Month: November 2014

At Veranda Rehabilitation and Healthcare in Harlingen, Texas, there is no greater incentive for our therapists to persevere through difficult cases than to see patients returning home to carry on with their lives. In the example of one client, admitted to Veranda with a gunshot wound to the mouth and presenting with ETOH abuse, B nephrolithiasis, malnutrition, liver cirrhosis and other symptoms, it was clear from the start that this patient would require extensive therapy. However, our therapists were up for the task, and his story is just one of many that demonstrates how our commitment to a positive outcome allows us to create a partnership for healing with even the most challenging patients.

This client, we’ll call him Joe, entered Veranda not only with multiple physical ailments, but emotional distress as well. Angry, depressed and unwilling to participate in therapy upon admission, Joe seemed determined to do anything but listen to his therapists. One can understand his frustration: After living independently in a mobile home community, now Joe required total assist for all mobility and ADLs and was eating a modified diet of mechanical soft food and honey-thick liquids.

With persistence and continual education on the benefits of therapy, we began to create a rapport with Joe. Once we turned that corner, Joe became an active participant in his treatment program and began to see progress, albeit slow. The road was long and winding leading up to Joe’s discharge, to say the least. During his stay, Joe was transferred to hospital three times due to multiple medical issues. While there, he went into both respiratory and cardiac arrest and was put on a ventilator.

Joe’s therapists remained dedicated to his treatment despite the bumps in the road. Physical therapy included functional exercise tolerance, BLE strengthening and coordination, standing balance facilitation and gait training. Our occupational therapists worked on NMR, BUE strength, sitting balance, UE coordination, self-care training and e-stim for pain management. Lastly, SLP treatment included oral motor retraining and dysphagia treatment.

After four months of hard work, Joe was discharged home and now lives alone and independently with all ADLs. He ambulates without an assistive device, eats a regular diet with thin liquids, manages his own finances and drives his own car. While we are thrilled with the outcome of Joe’s treatment, we are even happier that he has reclaimed his life and makes the time to visit us frequently at Veranda. Joe never fails to express his gratitude that our therapists did not become discouraged despite the initial challenges. To this, we would say, it is our great pleasure to serve clients like Joe and help them emerge from treatment with a new lease on life.

When 42-year-old Heather entered Park Manor Rehabilitation Center in Walla Walla, WA, she had already experienced more struggles than many people twice her age. With a medical history of diabetes mellitus and lower-back pain, Heather had visited the emergency room due to pain in her right lower extremity — at the time, thought to be sciatic pain. An MRI was negative for a herniated disc; however, an X-ray confirmed she had necrotizing fasciitis.

Heather’s diagnosis led to her transfer to Kadlec Medical Center, where the wound was debrided and a wound vac put in place. After receiving antibiotic treatment, she was life-lighted to Harborview Medical Center in Seattle for further care, which included debridement of the right thigh, calf and gluteal area, perineum and groin through four separate incisions. Admitted to the ICU, intubated and placed in a coma for four weeks, Heather underwent a total of 12 debridement surgeries.

During this time, Heather also developed VRE. Her family was told she had less than a 15 percent chance of survival. Despite the odds, Heather persevered and stayed at Harborview for a total of seven weeks. From there, her journey began with Park Manor Rehab for post-acute care.

With some prior experience as a CNA, Heather was high-functioning at admission and had been living with her daughter in an apartment on the ground floor. She was (I) with all ADLs, including bathing. Additionally, she was (I) with all IADLs, including driving. As for her functioning levels at evaluation, she required 100 percent mod assistance for grooming from her bed as well as maximum assistance with toileting, upper body dressing, bed mobility and transfers. She was dependent for lower body dressing and bathing and unable to ambulate.

The team at Park Manor enlisted the collaborative efforts of physical and occupational therapy to get Heather on the road to wellness. A combination of electrical stimulation and short wave diathermy in physical therapy worked to increase circulation in order to promote wound healing. Meanwhile, occupational therapy worked on increasing Heather’s upper extremity strength and coordination, activity tolerance and improving her ability to participate in functional tasks.

