Peer Support Groups

Adjustment to injury is a long process, especially when coping with a traumatic injury like spinal cord injury (SCI). Adjustment is defined as “adapting to a new condition” and in the case of SCI this means establishing a new sense of self and a new life plan. Everything is different and individuals are experiencing loss in all aspects of their life including mobility, daily activities, work status, relationships, and future plans. At Rancho, I have recently helped to develop a monthly support group to assist individuals in coping with their injury. I thought I’d share a little about it with you.

Our support group invites anyone with an SCI to attend. This includes inpatients at our rehab hospital, outpatients doing outpatient therapy, and community residing individuals who have completed all therapy. The fascinating thing to me about this group is to see the number of individuals who are seeking support who have been injured for many, many years. Last month, we had two gentlemen who had been injured for over 30 years come to the group. I think this clearly demonstrates the challenges of aging with a disability.

At first, I thought that the group would mostly be accessed by individuals who were newly injured. After all, these individuals are dealing with the day-to-day struggles of “Where do I go from here?”—and I assumed the people that would need more help with coping. There are a lot of assumptions about adjustment:

• People assume that within 1 year a person will be “okay” with their injury. It actually varies greatly between people. Some individuals will never adjust, some will take a few months, some will take 5 years.
• People assume that everyone is depressed after their injury. In actuality, only 25-30% of individuals with SCI have clinical depression following their injury, but this most occurs within the first year. Likewise, individuals who cannot cope with their injury are most likely to commit suicide within the first five years, and suicide is the most common cause of death 6 months post injury.
• People assume that individuals with tetraplegia cannot adjust to their injury in the same way that someone with paraplegia can. Again, this is not true. Although individuals with tetraplegia are more likely to be depressed within the first year, they can adjust to injury to the same extent as invidiauls with paraplegia within 5 years.

I learned first-hand through this support group that coping with a disability is really a life-long issue. The support group offers a person a group of peers with a similar condition to relate to, as well as to bounce ideas off of and share methods of coping. Peer support helps an individual realize, “I’m not the only one going through this.” These individuals can provide more information about “real world” experience and knowledge than I, an able-bodied therapist, could ever provide my patients.

In the first few years post injury, the most difficult things to adjust to might be relationships and work-related roles. But later in life, issues surrounding pain or pressure sores might be more relevant. Regardless, individuals post-SCI need support throughout the lifespan, and that it what I hope this group will continue to offer for many years to come.

Am I a Teacher? Or am I a Therapist? (Elise)

I first became interested in physical therapy because it was a health-related profession. Science had always come pretty naturally to me, and I liked the idea of being able to help people. As I shadowed PTs in different settings (hospital, outpatient, schools), I began to realize and appreciate the relationships that PTs formed with their patients. Unlike physicians who are confined to what seems like 5-15 minute interactions with patients, PTs are given longer treatment sessions. What evolves when you can take the time to really listen and understand a person’s injury experience? A trusting relationship. It is this, which I find most rewarding about being a PT.

Now that I have been working in the field for over 3 years, I realize that my job certainly involves helping others through health promotion. But a lot of my job is actually teaching: teaching others about their body/injury, instructing exercise programs, educating about equipment options or environmental changes, and training others how to change their lifestyle to prevent re-occurrence or further disability in the future. In PT school, I knew I would have to come up with an exercise program for a patient, but I never thought too much about the method in which I would instruct them. Did I consider what kind of learner my patient was? Did I introduce the program in a meaningful way? From my experience, I now realize that there are many crucial components to effectively teach individuals new ways to move:

1. Patient-Centered Programs: The patient should be at the forefront of developing the exercise program. I can provide suggestions on what muscles should be targeted and typical methods for strengthening, however it is up to the patient to tell me: how often they can perform it; is the gym/home/outdoors a more effective environment; are others (family, friend, caregiver) able to help or do they feel better doing it alone? As a student, I would often assume that the exercises would be a priority for the patient regardless of how I set it up. Now I realize that in order for a patient to be compliant with their program, it must “fit” into their daily routine and not be overly time consuming (ex: giving a 30 minute exercise program of leg lifts and bridging vs. incorporating heel raises into putting dishes away in cabinets or standing balance exercises while brushing teeth). Similarly, in therapy when working on walking (gait training) or transfers, I need to consider what environments are most meaningful to the patient. Would they rather practice on a real couch or bed compared to the therapy mat? Would home training be more effective?
2. Individual Learning Strategies: The patient’s capacity and ability to learn must be factored in. Is the patient a visual learner, in which case I should write out the exercise program with pictures to present them? Is the patient a kinesthetic learner, who would rather just stand up and start doing the exercises right away? Is the patient an auditory learner who needs to verbally repeat the instructions and positions back to me for retention? These strategies come into play not only in instructing an exercise program, but also when teaching a patient a new way to transfer safely out of bed, or a different method for ascending/descending stairs.
3. Forget about Errorless Learning: An individual must be given an opportunity to make “mistakes” in movement. Errors help the brain to learn what went “wrong” and to make adjustments for the next trial. A teacher who interrupts the patient or is constantly providing feedback (verbal or tactile) on the nature of the patient’s performance is interfering with the patient’s natural feedback loop – and prevents the patient from learning through experience what feels “wrong” (less efficient) and how the ideal movement strategy feels.
4. Time for Reflection: The patient needs to be given time to reflect on their performance. What did they do well in therapy? What exercises felt good? What could they do better next time? Reflection is a key aspect for learing in any experience. It challenges the individual to critically analyze their technique and evaluate how it could be improved. After the patient provides their evaluation of progress/performance, then the therapist can offer their feedback regarding performance, as well. Reflection also helps to improve a person’s self-awareness. I try to ask my patients for a therapy goal prior to their next session. This helps the patient to take ownership over their program, as well as provides me with insight into what is most important for them in their recovery.

These are just a few of the ways that PTs need to consider their role as a teacher within therapy sessions. There are so many aspects of the patient that a therapist must consider in order to help a patient reach desired goals. The patient’s learning strategy is just one example of a way for a therapist to improve his/her interaction with the patient in order to maximize the patient’s outcomes within the plan of care.

"You can't teach an old dog new tricks..." (Elise)

I have heard this saying many times before: “You can’t teach an old dog new tricks.” Often it was used in response to trying to ask an older adult to try a different method/technology to complete a task, such as using a remote control for the television or trying to make phone calls on a cellular phone. The saying suggests that an older person who has a technique for doing something may either find it too difficult to learn something new or is not interested in trying a different way. Research shows that this is quite false—the brain is capable of learning new things regardless of age (or even certain injuries) due to neuroplasticity, which is the brain’s ability to generate new pathways or re-distribute neurons (cells) to perform functional or cognitive tasks.

This quote came to mind this week as I worked with some of my patients on the pressure ulcer management service. Patients who have been injured for many years are very different in therapy from those with new injuries. You might think this is a pretty obvious statement. As a physical therapist, it’s been interesting for me to try to define my role with the new patient population I am working with. For the past 2 years, I have been working with individuals who sustained a spinal cord injury recently. In fact, very recently—anywhere from 2 weeks ago to a few months prior depending on the severity of the injury and the number of medical complications during their acute care stay. I was almost shocked this week when I interviewed some of my patients on the pressure ulcer management service. The three main people I worked with this week have been living with a spinal cord injury for between 25-40 years! That’s quite a change! When I spoke to my patients regarding equipment preferences, transfer techniques, and pressure relief methods, they were quick to inform me about their routine and hesitant to listen to my suggestions for alternatives.

I am learning a lot about maintaining patient-centered care and compromise. During a seating evaluation with one of my clients, we discussed the need for a new power wheelchair. His old chair was completely worn down due to his living environment: daily navigation of rugged, unpaved, and hilly terrain on his ranch. In no time, he stated the name, make, and model of the rear-wheel drive power wheelchair he wanted. This was a surprised to me! I was so accustomed to my clients with “newer” injuries choosing the mid-wheel drive power wheelchair design; the positives of these chairs (in my mind) seemed to completely outnumber those of a rear-wheel drive chair. For example: the smaller turning radius and better suspension provide a smooth and more accessible model. My client would not budge. He was comfortable in how the rear-wheel drive maneuvered, familiar with accessing home and community environments in it, and had no desire to order a chair that was completely new and different. It makes sense to me now, especially knowing he had been in the other chair for 11 years!

