Monday, January 30, 2012

Our Patients Are Our Teachers

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I was finishing up the work day when Marnee walked into the rehab department. She walked up beside me and handed me a small white envelope.

"Don't open it now. Open it when you get home."

It was stuffed.

On the outside back of the envelope she had hand written a beautiful saying by Kahlil Gibran, one of my favorite poets.

"Your living is determined not so much by what life brings to you as by the attitude you bring to life; not so much what life brings to you as by the way your mind looks at what happens."

Inside, this beautiful woman had written a card to me.

Dear Tre,
You are a beautiful young lady.
A gift from God
to so many of us
who need you.
Your smile
warms everyone's heart
and your expressions of confidence
and words of encouragement
are a blessing to this world - -
Thank you, thank you -
May God bless you
with peace of heart
and mind
and love of all -
Your grateful patient,

Inside the card was a beautiful olivewood rosary made in Jerusalem.

Tonight, I think about this wise woman who has taught me so very much. She has taught me more, I think, than I have taught her. Marnee has been my teacher. She has encouraged my spiritual growth.

I work in a setting in which many therapists are embarrased to admit they work. I am not only happy to work in skilled nursing facilities; I prefer to work there because of the quality of the relationships that are nurtured during our time together as patient and therapist.

It's like Kahlil Gibran wrote, Your living is determined not so much by what life brings to you as by the attitude you bring to life...

As therapists, it's the attitude we bring to skilled nursing. If you don't want to be there, don't take the assignment. You give yourself and your potential patients the gift of allowing someone who really wishes to serve this population if you choose to go somewhere else.

Getting Prepared to Bloom Somewhere New

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We've all heard this adage:

Bloom where you're planted.

My friend, Debbie, gave me a framed picture of this which I hung near my front door in my house. She has always known how itchy I get to "go places and do things."

By the way, blooms from my garden at my permanent home.

I believe in following its instructions wherever I am, even if it takes a couple weeks to get the roots in at a new place. I want a building to feel and act as if I am their permanent therapist.

I find it easy to become "one of them" if I learn their culture (every place has a different one!), try their cuisines, hike their trails, cycle their roads, visit their museums and explore their downtowns. I learn the relationships among the employees and the residents - so many connections!

I found out Friday that the building may have found a permanent OT, which makes me really happy. Happy and sad at the same time!

I've come to really enjoy this assignment. Soon comes the process of turning my sights to the next assignment. I'm mentally gathering the gardening tools and getting ready to dig....

Where to plant next?

Friday, January 27, 2012


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Peace is something many of my patients cannot capture.

I see several reasons why people can't reach this place:
  • Pain
  • Lack of sleep
  • Psychosocial or behavioral issues
  • Impaired cognition (decreased insight/attention/high distractibility)
  • A general lack of self awareness.
  • A simply "bad day!"

It's a difficult task for each of us at times to be peaceful. It was especially so for Tom yesterday. He arrived the day I returned to work last week following a total knee replacement at the smacking young age of 93.

Most of the time we don't see total knee replacements done in the 90's unless the person is very active with good physical strength and sharp cognition.  This guy checked out out fine on all the above.

Tom came in planning to leave on day #2. However, a team meeting with him and his daughter delayed his departure because of impaired posture, balance and activity tolerance, all of which put him at risk for falling and doing more damage. When he would go from sit to stand, you could hear a chorus of crepitus throughout his body.

crepitus: a medical term to describe the grating, crackling or popping sounds and sensations experienced under the skin and joints (thanks, Wikipedia).

My dear Lizzie had been on an all night performance of byyyyy-by-by-by-byyyyyy up and down the halls of the nursing facility. Poor residents. This happens occasionally when she stays up for about 24 hours and then sleeps 24 before getting back on track.

Tom, of course, got no sleep. He was new and every sound was unfamiliar, including that of a 99 year old lady singing all night. The natural progression of not wanting to be in a place like this,  listening to noise all night, terrific knee pain and overall frustration was the inability to participate in meaningful treatment.

"I can't do a thing. I want out of here. I can't take a shower until the staples are out, and it's making me crazy!"

Plans to take him to the gym for exercise? Out.

"I'll tell you what. You want to feel clean and fresh - I'm going to get some warm, soapy water and some linens. I'll be right back."

He gave himself a great clean up, just the way he does at home. (Many seniors can't make the step over the tub to take showers later in life.) I rubbed some lotion on his back and did a little manual therapy on his neck and shoulders (full of spasm which, I'm sure contributed to his feeling "out of sorts.")  I had the ability to assess his independence in bathing and dressing, his sitting balance edge of bed, his upper body range of motion and strength as well as his memory, sequencing, and safety awareness.

During this process, he began to talk. He was from the Midwest, too. He had loved to travel and spend time outdoors. He had built his own fishing boat. He was a terrific man!

