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By Gary McGiven, Therapy Resource, Milestone, UT
Since converting to a COVID-designated facility, City Creek has seen a more acutely ill patient population with an increased reliance on staff support for oral infection control. As COVID-19 patients are significantly more likely to experience complications if they also have poor oral health, City Creek’s SLPs have implemented a system to better track data on how frequently oral infection control support is being offered.

Even for patients who are cognitively and physically capable of performing it for themselves, staff support in the form of set-up assistance or verbal reminders has been valuable. Each patient has a laminated chart displayed in their room. It shows which staff member performed oral care and when. We note patterns of support being offered and frequently refused, or observing patients completing oral care independently.

For patients on the free water protocol, for example, the use of this chart has been extremely valuable. This system has increased patient and staff awareness of the importance of frequent oral care, and individual accountability in staff members. When we can identify patterns, for example, the frequency with which oral care is offered during AM versus PM shifts, we can better target staff education. We’re striving to move the perception of oral care toward an oral infection control program.

It’s no news flash that walking requires quite a bit of lower-body strength. You need powerful glutes, quads, hamstrings and calves to propel you forward. You might also recognize the crucial role your abs play in keeping you upright and lightening the load on your lower half. But there’s one muscle you probably never even think about when it comes to your stride. We’re talking about your “lats” (or latissimus dorsi), the biggest muscle of your upper body. Affording itself a large attachment centrally from the T7 to L5 spinouses, laterally to the iliac crest and thoracolumbar fascia, to the lower three or four ribs and inferior angle of the scapula, to travel superiorly and laterally to attach to the medial lip of the intertubercular sulcus, it is perfectly situated to effect both the upper and lower extremities in a large variety of movements. It is one of the quintessential and often overlooked muscles in gait. It is generally quiet electrophysiologically (EMG) during pre-gait activities (1,2) but as speed increases, the muscle becomes more engaged and active (2-4). The latissimus dorsi is the functional link between the upper and lower extremity, particularly through its connections with the thoracolumbar fascia (5,6).

The lat muscle is a key driver in the Posterior Oblique Sling System, which helps explain the relationship between the arms and legs during the gait “walking” cycle. The posterior oblique sling is a cross-body pattern composed of the gluteus maximus, thoracolumbar fascia (TLF) and contralateral latissimus dorsi muscle, which connects the shoulder with the opposite hip to facilitate locomotion. Dysfunction in this system puts the brakes on power, strength, speed and performance. To understand how your lats affect your walking performance, think about your gait or your movement pattern while you walk: “As your left leg steps forward, your right arm swings forward, thus you’re creating a rotational force, the abdominals and lats help with this rotational movement. The stronger your lats, the easier this twisting motion becomes and the more efficiently you nail your stride. Plus, strong lats help ensure the rest of your muscles don’t have to work in overdrive. Translation: You won’t tire out so fast and you’ll be able to walk/jog/run for longer time frames. Whatever was fatiguing you before won’t fatigue as fast, because you’re bringing more muscles to the party. You’ll be surprised just how much your lats are a part of the equation once you focus on strengthening them.

An easy way to tell whether you need to increase your patient’s or perhaps even your own lat strength is to assess form. Here are a couple of tell-tale signs to look for when walking: If the patient/client starts to fall forward or slouch their head forward, and if the shoulder blades are creeping up by the ears, this most likely indicates an opportunity to strengthen the lats. But before you get started with those strengthening exercises, you need to make sure the surrounding muscles aren’t getting in the way, for example, tight triceps (the backside of the arm) or upper trapezius (where your shoulder meets your neck) can inhibit the lats from activating during exercises. This would work against the patient/clients best efforts. Once you have had the patient/client complete a few tricep and upper trap stretches, it’s time to start strengthening the lats. Some suggestions to start with include:

1. Seated Row
   ● Using a resistance band or a cable row machine, sit upright with your legs out straight. If using a resistance band, hook it around your feet. No matter the equipment, roll your shoulders back and down, “packing” them into your lats.
   ● Keeping the elbows tight and close to your body, row your elbows straight back, pinching your shoulder blades together.
   ● Reset with control, then repeat.
   ● Do 3 sets of 10 to 15 reps.
2. Bent-Over Fly
   ● Stand with soft knees, holding a dumbbell in each hand by your sides. Hinge forward at the hips with a flat back and neutral neck. Allow your arms to hang down under your chin with a slight bend in the elbows.
   ● Leading with your elbows, bring your arms back and imagine you’re hugging a tree backward, squeezing your shoulder blades together. Hold for one second before lowering down with control.
   ● Do 3 sets of 10 to 12 reps with dumbbells appropriate for your patient/client.
3. Superman Lift
   ● Lie face-down on the floor with your arms and legs extended. Squeeze your glutes to glue your ankles together and lock your arms tight next to your ears. Keep your neck neutral, and gaze down toward the floor throughout the whole movement.
   ● Use your back to lift your legs off the ground, trying to lift your quads off the ground without bending at the knees. Lower with control. Repeat with just the upper body.
   ● Once you’ve mastered isolating the lower and upper, add them together, lifting all four extremities off the ground and holding at the top before lowering with control.
   ● Do 4 sets of 15 to 20 reps.

Beyond strengthening and stretching the lats to improve gait function, it’s also important to remember that if the patient/client has latissimus dorsi pain and/or referred pain, this can also impact range of motion and muscle activation patterns, including the patient’s gait quality. Dry needling is one modality that PTs may be able to use to decrease lat pain and improve the overall performance of this muscle by improving its function, thus improving range of motion and muscle activation patterns (7-9).

By Jon Anderson, DPT, Therapy Resource

References:

1. Houglum P, Bertoti D in: Brunstrums Clinical Kinesiology 6th Edition, FA Davis 2012 p.558
2. G. Cappellini, Y. P. Ivanenko, R. E. Poppele, F. Lacquaniti Motor Patterns in Human Walking and Running Journal of Neurophysiology Published 1 June 2006 Vol. 95 no. 6, 3426-3437 DOI: 10.1152/jn.00081.2006
3. Shin S, Kim T, Yoo W. Effects of Various Gait Speeds on the Latissimus Dorsi and Gluteus Maximus Muscles Associated with the Posterior Oblique Sling System. Journal of Physical Therapy Science. 2013;25(11):1391-1392. doi:10.1589/jpts.25.1391.
4. Kim T, Yoo W, An D, Oh J, Shin S. The Effects of Different Gait Speeds and Lower Arm Weight on the Activities of the Latissimus Dorsi, Gluteus Medius, and Gluteus Maximus Muscles. Journal of Physical Therapy Science. 2013;25(11):1483-1484. doi:10.1589/jpts.25.1483.
5. Vleeming A, Pool-Goudzwaard AL, Stoeckart R, van Wingerden JP, Snijders CJ. The posterior layer of the thoracolumbar fascia. Its function in load transfer from spine to legs. Spine (Phila Pa 1976). 1995 Apr 1;20(7):753-8.
6. Willard FH, Vleeming A, Schuenke MD, Danneels L, Schleip R. The thoracolumbar fascia:anatomy, function and clinical considerations. Journal of Anatomy. 2012;221(6):507-536.doi:10.1111/j.1469-7580.2012.01511.x.
7. Dar G, Hicks GE. The immediate effect of dry needling on multifidus muscles function in healthy individuals. J Back Musculoskelet Rehabil. 2016 Apr 27;29(2):273-278.
8. Ortega-Cebrian S, Luchini N, Whiteley R. Dry needling: Effects on activation and passive mechanical properties of the quadriceps, pain and range during late stage rehabilitation of ACL reconstructed patients.Phys Ther Sport. 2016 Sep;21:57-62. doi: 10.1016/j.ptsp.2016.02.001. Epub 2016 Feb 24.
9. Dommerholt J. Dry needling — peripheral and central considerations. The Journal of Manual & Manipulative Therapy. 2011;19(4):223-227. doi:10.1179/106698111X13129729552065.

