The Homeless Patient (Elise)

Recovery following an injury is difficult for any individual—but especially for a person who is homeless. As an employee of a county hospital, I often work with individuals who are homeless with very limited resources. These patients present a challenge to the rehab team for many reasons: 1) Multiple health problems secondary to prioritizing safety, shelter and food over non-emergent health needs; 2) Addiction to drugs or alcohol; 3) Mental health conditions; 4)Variety of educational levels (especially if did not complete high school education); 5) Lack of discharge destination, especially if the individual requires physical assistance or cognitive supervision; 6) Limited access to transportation for follow-up care after discharge. Consider these characteristics and add to them age-- how many years has the individual been homeless? How is homelessness impacting the aging process?

One past patient who comes to mind is Luke. He presented to the hospital after being struck by a bicycle while walking on the sidewalk. Only 55 years old, Luke had a history of alcohol abuse, prior knee problems due to a fall a few years prior, foot pain and bilateral lower extremity neuropathy (likely due to exposure to extremes in temperature). He looked and moved like a man much older than he was. As a result of the accident, he sustained an incomplete cervical spinal cord injury affecting his ability to move both his hands and his feet. Following surgical decompression and fusion to decrease consequences of cervical stenosis, Luke presented to rehab. His goal for therapy was to “Go back to the streets and continue working to collect cans.”

As a therapist, it is my responsibility to provide patient-centered care. This involves finding ways to motivate a patient to participate in therapy and helping the patient achieve his goals. If Luke was going to be able to function on the streets, he had to be able to get up/down off of the ground, be able to bend over to pick up cans/items from the ground, and be able to cross the street in adequate time on the crosswalk. In therapy, we worked hard on walking: progressing exercises from walking on the treadmill with a harness to overground walking with a walker on level indoor surfaces to outside on gravel/sand/concrete. We practiced navigating sidewalks, crossing the street, and carrying items on his walker while on grass. We talked about the importance of following up in outpatient, however we reviewed essential exercises (and progressions) in case this was not possible.

As the therapy team continued to discuss his progress and his discharge status, we realized that he was not going to be ready to discharge to a “standard” homeless shelter. A shelter discharge requires that a person will be completely independent with physical mobility/self-care and be able to manage medications. Los Angeles has a great new program for helping individuals who are homeless integrate into stable housing following hospital discharge (due to the common lack of follow-up after ER/hospital admissions). This “recuperative care” program allows an individual to discharge to a special type of shelter which provides a wide array of services to individuals recently discharged from hospitals. The goal of the program is to provide follow-up treatment (including transportation to medical appointments), education, stable housing, and job opportunities. Luke was a perfect candidate for the program, and he was very receptive to discharging there. The rehab team (physical therapist, occupational therapist, social worker) was able to visit the facility with Luke to assess his ability to access different areas using a walker, and to provide equipment recommendations (tub bench for showering). We were very impressed with the facility’s cleanliness and commitment to each individual’s success. It was a very supportive environment. Through these types of programs, it may be possible to decrease some of the negative complications of homelessness on recovery from injury and restoration of health.

For more information about the Los Angeles Recuperative Care Program, refer to: http://www.jwchinstitute.org/recup-care.htm.

The Memorable Patient (Elise)

Every patient I meet in the hospital is unique. They each have their own story, their own goals. Every day, I am handed a challenge: find a way to gain a person's trust during (perhaps) the most traumatic time of their life. This is no easy task. Some days, it comes naturally-- other days, it can be an overwhelming challenge.

Today, I think to myself: What is the key to a meaningful patient-therapist relationship? If I think back to the patients who stand out to me most over my past 3 years as a PT, many fond faces come to mind. What are the characteristics of these patients that link them together as some of the most rewarding people I have had the pleasure to work with?

Sarah: A sweet, slightly overweight woman in her early 70s. From the moment I met her, her quiet voice and gentle laugh struck me. When I introduced myself, she asked me about how my day was going. It caught me off guard. It was clear she wanted to get to know me as person before she would work with me. She even asked about my family. Sarah was clear in her goal: go back home independently. "I never needed help before and I don't want to need help now. Look at me! Someone had to just take me to the bathroom. It's so humiliating." In therapy we worked hard: I acknowledged her desire for independence and acknowledged my desire to push her a little more each day in therapy. Always with a laugh, she'd say: "You want me to try what?!" And that's how we'd spend time together every day for a month: laughing, chatting about home, and walking... farther and farther.

