Reported Knowledge of Dementia and Competency in Treating Clients

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by Ciara Cox, PhD, Therapy Resource –

Six Samuel Merritt University OT students and I just completed a study on rehab professionals’ self-reported knowledge of dementia and self-reported competency in treating clients with dementia. We wanted to see if there was a gap between knowledge of dementia and feelings of competency in treating clients with dementia. We collected data for our study via a web-based survey. Many of those who responded to our survey work at an Ensign-affiliated operation, and we thank you for your participation.

Although the response rate to our survey was low (27 OTs, five COTAs, 20 PTs, eight PTAs and five SLPs), we had some interesting findings:

  • As a group, OTs, COTAs, PTs, PTAs and SLPs feel both knowledgeable and competent.
  • There was no significant difference between self-reported knowledge of dementia and self-reported competency in treating clients who have dementia.
  • There was no significant difference in self-reported knowledge and competency between the three different rehab professions.
  • There were significant differences between groups of rehabilitation professionals who received different types of dementia care training and also differences related to years of experience working with clients with dementia.

Training

Therapists who received training in one or more of the following approaches reported a higher level of knowledge of dementia and competence in treating clients who have dementia than therapists who did not have the training:

  • Allen-Cognitive Levels
  • Behavioral Training
  • Cognitive Stimulation
  • Reality Orientation

Experience

  • Therapists and assistants with more than five years of experience with clients who have dementia reported significantly higher competency in training caregivers than those who had less than five years of experience.
  • Therapists and assistants with more than 10 years of experience with clients who have dementia reported significantly higher competency in treating clients with dementia than those with less than 10 years of experience.

The results show what you may already instinctively know: Experience and training lead to expertise.

With the baby boomers entering older adulthood and life expectancy continuing to increase, the number of people living with dementia is predicted to increase from 5.4 million currently to 16 million in 2050. As a profession, we will need more therapists who have expertise in working with this population. The majority of residents in our nursing homes have some cognitive deficit. If you have not received specific training for treating residents with decreased cognition, we recommend that you plan to do so.

The SMU OT students who worked on this study are Michelle Chan, Kristin Dunn, Laura Heinemann, Carly Keller, Cynthia Lyssikatos and Jennifer Warner. They are delighted to share our results with people who are interested. If you currently have OT, PT or SLP students in your department, ask them about their research. It is a great way to learn new information.

Dementia Capable Care Instructor Program

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by Ryan Hough, Therapy Resource – What is the first thing that comes to mind when you think of a patient who has dementia? Many people tend to think of what dementia patients typically can’t do — such as remember names, get dressed, brush their teeth and so on. However, I had the opportunity recently to take the Dementia Capable Care Instructor Program with the desire to bring the training I received back to each of the homes in my region. This training is designed to help anyone who is involved in caring for our residents to develop a new mindset and ideas on how to work and interact with patients who have dementia. This awesome training helps you to understand where a patient is at cognitively so that you can then formulate a plan — whether you are a therapist, an activity director, a nurse, an executive director or a maintenance worker.

As a physical therapist, I think back to all the times when I was trying to walk a patient but not having success. Through this course, you will learn spatial, verbal and tactile cues to assist you. Most important, the training inspires you to learn all you can about your patient and his or her past. The more you know, the better equipped you are to help your patient be successful. As your patients experience success with activities such as walking, getting dressed, playing cards and even feeling overall happiness, you’ll discover that dementia patients have so much potential. We all strive every day to offer the best care to our residents, and this course offers tools that will help you to change these patients’ care experiences for the better.

Massage Vibration Brings New Life to Northern Oaks

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by Billye J. Alford-Lee, DOR, Northern Oaks Living & Rehab Center, Abilene, TX – Mr. Lynn has been a resident at Northern Oaks for three years with a diagnosis of quadriplegia — he has struggled with seating issues due to extensor tone in UEs and LEs. After consulting with resources Deb Ellis and Jon Anderson, we trialed a massage/vibration mat to decrease tone prior to ROM and began assessment and fitting for a new custom power wheelchair. The vibration mat worked beautifully if applied approximately 20 to 30 minutes prior to treatment. The custom power wheelchair arrived five weeks later, with a head array and mouth control driving mechanism, allowing Mr. Lynn a newfound independence in mobility and quality of life that he had not experienced in several years. He also is able to control his television with the mouthpiece, as it is synced with his remote control.

Our therapy team has been so honored to work with Mr. Lynn in making a difference in his life. His amazing attitude and smile are such a joy to see, and the creative efforts of Ensign Therapy Resources and therapists have truly contributed to enhancing his comfort, independence and happiness here at Northern Oaks!