With our focus on meeting all the needs of our communities, we wanted to provide some information about our Colonial Manor of Randolph outpatient program. Randolph, Nebraska, is a town with a population of 894. Despite that, they have found a way to operate as one of the largest outpatient programs as an Ensign Affiliate. Here is what Eric Feilmeier, OT, CLT, DOR, has to say about why they have been able to have success!

When working to build a successful outpatient clinic, it is important to begin with Core Values. Here are few values that we have found to be important:

1. Deliver WOW through service.
2. Embrace and drive change.
3. Create fun.
4. Be adventurous, creative and open-minded.
5. Pursue growth and learning.
6. Build open and honest relationships with communication.
7. Build a positive team and family spirit.
8. Do more with less.
9. Be passionate and determined.
10. Be humble.

We have had success in our Nebraska market due to a number of reasons. First and foremost, be supportive of your therapists. Provide clinically centered CEU opportunities that focus on problems in your area. Here at Colonial Manor, we are LSVT certified and are going through power moves certification, urinary incontinence certification and Lymphedema Certification. Provide programming around the skills of your Therapists so they can get to the bottom of each patient’s problems. It’s important to educate on HEP for patients, but then leave that to them and focus on the true needs, utilize the specialty equipment in our gyms and provide proper intensity of treatment.

• Make sure the patient feels that they got a lot out of each session.
• Provide proper frequency. MAKE IT COUNT IN THE GYM! Remember, the patient won’t typically do as much at home. Modalities: We work closely with ACP rep to provide the best adjunct treatment options to assist with improving care. Patient’s Love modalities- modalities provide physical and psychosomatic results.

When working with your outpatient, always assess additional problems and needs that the patient may not realize themselves. Ask questions, because there might be a higher need for another discipline to step in. We are always looking out for one another’s skill sets and the potential benefit to collaborate our services to further meet the needs of our client.

Cancellation Management is the biggest obstacle of our Outpatient business. We do our best to stop cancellations, but that is not always easy. Some tips to reduce cancellations include:

Evaluations:

• Provide a message. Ask the patient why they are in your clinic, what they expect and what they want to gain.
• Hold their answers against them (In a positive way). Always have a conversation during the evaluation about the frequency and the importance of coming to therapy when they are scheduled, expressing to them that we can help them but they must come to scheduled appointments to make a difference (hold them accountable).Call ins: Problem-solve
• When you get the patient on the phone and they want to cancel, ask, Why? What are you experiencing? Many times, the reason for the cancelation is exactly why they should be coming into their appointment. Be adamant and convince them to come in, if you believe you can help them.
• When a patient leaves a message, call them and ask them the same questions. They may just need to be convinced that you can help them!
• Move treatment times to another time of day or to a whole other day. Flexibility in your clinic is the key!

Last but not least, build and maintain relationships with your Physicians and Nursing. Frequent updates to communicate patient results to Physicians is always appreciated. Send notes or small updates with the patient to their next doctor appointments, even if the doctor doesn’t request it. These notes can be a quick word Doc, a progress note that is timed with an appointment, or even a nicely handwritten note.

All in all, have goals to grow your Outpatient clinics. Focus on the patient, and you will see excellent results. I even encourage devising a patient satisfaction survey to monitor your success and areas of opportunity. Good luck!

By Eric Feilmeier, OT, CLT, DOR, Colonial Manor, Randolph, NE, and Ryan Hough, Therapy Resource, Gateway, NE

According to a recent article in The Wall Street Journal, “Cognitive problems are among the most persistent and common lasting effects of COVID.” Many of these cognitive issues are becoming long-term symptoms months after an active COVID dx.

