observed in the
increased breathing rate or increased breath- joints of the right lower extremity during
ing effort, and no recovery time was needed. ambulation. Based on the CODA movement
Heart rate was now 82 to 86 bpm before analysis system, the hip maximum range
ambulating and 91 to 100 bpm after ambu- increased to 42 degrees of flexion and –18
lating for 50 feet. These cardiovascular degrees of extension, maximum knee valgus
improvements, seen immediately postinter- decreased to 45 degrees, and maximum ankle
vention, were maintained the 2-week and motion decreased to 54 degrees of eversion
4-week postintervention reassessments. and 1 degree of inversion.
 Case 4 17

The patient’s Berg balance scale score also she was about the improvements that she
increased, to 33/56 immediately postinterven- had made. The patient was given charts to
tion and then to 35/56 at 4 weeks postinter- continue her home exercise program, and
vention. Specifically, improvements were her outpatient therapist continued to follow
observed in the following areas: standing her program and update it as needed.
unsupported, performing transfers, standing
with feet together, reaching forward with
outstretched arms, retrieving an object from
Discussion
the floor, turning to look behind, and turning A home exercise program as an adjunct to
360 degrees. physical therapy intervention is important to
By the end of the first week of interven- optimize functional gains within the natural
tion in the home, the patient was independ- environment. To be effective, an exercise
ent in performing her home exercise program program must be easy to follow and become
except for needing minimum assistance to part of the daily routine. Ideally, successful
secure her feet on the foot bike. In the programs should involve family members to
second week, during one of the home visits, help motivate and guide the child. In this
the patient reported that “I am walking so case, parental involvement was limited by
much straighter and feel so much better the mother’s employment status, and it was
when I walk.” not appropriate to seek sibling assistance. A
limited intense period of physical therapy
BEHAVIORAL ASSESSMENT allowed this patient to become independent
Reassessment with the modified version of in her home exercise program, gave her an
the ABC scale demonstrated the patient’s ability to function in her natural environ-
increase in confidence in such activities as ment, and positively impacted her social
walking around the house, reaching for her interaction with her peers.
videos off her shelf in her room, walking
from her front door to a car in the driveway,
REFERENCES
getting into or out of a car, walking in a
crowded place where she could be bumped, 1. Berg KO, Wood-Dauphinee SL, Williams JI, et
and walking outside in her own yard (see al: Measuring balance in the elderly: prelimi-
Table 4-4). The ABC test was not readmin- nary development of an instrument, Physiother
Can 41:304, 1998.
istered at the 2-week or 4-week postinterven-
2. Powell LE, Myers AM: The activities-specific
tion assessment. balance confidence (ABC) scale, J Gerontol A
Biol Sci Med Sci 50:28, 1995.
Outcome 3. Bower E, McLennan DL, Arney J, Campbell MJ:
A randomized controlled trial of different
The patient improved her ability to ambulate intensities of physiotherapy and different goal-
in her home and at school (although limited setting procedures in 44 children with cerebral
by staff availability to assist and supervise), palsy, Dev Med Child Neurol 50:28, 1996.
and was able to ambulate into her first high 4. Schreiber JM, Effgen SK, Palisano RJ: Effective-
school social. The patient and her peers and ness of parental collaboration on compliance
family were able to share in her success in with a home program, Pediatr Phys Ther 7:59,
1995.
ambulating 90 feet with a quad cane and
5. Magee DJ: Orthopedic physical assessment,
standby assistance into the dance. The social Philadelphia: WB Saunders, 1997.
support experienced by the patient at this 6. American Physical Therapy Association: Guide
school event made a significant impact on to physical therapist practice, second edition,
her confidence. She stated numerous times Phys Ther 81:1, 2001.
how much stronger she felt and how excited
 Case 5
LEARNING OBJECTIVES
The reader will be able to:
1. Identify the clinical tests necessary to distinguish the various upper
extremity symptoms that a patient with cervical radiculopathy may
experience.
2. Describe the proper position for the body and equipment during regular
office computer use.
3. Discuss the incidence, prognosis, and typical rehabilitation of a patient
with cervical radiculopathy.

Examination Weakness was also noted in the thenar

muscles.
HISTORY
The patient was a 47-year-old single white SYSTEMS REVIEW
female accountant with a chief complaint of Integumentary system. The patient
right upper extremity symptoms of 4 months’ exhibited decreased sensation to pinprick at
duration. Her symptoms began insidiously as the tip of the right thumb. She did not
a tingling and occasionally burning sensa- complain of any recent bruising or contact
tion over the lateral forearm, hands, and discoloration from the time that symptoms
thumbs. She also complained of a tingling in developed.
the right palm, which began 2 months earlier. Musculoskeletal system
She reported that she began dropping things Gross sym-metry. The patient presented
2 weeks earlier, and this caused her to seek with a marked forward head posture and a
medical attention. prominent angle at the cervical-thoracic (CT)
The forearm and thumb symptoms were junction. The upper extremities were inter-
worse at the end of the day, after prolonged nally rotated, with visible tightness of the
sitting or computer use, or after looking up anterior cervical and both upper trapezius
for more than 5 minutes. The tingling in the muscles. There was poor muscle definition
palms awakened her after 1 hour of sleep of the posterior scapular muscles and slight
and commonly occurred after 30 minutes of atrophy of the right thenar muscles.
computer use. Palpation. Palpation of the cervical spine
The patient’s past medical history included at C5-7 on the right elicited tenderness and
a right radial head fracture at age 21 and a reproduction of right forearm symp-
a rear-end auto collision at age 35. She had toms. Accessory movements of the cervical
no ongoing complaints from either of those spine revealed hypomobility at C1-2, espe-
episodes before the onset of the current cially during right rotation. Spinal segments
symptoms. She reported jogging 3 miles per at C3-5 were assessed as hypermobile, those
day. Cervical radiographs showed moderate at C6-7 could not be assessed because of
degenerative changes at C5-6 bilaterally and irritability of the segment, and those at C7-T3
mild changes at C4-5 and C6-7. Magnetic were found to be hypomobile.
resonance imaging showed osteophyte for- There was increased muscle tightness of
mation in the region of the right C5-6 neural the right cervical paravertebral muscles and
foramen, and an electromyelography study parascapular muscles, especially the sterno-
showed mild sensory loss in the right median cleidomastoid, levator scapulae, and scalenes.
nerve distribution and the lateral forearm. There was generalized tightness bilaterally in

19
20 Clinical Cases in Physical Therapy

the flexor muscles of forearms, identified by particular, the cervical symptoms), which
a “ropelike” feeling. should almost always be considered irrita-
Joint range of motion. Cervical flexion ble until proved otherwise. The nature was
was limited by 50% with no reversal of cer- identified as C6 cervical radiculopathy with
vical lordosis. Cervical extension was full, potential secondary carpal tunnel syndrome,
but no motion occurred below the CT junc- caused by the restricted mobility of the right
tion. There was an increase in right forearm elbow and cervical spine secondary to earlier
symptoms with prolonged cervical extension. injuries.
Side flexion to the right was 75% full range
without an increase in symptoms and side
flexion to the left was 50% of full range but
Diagnosis
eased the symptoms. Cervical rotation to the Physical Therapist Practice Pattern 5H:
right was only 40% of full range, limited by Impaired Motor Function, Peripheral Nerve
increased symptoms in the right forearm. Integrity, and Sensory Integrity Associated
Cervical rotation to the left was 80% of normal With Nonprogressive Disorders of the Spinal
range, and the symptoms in the right forearm Cord.
decreased.
Range of motion of the shoulders and the
left elbow was within normal limits. Flexion Prognosis (including plan
of the right elbow was full, extension was –7
degrees, and pronation and supination were
of care)
both 80 degrees. Bilateral extension of the The prognosis for conservative care of the
wrists was measured at 60 degrees with the cervical radiculopathy in this patient was
fingers flexed and 45 degrees with the fingers considered fair to good, because of motor
extended. changes. The prognosis for surgical laminec-
Strength. Weakness was noted in the tomy/fusion was considered good; however,
abductor (3/5) and extensor (4/5) pollicis surgery would not be considered until con-
brevis muscles of the right thumb. No servative management had been attempted.
other weakness was observed bilaterally. The prognosis for conservative management
Cervical motion was limited by the onset of the carpal tunnel syndrome was consid-
of pain and other symptoms, but strength ered good as long as contributing factors
within the available range was within normal were eliminated or managed and if symp-
limits. toms were caught early. The prognosis for
Neurologic system. There was a dimin- surgical release of the carpal tunnel was
ished brachioradialis reflex on the right considered good.
side compared with the left side. Nerve
tension testing utilizing full tension on the SHORT-TERM GOALS
median nerve pathway reproduced all The patient will:
symptoms. 1. Have less pain and tenderness arising from
Special tests. The Adson’s, military, and the neck by the end of the second week of
hyperabduction tests were negative. Phalen’s treatment.
test and Tinel’s sign were noted as positive. 2. Have decreased tingling sensation in the
forearm and hand by the end of the first
From the foregoing information, how were week of treatment.
the severity, irritability and nature of the 3. Increase the available range of motion in
symptoms rated? the cervical region by the end of the fourth
week of treatment.
The patient’s symptoms were considered of 4. Increase strength in the right upper
moderate severity. The irritability was mod- extremity gradually over the course of the
erate because of radicular symptoms (in treatment sessions.
 Case 5 21

LONG-TERM GOALS quadrant (including the upper extremities)