Celebrating OT Month at Osborn Health and Rehab Center

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by Joleen Linn, Therapy Resource

As many of you know, April was National Occupational Therapy month. In an effort to provide education to the staff on the role of Occupational Therapy in a SNF setting, Osborn Health and Rehab Center hosted a week of fun and informative activities for their co-workers and residents. Occupational therapists provide extensive education to their patients and family members as part of their treatment plans, but how many times have you heard OT introduced as, “This is OT — they work with you ‘above the waist.’ Osborn Health and Rehab Center wanted to inform their staff that occupational therapy is more than “arm bikes, peg boards and getting people ready for PT.” They felt that the best use of OT month was for staff education.

First, they did a quick presentation at their all-staff meeting and invited everyone to participate in the week’s daily activities. The OTs and COTAs made up an OT-related word search, crossword puzzle and true/false quiz. As employees completed the activity, they were presented with a “prize” consisting of chips or cookies (yes, they did bribe with food!). Then each day, Osborn Health andRehabCenterpresented an activity that demonstrated how various impairments affect their residents’ ability to complete basic tasks. For example, they mimicked visual deficits (blindness, macular degeneration and glaucoma) while the staff member navigated an FWW through an obstacle course and then sat down to complete a drawn maze. Another day’s activity involved dominant-sided weakness post-stroke. The employee had to use his or her non-dominant hand for a balance, gross-motor, eye-hand coordination task, which consisted of balancing on one leg on an unstable surface and tossing bean bags with the non-dominant hand to win various prizes. Other activities performed that week included a fine-motor “Minute to win it” type of game, and finally a speed, visual perceptual/cognitive task followed by root beer floats as the final reward.

The Occupational Therapy team did an excellent job of staff education, and more than once heard the comment, “Wow, is that what it is really like?” They had a good turnout and a lot of fun in achieving the objective of celebrating OT month and showing off OT!

Mentoring is an Opportunity for Both Therapist and Intern

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By Amy Lynn Gutierrez, SLP, Village Care Center, McAllen, TX –

I have been a practicing SLP for the past six years and have had the pleasure of working for Village Care Center in McAllen, TX, for five years. In 2011, I was presented with the opportunity to mentor a new graduate who was seeking to complete her CFY. I have to admit, initially I was a bit apprehensive as I did not feel I possessed the “tools” to educate and/or mentor a fellow clinician.

On July 11, 2011, Denise joined our team as an intern in Speech-Language Pathology. She has since then been a wonderful asset to our work family. Being a recent graduate, she has provided not only me, but also our whole team, with unique treatment approaches along with a different perspective. These past nine months have flown by so fast, it is astonishing to believe that it has come and gone. I remember her first day and how reluctant I was to provide her with her own list of patients. My director said to me: “She’ll be fine. You can’t follow her around forever, and you need to give her more than three patients!” I couldn’t help but recall when I was an intern and how terrified I was; she must have been feeling the same way. Slowly but surely, I let go of the reins and realized I would always be within walking distance in case she needed anything. I am very fortunate to have had such a wonderful first experience with my CF. We had many adventures together that provided us with a number of teaching moments.

The most important thing I learned throughout this experience is that we won’t always have the immediate answer, and that fear should not hinder us from taking on a task that may seem challenging. My apprehension toward becoming a mentor was unwarranted. I now understand that mentoring a fellow clinician should be viewed as a privilege. It’s a learning experience for supervisor and intern both and an experience we will both carry with us.

The Human Side of Physical Therapy

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Physical therapy school prepares you by giving you that archetypal “toolbox” filled with various resources and skills to be constantly adjusted and fine-tuned. The more tools, the better! Since every patient is unique, each treatment must be tailored to deliver the best interventions possible. During various courses preceding my first clinical internship, I filled my toolbox with functional outcome measures, neurological interventions and about 50 pneumonics to remember everything from the cranial nerves to the eight carpal bones. I practiced NDT, PNF, MMTs and goniometry on my classmates at length, sweated through practicals and wrote hundreds of study guides. I felt eager to apply this knowledge to actual patients, not my unimpaired classmates, so that I could learn from experience. My first internship brought me to Sonoma Healthcare Center, an Ensign-affiliated sub-acute skilled nursing facility.