Max: An athletic, tall man in his late 60s. Recovering from an aneurysm rupture, he was very confused and agitated the first time I met him. In fact, he was a bit scary. Because the aneurysm was in the area of his brain which affects the ability to understand spoken/written communication, he could not understand me and spoke in jibberish. On top of this, he was angry/agitated (which is common with brain injury because the brain does not know how to regulate all of the stimuli in the environment). The only way I could work with him was by letting him move around/explore his environment, and by using subtle non-verbals (hand on shoulder or reassuring smile). It was not pre-planned therapy; it was whatever Max was willing to do that day. His brain was healing quickly, though, and every day he started following simple commands more and communicating more. The most memorable day was a week later when I brought him outside to the basketball court. I had learned that he loved sports from his sister. When I handed Max the basketball, I saw a whole different side of him-- calm, smiling, dribbling the ball, and shooting baskets. Yes, he required help- but he started interacting and responding more. An hour later, when we got back to the room, he said to me "I loved this." Three words that couldn't have meant more-- words that showed that I had found a way to show him that I was trying to help.

Maria: A hard-working, friendly woman in her early 50s. She had a long list of medical problems: fibromyalgia, gall bladder flare-ups, uterine fibroids, and (most recently) a stroke. Maria had a lot on her plate- but always arrived to therapy early and with a smile on her face. Her determination was evident every day. But, I soon came to realize that she was having a hard time adjusting to her change in status. "At night, I cry sometimes," she finally told me one day. I reacted by reassuring her that it was okay to be upset, but that she had great potential to make continued gains. Together, we just sat and talked. Emotional support was going to be almost more important than physical improvement. This was a woman who had a lot of medical barriers that could have stood in her way-- but made the most of every day to improve her condition.

For me, each of these patients had certain qualities that made our relationships meaningful. With Sarah, it was her gentle nature, her bright spirit, and our mutual interest in one another's lives. For Max, it was meeting the challenge to communicate without words. For Maria, it was the importance of listening to one another. The patients whom I've learned the most from have been those who have challenged me to establish rapport, to think critically about their clinical picture, and to find a way to build their trust. But most of all, the most memorable patients are those who have overcome devastating injuries and strive each day to live life to the fullest. For them, I have only the deepest respect and admiration. I often ponder if I would respond to illness/injury the same way. At the end of the day, I feel privileged to have worked with these inspiring people as their therapist.

"Lean on Me..." (Elise)

It's amazing the difference that family support has in an individual's recovery from injury. Even patients with devastating injuries seem better equipped to handle life's changes and adjust to their injury if they have the support of loved ones (family & friends). One of my more recent patients was in rehabilitation after sustaining a stroke. He had been in "picture perfect" health, according to his family, so the stroke came as quite a shock to everyone.

Rubio was a very quiet man. He worked hard in therapy, but I could tell that he was depressed with the changes that have occured in his body following the stroke. He had minimal movement in his left arm/hand, and he needs help to transfer and walk due to leg weakness. He was been making good improvements in therapy (in terms of his motor control and functional status), I know that a key reason why is because he has such a supportive family.

Rubio and his wife, Maria, have been married for 47 years. They have 8 children. On the day of Rubio's family conference (a time when the patient/family meets with the medical team and therapy team all togther to provide information regarding diagnosis/prognosis/discharge expectations), we barely had enough chairs for everyone who came to participate from his family! I was so impressed by the questions his children and wife asked: "What are positive signs of recovery that we can look for in my Dad?"; "What kind of exercises can we do with him at home?"; "What can we do to prevent another stroke from happening?"; etc. It was a great opportunity for us all to talk and determine how we could continue to meet Rubio's goals even after discharge from Rehab.

Another striking thing about Rubio's family: someone is always at the hospital with him. His wife arrives early in the morning and different sons/daughters visit throughout the day to assist with his therapy and to learn from the therapists. They are his "cheerleaders" -- and serve a key role in helping to motivate him to continue working hard in therapy. For me, the family is a great source of information about him-- what his interests are, what he does for fun, what his role was in the family/at work. Rubio had a hard time telling me these things himself due to his quiet nature. After talking with the family, we started doing therapy more outside because he likes sunshine and doesn't like the other patients watching him (for example: balance exercises on the grass, curb training by the sidewalk, walking in an outdoor obstacle course).