The patient will: alignment, and frequent stretching breaks
1. Regain full range of motion in the cervical during the workday. Exercises for the fore-
region by the end of the eighth week of arm included gentle extrinsic flexor muscle-
treatment. strengthening activities accompanied by
2. Have no lasting altered sensation in the frequent stretching breaks.
right upper extremity 3 months after treat- The patient was also given soft tissue
ment has concluded. mobilization to the right upper quadrant mus-
3. Regain full strength in the right upper cles, especially the scalenes, pectoralis minor,
extremity by the end of the eighth week of sternocleidomastoid, and upper trapezius.
treatment.
4. Develop the knowledge during the first
2 weeks of treatment that will ensure that
Outcome
she avoids situations that will lead to The patient stated that the traction initially
similar symptoms in the future. produced decreased symptoms in the neck
followed by decreased symptoms in the fore-
arm. However, she did report increased symp-
Intervention toms immediately after the traction force was
The patient was given a prescription for a removed. The force was decreased for the
nonsteroidal antiinflammatory drug and subsequent sessions such that the patient felt
referred to physical therapy by her primary symptomatic relief but did not experience
care physician. The physician discussed sur- the posttraction exacerbation. The Maitland
gical intervention with the patient, consisting mobilization techniques produced a reduction
of a decompression laminectomy or a spinal in symptoms in the neck and forearm. The
fusion. Initial treatment of the cervical radicu- patient was very compliant with her home
lopathy began with extensive patient educa- exercise program and took steps at her
tion in sitting posture, computer use with workplace to rearrange her desk and ensure
consideration of both cervical position and proper postural alignment.
hand position, sleeping posture, pillow selec-
tion, avoidance of static positions, and avoid-
ance of the closed-pack position of the right
Reexamination
cervical region. The necessity of attaining The patient was treated three times per week
and maintaining correct posture during work for the first 3 weeks and then two times per
and activities of daily living was reinforced week for the following 3 weeks. The reexami-
throughout the treatment sessions. nation was done 6 weeks after the initial
Cervical traction was used on the first day examination, at which time the patient’s cer-
of treatment, with a very gentle 5 lb of trac- vical spine mobility had improved, with for-
tion applied. Other techniques used to reduce ward flexion now 70% of normal range but
nerve root irritation included Maitland grade still without reversal of the normal lordosis.
I central vertebral pressure techniques directed Cervical extension was full, with some limited
in a posteroanterior direction. These tech- motion at the CT junction. Side flexion to the
niques were applied in 30-second bouts sepa- right was 85% of full range with no increase
rated by 1-minute rest and reevaluation in symptoms, and side flexion to the left was
periods. A total of four bouts were applied. 60% of full range with a slight decrease in
The patient was sent home with a home exer- symptoms. Rotation to the right was 60% of
cise program that included the open-pack normal range with an increase in forearm
position for symptomatic relief, modified symptoms, and rotation to the left was 90%
dorsal glides (McKenzie chin retraction exer- of normal range with an associated decrease
cises) with progression to improved mobility in symptoms. Accessory motion of the cervi-
as tolerated, stretching to correct upper cal spine was normal for the C1-2 segments,
22 Clinical Cases in Physical Therapy

hypermobile for the C3-5 segments, and hypo-

Discharge Summary
mobile for the C6-7 segments, and C7-T3 had This patient was progressing very well with
achieved more normalized motion. treatment up to this point and was educated
Ranges of active elbow flexion and exten- on the need for her to continue with her home
sion were full, and pronation and supination exercise program and to continue attending
were both 85 degrees actively. Wrist exten- the clinic for at least another 4 to 6 visits.
sion was 75 degrees with the fingers flexed The patient was discharged from the clinic
and 60 degrees with the fingers extended. once her maximum pain-free range of motion
The patient exhibited improved sensation was achieved at the cervical spine. Symptoms
to pinprick at the tip of the right thumb, but at the forearm and thumb persisted; however,
weakness (4/5) of the abductor and extensor the patient was advised to continue with her
pollicis brevis muscles persisted. The brachio- exercises and was reviewed every 3 months
radialis reflex was approaching normal, and for the following year.
full pressure on the median nerve pathway
(plus overpressure) reproduced symptoms in
RECOMMENDED READINGS
the right forearm. Tinel’s sign and Phalen’s
test remained positive. Cailliet R: Neck and arm pain (ed 2),
Philadelphia: FA Davis, 1991.
How was the patient’s knowledge of Maitland G, Hengeveld E, Banks K, English K:
Maitland’s vertebral manipulation (ed 6),
workplace ergonomics assessed?
Melbourne, Australia: Butterworth Heinemann,
2001.
Assessment of the patient’s knowledge of American Physical Therapy Association: Guide to
workplace ergonomics includes the following: physical therapist practice, second edition,
1. The patient was seated at a work station Phys Ther 81:1, 2001.
in the clinic.
2. She was asked to state which parts of her
posture were not in an optimal position.
3. She then demonstrated how to adjust that
work station to specifically suit her body
shape and needs.
 Case 6
LEARNING OBJECTIVES
The reader will be able to:
1. Define the term “scoliosis” and identify how the curves that occur in the
spinal column are classified.
2. Identify the common postural deviations that occur with idiopathic
scoliosis.
3. Discuss the common management principles utilized with patients with
idiopathic scoliosis.
4. Identify the role of the physical therapist in the management of
idiopathic scoliosis.

crests after the brace was removed. This

Examination redness resolved within 10 minutes of
HISTORY doffing the brace.
The patient, a 12-year-old white female, was Musculoskeletal system
referred to physical therapy by an orthopedic Gross symmetry. No leg length discrep-
specialist with a diagnosis of idiopathic sco- ancy was seen. Observation from the posterior
liosis. The referral requested that an exercise aspect revealed a thoracic curve with right
program be implemented in conjunction with convexity and a lumbar curve with left con-
orthotic management of the spinal curve. The vexity. The curvature was generally well
patient’s pediatrician initially detected the sco- compensated for, but the patient presented
liosis during an annual physical examination. with her head tilted to the right, her left
The presenting curve was measured radio- shoulder lowered, and her left waist fold
graphically as a 33-degree right thoracic (T5- higher. Her right ribs humped posteriorly on
11) curve and a 30-degree left lumbar (T11-L4) forward bending, and she had a more promi-
curve. The patient received a Boston brace 2 nent erector spinae muscle on the right side.
weeks before the initial physical therapy exami- Mildly winging scapulae were also apparent
nation and was advised to wear the brace 23 bilaterally. Observation from the anterior
hours each day. The patient reported some diffi- aspect revealed that the chest wall was more
culty getting used to the brace, due to the initial prominent on the left side.
discomfort associated with wearing it and gen- Palpation. No palpable muscle spasm was
erally feeling self-conscious when wearing it; noted on either side of the spinal column.
however, she also reported “no pain” in her Joint range of motion. The lower extrem-
back after wearing the brace for 2 weeks. ity active range of motion (ROM) was within
The patient was in the seventh grade and normal limits with the exception of tight
participated in gym at school but undertook hamstrings, which produced a popliteal
no other extracurricular activities. She was angle of 145 degrees bilaterally. Active ROM
generally healthy, with no previous significant testing for the trunk identified that forward
history of musculoskeletal injury. She had not flexion was decreased by 50% (i.e., the
started menses at the time of examination. fingertips reaching only the middle of the
thighs), lateral flexion to the right was
SYSTEMS REVIEW decreased by 30% (i.e., the fingertips just
Integumentary system. There was no reaching the knee), and rotation to the left
remarkable findings except for two small was decreased by 30% when compared with
slightly reddened areas noted on both iliac the opposite direction.

23
24 Clinical Cases in Physical Therapy

Strength. In general, the patient’s strength • More prominent erector spinae muscula-
was fair to good, with the following measure- ture on the convex side of the thoracic
ments noted: gross scores of 4/5 for the upper curve.
and lower extremities, 4/5 for the rectus • More prominent chest wall on the concave
abdominus, and 3/5 for the oblique abdomi- side of the thoracic curve.
nals, trunk extensors, and scapular muscles.
Other joints. The patient had no com-
plaints at either the hips or knees, with full
Diagnosis
pain-free ROM available, aside from the specific Physical Therapist Practice Patterns 4A:
signs and symptoms previously identified. Primary Prevention/Risk Reduction for
Special tests. Both the Thomas test and Skeletal Demineralization, and 4B: Impaired
the Ober test were positive bilaterally, although Posture.
no objective measure was taken. The patient
was independent with dressing and all
activities of daily living. She required some Prognosis (including plan
assistance to don the brace but was inde-
pendent with doffing. She was able to walk
of care)
for 10 minutes on the treadmill at 2.5 mph It was anticipated that with time, wearing the
and level grade. Conversational dyspnea brace, and a good home exercise program, the
commenced at 7 minutes with a verbal patient would gradually regain a more normal
report of fatigue. Values for heart rate and alignment of the spinal column without
respiratory rate were as given in Table 6-1. lasting significant complications. The expected
number of visits was between eight and
The patient was well compensated, with a twelve. Initially, the patient was seen for five
right convex thoracic and left convex to six appointments for instruction in the home
lumbar curve. Which asymmetries identified exercise program, which was designed to
were expected for this patient? improve flexibility and strength as well as to
establish an aerobic program. The patient
The following asymmetries were expected: and her parents jointly established a check-
• Shoulder lower on the concave side of the list to document compliance with the exer-
thoracic curve. cise program and brace use. The patient was
• Scapula farther away from the spine on followed up every 3 to 4 months to reevaluate
the concave side of the thoracic curve. and update the exercise program as needed
• Waist folds higher on the concave side of through her growing years.
the lumbar curve.
• Iliac crest higher on the concave side of SHORT-TERM GOALS
the lumbar curve. The patient will:
• Rib hump on the convex side of the 1. Become more accustomed to wearing the
thoracic curve. brace and more accomplished in donning
and doffing the brace independently
during the first week after the brace is
prescribed.
2. Undertake a home exercise program to
TA B L E 6 - 1
prevent disuse atrophy associated with
TA R G E T H E A R T R AT E : 1 5 6 T O 1 6 9
brace wear beginning during the second
RESTING PEAK COOL DOWN week of treatment and continuing while
Heart rate 78 168 84
she attends therapy.
Respiratory 18 36 24
3. Become more physically active while
rate wearing the brace to develop and improve
spinal position.
 Case 6 25

LONG-TERM GOALS Outcome

The patient will: Initially, the patient was relatively noncom-
1. Develop increased strength in the trunk pliant with both wearing the brace and
muscles and continue to improve her static performing her exercise program. After some
posture by the end of the eighth week. discussion, the patient admitted that she felt
2. Increase trunk flexibility, trunk muscle very self-conscious wearing the brace and
strength, and endurance associated with had been teased in school when she wore it.
disuse muscle atrophy by the end of the
tenth week. What steps were taken to encourage the
3. Develop sufficient strength to ensure that patient to continue to wear the brace and
improvements in static posture are main- perform the exercise program?
tained during dynamic activity continuous
from the early stages of treatment until The alternative to wearing the brace—
the end of the twelfth week. surgical intervention—was discussed with
4. Gradually decrease her reliance on the both the patient and her parents. They
brace and become more independent, with agreed to try using the brace for at least 6
maintenance of normal spinal curvature months to avoid the surgical route.
beginning by the tenth week and gradually After wearing the brace and performing
working toward independence without her exercises for 3 weeks, the patient stated
the brace by the fifteenth week. that she had experienced some discomfort
when stretching the trunk muscles on the
concave aspect of her curve and also similar
Intervention discomfort when stretching her hamstrings.
Initial treatment comprised passive move- The therapist reviewed the patient’s stretch-
ments of the thoracic and lumbar spinal sec- ing technique and determined that the
tions to assess the possibility for the scoliosis patient was performing her stretching exer-
to resolve and return to a more appropriate cises correctly, but too vigorously. At this
spinal alignment. Once the curve was evalu- point, all of the strengthening exercises in
ated to be completely reversible, the patient the patient’s program were also reviewed
and her parents were educated as to what and any problems were corrected.
constitutes a “normal” spinal position. The
end point of the treatment program was iden-
tified, and a more specific exercise program
Reexamination
was devised to assist the patient in achieving On reexamination after 6 weeks, the patient
her goals. The exercises were designed such complained of some slight discomfort when
that those muscles on the convex aspect of stretching and occasional discomfort from
the curves were contracted to encourage wearing the brace but little else. In terms of
flattening of the concavity on the opposite postural dysfunction, her head no longer
side of the spine while the muscles on the tilted to the right, her left shoulder remained
concave aspect of the curvature were slightly lower, and her left waist fold was
stretched to allow the appropriate movement. now equal to her right waist fold. The right
There were a number of exercises performed rib hump, which occurred posteriorly during
independently by the patient and a number forward bending, remained. The prominent
of exercises performed by the patient with erector spinae muscles were also still visible
her parents’ assistance. Electrical stimu- on the right side. The reddening of the iliac
lation was used on the convex side of the crests was not present; however, there were
curve (at night) to alter the direction of signs of old blister scars.
deformity, decrease pressure on the concave Active ROM remained within normal limits,
side, and allow for more normal vertebral and the tightness noted in the hamstrings
growth. was decreased somewhat, with the popliteal
26 Clinical Cases in Physical Therapy

