(hope this shows up – my interpretation with time on x axis, function or QoL on y axis)

What if we could help reduce the number of bumps and the decline?  This is what piqued my curiosity in this paper.  Research in this population isn’t sexy – I can’t remember seeing an article about nursing home research in the media.  It is a niche population currently, but as Boomers age I would expect it might come to the fore of our minds (first keep them out of nursing homes, then how to maximize independence in one; as a tangent, there is a great article about transitioning between levels of care entitled “But I am not moving”: residents perspectives on transitions within a continuing care retirement community, in The Gerontologist 2009; 49:418-427, by Tetyana Pylypiv Shippee).

Falls in nursing homes are a serious problem.  The stats may be a bit old (I suspect there are more recent references they could use), but the CDC reports that 1/2 – 3/4 of nursing home residents fall a year (2x the rate in the community), with the average being 2.6 falls per person per year!  Of those falls, 10-20% result in serious injuries, 2-6% result in fractures, but even worse is an increase in disability, functional decline, QoL, and fear of falling.  Falls are multi-factorial (strength and balance and gait, environmental hazards, meds, etc), but PT’s can play a major part in addressing the problem.

Physical Tools

1. BP cuff: In PT school we were issued a generic (cheap, but not super-cheap) supply kit which included a BP cuff and a stethoscope.  Considering I take BP’s regularly throughout my day, and that I’d be learning more about cardio-pulmonary issues in the residency I thought I should upgrade my equipment before I got here.  I found out about a cool BP cuff that has the gauge and the bulb together (so one tube instead of two) from the medical director I used to work with, which reduces how much you are having to juggle – well worth the money, and it doesn’t cost that much.
2. Stethoscope:  I searched for guidance on picking out a new stethoscope and didn’t found much online.  One tube or two?  What is the difference in the different materials for the head?  Bell and diaphragm, or just the diaphragm? What makes one over $200 vs. a $20?  I steered away from the 2-tube version (the tubes can rub, although there is debate if the overall quality is better).  I ended up going with the Littmann Master Classic II, and I was amazed at the improved quality over the cheap one from school.  Mine has a tunable diaphragm (light pressure = bell for higher pitches; apply more pressure it becomes the standard diaphragm for lower pitches).  Why this one, vs. a cheap one?  Some may say “do you really need one like that for PT?  Are you diagnosing a heart condition or lung disease?  Don’t you just take blood pressure?”  Yes, I do take BP’s, but I also listen to the lungs, not just of my SNF/TCU patients, but also of my outpatients.  Why?  Because we have the time, we can catch things before it becomes a problem, and we can document it and how it can impact outcomes.
3. Pulse oximeter:  I haven’t gotten one yet, but they are cheap now.  A quick and easy way to get HR and O2 sats before, during, and after exercise.

Tech Tools

1. “The cloud”:  Have you ever wished you had access to articles that are on your home computer (or vice-a-versa)?  I no longer have to carry a USB key, or email the article to my work email when I get home.  Evernote is a great tool to keep articles, tools, references, etc within easy reach wherever you are.  You can create folders to organize by topic.
2. A dashboard: Have you ever been frustrated by staying on top of current evidence, or keep up with the blogs you read?  I was using Google Reader for subscribing to blogs, but my mentor introduced me to NetVibes.  On my dashboard, I have a page for blogs, a page for journals, and a page for news.  I also have some PubMed searches I keep track of (with my interests in exercise adherence and hip fractures).  Once you have it set up, it is just a matter of checking it once a week or so to see what is new.
3. iPad:  What better way to work on coordination than through a game with the iPad?  Okay, that was a joke, although I’m sure I just gave someone a bad idea.  Seriously though, it is not only a great tool for reference (I have a basic phone that just makes phone calls), but also for patient education.  Some good/ great apps that I have: MB Anatomy, DrawMD Cardiology and Orthopedics, Bamboo Paper (for drawing), Medscape (GREAT for conditions, meds, and med interactions), 3D Brain, Evernote (the cloud!), CORE Clinical Orthopaedic Exam (haven’t purchased OMT’s Spine, UE, and LE apps, also by ClinicallyRelevant), Hootsuite for Twitter, and a BMI calculator.  I’m trying to convince the powers-that-be that allowing me to have wireless access would be a benefit to the clinic.  We’ll see how that goes.

Radiation Fibrosis Syndrome – I can’t access this article through the UMN, but I did do a PICO question during school for reduced ROM due to radiation-induced fibrosis.  I recently had a patient with radiation fibrosis resulting in reduced ROM/ strength/ sensation – if you have had a patient undergo chemo or radiation years ago, it may be helpful to know the treatment parameters (radiation field, chemo agents used, any surgical procedures, etc) to give a better picture for past medical history and how it may direct your treatment and impact outcomes.

Low back pain and muscle activation during gait in older adults – again, I don’t have access to this article, but I’ve requested a copy.  It will be interesting to see the discussion section, given their results: “The control group participants activated their lower rectus abdomini muscles (P < .05) and right internal oblique muscles significantly more than did the LBP group (P < .05), whereas the LBP group activated their left lateral erector spinae and both lumbar multifidi sites significantly more than did the control group (P < .05).”

