Danielle Kistler, OTR/L, is a new CLT at Holladay Healthcare. We are so excited to have a CLT at our facility, and we are already seeing some great successes with her interventions. We have an LTC resident that had LE skin tears that developed into stasis ulcers. The nurses were providing wound care for about six months with the patient being on and off antibiotics due to infections, with the ulcers being unable to heal.
At the same time Danielle became certified in lymphedema management, the patient was referred to a wound clinic for further wound treatment. With Danielle being able to provide appropriate compression wraps at the same time the patient was attending the wound clinic, his stasis ulcers are now healed. The nurse manager received multiple calls from the wound clinic on how well his legs were being wrapped and how impressed they were with the healing of his wounds. This patient also has aphasia and has difficulty communicating with his caregivers. We have seen a change in this patient, with signs of reduced pain, increased participation in ADLs, decreased outbursts, and improved quality of life.
Submitted by Jeremy McCorristin, DOR, Holladay Healthcare, Salt Lake City, UT
The Momentum Therapy Culture Committee has been rolling out simple yet fun and meaningful activities that help ignite partnerships between departments. Some of you might have even received heart-shaped lollipops from your favorite therapists during our February Love one Another Project.
In the spirit of March madness, we kicked off the month with our fabulous Rehab team from St. Catherine, “tossing” it out with our hard-working maintenance department, for some great memories. The Rehab vs. Maintenance crew bean bag toss was a hit, with everyone cheering on one another, for a chance to win a scratcher worth up to $1,000! Our maintenance crew came out on top with the most winnings!
A few minutes of fun not only lifted our spirits with smiles and cheers, but also made us forget about work and bond over a simple childhood game of toss.
It’s no news flash that walking requires quite a bit of lower-body strength. You need powerful glutes, quads, hamstrings and calves to propel you forward. You might also recognize the crucial role your abs play in keeping you upright and lightening the load on your lower half. But there’s one muscle you probably never even think about when it comes to your stride. We’re talking about your “lats” (or latissimus dorsi), the biggest muscle of your upper body. Affording itself a large attachment centrally from the T7 to L5 spinouses, laterally to the iliac crest and thoracolumbar fascia, to the lower three or four ribs and inferior angle of the scapula, to travel superiorly and laterally to attach to the medial lip of the intertubercular sulcus, it is perfectly situated to effect both the upper and lower extremities in a large variety of movements. It is one of the quintessential and often overlooked muscles in gait. It is generally quiet electrophysiologically (EMG) during pre-gait activities (1,2) but as speed increases, the muscle becomes more engaged and active (2-4). The latissimus dorsi is the functional link between the upper and lower extremity, particularly through its connections with the thoracolumbar fascia (5,6).
The lat muscle is a key driver in the Posterior Oblique Sling System, which helps explain the relationship between the arms and legs during the gait “walking” cycle. The posterior oblique sling is a cross-body pattern composed of the gluteus maximus, thoracolumbar fascia (TLF) and contralateral latissimus dorsi muscle, which connects the shoulder with the opposite hip to facilitate locomotion. Dysfunction in this system puts the brakes on power, strength, speed and performance. To understand how your lats affect your walking performance, think about your gait or your movement pattern while you walk: “As your left leg steps forward, your right arm swings forward, thus you’re creating a rotational force, the abdominals and lats help with this rotational movement. The stronger your lats, the easier this twisting motion becomes and the more efficiently you nail your stride. Plus, strong lats help ensure the rest of your muscles don’t have to work in overdrive. Translation: You won’t tire out so fast and you’ll be able to walk/jog/run for longer time frames. Whatever was fatiguing you before won’t fatigue as fast, because you’re bringing more muscles to the party. You’ll be surprised just how much your lats are a part of the equation once you focus on strengthening them.