angles measured at 170 degrees bilaterally. The

Discharge Statement
Thomas and Ober tests were still assessed as Discharge from physical therapy did not
slightly positive bilaterally. ROM of the trunk officially take place; however, after 6 weeks
had improved with forward flexion from a of treatment the patient was given a revised
decrease of 50% to one of 25%; lateral flexion home exercise program, and a return appoint-
to the right improved from a decrease of 30% to ment was scheduled for 6 months from that
one of 15%; and rotation to the left improved date. The patient was advised to adhere to her
from a decrease of 30% to one of 15%. exercise program and to contact the therapist
Strength measures had apparently improved if anything untoward occurred before her
slightly, but not in all areas. The oblique next appointment.
abdominals, trunk extensors and scapular mus-
cles all improved to 4/5, whereas the upper
RECOMMENDED READINGS
extremities, lower extremities, and rectus
abdominus remained at 4/5. Calliet R: Scoliosis: diagnosis and management,
The patient was now independent with Philadelphia: FA Davis, 1985.
dressing and activities of daily living, including Campbell SK: Physical therapy for children.
Philadelphia: WB Saunders, 1994.
independent donning and doffing of the brace.
Tachdjian MO: Pediatric orthopedics, vol 3,
Her endurance increased to 20 minutes on the
Philadelphia: WB Saunders, 1990.
treadmill at 2.5 mph on a level grade. Conver- American Physical Therapy Association: Guide to
sational dyspnea commenced at 12 minutes physical therapist practice, second edition,
with report of fatigue. There were no signifi- Phys Ther 81:1, 2001.
cant changes in heart rate or respiratory rate.
 Case 7
LEARNING OBJECTIVES
The reader will be able to:
1. Identify pertinent information to support a physical therapy diagnosis of
inefficient/ineffective movement patterns resulting in greater energy
demand to perform tasks.
2. Explore approaches to address energy-conserving devices and movement
patterns.
3. Discuss aerobic activity benefits for those who have fatigue as an
impediment to quality of life.

The reader should know the patient participated had a Kurtzke expanded disability status
in an outpatient education program for people scale (EDSS) score (i.e., disability index) of
with multiple sclerosis (MS) and their stage 2, meaning that she had minimal dis-
significant others. Each participant was ability, with slight weakness or stiffness,
encouraged to bring questions, concerns, and minor gait disturbances, or mild motor dis-
activity goals to the medical team. The team turbances. She was married, lived with a
assessed the patient’s physical capabilities and supportive husband, and had two grown
interests, then formulated an activity program daughters who lived in a neighboring state.
congruent with the patient’s goals and abilities.
According to the Guide for Physical What home modifications may have helped
Therapist Practice,1 the potential functional this patient to conserve her energy and help
limitations or disabilities displayed by patients create a safe environment for her to work
with MS include deconditioning from a cardio- and live in?
vascular, neuromuscular, or musculoskeletal
deficit that could lead to impaired endurance The patient’s house was equipped with an
and progressive loss of function. Neuromuscular office so that she could perform her work
difficulties resulting from this patient’s duties at home without having to go outside.
disorder included difficulty in coordinating She lived in a three-bedroom, two-bathroom,
movement related to gait on home, work, or single-level home. On the outside of the house,
community terrains. This impaired motor there were three steps to both the front and
function and impaired sensory integrity back doors. Handrails were installed on both
impeded the patient’s ability to perform her sets of steps. She was able to go up and
employment duties as a software technician down the steep basement steps, but did so
because her hands were involved, and she only when absolutely necessary.
complained of decreased fine motor skills The patient enjoyed generally good health,
interfering with her ability at the keyboard. although she experienced numbness in her
hands and fatigue that required rest. She
walked around the house without any assis-
Examination tive devices, but used a straight cane or a cane
GENERAL DEMOGRAPHICS with a folding seat for outings. She was able
The patient, a 5-foot, 5-inch, 55-year-old to manage her household with her husband’s
female software technician who weighed 149 help. At times, she had difficulty managing
pounds with a body mass index (BMI) of multiple tasks requiring short-term memory.
24.4, had an 11-year diagnosis of MS (although She participated in physical activity about
her symptoms began 16 years earlier). She three days per week, including stretching for

27
28 Clinical Cases in Physical Therapy

15 minutes and cycling for 10 minutes. In the score on the Tinetti balance assessment was
summer months, she also swam for 1 hour 25/28, indicating a low risk of falls.8
three times a week. The only medications that
she took were Avonex (an interferon used to What modifications may enable someone
slow disease progression),2 Evista (for osteo- with sensory and cognitive loss (problems
porosis prevention),3 and aspirin for preven- with multiprocessing with short-term
tion of heart disease and stroke. memory) to perform their computer
technical support duties at work?
What examination procedures could be
included for a patient with MS at Kurtzke The patient worked as a software consultant
stage 2? from her home office, where she used an
exercise ball as a chair during work. She tried
TESTS AND MEASURES to be as active as possible with cooking,
The patient’s EDSS score was 3.5.4 Testing of cleaning, gardening, and other activities, but
her aerobic capacity on a Schwinn Airdyne she was limited by her energy levels. She
cycle ergometer yielded the results given in learned to pace herself and to sit with proper
Table 7-1. posture. At work, she kept a detailed diary of
Significant weakness was found in right conversations with customers. She stated
shoulder abduction, external rotation, and that others in her position might not need to
elbow flexion (4/5) and in left shoulder flex- do this, but that it helped her focus on one
ion and external rotation (4-/5). In the left problem at a time.
leg, strength was assessed at 4/5 in straight-
knee hip flexion, 4/5 in hip external rotation,
4-/5 in hip extension, and 3/5 in hip extension.
Evaluation
In the right leg, strength was 4/5 in bent-knee The patient presented as a very functional,
hip flexion, hip external rotation, and knee well-adjusted woman with minimal physical
flexion. Strength in trunk flexion was 3/5.6 A dysfunction, although she stated she felt
hip flexion contracture of 5 degrees on the “wobbly” on her feet and thus used a straight
left was also noted.7 cane for balance and reassurance. Her
The patient was hyperreflexic in both lower weight was within a healthy range, and her
extremities and the left upper extremity, but balance and gait skills were good. She had
exhibited no clonus or nystagmus. Her vibra- weakness in her hips and trunk flexors,
tory sense and stereognosis were intact which may have contributed to her feeling of
bilaterally, although blunted on the left side. insecurity while ambulating on level and
On ambulation, the patient exhibited a unlevel surfaces. She had good exercise
forward head, anterior pelvic tilt, and mild tolerance, and was in need of education
ataxia. She was able to walk 25 feet in 6.3 regarding safe levels of aerobic exercise and
seconds (the average of two trials), and her daily activity.

TA B L E 7 - 1
A E R O B I C C A PAC I T Y T E S T I N G
RESTING PEAK COMMENTS

Heart rate 79 142 Resting ECG showed nonspecific ST changes

Blood pressure 144/90 160/92 Test duration: 6 min
Peak RPE 7 (1-10 Borg scale)5

ECG, Electrocardiogram; RPE, rate of perceived exertion.

 Case 7 29

Diagnosis • Aerobic: Stationary bike, four to five days

Physical Therapist Practice Patterns 5A: per week at a rating of perceived exertion
Primary Prevention/Risk Reduction for Loss of 3 to 4 (on a scale of 1 to 10), moderate
of Balance and Falling, and 5E: Impaired to somewhat hard for 6 minutes. Include
Motor Function and Sensory Integrity Asso- warm-up and cool down periods. Increase
ciated with Progressive Disorders of the duration by no more than 10% per week,
Central Nervous System. as tolerated, to 20 minutes.
• Balance and coordination: Swiss ball, pool,
or counter exercises, two to three days
Prognosis per week.
Few factors that could prolong the need for • Strength: Abdominal and lower extremity
continued intervention were present in this strengthening exercises, two to three days
case. The patient had a consistently supportive per week.
husband and employer. Her work setting was
adjusted to allow continued employment with- What strategies could be suggested to improve
out interruption resulting from her disorder. the endurance of a patient complaining of
She had no comorbidities, she maintained fatigue after walking with a standard cane
adequate nutrition, and her disorder had not for 3 minutes at a moderate speed?
progressed markedly over the past 11 years.
She enthusiastically embraced the exercise The patient’s cane height was adjusted and
recommendations. the hand position altered for thumb and
wrist safety (Figure 7-1).
Intervention
C O O R D I N AT I O N , Reexamination
C O M M U N I C AT I O N , The patient was given a home exercise
A N D D O C U M E N TAT I O N program and ideas of how to integrate the
As part of a multidisciplinary approach, the suggested activities into her life. She was
patient was given a binder in which to place supplied with a log sheet to fill in as she
lecture notes and exercise recommendations, continued her activities. She was to return
as well as any questions that arose during the the completed sheet with her subjective
class times, to maintain a record of what she comments to have the exercise prescription
learned and to help her review material after modified accordingly.
returning home. The exercise prescription
was practiced throughout the educational
program, and was provided to the patient in
Outcome
both audiotape and written formats on the The patient was very aware of her activities
last day of the program. during the day and stated that she had a hard
time stopping before she became overtired.
Which interventions for decreasing muscle She improved in monitoring her activities
tone are efficacious for patients with MS? (including rest periods and prioritizing tasks)
and was learning to pace herself by keeping
The exercise program included the following a diary of her activities and how she felt. As
activities: she controlled her life better, she found that
• Flexibility: Daily stretching with empha- she had more energy and focused on partici-
sis on the lower back and lower pating in activities that she enjoyed and was
extremities. able to enjoy them even more.
30 Clinical Cases in Physical Therapy

A B

F I G U R E 7 - 1 Hand placement on the cane. A, Correct hand placement. B, Incorrect hand

placement.

