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A Team Approach to Falls Prevention

Fri, 04 Dec 2009 08:50:13 GMT

Falls are a serious problem with seniors. It has been estimated that one out of three people over the age of 65 have at least one fall each year. Unfortunately, many falls lead to injury and may cause loss of mobility and independence for seniors. It’s an even worse problem for older adults with dementia.

Traditionally, physical therapy has been the primary discipline involved in the development of falls prevention programs, whereas occupational therapy addressed only the environmental changes like removing scatter rugs and installing grab bars for the bathtub and toilet. In order for a falls management program to be successful, I believe that occupational therapy needs to play a much larger role.

Some think falls prevention is only about improving balance and strength. However, balance is a dynamic process that integrates both sensory and motor processes. Therefore, I believe an effective falls prevention program needs to be comprehensive in nature. It should involve a team approach that focuses on the many components of balance. In a skilled nursing facility that team would include the nursing staff, the maintenance staff, the activities coordinator, the dietician and the physical, speech-language and occupational therapists.

Maintaining balance requires applying the correct sequence of sensory input. This involves the processing of that input, the response planning of it, and then acting out that response by applying the appropriate amount and duration of muscle activity. Sensory deficits and cognitive dysfunction can have a significant impact on this process. Knowing a person’s cognitive ability is a key factor in developing a successful program for the individual.

One of the most popular approaches we use to address cognitive disabilities is the Allen Cognitive Model, which measures cognitive ability according to six hierarchical levels. These levels range from Level 0.8, which indicates a profound disability and near unresponsiveness, to Level 6, which indicates normal functioning. The cognitive levels are further classified into 52 modes of performance that measure and classify smaller increments of change.

There are many assessment tools available to help determine a patient’s Allen Cognitive Level (ACL) score. Once an occupational therapist has an ACL score for a patient, they can then choose from the many treatment guidelines out there to assist them. These resources are unlike cookbooks with step-by-step recipes; they are reference guides meant to provide therapists with suggestions for treatment planning. The Allen Model addresses motor skills, self-care, functional mobility, communication, instrumental activities, continence, safety, environmental modifications, community activities, productive activities, etc.

Even though the ACL score provides the treatment team with valuable information, it is still very important they consider other underlying factors that impact performance such as sensory and motor dysfunction. Additionally, the environment, current routines, past roles, interests, and the ability of the caregiver are also important elements that must be considered when developing an optimal program for a patient. It is also important to remember that cognition is dynamic, and therefore, fluctuates with treatment planning. Because of this, therapists must always use their clinical judgment when making recommendations based on an ACL score.

Managing Arthritis with Alternative Treatments

Mon, 16 Nov 2009 16:44:07 GMT

As a Regional Director of Clinical Services for Aegis Therapies, I am always excited to help our teams improve the quality of the clinical care they provide throughout our facilities. Although it has been many years since it was my job to be a hands-on therapist on a daily basis, I still love finding ways to improve and add to the types of care we provide.

My training to become a physical therapist took place back in the early 1990s at the University of Missouri. One of my professors focused a lot on arthritis and managing all aspects of an individual’s care. Since arthritis is basically inflammation of the joints that causes pain and loss of movement, reducing that inflammation is part of what helps an individual’s symptoms improve.

For physical therapists, managing arthritis through diet or other alternative treatments isn’t necessarily something that would be a primary consideration. Physical therapists tend to focus on strengthening and protecting joints, managing pain and maintaining or improving range of motion.

However, we shouldn’t lose sight of non-traditional interventions. I think back to my professor and the way she used to focus on the whole person, not just their joints. A nutritious diet was important to the patient with arthritis because certain foods are shown to decrease the inflammatory response in the body. Foods rich in antioxidants or omega-3 fatty acids, such as spinach, salmon, walnuts and blueberries have been shown to reduce inflammation.

In the past, I had a patient who had terrible arthritis and need a bilateral hip and knee replacement. Her doctors wouldn’t perform surgery until she lost 50-60 pounds. As part of our wellness program, we worked with her to lose weight. She modified her diet and participated in water aerobics and low-impact strengthening classes. She ended up dropping 65 pounds. Her arthritis had improved so much from her lifestyle change that she no longer needed the surgery!

