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Mark (name changed), a 66-year-old male, presented at Coral Desert Rehab with pneumonia, COPD, diabetes mellitus, hypertension, and most notably, bilateral BKA. He had previously been admitted to an acute hospital following surgery resulting in L BKA, but he checked back into the hospital after coming down with pneumonia, after which he came to Coral Desert.

In his initial evaluation, physical therapists noted the patient’s goal to return to living independently with functional transfers and household ambulation and noted his “good rehab potential.” The task ahead was monumental, as the patient had fallen twice in the last year, was unable to complete any functional tests or measures, and was Max-to-Mod Assist on all transfers.

Treatment

Initial treatment focused on regaining ROM and strength in the patient’s LEs, transfer training, UE strengthening and core stability. While the patient was highly involved and motivated in his rehabilitation, at one week of treatment, he was unable to make any progress on any short-term goals.

Oxygen saturation, dyspnea upon exertion and overall weakness remained serious barriers to progress, and the patient still required Mod-Max Assists for most transfers. After having been treated for just over a month, while a few of his transfer levels had gone from Mod to Min Assist, the patient’s inability to ambulate limited any further progression and visibly frustrated the patient.

Turning Point

Four weeks after being admitted to Coral Desert, the patient’s lead physical therapist brainstormed an idea to get the patient spending more time upright and headed toward ambulation. The patient stood in parallel bars upright on his RLE and his LLE on a stool. This was progressed to having the patient ambulate within the bars, sliding the stool along with him. Then, the stool was replaced by a knee caddy placed backward to support the LLE.

Once the patient adjusted to this new setup, he progressed to ambulating outside of the parallel bars with the knee caddy facing forward and therapists guarding both sides. The patient loved being upright and the feeling of walking again, and it seemed to lift his spirits greatly.

Carpe Ambulation

After six weeks at Coral Desert, the patient’s doctor had expressed that the patient just wasn’t strong enough and that plans for a second prosthesis should not be followed as the patient wouldn’t be able to walk.

However, the patient was dedicated during rehab sessions and even put in extra time after-hours. Soon, he was able to show off his progress while ambulating with the knee caddy while representatives from a prosthetics company observed. He impressed them enough that plans to get his second prosthesis were put in place. Within several days, a temporary prosthetic was being fitted.

Conclusion

Throughout treatment, clinical expertise and results implied that the patient would struggle given the opportunity to not only perform a sit-to-stand transfer, but also ambulate with both prosthetics. However, once the prosthetic was on, Mark not only stood up with only CGA, but also proceeded to walk on both prosthetics much better than expected for 50 feet, with a therapist only occasionally giving a Min-Assist and mostly just Contact-Guard Assist.

In the following sessions, Mark also began training to step up one step, weight-shift between his legs, and continue increasing his ambulation distance. Although Mark still has impairments to overcome, his progression increased exponentially upon spending more time upright. This has not only allowed his strength and functional mobility to greatly increase, but has led to his prognosis to eventually return home as well. Mark’s story is an amazing example of the power of both physical therapy and of giving people a chance.

Submitted by Coral Desert Rehabilitation, St. George, UT

Research indicates that older adults treated with a “client-centered” focus and approach show positive results in meaningful engagement, socialization, activity tolerance, UB/LB strength, ADLs, IADLs, balance, emotional well-being, motivation, participation and overall quality of life (Law, 2002). Our goal is to improve the overall quality of life for Carrollton Health and Rehab residents by including meaningful functional activities of choice in our clients’ treatment plans.

Process

We began our research by meeting as a rehab team and reviewing our current treatment approaches. Through our discussion, the Carrollton Health and Rehab team identified the following process to better assist our clients:

1. Identify clients’ occupational needs
2. Provide active and meaningful tasks that engage our clients
3. Evaluate their occupational performance based on functional activities provided

Evaluations

In order to assess client needs, our therapists used the following standardized assessments to assist in addressing occupational performance:

• Physical Therapy: Tinetti, Timed Up and Go, 30-second sit to stand, Berg balance
• Occupational Therapy: Canadian Occupational Performance Measure, BaFPE, Kels, Activity Index & Meaningfulness of Activity, Florey Occupational Role and screen interview, Leisure Profile for Adults/Seniors
• Speech Therapy: MOCA, SLUMS

Interventions

• PT: Treatments to improving gait and balance included walking outdoors on uneven surfaces, playing sports, dancing, and cultural group with activities that were fun and challenging
• OT: Treatments included cooking, decorating during holidays, crafts, planting, flower arranging and any meaningful client-oriented functional task
• ST: Treatments included medication management, menu reading, playing fun cognitive games and tasks to assist with cognition

Results

Therapists evaluated their interventions by answering an informal yes/no survey and program evaluation. The overall findings were that the therapists at Carrollton Health and Rehab were successful in providing fun, functional tasks to help their clients achieve their overall goals and to improve quality of life.