Upon discharge 96 days later, Heather had achieved modified independence with ambulation, grooming, toileting and upper-body dressing. She required standby assistance with lower-body dressing, minimal assistance with bathing, and modified independent or standby assistance with transfers. Perhaps most astounding was the remarkable healing of her wounds. In fact, when she went to a final appointment to schedule a skin graft for her right lower extremity prior to discharge, her doctor decided instead to suture the last remaining opening, and no skin graft was required.

Heather was discharged home to her apartment with home health services initially. Later, she returned to Park Manor for outpatient therapy. Although Heather’s necrotizing fasciitis case was complex, it served as a benchmark by which to design future treatments. Park Manor has since received two more cases of necrotizing fasciitis and also has seen an increase in patients with extensive wounds and wound vacs, which we have treated successfully with the high-volt e-stim. As for Heather, we are happy to see her continuing to make great strides in her recovery!

For patients with a terminal illness such as cancer, hospice is not the only answer — and certainly not the best one in many cases. That’s something Northeast Rehabilitation Center in San Antonio, TX, learned firsthand in working with Patient P., a woman who presented with stage III lung cancer and whose chemotherapy treatment had proved ineffective. When told by her doctors that she needed to consider hospice, P. refused — and those of us at Northeast Rehabilitation and Healthcare Center stepped in to provide rehabilitation services.

P. entered our facility with multiple confounding factors, including aspiration pneumonia, neuropathy, COPD, poor trunk control, Hx of hip fx with resultant leg discrepancy, a peg tube and oxygen dependency. Moreover, she weighed just 80 pounds and was both emotionally and financially devastated by her diagnosis. To make matters worse, her husband needed to work and was therefore unavailable to assist her during the day. P. simply was overwhelmed and wanted to be at home.

Doing our best to create a home away from home for P., the team at Northeast Rehab took an interdisciplinary approach that included occupational, physical and speech therapy. For occupational therapy, we emphasized BUE strengthening exercises, sitting balance, progression from Hoyer to sliding board transfers, wheelchair mobility, coordination and feeding. Physical therapy focused on bed mobility, BLE strengthening, balance, trunk control, transfer training, sitting and standing tolerance, and wheelchair mobility. Lastly, speech therapy included laryngeal elevation exercises to increase airway protection, positioning during and after PO intake, nutrition, and swallow strategies and training. Needless to say, we all had a busy schedule, especially P.!

The three teams collaborated frequently to continue encouraging P. along her journey, reinforcing a positive approach and reminding her daily of her progress in each discipline. Although P. would become discouraged at times, we would invite her to reframe her thinking and notice how far she had come since admission. Gradually, P. began to realize that each incremental gain was another step toward reaching her larger goal of going home.

Indeed, it truly was a team effort that enabled P.’s positive outcome and ability to return home after being in our facility for 55 days. At the time of discharge, she required Min A for standing pivot transfers, SBA for bed mobility, and SBA/CGA for dressing and toileting. She was (I) with self-feeding and grooming/hygiene, her endurance had increased from less than one minute to greater than 30, and she was able to propel her own wheelchair. With her family trained on transfers and a home exercise program, P. went home on a regular diet and thin liquids with no further need for a peg tube.

P.’s success in the cancer rehabilitation program not only improved her quality of life and allowed her to go home with her family, but also allowed for greater visibility and credibility of the program with insurance companies and with the medical community. We negotiated with P.’s insurance provider for maximum visits and also received more patient referrals to our facility as a result of working with P.

In addition, our own rehab team increased their understanding of rehab for terminally ill clients. As evidenced with Patient P., working with these residents is often one of the most rewarding and inspirational experiences we could ever have.

Sometimes, one new piece of equipment makes all the difference for a patient. Take, for instance, the case of one resident at Mountain View Rehabilitation and Care Center (MVR) who was admitted following a right middle cerebral artery aneurism, with coil embolization of aneurism, aneurism perforation and resultant subarachnoid hemorrhage. Hospitalized for three and a half months prior to admission at MVR, Patient R. entered our facility with multiple challenges preventing her from living a more independent life. However, with our therapists’ patient and caring approach, plus the addition of a Barihab table to her treatment routine, R. has made incredible strides in her recovery.