Freshly bathed and dressed, his temper had softened. He smiled. He even felt up to some exercise.  He had returned to a place of peace.

I left him feeling peaceful as well.

How lucky that we, in our service to others, help transport others past their times of turmoil and reach a personal peace that sweeps us through our day.

Tuesday, January 24, 2012

Lesson of the Day (Thanks, Syn!): "Enjoy the Funk"

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So, today, I had a tough time being positive. At moments that I had to fight being a real bitch! I'm sure that Dan, the PT, would agree with me. He has to put up with me all day long.

I had posted a note to friends on Facebook this morning:

Needing to look for the positive today,
the negative wants to seep in!!

I spent the day trying to close my ears to the crazy activity outside the rehab department. They moved all the "yellers" to the the two rooms closest to the rehab department. The three former yellers I wrote about last fall aren't really yellers anymore! These are new yellers. Two of them have alcoholic dementia. One is a woman who has lived like a princess, and she's not used to having to wait a bit for service.

I was beleaguered by the time I got home. After checking email, I found a few lovely replies to my morning post on Facebook. I want to share this one with you (compliments of Syn, thank you, girl!)
It gave me a different perspective of feeling this way:
"Rather than battle difficult personalities, I have come to accept that some people are just good examples of bad examples. Similarly, I have come to believe that a lot of good may be gained in allowing a funk room to be itself, to run its course. I am a big believer in allowing ourselves to feel what we feel (good or bad) and simply be discerning about how we interpret the feelings. I am not a proponent of forcing our minds to focus on the positive when a helpful lesson may be gained through a bit of stewing about the negative. Sometimes a negative inner voice has an important point to make. In my view, authenticity and quiet discernment trump positivity. So enjoy the funk and the lesson it may be trying to communicate. :)"
So, let it run its course.
That makes me feel better already.

Monday, January 23, 2012

Goodbye, My Friend

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Phone calls have quite a power. In less than a few minutes, a phone call can change your life. It can make you feel excited, upset, glorious, distraught or full of grief.

I got one of those calls tonight. Actually, it started as a text from my friend, Rose, from my last assignment. I had the great fortune of staying there for a whole year, so I connected not only with my co-workers, but also with a number of the residents at the SNF.

Rose texted me a message that concerned me immediately.

How are you doing? Did you hear the sad news at _____ Healthcare? Not sure if you talked to (the DOR) or (the tech)?

(DOR = director of rehab)

I immediately thought about Joan. Oh, no!

Hi, Rose! I haven't heard anything....please tell me.

...Are you sure you are okay with a text?

Okay...then I knew I needed to call her. I just picked up the phone and dialed.

It wasn't Joan. It was Brendon.


I feel crushed. Brendon passed away this morning. I logged out of my documentation on Casamba. I was finished. I could do no more. I needed to go home.

Oh, Brendon...

Many thoughts cross my mind tonight....memories of our interactions, discussions we had, goals he wanted to reach despite his quadriplegia, my hopes for him to lead a full life. Relief that I stopped in to see him last time I drove through the area.

Brendon changed my life. He really did. His case made me think outside the box. He stretched me as a professional. He made me a better patient advocate. He also brought me joy and laughter. He taught me about living gracefully within life's limitations, whatever they may be.

Brendon and I were talking one day last summer, and I asked him where he would go if he could go anywhere in the world. What would he do?

"I would take my mom to Hawaii. I haven't seen her for 3 years."

Granted Wish Foundation didn't grant his wish, despite close consideration of the thick packet I submitted with beautiful letters of recommendation. Brendon never saw the ocean, and he lived his whole 32 years less than an hour from it.

Brendon, here is your ocean. Goodbye, my friend.

Thank you for blessing me with your presence.

Sunday, January 22, 2012

Energy 101

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Today, I want to share about the ENERGY that resonates in all of us.

Have you ever been around someone and when you parted, the interaction left you feeling full of energy? In reverse, have you ever left the presence of someone completely exhausted for no apparent reason at all?

What you may have felt but not seen or been aware is that your energies co-mingled. Interaction with some people can enhance your energetic vibration, and with others, it can drain your energy source like a sieve, leaving you almost weak.

People can sometimes be somewhat threatened by that which they cannot see. When the talk turns to energy work or people who are gifted with it, out come silly assertions like, "It's evil" or "dangerous." This could be further from the truth!

“A mind is like a parachute.
It doesn't work if it is not open.”
Frank Zappa

If you read the Bible, a person's ability to assist with healing is even mentioned right in 1 Corinthians 12:28:

Here are some of the parts God has appointed for the church: first are apostles, second are prophets, third are teachers, then those who do miracles, those who have the gift of healing, those who can help others, those who have the gift of leadership, those who speak in unknown languages.

When I offer energy work (in my practice, I use Reiki), I explain it to the recipient and let them decide if they want to receive it. For people who are Christians, another term for energy work is "laying on of hands."