By Julie Hebert, OTR, OTD, Carrollton Health and Rehabilitation Center, Carrollton, TX

In March 2016, 43 Milestone therapists and assistants attended “Clinical Pathways for Successful Orthotic Contracture Management Therapy” taught by John Kenney. The course included instruction in NeuroStretch, a technique that stimulates the Golgi tendon organ at the muscle-tendon junction and creates an inhibitory effect on the muscle.

This technique can be used effectively with neuro-contractures where there is a neurological opposition to stretch and adaptive tissue shortening. Contractures can lead to skin breakdown, increased difficulty with personal care and hygiene, impaired mobility and increased pain. The following illustrates the results of incorporating NeuroStretch with a 35-year-old sub-acute resident.

NeuroStretch Case Study

The resident has a history of a TBI with resultant spastic quadriplegia. He had developed progressive contractures in the bilateral elbows, wrist, fingers and ankles.

Intervention included:

• Assessment of resting position and tone using the Modified Ashworth Scale
• Application of moist heat
• Use of NeuroStretch PROM/low load prolonged stretch followed by application of a splint (modified as needed) for two to four hours, five times per week
• Training of RNA staff in using the NeuroStretch technique and proper application of splints
• Follow-up and re-evaluation post-treatment to evaluate splints and modify as needed

Results

Using NeuroStretch, the patient’s left elbow flexion contracture improved PROM by 18 degrees, while the right plantar flexion contracture improved PROM by 25 degrees. Factors impacting results included different clinicians measuring PROM and two different RNAs performing PROM and don/doffing splints. We also noted that our resident’s PROM was affected by visual external cues, so we were careful to create an environment conducive to relaxation.

Conclusion

Based on this case study, we have concluded that communication and collaboration between therapy, RNA and nursing is important for effectively managing contractures. Having one designated RNA doing all PROM for residents (with carryover of weekend CNA staff) produced the best results. To ensure the greatest success, our therapy team works collaboratively with the entire clinical team in managing contractures.

Submitted by St. Joseph Villa, Salt Lake City, UT

Person-Centered Dementia Management, a Montessori-Inspired Program

At Legacy Rehab and Living, the protocol is a referral to therapy for any patient with a dementia diagnosis, a decline in function, and/or increased adverse behaviors with a goal to reduce psychotropic medications.

With these patients, we complete a comprehensive Life History Profile to develop personalized activities that tie in to the resident’s interests. We also administer the Allen Cognitive Level Screen/Allen Diagnostic Module to determine the resident’s cognitive levels and cognitive capabilities.

Motivating Patients

We value and appreciate each individual with dementia at Legacy Rehab and Living. We design interventions to facilitate the highest level of independence and to reduce adverse behaviors.

We begin by discovering activities that each resident enjoys to help motivate them to participate. By examining a resident’s preferred activities, cognitive capabilities, past experiences and remaining abilities, we are able to design meaningful activities that are appropriately adapted to the individual. Activities are:

• Modified to be the just right challenge for the resident’s cognitive ability
• Designed to engage all five senses
• Designed to be meaningful and to provide the individual with dementia a purpose for an improved quality of life

Outcomes

Using this approach with dementia patients, we have seen a decrease in psychotropic medications, a decrease in behaviors, an improved quality of life and patient/family satisfaction, and improved quality measures. Above all, we strive to understand each person’s past in order to connect to their present and set them up for success at our facility.

By Marisa Parker, MS, CCC/SLP/DOR, Legacy Rehab and Living, Amarillo, TX

As you may know, treatment for a total hip arthroplasty and/or total knee arthroplasty involves surgical repair, stabilization and post-acute rehabilitation. While costly, these procedures often improve quality of life for patients.