An easy way to tell whether you need to increase your patient’s or perhaps even your own lat strength is to assess form. Here are a couple of tell-tale signs to look for when walking: If the patient/client starts to fall forward or slouch their head forward, and if the shoulder blades are creeping up by the ears, this most likely indicates an opportunity to strengthen the lats. But before you get started with those strengthening exercises, you need to make sure the surrounding muscles aren’t getting in the way, for example, tight triceps (the backside of the arm) or upper trapezius (where your shoulder meets your neck) can inhibit the lats from activating during exercises. This would work against the patient/clients best efforts. Once you have had the patient/client complete a few tricep and upper trap stretches, it’s time to start strengthening the lats. Some suggestions to start with include:
Seated Row ● Using a resistance band or a cable row machine, sit upright with your legs out straight. If using a resistance band, hook it around your feet. No matter the equipment, roll your shoulders back and down, “packing” them into your lats. ● Keeping the elbows tight and close to your body, row your elbows straight back, pinching your shoulder blades together. ● Reset with control, then repeat. ● Do 3 sets of 10 to 15 reps.
Bent-Over Fly ● Stand with soft knees, holding a dumbbell in each hand by your sides. Hinge forward at the hips with a flat back and neutral neck. Allow your arms to hang down under your chin with a slight bend in the elbows. ● Leading with your elbows, bring your arms back and imagine you’re hugging a tree backward, squeezing your shoulder blades together. Hold for one second before lowering down with control. ● Do 3 sets of 10 to 12 reps with dumbbells appropriate for your patient/client.
Superman Lift ● Lie face-down on the floor with your arms and legs extended. Squeeze your glutes to glue your ankles together and lock your arms tight next to your ears. Keep your neck neutral, and gaze down toward the floor throughout the whole movement. ● Use your back to lift your legs off the ground, trying to lift your quads off the ground without bending at the knees. Lower with control. Repeat with just the upper body. ● Once you’ve mastered isolating the lower and upper, add them together, lifting all four extremities off the ground and holding at the top before lowering with control. ● Do 4 sets of 15 to 20 reps.
Beyond strengthening and stretching the lats to improve gait function, it’s also important to remember that if the patient/client has latissimus dorsi pain and/or referred pain, this can also impact range of motion and muscle activation patterns, including the patient’s gait quality. Dry needling is one modality that PTs may be able to use to decrease lat pain and improve the overall performance of this muscle by improving its function, thus improving range of motion and muscle activation patterns (7-9).
By Jon Anderson, DPT, Therapy Resource
References:
Houglum P, Bertoti D in: Brunstrums Clinical Kinesiology 6th Edition, FA Davis 2012 p.558
G. Cappellini, Y. P. Ivanenko, R. E. Poppele, F. Lacquaniti Motor Patterns in Human Walking and Running Journal of Neurophysiology Published 1 June 2006 Vol. 95 no. 6, 3426-3437 DOI: 10.1152/jn.00081.2006
Shin S, Kim T, Yoo W. Effects of Various Gait Speeds on the Latissimus Dorsi and Gluteus Maximus Muscles Associated with the Posterior Oblique Sling System. Journal of Physical Therapy Science. 2013;25(11):1391-1392. doi:10.1589/jpts.25.1391.
Kim T, Yoo W, An D, Oh J, Shin S. The Effects of Different Gait Speeds and Lower Arm Weight on the Activities of the Latissimus Dorsi, Gluteus Medius, and Gluteus Maximus Muscles. Journal of Physical Therapy Science. 2013;25(11):1483-1484. doi:10.1589/jpts.25.1483.
Vleeming A, Pool-Goudzwaard AL, Stoeckart R, van Wingerden JP, Snijders CJ. The posterior layer of the thoracolumbar fascia. Its function in load transfer from spine to legs. Spine (Phila Pa 1976). 1995 Apr 1;20(7):753-8.
Willard FH, Vleeming A, Schuenke MD, Danneels L, Schleip R. The thoracolumbar fascia:anatomy, function and clinical considerations. Journal of Anatomy. 2012;221(6):507-536.doi:10.1111/j.1469-7580.2012.01511.x.