REFERENCES 5. Stuifbergen AK: Physical activity and perceived

1. American Physical Therapy Association: Guide health status in persons with multiple scle-
to physical therapist practice, second edition, rosis, J Neurosci Nurs 29:238, 1997.
Phys Ther 81:9, 2001. 6. Kendall FP, McCreary EK: Muscle testing and
2. Rudick RA, Goodkin DE, Jacobs LD, et al: function (ed 3), Baltimore: Williams & Wilkins,
Impact of interferon beta-1a on neurologic 1983.
disability in relapsing multiple sclerosis, 7. Hislop HJ, Montgomery J, Connelly, B: Daniels
Neurology 57(12 Suppl 5):S25, 2001. and Worthingham’s muscle testing: Techniques
3. Barrett-Connor E: Raloxifene: Risks and of manual examination (ed 6), Philadelphia:
benefits, Ann N Y Acad Sci 949:295, 2001. WB Saunders, 1995.
4. Kurtzke J: Rating neurological impairment 8. Berg KO, Maki BE, Williams JI, et al: Clinical
in multiple sclerosis: an expanded disability and laboratory measures of postural balance in
status scale (EDSS), Neurology 33:1444, an elderly population, Arch Phys Med Rehab
1983. 73:1073, 1992.
 Case 8
LEARNING OBJECTIVES
The reader will be able to:
1. Classify a patient with Bell’s palsy according to preferred practice
pattern, diagnostic classification, and ICD-9-CM codes.
2. Determine appropriate examination process, including tests and
measures.
3. Evaluate to determine the appropriate diagnosis, prognosis, and
interventions.

The reader should know that the patient was following components: muscle strength,
a 32-year-old male who was otherwise healthy. power, and endurance during functional
On awakening, he noticed drooping of the right activities; electroneuromyography; strength-
corner of his mouth and an inability to duration testing; and reaction to degeneration
completely close his right eye. He later noted an testing.
inability to keep food in the mouth when eating.
Later that day, he visited his physician, who
made the diagnosis of Bell’s palsy. The physician
Examination
prescribed oral corticosteroids for 1 week HISTORY
(with gradual discontinuation during the The patient, a high school English teacher,
second week) and an eye patch and referred the reported several bouts of low back pain in
patient for physical therapy. The patient arrived the past that had resolved with modification
for the first physical therapy visit 1 day after of activities for several days. He reported no
onset with a referral that read “Bell’s palsy— significant health problems. He did not use
right. Evaluate and treat.” tobacco, and he consumed alcohol only
occasionally.
What components should the physical
therapist incorporate into the examination SYSTEMS REVIEW
process (including tests and measures)? The systems review yielded no signs of
undetected health problems.
The referring physician gave the diagnosis as
Bell’s palsy. The physical therapist should TESTS AND MEASURES
complete a patient history and systems review The patient was unable to voluntarily contract
to learn about issues that may influence the any of the muscles innervated by the right
plan of care. For example, a history of cardiac cranial nerve VII. He could not close the
arrhythmias may preclude the use of electric right eye voluntarily, and saliva drooled from
stimulation devices as an intervention. The the right corner of his mouth. The therapist
therapist uses the information obtained from was able to produce strong twitch and
the history and systems review to screen for tetanic contractions in the muscles inner-
undiagnosed problems that may require vated by the right cranial nerve VII using
further evaluation by the referring physician pulsatile current. The stimulation parameters
or other health care practitioner. were biphasic, asymmetric, balanced pulses;
For a patient with Bell’s palsy, the thera- 300 μsec initial negative phase duration and
pist should conduct a detailed examination 1200 μsec positive phase duration; no interval
of facial musculature and cranial nerve VII between phases; 30 Hz and amplitude 1.5 mA
function. This examination might include the (Figure 8-1). Contractions of similar quality

31
32 Clinical Cases in Physical Therapy

What is the expected natural course of

1.5
ma recovery for this patient?

300 ␮s 1200 ␮s Prognosis (including plan

of care)
FIGURE 8 - 1 Biphasic, asymmetric, balanced
pulse. If the patient had sustained a first-degree
injury, then conduction distal to the injury
site would be preserved, and recovery would
be expected within a few weeks of onset. If
and strength could be produced on the left he had sustained a second-degree injury, then
(unaffected) side using the same pulse the prognosis for recovery would remain good.
characteristics. Axon regeneration would be expected to
A 1-cm-diameter handheld electrode was occur at a rate of about 1 to 2 mm per day.1
used to apply current to the seventh cranial Electrodiagnostic testing (i.e., nerve con-
nerve and the involved muscles, and a 10-cm duction velocity testing) may aid in formu-
× 10-cm electrode was applied to the right lating a more accurate prognosis. If Wallerian
arm. The therapist was able to produce twitch degeneration had occurred, then signs of
contractions in the muscles innervated by gradual denervation would become evident
cranial nerve VII bilaterally using direct during the 21-day period after the initial
current. Twitch contractions were observed onset of symptoms. Signs of denervation that
when the cathode was applied to the muscle the therapist could elicit would include
motor points and when the tap-key of the decreasing response to increasing amplitudes
hand-held electrode was closed. of pulsatile current and a slow, wormlike
response to direct current.
Evaluation SHORT-TERM GOALS
The ability to induce tetanic contractions Goals for this patient included restoring
with pulsed current and twitch contractions muscle performance (i.e., strength, power,
with sudden-onset cathodal direct current endurance) and the ability to perform physical
indicated that Wallerian degeneration had not actions, tasks, and activities related to self-
taken place. Because there was no trauma, care.3 The timeline for achieving these goals
and considering the medical diagnosis (Bell’s was 8 weeks. The plan included five visits
palsy), it seemed likely that the patient had during the first week, then reevaluation of
sustained either a first-degree (neurapraxia) visit frequency at the beginning of the second
or second-degree injury to cranial nerve VII.1 week. Based on the identified preferred
Presumably, Bell’s palsy is due to compres- practice pattern, ICD-9-CM code 351.0 was
sion and ischemia of cranial nerve VII as it selected for billing purposes.
courses through the temporal bone. This may
be due to swelling associated with immune
or viral disease.2
Intervention
Pulsatile current, with pulse characteristics
as noted earlier, was used daily for the first
Diagnosis week of treatment. A total of 20 contractions
Physical Therapist Practice Pattern 5D: were elicited in each of the affected muscles.
Impaired Motor Function and Sensory The patient was taught how to perform
Integrity Associated With Nonprogressive massage to the affected muscles and how to
Disorders of the Central Nervous System— attempt voluntary muscle contractions using
Acquired in Adolescence or Adulthood. a mirror for feedback.4 At 1 week after onset,
 Case 8 33

