The topics of light and darkness are widely explored in the holy books of the Jewish and Christian faiths, beginning with the very first verse of the book of Genesis. The concept of light versus darkness is further explored throughout the remaining scriptures. At Christmas time, we re-read the words of the prophet Isaiah, who proclaims:
“The people who walked in darkness have seen a great light, those who dwelt in a land of deep darkness, on them light was shined.”
We are reminded that our ancestors lived in a dark world. Today, over two thousand years later, our world is still dark. We fear domestic and international terrorism and classroom bullies. We worry about our safety, finances, politics, and the effects of the recent elections. While the darkness of our world can sometimes make us despair, the light that we celebrate at Christmas provides hope, for “‘in Him was life, and the life was the light of all peoples. The light shines in the darkness and the darkness has not overcome it.” This message of hope that dispels darkness brings us great comfort in a world that needs this love and peace.
To help spread the light and joy of this season, Baker Rehab Group has made a donation to a local charity on behalf of our partners. The donation was made to Gateways2Life and will help provide support and resources to refugees on the shores of Greece. We hope that the love, compassion, toiletries, backpacks and sleeping bags brought by missionary workers will provide hope to the refugees through their frightful journey from war and despair to a new life.
I hope that you carry this message of joy with you throughout the year. Merry Christmas, Happy Hanukkah and Happy New Year!
When someone is jostled by a bump or a stumble, the brain uses two strategies to maintain balance and prevent a fall, according to Alexander Aruin, PhD, professor of physical therapy at UIC and principal investigator on the two studies.
‘When the perturbation is predictable, for example, if when walking down the street you see someone about to bump into you, you brace yourself,’ Aruin said in a news release. This is the first strategy, in which the brain activates muscles in anticipation of the jolt.” Read more…
Alzheimer’s and other dementias are neurological diseases
Cognitive impairment in early stage Alzheimer’s disease limits a physical therapist’s ability to accurately assess motor skills, muscle tone, and strength. Because therapists typically use traditional fact-finding approaches like question/answer and verbal commands, Alzheimer’s patients can be dismissed as “within functional limits” or “not appropriate for therapy” due to the inability to follow instructions. But physical therapists are well equipped to assess patients with other brain dysfunction like CVA or TBI, who may or may not present with obvious motor issues. It is important that therapists look at Alzheimer’s and other dementias through the same lens. Alzheimer’s is a neurodegenerative disease. PT’s need to work around behavior or personality issues, confusion, denial, and resistance and look for ways to improve strength, mobility, and access to the environment- at all stages of decline. Target areas should include balance, vestibular disturbances, and awareness of barriers and hazards in the environment.
Procedural memory trumps working memory
I couldn’t train my son to pitch a baseball by simply telling him how to do it. Just because a person can understand the instructions you give and remember them long enough to tell them back to you does not mean that he or she can physically perform the motions correctly. If you expected your son or daughter to be able to throw a baseball that way, your child would have failed T-ball! Procedural Memory is solidified by repetitive performance, and it is not dependent on the conscious awareness of actually doing the action. Practice breeds performance. It’s true with our kids sports and it’s true with our dementia clients trying to stand. So just because a person with Alzheimer’s cannot see the value in multiple sit to stands, or cannot sequence proper hand and foot placement with verbal cues, does not mean that the task is unlearnable. Repetition with consistent approaches over a period of weeks will result in motor learning. The same principle holds true for strengthening, using an assistive device, or locating the bathroom or dining room.
The visual and motor cortices are the secret back doors
In most dementias caused by neurodegenerative disease, the visual cortex is left largely intact until the later stages of the disease. Language, memory, and reasoning are usually affected early on, resulting in the impairment of the ability to follow conventional learning approaches. The visual and motor cortices are fairly well preserved. “Functional” or meaning that non-traditional approaches can be an effective way to elicit desired activity. The take-home message: use demonstration for instruction and repetition for learning. And remember, stay in their visual field. They need to “see you” do the task.
Most people who experience joint dysfunction over time don’t just lose mobility in a single joint; they lose entire patterns of movement. A person with an unstable knee or painful hip gradually stops squatting, bending, and rotating. He or she may lose vestibular and peripheral balance responses due to lack of use. Compensatory movement patterns eventually replace normal movement, which can cause undo stress to otherwise healthy joints. By the time a patient presents for joint replacement surgery, multiple movement patterns and functional abilities have been adversely affected.
