Physical Therapist Practice in the ICU

Dan Malone just published (as first author) a paper in the journal Physical Therapy (Volume 95, Number 10) October 2015 titled “Physical Therapist Practice in the Intensive Care Unit: Results of a National Survey”.

The group sent out a survey to members of the Acute Care Section of the APTA addressing staffing, training, barriers and protocols to determine perceptions about providing rehabilitation in the ICU. The survey identified barriers to providing ICU rehabilitation as: insufficient staffing (the primary reason), lack of training, departmental prioritization policies and inadequate consultation criteria. Other barriers included sedation of the patients and scheduling conflicts related to the timing of medical procedures.

The type of training for this setting most frequently cited in this survey was “informal training” relying on mentorship and department-based competency requirements. The article mentioned that there are very few cardiovascular and pulmonary residencies and critical care fellowships currently credentialed by the American Board of Physical Therapy Residency and Fellowship Education to train this at this high level.

The survey group was given 6 hypothetical cases that might be encountered in this setting and was asked to recommend treatment frequencies for each diagnosis. Interestingly, none of these cases received recommendations for daily physical therapy. Although each of the cases was deemed to be “medically stable”,  ambulation was not recommended for the majority of patients. More therapists working in an academic setting were apt to recommend early mobilization/ambulation than those working in a community hospital setting. The conclusion drawn was that physical therapists working in acute care and ICU environments need further training to recognize the need for safe early mobilization.  

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Why is Sensory Such a Mystery?

GUEST BLOGGER: Kathryn Biel

We’ve all sat in those meetings. The one where the Committee Chair, or the pre-school director, or the classroom staff, or the administration says those dreaded words.

“We don’t treat just sensory.”

“OT is for fine-motor and visual-perceptual skills.”

“We don’t provide sensory diets.”

If you’ve never heard these cringe-worthy statements made, consider yourself lucky.

I get it. Sensory issues are tricky. Truth be told, I feel lost with them. I feel like I understand a fraction of what there is to know about Sensory Processing Disorder (SPD). Admitting this is difficult, considering my own child has SPD. But I know, if I’m mystified, then others out there must be equally as lost.

I know they are.

Classroom teachers’ eyes glaze over at the mention of a sensory diet. Shall we count how often the sensory diet recommendations are carried out? I’m guessing we can do it on one hand. It’s not for lack of trying on the teachers’ parts either. Resources are stretched too thin. Training is too sparse. It’s easier just to refer out to OT to get the job done. It doesn’t work if it’s treated with a “one-size-fits-all” approach. Heck mention of the Wilbarger protocol alone sends shudders of terror down my spine. And let’s be frank–our kids barely get time to eat and have recess. No one has time to brush someone every two hours, not to mention how socially off-putting this can be to other children. (NOTE: While writing this, a teacher came in and asked about a standing desk to try with a student. The student is currently using a T-stool but a classmate has started picking on her for it.)

But then there’s flip side–we can’t expect children to learn until their sensory systems are modulated. Sure, some information can get in here and there. These kids are smart and will find a way. But smooth, coordinated learning, not to mention social interaction–in other words, success–will be impacted in children with an undermodulated or overmodulated nervous system.

Just because we know these issues are there doesn’t mean there’s an easy solution. From a therapist point of view, providing a sensory diet seems like a good solution. But we all know the reality of this. The cookie-cutter approach doesn’t always work. So, what else can we do? How can we meet our children’s sensory and social needs?

Like most therapists (and those awesome Tiger parents), we know it’s time to think out of the box. Sometimes, the answer is easy. For my son, Jurassic Park, with its roaring T-rex was too loud. We had to leave the movie. When the Jurassic World came out, we had a new plan. That pair of headphones (the cheap version of Beats)–they block the sound too. And my 11 year-old looked like any other kid with his iPod in the pocket of his hoodie. Thinking outside the box while fitting in. We’ve been doing this all along. Or we should be.

OT Doreit Bailer explores a problem solving approach to sensory issues in her seminar, No Longer A SECRET:  A Theoretical, Practical Approach to Helping Students with Sensory and Motor Challenges Experience Success at the Sixteenth Annual Therapies in the School Conference.

~Kathryn Biel, PT, DPT

 

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NEW COURSE – Connective Tissue Mobilization

Education Resources is thrilled to be able to offer this new course:

[caption id="attachment_2817" align="alignleft" width="100"]Patricia West-Low Patricia West-Low[/caption]

Connective Tissue Mobilization for Pediatric Therapists presented by a new member of our faculty; Patricia West-Low PT, MA, DPT, PCS 

Research and clinical evidence suggest that connective tissue changes may contribute to postural malalignment and movement dysfunction in children.  This course is designed to introduce pediatric Physical and Occupational Therapists to the scientific rationale for basic practices of connective tissue mobilization.  Through structural alignment observation, and hands on practicums, participants will gain the ability to identify and treat connective tissue restrictions resulting in structural misalignments, which interfere with efficient functional movement.  Participants will learn approaches to neuromuscular re-education to improve muscular control and coordination. Treatments specific to children with neuromotor impairment, musculoskeletal injury, post-surgical scars, and torticollis will be explored.  Case examples will be presented.