At the same time, the costs of rehabilitation have been on the rise, and the Centers for Medicare and Medicaid Services has developed policies to ensure rehabilitation treatment is given in an appropriate setting.

At Palm Terrace Skilled Nursing Facility, we have undertaken a project that focuses on clinical outcomes for THA and TKA patients who choose to recover at a skilled nursing facility. We strive to inform patients and medical stakeholders of the potential clinical outcomes when SNFs are used to provide rehabilitation at a reduced cost and with positive results.

Through careful literature review, quantitative coding, data collection and analysis, we are able to observe the following results:

• The outcome measures display a significant improvement from baseline records to discharge.
• The option for post-acute rehab at an SNF will reduce costs while providing optimal care and recovery for THA and TKA patients.
• Patients show improvements in all the outcome measures with the exception of maintaining a baseline for negotiating stairs during their stay at an SNF.
• Providing both occupational therapy and physical therapy enables post-acute patients to have a longer stay in a facility that offers rehabilitation at a lesser cost compared with a hospital stay.
• This study revels that a THA or TKA patient can return home with significant improvements.

Continued research is needed to determine which setting would be the most appropriate for THA and TKA patient rehabilitation. However, we are encouraged by the results of our study thus far. We have seen patients undergo rehabilitation at our SNF and return as close as possible to their prior level of function for ADLS in the least restrictive environment.

Submitted by Palm Terrace Skilled Nursing Facility, Laguna Hills, CA

Time and again, we see the benefits of an interdisciplinary approach to therapy with our patients at Rosewood Rehabilitation Center. Take, for instance, the case of our patient who was hospitalized due to Guillan-Barre Syndrome with symptoms of progressive weakness and impaired coordination. Our combination of physical and occupational therapy created a pathway for success with this patient.

Prior to the hospitalization, the patient was living with a spouse in a country home and was independent with all ADLs, IADLs and functional mobility without an assistive device. We recognized the following factors as being critical to the patient’s success at our facility.

Keys to Success With Physical Therapy

• Neuro PENS three times per week with electrodes on the hip flexors and vastus medialis, and another line from just distal to the ischial tuberosities to the belly of the hamstring group.
• HEP exercises for completion outside of therapy from the SOT.
• Lateral and anterior/posterior weight shifting to increase proprioception at the ankles.
• Use of the spectrum of assistive devices for ambulation fluidly during progression, from the parallel bars to a single point cane. With progress, we would constantly revisit more restrictive devices to refine a specific aspect of the gait pattern.
• High and appropriate family involvement.

Keys to Success With Occupational Therapy

• High cognitive function, active/fit before onset and motivated
• CNA and family training to ensure carryover with OOB schedule and HEP for fine motor and UE strengthening
• High and appropriate family involvement
• Knowing your tools: E-stim versus therex versus fine motor activities, such as theraputty, to address deficits
• Continuous evaluation of deficits and active grading up and down for the Just Right Challenge

This is just one example of a success story at our facility. We continue to explore the best ways to provide rehabilitation services for each individual using this interdisciplinary approach to care.

By Craig Chang OTR, Scott Judd PT, & Kristen Weaver OTR, Rosewood Rehabilitation Center, Reno, NV

Holladay Healthcare has been developing programs to assist people with Parkinson’s disease. We currently provide both the LSVT BIG and LSVT LOUD therapy treatment approaches by licensed and certified PTs, PTA and SLP. These approaches focus on improving amplitude of motor movements and voice projections, due to the decrease of these processes associated with Parkinson’s disease.

To go along with our LSVT therapy, Holladay Healthcare started providing tai chi classes to the community last year. We have been working with the Mountain West Parkinson Initiative (formerly known as the Utah Parkinson Association) to help increase awareness of these classes.

Tai chi involves a series of slow, rhythmic, meditative body movements that were originally designed to promote inner peace and calm. There are many benefits of performing tai chi, including balance/fall prevention, strength, flexibility, endurance, coordination, gait and decreased stress.

There are quite a few research studies being published about the benefits of tai chi as a viable exercise routine for people with Parkinson’s disease. For example, a randomized control trial published in The New England Journal of Medicine in 2012 researched the use of tai chi to improve postural stability for fall prevention. This study performed tai chi twice a week for 24 weeks and compared it with two other groups who performed a resistance training program or a stretching program.

