Orem OT Medication Reduction

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By Ryan Porritt, OT, Orem Rehabilitation & Nursing, Orem, UT

Occupational Therapy (OT) used non-pharmaceutical mindfulness-based interventions (HeartMath and Acceptance and Commitment Therapy) to support a patient while the physician reduced anxiety medication that she had been on for years. The patient has several mental health diagnoses, including bipolar disorder, PTSD, generalized anxiety disorder contributing to frequent panic attacks and high levels of anxiety. Her independence and quality of life is further complicated by several physical comorbidities that exacerbate the functional impact of her anxiety. She has a history of significant trauma as measured by scoring a 9/10 on the Adverse Childhood Experience scales.


The following are the step-down dosages of clonazepam:
Staring at 1 mg 3x daily
Reduced to 0.5 mg 3x daily on Jan. 21, 2020
Reduced again to 0.5 every 12 hours on Feb. 1, 2020, to present

The OT trained the patient in several meditations to reduce the emotional struggle resulting from her anxiety in order to increase participation in value-based activities. With assistance, the patient identified three value-based activities: writing poems, quilting and facilitating a weekly bible study group for her religious congregation. After 30 years of not writing poetry, she is able to express her pain, anxiety and other emotions through regular poetry writing. She has assumed a leadership position to prepare and facilitate weekly bible study groups, and she is currently being trained to lead a resident-run quilting group in collaboration with Recreation Therapy and the Therapy Department.

While the patient still faces daily challenges resulting from anxiety, she reports the duration and frequency of panic attacks have reduced and that “I am not struggling with my emotions as much anymore.” With less medication, she reports both increased quality of life and increased participation in value-based activities. While significant progress has been noted, she will require continued skilled OT under a maintenance plan due to the complexities of her physical and mental health. As illustrated by this example, skilled therapists are in an ideal position to have a significant impact on both function and quality of life while assisting physicians to reduce medications.

The 5 E’s – The St. Elizabeth Story

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By Dennis Baloy, OT/DOR, St. Elizabeth Healthcare and Rehabilitation, Fullerton, CA

The acquisition of St. Elizabeth Healthcare and Rehabilitation happened in May 2019. The transition was remarkably successful, but it did not come without challenges. Equipped with knowledge and guidance from our resources, we were ready for the speed bumps ahead — from changing guidelines of our managed care partners, new state and federal regulations to the Star Rating Data, onset of PDPM and many more. Our relentless, action-oriented and fearless yet compassionate leaders, Rand (Administrator) and Mady (Director of Nursing), knew that the only way to achieve these things is staying the course toward our true north — that of providing the best individualized care to all our residents while continuing to embody the CAPLICO values toward one another.

Fast forward to January 2020, when the Department Heads of St. Elizabeth decided to jumpstart the year with a team-building/planning event. In this meeting, they picked the brains of all the adroit minds (fueled with everyone’s genuine love and compassion), and the best ideas in each department were laid down on the table to create a blueprint for “greatness” of St. Elizabeth.

From St. Elizabeth to St. E! Yes, plain and simple St. E!

Why the “E”s? We have narrowed down the core values that each St. Elizabeth employee embodies. They serve as our cornerstones and foundations for each intention and action we make when we go to this second home we call “St. E”!

Excellence. Empathy. Extraordinary. Engaged. Empowered …

Our building was undergoing a considerable renovation (front yard, room renovation, repainting) — an extensive overhaul. We also had a series of fun and educational inservices for all the staff. Keeping the blinders on and riding on this momentum, we were set to relaunch “St. E” to the community this May 2020.

Then COVID-19 came, and the world was shaken.

We paused.

It took only a few moments of realization that all our plans and efforts for our big relaunch were perhaps meant for this. Our facility is more prepared, more reinforced and better structured. The staff’s culture and morale are at an all-time high — bonded tighter than ever.

Yes, it is a different calling now, and everyone is well aware of it. The next few days and weeks will be a grueling test of the core values that is St. E. To say it will be a hard battle is an understatement, but united together we will succeed.

Bottom line is, surely now more than ever, nothing can replace the E’s that all the employees of St. Elizabeth/St. E embody: Excellence, Empathy, Extraordinary, Engaged, Empowered.