It is important for me to provide education on the importance of patient independence when a family is this motivated and participatory in a patient's rehab stay. Although the family wants to help as much as possible (and this is common in Hispanic culture), I have needed to explain how important it is for Rubio to do as much as possible for himself. Not only does it help him to realize his abilities and use the side that was affected by the stroke, but it also helps him feel more like the independent man he was prior to the injury. A big part of my preparation for the family prior to discharge is about how we can set-up the enviornment so that Rubio can be independent- and only ask for help when he really needs it.

One of the things I like best about rehab is showing patients (and families) how much they can do. It seems like after injury, people mainly focus on what they can't do. We had family training last week to prepare for Rubio to go home for a day over the weekend. This is common in order for us to find out if there are any major barriers in the home prior to official discharge from program-- it gives us an opportunity to work on any issues in the last few days of therapy. In training, Rubio's son could hardly believe that he only needed a little help (maybe 15% for balance) to walk up 3 stairs. The last time his son had been there, Rubio needed 2 people to help with walking; he was astonished at his progress! Father & son both got a little teary eyed as they realized together that he was getting better, that he was going home soon, and that there was a brighter future ahead.

Addressing Falls in Older Adults: Part II

As discussed in my last blog post, fall prevention is important to address in older adults, but even more so for individuals who have progressive diseases (diseases which get more severe over time). Multiple Sclerosis is an example of a neurological disease for which fall prevention is critical.

I had the pleasure of working with Vicky, a 60 year old female who had a history of relapsing remitting multiple sclerosis, last Spring. Overall, the progression of Mary’s disease had been slow over the past 15 years until a recent fall down the stairs at her home resulting in a hip fracture. Mary was admitted to inpatient rehabilitation following hip surgery in order to improve her functional status before discharging home.

In speaking with Mary and getting to know her better, I realized that anxiety about falling was a major problem for her:
1) Mary had been restricting how often she would go out of her apartment to once a week because she was afraid of falling in public. [This got my attention! When a person limits their current activities due to fear of falling, it results in deconditioning, decreased strength, and even frailty—which puts a person at higher risk for falling in the future.]
2) Feeling that a cane would label her as “disabled”, Mary refused to utilize an assistive device while walking. [This required significant PT education regarding the benefits of using an assistive device to prevent falls versus not using one and falling—which is exactly what had happened to Mary.]
3) Finally, Mary disclosed that she had a number of falls around her home recently. [Which told me that her condition was progressing and she clearly needed intensive PT intervention.]

Working with Mary involved a multi-dimensional approach to improve her daily function and independence. Firstly, I had to “coach” Mary on her current abilities (how much she could do on her own) and her current functional limitations. I had to help to build her confidence by putting her in challenging situations (ie. practicing flights of stairs, walking on gravel/grass/sand, moving out in the community) to show her how much she could do on her own. We talked at length about the negative effects of another fall—pain, decreased function, decreased independence, etc. By opening her eyes to her actual balance abilities and education about the consequences of decreased balance, I slowly introduced Mary to different potential assistive devices to help her (including cane versus forearm crutch versus walker) and we practiced using them in different environments.

In addition, I utilized standardized “Fall Assessment Measures” to determine her risk for future falls. We commonly use these in physical therapy to objectively show change in our patients over time (from initial evaluation through discharge). Even more importantly, I use these balance assessments to educate my patients about their score and the implications about their score (based on research). For example, the Berg Balance Scale involves 14 items of a person performing different standing balance positions (single limb stance, tandem stance) and functional activities (reaching forward, picking something off the floor, sit to stand). The person is rated from 0-4 on each item depending on their score. A maximum of 56 is possible with scores less than 36 indicating a 100% chance of falling within the next year and scores less than 45 at high risk for falls. Other balance measures I commonly use are: Dynamic Gait Index, Functional Gait Assessment, and the Activities-Specific Balance Confidence Scale (to name a few). You might want to look some of these up online to get more information.

Before Mary discharged from rehab, I made sure that we had evaluated her home to decrease fall hazards: removing throw rugs, decreasing clutter on the floor, placing nightlights in bedroom/bathroom, installing a grab bar and non-stick rug in the tub, and creating more space between furniture so that a clear path for walking was established. Mary also went home with a home exercise program that targeting: strengthening of her hip muscles, balance exercises with a narrow stance, and a daily outdoor walking program with her crutch. Our biggest goal for her home program: No falls for one year! :-) She is checking back in with me every month to tell me how she’s doing.

Addressing Falls in Older Adults (Elise)

You've heard it a million times: falls can be devastating in the elderly population. "Fall Prevention" has a lot of buzz now in the healthcare industry because falls are so costly to the healthcare system. As a physical therapist, I have an important role in helping individuals recover function after falls, but moreso in identifying risk factors of persons who are at high risk for falling in the future.