I became aware of the energies of others in 1998, when I was doing OT with patients in the midwest. I did not seek this out!  I was initially taken aback and a little freaked out that I could "feel things." I decided to study energy medicine to understand what I was able to intuitively feel with my hands.

What Did I Feel?

I could feel warmth or cool, tingling, and density when my hands passed within a person's energy field. (A person's energy field reaches approximately as far as their arms will reach in all directions around them.)

A very basic description of what I discovered:

We have seven energy centers called chakras in the human body. They are spinning vortices aligned just outside the physical body along the spine. The chakras run from the base of the spine through the crown of the head. Take a look:

Location of the Seven Main Chakras:

As you can see, they run like ROY G. BIV (remember the colors of the rainbow from school?) Their colors are significant. Their roles are specific. Their names relate to their location.  We'll go over that later. There's too much information to share in one blog entry...

The most basic point I want to make is that if you have an imbalance in your energy centers, you cause dis-ease. 


Got it?

All the more reason to keep our energy centers in our body clear and flowing.

What is so important about the chakras?

Each chakra has its own electromagnetic property. Each chakra influences the organs, muscles, ligament, veins and body parts within its energy field. Chakras influence the endocrine system. They are also associated with your moods, personality, and overall health. .

If you understand how energy centers work in each of us, and the symbolism behind illness in each part of the body, you can assist your patients, friends, or family members to participate in their own healing.

For example, when I see someone with chronic stomach or GI (gastointestinal) issues, I am aware that they have probably been in deep conflict within themselves, with someone else or even with a system. This may be someone who has worked for years in a job they hated, someone who has lived an antagonistic lifetime with a spouse or who has fought an ex-spouse, or someone who has an extreme beef with a institution like a government agency (the Timothy McVeigh types).

The solar plexus (stomach area) is the chakra here that is out of balance.

The Solar Plexus Chakra (yellow) is located at the stomach area, near the bottom of the rib cage. This chakra represents your body, mind and emotions and relates to how you see yourself in the world.

The solar plexus chakra meanings relate to self esteem and confidence as well as a sense of self worth. This chakra's meaning is all about the concept of ‘the will’. This chakra is responsible for the effective flow of energy not only to this region but throughout the whole body.

Improving energy flow to the solar plexus may clear problems that have been producing lack and limitations.

This chakra stores energy, be it good or bad – pain, fear and stress as well as positive energy for growth and healing. It controls our will, our issues from the past, our pain and fear as well as our ambition to succeed.  

This great description is from

 The easiest way to become aware of energy is to rub your hands together briskly until you feel heat (energy!)....then pull them apart a foot and right away start to bring them slowly back together. What you will feel is a magnetic pull, almost a density. You may feel tingling.

This is the energy of your own body.

As you become aware of how you feel around others, like an ebb and flow within your system, you will find yourself more present to who you feel good around and who you don't.

You'll become more aware that energy imbalances are what cause illness. With that information, you can begin to manage your own energy for better health.

More on the chakras later....

Check out   for Tre's insights on the "new project."

Friday, January 20, 2012

I'm Back!

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I'm back! I'm actually almost back...sitting in Denver International Airport waiting on my delayed flight and happy to be back on the internet after almost a week "away."

I've just spent the past five days purchasing a cottage near my parents and demolishing the inside of it in preparation for some major renovations. It's always great to have a project in the pipeline!

The week has not been without excitement, from the real estate closing to the gathering of all seven brothers and sisters with our parents, to visits with those I love (you know who you are, you special people!), and an unexpected incident in Kansas City last night....

Before I tell you what happened,  I'll set the scene at the rental car company last weekend when we picked up the car. We always pay extra to list both of us as drivers.

 "Do we need the extra insurance?"

She has picked up the car early to save us time, and the car company is going to charge an extra $125 for insurance since she doesn't have any here. (She lives overseas, so her insurance is moot here.) If I had picked up the car, it would be no problem. My insurance covers me. We end up opting out of the insurance, as we plan for me to pay for the car.'s on my mind that I really need to check all the details before we rent a car together again. Do I do it this week?


I drop Elle off at the airport yesterday afternoon and begin a series of tag team visits with dear friends in the City. As I drive, I am thinking, this little VW has some "get up and go!"

It's getting dark and is at the beginning of rush hour when I exit one major interstate to enter another on a wide cloverleaf.

The traffic slows down.
I slow down.
The high school kid behind me does not slow down.

He later tells the Missouri Highway Patrol that he was reaching down to pick up his cell phone off the floor, looked up and smashed right into me.

I could not believe it!!

The first think I thought about was my twin and our conversation about insurance.

She is not going to believe this!!

I would have called her when I got off the phone with 911, but by that time, she was somewhere over the Atlantic Ocean.