 

December 4-5, 2015 – Canton, MA

March 4-5, 2016 – Cedar Knolls, NJ 

April 2-3, 2016 – Orland Park, IL

Any questions or thoughts? Let us know.
Post your comment here or contact the office:

800-487-6530 info@educationresourcesinc.com

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Hands-On Therapy

It’s that uncomfortable moment in our professional development where they talk about not touching students. You know, that you shouldn’t really hug or touch students, and specifically not below the waist and above the knee.

I know the point of the training (and am not in any way minimizing the need for our children to be safe in school), but I can’t help but feel that it doesn’t apply to me. My hands are frequently on my students. Because it’s my job.

Whether it’s providing joint compression or deep pressure or joint mobilization or myofascial release, I need to be using my hands. My hands, and actually my whole body for that matter, are a tool in my toolbox. They help to provide the necessary modality to address impairments that are leading to dysfunction in my students. This dysfunction is the focus of my treatment. Especially in school-based therapy, the goal is to improve function.

Take, for example, the child who enters Kindergarten with great functional goals, like reciprocal stair navigation, ball play, cutting, and manipulating the zipper on his backpack. Yes, these are all the things a Kindergartener should be doing or working toward. But in this case, the child has a right hemiplegia, has not worn his hand splint or AFO in months, and basically does not use his right side (other than in ambulation). He is plagiocephalic and has a history of extensive abdominal surgery.

Range of motion limitations prevent the child from putting his foot flat on the floor. Muscle tone issues prevent spontaneous ease of use. Limb-neglect is present. Motor control and motor planning also stand in the way.

Based upon the child’s presentation, it’s apparent that extensor development is lacking. This impacts mid-range postural control and is another complicating factor in his overall functional deficits. While outside modalities (such as medical management and bracing) are often needed, we have some tools in our toolbox to start addressing some of these concerns. Going back to the developmental sequence, using an NDT frame-of-reference can help to address some of those skills that have been missed. Developing extensor and then flexor control through prone and quadruped will improve balance and stability for fine and gross motor tasks.

For example, positioning in prone prop while attending to an activity, for this child, can provide the following benefits:

  1. Development of strength and endurance in the upper back, scapular, and neck extensors.
  2. Elongation of the hip flexors and abdominal muscles that are often shortened due to frequent sitting.
  3. By flexing the non-involved leg (in this case left) slightly, weight bearing through the right hemibody is occurring to improve proprioception.
  4. Shoulder girdle strengthening.
  5. Right shoulder proprioceptive input through joint approximation, which can help maintain capsular integrity as well as decrease muscle tone through weight bearing.
  6. Work on visual tracking, convergence and divergence.
  7. Extension of the head and neck activates the reticular activating system, which increases attention and arousal.

But, passive positioning, especially in this case, isn’t quite enough. Hands-on techniques such as joint mobilization, range of motion, PNF, and myofascial release are often needed to inhibit muscle tone and lengthen muscles to achieve neutral alignment. Once in neutral, strengthening and motor control can be developed.

While we often think about these techniques as clinical skills that aren’t used in school, they’re often a valued resource in improving overall function within the school environment. If you’re interested in learning more about how to use NDT and MFR to treat moderately to severely involved children in the school environment, check out Barbara Hodge’s seminar, The Moderately-Severely Involved Child: Integrating NDT and MFR into a School-Based Program at the Sixteenth Annual Therapies in the School Conference.

~Kathryn Biel, PT, DPT

 

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How to Deal with Students with Mental Illness

GUEST BLOGGER: Kathryn Biel

This week before students return, I’ve been spending copious amounts of time in district mandated professional development. One of the seminars was on what to do if there is an active shooter/active killer in the school. It a sad commentary that this is a necessary seminar for those of us in education. The presenter discussed several past episodes of school violence, and talked about lessons learned from them, and how those lessons have shaped changes in policies and procedures.

He touched briefly on the need for collaboration between various team members, especially when dramatic shifts in behavior are noted. Although the term was mentioned casually, what he did not address is mental illness in students. My colleague leaned over to me and said, “What we really need is professional development on how to deal with students with mental illness.”

As suicide rates and incidences of school (and community) mass violence continue to rise, this is an issue that can no longer be ignored. As of the latest available data, the suicide rate in teens is 10%. One in ten teenagers aged 14 to 19 will attempt suicide at some point in their lives (the percentage jumps to 25% in LBGTQ teens).

Personally, I know that over my sixteen year career, I’ve not only seen a startling number of young children diagnosed with some form of mental illness, but the severity and frequency appear to be increasing. From children virtually paralyzed by anxiety to selective mutism to depression to bipolar disorder, we are seeing these kids on a daily basis. We are dealing with the fall out of their disorders (whether being treated or not) through behaviors. As a therapist, I know that behaviors resulting from a mental illness can significantly derail the productivity and therefore progress my student makes.

This is a topic in which there are no easy answers. Then, fold in the dynamic educational aspect with its rapid fire pace and high demands, and it is no wonder we are seeing aggression and behaviors from our students. They are in a world that doesn’t always make sense, with chemical imbalances that impair their ability to respond, and we are expecting so much.

But we have to have expectations. So, how do we handle this? How can we ask our students to do their best without increasing anxiety and depression? How can we improve mental health while getting the most out of our students? If you’d like to know more, John Pagano will be discussing behavior management and strategies for improving mental health at the Sixteenth Annual Therapies in the School conference.

~Kathryn Biel, PT, DPT

 

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