Though we use many traditional methods to treat arthritis at Aegis Therapies, we are also beginning to incorporate more non-tradition methods. In addition to utilizing Freedom Through Functionality (FTF) and Geriatric Enhanced Modalities (GEM) programs, we also include aquatic exercise, low-impact strength-building and cardiovascular exercise classes. We’ll also be rolling out new programs in 2009, such as tai chi and relaxation programs that may help manage pain in arthritic patients.

When coaching my team, I always remind them of one thing: they have great therapy tools at their fingertips. We should always consider new research and innovative, alternative ways to help our patients. If they don’t explore their patients’ options, they’re doing them an injustice. Our goal is to improve the lives of our patients, and that means considering all the alternatives.

Exercising with Arthritis

Mon, 16 Nov 2009 16:40:15 GMT

A common question we, as therapists, get from patients with arthritis is, "Should I really exercise? Won’t that make my arthritis worse and cause me even more pain?"

When you have arthritis, exercising may not be first on your list of things to do. You may be worried that if you take a walk, ride a bike or go for a swim that you may increase your arthritis pain. Actually, this isn’t so. There are many benefits of exercise for people with arthritis. And there is plenty of research evidence to prove that not only is exercise safe, it actually, more often than not, results in decreased pain.

There are three main types of exercise that benefit individuals with arthritis: flexibility exercises, strengthening exercises and cardiovascular exercises. Regular exercise will help strengthen muscles and decrease stiffness.

Flexibility and stretching exercises are great for alleviating stiffness, and they decrease the risk of joint injury. They can also be done in water as the buoyancy of the water feels good on the joints. Exercises such as yoga and tai chi offer a way for individuals to increase flexibility in a gentle, relaxing way that may be less stressful on arthritic joints.

Strengthening or resistance exercises are important for strengthening the muscles that support the joints, thus protecting them from injury. Exercises can be tailored to an individual’s needs, taking into consideration any particular limitations or pain that they are feeling. Patients with arthritis that participate in strengthening exercises – even vigorous strengthening – very often report a decrease in arthritic pain.

Cardiovascular exercises help increase endurance and manage weight. Walking the dog, gardening or taking a bike ride are all simple, low-impact ways that people can raise their heart rate.

On a cautionary note, though, all patients with arthritis should check with their own doctor before beginning any new exercise program, and if experiencing an exacerbation of symptoms, as can happen with arthritis, you may need to decrease the intensity of your exercises during the exacerbation.

Therapies for Continence Management

Mon, 16 Nov 2009 15:45:33 GMT

Most people feel uncomfortable talking about problems they may be having with urinary incontinence. Oftentimes, they are embarrassed and feel it’s just a normal part of aging, which it’s not. They are also unaware there are treatments available, which there are. Sadly, when urinary incontinence goes untreated, it can become a psychological, life changing event that often leads to social withdrawal and depression. But it doesn’t have to be this way. Urinary incontinence is not a disease, but a medical condition with a wide range of possible causes that can be simple or complex in nature.

If urinary incontinence is affecting someone’s daily activities, it’s important they bring it up with their doctor so he/she can do a full evaluation to determine what the issues are behind their incontinence, and prescribe the necessary treatment. Even if the condition can’t be completely eliminated, there are ways to manage it so that a person doesn’t stop living their life.

There are medications available to help treat urinary incontinence, but some people can’t tolerate or afford them. For those people the following recognized therapies are available. The first step to increasing bladder control is to work on strengthening the pelvic floor muscles through progressive exercise. Just like building up biceps or quads, the exercise routine should increase in difficulty over time. This can be done by changing the position each exercise is performed in, or the through increased duration/intensity of the exercise.

The prescribed strengthening routine targets not just the pelvic floor muscles, but also includes movements that develop the core muscle group; the abdomen, diaphragm, hip and back-extension muscles. Increasing the strength of the core muscle group also strengthens the pelvic floor muscles.

Electrical stimulation can help strengthen the pelvic floor muscles. The current used in this type of therapy is gentle and is typically tolerated well. The autonomic nervous system plays a role in some types of incontinence. “Quieting” this system through a series of techniques called physiological quieting can be very effective.

Like many health conditions, certain foods are known to aggravate urinary incontinence. Not surprisingly, caffeine is one of them. Acidic foods like tomatoes, spicy foods and foods with high sugar content are also known irritants. This condition can also be the side effect of some medications. It’s very important that a person not cut back on their fluid intake as a precautionary measure. Those with urinary incontinence should continue to drink the recommended amount of fluids per day, because, if not, it could lead to urinary tract infections.