obvious signs of denervation were present, with acoustic neuroma excision, and con-
and the therapist added direct current to the cluded that long-term electrical stimulation
treatment regimen. At 3 weeks after onset, may facilitate partial reinnervation. It is
the therapist could no longer elicit contrac- worthwhile to note that stimulation was kept
tions using pulsatile current. Direct current at submotor levels for this study. Jaweed1
was continued, and the patient was instructed has indicated that excessive physical or
in the use of a home stimulator. The patient electrical activity during reinnervation may
returned for reevaluation weekly. have deleterious effects.
Given the ambiguity of the evidence, it
seemed prudent to use motor-level electric
Outcome stimulation in an attempt to maintain muscle
At 4 weeks after onset, contractions of contractibility while denervation, and then
minimal strength could be elicited by maxi- reinnervation occurred. The therapist chose
mum voluntary effort in some of the affected to induce 20 contractions of moderate strength
muscles. During the next three weekly visits, daily, hoping that this regimen would not
the patient exhibited increasingly stronger constitute excessive activity. Massage was
voluntary contractions in increasingly more used to maintain flexibility and perhaps
of the affected muscles. By 8 weeks after increase circulation in the affected muscles.
onset, muscle strength improved to “fair” (i.e., The therapist believed that voluntary effort
complete range of motion against gravity), with mirror feedback served to promote
and electric stimulation was discontinued. muscle reeducation.
The patient was able to consistently close his
right eye and no longer experienced drooling
REFERENCES
from the right corner of his mouth. Because
the goals had been met, physical therapy was 1. Jaweed MM: Peripheral nerve regeneration. In
discontinued. A follow-up visit was scheduled Downey JA et al (eds): The physiological basis
for 6 months after onset. At the 6-month of rehabilitation medicine (ed 2), Boston:
Butterworth-Heinemann, 1994.
follow-up visit, muscle strength had improved
2. Beers M, Berkow R (eds): The Merck manual
to “normal” (i.e., complete range of motion of diagnosis and therapy (ed 17), Whitehouse
against strong pressure). The patient was Station, NJ: Merck & Co, 1999.
satisfied with the outcome and noted no con- 3. American Physical Therapy Association: Guide
tinuing impairments, functional limitations, to physical therapist practice, second edition,
or disabilities. Phys Ther 81:9, 2001.
4. Ross B, Nedzelski JM, McLean A: Efficacy of
feedback training in long-standing facial nerve
Discussion paresis, Laryngoscope 101:744, 1991.
Evidence for the efficacy of electric stimula- 5. Ysunza A, Inigo F, Oritz-Monasterio F, et al:
tion in treating Bell’s palsy is ambiguous. Recovery of congenital facial palsy in patients
with hemifacial mocrosomia subjected to sural
Ysunza et al5 studied the use of electric
to facial nerve grafts is enhanced by electric
stimulation in patients who underwent nerve field stimulation. Arch Med Res 27:7, 1996.
grafting after facial palsy and concluded that 6. Targan RS, Alon G, Kay SL: Effect of long-term
electric stimulation induced improvement. electrical stimulation on motor recovery and
Targan et al6 studied the effect of electric improvement of clinical residuals in patients
stimulation on two groups of patients with with unresolved facial nerve palsy, Otolaryngol
chronic facial nerve palsy, one group with Head Neck Surg 122:246, 2000.
idiopathic Bell’s palsy and the other group
Exploring the Variety of Random
Documents with Different Content
contracts, as had been the custom of the ' Bingham Estate," were
very strict. Nearly all the money received from those contracts and
from sale of land was expended in buying and improving projjerty,
and for living expenses in Potter county. Many a man still remembers
his prompt payment of liberal wages. " The private charities of
himself and his mother need not be detailed, but I may mention a
gift of a ' town clock ' for the new court-house, costing him about
$300. I well remember his pained expression when some men
suggested that the present was made to gain popiilarity. Few men
are found that have less of selfishness than he had. " Mr. Dent was a
Democrat, but his personal friends were in both parties, and, while
fixed in his political opinions, he was friendly toward opponents,
unless they assailed his personal integrity. His sympathies were with
the South in the Civil war. " Jefferson Davis and many of the
Southern leaders were personal friends and associates. He regarded
slavery (if an evil) as a necessary evil, and the duty of the white man
to take good care of his slaves; and thought it better to let the
States go than have the war. I was a radical Republican, but our
personal and business relations were not disturbed. The immense '
war taxes ' were a severe drain, for Mr. Dent owned considerable
unseated land, and the interest-bearing contracts had been reduced
and put into other land. Therefore, while owning considerable
property, Mr. Dent did not have any income tax to pay. Some men
now living remember that this fact was a sore spot
 1234 HISTORY OF POTTER COUNTY. with some who gave
attention to the matter. Mr. Dent paid every dollar of taxes that the
law required, and that without outside grumbling. "His instructions
to me were to pay all that were legally assessed, at same time
adding, ' bitter as it is to pay to support a war that I do not think is
for the good of the country.' ■' Mr. Dent was a polite, Christian
gentleman, and while he had some few personal enemies, I could
see that nearly all arose from the fact that, owing to the difference
in early training and habits, he and some of the Coudersport people
did not understand each other, and I was glad to know from them
and from him, in later years, that both recognized this fact, and gave
each other credit for honest intentions." E. U. EATON, M. D.,
Lewisville, son of Charles Eaton, was born in Andover, Allegany Co.,
N. Y. , in 1844, and was there reared and educated. He began the
study of medicine with Dr. Crandall, of that place, attended lectures
at Ann Arbor, Mich., in 1805-66-67, and subsequently at BufFalo
Medical College, from which he graduated in 1884. He first began
the practice of medicine at Lewisville in 1867, and now has a very
large practice, being one of the moHit successful physicians in the
county. He married, in October, 1868, Marcella R. Crandall, of
Independence, N. Y. , and they have two children, Nellie and Carrie.
Dr. Eaton is a member of Lewisville Lodge, No. 556, F. & A. M. , and
of Ulysses Chapter, No. 269, R. A. M. In politics he supports the
principles of the Republican party. ANDREW J. EVANS, editor and
proprietor of the Ulysses Sentinel, was born at West Union, Steuben
Co., Penn., N. Y., October 30, 1857. His father was a mechanic, a
stone mason, and moved about a great deal wherever he could tind
most employment at his trade. Shortly after the birth of the subject
of these lines, his parents removed to Tompkins county, N. Y. While
there the Civil war broke out, and his father enlisted in the army,
leaving the mother to take care of six children, of which Andrew J.
was next to the youngest. This she did as faithfully and devotedly as
any of the thousands of other mothers who were doing the same
self-sacrificing work at that period, so critical to the safety of the
Union. After the war closed, the family moved back to Steuben
county, and fi'om there to Whitesville, N. Y.. where the mother died
when Andrew was twelve years old. A year later the father married
again, and part of the family of eight children was quickly scattered,
three children only being left at home. Soon after this the family
moved to the backwoods of Potter county, Penn. , where school
privileges were very limited. Andrew was now old enough to
appreciate the benefit of an education, and by dint of much study at
home, with the aid of one term at select school, he was enabled to
get a teacher's certificate. At eighteen he began to teach school,
and, with intervals of attending school, followed the profession for,
twelve years. From the time he began to teach, he was practically
independent of his father, and received no pecuniary assistance from
him. He saved his earnings, and attended the Mansfield State
Normal School, where he graduated in 1884. After this he was
principal of the Lewisville graded school for three years, and in the
spring of 1887 became a candidate for the office of county
superintendent. His liberal views on the subject of religion, however,
defeated him. On the first of January, 1888, Mr. Evans bought a
halfinterest in the Ulysses Sentinel, and the following September
purchased his partner's interest in the same, and at present he is
sole owner and proprietor. September 5, 1889, he was married to
Miss Anna Evans, of Spring Mills, N. Y. Mr. Evans' parents were S. A.
Evans and Nancy (Somers), both native Americans and traceable
back to English stock. Mrs. Evans' parents were G. F. Evans and
Luciuda (Murdock), also native Americans.
 BIOGRAPHICAL SKETCHES. 1235 DANIEL FULLER, P. O.
Tlysses, son of Thomas and Sally (Jincks) Fuller, was born in
Wyoming county, N. Y., in 1S3L In 1839 his parents removed to
Ulysses township, Potter Co., Penn., near Gold, where they
purchased a farm, and here his father lived and died, after which
Mrs. Fuller made her home with Daniel, until her decease. Their
children were Nathan, now a resident of Michigan; Mrs. Huldah
Gallup, of McKean county ; Hannah, now Mrs. Norman Rodgers, of
Nebraska, and Daniel. Daniel Fuller made his home with his parents
until twelve years of age, after which he engaged in various
occuiiations, and learned the carpenter and goldsmith trades.
October 16, 1861, in answer to his country's call for men, he enlisted
in Company G, Fifty-third Pennsylvania Volunteers, and September
17, 1862, was wounded at the battle of Antietam. The Irish brigade
were in advance and had made several charges to drive the rebels
from an adjacent corn field, and the Fifty-third was held in reserve
with orders to lie down. He, with other men lying close to the
ground in the second line of battle, heard a cheer in front, and,
having curiosity to know its occasion, raised himself on his hands
when a shell hit both arms, necessitating their amputation, the first
operation being performed on the field, and the next on the 5th of
October. He was of course discharged and returned to his former
home, and was made a pensioner, receiving the highest amount
then paid, $8 per month. Wholly incapacitated from performing any
kind of manual labor, the future to him held not much of promise.
However, on the presentation of his case to some of his personal
friends, and receiving assurances of their willingness to loan their
services to secure an increase of pension, he was induced to visit
the city of Washington, to present his case in person. His friends and
neighliors learning that a little financial assistance would not be
unacceptable, gave an oyster supper, which netted 1163, and this
money, so kindly given, enabled him to make the contemplated trip,
and when he appeared before the committee on pensions, and
before the House, he secured in July. 1864, the first increase of
pension given to those who lost both hands or both eyes, $25 per
month, and to those who lost both legs $20. During his trip he was
of course accompanied by a friend, and received continually
assurances of sympathy and respect, in substantial form. Before the
war he became acquainted with Mrs. Sophia F. Scott, and they were
married after his return in 1863. They have one son, Charles A. ,
now a farmer of Allegheny township. They are members of the
Presbyterian Church. Mr. Fuller is a member of O. A. Lewis Post, G.
A. R. He is a Republican in politics, and has held several township
offices. AV. J. GROVER, merchant and farmer, P. O. Newfield. A. M.
Grover, the father of this gentleman, is a native of Johnsburg,
Warron Co., N. Y., born in 1814. In 1842 he married Sabra Dunkley,
aud in 1853 they moved to Potter county, Penn., locating on the
farm now owned by Alva Carpenter, and two years later they
purchased a portion of the farm now in possession of their son, W. J.
; then, in 1885, they bought the T. A. Galutia farm, still owned by
them, though they reside at Newfield. They are the parents of the
following named children: Phebe L., Myron S. (deceased), W. J.,
Roxie M., Nettie A. and John J. , the last two having" been born in
Potter county. Mr. and Mrs. A. M. Grover having been among the
early settlers of Potter county, and their means being then limited,
they naturally had an active share in the hardships experienced in
the pioneer lives of the settlers in the forests of Potter county. W. J.
Grover, whose name heads this sketch, was born in Johnsburg.
Warren county, N. Y., May 10, 1847, and came with his parents to