There can be many different contributors to falls, which makes it a complex and challenging construct to assess in people. Think about it! Falls can be caused by: poor balance, gait deficits (including using an assistive device), muscle weakness, visual changes, polypharmacy (multiple medications), decreased cardiovascular function, neurologic deficits, depression, decreased cognitive capabilities, and fear (to name a few!). By carefully collecting information during the patient interview, as well as taking objective measurements during the PT evaluation, I can develop a treatment strategy to specifically target those areas that place individuals at risk for falls and future falls.

During a subjective interview with older patients, it is important to ask about "fall history" (if the patient has fallen in the past). If they have fallen, one must follow-up with questions:
--How many times they have fallen (one fall suggests an acute medical problem versus several falls suggests slow deterioration of balance ability)
--Where they have fallen (environment)
--What activity they were doing (multi-tasking? one-legged stance? reaching?)
--What time of day (at night when more tired? poor vision in dark?)


Remember-- the interview can help you to form a hypothesis for what can be contributing to falls, but your objective examination will provide you with important information, too. There are many body systems to consider: 1) Sensory systems (vision, vestibular (inner ear), and somatosensation (feet)); 2) Musculoskeletal systems (strength, range of motion, endurance); 3) Cognitive/Affective factors (fear of falling, depression, anxiety, medications)

In addition to these, an environmental assessment is helpful to determine hazards that exist (home/apartment, carpet/wooden floor, stairs, lighting, excess clutter). Also, consider the impact of family support on the person. Are they living alone and forced to be independent with activities that they really should not perform on their own? Or is a family member present to assist or prevent the person from taking "risky" action?

Can you see how much is involved in fall assessment?! In my next post, I will share a patient case with you involving a patient with multiple sclerosis who came to me with a long fall history-- and whose treatment program addressed many of the above issues in order to allow for safe and independent functioning at home and the community.

Being a Manager (Joanna)

As the Manager of my building's Engage Life Department, I must have staff meetings as well as training sessions for staff. My two most recent training sessions for staff included "Back Safety" & "Activities for Residents with Alzheimer's and Dementia" Doing these staff training sessions requires some research, planning, creativity, as well as being comfortable getting up in front of a large group of staff. (No public speaking phobias!) My goal is to always make the training somewhat fun, or at least interesting, after all, I want our staff to get something out of my training sessions!

A challenge I have to deal with on a daily basis is that I'm a young manager. I was promoted to my current manager position at the age of 23. Now I'm 25, no longer rent an apartment (have a house!), currently engaged (wedding this September!), and have four cats (yes...four!!). So, many things have changed for me since I was 23 years old, especially when it comes down to different types of responsibilities. One female resident (in her 90's)always laughs and tells me I look like I'm 12 years old! (Although once in a while there are some days she'll tell me I look like I'm a 14 or 16 year old!) I brought in pictures of when I was 12, 14, and 16 years old so she could see the difference between then and now, but this didn't change her mind of course! Now, it's just an inside joke between her and I. My assistants & I joke around about our ages as well, since my 70 something year old assistant could be my "grandmother", my 50 something year old assistant could be my "mother", which then makes me the "daughter/granddaughter" of the two. All three of us believe that the three different generations truly make us a unique and dynamic Engage Life trio.

Another thing that goes along with being a young yet new manager is constantly learning, and practicing my manager style. I do not like to micro-manage my staff. Instead, I prefer to give my staff space and freedom, while having an understanding that they will give their very best within the rules and expectations of the company. Sometimes I'll give my assistants a to-do list. I like to see and treat my staff as equals, the only difference being that I carry the responsibility for my department. We all share an office, and share doing the activities and other related jobs each day. I make sure that my assistants are aware that I can do and will do everything that they do whether that be moving furniture, driving the 14-seat van, calling Bingo, leading exercise classes, wiping tables down, decorating on theme days, taking pictures, doing trivia, etc. Half the time, my assistants and I ask each other, "which activity would you like to do today at 2:00pm? Bingo or drive residents to the boardwalk downtown to go walking? And then of course we both say, "I don't care, you pick" and this goes on back and forth until we reach a decision. I personally like to give my assistants the option to pick (unless there's a good reason why I must do a particular activity due to any other meetings, conference calls, etc. on my manager schedule for the day that I may need to be at). I do not like being a "bossy" boss. I am also always listening to my staff--I love to hear their ideas, input, and advice. They are a great source of support and creativity.