It’s important that we understand Post-COVID-19 syndrome, which is signs and symptoms that develop during or after an infection consistent with COVID-19, continue for more than 12 weeks, and are not explained by an alternative diagnosis. Post-COVID-19 syndrome may be considered before 12 weeks while the possibility of an alternative underlying disease is also being assessed. These patients are also commonly referred to as “long-haulers.”

Therapy teams need to take an active role in the ongoing assessment and intervention of cognition. It’s especially important to know the patient’s PLOF and not discontinue services too soon, knowing that cognitive impairments with this population will continue long after the active diagnosis. Cognitive intervention is also important for our outpatient population in both ALFs and in the community. Physicians need to know that we are available to partner with post-COVID patients who have lingering cognitive issues.

Starting with a brief assessment such as the St. Louis University Mental Status Exam (SLUMS); Clock Drawing Test; Addenbrooke’s Cognitive Exam (ACE); or MINI-COG will provide initial information on the level of cognitive impairment (none, mild, Dementia level).

Once determined, it is clinically recommended to complete a formal standardized assessment and log Cognitive Performance Assessment 96125. Examples include: Ross Information Processing Assessment-Geriatric Edition (RIPA-G); Cognitive Linguistic Quick Test (CLQT); Functional Linguistic Communication Inventory (FLCI); The Scales of Cognitive and Communicative Ability for Neurorehabilitation (SCCAN); and Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES). Utilize assessments that at minimum can address: memory (i.e., list learning task; paragraph recall task; digit repetition, etc.); working memory/executive function; executive function (problem solving; planning; inhibition/initiation); and processing speed.

Once the assessments are completed, clinicians will know which areas of cognition to target with skilled intervention. Please refer to the various POSTettes (Post COVID; Cognitive Performance Assessment; SLP Cognitive Impairments) and the Cognitive Impairments Clinical Guide for additional information.

https://www.wsj.com/amp/articles/new-long-covid-treatments-borrow-from-brain-rehab-tactics-11617652800

By Tamala Sammons, M.A., CCC-SLP, Therapy Resource

By Ryan Hough, Therapy Resource – Gateway NE
Kim cooper, our lead OT at Wayne Countryview Care and Rehab in Wayne NE, is a very clinically driven therapist who is always creatively implementing programming to address the needs of the residents. Kim recently identified several patients with low vision, and immediately went to work to strategize ways to improve their lives. She pursued a partnership with The Nebraska Commission for the Blind and Visually Impaired, and with their help and generous donations, they now have products for these residents to enhance their ability to participate and do day-to-day tasks. Some examples of the products donated are large bingo cards, large playing cards, writing templates, glare reducing sunglasses, dice with raised numbers, and an Eschenbach magnifier that works like a smart phone that you can move with fingers. When implementing any of these strategic interventions, remember to work with nursing to care plan the findings and the interventions provided.

Case Scenarios

Kim has a resident with severe macular degeneration. She has been staying in her room for meals because she was constantly spilling at meal time. Kim initiated therapy and worked closely with Nebraska Commission for the Blind. Kim designed a placement (picture attached) that lays out where the meal is all located so that she can find all of her utensils, foods and liquids. The placement is laminated and fits into the tray based on her vision loss. Patient was educated on the design of the placement along with the caregivers so that the lay out is always the same. This has resulted increased independence and self-esteem, as she now doesn’t need to stay in her room to eat meals. In part because of this success, they are exploring a discharge to an ALF that otherwise may not be possible.

Resident number 2 has severe glaucoma. This resulted in not being able to read the lunch menu, read the clock, read the activities schedule, and she stopped playing bingo because she couldn’t see the cards. They worked with Commission for Blind to get a talking clock, a magnifier similar to IPad size/Eschenbach magnifier that gives her color contrast, up to 12x the magnification, and camera to take a picture. Resident is much more engaged in daily activities within the facility and even resumed doing her cross-word puzzles.

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