Even if his choice was not “justified”, a patient-centered therapist will always allow the patient to make the ultimate decision regarding their care. Certainly, we can provide education regarding other equipment options, access to trial equipment for demonstration, and even suggest a network of current equipment users to contact. It is important to remember that our clients are the ones who will be using the equipment every day and have an extensive knowledge of their own body and living environments. I am looking forward to learning many things from my new patients, as their “injury age” provides them with a certain wisdom that I could not possess. I am certain that information and experience I gain will only help me to better serve and work with individuals who sustain spinal cord injuries at all aspects of the acuity continuum (acute à chronic).

Switching It Up (Elise)

One of the great things about being a PT is the many different patient populations we can work with and many different environmental settings (home, hospital, outpatient, nursing home). I find it a challenging and stimulating part of my job that I can be exposed to different patient diagnoses. Next week I'm moving to a new service at the hospital. Although I'll still be working with individuals post-SCI, my new caseload will include many other diagnoses including congenital diseases (spina bifida, cerebral palsy), multiple sclerosis, etc. I'm going to be the PT on the Pressure Ulcer Management Service.

Pressure ulcers are a serious issue. In addition to the above diagnoses, older adults are very susceptible to skin problems as a result of normal aging. The combination of thin skin (more prone to damage), low body weight (less cushion over the bones), decreased nutrition (poor nourishment to skin), less movement during sleep, and slower skin repair (by cells if skin is broken) places older adults at increased risk for pressure ulcers. Furthermore, diabetes and vascular diseases (common in older adults) decrease the blood supply to the skin placing it at high risk for damage. Finally, decreased mental capacity/dementia can make an older person unable to consider or perform preventative measures against pressure ulcers.

A pressure sore does not just occur out of "thin air"; it is generally preceded by illness or disease associated with weakness and debility requiring significant time spent in bed or in a wheelchair. If a person is unable to move around to shift their weight, or is not regularly turned in bed, excessive pressure on the skin over bony areas causes decreased circulation to that area and eventually skin breakdown. Pressure alone is not the only cause of sores; incontinence, shearing or friction (i.e. during transfers) are also common contributors. Some important means of prevention include: turning at night every 2 hours, performing regular pressure relief/weight shifting in wheelchair every hour, maintaining equipment (wheelchair cushions), keeping good hygiene, and eating a well-balanced diet. We stress these means of prevention with all of our newly spinal cord injured patients, and to individuals who are weak/debilitated at the hospital.

Pressure sores are graded on a scale from Stage I to Stage IV (most severe). I will be working with individuals whose sores have progressed to Stage III or IV; this means that the skin has been broken and the wound is very deep-- to the muscle or even the bone. After debridement of the wound (surgical cleaning) and/or "Flap Surgery" (which "transplants" a muscle from the lower leg over the existing wound), the patients require an extensive hospital stay. During the course of their stay, my role is to re-evaluate their current equipment (wheelchair, cushion, etc.) to ensure that it does not contribute to future sores. I can use a specialized computer system (Pressure Mapping System) to measure the pressure underneath each of the sitting bones of the pelvis. By placing a mat underneath the patient while they are seated on the cushion, I can immediately visualize on a computer the pressure differentials on the cushion to determine if it is the best option for the patient. [If you're interested in learning more about pressure mapping, check out: http://www.xsensor.com/medical-video.php. This is just one of many companies that have mapping systems available.] After I perform mapping, I can order a new cushion or modify their existing cushion. In addition, I will assess their current wheelchair for any repairs or changes that might decrease their seated pressures.

I'll be updating you on my switch to this new patient care area- and the great things I am learning and the challenges I am facing!

The Effect of Age on Adjustment to Injury (Elise)

I have been thinking a lot this week about how age can affect one's adjustment to injury. On the spinal cord injury (SCI) service, I work with individuals of all ages who are dealing with a tremendous loss of function and independence. Lately, I've observed a difference in how patients react to the changes in their bodies and in their lives.