I can say that it is definitely easier being a manager now compared to when I just started as one two years ago, but this is most likely just due to practice and learning from my experiences. I must not forget to add that I have learned a lot from the other "seasoned" managers at my work. Some of these managers, including my Executive Director, have been working at my building for 10 or more years!

Dementia in the Inpatient Rehab Setting (Elise)

Admission to inpatient rehabilitation involves meeting strict criteria. A person must have certain diagnoses (such as stroke, spinal injury, traumatic brain injury, Multiple Sclerosis, etc.) which have a good prognosis for functional improvement. A person must medically stable and able able to tolerate at least 3 hours of therapy every day from an interdisciplinary team (PT, OT, Speech). Dementia is a common health problem among the aging, but generally is not a qualifying diagnosis for acute inpatient rehabilitation.... unless it is a co-morbid condition occuring along with one of the aforementioned primary diagnoses. Mae is an example of one such patient.

Last fall, Mae was admitted to inpatient rehabilitation following a laminectomy and posterior spinal fusion for lumbar stenosis. She had a 5 year history of progressive dementia and lived with her husband (of 55 years) in a nearby town. Over the course of the past year, Mae had experienced progressive weakness in her legs that eventually required her husband to perform dependent lifts in order to transfer her into bed, onto the toilet, or into the car. She was eventually referred to a neurosurgeon and then became a patient of mine following her surgery.

Mae sticks out in my mind as an especially challenging patient to work with. As a consequence of her dementia, she had frequent "ups" and "downs" in her ability to communicate with me, her ability/desire to participate in therapy, and her tolerance of therapy. Every day, I would walk into her room not knowing if it was a "good day" (where she would be happily smiling in bed eating her breakfast), or a "bad day" (in which she was crying, unsure of where she was, confused of what day it was, and demanding to see her husband or her dog).

My rehab goals for Mae's program significantly differed from other patients on the service. The goal for most patients is to improve their ability to complete daily functional and mobility-related tasks to the level of independence. For Mae, this was not a realistic goal given her cognitive status. My hope was to:
1) Improve her overall function (including lower extremity strength and overall aerobic endurance) for the "good days"
2) Complete family training for her husband and primary caregiver, Jim, who was 80 years old (dependent lifts were not a safe strategy for either of them!!) to determine safe strategies to assist her
3) Prescribe equipment including bath chair, transfer board, and permanent wheelchair to assist her husband during the "bad days"
4) Develop a home exercise program to help maintain her current level of function and prevent secondary impairments (muscle tightness, deconditioning, etc.)

On a day-to-day basis, I asked myself many questions regarding her therapy. She was very different from my other patients. Did I expect Mae to be independent with her exercises like my other patients? Did I expect Mae to remember new techniques for transfers without cueing? Did I expect Mae to independently arrive to the gym at a given time for therapy? Did I expect Mae to demonstrate the ability to walk around and transfer herself no matter what time of day by discharge? The answer to all of these questions was NO.

I had to develop many compensatory techniques to help Mae benefit from rehab. Every day, we worked on therapy in the same environment to establish familiarity. The room was quiet and distraction-free in order to help her to focus. Giving Mae choices in what she wanted to work on was important in engaging her in therapy. Sessions focused on "automatic" tasks to improve her leg strength and overall endurance, such as walking and standing transfers, instead of teaching leg lifts or other exercises requiring multi-step commands. Standardized tests for balance or endurance were not appropriate because the instructions were too complex. One hour sessions were too long for Mae to concentrate and participate in, as she fatigued very quickly and became irritable. Instead, we adjusted her schedule to multiple 30 minute sessions over the course of the rehab day. We continued to work on standing transfers instead of introducing new equipment (such as a transfer board) which was unfamiliar and confusing to her. Repetition was very important to the structure of her therapy-- we had to give her many many opportunities to practice. We provided her with simple, explicit, written instructions (and pictures of her performing them!) for the exercises of her home program.

Finally, it was crucial to address how her husband, Jim, was managing with the changes in his wife and the demands of her care. He was an older man who was deeply concerned about her well-being. More than anything, he wanted to care for the woman he had shared the last 5 decades of his life with, and their bond was inspiring. But, he had to consider if the level of care she required was too much for him. Would it better for her to be in a nursing home? Despite many days of discussing the options with him, performing training, and even doing a home evaluation and home training, Jim decided that he wanted to take Mae home. "We always said that we would love each other and take care of each other for our entire lives," he said.