I'll keep this abbreviated. The kid was at fault. The insurance company is taking care of the damaged bumper with the rental car company. My back is sore and tight but not acutely injured to require emergent care, so I'm going to get it checked out when I get back home to northern Cal.

The lesson today is get those insurance questions answered before  you rent the car with multiple drivers!

Flight is boarding....write more later....Tre

Friday, January 13, 2012

Me, Lacking Grace Tonight

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So, I am headed home to the midwest for a week to close on a cottage near my parents with my twin sister. We are going to "gut" the inside this week, knock out a wall and get everything going for a new kitchen and bathroom.


We'll get to the outside later in the summer, when it's perfect painting and landscaping weather!

In order to get home, I have to drive 4 hours to the nearest airport. After living only a few minutes from the airport in the last "Tre House," I am pretty spoiled. 

...(Yes, my name is pronounced "tree.")

Then, after the long drive, a 5-6 hour flight will get me to the city 2 hours from my parents' farm.

Deep sigh. One of the drawbacks of being this far away.

None of my assignments have been this far from an airport. I've never done park and fly as a traveler, so I thought I would get in early, rest and be up and fresh for the 8am flight. Great idea, right?

It didn't go as planned. I left work a half hour late after a patient's son showed up to talk minutes before I was scheduled to leave. I got a phone call once I walked in the door to pull my bags out to the car. I had loaded some books in both bags so I don't have to move them in 2 months when my assignment changes.

I had forgotten to get cash and gas....blah, blah, blah....all reasons why I left the coast late!

I really did quite okay until I got past my usual turn from I-80 to head north on Hwy 113 for the Sacramento airport. But I wasn't going to the airport tonight! I was headed to a hotel...

the road bifurcated. Damn it! They both said I-80....and I took the one on the left.


It was 8:30, pitch black, and for those of you who aren't in California, the state has cut its use of lighting along highways and roads. Suffice to say that the barrage of foul language spurting from my loose lips would have shocked my mother!

It was not graceful at all, especially during the conversation with the desk clerk at the Hilton Garden Inn....who did not know how to direct me in from where I was sitting on the side of the other I-80....

I was p.o.'ed. For no other reason than that I had been up way earlier than my normal day, had pushed hard all day, had just sat for over 4 hours and was not tucked in relaxing.

So be it. I didn't handle it well. The great thing about tonight is that it's the ending to the day. And tomorrow is another chance.

I resolve to be a little more graceful...

Carry on!!

Thank You, You Tube

Thursday, January 12, 2012


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My assignment should have ended tomorrow. 18 weeks. I can't believe I have been here 18 weeks. (I've extended until the end of March!)

I remember my first week here.

The noise from the residents with dementia was overstimulating. The well-meaning staff had not been trained how to deal effectively with behaviors.

Remember this little chicklet at the Royal Wedding?  This was how I felt, too, for the first few weeks of this assignment!

I'm happy to report that it's gotten much better.

In fact, if you review the blog I linked to above, you'll remember the tiny  lady, Lizzie, who cruises her wheelchair down the hall singing, "Dum dum dum dum dum" and "By by by by byyyyy."


The most curious thing happened with her. I sat at her table the other evening when I was working with her tablemate on another ADL (activity of daily living), feeding. I started talking with her, and she could hold quite a conversation.

I realized something...I had not given her the benefit of the doubt!

I had simply resented her for making noise.  I had not made the attempt to figure out what made her tick. I had made no connection with her until now.

After that dinner, she recognized me when I passed in the hall. I stopped and greeted her, held her hand for a moment several times this week. I realized yesterday that her behaviors have curbed quite a bit over the last month or so.

Until tonight.

I was trying to get the heck out out of the building in 8 hours! (Isn't every SNF like a black hole?!) I was banging out my billing and daily docs on Casamba when I heard her singing down the hall. The sound was getting closer and closer. I knew she was headed to the exit door, and I prayed to God she wasn't going to set off the alarm!


Instead of heading straight toward the alarmed door, she wheeled right into the rehab department toward me.

"Well, Lizzie! How are you?"

I gave up all hope of leaving quickly. She had the sweetest smile on her face. I asked her about dinner. She told me she had a lovely dinner with her family even though I know she had been in the dining room with all the other residents. She talked about her son and the rest of her family.

Finally, I told her I needed to get the paperwork done so I could leave. "It's been so nice to see you!"

I really meant it.

She took my hand and stroked it. (I just love those tactile little old ladies.)

"You're a grand person..." and she lifted my hand and kissed it.

I've had people compliment me, but I've never had anyone tell me that I am grand.

She melted my heart.  Really.

She made my day.


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Clarence is 101 and as feisty as ever.

The "home" threw him a huge birthday party on his 100th birthday. You should see pictures of the 100 candles on his cake. It looks like a bonfire! There's a large collage of that event on the wall in the hallway.