At admission, R. had a host of challenges to overcome, among them:

• Severe right-side neglect causing her to persist in twisting her trunk to the left and grabbing the bed sheets and bed rails on her left side
• Inability to maintain an upright position for more than five minutes
• Total dependent standing pivot transfer with a left prosthetic limb, requiring two therapists due to R.’s severe retropulsion and falling to the left
• Peg tube for feeding with NPO
• Two therapists required for bed mobility, including rolling and transferring from supine to sitting at the edge of the bed
• Total dependency for all dressing, hygiene and grooming

Before joining us at MVR, R. had received some rehab services at the hospital, but she had failed to make any progress. Her situation changed once our therapists began to work with her and encourage progress throughout her ups and downs.

Initially, R. required transfer with a Hoyer lift and had difficulty remaining seated in her wheelchair because she was sliding or squirming out of it. Therapists continued to work with her on standing pivot transfers, balancing from sitting, and sitting balance on the treatment mat in the therapy gym. Eventually, R. progressed to standing by positioned parallel bars close to the high-low table.

The game-changer came about when MVR acquired a Barihab table and began to incorporate it into R.’s therapy regimen. Because the table provides greater security, R. felt less fear of falling, and over time, she gained greater confidence in her own mobility. She now stands using the Barihab table and self-supports with her UEs while ambulating through the parallel bars, then transitions to a FWW and walks 35 to 40 feet while wearing her left prosthetic limb.

Says Sam Wipf, OTR/L (DOR), “We have just opened a new world of possibilities with the Barihab table, no question about it.”

R.’s family and therapists agree that the table has enabled a remarkable recovery for the resident. Among her many accomplishments, she is now self-feeding on a mechanical soft diet, no longer requires a bed pan and needs one person for toileting, ambulates with a FWW across the rehab gym and into the hallway, and is completing the majority of her transfers with a standing pivot approach with one person.

The Barihab table has proved to be an invaluable addition to MVR’s therapy program — one that continues to benefit patients like R. and others. “I can now stand residents who I never thought I would ever be able to stand,” says one therapist.

Adds one family member of another patient: “He actually stood for 10 minutes. He hasn’t stood for months.”

Another therapist perhaps sums up our sentiments about the Barihab table most succinctly: “Why didn’t we know about this before?” Now that we know, we expect to continue using the Barihab table for many of our patients who are mobility-challenged.

For patients with excessive pannus, whereby the skin on the lower abdomen hangs down due to rapid weight loss, there are multiple complications that can arise. The condition increases the risk for excessive external hip rotation contracture, skin breakdown due to trapped moisture and decreased lower-extremity strength and range of motion.

Patients with no medical complications might choose to have the excess skin surgically removed. However, for some patients, such as Patient G.D. at Wellington Place Living & Rehab, surgery is not an option and we must find alternative treatments.

G.D. is an older woman who had lost a significant amount of weight, resulting in a pannus that would sit in between her legs. She was scheduled to have surgery to have the pannus removed, but due to some co-morbidities, she was unable to proceed with the surgical procedure. The patient’s health declined, and she was no longer able to transfer herself. That’s when she joined us at Wellington.

We initially used a sheet to address G.D.’s pannus complications, which included rashes and candidiasis, but the sheet was quite cumbersome, and the patient was unable to self-release from it quickly. The sheet also made G.D. overly warm, thus increasing the moisture to her perennial area and the top of her thighs.

Next, we tried a wheelchair security belt with a padded area meant for the stomach. We secured the belt to her bed rails with cable ties, which we then used as positioning devices for bed mobility. The quick-release button made it easy for G.D. to release from the belt, and the padded belt was smaller, cooler and more comfortable for her.

By consulting with our PM&R physician, DOR, Physical Therapy and Nursing, we created a treatment plan for G.D. that addressed her various needs. As a result of our collaborative efforts, G.D. is now able to complete a HEP to maintain strength and range of motion in both lower extremities. She also has increased leg adduction, is able to keep neutral hip positioning while at rest in her bed, and is no longer experiencing rashes or discomfort due to excess moisture. Most importantly, G.D. is happier and healthier now that we’ve found a solution that works for her particular needs.