It’s my mission at Aegis to insure that patients suffering from this condition are provided the therapy(s) needed to eliminate or manage this condition. Like I said earlier, when it goes untreated, urinary incontinence can have a really negative impact on a person’s life. With the right treatment this reaction can be avoided or minimized.

Balance Management: It's the Little Things

Mon, 16 Nov 2009 15:07:39 GMT

They say it's the little things in life that will trip you up. Nowhere is this truer than for someone with balance deficits. Everyday obstacles that go unnoticed to most, pose likely hazards for those with balance deficits.

We have a comprehensive Balance Management program at Aegis Therapies, which provides us with the necessary skills and environment to help patients with this condition. The key to good balance requires the patient to overcome the extenuating factors of his/her condition. There are many extenuating factors that can impair one’s balance; the two I will be addressing here are intrinsic and extrinsic factors.

Intrinsic factors include muscle weakness, loss of sensation, pain, visual perceptual impairments and more. Extrinsic factors include side effects from medications, the physical environment and the patient’s need for adaptive equipment (i.e. walker, wheelchair, quad cane, etc.).

Working as a physical therapist I've helped many patients who have endured this impairment, but one case always comes to mind. The patient was a retired businessman who had suffered a severe stroke, resulting in significant motor and balance impairment on his right side. A man with a lot of pride, he had always been the "breadwinner" of the family, and not at all used to the dependent role he now faced.

We worked with him for almost three months providing occupational, physical and speech language therapies. Physically he regained the use of his right leg much sooner than his right arm. Without a natural arm swing this posed a challenge for him to walk. He also required a short leg brace and the use of a quad cane for gait and mobility.

The patient was faced with a huge obstacle in the course of our treatment. His youngest daughter was getting married. As father of the bride, he was determined to walk her down the aisle. This proved to be a true test of his newly regained intrinsic balance skills, in addition to the extrinsic factors he would be facing at the church.

Weeks prior to the wedding, our team made an assessment of the church and the extrinsic factors he faced. This included his car transfers, ability to access the church, walking down the aisle and standing at his daughter’s side. Our patient had a lot of anxiety surrounding the event. But he was determined to overcome any challenge that would prevent him from successfully escorting his daughter down the aisle.

The patient was very focused and learned how to use the environment to his advantage. We proceeded with treatment adaptations and the compensatory techniques required for improving toe clearance over the church's plush carpeting. He practiced weight shift skills for walking down the incline of the center aisle. And finally, he learned standing balance skills that allowed him to safely lift his daughter's veil for his kiss and well wishes.

Once he mastered these skills, he had to adjust his balance and walk from her side to the first pew, and then sit down next to his wife for the remainder of the ceremony. He was determined to accomplish this without the use of his quad cane. With progressive treatments and some accommodations, such as accepting the need for his quad cane to exit the church, the patient successfully attained the balance and functional endurance needed for this important milestone.

We continued to treat the patient after his daughter's wedding, and he was able to return home to his wife and attended out-patient therapy. His story reminds me of how I, and my fellow rehabilitation therapists, can make such a positive impact on the lives of others.

Health Benefits of Tai Chi

Mon, 16 Nov 2009 14:02:14 GMT

Although tai chi originated in China, it is quickly being adopted by western culture because of its wide range of health benefits. It has been practiced for over 600 years, and according to Chinese philosophy, it improves the flow of “qi” or “life energy.” However, one does not have to adopt this Eastern philosophy to recognize the proven health benefits of tai chi.

Tai chi consists of a series of slow, fluid movements that gently work the muscles and take the joints through their range of motion. A high degree of concentration and mental focus is required. Careful attention is paid to breathing and posture.

The health benefits of tai chi are now widely recognized, and it is an exercise that can be practiced by almost anyone. However, if you have any medical conditions, it is important to check with your doctor before trying tai chi.

As a physical therapist, I recognize that many of the advantages of tai chi may benefit seniors. Tai chi improves muscle strength, balance and flexibility in those who practice it regularly. In seniors, improving balance is one of the best ways to reduce the risk of falls and therefore prevent injuries. Additionally, improved muscle strength and flexibility may allow seniors to recover more easily from a stumble.

Tai chi may also help ease the symptoms of certain medical conditions. Studies have shown that those with arthritis may perform tai chi without making their joint problems worse. Tai chi may also help postmenopausal women maintain bone density.