A shift in traditional thinking has led many physical therapists to consider the needs of their joint replacement patients more holistically. In the not too distant past, physical therapists used the hash marks on the goniometer and the distance a patient could ambulate with a single point cane as indicators of successful joint replacement surgery. With fewer healthcare dollars and increased comorbidities, physical therapists now need to integrate bodies of knowledge across orthopedic, neurological, respiratory, and circulatory systems and break away from the conventional approaches that targeted the optimization of movement of a single joint in a cardinal plane.
Optimal outcomes following single joint arthroplasty are rarely limited to the pain, range of motion, and integrity of a single joint. In fact, the buzzword “outcomes” means different things to different people. Positive outcomes for the engaged consumer have mushroomed to include nebulous measures like quality of life, resumption of activities, and a rehabilitative course that matches his or her expectations. The healthcare industry, including payers like Medicare and private insurance companies, consider complication-free procedures, timely discharges, and low re-hospitalization rates to be the benchmarks for success.
Such are the challenges of the new-age physical therapist specializing in joint replacement surgery.
Gone are the days of lengthy hospital stays- where in-bed exercises consisting of feeble ankle pumps and gentle heel slides dominated the first few physical therapy visits following a hip or knee replacement. Gone, also, are the seven page home exercise programs, neatly assembled by the therapist and ultimately ignored by the patient whose only desire is to get back to walking. Shorter hospital stays and pressure for quicker outcomes translate into immediate out of bed and weight bearing physical therapy protocols.
The optimal exercise program, the one that offers the greatest bang for the buck, consists of closed chain, multi-joint, functional movement patterns performed in standing. Instead of passively stretching a tight calf in bed, adequate calf stretch can be achieved in standing, with the body weight shifted onto the foot and the knee dropped slightly forward. This simple stretching pose also provides trunk stabilization, hip and knee control, proprioceptive and somatosensory feedback, bowel motility, cardiovascular training, and pneumonia prevention. A simple head turn during a sit to stand exercise engages the vestibular system. Three or four standing, weight-bearing exercises can accelerate the rehab process, largely by improving the general health of the body’s systems, improving compliance with home exercises that promote function, and optimally recruiting more motor units with the closed chain.
In today’s healthcare environment, physical therapists are being pressured for better and quicker results with their joint replacement patients. The fitness industry has been employing these techniques with growing popularity- as seen in sledge hammer swinging, shovel scooping, and overhead heaving movement patterns dominating the curriculum of warehouse fitness clubs. The diverse definition of “outcomes” among decision-makers, limited healthcare dollars, and an increase in medically complex patients receiving joint replacement surgery requires physical therapists to produce excellent results in shorter timeframes. Functional movement patterns may be the secret sauce.
Sometimes while I am interviewing potential new hires, I feel their apprehension and anxiety about moving into the field of home health physical, occupational, and speech therapy. Although the idea of home health sounds like a flexible and rewarding career path, they are still nervous about the “what-ifs”. Let’s break down the common myths and misconceptions about home health therapy, keeping in mind that the reward is worth the risk:
What if the house is dirty or in disrepair, or if there isn’t good caregiver support? I don’t know what I’m walking into.
Ok, so this one is not exactly a myth. Sometimes you really don’t know what you’re walking into. But by the time you are ready to make your first visit, you’ve already spoken to someone on the phone and/or another healthcare provider has already been to the house. You can pick up on a lot of what’s going on before you even arrive. If you hear dogs in the background, you can ask that they be put away when you arrive. If you can tell the person on the phone is a little confused or unreliable, you can call the emergency contact person and arrange for someone else to be there when you arrive. It is rare that the “worst-case scenario” in your head even remotely approximates the reality of bad situations. You have a team of people supporting you, and together you all support the patient.
Keep in mind that, usually, the patient has just spent some time away from home in the hospital, or they’ve been chronically ill and unable to maintain the home. This is a reality that is out of everyone’s control. Your job is to improve their home environment and physical status so that self-home management is possible, or to put support systems in place to improve the situation. The more you get to know and understand the human being you’ve been sent to help, the less you notice things that would normally make you uncomfortable. Compassion and empathy are sometimes the substance of miracles.