Clarence doesn't let much stop him. He led an amazing life of working in national parks all over the West. The black and white framed photographs of his adventures and his lively family hanging over this walls leave me standing there in awe.

I am enamored by the personal history of each person with whom I work!

There is an tall, elegant, outdoorsy woman adorning on Clarence's wall. She reminds me of Amelia Earhart...

That kind of amazing gal.

I ask Clarence about her as I ice his ankle. He has fallen on his way to the bathroom at 2 in the morning.

"What's her name?"


I had seen the name "Ede" written beneath some of the photos.

"What do you call her?"

"You come here!"

I stop for a bit. I have to admit, I am a bit slow to certain types of humor. Then, I, and everyone else in the gym, start to laugh.

"Where did you meet her?"

"Behind the barn."

"Behind the barn??  How old were you?"


No more questions asked! Eighty seven long years ago a feisty young man met up with a feisty young woman, and they shared 80 amazing years together. I don't know about you, but I think that is close to the record of a long term relationship!

Clarence and I go on to discuss other topics, mainly, something that had been on my mind since Sunday. I had gone to the local outrigger canoe place to look into renting a canoe to paddle up the local river estuary which is accomplished according to the tides calendar. (Something foreign to this land-locked girl from Missouri).

The owner of the company and I started a long-winded discussion. It meandered into an hour during which I learned many great things about the area! 

When he learned that I work with seniors, he shared that he was in the process of completing work on a solar powered outrigger that would carry 9 people, some of whom would not have to power the canoe....he suggested that if I knew of any seniors interested in traveling up the river estuary on a nature tour, he would love the opportunity to market a trip to older people.

The first person I thought about was Clarence. He had hiked, fished and worked all over the land and water.

I mention this to Clarence. Imagine a light bulb when the switch is flipped on.

"Tell him yes," Clarence says.

This man, who yesterday was non-compliant with non-weight bearing orders on his right foot is following the plan of care! He wants to get that ankle healed and walk the dozen + steps it takes to get to the dock.

Clarence can't go out in nature like he once did, so we will bring it to him. He can be surrounded by all the things he has loved...water, trees, wildlife and bright sky. From the seat of a canoe he doesn't have to paddle.

One of my best friends from my last assignment is an 89 year old physical therapist named Dorrys. We met every Wednesday night for dinner when her partner died, and she told me what motivated her as a therapist.

"If I can make just one dream come true, I've done my job. Find out what their dream is, Tre. Make it happen."

Okay, Clarence....let's return you to the woods and the water!

Tuesday, January 10, 2012

The Yellow Shirt Story

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My  mom is not a fan of "forwards" at all! We actually have a joke about it. Imagine my surprise when I wake up this morning (2 hours behind her time zone) and find a "forward" from her in my email inbox!

I immediately understood why she sent it. It is a keeper. What warmed my heart is that she added:

"Read it because it is us."

What I know about it is that it was a lotus totus from the Anthony Robbins organization. He is a famous life coach who's been motivating people for years. I don't know the name of this writing's author; if anyone knows, please let me know so I can give credit where credit is due!

Here goes this heartwarming story:

The yellow shirt had long sleeves, four extra-large pockets trimmed in black thread and snaps up the front. It was faded from years of wear, but still in decent shape. I found it in 1963 when I was home from college on Christmas break, rummaging through bags of clothes Mom intended to give away…

'You're not taking that old thing, are you?' Mom said when she saw me packing the yellow shirt…'I wore that when I was pregnant with your brother in 1954!

It's just the thing to wear over my clothes during art class, Mom. Thanks!' I slipped it into my suitcase before she could object. The yellow shirt became a part of my college wardrobe. I loved it.

After graduation, I wore the shirt the day I moved into my new apartment and on Saturday mornings when I cleaned.

The next year, I married. When I became pregnant, I wore the yellow shirt during big-belly days. I missed Mom and the rest of my family, since we were in Colorado and they were in Illinois... But that shirt helped. I smiled, remembering that Mother had worn it when she was pregnant, 25 years earlier.

That Christmas, mindful of the warm feelings the shirt had given me, I patched one elbow, wrapped it in holiday paper and sent it to Mom. When Mom wrote to thank me for her 'real' gifts, she said the yellow shirt was lovely. She never mentioned it again...

The next year, my husband, daughter and I stopped at Mom and Dad's to pick up some furniture. Days later, when we uncrated the kitchen table, I noticed something yellow taped to its bottom. The shirt! And so the pattern was set.

On our next visit home, I secretly placed the shirt under Mom and Dad's mattress. I don't know how long it took for her to find it, but almost two years passed before I discovered it under the base of our living-room floor lamp. The yellow shirt was just what I needed now while refinishing furniture. The walnut stains added character.

