Showing posts with label ROM. Show all posts
Showing posts with label ROM. Show all posts

Saturday, August 17, 2013

Medical Care Hermano Pedro Hospital Style

Back to my blog home page: http://travelingotr.blogspot.com

I need to update you on my activities!

For the first time in my travel career, I left an assignment early.

I wrote a separate blog about it, but I want to reiterate to you if you feel a sick knot in your gut about what you see in a building, call your recruiter and your clinical liaison immediately and tell him or her what you see. It is vital to start the process of communication between the two companies. My recruiter told me, "Tre, you have never complained in the years we have been working together, so I know something is not right."  Within a week or so, the travel PT and I were released on the same day. Until then, I dotted every "i" and crossed every "t."

Thank God!

Within a week of leaving this job, I was on a plane headed to Antigua, Guatemala. These transitions can be blessings in disguise!


Plaza Mayor, Antigua, Guatemala
 
I had the good fortune to complete two weeks of Spanish as a Second Language training and medical Spanish at Christian Spanish Academy  (CSA), which I highly recommend! My studies, which concluded yesterday, included five hours of 1:1 instruction with my teacher daily and about two hours of homework each night. I developed a list of many questions/cues I use during evaluations and treatment, got them translated (look for these on another blog article soon) and learned the parts of the body. I would actually recommend four hours of training a day because the fifth hour is really fatiguing!
Me and mi maestra, Cristina

Last week, I had the wonderful opportunity to tour Hermano Pedro Hospital as an extracurricular activity through  CSA. It is located at 6a Calle Oriente #20, between 3a and 4a Avenida Sur in Antigua.
 
I was so touched by what I saw that I immediately asked about volunteering. By the way, there are a few requirements to volunteer at Hermano Pedro, just so you know.

REQUIREMENTS TO VOLUNTEER:

1) Take the tour, which is offered Tuesday/Thursday afternoon at 3pm
2) Provide two passport size photos of yourself for your ID
3) Complete an application to volunteer


Beautiful inside and out
4) If you are a licensed medical professional, you must submit a copy of your license.

Hermano Pedro Hospital houses almost 250 people from babies to ancianos (older people), most of whom have been abandoned, have severe physical or cognitive disabilities or who have outlived their relatives. The hospital has separate living areas for male and female adults and children.

What was amazing me to was the amount of great patient-specific equipment there due to donations from different groups in the US, especially the Knights of Columbia Wheelchair Foundation. Bravo, Knights! The wheelchairs below were donated by the K of C. I didn't get a chance to take a photo of the real specialty wheelchairs - the ones you fit during a seating clinic. There were more than I could count.


The wheelchairs I saw at this hospital that is run solely on donations were on average better than the wheelchairs I see in for-profit facilities in the United States.
 What does this say
about our for-profit skilled nursing facilities?

Just a thought.

I spent most of my time with the adults because that is what I do in the States. The women were housed in long dorm rooms with about 14 beds per room. Their beds were positioned so that each woman was just out of reach of being able to touch another. Their clothing was neatly folded on tall open shelves at the end of the room.

As I spoke with each of these women, I found that every one of them had one thing in common. They had no family. They were SOLA. My heart went out to each of them. In fact, I saw this picture on facebook yesterday, and it made me think of them:


So. I knew that the way of the Guatemalan therapists would be
different than the US. I wanted to integrate into their system. I was not there to teach them all I know. I wanted it to be the opposite. I was assigned to the PT gym for the adults. I never met the three OTs. I was told they did fine motor coordination activities and that they mostly worked with the kids. (I did meet a group of six OT/PT/ST students from University of Texas-El Paso on the street on my way to school and later in the pediatric area working on specialty wheelchairs.)

Let's strip away everything we know about the US rehab system:
  • efficiency
  • documentation/paperwork/charts
  • Medicare guidelines.
Hmmmm. What a change.

They weren't watching the clocks nonstop. They weren't pecking out documentation on a computer or writing in a soft chart. They weren't coding billing. They simply focused on treating patients.

They didn't have a standard mat to do matwork. They treated people on plinth tables. They didn't use gait belts to get them up on the tables, either. They hoisted them up onto the plinths.

Most of the ancianos I saw did not have knee contractures. They had pain and stiffness, but not contractures. "Why?", you may ask...
 ...I have to believe it is because of the way they begin every session. They begin every session with a 15 minute footrub.

LOVE it. It completely confirms what I learned in a reflexology CEU that the body can respond beautifully to treatment in other areas than where we normally see the symptoms.

 
The PT, Amanda, really surprised me when she had her 80+ year-old patients roll from supine to prone on the plinth and then do modified push ups for arm strengthening. Wow.

They did not have a plethora of therapy equipment other than their hands to do their treatments. If we want to get down to basics, let's acknowledge that the best tools we have are our hands and minds that can critically and clinically reason.

They do not have restorative aides to do range of motion (ROM) on their residents (which is especially needed for their adolescents with cerebral palsy). I spent one afternoon with Amanda in the adolescent unit doing Neuromuscular Re-education and passive range of motion (PROM), which was an entirely different world than the older ladies. These young ladies are mostly bedbound, nonverbal and locked in their own worlds. They need daily work, but there is just not enough staff to provide it.

The therapists had a lovely connection with their patients. They were respectful, playful and caring. By the time I left, I felt as if I was saying goodbye to a family.

My week at Hermano Pedro is simply a drop in the bucket of what I would know about the place if I stayed longer. I'm sure I'll learn more when I return next year. If any of you have visited or volunteered there, please drop me a line and tell me about your experience. It's an amazing place with a grand mission of service.

A tip:  If you are in Antigua and you wish to volunteer your OT or PT services, ask to work with the adolescents. They are the ones with severe contracture formation and appear to be a semi-forgotten population.

A request: if you work in a building that has a bunch of old Neuroflex-style splints laying in the closet or in storage under the mats, would you do me a favor? Ask your manager if you might donate a few of them to Hermano Pedro. Email me and I can get them sent to Amanda. They really need splints!

Tuesday, January 10, 2012

For SNF PT and OTs: 781.92

Back to my blog home page: http://travelingotr.blogspot.com


781.92

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!
Kyphosis:
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.
Ciao!

Acknowledgments:
http://cbppatient.com/health-conditions/thoracic-kyphosis/