What if there is an emergency?
Then you get to be a hero. How fortunate for your patient that you arrived just in time to recognize the worsening symptoms of congestive heart failure, that you were there to notice the spike in blood pressure, that you were able to call the doctor about a possible infection brewing along the incision site! Whatever the emergency, it’s YOUR eyes that caught it. You will deal the emergency calmly and swiftly, with the guidance of the physician and home health agency supervisors. You are a trained professional… you can handle it!
I worry I’ll be out there all alone.
Valid concern- you will be alone. BUT, you will also be a part of an amazing group of professionals who are only a text, email, or phone call away. You have resources in the relationships you build with other therapists, nurses, and administrative staff who are always available to help. Autonomy is a great feeling of professional achievementabandonment is not. When you don’t know something, ask. It’s as simple as that.
Ugh, all that driving.
Love, or contempt, for driving from home to home is a personal preference. We have therapists who love driving along winding, rural roads, as much a 10-15 miles between clients. We also have therapists who navigate some of the most congested highways and city streets in the country. What they will tell you is that they use that time for some productive purpose: for reflection, for decompression, for making calls (hands-free devices of course), for listening too books on tape or music, for planning the next treatment session or arranging carpools for the kids. Traveling between patients also allows for a quick detour into Target or the grocery store that a clinic job can’t provide. There is also the opportunity to work in the assisted living environment, where the need to travel between patients is minimal to naught.
I don’t want to be a full-time employee, but I worry about not having a consistent paycheck.
In our company, where we pay our clinicians per visit, there is a risk of ebbing caseloads and smaller paychecks. Other companies do offer full time compensation, but it is tied to productivity minimums and time management oversight.
As a per visit employee, it can be hard to deal with fluctuations in income. There are ways to manage the risk, however, by learning how to effectively manage your time and capitalize on opportunities. Establish a “take home” minimum and work to save the profit from the fatter checks to supplement thinner times.
It is important to understand the ebbs and flows of home health. A boat load of clients are discharged from inpatient facilities just before holidays, so take these cases if possible for when things are slow during the holidays. I find things get slow from Dec 25th to about Jan 10th each year and the last three weeks in August for physician vacations with less elective surgeries like joint replacements. So, this is a good time to plan vacations or other projects.
Work on the “honey do” list, start that painting project, or get caught up with your exercise workouts to “redeem the time.” Usually, the problem
always seems to be too much work, so enjoy the short break.
I won’t become a better therapist unless I work in a more structured environment.
There are many advantages in working in hospital or clinic settings, and experience in those settings certainly enhances the skill sets of therapists with diverse backgrounds. But in busy clinics, where there may be ten to twelve therapists buzzing around with three patients to see each hour, how much collaboration is there? How much time do you have to figure something out, or try something new? How personalized is the care one joint replacement patient is having compared the joint replacement patient on the next mat table? In the home health setting, where the client is receiving 1:1 care in his or her own environment, each situation is different from the last. You learn how to apply neuro techniques during a real, functional activity, instruct stair training on his or her own stairs, provide strength and balance programs using whatever equipmentis available in the home, fatigue a muscle group with your bare hands. No, you don’t have a $40,000 balance trainer but you do have a sofa cushion or square foam, walker and your gait belt to do an awesome balance training treatment! Home health helps you develop creativity and resourcefulness. You find yourself digging deep when you’re challenged, reaching into a wealth of knowledge and experience and never coming up empty. You routinely go above and beyond the minimal requirements because this person in front of you needs you to. And that, my friends, is the essence of excellence.
Isn’t home health a side job?
Once upon a time, home health was viewed as the “extra job”. It was a way for therapists with full time jobs to earn a few bucks after work and on the weekends. Home care, however, is no longer a casual commitment.
Ever changing and expanding Medicare guidelines regarding the provision of physical, occupational, and speech therapy under the Part A home health benefit have turned home care into a highly regulated industry. With more and more baby boomers coming of age and utilizing their Medicare entitlements, the Centers for Medicare and Medicaid have really tightened up the purse strings. Keeping track of therapy dollars and having therapists routinely justify and qualify the need for intervention requires constant therapy input. Making the most of limited Medicare dollars drives therapists to accomplish goals that are necessary for the client to function at home. Developing a repertoire of tricks and a knack for prioritizing issues that need to be tackled are skills that are learned… leading to mastery earned.