 In 1975 my husband and I divorced. With my three children, I prepared to move back to Illinois. As I packed, a deep depression overtook me. I wondered if I could make it on my own. I wondered if I would find a job. I paged through the Bible, looking for comfort. In Ephesians, I read, 'So use every piece of God's armor to resist the enemy whenever he attacks, and when it is all over, you will be standing up.'

I tried to picture myself wearing God's armor, but all I saw was the stained yellow shirt…Slowly, it dawned on me…Wasn't my mother's love a piece of God's armor? My courage was renewed.

 Unpacking in our new home, I knew I had to get the shirt back to Mother. The next time I visited her, I tucked it in her bottom dresser drawer.

Meanwhile, I found a good job at a radio station. A year later I discovered the yellow shirt hidden in a rag bag in my cleaning closet.

Something new had been added. Embroidered in bright green across the breast pocket were the words 'I BELONG TO PAT.'

Not to be outdone, I got out my own embroidery materials and added an apostrophe and seven more letters.

Now the shirt proudly proclaimed, 'I BELONG TO PAT'S MOTHER.' But I didn't stop there. I zig-zagged all the frayed seams, then had a friend mail the shirt in a fancy box to Mom from Arlington, VA. We enclosed an official looking letter from 'The Institute for the Destitute,' announcing that she was the recipient of an award for good deeds.

I would have given anything to see Mom's face when she opened the box.  But, of course, she never mentioned it.

Two years later, in 1978, I remarried. The day of our wedding, Harold and I put our car in a friend's garage to avoid practical jokers. After the wedding, while my husband drove us to our honeymoon suite, I reached for a pillow in the car to rest my head.  It felt lumpy. I unzipped the case and found, wrapped in wedding paper, the yellow shirt. Inside a pocket was a note: 'Read John 14:27-29. I love you both, Mother.’ That night I paged through the Bible in a hotel room and found the verses: 'I am leaving you with a gift: peace of mind and heart. And the peace I give isn't fragile like the peace the world gives. So don't be troubled or afraid. Remember what I told you: I am going away, but I will come back to you again. If you really love me, you will be very happy for me, for now I can go to the Father, who is greater than I am. I have told you these things before they happen so that when they do, you will believe in me.'

The shirt was Mother's final gift. She had known for three months that she had terminal Lou Gehrig's disease. Mother died the following year at age 57.

 I was tempted to send the yellow shirt with her to her grave. But I'm glad I didn't, because it is a vivid reminder of the love-filled game she and I played for 16 years. Besides, my older daughter is in college now, majoring in art. And every art student needs a baggy yellow shirt with big pockets.

For SNF PT and OTs: 781.92

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If you know that code, I am proud of you! It's the ICD-9 code for Abnormal Posture.

Did you realize you could use that as one of your treatment codes for about 95% of your patients in a skilled nursing facility?

Step One: Identify Poor Posture in your Patients
How many of you document posture in your evaluations? You should be! 

Off the top of my head, some aspects of abnormal posture could include:
  • Forward neck flexion
  • Lateral neck flexion
  • Neck rotation (or a complex pattern of all three above!)
  • Protracted shoulders
  • Acquired kyphosis
  • Forward trunk flexion when standing
  • Asymmetrical shoulder height
  • Unequal weightbearing on ischial tuberosities
  • Posterior pelvic tilt or "sacral slide"
  • Abnormal hip internal rotation with marked knee adduction
  • Abnormal hip external rotation with marked knee abduction

Step Two: Document Abnormal Posture in the Evaluation

Document measurements of abnormal aspects of the posture from head to toe in the evaluation. How???

Get out your goniometer!

(or your Baseline Bubble Inclinometer to measure!)

Take measurements of any of the above deficits. Not sure how? Pull out your lab book from school! I started to write instructions, but it would fill pages...

Step Three: Setting and Writing the Goals

Of course, the goals have to be functional, so you'll want to increase the ROM for improved posture to enhance an ability. Here are some reasons why you want a patient to improve postural deficits:

to improve swallow
to improve visual field
to improve ability to weight shift
to reduce risk of pressure sore formation on ischial tuberosities, sacrum, thoracic spine or inside of knees
to improve respiration
to improve digestion and decrease constipation
to improve standing balance and decrease risk of falls
to improve overall ability to perform ADLs and functional mobility

Effective Treatment Ideas

Reducing forward neck flexion:
  • The easiest thing to change is to train CNAs to quit putting 2 or 3 pillows under the patients' heads when they are in bed! What does that cause??  Forward neck flexion! It's my pet peeve!
  • Have the patient tuck the chin and push straight back onto your hand which is positioned on the occiput. Work up to 5 sets of 10. You'll see wonders by the end of a week.
  • Try PENS (Patterned Electrical Neuromuscular Stimulation) e-stim using 2x2 electrodes. I love ACP because they will train you how to do it.  I'm a huge fan of e-stim for postural retraining

Reducing lateral neck flexion:
  • Position the hand on the side of the head opposite the lateral lean. Have the patient push against your hand. 5 sets of 10
  • Try myofascial release on the side of the neck that is laterally flexing, if MFR is in your bag of tricks.
  • Again, PENs to the side of the neck that is flexing.
Protracted Shoulders:

These are caused by a couple factors, including tight pecs and tone or strength issues with the scapulae.
  • I like to start with the scapulae with a subscapularis stretch, which opens the scapulae and increases rotation to open the whole shoulder complex.
  • Scapular retraction exercises will help pull the scapulae together, just make sure the patient doesn't elevate shoulders when they are retracting scapulae!