Dar G, Hicks GE. The immediate effect of dry needling on multifidus muscles function in healthy individuals. J Back Musculoskelet Rehabil. 2016 Apr 27;29(2):273-278.
Ortega-Cebrian S, Luchini N, Whiteley R. Dry needling: Effects on activation and passive mechanical properties of the quadriceps, pain and range during late stage rehabilitation of ACL reconstructed patients.Phys Ther Sport. 2016 Sep;21:57-62. doi: 10.1016/j.ptsp.2016.02.001. Epub 2016 Feb 24.
Dommerholt J. Dry needling — peripheral and central considerations. The Journal of Manual & Manipulative Therapy. 2011;19(4):223-227. doi:10.1179/106698111X13129729552065.
Our long-term care population is now fully vaccinated, and it seems as if we are entering, dare I say it, a post-pandemic environment. We made it, but now what?
During the pandemic, we have seen our residents’ version of normalcy altered. Those who used to spend most of their day in the dining room, in activities or the therapy gym, and visiting with their friends and family now are found sleeping in more, not eating as much or as healthy as before, and no longer have the desire to engage in social activities. When they do feel like getting out of their room, seeing them use a wheelchair is more common. Some of them are COVID-recovered and have never fully bounced back after fighting the virus.
Our therapists opened their minds to different therapy approaches and gained the skills that it takes to truly dignify the lives of long-term care residents. We knew these effects of illness and quarantine isolation would take a toll on our vulnerable population, and we did everything we could to combat them in real time with preventative therapeutic approaches. In a pre-COVID world, our building was predominantly a rehab-to-home facility, and it was uncomfortable at times for our therapists to develop long-term care treatment plans. The pandemic highlighted the necessity for our services, and now it is hard to imagine not being this involved with them.
Our Speech Therapists, with multidisciplinary collaboration, hosted a new program this month called “Rise and Dine.” This program began as a nutrition and hydration-based club that requires participants to get out of bed and engage cognitive and communication skills in choosing meal preferences for the event. “We are all very passionate about our residents’ quality of lives and saw this as an opportunity to meet our residents’ nutritional and social needs. The excitement and feedback of our residents really fueled the idea and brought our entire dietary and therapy staff together to make this such a successful event!” — Breean Ludwig, HCRO Speech Therapist
As excitement grew, we realized this program could address almost all the abilities we have seen deteriorate. We ordered T-shirts to encourage dressing and hygiene before the event, and all our therapists came in to facilitate transfers, self-care routines, and mobility to and from the dining room. We also were able to treat goals related to self-feeding, dynamic standing, and sitting tolerance and positioning.
“We saw such a negative impact after so many in-room isolations during the COVID pandemic. Our Residents were discouraged, losing weight, not socializing, showed physical and cognitive changes, and did not want to come out of their rooms. We wanted to do something to bring excitement back into their lives while still being able to target our goals in therapy. This program offers an opportunity for all disciplines (PT/OT/ST) to participate.” — Ke’ren Grimaldo, HCRO Speech Therapist.
Although we are striving to return our residents back to “normal,” I am proud to say our Therapy team has established a new norm as well, and we are not looking back. Just as preventative interventions were important during the pandemic, how we move forward now is just as crucial. 85% of our long-term care residents got out of their rooms to participate in this program. We owe a big thank-you to our dietary manager and her team for being as excited for this program as we were. Our team has a seasonal themed event planned for the rest of the year, and we can hardly wait! Remember, every county and state Department of Health has specific guidelines for re-opening, so always consult with your DNS with your “back to normal” plan.
Submitted by Elizabeth Munford, PTA/TPM, The Healthcare Resort of Olathe, KS
Resident K is a 52-year-old man who was referred to Physical Therapy for chronic, non-healing pressure ulcers of the coccyx and ischial tuberosity and severe pain.