Potter county in 1853. At the time' of the battle of Gettysburg, and
during the excitement when there was an urgent call for militia
troops, young Grover,
 121C) HISTOKY OF POTTER COUNTY. again^^t the will of
his parents, enlisted ia the militia, but through their influence at the
time he did not proceed to the front. In February, 1S64, he again
enlisted, this time at Coudersport, iu the Forty-sixth Regiment P. V.
I., under Lieut. Rees, but was prohibited from going with his
regiment by his parents. However, on March 31, same year, by the
assistance of his fellow-comrades, he succeeded in enlisting in
Company H, Fifty-third Regiment P. V. I., in which he served his
country till the close of the war, being dischargeil June 30, 1865.
After the war he returned to the pursuits of peace, and settled down
to a farming and commercial life. Mr. Grover has been three times
married: First in 1875, to Eugenie L , daughter of Alva Carpenter,
and she dying February 22, 1879, he married, in 1880, Mrs. Sarah A.
Presho, daughter of Seth Conable; this wife died October 30, 1882,
leaving one child, Willie M. , and in 1883 our subject married Miss
Nellie M., daughter of William and Irena Knapp, by which union
there is also one child, Sarah Eugenie. Mr. Grover is a member of O.
A. Lewis Post, No. 279, G. A. R. ; in politics he is a Republican, has
served his township as supervisor and overseer of the poor sis years,
and has held various township offices. He owns a farm of -100
acres, and is the founder of and the only merchant in Newfield, the
manufacturing concerns of which place he was mainly instrumental
in establishing. ALBERT L. HERVEY, farmer. P. O. Ulysses, son of
Joseph and Rhoda (Baker) Hervey, was Ijorn in Triangle, Broome
Co., N. Y. , iu 1830. His father was a native of Berkshire. Mas^.. and
his mother of Lebanon, N. H. Each with their parents removed to
Broome county, where they were married in 1824. They located at
Triangle, where they remained until their removal toJBingham
township. Potter Co., Penn., in 1847, where the father died iu 18/').
The mother survives, and makes her home with her children. They
had a family of four sons: Jerome (of Bingham township, on the old
homestead), Albert L., A. B. (of Canton, N. Y^, and now president of
the Universalist Tbeological College, and J. E. (of West-field, Penn.).
In August, 1862, Albert L. Hervey entered as a private in Company
K. One Hundred and Fortyninth Pennsylvania Volunteers. He was
wounded at Gettysburg, losing the thumb and forefinger of his lett
hand, but remained in the field. In April, lS(i4, he was made second
lieutenant, and was mustered out of the service in June, 1865. He
then returned to his old home in Bingham township, and in 1874
purchased the farm he now owns in Ulysses township, erected fine
farm buildings, and is now recognized as one of the able and
successful agriculturists of the cjunty. He has also been largely
engaged in raising stock, and has one of the best dairy farms of the
county. He is a member of Lewisville Lxlg.A, No. 556, F. & A, M.,
Ulysses Chapter, No. 269. R. A. M., and of O. A. L3wis Post, No. 279,
G. A. R. In politics he is a Republican. In 1871 he was elected
treasurer of the county, serving one term of two years, and has been
honored officially in various ways in his township. He was married in
1855 to Sarah E., daughter of Jason Spencer, of Triangle, N. Y., and
to them have been born two children: William W. (now a merchant
of Havana. N. Y. ) and Mark S. (now a book-keeper in W. K. Jones'
Bank of Coudersport). WILLIAM T. LANE. The family of Lanes, from
which the subject of this sketch is sprung, can be traced back in
direct line to one John Lane, who came to America from Derbyshire,
England, more than two hundred years ago, and settled at
Killingsworth, Middlesex Co., Conn. Azel Lane, the seventh in the
genealogical line, and the father of William T. Lane, was born in
Killingsworth, Conn., September 2, 1793, and removed to
Jacksonville, Tompkins Co.. N. Y., about 1818. and there married
Mrs. Asenath (Thompson) Smith, widow of Capt. Enos Smith, who
died in the war of 1812; they
 BIOGRAPHICAL SKETCHES. 1237 were the parents of one
child, Willett B. Smith, who was born in Jacksonville in ISOS, and
died in the Honeo^-e Valley in 18S9. To the union of Azel and
Asenath (Thompson) Smith Lane were born three children: Norman
B. , William Thompson, and a daughter who died in childhood. The
father of these children had limited school advantages, but he made
up in energy what he lacked in early education; he was a life- long
student, and in his later years made the study of languages a
speciality, and was enabled to sjjeak several tongues, the knowledge
of which he acquired by his own unaided efforts. He was a millwright
b^y trade and a practical mechanic. He was also a man whose
morals were stainless, and whose life was above reproach, and who,
dying, left to his two sons the legacy of a name untarnisbed. He
departed this life May 14, 1876, his wife having met her death
several years before, the result of an accident. William Thompson
Lane was born in Chemung county, N. Y., near New Town (now
Elmira), March 27, 1825. He came to the Honeoye Valley, Potter Co..
Penn., about 1845. in company with his father and older Ijrother
Norman, now of Brockwayville. Jefferson Co., Penn. In June. 1846.
he married Miss Sarah J. Mead, of Greenwood, N. Y. , and to this
union were born seven children, named as follows: Homer K.
(druggist, Lewisville. Penu.), Mary S. (wife of E. S. Remington).
Frances A. (wife of Dr. L. D. Rockwell, Union City, Penn.), George H.
(deceased September 3, 1889), Helen A. (wife of F. S. Hover.
Honeoye, Penn.), Wilbur F. and Charles A. (telegraph operator. Postal
Line, Alma, N. Y.). After the marriage of Mr. and Mrs. Lane they
remained upon the farm which the husband had purchased upon
coming to Potter county, and where he was engaged in lumbering
and farming until the autumn of 1868, when they removed to Elk
county, where Mr. Lane engaged more extensively in lumbering, for
which business he possessed a particular aptitude. In this line he
was successful, and, after a few years spent here, he returned to the
farm, erected a fine, large house, and proceeded to improve and
beautify the home place. In 1878 Mr. Lane was nominated by the
Republican party for representative to the State legislature, but was
defeated by the combined vote of the Democrat and Greenback
parties. Mr. Lane is one of the few men who lives ujJ to his
conceptions of right, even though they conflict with his interest and
convenience. He has always helped in every good word and work,
and few men are held in higher esteem by those to whom he is
thoroughly known. The church at Honeoye, Potter county, now being
erected, owes much to his enterprise and enthusiasm. He is an
ardent temperance man, and in this, as in any matter of conviction,
never hesitates to speak and work for the right. This sketch would
not be complete without a few words in regard to the wife of his
youth, who has borne with him the burdens and heat of the day. and
who has, in the highest sense of the word, been a helpmate unto
him. Few women have so thoroughly fulfilled their mission as a wife
and mother as she of whom we write. No labor was ever too great,
no sacrifice too much for her to make, in order to give each child
every advantage within her power. Nor has her kindness and self-
sacrificing spirit been confined to her own home circle, no one in her
vicinity ever needing aught within her power to give. Verily, she has
walked the long pathway of her pilgrimage with feet shod with the
sandals of the peace of God. Both Mr. and Mrs. Lane have been
members of the Methodist Episcopal Church for many 3-ears.
HOMER K. LANE, druggist, Lewisville. was liorn in the town of
Sharon. Potter Co., Penn.. June 7. 1847. a son of William T. and
Sarah J. (Mead) Lane. He was given the advantages of a good
common-school education, tin 
 1238 HISTORY OF POTTER COUNTY. ishinf^ at an academy
in Kichburg, Allegany Co., N. Y. He was employed by his father, in
Sharon, in the lumbering business until August, 1867, when both
went to Blue Rock, Elk Co. , Penn. , where they were engaged in the
same business until 1874, when the father returned to Sharon,
where he still resides. Homer K., however, went to Brockwayville,
Jefferson county, where he was engaged in general merchandising
with Wellman Bros., until the fall of 1875, when he went to Union
City, Erie county, where he purchased a drag store from R. W.
Hazelton. and remained there until the fall of 1878, when he sold
out to R. W. Wilkins, and in the spring of 1879 he came to Lewisville
and bought a small stock of drugs from C. E. Hooley, and also a
stock from Chappel Bros., renting the store from the latter firm.
About 1885, his trade having been a thriving one, he erected the
store building which he now occupies at Lewisville, and in which he
keeps a large and well selected stock of drugs and medicines, tine
perfumes, toilet articles, fancy goods, school and miscellaneous
books, wall-paper and ceiling decorations, and is doing a very
successful trade. September 27, 1869, Mr. Lane married Miss Hettie
E. Huhn, of Brockwayville, Jefferson county, who bore him one son,
August 3, 1870. November 21, 1872, Mrs. Lane died of consumption,
and ten weeks later the son was carried away lay lung trouble
complicated with other disorders. December 22, 1875, Mr. Lane
chose a second bride, Miss Carrie J. Eaton, of Andover, N. Y. , and
this union was blessed, March 13, 1880, by the birth of a daughter,
Edith E. Mr. and Mrs. Lane are members of the Baptist Church. Mr.
Lane is a member of Lodge, No. 556, F. & A. M., and Ulysses
Chapter, No. 269, R. A. M. SETH LEWIS, attorney at law, Lewisville,
a son of William and Ruth A. (Bierce) Lewis, was born at Upper Lisle,
Broome Co., N. Y., January 27, 1829. His parents came to Potter
county, Penn., February 14, 1839, and located in what is now
Lewisville. William Lewis made farming his business, which he
continued until his death, September 26, 1866, his widow surviving
until February 18, 1869. They reared a family of nine children:
Crayton, Angeline, Louisa, Anna, Perry, Martha, Thomas, Seth and
Burton. Seth Lewis came to Potter county with his parents,
remaining with them until 1850. The following sis years he devoted
to agriculture, and also attended Alfred University. He then taught
school two years, and in 1860 was elected county superintendent of
schools, serving one term. In 1863 he enlisted in Company K, Thirty-
seventh Pennsylvania Militia, and September 23 was mustered into
Company A, Eighth United States Colored Troops, as second
lieutenant. He was wounded in the left thigh at the battle of Olustee,
Fla., February 20, 1864, and October 13, 1864, was wounded in the
left hand near Richmond, Va. November 28, 1864, he was promoted
to lirst lieutenant, and February 8, 1865, was made captain of
Company C. He was present at the surrender of Gen. Robert E. Lee
at Appomattox, and, on May 31, 1865, left Fortress Monroe for
Texas, reaching Ringgold barracks July 31, when he returned to
Brownsville, and was mustered out November 10, but was retained
and paid until December 13, 1865. After his return home he studied
law with Judge A. G. Olmsted, and was admited to the bar in 1867.
He iirst practiced at Union, West Va. , but returned to Ulysses, where
he is still engaged in the practice of his chosen profession. He was
also editor of the Ulysses Sentinel from Sejatember, 1882, to
January, 1888. He was married, January 30, 1851. to Sarah E.,
daughter of Adna A. and Rodentha Gridley. Their children were
Charles H. (deceased), Mary Eloise (Mrs. George A. Farnsworth),
Jessie Florence (who graduated from the Genesee Wesleyan
Seminary, at Lima. N. Y., June 20, 1889, ) and Sarah Rodentha
(deceased). Mr. Lewis is a charter member of Lewisville Lodge, No.
556, F. & A. M., and has been its secretary since
 BIOGRAPHICAL SKETCHES. 1239 its orgauization. He is also
a member of Ulysses Chapter, No. 2(59, R. A. M. , and of O. A. Lewis
Post. No. 279, G. A. E. He is an active worker in the ranks of the
Republican party, and a radical tariff man. He was elected district
attorney in 1869, and served ionr years. He was either a teacher,
school director or superintendent from the age of twenty years to
the beginning of the war, and subsequently, until the past twelve
years, was school director. Ckattox Lewis, the oldest son of William
and Ruth A. Lewis, was born at Upper Lisle, Broome Co., N. Y.,
February 11, 1813. He was married March 3, 1835, to Caroline
Hinman, and very soon after moved to Potter county, Penn. He
settled on a piece of wild land now within the limits of the borough
of Lewisville, and in a few years made it one of the finest farms in
the vicinity. He had but a limited education, but he was an
industrious reader, had a very retentive memory, and he soon
became one of the most intelligent men of the locality. He was very
benevolent, with tender sympathies and a keen sense of justice, and
