For SNF PT and OTs: 781.92

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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.

ACP's PENS machine

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.

HKO

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/

Lesson of the Day: ENDINGS = BEGINNINGS

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The theme today was endings, or it is... beginnings? I think it's both.

An absolutely stunning, petite woman was admitted for rehab just before I went on vacation. While I hoped that she would be well enough to go home before I returned to work, I was secretly pleased yesterday when I turned the corner at the nurses' station and set sight on Rita's serene smile.

She's bald and less than 85 pounds. Her baseline? Thick, black, luxurious hair and 110.

She's fighting her cancer with a vengeance. And she has four daughters doing battle alongside her. You could say, in fact, that at times, they are doing battle with her.

"Ma, maaaaa, take another bite! Just one more..."
"Ma, it's time for your exercise."

There have been moments in the process when her grip on the armor lessens, and I see fatigue. Fear. She has confided that her girls are afraid she is going to starve to death because of how the cancer affects her ability to eat and eliminate waste.

Rita is primarily concerned about her adult children: "What will they do? They have already given so much of their time and energy. They have their own lives to live. I'm afraid they will burn out."

Yesterday, she had a procedure done to drain fluid off her abdomen that set her back five paces. Her stomach pain throughout today was at times intense.

I spent a few extra minutes with her to provide a Reiki treatment, a Japanese technique for stress reduction and relaxation that also promotes healing. I knew this would allow her to relax and manage her pain more effectively.  I have integrated Reiki into my OT practice for years.

If you're curious, check out the International Center for Reiki Training.

In the middle of the treatment, she popped up for a moment, rolled from her back to her left side and picked up what looked like a thin, green pocketbook off her tray table. When she snapped it open, it was a photo album that her granddaughter had made for her, a complete collection of family photographs of her with kids and grandkids interspersed with Bible quotes .

She pointed out each family member, and then, her finger stopped on a gorgeous, sophisticated woman.

"This is me with hair."

I focused on this woman who I already felt was beautiful without hair.  I suddenly realized the severity of her loss. Literally, physically, emotionally. It was more, of course, than just about hair. 

"You know, Rita," I said, "has anyone told you how perfectly your head is shaped?" (It really is.)

She smiled. "Quite a few."

"Well," I said, "I think you look great with very little hair!"

And she replied, "I think I might keep it short...even though it is going to be gray now."

I told her about a friend of mine who did that in her late 40's, went gray. Quit coloring. She looked stunning.

I also told Rita that she is still the same Rita that had hair, that weighed a little more, that had the energy to cook for her big family. The same Rita. That Rita had not extinguished. She was still right here in my presence.

The crease between her eye brows deepened, and a tear welled up in her left eye.

"OK."

An ending; a beginning.

Later that day, Eileen arrived. When I knocked on the door to introduce myself, an aide was guiding her out of the bathroom. As she pushed with a walker, I observed a bobbing and weaving pattern unlike the more characteristic symptom of Parkinson's Disease, the tremor.

During her evaluation, I had to concentrate deeply on 2 things. 

First, I had to focus on the movement of her lips to understand her, because her speech was barely audible.

Second, I had to follow her lips, as her head and upper body weaved back and forth rhythmically. The only time they stopped was when she took a deep breath. I was exhausted from concentrating by the end of our session, but this time with her was one of the highlights of my day.

Eileen was lovely!

As we tested strength, balance, and cognitive abilities, we made a list of all the activities she cherished the most. After all, as an occupational therapist, it's all about returning people to the highest level of function so they are able to engage in life!

A short time ago, Eileen had been walking 9 holes weekly with a ladies golfing group. "We can swing golf clubs during your balance retraining!" I told her. She had been a voracious reader, but macular degeneration had limited her sight, making her central vision blurry.

"Are you open to audio books?" I asked her.

"Absolutely!"

"Perfect!" I'll bring the application tomorrow for the State Talking Book Library in Sacramento. You'll be going through a book a day in no time."

I explained to her that when we do OT, if a person cannot fully return to the activity they once loved, it is not lost forever. The activity may simply need to be modified.

Eileen paused for a moment during the evaluation. "Sometimes, I wake up in the morning ready to bounce right out of bed like I used to. I forget that I can't. I think it's time to load the clubs in the back of the car and take off.  Then, just getting out of bed is a reminder."