As a student embarking on my first internship, I had some expectations of what I should gain out of the seven weeks I was to spend at Sonoma Healthcare Center. I expected to learn, to be challenged applying my knowledge, to experience a wide variety of patients and their unique impairments. What I did not expect was that my experience would take me above and beyond these conjectures and give me an opportunity to not only utilize my “tools,” but also to foster meaningful relationships with both my peers and my patients. It’s the human side of physical therapy: that knack for communication, the willingness to have an open heart. These are skills no professor can teach — skills that only can be gleaned by experiencing firsthand a patient with C-Diff precautions who doesn’t want to feel socially isolated, a patient who looks to you to teach her how to deal with an amputation, a patient who struggles with panic and fear of falling with every sit to stand. Sonoma Healthcare Center opened up a world in which each patient demanded my skilled interventions, my creativity and above all my compassion. I knew that these skills would shape my career as a PT. To ensure that these skills were honed and refined during my time at SHC, I looked to my mentor and clinical instructor for guidance.

My clinical instructor, JB Chua, has been an incredible teacher because he teaches by example. JB understands that aforementioned human side of physical therapy. He harbors great respect and obvious compassion for his patients, as well as an infectiously positive demeanor that is difficult to ignore. And for these reasons, his patients adore him. As a mentor, he has been a terrific role model as I strive to achieve such a rapport with my patients. JB’s willingness to take me on as a student, and his undying patience as I worked through documentation and clinical reasoning, have created an environment in which I have learned more than I could ever have hoped for. So I have to thank my clinical instructor (and the rest of the stellar rehab team with which I have been honored to work, and whom I am proud to call my friends) for such an educational — and memorable — clinical experience. The bar has been set high for my future clinical experiences, and my future as a physical therapist. Thank you to Sonoma Healthcare Center for bringing me into your rehab family, taking my toolbox beyond pneumonics and study guides, and providing me with an example of the clinician I aspire to become.

by Courtney Sinclair, SPT — Student Intern at Sonoma Healthcare Center, Sonoma, CA

I have really enjoyed my experience at Park View Gardens and have learned so much more than I could have imagined about practicing in a skilled nursing environment. This was completely new for me since my experience has been primarily in an outpatient setting, and the staff at Park View Gardens welcomed me with open arms and helped me to really get the most out of this opportunity.

by Shelby McCalla, SPT — Student Intern at Park View Gardens, Santa Rosa, CA

It was a great experience for both me and my CI. Her vast clinical knowledge, mixed with my resources and fresh ideas from school, made for an ideal pairing to offer the best clinical approach in patient care.

by Murphy McCarty, SPT — Student Intern at Cloverdale Healthcare Center, Cloverdale, CA

Have You Thought About Advancing Your Education?

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… Or, perhaps even advancing your degree? Many of our facilities offer programs to assist you with living your “passion for knowledge.” Some of these programs include financial support for continuing education courses. Other programs may include tuition reimbursement for university courses or certification credit. Through one of our most recent relationships with the Rocky Mountain University of Health Professions (RMUoHP), we will be tailoring some courses to fit your needs in the area of leadership development. The RMUoHP also offers post-graduate doctoral programs in both Physical and Occupational Therapy, which are designed to meet the needs of the working learner. If the pocket book is a little tight right now, take advantage of the new courses being added to our Learning Management System, Brainshark. Not only are the Brainshark courses helpful for navigating through our ever-changing healthcare environment, but our development plans include information to challenge you to grow as therapists and leaders. Watch for a release mid-summer 2012 on the Allen Cognitive Levels, Part I. And Part II, being released in August, will include demonstration training for administering components of the Allen Cognitive Battery of Assessment Tools.

If you haven’t had an opportunity to attend a learning event sponsored by your therapy resource team at Ensign Services, please watch www.ensigntherapy.com for upcoming opportunities. During the past 6 months, we have partnered with facilities in different states throughout our company to bring a variety of educational events to you. South Texas has co-sponsored Kinesio Taping I, II, and III. The KT I and II course will be offered in Dallas, Provo, Arizona and Southern California sometime over the next few months. Therapy Resources Gina Tucker-Roghi, Ryan Hough and Debbie Ellis have also become certified trainers in an 8-hour course on Dementia Care, and they are beginning to schedule trainings with interested facilities in select areas. We are developing a seating and positioning training to assist with filling a need identified by several of our DOR’s. Our Southern California Resources are working with education specialists to offer modalities courses. We are also looking to offer another CI Certification Course sometime later this year.

Your therapy resource team at Ensign Services is proud of the therapy programs you have built and continue to build in your rehabilitation departments. Your programs are creative, individualized, transformational and second to none! By providing students and interns an opportunity to see the team in action and learn from Clinical Instructors (aka, CI’s or mentors) who are absolutely passionate about the work that they do each day, you will make an impression and dispel any preconceived ideas about long-term care that any of these students may have had . Students are our lifeline, our future, our profession. The golden opportunity we have created as an organization, by partnering with so many different accredited Therapist and Assistant training programs (over 80!), provides us the ability to mold our future.