he early became an Abolitionist, but when the Republican party was
formed, he joined it and remained through life a member. He early
espoused the cause of temperance, and as early as 1S43 he
circulated a pledge and procured numerous signatures, starting a
movement which resulted in the organization of Ulysses Division of
the Sons of Temperance, in 1849, and of Lewisville Lodge of Good
Templars, a few years later, of both of which organizations he was
an active and honored member. To his labors, more than to the
labors of any other man, is due the strong temperance sentiment
which prevails in the northeastern part of Potter, and which has
made Lewisville borough the stronghold of prohibition, this election
district having given at the election June IS, 1889, 125 votes for the
amendment and only seven votes against it. In August, 1857, Mr.
Lewis was thrown from a buggy and received an injury in his head,
from which he never fully recovered, and January 13, 1870, he was
killed by falling in his barn. He reared five children, all of whom are
living: Emily, now Mrs. T. E. Gridley, of Bingham, Penn.; John, living
on the old homestead with his mother; Martin, a farmer of Ulysses,
Penn. ; Fayette, a surveyor and lumberman at Genesee Forks, Penn.
, and Carlos A.. , a merchant of Lewisville. C. A. LEWIS, merchant,
Lewisville, son of Crayton and Caroline (Hinman) Lewis, was born in
Ulysses township. Potter Co., Penn., in 1850. His parents came from
Broome county, N. Y., and were among the pioneers of Ulysses
township, being the third family to settle there, locating on the farm
now owned by his mother. Their nearest mill at that time was at
Jersey Shore, a distance of sixty-five miles, and Crayton Lewis on
one of his trips thither camped out with a yoke of oxen. Having
broken his ox yoke when beyond the reach of any assistance, and
having no tools except an ax, with this he cut a beech stick of the
proper length, and, as there had to be openings made for the bows,
he split it and bound it with withes, and went on his way. At one
time his family and the neighbors were short of provisions, but he
"had a small patch of ground sown to buckwheat, which he worked
during the day, chopping in the woods by moonlight. One day when
they had not a mouthful of food in the house, except milk to drink,
and were eagerly awaiting the ripening of the buckwheat and
potatoes, as his wife stood at the door watching him at work, an
idea, all at once, oecixrred to her. Selecting some buckwheat from
the unripe crop, she picked a lot of it, dried it by the fireplace,
pounded and sifted it, and having fully prepared it, blew the horn, as
usual, for dinner. On her husband's coming to the house, he was
rejoiced and surprised to find a meal prepared from his own crop.
This old pioneer unfortunately met with an accident, which resulted
fatally; his widow still lives on
 1240 HISTORY OF POTTER COUNTY. the old homestead.
Their children were Emily (Mrs. Thomas Gridley), John, Martin,
Fayette and C. A. The last named was reared in his native township,
and during his youth was variously employed, but in 1873, locating
at Lewisville, he here embarked in general mercantile business. He
was married April 23, 1874, to Kate Gushing, and they have two
children: Irving C. and Archie C. Mr. Lewis is a member of Lewisville
Lodge, No. 556, F. & A. M. In politics he is a Republican, and has
served as school director, auditor, and in minor offices of trust.
CORNELIUS H. LOUCKS, P. O. Ulysses, son of Cornelius and Naomi
Loucks, was born in Cortland county, N. Y., in 1831. His parents
came to Hector Township, Potter Co., Penn., and located on the farm
now owned by Clarence Stiles, where the father was a lumberman
and farmer, and where they both died. Their children were Mary J.
(Mrs. Russel Potter, of Skaneateles, N. Y.), Cornelius H., Mehitabel
(deceased), Betsy (deceased), Steven L. (who enlisted and died in
the army, aged twenty-sis years) and William J. Cornelius H. Loucks
remained with his parents until 1853, when he married Arty C.
Calkins, and located on the farm adjoining the old homestead, where
they remained several years. In 1864 he enlisted in Company G,
Fifty-third Pennsylvania Volunteers, and on Friday, March 31, 1865,
in battle in front of Petersburg, Va. , he received a wound in the left
shoulder joint which necessitated the amputation of his arm. He was
discharged June 12, 1865, and returned to his old home,
subsequently removing to Lewisville, where . he now lives. His wife
died, leaving four children: Frank (since deceased), Darius, James
and John, and March 26, 1883, he married Mrs. Louisa V. Stout,
daughter of James J. Stewart. Mrs. Loucks is a member of the
Methodist Episcopal Church. Mr. Loucks is a member of O. A. Lewis
Post, No. 279, G. A. R; in politics he is a Republican, has been
supervisor of Hector township, and has held various offices in his
township. GEORGE MERRILL, contractor and builder, Lewisville, son
of Erastus and Elizabeth (Ayer) Merrill, was born in Ulysses
Township, Potter Co., Penn., in 1838. His parents were natives of
Vermont, and each, with parents removed to Broome county, N. Y.,
where they married, and in February, 1838, located in Ulysses
township. Potter county, where the father of our subject was a
farmer until his decease in 1884. The mother still has her residence
on the old homestead with her daughter, Mrs. Caleb Gridley. Their
children were Warren (who died when nineteen years of age),
Obediah, Harriet (deceased), George Lyman, Esther (Mrs. Gridley)
and Henry (deceased). George was married in 1864 to Amelia
Kidney, of Wyoming county, after which he located in Lewisville,
where he is a contractor and builder. Their children were Henry (who
died when eleven years of age), Herbert and Maud. Mrs. Merrill is a
member of the MethodLst Episcopal Church. In politics Mr. Merrill
affiliates with the Prohibition party, having formerly been identified
with the Republican party. He has held various township offices. O.
A. NELSON, merchant, Lewisville, son of Henry and Speedy (Clark)
Nelson, was born in 1845, near Colesburg, on the place now owned
by F. A. Nelson, in Allegheny township. Potter Co., Penn. He made
his home with his parents until 1864, when he traveled for several
years, and engaged in various occupations. In 1875 he married Ellen
M. , daughter of A. F. and Juliette (Grove) Raymond, and located at
Gold, on her father's farm, where they remained a year. He then
worked at his trade (carpenter and joinei'), and was also in the stock
business, until his removal to Ceres, where he embarked in the
mercantile business. Later he moved to Lymansville. where he was
engaged in selling wagons, buggies and harness, afterward locating
 BIOGRAPHICAL SKETCHES. 1241 for a time in Austin. In
November, 1887, he moved to Lewisville, where he is engaged in the
clothing and gents' furnishing goods business, the firm name being
Nelson & Presho. In politics Mr. Nelson is a Democrat. MRS. KATE
STEARNS PARKER, P. O. Ulysses, daughter of Anson S. and Betsy
(Blackman) Bart (now deceased), was born in Cortland county, N. Y.,
in 1829. Her maternal grandfather, James Blackman, was a native of
Pittsfield, Mass. , where he married Elizabeth Andrews, and came to
Potter county. Penn., in 1834, locating in Ulysses township, where
they lived the rest of their lives. Their children were Betsy, Sally,
Anson, Dennis and Laura (the late Mrs. Edmund Alvord). Anson S.
Burt was a native of Pittsfield, Mass., where he married, and in the
spring of 1832 located in Ulysses township, Potter county, about a
mile east of the village, where he bought a hundredacre farm, which
at that time was wild land, he being obliged to cut his own roads.
His children were Laura (deceased), Sally (Mrs. William Canfield, of
Willett, Cortland Co., N. Y. ), James T.. William F.. Betsy (the late
Mrs. Charles Monroe), T. W., and Kate S.. who married Thomas
Parker in 1846, a prosperous farmer of Ulysses township. Mr. Parker
died July 26, 1.SS3. W. B. PERKINS, farmer. P. 0. Newlield, son of
William'M. and Marissa M. (Dean) Perkins, was born August 28.
1861. in Ulysses township, Potter Co.. Penn., on the farm he now
owns. His father was a native of Andover, Allegany Co., N. 1'., and
his mother of Potter county, Penn. After their marriage they located
at Independence, Allegany Co., N. Y.. but sold and removed in the
spring of 1850 to the farm now owned by W. B. ; in the spring of
1886 his father removed to Sweden township. Mrs. Perkins died in
the spring of 1862, leaving three children: Luther L.. Manson B. and
W. B. Mr. Perkins afterward married Fannie Gloss, their children
being Arthur and Rosa. W. B. made his home with his parents until
1877. when he went to Deerfield, Tioga county. Determined to
secure an education, he worked for S13 per month, and when his
father learned of his laudable efforts in that direction, he cheerfully
loaned him .?800, which enabled him to complete his education at
the State Normal School at Lock Haven, and from which he
graduated in 1883. While at the State Normal School he joined the
Baptist Church, and, becoming interested in Sabbath-school work,
was made its superintendent, and at the county convention, or pic-
nic, each superintendent was supposed and expected to deliver a
speech; his was so elaborate, and so far beyond what had been
expected, that he soon received urgent invitations to attt-nd" their
theological seminary, at Lewisburg, Union Co.. Penn., and after
repeated solicitation accepted, remaining a year, when a change in
his religioiis views induced him to sever his association with that
institution. After leaving school he located on the old homestead,
and engaged in business as a farmer and dairyman. He continued
the dairy until the close of the summer of 1888, when he sold his
cows and invested the proceeds in horses. Mr. Perkins married Mary
A. Bigony, and they have a family of four children: Guy S., Marissa
D.,"Sally B. and Samuel B. Mr. Perkins is a member of Lewisville
Lodge, No. 556, F. & A. M., and Ulysses Chapter, No. 269, R. A. M.
He is a Democrat in politics, and has held various official positions in
the township. A. F. RAYMOND, merchant and farmer, P. O. Gold, was
born in Tompkins county, N. Y., November 3, 1825. In 1836 his
parents moved to Potter county, Penn., and settled in Allegheny
township, where his father bought a tract of wild laud. He remained
at home until after his marriage, and then bought a part of the old
homestead, where he has since lived. He has a good home, and
attends to the cultivation of his farm, at the same time carrying on a
general merchandise business in Gold. He was married in 1850 to
Miss Juliet
 1242 HISTORY OF POTTER COUNTY. Groverof Bingham
township and they have five children: Frank A., of Gold; Ellen, wife
of Oscar Nelson, of Ulysses; Fred H., of Ceres; Kate L., wife of Wilton
Elliott, and Matilda. Mr. and Mrs. Raymond are members of the
Baptist Church. He is a member of Gold Lodge, No. 658, E. A. U.
AMOS RAYMOND, P. O. Gold, son of Daniel and Amanda (Freeland)
Raymond, was born in Tioga county, N. Y., September 24, 1821, and
with his parents came to Potter county, Penn., in March, 1830. They
located in Allegheny township, at that time a wilderness, and cleared
a farm, the nearest marked tree being at what is now Ford Nelson's,
in Allegheny township, and there was no wagon road within three
miles. They were compelled to go to AVilliamsport for corn, which at
that time was worth $3.50 per bushel, in Potter county, and suffered
all the other privations incident to the settlement of a new country.
Their children were Lucinda, Amos, Daniel, Asa, Alvira, Perces,
David, Joseph, Mary and Betsy. Amos made his home with his
parents until his marriage, when he located in Allegheny township,
but now resides on the farm he owns in Ulysses township, which he
has carried on for some time. He has also devoted some time to
contracting, was a merchant for several years, and also for several
years was proprietor of a hotel at Raymond's Corners. He was
married, March 31, 1842, to Rhoda Daniels, and they had six
children : Harriet Lovina, Alice Lavina, Asa A. , Miriam J. (who died in
1852 ), Josephine R. and Sarah J. Mrs. Rhoda Raymond departed
this life November 26, 1876, and Amos Raymond, on March 15,
1878, married Miriam Daniels. Mr. and Mrs. Raymond are members
of the Baptist Church. In politics he is a Democrat, and has held
various official positions in the township. HENRY T. REYNOLDS, P.O.
Uly.sses, son of Foster Reynolds, was born in Hebron township.
Potter Co., Penn., in 1834. His father was a native of Rensselaer
county, N. Y., where he married Fannie Potter, removed to Hebron
township in 1831. and engaged in farming. He built two mills — one
water and one steam power. They reared a family of five children:
Steven P., William C, Henry T., Sarah and Celestia. The parents, with
two daughters, are now residing in Jefferson county, Kansas. Henry
T. Reynolds received his education in the Potter county schools,