PMH: Spina Bifida, B AKA, HTN, colostomy; wounds have been present approximately 10 years. Patient underwent flap surgery five years ago; wound vac has been unsuccessful in promoting healing
PLOF: Modified Independent in transfers and wheelchair mobility; has resided in nursing homes for 10 years; history of being non-compliant with pressure relief and positioning
Evaluation status (4/2020):
Mobility: Modified I transfers and wheelchair mobility; tilt in space motorized chair with ROHO cushion
Wound 2: Ischial Tuberosity: Stage 4 pressure ulcer: 3.5L x 3.0W x 3.0D
Pain: 7/10 with any movement, related to wounds
Wound care: Dakins solution
Patient reluctantly agrees to PT POC to initiate in-wound electrical stimulation (HVPC) five times a week to facilitate increased wound bed granulation, decrease necrotic tissue, decrease pain and facilitate wound healing. Patient states, “These wounds won’t heal; they’ve been there forever and I’ve tried it all.” D/C plan: reside in skilled nursing facility
Discharge status (10/2020):
Wound 1: Coccyx: Resolved
Wound 2: Ischial Tuberosity: .3L x .3W x .2D
Pain: 0/10
Patient is discharging to an Assisted Living Facility
As the wounds began to improve, patient K began to be compliant with positioning and pressure relief. During the course of treatment, estim protocol changed from negative to positive polarity in wound, and then finally peri-wound as wounds became too small for in-wound electrode placement. Dressing changes occurred through IDT wound team consultation. Treatment included patient/caregiver education throughout.
Kudos to the Pueblo team for being willing to tackle the “impossible” wounds and having the perseverance to hang in there! They understood that chronic healing takes time. Meeting requirements of documenting progress every 30 days, changing protocols when healing began to plateau, and using skilled assessment allowed them to continue the POC to closure/near closure of the wounds.
Submitted by Shelby Donahoo, M.S., OTR/L, Therapy Resource, Bandera
The strength of a team can truly be powerful when everyone sees and feels the vision. Employee culture and retention has been at the top of the initiative list. How can we improve this area and create an environment that truly embodies Customer Second? Well let me introduce you to the M.E. committee. I spent time with one of the M.E. committee members, Loretta Johnson, PTA, to get a better understanding of what this committee has to offer.
As explained by Loretta, the Copperfield Healthcare and Rehab facility created the M.E. Committee (Motivating Employees), with a purpose to engage, support and reward their fellow coworkers. They have designed and cultivated strategies to build interpersonal skills, through exciting team-building exercises. This level of cultural promotion encourages open communication, challenges employees with friendly competition, and assists with facilitating a healthy work-life balance.
The M.E. committee has put together a calendar of events that caters to employee engagement. As Loretta put it, “An employee who enjoys coming to work is a worthy investment, and a good day at work fuels the desire to be better the next day. This feeling of happiness at work will spill over into the love and care that we provide to our patients.”
Most recently, the M.E. committee hosted a Coloring Contest. All employees were asked to color a picture of a butterfly. Each butterfly was judged by the panel of patients, employees and visitors. The grand prize winner received a beautiful, laundry-themed gift basket. Other events included: Chili Cook-Off, World Water Day, and National Laugh Day. The time spent together is intentional, and it has allowed new-hires to comfortably blend in with the team.
The Copperfield Healthcare and Rehabilitation facility leadership team includes: Noni Gill, ED; Unnati Patel, DON; Shayla Goode, M.Ed CCC-SLP
Submitted by Kai Williams, Therapy Resource, Keystone-East
The Rehab team at McCall Rehab and Care Center in McCall, Idaho, has had a vision of providing community-based outpatient therapy in people’s homes since the facility became part of the Pennant-ID/NV market in 2018.
McCall’s DOR, Jenny Sowers, DPT, couldn’t ever seem to find the consistent time to grow an outpatient program, so she decided she should find a therapist willing to take on that challenge. In September of 2020, Jenny hired Ellie Toscan, DPT, with the goal of Ellie building their Community-Based Outpatient program.