We recognize that the commitment required to mentor a student is great. We have committed resources to developing tools and education to enhance the mentoring experience. In November 2011, we held a CI Certification Course in Southern California, which was attended by 22 of our therapists. We are developing an instructor “manual” which will help to streamline answers to questions regarding regulatory requirements, How-To’s for Students when it comes to ROX and PCC, as well as time management and scheduling strategies. We are developing two new Brainshark Curriculum programs and will introduce our first modules in June 2012. The first curriculum will be designed for the student learner in one of our facilities (Orientation Basics, ROX /PCC for Students, Etc.). The second curriculum will be designed for the mentor with short trainings meant to compliment the manual mentioned earlier.

We are deeply passionate about learning and knowledge. Please share your ideas and needs for continued enhancement of our development offerings. You can provide your suggestions here on this website by submitting a blog or via e-mail to dbielek@ensigntherapy.com. Thank you for giving us the opportunity to better serve you and your therapists.

Bridging the Gap: Clinical Research and Rehabilitation

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by Curtis A. Merring, DOR, Wellington Place, Temple TX –

Professionals and administrators in any rehabilitation setting need intrinsic motivation to pursue evidence-based treatment strategies to stay ahead of market adjustments and reimbursement trends. In our current healthcare system of cost-cutting and cost-saving payers such as Medicare (the lifeline of skilled nursing facilities), it is only a matter of time before regulators request from facilities quantifiable results of treatments. Active participation in this process, including preemptively taking these steps, will put any organization or facility at an advantage.

In my experience as a therapist, it has been rare to witness therapists who review current research when planning their treatment strategies, and current trends show no remarkable change in their approach. This is problematic for both established therapists and new graduates entering the field. Therapists in the field are used to the status quo of not integrating research or evidence. New graduates, equipped with the newest evidence- based treatment strategies and the know-how for obtaining this information, come into a field that is dominated with non-evidence-based practice. As clinicians with the least experience, they are challenged with implementing research-based treatment among the norms of existing therapists, not to mention many superiors who have routinely practiced non-evidence-based practice. Shifting the paradigm will require a change in our culture.

At Wellington Place Living and Rehabilitation, our staff has accepted the challenge of integrating evidence into our practice. The rehabilitation department actively engages in addressing the above stated challenges in the following ways. First, all disciplines have at least one evidence-based outcome measure they are responsible for using, tracking and reporting on to objectively measure progress in addition to and in support of less objective functional level measurements (e.g., Min A, Mod A). Next, a relationship has been established with Texas State University through my current collaboration and consistent, open dialogue regarding new treatment strategies and proven innovations in practice. Also, all therapists are encouraged to attend courses with strong evidence-based, progressive topics and present on them to the whole staff upon completing the course. Applying these steps in order to increase evidence-based practice in our department has increased accountability for both the staff and me. In return, we have been able to provide a better service rooted in proven rehabilitation strategies.

Geriatric Sports Medicine — Total Shoulder, Hip and Knee

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This is the third year that we are providing seminar/CEU credits for Flagstone and Touchstone therapists. This year, the topic is Geriatric Sports Medicine presented by Wilson Seminars. It will be held July 14 and 15 (and is already full with more than 90 participants). The later dates are September 8 and 9 on the same topic to accommodate the rest of Flagstone and Touchstone therapists. We have received overwhelming responses from our therapists, and they are hoping that Ensign Therapy will continue with the programs.

Osteoarthritis is a disease characterized by degeneration of cartilage and its underlying bone within a joint as well as bony overgrowth. The breakdown of these tissues eventually leads to pain and joint stiffness. With decreased activity, patients can expect a vicious cycle of increased pain and impaired mobility. Currently in the United States, there are more than 231,000 total hip replacements, 542,000 total knee replacements and 40,000 total shoulder replacements performed per year. Projections state this number will quadruple by 2030. Though the baby boomers are coming, joint replacement surgery is no longer reserved for patients older than 65. In fact, 35 to 45 percent of all Total Joint Arthroplasties (TJA) recipients in the United States are below age 65. The success of joint arthroplasty (and marketing) has created an improved general acceptance and expanded recreational opportunities for younger patients suffering from osteoarthritis. Rather than avoid activities and put off surgery until a later age — when there could be weight gain from inactivity and a greater risk from co-morbidities — younger patients are eager to elect surgery sooner rather than later.