In general, I feel like many of my young patients seem to more visibly/verbally express their emotions/feelings about the changes in their body. One patient in particular said, "I've barely even had a life. I was just starting to get out on my own and be my own person. Then this happened." A common theme with younger adults is how "unfair" the injury and situation is. In contrast, my older patients have more rarely expressed anger or denial in regard to their change in status. They seem to be more quiet in dealing with their body changes... and more accepting. Maybe they think that there were going to be changes to their body with aging anyway? Maybe it helps that most of the older patients are married, have had children (currently living at home or grown), worked a job, and got to see some of the world? Maybe they have more psychological resources to overcome life challenges because they have experienced more?

I decided to look to the literature this week to see what affect age has on adjustment post-injury. The literature does not support my hypothesis. A study by Krause et al. that examined adjustment over the course of 30 years post-injury showed that spinal cord injuries which occurred later in life resulted in an individual being more likely to have lower subjective well-being, poorer health, and a less active lifestyle. Dorsett et al. indicated that the two most significant factors leading to depression after SCI are 1) self-rated adjustment; 2) medical complications (pressure sores). Older adults are at higher risk for developing post-injury complications due to the aging nature of their systems: ex) less resistance of skin, less reserve in cardiac system, etc). Varma et al. showed that because older adults have more pre-existing conditions (ie. cardiac disease, diabetes, joint deterioration), their adjustment was less post-injury compared to younger individuals. It makes sense... but I was still surprised!

Certainly a number of factors affect an individual's response to injury: social support, educational level, employment history, financial resources, pre-morbid health, and prior coping methods (to name a few). The nature of the injury is also an important consideration: Was it a traumatic or gradual/degenerative? Was it violence-related, sport-related, or employment related? Over my years in working with individuals with SCI, I've come to realize that personality and outlook on life are probably the most crucial traits to adjustment post injury. Someone who can face adversity, have the motivation and desire to overcome many obstacles, have the willpower to set high goals, and to find positive in most situations-- they are the ones most likely to thrive post-injury. So maybe age doesn't matter that much after all...

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.

Aging with a Disability (Elise)

I think it's fair to assume that most people expect their health to decline with aging. Take, for example, the anticipated hip/knee joint problems, hearing or visual loss, osteoporosis, or maybe even a minor neuropathy. Those of us with a family history of more serious diseases like diabetes, cancer, heart disease, or stroke may take proactive steps to prevent or delay the onset of "aging" conditions in the future. Few of us, however, are prepared to age with serious permanent disability, such as a traumatic complete spinal cord injury.

Sam, a 63 year-old hispanic male, was enjoying his life as a husband, construction worker, father of 3 and new grandfather of 1. Last winter, his construction vehicle was rear-ended on the freeway going 50 mph. Immediately upon impact, Sam lost feeling in his legs and the ability to move them. After being emergently transported to the hospital, imaging revealed a thoracic-level complete spinal injury and he underwent spinal stabilization surgery. One week later, he was referred for inpatient rehabilitation. His wife and 3 daughters (and their families) were very supportive of Sam and provided much encouragement as Sam coped with this major life change.

As a PT, there are many things that I must consider when working with an older individual post-SCI:
1) First and foremost, I must consider Sam's desired life roles: What was involved in his role as husband (did he BBQ? fix appliances? do laundry?)? How will he remain intimate with his wife? How will a wheelchair impact his ability to play with his grandchildren? Does he see himself going back to work? What recreational interests does he have?
2) I must consider Sam's body: Does he have a prior injury to his shoulder that would prevent propelling a manual wheelcahir? Does he have a scoliosis, kyphosis, pelvic obliquity, or other postural deformity that requires special seating considerations? Does he have a significant history of diabetes or poor nutrition that may place him at increased risk for skin problems? Does he have heart or lung problems? Did he regularly exercise prior to his injury?
3) I must consider Sam's home: Can he access the kitchen, bedroom, bathrooom, etc? Are the doorways wide enough for his wheelchair? Are there stairs? Can he access his community?
4) I must consider equipment options: A padded bath chair for tub & toilet? A ramp for entering the home? A slide board to transfer into the car? Would a power w/c be more appropriate if it is medically justified?
5) I must consider Sam's ability to learn and desire to prevent long term complications: Will he understand the importance of regular pressure relief to avoid skin ulcers? Will he participate in a regular gym program to promote cardiovascular health and strong shoulder/trunk musculature? Will he understand the importance of a healthy diet to promote healing and avoid weight gain? Will he recognize the need for regular bowel/bladder management to prevent infection?