  • Once the scapulae are open, we work from the front to open the chest. This increases respiration like you would not believe!
One of my favorite things to reverse!
  • Hands down, PENS is the best treatment for kyphosis.
  • Postural supports from Patterson Medical also help provide proprioceptive input for neuromuscular re-education.
  • Scapular retraction exercises also help to reduce thoracic kyphosis.
Forward trunk flexion when standing:

  • Favorite exercise here is to have the patient standing with feet and buttocks against the wall and extending back and head until they are fully aligned. Work up to 5 sets of 10.
Asymmetrical shoulder height:

  • Postural retraining in front of the mirror. They have to see what is wrong before they can fix it. This is generally a tone or strength issue.
Unequal weightbearing on ischial tuberosities:
  • Many times this is due to tone issues or trunk weakness. Assess what is causing them to put increased pressure on one side and treat it. Email me if you need to brainstorm.
Posterior pelvic tilt or "sacral slide":
  • PENS e-stim on the lower abdomen will improve trunk flexion over hips for a much improved sitting position!
  • Therapeutic activities with patient sitting on mat while picking up items from the floor and then reaching straight up and crossing midline will strengten the trunk.
  • Positioning with proper cushions in the wheelchair. I like to use the Comfort Company products with Quadragel for extra pressure relief.

Abnormal hip internal rotation with marked knee adduction:
  • Therex: Have patient push out against your hand on the affected leg to open the angle of the hip and to strengthen ability of the knee to abduct
  • Use a hip abduction orthotic when sitting in wheelchair - I couldn't find an exact photo of what I use, but this is close. The ones I use open the legs with an air bladder instead of a bar.

Abnormal hip external rotation with marked knee abduction:

  • Therex: Have patient push in against your hand on the affected leg to close the angle of the hip and to strengthen ability of the knee to adduct.
  • I'm not a big fan of putting lateral supports on wheelchairs. I've found they cause pressure sores on lateral thighs.
OK, it's 1am, and I need to get stop thinking about Abnormal Posture! You guys have a great night out there, and write me if you have questions.


Monday, January 9, 2012

Kelsey: Following Her Own Path

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I don't write about my personal life, but tonight I want to laud my daughter, Kelsey. She is full of life, hope and adventure. She arrived today in Blagoevgrad, Bulgaria, for a semester abroad.

I would never have guessed she would go there! When she was younger, we had always discussed England or maybe France.

It really wasn't up to me where she wanted to go. My role was to be supportive of wherever she decided to live and study.

This is one of those forks in the road that shifts the whole direction of her life. For me, it was a semester in London. It opened my eyes to how accessible the world really is. It whet the appetite to see as much of the world as possible.

Bulgaria was Kelsey's decision; it is her path.

And what a path it shall be!

Kelsey, I am proud of you. Happy Travels!

Saturday, January 7, 2012

Who has changed your life?

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Who has changed your life??

The good stuff is easy to appreciate. It's the next step that is more difficult.
Even changes from struggle or loss come with a gift
 if you can shift your vision to see it.

Think about it...

WHO has changed your life?

Thank them!

Not soon. Not later....


Photo credit: Don Paulson at

Thursday, January 5, 2012

Blog Recommendation

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Here is today's post:

You cannot explain
occupational therapy
any better than that!!

Balance in life between work, rest and play with optimal performance of our physical bodies, cognitive capacities and emotional health create a happy and meaningful existence!!

Wednesday, January 4, 2012

Unexpected Admiration

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Happy is a WWII vet, long, lean, with usually sad eyes and a gray five-o'clock shadow. He gets around with one foot pushing his high back reclining wheelchair and makes his way from one end of the building to the other several times a day.

He stops in regularly to find out when "he is going to walk again."

I wish I had known him after his stroke; maybe we could have done some good neuromuscular re-education (layman-speak: making his muscle tone normal to retrain movement after a person loses movement in their limbs).

Now, it's been too long;  this lovely place did not have a therapy team in place when he moved here years ago. His knees have contractures, and he can't straighten his legs.

I am in the building late tonight, working on evening ADLs (activities of daily living) which include the residents' regimens for getting ready for bed after dinner.