Home health therapy is very much a specialized field- one that requires out-of-the-box thinkers with big hearts and broad perspectives. Previous experience in nearly any field, from pediatrics to orthopedics to burns to cardiac care, will all come in handy at some point. Home health introduces you to such diversity of conditions and expectations that it could easily be labeled as the rehabilitation world’s box of chocolates- ya never know what you’re gonna get.
I recently treated a client who made tremendous progress and experienced very successful outcomes. It’s a great example of how family involvement can facilitate positive changes with only a few helpful, yet firm, recommendations.
An elderly woman with a history of Parkinson’s disease was referred to home physical therapy by her physician due to multiple recent falls. She had already had therapy in the home before, but still she continued to fall. During my first visit to her home, it was immediately clear why she kept falling.
Her house was cluttered- not to “hoarder” status- but so full of furniture and piles of stuff that neither her rolling walker nor rollator could fit through some of the passageways. Without being able to use an assistive device, she relied on furniture and walls for stability. She also demonstrated some impulsive behaviors, common in many neurodegenerative diseases, which only increased her risk of falling.
I knew that the only way to achieve positive outcomes in this situation was to modify the environment, and that was going to require the family’s help.
I posed the options to the client and family clearly and gently, “Unless this house is decluttered and cleared out, she will continue to fall. This will lead to a downhill spiral in her general health that could have been prevented with a good spring cleaning.” I told the family that I couldn’t help her unless her environment improved. I walked through the house with the family, questioned the necessity of each chair, table, and ottoman, and suggested that anything that wasn’t regularly used be moved to the garage. These items were largely valued for their sentimental meaning, not for their practical significance. I told them that on my next visit I expected a clear path into each room on both levels of the house, with wide-open, accessible spaces in each room.
On my second visit, I was pleasantly surprised to see that my recommendations had been followed. My client was able to use her rollator to travel safely from room to room. She had space to turn around and navigate around corners and obstacles. Her risk of falling had been largely mitigated.
On my third visit, I taught my client how to enter and exit the house. I instructed her how to navigate the three steps to the front door. I also taught her techniques to alleviate “gait freezing”- the phenomenon that occurs in some people with Parkinson’s disease where they have trouble initiating movement. She was able to independently use these strategies whenever she got “stuck” and get herself moving again.
On my fourth visit, my client was able to show her family her newfound sense of independence. The family was amazed at how stable she was when she used her rollator, how easy it was for them to help her enter and exit the home, and how she was able to “unfreeze” herself without falling.
I was most pleased that this level of achievement was accomplished in only four visits, and that the successful outcome was directly correlated to her family’s willingness to make hard decisions and implement changes. Sometimes just helping people view a lifetime collection of sentimental items as just “stuff”- stuff that gets in the way of leading a safe, productive life- is the best way to be of service to our clients.
For many years, the Baker Rehab Group (aka HomeCare Rehab and Nursing) machine was meticulously maintained by our office manager Lisa Baker (no relation to Dr. John Baker). It was in the spring of 2009 that we lost Lisa, one of the world’s most caring, genuine, and loving individuals, to cancer.
With bittersweet irony, Lisa’s daughter Brittany started working with BRG during her high school years and continued through her four years at the University of MD as her schedule would allow. She acquired enough knowledge of the various administrative duties that are required to keep Baker Rehab Group running that she became a valuable resource for us. Brittany will be graduating this month from Hagerstown’s Community College with a degree in nursing. Brittany has literally grown up in our company, and we are so proud of her.
In addition to Brittany’s hard earned success, the Lisa Baker legacy also lives on at Baker Rehab Group. A few years ago, we decided to both honor Lisa’s memory and give it a name- defining the qualities with which she set the bar as an exemplary employee and overall wonderful person.