Many ways that Sam and I work together as patient-therapist are similar to younger patients. I must consider him as a whole person and understand those daily life activities which are most meaningful to him. But the things which are inherently different in working with older adults are: how prior medical history/past injuries impact current presentation; how prior life views on exercise and health will impact response to therapy education; and how cognitive ability to learn new information and movement strategies will promote reintegration to desired activities.

Let Me Introduce Myself! Elise

Hello Ithaca College Gerontology Friends! I'm excited to be the newest blogger on the Field of Aging Blogspot. :-)

My name is Elise Ruckert. I am a physical therapist who graduated from Ithaca College in 2006 with my DPT and a double-minor in Gerontology and Integrative Health Studies. As a PT, every day I am reminded why I chose to concentrate part of my education on aging studies: older adults are huge consumers of health care. Unfortunately, there are a lot of health care practitioners out there today who do not have a strong understanding of how much we can improve the function of older adults. For example, falls are often attributed to weakness and immobility from "old age"-- with little thought on prevention. There is so much we can do to help older adults continue their involvement with or get back into the activities they love at home and in the community!

I work on the Spinal Cord Injury Service at Rancho Los Amigos National Rehab Center in Los Angeles, CA. Here, I work with individuals of all ages-- young, middle-aged, and older adults. People arrive at our hospital with injuries from a variety of causes: motor vehicle accidents, sports injuries, falls, violence, and disease (among others). Most of the older adults I see have sustained spinal injuries due to falls or degenerative conditions (such as spinal stenosis). Every patient is unique, and I am grateful for an ever-changing and dynamic work environment. It keeps me on my toes!

My goal for participating in this blog is:

• For you to consider the benefits of having a foundation in gerontology studies as a new health care clinician.
• For you to understand the influence of an aging society on current physical therapy practice and research.
• To expose you to the role of PT in improving quality of life for older adults with different health conditions (ex: cerebrovascular disease, diabetes, Parkinson's Disease, etc.).

If you have specific questions or comments, feel free to pass them along. I'll look forward to hearing from you and sharing my experiences with you!

Adapting to Changes (Joanna)

After working over two years for Atria Senior Living Group, I have observed and realized that older adults who use a cane or walker very often run into the problem of forgetting their cane or walker. They might leave it in a room after a specific activity, or forget altogether to bring their cane or walker from their apartment with them to other common areas in the building. Some of these older adults have dementia (which can contribute to their forgetfulness about this), but not all of them have dementia as their “excuse.” I have realized that having to use a cane or walker is comparable to getting glasses. After all, when any person gets glasses for the first time, they must adjust and adapt their mind, body, and lifestyle to this change. I'm a little far-sighted, and I remember having my own moments where I would forget to wear my glasses. I would be dressed and ready to drive to work, turn my car on, look out my windshield, and then wonder for a second or two why I couldn't see something clearly in the far distance. Then surely enough, I'll remember that my eyes are not what they used to be, and that I need my glasses! After all, I have lived the majority of my life without any glasses, right? We are creatures of habit. Then, when I started to wear contacts, I had experiences where I completely forgot I was wearing them! I accidentally went to bed at night still wearing my contacts, and discovered this when I woke up the next morning with very dry uncomfortable contacts and irritated eyes! Again, I had been accustomed to not using any kind of visual aid for most of my life. Similarly, older adults may forget their cane or walker, just as I forgot to wear my glasses (or forgot to take out my contacts), since they have lived the majority of their life (70, 80, 90+ years) without the assistance of a walker or cane. It does take time to adapt to changes like this, and sometimes also requires developing new routines.