The goals of joint replacement surgery are to relieve pain and to restore function and mobility. Physical and occupational therapists and assistants are the best trained and arguably in a good position to excel with the pre-and post-surgical treatment needs of this medical population. Wilson’s basic- to intermediate-level course combines lecture and extensive lab time designed for participants to practice motor skills covered in lecture that will immediately enhance a clinician’s ability to treat this population. This two-day course will investigate the total shoulder, reverse total shoulder, total hip, hip and knee fractures (S/P ORIF) and total knee replacement rehabilitation of patients. We will look at orthopedic hardware and healing principles, basic joint mobilization of the shoulder, hip and knee, therapeutic exercises and activities. An evidence-based medicine approach will be followed in regard to: 1) what surgical approaches are best and 2) what rehabilitation protocols are best.

Participants will leave this course with a safe, progressive, evidence-based approach of manual therapy dosed with individually prescribed, proprioceptively enriched, therapeutic exercises to allow for optimum therapy outcomes regardless of therapy background.

UAB Training for Constrained-Induced Therapy

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by Franco Yap, PT, Alta Vista Rehabilitation & Healthcare, Brownsville, TX –

The 1990s has been considered the decade of the brain. With advancements in neuro-imaging and the publication of more and more research in the realm of neurologic recovery, there has been a greater awareness and understanding into the mysteries of the brain. Recovery after a stroke is possible. The centuries-old notion that the adult brain is fixed and unchanging is now being reexamined and questioned. “Arguably, the most important breakthrough in neuroscience since scientists first sketched out the brain’s basic anatomy is the revolutionary discovery of Neuroplasticity. This concept that the brain is malleable and able to recover and change, even after an injury, continues to show a lot of hope for those dealing with neurologic injury.

Recently, the University of Alabama has been offering a week-long constrained-induced (CI) therapy training course for clinicians. CI therapy has been derived from basic behavioral neuroscience research with primates, pioneered by Dr. Edward Taub of the UAB CI Therapy Research Group. Typically, CI therapy involves constraining (usually with a mitt restraint) the unaffected arm in patients with hemiparetic stroke or hemiparetic cerebral palsy (HCP) for 90 percent of waking hours while engaging the affected “weaker” limb in a range of everyday activities. The treatment sessions are usually six hours per day for two weeks, although recently there also have been reports that three hours of therapy per day has been shown to be of equal benefit for patients.

This concept is revolutionary in that over the past few decades, conventional rehabilitation therapy has focused more on compensatory measures and use of the unaffected “good side” in the performance of functional motor tasks. The idea of CI therapy is to force the patient to use the affected extremity more in order to facilitate motor recovery. With the use of objective measures, close monitoring and behavioral techniques, it has been shown that about 80 percent of stroke patients who have lost arm function can improve substantially. Over the last 20 years, a substantial body of evidence has accumulated to support the efficacy of CI therapy for hemi paresis following chronic stroke; i.e., more than one year post-injury.

The training seminar involved an introduction to CI therapy, screening/recruitment of patients, treatment protocols, outcome measures and a home skill assignment package. Participants attended lectures given by Dr. Taub and his team and lab training exercises with actual patients. CI therapy protocol involved the use of behavioral techniques like shaping and task practice, adherence enhancement strategies and constrained use of the affected UE with a mitt restraint.

It is common in the rehabilitation world for patients to exhibit a decline in function once discharged from skilled therapy. Education and problems with compliance to home exercise programs given to patients often are overlooked by most therapy approaches. Therapists would work hard to get patients to a certain level appropriate for discharge, only to see them readmitted after several months or days. CI therapy is unique in its repeated focus on bridging the gap between progress made in the clinic and the carryover of continued use of these functional skills at home. Instruments like the Behavioral contract (a written document detailing the patient’s sworn compliance to the use of the constraint (mitt restraint) and Home Skills Assignment (a list of tasks the patient had to perform at home using the affected limb) were always emphasized for enhanced compliance. Every day before each treatment session, the Motor Activity Log, a structured interview instrument, would be used to measure and monitor the use of the affected limb on a list of daily activities. The patients would also have follow-up interviews scheduled after their discharge from CI therapy. This robust protocol, along with the use of Shaping and Massed practice, enforces a strong adherence and retention of learned motor skills.

CI therapy is but one of the many approaches that is part of the current renaissance in neuro-rehabilitation, and it is one of the few that is supported by randomized control multi-center trials. It continues to be refined by ongoing research and is currently being developed for use in the improvement of speech pathologies, lower extremity rehabilitation and other neurological diseases like Traumatic brain injury and Multiple sclerosis. It definitely shows a lot of promise for the future, and there has never been a more exciting time for physical medicine and rehabilitation.