We present this award each year at our holiday party to the employee who demonstrates Lisa’s “just get it done” work ethic. It recognizes those who rise above the status quo, who possess the insight to always see the bigger picture, and fulfill their prospective roles with integrity and honesty. And in true Lisa Baker fashion, they do all this with a smile on their face. It boils down to three words:
SERVICE- ATTITUDE- TEAM
Previous winners of The Sunshine Award include our current office manager, Lisa Eyler, who stepped into Lisa Baker’s shoes once she could no longer work, and has operated as the wizard behind the curtain ever since. A year later, Jin Park PT won the award in recognition of his dedication and easy-going attitude. Tracey Cannon, also a physical therapist, won the honor last year as someone who is 100% dependable, competent, and professional. Each of our previous winners continues to demonstrate the same outstanding qualities for which they were acknowledged.
This year, we had a much harder time selecting a winner because there are so many outstanding team members at Baker Rehab Group. It was hard to pick just one… so we didn’t. Although there was no shortage of potential winners, two candidates stood out and were both equally deserving of recognition… so we awarded it to both of them.
Introducing The Lisa Baker Memorial Sunshine Award Winners 2012….
Sunshine Award 2012 Winners: Theresa Davis and Patricia Dahlen with John Baker and Sue Paul
Theresa Davis (Spotlight on Excellence, November) is an occupational therapist who has really stepped up in the company as someone you can count on to help others. She has emerged as a trainer and mentor for new hires and plays an integral role in developing and maintaining professional relationships in the community. She is someone who requires little to no direction or oversight- just give her a project and let her go. Rest assured it will be done efficiently and correctly…. and with a smile on her face. Congratulations Theresa! And thank you for all of your hard work.
Patricia Dahlen (Spotlight on Excellence, September) runs the back office of Baker Rehab Group as a master of many skills. She is a multitasker extraordinaire! This past year, we have relied on Pat to deliver on several creative projects, to “drop everything“ and respond to urgent matters, and to juggle the continuously added responsibilities of a growing business. Because she can do these things with a smile on her face and song in her voice, she is clearly Sunshine-worthy. Pat, we are so lucky to have you!
Thank you to all our wonderful therapists and office staff for your tireless energy and generous hearts. You are like family to us.
I am brimming with such pride and admiration that, being without a platform or mountaintop to holler from, I felt had no choice but to hijack John Baker’s blog while he is on vacation.
I’ll ask his forgiveness later.
But for now I must share with you some warm fuzzies- the kind that leave a mark on this world. I have the dubious responsibility of completing annual supervisory visits with the occupational therapy staff at Baker Rehab Group. It is a mechanism to ensure quality care and compliance with our staff, and is used as a framework for important feedback and suggestions to help us all grow as clinicians.
Though not designed to be an ambush of sorts, I usually end up stumbling across an OT in one of our assisted living facilities, whipping out my paper, and observe a treatment session there on the spot without warning. It’s purely out of convenience on my part due to my slippery schedule, but it can be genuinely surprising and slightly disconcerting to the unprepared therapist.
Today was one such day. I ambled down the hallway at a facility and overheard one of our OT’s talking with a resident and staff caregiver. The OT described the purpose of the task to both parties (check!). I peeked through the crack in the door and watched her demonstrate instructions to a patient with cognitive impairment (check!). I listened to her providing cues, educating the caregiver, and rearranging the environment to make the patient more successful and safe (check, check check!!!).
Then I listened to the feedback from the caregiver, thanking her for the wonderful suggestions and impact that therapy is having on the resident’s quality of life (there is no check box for that, but there should be!).
Only a few rooms away was another of our stellar OT’s. I listened through the door for a bit, mostly just to gauge if it was an appropriate time for me to enter. I heard easy banter and a few laughs coming from the bathroom. I knocked and entered the room, asking the patient if it was ok for me to observe. Standing slightly behind the patient and mouthing to me over her shoulder, the OT whispered, “I love her” to me and gave the patient an affectionate rub on the back.
I watched them work on activities at the bathroom sink- where to park her walker, where to place her hands, in what sequence to perform tasks, where to place the items. The OT told me that the patient is highly motivated to be able to complete all bathroom tasks without help from the staff- and together they would make this goal a reality.
Feeling any warm fuzzies yet?
The OT then set her up with some exercises to strengthening her weak, arthritic hands, so that she would be better able to open the containers at the bathroom sink. And then she reviewed the things they had worked on, what else they would still work on that visit, and what they would address during the next visit.