Another thing my residents have taught me is that if you have some type of handicap, you can still do many things, although you might have to do them differently. For example, one of my residents with a vision handicap told me how it started to become difficult for her to put toothpaste onto her toothbrush. So, she started to just squirt some toothpaste into her mouth, and continue with brushing her teeth in this way. Of course she doesn't share her tube of toothpaste with others! Therefore, being creative in discovering simple ways to adapt a particular routine (such as tooth brushing), can be very helpful for some older adults to remain independent instead of struggling, getting frustrated, and experiencing another loss. (The majority of people without vision problems wouldn't ever think to do this, even though there's really nothing wrong about it, especially if you live by yourself or use your own personal tube of toothpaste.)

Listen & You will Learn! (Joanna)

Listen to seniors and I guarantee that you will learn oodles of interesting things. Throughout each day, I take the time to listen to my residents (as well as observe them). I like to hear their stories, jokes, ideas, fears, questions, and opinions. Each resident is just filled (actually overflowing) with so many years of memories and history. It's pretty fascinating stuff...

For example, there's several residents in my building that have macular degeneration, a medical condition where the retina is damaged and causes loss of vision in the center of the visual field. I used to not know too much about macular degeneration and how it affects older adults, everyday life. One female resident taught me that she can no longer recognize faces, but can still recognize people by how they walk, talk, laugh, or by their hair color/length/etc. Interestingly, one's peripheral vision is not affected by macular degeneration, which is why she will not become completely blind. Despite her vision handicap, this same female resident is always smiling, socializing, and optimistic. I had a recent conversation with her in the dining room about her vision condition and she started to tell me how she's really starting to enjoy her new visual world--how she manages to see the positive and beauty with her vision loss. Smiling, she pointed to the banisters of the large staircase in the dining room, and told me that all those vertical supports dance around whenever she moves her head! How cool is that?! Definitely unique. Whereas some people with macular degeneration would interpret this as a scary or negative visual experience, she simply learned how to enjoy and make the best of it. She could easily let her visual handicap make her isolated and depressed; however, she chooses the exact opposite and shares her perspectives with others. Meanwhile, I'm listening to this resident and just trying to imagine her visual experience to the best of my ability. It would be a challenging, yet creative project to attempt to have this resident help someone else draw/paint/photograph/video what the world looks like through her eyes...because it is like an art. One thing is definitely true though: Seeing the positive in things (such as handicaps) and being optimistic can do so much for your quality of life....if you have these two qualities, you really have it all.

Karisha networking - Blogs, Newspapers, Brief Reports, Websites ...

I know that I will change careers many times in my life just as you will. One major thing that has changed for me & you is that my next job will not be determined by the health care that I can receive. You can now follow your dreams with out the extra concerns!
I have continued to follow my interests in other ways besides my career. You should do the same to keep narrowing down on your talents and spreading the word about what you can offer as a gerontologist.

A few ways I network:
I wrote my thesis on an interest of mine (that made it a lot more fun to complete)
Check it out on a website that I like to chat and see what is new in the field
Creating Aging Friendly Communities .

I also write anything I can related to aging in place, universal design, livable communities, interior design, architecture, products and of course relate it to gerontology. You have to put effort into networking and that does not stop because you have a job.

Another way I have tapped into my interest is through a blog called Homebody.
Homebody
It is a blog that shows people how they can have stylish and functional homes. You really need to check it out.

Here is a brief report I co authored:
Scripps Gerontology Center Brief Report
Livable Communities: Helping Older Ohians Live Independent and Fulfilling Lives

Below is an article in the local paper about my thesis project



I am also a member of Linkedin. This web based networking is like the career related facebook where you post your resume and interests.

At this time I can not afford to attend conferences with out the student rate so
I am always looking for new ways to network. If you have any ideas please let me know!

Note: Always be true to yourself and treat people the way you want to be treated
Send a thank you note (not an email or text but a hard copy card)to each person that has helped you along your journey and your kindness will be repaid in untold ways in the future.