Their results showed that the tai chi group performed better than the other two groups in their primary outcomes of maximum excursion and directional control. Tai chi outperformed the resistance group in stride length and functional reach; it also outperformed the stretching group in all secondary outcomes, which included stride length, knee extension/flexion strength, functional reach, and timed up and go test. Patients who participated in the tai chi group also had fewer reported falls during the study compared to the other groups. The gains made during the 24-week study were maintained three months following the study.

Here at Holladay Healthcare, we have been able to offer tai chi once a week for eight weeks. We are finishing our fifth class and have been able to help several people in our area with Parkinson’s disease. The community is starting to recognize us as a center to provide Parkinson’s treatment. Holladay Healthcare presented tai chi on Oct. 22 at the Mountain West Parkinson Initiative’s annual Parkinson Symposium.

References:

1. http://www.medicinenet.com/tai_chi/article.htm

2. Li F, Harmer P, Fitzgerald K, et al. Tai Chi and Postural Stability in Patients with Parkinson’s disease. N Engl J Med 2012;366:511-9

By Jeremy McCorristin, PT/DPT and DOR, Holladay Healthcare, Salt Lake City, UT

In the post-acute rehabilitation setting, we see many different types of patients from different socioeconomic backgrounds, ethnicities and cultures, as well as different prior levels of function. As occupational therapy professionals, it is our job to identify the needs of our different patient populations and address a treatment plan that allows for a safe return to prior levels of function. Oftentimes, this includes our independent activities of daily living in our community-dwelling older adult population. I strongly feel that while basic ADLs definitely have a role in the SNF setting, with insurance companies constantly looking for progress in these areas, IADLs have been largely overlooked in this setting.

At my facility, I have been working diligently to expand our role with IADL retraining. I believe that IADLs are not only important for a successful return to a prior level of function, but also as a treatment modality to be implemented according to our occupation-based principles. In my experience, many patients demonstrate improved standing activity tolerance, functional reach and dynamic balance when engaged in valued IADL tasks.

As such, my goal with this article is to encourage and provide resources for occupational therapy departments in developing IADL programs. Of importance to note is that the majority of the items for these programs were purchased from dollar stores or using items already around the rehab department. If you have additional questions, feel free to contact our department.

Meal Preparation/Cooking

When addressing meal preparation or cooking, we first identify the patient’s prior level of cooking. In order to best assess safety with these different aspects, we obtained a hot plate to simulate a stovetop and a toaster oven to simulate an oven, in addition to the microwave we already had available in our kitchen. Besides the standard safety assessment with cooking (can the patient turn off the hot plate/stove, reach all necessary items and handle hot items with caution?), it is also important to assess the ability to follow multi-step directions. Challenge the patient or adapt/grade the task accordingly from a three-step meal to a five-step meal and vice versa.

Grocery Shopping

For grocery shopping, I created a simple activity using items purchased from the dollar store or found around my home. With the help of our rehab aide, we affixed labels as price tags to the food items and created various shopping lists. Each shopping list incorporates different levels of difficulty. With the task, the patient can also practice money management and organizational skills, as well as identify potential issues related to item retrieval tasks with a new AD.

Community Reintegration

Depending on the socioeconomic status of the patient, both the physical therapist and the occupational therapist can be important in addressing community mobility options for the patient. Community mobility can be important in the patient’s ability to attend future medical or outpatient therapy appointments. As such, we developed a public transportation program to enhance our community reintegration services. The patient can practice identifying bus routes and estimating times and can even participate in an actual bus outing.

Medication Management

One of the first steps we try to address with new patients with a high PLOF is to assess their ability to manage new medications using an assessment tool. We can also practice using the patient’s own medication regimen and

beads to improve the patient’s ability to manage medications upon discharge. Furthermore, we are able to provide necessary recommendations regarding the type of pillbox (one time per day, two times per day, four times per day, etc.) and potential need for assistance or reminders via a phone or an alarm.

Other IADLs

In addition, other IADLs and leisure tasks can also be important to address in improving functional outcomes for our community-dwelling population as well as improving motivation with participation in therapy programs. Other programs that we have expanded upon at our facility are gardening, laundry and item retrieval tasks. My next project and goal is to develop a simulated pet care program to include feeding, washing and grooming, as many patients state this as one of their main goals and prior activities.

By Kathryn Case, OTR/L, Magnolia Post Acute Care, El Cajon, CA