Ellie has shown tremendous ownership of the program, from marketing to clinical to financial. She independently tracks the financials weekly and monthly to ensure the program is financially viable. Executive Director Kurt Holm’s main goal for the program is to build relationships and reputation in the community. A recent admission gives clear indication that Kurt’s goal is being realized. Ellie was working with a patient in her home. She had a change of condition, went to the hospital, and was referred to McCall Rehab. Because of the relationship that Ellie built with this patient, she readily agreed to the discharge plan. The patient is now receiving skilled therapy and nursing services in our facility. Thanks Ellie for this great example of the power of our core value of ownership!
If you are looking to grow your community based outpatient program, please consult your therapy resource or Deb Bielek for regulatory help specific to your state.
Submitted by Dominic DeLaquil, Therapy Resource, Idaho/Nevada
With our focus on meeting all the needs of our communities, we wanted to provide some information about our Colonial Manor of Randolph outpatient program. Randolph, Nebraska, is a town with a population of 894. Despite that, they have found a way to operate as one of the largest outpatient programs as an Ensign Affiliate. Here is what Eric Feilmeier, OT, CLT, DOR, has to say about why they have been able to have success!
When working to build a successful outpatient clinic, it is important to begin with Core Values. Here are few values that we have found to be important:
Deliver WOW through service.
Embrace and drive change.
Create fun.
Be adventurous, creative and open-minded.
Pursue growth and learning.
Build open and honest relationships with communication.
Build a positive team and family spirit.
Do more with less.
Be passionate and determined.
Be humble.
We have had success in our Nebraska market due to a number of reasons. First and foremost, be supportive of your therapists. Provide clinically centered CEU opportunities that focus on problems in your area. Here at Colonial Manor, we are LSVT certified and are going through power moves certification, urinary incontinence certification and Lymphedema Certification. Provide programming around the skills of your Therapists so they can get to the bottom of each patient’s problems. It’s important to educate on HEP for patients, but then leave that to them and focus on the true needs, utilize the specialty equipment in our gyms and provide proper intensity of treatment.
Make sure the patient feels that they got a lot out of each session.
Provide proper frequency. MAKE IT COUNT IN THE GYM! Remember, the patient won’t typically do as much at home. Modalities: We work closely with ACP rep to provide the best adjunct treatment options to assist with improving care. Patient’s Love modalities- modalities provide physical and psychosomatic results.
When working with your outpatient, always assess additional problems and needs that the patient may not realize themselves. Ask questions, because there might be a higher need for another discipline to step in. We are always looking out for one another’s skill sets and the potential benefit to collaborate our services to further meet the needs of our client.
Cancellation Management is the biggest obstacle of our Outpatient business. We do our best to stop cancellations, but that is not always easy. Some tips to reduce cancellations include:
Evaluations:
Provide a message. Ask the patient why they are in your clinic, what they expect and what they want to gain.
Hold their answers against them (In a positive way). Always have a conversation during the evaluation about the frequency and the importance of coming to therapy when they are scheduled, expressing to them that we can help them but they must come to scheduled appointments to make a difference (hold them accountable).Call ins: Problem-solve
When you get the patient on the phone and they want to cancel, ask, Why? What are you experiencing? Many times, the reason for the cancelation is exactly why they should be coming into their appointment. Be adamant and convince them to come in, if you believe you can help them.
When a patient leaves a message, call them and ask them the same questions. They may just need to be convinced that you can help them!
Move treatment times to another time of day or to a whole other day. Flexibility in your clinic is the key!
Last but not least, build and maintain relationships with your Physicians and Nursing. Frequent updates to communicate patient results to Physicians is always appreciated. Send notes or small updates with the patient to their next doctor appointments, even if the doctor doesn’t request it. These notes can be a quick word Doc, a progress note that is timed with an appointment, or even a nicely handwritten note.