Case Managers working with Contractors- Karisha

When I first started working as a case manager I agreed to help my supervisors create a training binder for all case managers. As I learned something new I wrote it down anyway and put it into a binder as a reference for everyone else. This helped everyone compile needed information in one spot and to create new documents where there were none. For example, it was very confusing for the case manager to work with the contractors when doing home modifications because our relationship is different than if the contractor was working for the client private pay. I created the documents below to help the contractors understand the role of the case manager and they all appreciate having this.

Environmental Modification Guidelines for Contractor and Case Manager/ Client
1. Determine client need for environmental modification
2. Case manage contact the doctor to have a script written stating the need for the environmental modification
3. Client to choose 3 contractors from the Pick List and put them in order by choice.
4. Case manager determines the needs of the client and with the clients input decides on the design of the construction to be done.
5. Case manager calls contractor asking to send information to their business if they are interested in the environmental modification job
6. Case manager sends a fax including
o Drawing outlined by the case manager and client
o Check list of what to bid on
o Case managers responsibilities and contact information
7. All contractors are to bid on the same job/materials needed to complete the home modification


Contract between Case manager and contractor

I __________ agree to communication with the case manager ___________________ who is representing the needs of the client _____________. I understand that no deviations from the drawing presented for the bid can be made unless discussed in detail with the case manager. All bids that do not follow these guidelines will be dismissed from the bidding process. All communication from the contractor is to go through the case manager and will be discussed with the client. I understand that all code requirements and permits are the responsibility of the contractor that bid the job through Area 9 Agency. If any sub contractors are working under the main contractor the contactor signing this agreement is held responsible. A satisfaction release form will be signed by the client.


Name:_________________________ Date:______________________________

By signing below you acknowledge that you have read and understand the relationship between the client, case manager and contractor.

1. Case Manger will assess individual and determining need for service and environmental modifications
2. Case Manager will develop Plan of Care
3. Case Manager will be determining the cost effectiveness of environmental modification
4. Case Manager will ensure use of Person Centered Planning in having the environmental modification fit the needs of the individual being serviced
5. Client and Case Manager will determine the environmental modification that will be done
6. Case manager will submit one drawing to the 3 selected contractors
7. No deviations are to be made from the drawing by the client or contractor
8. Case manager is acting as the advocate between the client and contractor
9. No additions by the client or contractor to the environmental modification are to be made after the construction has started unless discussed with the case manager
10. Any additional construction being done to the home must be completed separately from the approved bid.
11. Case manager and supervisors will be reviewing all bids from contractors and selecting one to complete work
12. Case Manager will be explaining to client services that will be provided
13. Case Manager will be supervising implementation of construction for the client
14. Case Manager will be advocating on behalf of the clients’ interests and having all decision making communication with contractors
15. Case Manager will be monitoring the quality of HCBS and ensuring that POC objectives are being met
16. Case Manager will be performing record keeping of all construction activity
17. Case Manager will reassess POC to determine need for additional modifications
18. Case Manage and contractor will ensure confidentiality of individual information
19. Case Manager and contractor will maintain the highest professional and ethical standards

Client ___________________________________________ Date: ___________
Case Manager:_____________________________________ Date:____________
Contractor:_________________________________________ Date:___________

Salary and Benefits for Case Managers

Oh I almost forgot the niddy griddy:

Case Manager salaries range from $25,000- 40,000
Supervisors $35,000 - 45,000
Administrators $45,000- 65,000

I work for a University so I have really good health care benefits and 6 weeks of vacation a year.

I have the opportunity to attend lots and lots of continuing education seminars ranging from domestic violence training, eating healthy, wheelchair evaluations, dealing with difficult clients, elder fraud and abuse...

The best part of my job is the flexibility. I work 40 hours a week. We are not allowed to go into overtime. If I have a late visit with a client I leave early on Friday or come in late the next day. I independently monitor my hours and can work out during my lunch break or not take one and go home early.
I would not want it any other way.

Karisha explains how to do a wheelchair ramp

This is an example of a ramp drawing. If the modification is over $1,000 the cm has to obtain 3 bids from separate contractors. I have found the more detailed and accurate the drawing is the easier it is to communicate with them and the quicker you get their bid back.