It goes without saying that these OT’s follow procedural policy flawlessly. I can check off competency in all skills related to this setting without hesitation.
But what I was most struck by was the compassion… and the incredible desire to improve the lives of their patients. Before they were even aware of my presence, I could hear the patience and kindness in their voices. I witnessed excellent communication coupled with gentle, non-threatening body language. Their presence was calm and confident. They were easy to understand and easy to trust.
I then went in search of assisted living staff, looking for feedback and opinions about these therapists and the work they do with the residents. They were so genuinely appreciative of these therapists, and others that work in the building, and told me that their expectations had been exceeded beyond measure. I was humbled by the success stories and puffed up my chest like a proud mother hen.
I am so honored to work with these therapists, and all the others at Baker Rehab Group, who show the same commitment to excellence and beyond-job-requirement effort in everything they do.
It may sound cliché to be so positively affected by a group of coworkers, but they truly inspire me. They are difference-makers.
Received a referral from an orthopod for home physical therapy to see a client who had fallen at home. She had both hips replaced in the last few years. The referral said “Left Hip Pain. Eval and Treat.” I figured I was walking into a situation of someone who had a painful left hip…possible hip contusion…probably would need a home safety assessment, some ice/heat, massage, gentle stretching and move toward more aggressive strengthening and fall prevention strategies.
When I saw her, she could hardly move and was in a lot of pain from the most recent fall that occurred the night before. Pain not from her hip but instead her back and left rib area because of the latest fall. She could hardly move from the pain. I arranged for an x-ray for possible rib or spinal fractures. The x-ray did show left side rib fractures.
But things still just didn’t add up. Her motor recruitment or muscle contractions were diminished generally…she couldn’t move as well as I would have expected. She had a scissoring gait pattern…walked kind of pigeon toed, slight resting tremor or shake on right forearm that was worse when stressed. When her physicians asked about it she told them “doctors make me nervous” and her dad had it too. Awgh! Essential tremor…maybe. But the dulled emotional tone on her face…she didn’t laugh outwardly at my amazing jokes….bad sign! …and the akinesia…all those light postural adjustments and lack of head rotation to track me as I moved around the room as we continued our conversation. Hmm….
So, I prodded a little deeper. Reviewed her medications again…hmm…depakote, clonazepam… and about ten other meds including a narcotic for the pain. That explains it…or does it?
Time to call her primary care doctor. I hate this! Get put on hold, get screened, someone tries to decide if my information is worth putting “the man” on the phone with me. I’ve done this before and learned the hard way. Don’t assume you know the “new and unknown diagnosis that will save the day!” Just ask questions and state your observations and concerns. Anticipate what they will ask you and have your responses ready. State objectively your findings, then ask a few questions of your own. Why is this sweet woman falling so often? Why is her motor pattern and response the way it is? Have you seen her get up in the office and walk across the room, moved her arms and felt her tone?…why no right arm swing when she walks at normal speed? Why no little postural adjustments that we all usually make all the time? Why does she not rotate her head and follow me as I move around her apartment?
It is very easy to get “tunnel visioned” into seeing what the referral script says…left hip pain. But do I see the tree and miss the forest. A tree can tell you a lot, but step back and look at the forest…you may be surprised at the view.
This is one reason I love working as a home health physical therapist. I can make time to look at the tree and even step back and view the forest.
Let me take a moment to introduce you to the Dementia Queen!
The “Queen of Dementia” a.k.a. Sue Paul has been the Chief Operating Officer of Baker Rehab Group since 2002.She has held certifications in geriatrics through the American Occupational Therapy Association and served as AOTA representative for the End of Life Practice Recommendations for the National Alzheimer’s Association in Washington D.C. She is the author of the Head, Hands, Heart Dementia Assessment System, which is a healthcare provider tool for assessing and treating persons with dementia.
Check out her blog The Dementia Queen for insight into a segment of the population that is largely neglected by our healthcare system. As the body of knowledge pertaining to the causes, symptoms, and treatments of Alzheimer’s disease and other dementias evolve, Sue shares her findings in hopes that it helps someone, somewhere, who struggles with the challenges of Alzheimer’s.