"Eileen, you are still the same woman who golfs with friends. You are the same woman who has helped so many children in your job. You are still the same person on the inside."

So many of my patients tell me stories like this. Someone with a stroke whose arm won't move will report that they dreamed they had full use of that hand or another will say he walked. It all feels so natural and "complete" in the dream state.

Some awaken dejected. Others are motivated by their dreams. Their reactions are usually consistent with their outlooks on life.

They will either see their current station in life as the end of the road, or they will shift through their former perceptions of what life was into a new and meaningful way of living . Living fully. Despite the obstacles.

Dr. Wayne Dyer wrote a small paperback called Living the Wisdom of the Tao. In it, he includes the 16th verse of the Tao Te Ching, part of which goes like this:

"...let your heart be at peace.
Amidst the rush of worldly comings and goings,
observe how endings become beginnings.
Things fluorish, each by each,
only to return to the Source...
to what is and what is to be. "

If a major illness or injury happened to you, would you choose to think your life was ending or beginning?

Endings = beginnings.

Lesson of the Day: WORDS OF AFFIRMATION

 I noticed a trend today. Appreciation!

I was greeted this morning by nursing facility residents with bright smiles, "ohs!" (new hair style - they all noticed, even the ones with dementia!) and sweet words ("We missed you, Tre! We're so glad you're back! How was your vacation?) I felt such appreciation!

Isn't that a great way to start the week!

There's a book I'd like to recommend. The 5 Love Languages by Gary Chapman.  In the book, Chapman introduces five ways in which people demonstrate their love for each other.

One of these is words of affirmation.

Receiving such sweetness from my older friends fueled a desire to pay forward positivity today. What "something special" could I note and share with each person in appreciation of them?

I understood more about Hank during his occupational therapy appointment today. I palpably felt his anguish as he opened up about a childhood rife with abuse by his mentally ill mother and social isolation at school.

This man, however, navigated through a miserable childhood into a meaningful life as an artist and teacher, father and friend.

By the time we parted, I realized that tatoos were Hank's route to a life of creative expression, friendship and empowerment. Every tatoo represented a significant moment or mark of friendship in Hank's life. Some of us may choose photos or jewelry or momentos to remember special events or beloved people.

Hank chose art...
...on his skin.

He morphed today from just a guy with tatoos to an authentic creative professional.

What I appreciated about Hank was his dedication to his art form and his contribution to the education of future tatoo artists. College degree in art, years spent teaching newbies in a seven-year apprentice program...

Seven years?! I had no idea....this wasn't just a two-week training session...

I gave him kudos. That's all I could do. He beamed.

Appreciation.

Shortly after, I sat down with a resident with dementia who had recently undergone inguinal hernia surgery. Earlier in life as a surgeon, Ron  had corrected inguinal hernias.

I explained to Ron that we needed to work together because his surgery and hospitalization had weakened him.

"What surgery?" he asked.

"Well," I replied, "you had a right inguinal hernia surgery last week."
He immediately touched his right groin area. I asked, "Dr. Ron, how do you fix a hernia?" And he launched into an admirable description of how to surgically correct it.

Wow.

In the healthcare world, we always check something called orientation. Do you know:

1) who you are
2) where you are
3) when it is; and
4) why you're there?

Dr. Ron was oriented only to who he was, yet he could retrieve from memory how to perform surgery!

Dr. Ron was not the same after surgery as before; something subtle had shifted in his affect. When I looked him squarely in the eyes at the end of the treatment to congratulate him on a job well done, his dull eyes locked with mine, and suddenly, it was as if they lit up. They sparkled...and then a smile emerged that I had not seen in quite some time.

My heart squeezed. "Dr. Ron, you just made my day."

He winked.

I wanted to talk a bit more about Dr. Ron's work. "So, tell me about the other surgeries you used to perform."

"Surgeries?"

The moment was lost.

Dr. Ron may not always remember what a difference he has made, but it didn't stop me from reminding him.

We all want to know that we contribute in some significant way. It's also up to us to acknowledge the contributions of others.

 Appreciation...pay it forward!

Lesson of the Day: DON'T JUDGE A BOOK BY ITS COVER...

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It's Saturday, July 30, my first day back to work in the rehabilitation department of a small tourist town nursing facility in northern California following a whirlwind 2-week vacation in the Mediterranean. It's during this vacation that my twin sister pins me down.