In-Room Treatments — Creative Therapy Solutions

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Here are some in room therapy treatment suggestions from our Keystone Resources:

● “Boxing” while supine in bed to work on trunk rotation, rolling side to side for bed mobility, UE strength and activity tolerance; add weights if appropriate
● “I Spy” game for word finding/verbal reasoning goals
● Bird identification out the window. Laminate photos of birds/scavenger hunt looking out window
● Cleaning the bathroom mirror
● Decorating or making a calendar for orientation
● Decorating the room
● Drawing, window painting/drawing
● Fall recovery
● Folding laundry
● Game cards and play this while standing to add in cognition component
● Have a therapist in the hallway and have some residents in the doorway and do some deep breathing and gentle exercise! Maybe have some questions to help facilitate conversation.
● Have some pictures ready for them; have them pick a picture from the pile and have them describe it to you!
● Have them tell us a hobby and modify it for them! We are super creative!
● If they have flowers in their room, trim them and replace the water. This can be done sitting or standing. If they are higher level, have them sweep up the fallen leaves and petals.
● Instructing patients in correct hand-washing techniques
● Introduce HRV training to help relieve anxiety during this time
● Item retrieval/transport
● Making the bed
● Making a collage with family pictures
● Making a cool Easter egg balloon with yarn to hang in their room
● Making cards for their loved ones
● Organize closet by colors/season of clothes
● Painting on paper
● Place patient’s clothes around the room at various levels, have them walk around and gather items, make decisions on whether to use reacher or not, manage reacher and RW, energy conservation education regarding rest breaks, etc.
● Plant something in a flower pot to put in the window sill for them to watch grow
● Postural exercises, high/low reaching

Tic Tac Toe technique–turn this into skilled intervention while distancing and sitting and standing.

● Put laundry on hangers and hang in closet (gross/fine motor and reaching)
● Scavenger hunt in room (list of objects to find)
● Small space functional mobility
● Talk about their life while they are rocking their wheelchair back and forth 🙂. They need to feel calm.
● Teaching them how to use the phone, FaceTime, and trying with a loved one … which brings happy tears, messenger on FB has a video chat as well, so setting them up to keep in touch with loved ones. Also, setting up a free music app on their phone, or a simple game like solitaire.
● Wall pushups working on posture
● Washing windows
● Wheelchair mobility “obstacle course” having to navigate around actual items and furniture in room
● Wheelchair pushups (5xSTS test)
Sequencing for sit to stand (brakes on, scoot up to edge of seat, back, hands in arm rest, fwd trunk nose over toes, 1, 2, 3, push up thru arms and LEs!). Get picky; perfect practice is the only way to instill good habits and break bad habits.
Sequencing for stand pivot transfers with assistive device
Standing balance (Romberg test), standing scalp retracts for stability, steps fwd, lateral, retro
Berg/Tinetti/TUG tests can be done in patient’s room and some aspects of them if anything can be worked on like 360-degree turns in place or picking object up from floor, etc.
● Writing letters/cards/postcards to loved ones
● Use AAC device to give instructions on how to set up/decorate the room; use patients’ phones or tablets for higher-level problem solving (e.g., sequencing steps to write a message on a niece’s Facebook timeline); use their phones/tablets to teach them to set up external memory aids (ex- add doctors’ numbers to contact list, set daily alarms for times they need to take meds); help them set up a grocery delivery acct for when they discharge home; use dysarthria (or aphasia or voice!) techniques during functional phone calls (talk to family, pay bills via phone, etc.); use objects in room for receptive language tasks (“Point to the razor THEN pick up the comb”).

Taking Care of Ourselves — Don’t Let Shelter in Place Shelter You from Staying Active

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By Brian del Poso, OTR/L, CHC, RAC-CT, Therapy Resource

Through this difficult time, all of us are doing what we can to pitch in while at the facility, or remotely for those of us who can’t go to our facilities at the moment. With the stress of our jobs, schools being closed, scavenging for groceries, etc., it’s easy for us to forget about taking care of ourselves or make excuses for why we can’t take care of ourselves right now. We tell ourselves “I’m too tired from my crazy day”; “I have to find something for my kids to do”; “The gyms are all closed”; “If I don’t read all of Mary’s COVID-19 emails right at this moment, I won’t be prepared for tomorrow” (yes, people, it’s sarcasm) … well, STOP IT! Yup, a Bob Newhart reference, and if you don’t know what I’m talking about, check out this clip here. I promise, it’ll brighten your day! https://www.youtube.com/watch?v=Ow0lr63y4Mw