remaining with his parents until his majority. After his marriage he
located on the farm he now owns in Ulysses township, and engaged
in agriculture. He was married in 1857 to Margaret Weidrick, and
they have four children: Willard E. , Nellie E. (now Mrs. Henry
Francis), Nettie F. (now Mrs. Arthur Bice) and Foster. Mr. and Mrs.
Reynolds are members of the Episcopal Church. He is a member of
Lewisville Lodge, No. 556, F. & A. M. , Ulysses Chapter, No. 269, R.
A. M. In politics he is an active Republican. He was elected sheriff in
1868, serving three years. In 1887 he was elected associate judge,
and is now serving his term of live years. He has always been
prominent in local politics. August 16. 1862, he enlisted in the
defense of his country in Company K, One Hundred and Forty-ninth
Pennsylvania Volunteers, or Second Regiment of Bucktails; sixteen
days later he was promoted to second lieutenant, and May 1, 1863,
was made first lieutenant. He was wounded three times at the battle
of Gettysburg, and was captured; March 13, 1864, he was
discharged on account of disability, and returned to his home in
Ulysses township. He now lives in Lewisville. He is a charter member
of O. A. Lewis Post, No. 279, G. A. R., of which he is adjutant. E. A.
WAGNER, retired, P. O. Ulysses, son of Abram Wagner, was born in
Oneida county, N. Y., in 1826. His parents removed to Steuben
county, N. Y. , and thence to Ulysses township, Potter Co., Penn., in
1842, locating on the farm now owned by Frank Wagner. They
located in the woods and
 BIOGRAPHICAL SKETCHES. 1243 cleared a farm, which
they made their home until the father's death in 1876; the mother
died in 1879. Their children were born in the following order: Mrs.
Lorenzo Drake, Andrew J., Frances M., Edward A., Mrs. J. N. Crowell,
Mrs. J. T. Burt, Mrs. -J. A. Brown, Gratton H., James B., Mrs. A. G.
Stewart, Mrs. C. T. Halleck and Mrs. L. Dean, all having homes of
their own. E. A. Wagner has from _youth followed agricultural
pursuits. His first location was in Ulysses township, on the farm now
owned by Charles Crowell; then at Kibbyville, in 1851, where he
lived until 1871, when he removed to the borough of Lewisville,
where he has since lived, and having secured a competency, has
retired from active life. Politically he is a Republican. He has been a
member of the council two terms; street commissioner, school
director, nine years, and township assessor. His wife, to whom he
was married in 1819, was formerly Miss Angeroua Crowell, daughter
of David Crowell. ALLEGHENY TOWNSHIP. A. W. ANDREWS, farmer,
P. O. Andrews Settlement, son of Levi and Polly (Porter) Andrews,
was born in Spring Mills, Allegany Co., N. Y., in 1824. His jjarents
removed to Bingham township. Potter Co., Penn., in 1825, where
they remained until 1833, when, with household goods loaded on a
wagon, and drawn by three yoke of oxen, they proceeded on their
way to what is now Andrews Settlement, named in honor of Levi
Andrews. When about a mile from Ellisburg, the snow being knee
deep, and it being springtime and just in the midst of a freshet, they
discovered a bridge had been washed away, but by chopping a tree,
which fortunately fell across the stream, they were enabled to cross,
the oxen swimming the creek. Having a cow and calf, Mr. Andrews
carried the calf over in his arms, and the cow followed through the
creek; they had to walk about a mile through water knee-deep to
reach a stopping place, and, it is superfluous to add, were in an
exhausted condition. This but feebly illustrates the adventurous
career of pioneers in this county. They eventually reached their
destination, locating in the woods and clearing a farm. They had a
family of ten children: Chester; Cloe; Lawson; Maria, afterward Mrs.
Timothy Ives, of Coudersport; Louisa, now Mrs. Isaac Prink, of
Hebron township; Lowata, wife of Bartell Dickinson, of Ellisburg;
Sally, now Mrs. Samuel Newell, of McKean county; Orren; Susan,
now Mrs. Benjamin S. McConnell, of Canisteo, Steuben Co., N. Y. ,
and A. W. Louisa, Sally, Susan and A. W. are the only ones living.
The father died in March, 1861; the mother had died of cancer on
February 10, 1844. A. W. Andrews made his home with his parents
until their death. In 1859 he located on the farm he now owns in
Andrews Settlement, where he has since devoted his attention to
agriculture and the lumber interest. While a boy, Mr. Andrews
chopped cord-wood in the winter time in his stocking feet, heated
boards or slabs being brought to him upon which to stand; he has
hunted cows barefooted, and been pricked with nettles until actually
compelled to stand in the mud, the only method of relief. But
notwithstanding all these experiences, he has been successful, and
now owns a fine farm with good buildings, and is the possessor of a
competency. He was married, in 1859, to Martha N. Scoville, of
Harrison township, and to them have been born six children: Luman
F., Roscoe, Florence (now Mrs. Clinton Olmsted, of Emporium), Fred
and Frank (twins) and Arch. Mr. and Mrs. Andrews are members of
the Presbyterian Church. He is an active supporter of the Democratic
party. REV. EDWARD D. CARR, P. O. Raymond, is a son of George
and Nancy (Griswold) Carr. E. D. Carr was born in Dryden. Tompkins
Co., N. Y., December 29, 1819. His parents were married August 22,
1813, and
 12-44 HISTOBY OF POTTER COUNTY. removed to Almond,
Allegany Co., N. Y., in 1835, remaining until about 1857^ when they
came to Hector township. Potter Co., Penn., where they purcliased a
farm and built a residence. The mother died about 1878, in North
Almond, Allegany Co., N. Y., and the father April 13, 1870, in Hector
township, Potter Co., Penn. Their children were Mariett (born March
28, 1815), Syble A. (born December 10, 1816), Susan (born
December 12, 1818, now deceased), Edward D. (born Decemlier '29,
1819), Stutely H. (born January 11, 1822), George S. (born
December 23, 1823, now dead), and G. N. (born August 15, 1826).
Edward D. made his home with his j^arents until manhood. He tirst
located in West Almond, but later removed to Hector township,
where he was a local preacher. He, however, changed his residence
to Knoxville, for the purpose of affording his children better
educational advantages. In 18(32 he enlisted as a private in
Company G, One Hundred and Forty-ninth Pennsylvania Volunteers,
and was mustered out in April, 1865. He returned to his home, but
soon after removed to Wellsville, N. Y., where he remained eleven
years; thence moved to Spring Mills, N. Y., thence to Kansas, and
finally returned to Potter county, purchased the farm he now owns,
and has since been engaged in farming. While in Kansas he was for
five years engaged m the ministry, and organized seven churches.
He was married, December 11, 1845, to L. S. Schoonover, and their
children are Lenora M. (now Mrs. George Presho), Mary A. (who died
at the age of five years), Emma Lucine (now Mrs. Robert Allison),
George Norman and Edward Augustus. His son and daughter,
Edward A. and Emma L., belong to the Methodist Episcopal Church.
Mrs. George Presho belongs to the Presbyterian, and George
Norman to no church. WILLIAM CURRIEE, proprietor of a saw- and
grist-mill, Andrews Settlement, is a son of Daniel and Martha
(Gilliland) Currier, and was born in Andrews Settlement in 1863, on
the place now owned by his parents. Daniel Currier was born in
Cattaraugus county, N. Y., and Martha (Gilliland) Currier in the town
of Cuba, Allegany county, same State. His parents came to Potter
county in 1849, and located in Hebron township, where his father
worked in a lumber-mill until their removal to Elk county, in 1853. In
1859 they returned to Potter county, and located where they now
have their home. Their children are Mary J. (now Mrs. C. Tucker)
James (both born in Hebron, Potter Co., Penn.) and William. James
was married to Kate Bishop, daughter of Squire Bishop, of Andrews
Settlement. William, whose name heads this brief sketch, was born
and reared on the old homestead, and was given a good common
school education. Since reaching manhood he has been engaged in
the lumber business, and built a steam saw- and grist-mill, shingle-
and planing-mill, which he operated and eventually removed it to the
present place of business. The saw-mill has a capacity of 10,000 feet
per day, and the shinglemill is capable of turning out 10,000 shingles
per day. He was married to Hattie Carpenter, of Angelica, on
December 18, 1889. Mr. Currier is a prosperous young man, and is
the owner of one of the principal business enterprises of his
township. WILLIAM H. MATTESON. merchant. Andrews Settlement,
son of Elias Matteson, was born in Whitesville, Allegany Co., N. Y. , in
1841. He was reared and educated in his native county, also in Yates
and Ontario counties, and in 1863 enlisted in Company G,
Eighteenth New York Voli;nteers. He was mustered out in the same
year and re-enlisted in the Fiftieth New York Engineers, and
remained in the service until the close of the war in 1865. He then
returned home, and soon after located in Allegheny township. Potter
Co., Penn., where he engaged in farming, which he continued until
1885, when he
 BIOGRAPHICAL SKETCHES. 1245 removed to Raymond's
Corners and embarked in the mercantile business, and in October,
18S7, came to Andrews Settlement, where he hae since conducted a
general mercantile store. In 1860 he married Nettie, daughter of
Marcus Wildman, of Allegheny township. Their children are Fannie
Maud (now Mrs. Samuel Hancock, of Ellisbnrg) and Merton W. Both
Mr. and Mrs. Matteson are members of the Methodist Episcopal
Church. He is a member of Coudersport Post, G. A. R; is an active
supporter of the Republican party, and was elected county
commissioner in 1S84. serving one term, and has held various
otficial positions in the township. GEORGE NELSON, farmer, P. O.
Colesburg. son of Silas and Cynthia (Felt) Nelson, was born in
Hebron, Washington Co., N. Y. , in 1816. His parents located at
Lymansville, Potter Co., Penn., about 1822, and engaged in farming.
Their children were Horace, George, Ira, Cephas, Leroy, Lucinda
(Mrs. Jack Brown, of Millport) and Sarah (Mrs. J. R. Miller, of Sweden
township). Mrs. Nelson died in 1832, and Mr. Nelson for his second
wife married Mary A. Bellows. Their children were Cynthia, L.,
Darwin, Kilborn (deceased), Caroline, Louise Etta, Philena, Dora Cass
and Lester. Mr. Nelson was a soldier in the war of 1812, and in
October, 1818, received an injury from which he never fully
recovered; he died about 1868, and Mrs. Nelson died in 1888.
George made his home with his parents until 1839, when he married
Abigail Cannon, and located on the farm he now owns in Allegheny
township, where he built the tirst saw-mill (water power) in that part
of the county. To Mr. and Mrs. Nelson have been born three children:
Helen M. (now Mrs. Samuel W. Copeland, of Dolonga, Ga.), Eli H.
and Adolphus I. The last named enlisted in Company G, Fifty-third
Pennsylvania Volunteers, and was killed at the battle of Antietam. Mr.
Nelson is a supporter of the Democratic party, and has held various
ofdcial positions in the township. FORD A. NELSON, P. O. Colesburg,
son of Henry Nelson, was born in Allegheny township, Potter Co.,
Penn., in 1843. He made his home with his parents until about
twenty-five years of age, after which he purchased the old Nelson
homestead, where he has since lived, combining the lumber
business with that of farming. He was married in 1869 to Bettie,
daughter of John H. Heggie, of Allegheny township, and they have
had two children: Ray H., who died at the age of eleven years and
nine months, and Harry L. , now a promising boy of eleven years.
Mr. Nelson is a supporter of the Democratic party. In 1883 he was
elected commissioner of Potter county, served one term of three
years, and in 1886 received the nomination for treasurer, but was
defeated by only forty-three votes. He is one of the enterprising men
of Potter county. JOHN PEET, farmer, P. O. Colesburg, son of John
and Sarah (Morehouse) Peet, was born in Eulalia township. Potter
Co., Penn., in 1819. His parents came to Potter county in 1811 and
took up a tract of land, John Keating presenting him with fifty acres
to induce him to locate here, the family being the fourth in the
county, Isaac Lyman, Benjamin Burt and William Ayers being the
other three. They endured all the hardships and privations peculiar
to a new and almost unexplored country; their nearest grist-mill was
at Jersey Shore, and it took about eighteen days to go and return.
The nearest postotfice was at Williamsport. The children of John and
Sarah Peet were Mary, deceased wife of David Worden, of Iowa;
William (deceased); Rhoda, deceased wife of Seth Taggart, of Eulalia
township; Susan and Samuel (the first twins born in Potter county;
Susan is now Mrs. William Worden of Iowa; Samuel is deceased);
Abigail, the sixth child, was married to William Jackson, moved to
Erie county and then died; John is the seventh; Sarah married David
Colcord,
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