My Life as A Physical Therapist – Part 13

Written by: Yaffa Liebermann, PT,GCS,CEO

Understanding the role of Physical Therapy in Sub acute nursing home

I thought that working in a nursing home would be similar to any environment in which I previously worked but I was wrong.  There are rules and regulations that a therapist has to learn and integrate into the  treatment plan.  My education related to nursing home residents occurred mainly in my first month.

Insurances are guiding the program: A 67 year old man, post hip fracture repair, was about to complete his 20 days of rehab being fully paid by Medicare.  He was walking with a walker at supervision level.  He had not achieve full extension and his pace was slow.  He made the decision to go home at the end of the 20 days.  His son called me from California and asked me to convince his father to stay longer in order to rehabilitate completely.  I listened to his son but also explained that his father is alert and oriented and I could not force him to stay until his rehabilitation was completed.  I did mention the conversation to the father and his reply was very simple: “Yaffa, are you going to pay my copay after 20 days to stay in the facility?”.  Well, I did not have such intentions. That was the point when I learned that the first 20 days in the sub-acute nursing home is fully covered by Medicare but the patient is responsible for a copay during the remaining 80 days.  His son also did not see the female visitors who came to have lunch with him most every day!

A 70 year old woman suffered from left side hemiplegia. She progressed well and, after 60 days, she reached a plateau.  Her daughter was very stressed throughout the treatment and demanded 100 days of therapy as was promised to her by the admission’s director.  The OT and PT reached their goals and did not have additional progress to justify providing more therapy.  The daughter was very angry but I discovered the reason – At home, she had to pay for an aide 24 hrs per day.  If her mother would stay in the facility the financial burden would be much less.  Again I found myself thinking that although I am a skilled therapist, this was a decision guided by finances.  Today insurances continue to push for a very short stay.

ROM for a contracted patient: The guideline in nursing homes is to screen every patient quarterly in order to ensure they are maintaining their typical level of independence.  When I screened a patient who was very contracted I knew he would benefit from a  few sessions of passive and active ROM, as well as stretching to restore movement or at least to increase ROM in shoulders and hip to make it easier on the aid who bathed him.  Teaching the nursing staff to complete these stretches is beneficial so they can perform it every day in the morning while they wash and dress the resident.

RANGE OF MOTION (ROM) FOR THE CAREGIVER 

Range of Motion (ROM) 

PROM = Passive Range of Motion – The person has difficulty moving their joint, therefore the caregiver moves the joint passively.

AAROM = Assisted Active Range of Motion – The person can move the joint only part of the range, therefore the caregiver helps him to move the joint.

AROM = Active Range of Motion – The person moves the joint by himself without external assistance. 

Exercises are the most important part of the body’s healing process as it helps it to recover from any injury.  The movement of muscles and joints has a mechanical pumping effect, which assists venous and lymphatic return.  Exercises increase blood flow which results in reduced pain, edema and muscle spasms, and in increased muscle strength, enhanced range of motion, flexibility, and endurance.

When the patient is weak and does not move, the joints will stiffen and his muscles and ligaments will shorten.  When his medical condition improves, he will not be able to move the stiffened joints and his muscles will be weakened.  The responsibility of the caregiver is to make sure the joint will be moved through its full range and to enable the muscles to activate the joint as the patient regains his strength.

When the patient’s medical condition is such that he cannot move, the caregiver should move the joint for the patient passively (PROM).  As the patient gets stronger, the patient should be encouraged to move it together with the caregiver (AAROM).  As the strength comes back and the patient can move the joint by himself, he performs AROM.  If the patient can perform activities by himself, he should be encouraged to do so by all caregivers.

Range of Motion Procedure

• The physical therapist evaluates the patient and establishes the ROM program during therapy to be implemented upon discharge from therapy.
• The therapist demonstrates the activity first, and then observes the caregiver performing the ROM.
• The therapist performs it on one extremity while the caregiver, nurse, or a family member performs the ROM on the other extremity.

Range of Motion Guideline for the Caregiver

Discuss your objectives with the patient and their family before you begin the exercises.  Be fully aware of the following before beginning an exercise program with the patient:

• The kind of exercises the patient needs to perform.
• The condition which indicates that the patient needs ROM.
• The objectives and expected outcome of the exercises.
• The patient’s range of motion in each joint before exercise.
• All conditions which may affect the patient: fractures, brittle bones, pain, loss of sensation, etc.
• Any condition, which may affect the patient’s tolerance, endurance, etc.
• How much assistance the patient needs, level of function and independence.
• The patient’s individual body schedule for ROM exercises.
• The patient’s ability to understand objectives, etc. 

DOs

• Take a moment before you start to introduce yourself.
• Describe the exercises and objectives to the patients before you begin.

• Perform ROM exercises under the supervision of the physical therapist or nurse supervisor.
• Always be aware of and use proper body mechanics.

• Place yourself in the line of the joint for proper body mechanics.
• Move your body as you perform the movements from your ankles, do not stretch your body.

• Always maintain a comfortable and safe work environment for you and your patient.  For example, check to be sure bed wheels are in a locked position; be sure the patient is in non-restrictive clothing, etc.
• Adjust the bed to the appropriate level.  Raise it up to your level to avoid excessive bending.
• Assure maintenance of proper alignment and position of the patient in bed or in the chair.

• Place your hands close to the joint being moved for stabilization.
• When performing the ROM, grasp the limb gently, but firmly, using the palm of the hand instead of pinching with the fingers.

• Use slow, smooth motions in ROM exercises; try to develop a comfortable sense of rhythm.
• Repeat each motion 3-5 times or as directed by a physical therapist or nurse supervisor.
• Always report changes (increase or decrease) in the ROM of any joint to the physical therapist or nurse supervisor.

• It is preferable to perform ROM during AM care in bed and later sitting in the wheelchair.
• Make sure you perform ROM to each joint starting either proximal to distal or reverse.
• Perform each movement to full range, count to eleven and avoid pain or overstretching.
• Always observe the patient during exercise to see any changes of color or sweating.  STOP if the patient shows such changes.

• Always stop the particular exercise or motion if the patient indicates he feels pain.

• Perform trunk rotation; it will improve the patient’s flexibility and improve sitting posture. 

DON’Ts

• Don’t perform ROM unless directed and supervised by the physical therapist or nurse supervisor.
• Don’t attempt to go beyond the patients’ present range of motion for any joint.
• Don’t force a joint movement.
• Don’t continue a motion when a patient demonstrates discomfort or tells you he feels pain.
• Don’t grasp a patient on or very near a pressure sore, incision, or wound.
• Don’t continue neck or head exercises if the patient complains of dizziness or faintness.

The patient needs your hands.  The flow of energy from you to the patient will give them the support that they need, so they can continue the battle with their condition and gain strength to improve their situation.

The patient will be prepared for a pleasurable day! And it will be easier for you.

The geriatric area was fascinating to me and I prepared  to take the test  from APTA to become certified as geriatric clinical specialist.