She's the Director of Online Communications for a multi-national there. She insists I start a blog to share the tidbits of LMAO or bring-you-to-tears material that I shoot off to my mom and sisters via email or tales I tell when all seven siblings and spouses huddle at "the farm."

I oblige. I realize it's time.

Thank God she has the skills to set me up. Ask me to figure out how to make a muscle move after a stroke or how to treat a cognitive disorder, and I'm fine. Starting a blog is another story. So, here goes!

I am a traveling occupational therapist...an OT.

Travelers can land anywhere across the US for short stints of, say, 8 to 52 weeks. We work in hospitals, nursing homes, or home health agencies.

In my current assignment, I started shortly after Labor Day 2010 on an 18-week contract at what some family members there refer to as a "convalescent home" in northern California. I fell in love with them, and they with me. I kept extending my assignment. Voila, in 5 weeks time, I bid them farewell, or I am considered a permanent employee at the year anniversary.

It's unusual to linger in a travel spot.

These positions are sometimes (not always!) vacant in facilities you'd feel ill at ease to consider for your ailing loved one. Telltale signs of a poorly run facility, in case you're wondering (thank goodness, it is not like this industry wide):

wheelchairs caked with old food or worse,
dirty fingernails,
the smell of urine,
people sitting in the front lobby without their false teeth or glasses...

Surroundings aside, there is one thing that keeps me consciously choosing this setting - the feisty, beautiful, confused, graceful, crabby, hilarious, angry, and honest old people.

But let me tell you now. This is not a glamorous field.

Today, I would have welcomed a slide-into-work-again easy day, but it was not to be. The first patient I introduced myself to was a 72 year old cardiac patient splayed out on his bed, beer belly exposed, tatoos completely painting his arms and legs, and whining that he couldn't move in the bed to reach his bedside urinal.

While I bit my tongue 5 times in the hour I was with him, counting the minutes until I had evaluated his ability to toilet, groom and get back into bed (we call that ADLs - Activities of Daily Living), I was humbled when he said something really serious.

I asked him what he wanted to be called. "Hank," he said. "Please don't call me Robert" (the name on his chart) - "my mother and step father used to beat me, and that's what she always called me...Robert."

"I hate that name," as he cast his eyes away.

I assured him that I would inform everyone of his wish. He paused a moment and followed with a sincere apology for ranting and raving through the whole treatment...and I thought, I am so glad I bit my tongue!

We simply do not know what rocky, curvy paths others have sailed, trudged or crawled. It's easy to look at someone and judge. He's got tatoos. She's bald. He's a dirty old man. She's a bitch.

In the past couple months, I have held hands with, listened to, praised, instructed, solved the world's problems with and encouraged former campaign managers, a law professor who pens travel guides, a spunky 92 year-old who outfitted half of Hollywood's costumes in the 1950's, a physical therapist who treated WWII soldiers and Hollywood's finest, friends of the real Linus from Charles Schulz's 'Peanuts' cartoon, winery warehouse managers, and an orthopedic surgeon with dementia.

I have learned valuable lessons from a electric pole climber who nearly killed himself drinking too much, a homeless guy whose truck rolled over on him at a truck stop (long story), British war brides and a number of indigent patients just trying to survive.

They each look different on the outside, yes, but guess what? We all have the same feelings, experiences and challenges on the inside. When we strip away all the reasons we set ourselves apart, we are all people simply trying.

To survive.

To love.
To be heard.
To live.

I entered a room today, glanced at the A bed, closest to the door. The pale, gaunt man was laying on his right side covered with a sheet, legs curled up despite the knee splints to attempt to straighten them. He was reaching into thin air for something only he could see. Muttering.

I discovered photos newly hung on his wall. His daughter must have stopped by when I was on vacation. There Tom was...a life collage of an incredibly good looking and successful man. Soldier with a strong and eager face, vibrant NYC professional in a starched suit, enthusiastic husband and father, surrounded by his smiling family.

I paused my gaze on him. He had returned to his youth and was pulling a sheet of paper out of a manual typewriter, chasing a deadline for the Wall Street Journal.

If I am one day old, confused and bedbound with contractures, who will have the eyes and heart to realize that I have led an adventurous, boisterous and full life? I do very much hope by then that they don't judge my book by its cover.