Certain studies have also shown that high blood pressure may be improved in patients who practice tai chi. A reduction of stress that may result from practicing tai chi may also improve the quality and duration of sleep.

Regardless of your current health conditions, tai chi may help improve your general health and improve your stress levels. Due to the increasing popularity of tai chi, classes may be found at many different gyms, senior centers and community centers. Ask your doctor if tai chi may be a good exercise to add to your routine as part of an overall health and wellness plan.

Dementia Management - Accentuate the Positive

Wed, 24 Jun 2009 12:08:43 GMT

There are several different forms of dementia as well as other conditions, like depression and Parkinson’s, which mimic the disease. Therefore, it’s important to have a doctor determine if a patient or your family member is, in fact, suffering from dementia, and if so, whether it is a progressive form (e.g., Alzheimer’s). Some types of dementia are caused by illness or an adverse reaction to a medication and are reversible. In this blog, I will focus on managing the progressive forms of dementia including Alzheimer’s.

Having been a speech-language pathologist for many years, I can remember when, as therapists, we believed there wasn’t much we could do to help dementia patients improve their cognitive function. I’m happy to write that, because of the advances in brain research and cognitive therapy, these opinions have changed dramatically, and now there’s a lot we can do. It’s exciting to know that at certain levels of decline it’s been proven that many persons with dementia are still able to learn new things. It may be something small, like learning how to find their room in a skilled nursing facility. But things like this are really important because it helps foster a form of independence in patients and keeps them more engaged in their activities of daily living.

I feel fortunate that at Aegis Therapies, we have many resources available to help us address a broad range of dementia issues. Aegis offers a comprehensive core program in dementia management that first utilizes the Allen Cognitive Disability Model to identify a patient’s cognitive level. This model takes observations about a patient’s attention to sensory cues, sensorimotor associations and motor actions, categorizing them into six cognitive levels of decline.

Once the patient’s Allen Cognitive Level is determined, an Aegis team of therapists will develop a therapy course that focuses on what the patient can do versus what he cannot do. Our dementia management program is also based on the assumption that cognitive decline seen in dementia mirrors, in reverse, the cognitive development stages from birth. For example, from birth, learning to feed yourself typically comes before toilet training. Therefore, a patient with dementia will lose the ability to handle toileting needs before losing the ability to feed himself.

One aspect of the dementia management program we often use and have had a lot of success with is called Spaced-Retrieval (SR), which is a memory intervention tool that was developed by Cameron Camp, Ph.D. With this tool, we have patients practice recalling information correctly over progressively longer intervals of time. We begin with a 10-second interval and gradually increase the intervals. If at any interval increase, the patient is unable to recall the correct information, we then have the patient go back and start the recall practice back at a successful level.

SR is an effective technique that’s easy to teach. It can be used in many different settings by care givers, therapists and the health care staff. For example, patients with dementia often have difficulty remembering the safe sequence for transferring, for example, from a wheelchair to a standing with a walker. The SR method can help the patient remember the transfer sequence or help the patient to remember to refer to a card where the bulleted steps are written. This technique can also help patients with dementia learn to read a calendar, use adaptive equipment, remember the names of objects related to their basic and medical needs, and perform activities of daily living at higher levels of independence.

Another valuable tool we use is called Brains Storms, which is a cognitive-stimulation program developed by speech-language pathologist Lou Eaves. Communication issues are often at the heart of many of the challenges faced by patients who have dementia. Behavioral problems seen with dementia are often due to inability to communicate effectively. For example, if a patient is in pain but unable to tell this to the facility staff or caregiver, the patient’s frustration may then mount into anger or acting out.

Another devastating effect of communication problems with dementia is that it often leads to increased isolation from friends and family. This can cause increased anxiety and depression with the patient. Sadly, you’ll see where family visits will become fewer and farther between. This sometimes happens because family and friends become frustrated with the lack of conversation with their loved one, but our therapists have seen the Brain Storms program work wonders in many cases. Through 130 different exercises outlined in the program, cues are developed to help engage the patient. Interestingly a pilot study, where therapists also worked with patients’ families by teaching them these cues, found there was an increase in the number of patient visits by friends and family. Also, the study showed that after six months the patients’ speech and language function on certain variables either remained the same or had even improved.

Although treatment in dementia management begins with the therapist, I believe it must involve a continuum of care with the patient’s nurses, activities coordinator and family members to get the best possible results.