All in all, have goals to grow your Outpatient clinics. Focus on the patient, and you will see excellent results. I even encourage devising a patient satisfaction survey to monitor your success and areas of opportunity. Good luck!
By Eric Feilmeier, OT, CLT, DOR, Colonial Manor, Randolph, NE, and Ryan Hough, Therapy Resource, Gateway, NE
According to a recent article in The Wall Street Journal, “Cognitive problems are among the most persistent and common lasting effects of COVID.” Many of these cognitive issues are becoming long-term symptoms months after an active COVID dx.
It’s important that we understand Post-COVID-19 syndrome, which is signs and symptoms that develop during or after an infection consistent with COVID-19, continue for more than 12 weeks, and are not explained by an alternative diagnosis. Post-COVID-19 syndrome may be considered before 12 weeks while the possibility of an alternative underlying disease is also being assessed. These patients are also commonly referred to as “long-haulers.”
Therapy teams need to take an active role in the ongoing assessment and intervention of cognition. It’s especially important to know the patient’s PLOF and not discontinue services too soon, knowing that cognitive impairments with this population will continue long after the active diagnosis. Cognitive intervention is also important for our outpatient population in both ALFs and in the community. Physicians need to know that we are available to partner with post-COVID patients who have lingering cognitive issues.
Starting with a brief assessment such as the St. Louis University Mental Status Exam (SLUMS); Clock Drawing Test; Addenbrooke’s Cognitive Exam (ACE); or MINI-COG will provide initial information on the level of cognitive impairment (none, mild, Dementia level).
Once determined, it is clinically recommended to complete a formal standardized assessment and log Cognitive Performance Assessment 96125. Examples include: Ross Information Processing Assessment-Geriatric Edition (RIPA-G); Cognitive Linguistic Quick Test (CLQT); Functional Linguistic Communication Inventory (FLCI); The Scales of Cognitive and Communicative Ability for Neurorehabilitation (SCCAN); and Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES). Utilize assessments that at minimum can address: memory (i.e., list learning task; paragraph recall task; digit repetition, etc.); working memory/executive function; executive function (problem solving; planning; inhibition/initiation); and processing speed.
Once the assessments are completed, clinicians will know which areas of cognition to target with skilled intervention. Please refer to the various POSTettes (Post COVID; Cognitive Performance Assessment; SLP Cognitive Impairments) and the Cognitive Impairments Clinical Guide for additional information.
By Kelly Alvord, Therapy Resource, Sunstone UT The Sunstone DONs and DORs recently participated in a combined meeting. This meeting of minds was designed to make sure we understand the challenges and initiatives of each other’s departments and to really collaborate where we could to help each other meet goals and obtain great clinical results.
We first pulled the “Rehab Screen Consultation F TAGs” POSTette from the portal. Each DOR presented on an F-tag from the POSTette and how the Therapy team will support and take the ownership of these tags for survey. For example, F Tags F684, F676, F677, and F810 all have to do with Activities of Daily Living (ADLs). The teams addressed their strategies for therapy partnership with ADLs for this group of F Tags. We discussed specific actions and roles Therapy has to support the DONs to prepare for survey. The DONs learned how their DORs are truly their clinical partners. This discussion was very interactive. The DONs were excited to know we “have their back” when it comes to involvement with patients to prevent decline and help with survey results.
Deb Bielek introduced our Excellence in Programming and Clinical Care (EPIC) Programs. EPIC programs. The DONs and DORs all committed to collaborating and establishing an EPIC program for each of their facilities based on clinical needs and trends.
Clay Christensen presented on the 5 Dysfunctions of a Team, which focused on establishing trust, being vulnerable, and not fearing conflict. This information was further validation of power of a strong DON and DOR partnership.
We also had fun together and had cluster competitions with an offsite activity.
With these dynamic partnerships with DONs and DORs, Sunstone is unstoppable!