As therapists, we know that exercise is one of the best ways we can take care of ourselves, relieve stress and increase our happy hormones! Just STOP IT, and create 15 to 30 minutes for you and your well-being to do some exercise while at home. Here are samples of some simple, basic routines you can try (a quick Google search will give you an idea of how to do the exercise if you’re not sure):

No Weights … No Problem! Body-Weight Circuit It Is!
Perform each exercise in the circuit for 45 seconds at your own pace, with 15 seconds of rest between each exercise. You can increase progression simply by increasing the number of reps you can perform in the 45 seconds or by increasing your work time/decreasing your rest time.

Routine 1
– Squats (modify by how deep into the squat you go)
– Push-ups (modify by performing on your knees or against a wall/table)
– Walking lunges (modify by how deep you lunge)
– Plank
– Side lunges (modify by how deep you lunge)
– Mountain climbers (modify by how high you bring your knee toward your chest)
– Standing scapular retraction (3-5 second holds)

Routine 2
– Diamond push-ups (modify by performing on your knees or against a wall/table)
– Glute bridges
– Crunches
– Triceps dip on a chair (modify by bending your knees in your start position)
– Single leg Romanian deadlift
– Leg raises
– Door-frame rows (modify by body angle)

Feeling frisky? Perform two to three sets of the circuit with two to three minutes of rest between circuits, or grab some of those cans and bottles you bought from the grocery store and add some weight to the routine! (Pro Tip: You can use HeartMath with quick coherence in-between sets to concentrate and slow your breath, re-clarify and refocus for the next set … I know, MIND BLOWN)

But Wait, I Only Have 5 Minutes to Spare … Perfect, Tabatas Only Take 4 Minutes!
Tabata Training is a form of High Intensity Interval Training (HIIT) that requires 20 seconds of high intensity exercise (going all out!), followed by 10 seconds of rest, for eight rounds. This 4-minute method is a fat-burning, metabolism-boosting, sweat-drenching workout that is the equivalent to doing 20 minutes of normal cardio.
– High knees
– Burpees
– Jumping jacks
– Mountain climbers
– 20 seconds of all-out work, 10 seconds of rest between each exercise, repeat for a total of 8 rounds

Not into these types of exercises? Some other things you can try: March in place while you’re reading that book or watching your favorite show; take a few laps up and down your stairs if you’re in a multi-story home; chase that dog of yours around your home for a few minutes; you get the drift. Also, if you are already part of a local gym/fitness club, check in with them. Many companies are offering their members online home training options. The main thing is, don’t concentrate on what you can’t do anymore because of the restrictions in place, but focus on all of the things we can do, and just keep yourself active!

An Invitation to Global Coherence

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We invite anyone who is able and interested to join us with HeartMath at 8:30 a.m. Pacific daily during this time. Totally optional! You can join for one minute or join for longer. We would like to use the “Global Coherence App” that is available for free to download if you are able! Here are the instructions:

1. Download the free Global Coherence App
2. Click “JOIN NEW GROUP” at the bottom of the screen
3. Our group is called CAPLICOwell
4. Enter the ACCESS CODE: IndigoOcean06
5. You don’t need a sensor! You can join with or without a sensor.

When you start the session and click on “map,” you can see everyone around the organization using the app!

Once in the group, I invite you to follow our steps to get your neurological system in balance as you regulate your autonomic nervous system:
1. Slow your breathing down to a comfortable rhythm of four to five seconds in and out.
2. Close your eyes if you are able.
3. Shift your awareness to your heart. It might help to imagine a warm light in the center of your chest, or place your hand on your heart.
4. Imagine your breath as flowing in and out of your heart.
5. Make a sincere attempt to bring up a positive renewing emotion such as gratitude, appreciation, maybe hugging a loved one or pet, maybe the feeling after an invigorating run, or the feeling looking at a sunset. Try not to think about the emotion, just feel it in your heart. It gets easier the more you practice!
6. Radiate this feeling out to our facilities and teams, our leaders and our patients.