Happy wheels down Station One and holds out his hand. I take his hand and lean down. He is hard of hearing. He looks up and starts to speak.

Out comes his sweet, soft Southern accent, foreign on the northern California coastline:

"Did you ever see someone
and get a passion for 'em?
There's no law against that,
is there?"

Then, I realize he means me. And I smile back at him,

"No, Happy, there's no law against that."

Saying Goodbye

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Elizabeth had been at "the home" for 2 months, fluctuating between major decline and rallying to get back home with Lloyd. Those two were one of the handful of couples I have met during my career who gazed into each other's eyes after 60 years as if they had just fallen in love.

In fact, Lloyd told his cousin when he was 16, and Elizabeth 14, that he was going to marry that "pretty little thing" who was visiting her grandparents on the coast from her home in Sacramento.

He did, 3 years later. Lloyd is one of the most devoted husbands I have ever met. He visited our facility twice a day for the 2 months Elizabeth was rehabbing.

It became a struggle to make progress. She went into what we in the industry call "failure to thrive."  It means what it says.

Lloyd and I had moments during the last several weeks in which we knew Elizabeth would not return to her former state. My mission evolved from rehabbing her to home to dealing with more basic issues like making sure she did not choke when she ate and positioning her in bed to prevent decubitus ulcers.

We could no longer "skill" her for rehab. That means we had treated every area we could, and there was no longer anything else we could do.

Lloyd planned to take her home last Thursday, December 29. That morning, one of the aides informed me that she had already been assisted to his car. I knew I had to say goodbye.

I ran to the car and rapped on the passenger window. Lloyd was still inside signing her release. Elizabeth was so frail she could not reach to open the door, so I eased the door open and leaned in beside her.

We looked into each other's eyes. We smiled deeply. I told her what it meant to me that I had the privilege to know her. She told me she would never forget me. We hugged, knowing it would be the last time we would see each other. Lloyd's sister sat in the driver's seat and wept.

I left town after Thursday and returned late last night. I was treating a new patient in the gym this morning when one of the aides walked down to inform me that Lloyd was in the building. Elizabeth had passed away Friday morning, the day after she returned home.

Lloyd stopped by the rehab department, and we held each other tight for a moment. We recounted precious moments, like when he brought photos of their life together when they were young, how hard she worked in therapy, how devoted she was as a wife and mother, and how happy she was to return home. "She was so happy to look around all the rooms and see all the things she had collected over the years," he said.

" got her home. That was such a gift for her."

He agreed.

I knew it wasn't the time and place to cry, so we said goodbye, and I went back to my treatment and squeezed back tears.

Tonight, though, I figure it's just fine to feel emotional. Elizabeth had held on through so many days just to go home with her husband. She made it! It took everything she had. She barely held on each day so that she could leave this world from her own home. With her loving husband by her side.

Elizabeth and Lloyd touched my life in such a deep and simple way. We had a connection that many people never find in their work.

That is why I work with older people in a skilled nursing facility. It's not a glamorous place, but of all the environments in which I have worked, it is by far the most satisfying.

I get the privilege to share my days with people like Elizabeth and Lloyd.

God bless you, Elizabeth. Rest in peace!

Photo credit:

Tuesday, January 3, 2012

Resolving at New Years....

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People are quite divided on the topic of setting resolutions for New Year's Eve. How about shifting the "I have to lose 30 pounds this year" at New Year's Eve to

"I'm going to track my progress
toward living life as fully as possible
right now."

Think of it like you're writing a Plan of Care for your patients, only you're writing your Plan of Care for your life.

Set a goal!

Worried that you're not going to reach it already? Set more than one! I set goals for health, family, financial, travel, spiritual and professional every year. At the end of the year, if I have reached half of them, I'm pretty happy!

Part of my list this year: become a better kayaker, gut and renovate a small cottage near my parents, plant a huge garden, walk El Camino de Santiago in Spain, finish writing a CEU course on rehab in long term care, and meditate more. Oh, and take a little more time off between assignments....

Write it down.

I've heard promotional speakers say that 5% of the population sets goals every year and only 3% write them down. That's like signing a contract. It ties you more closely to what you want. I can tell you that during years that I have written goals down, I have made them happen far better than years when I have not.

Make it happen.

Do it! Keep your eye on your prize. We attract that which on which we put our focus. Really. Try it. It's that simple.

Review the list regularly.

Each month, I pull the list off the fridge. Sometimes, I have checked off when I have accomplished a goal. Sometimes I don't. The important thing is that I turn my vision to what I want to accomplish. My brain starts ticking about the steps needed to reach the goals.

It's not work!  It's fun. It's life.

Don't beat yourself up if you don't reach certain goals. It's counter-productive. In fact, think of it like this (in the words of my favorite poet, Kahlil Gibran)

The significance of a man
is not in what he attains
but in what he longs to attain.