Tuesday, January 10, 2012

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.


1 comment:

  1. Nice job Tre... I love it and some of the tips you offered clinicians.