It has been a rather chaotic few months, but our condo in Seattle sold and we are now settled in an apartment in Minneapolis. The residency has started (practice paperwork is very different here).

Last Tuesday I met with Dr. Kimberley and discussed two papers. The first was an observation of the number of repetitions performed during stroke rehab, and the second was looking at stroke and TBI. They were both interesting reads and provoked good discussion (her expertise is in neuro). Why do new grads and the most experienced do the least number of repetitions, and no one approaches anywhere near the number of repetitions recommended for neuro rehab/ recovery? They definitely got me thinking, and examining my own practice pattern and approach.

We also talked about various aspects of skilled nursing and ortho, and are talking about doing a single-subject design looking at dose/ repetitions in their rehab. I just finished my draft of Aging in America (I may post it here), so my plan for tomorrow evening is searching the literature for hip fracture rehab, starting with the recent Cochrane review. Stay tuned!

Addendum: the two papers we discussed were:

1. Lang CE, MacDonald JR, Reisman DS, Boyd L, Jacobson Kimberley T, Schindler-Ivens SM, HOrnby TG, Ross SA, Scheets PL.  Observation of amounts of movement practice provided during stroke rehabilitation.  Arch Phys Med Rehabil 2009;90:1692-8.
2. Jacobson Kimberley T, Samargia S, Moore LG, Shakya JK, Lang CE.  Comparison of amounts and types of practice during rehabilitation for traumatic brain injury and stroke.  J Rehabil Res Dev. 2010;47:851-62.

Photo credit: #ds286 repetition, originally uploaded by rosipaw

Be engaged.  Just because you have a job lined up from one of your previous internships does not mean that you can coast. It is dangerous to your patients, your reputation, your school’s reputation (the facility might not take any future students from your alma mater based on your attitude and ethic), and can harm your internship.  This is your education, and while your future job is in an one setting, you can learn a lot from your other internships.

Show initiative.  You might not be ready for working with a complex patient independently, but ask to do something (evaluate a simple case, try a technique you learned in school for treatment, etc), or research recent evidence for treating [X] condition.  Be familiar with tomorrow’s new eval by doing a quick chart review and have a plan in mind.  If your CI can’t quite let go toward the end of your rotation, talk with him or her about it.

Take responsibility.  While it is the CI’s license, they are “your” patients.  Do a thorough chart review, be familiar with their condition(s) (and medications) and how it may affect or be affected by therapy.  This is your clinical education – be clear to your CI how you learn best, be open to (and request) feedback and be willing to give it. If you find your didactic education was lacking in a certain area, do whatever it takes to improve it.

Be professional.  Consider what you wear. Stand up for what is right – don’t be so eager to please that you violate company policy or federal/ state laws.  If you have questions, ask the CI, then the ACCE.

You are entering a great profession.  Make the best of all of your internships.

1. Hip fracture recovery:  Kristensen M.  Factors affecting functional prognosis of patients with hip fracture.  Eur J Phys Rehabil Med. 2011 Jun;47(2):257-64.  (free text).  I have wondered why some patients do really really well after a hip fracture and others have not done as well.  This paper is a good overview of the answer to that question, and maybe a few ideas for treatment (dovetails well with the recent Cochrane review about hip fractures and rehab).
2. More on hip fracture recovery:  The lead author on this is also an author on the recent Cochrane review, but this is free text (yeah for open access!).   Sherrington C, Tiedemann A, Cameron I.  Physical exercise after hip fracture: an evidence overview.  Eur J Phys Rehabil Med. 2011 Jun;47(2):297-307. Epub 2011 May 10.
3. Adherence to exercise:  I had the opportunity to hear Dr. Resnick present at ExPAAC last summer – she is a great speaker and I got a lot of great ideas that I would love for my employer to implement to improve physical function in older adults in assisted living and LTC.  I haven’t had a chance to read the study itself yet (requesting a copy of the study), but according to the abstract “self-efficacy and negative outcome expectations are directly related to exercise behavior.”  We as PT’s need to be encouraging our patients’ self-efficacy and addressing outcome expectations (I love the topic of adherence – if/when I go back for a PhD, that will most likely be my focus somehow)  Resnick B, D’Adamo C.  Factors associated with exercise among older adults in a continuing care retirement community.  Rehabil Nurs. 2011 Mar-Apr;36(2):47-53, 82.
4. Land vs. aquatic therapy for hip or knee OA:  We have a pool onsite, so when I saw the title I wanted to read further.  They found no differences between the two for outcomes, and unfortunately  the variability of the programs and the quality of the designs were not great, and they reported that the components of the programs were not described (this could be due to space limitations of the paper – word limits can hamper what you want to say which is good in that you are concise but bad because you might not be able to be as thorough).  If you ever write a case report or conduct a study, see if you can include this type of information in an appendix.  Batterham SI, Heywood S, Keating JL. Systematic review and meta-analysis comparing land and aquatic exercise for people with hip or knee arthritis on function, mobility and other health outcomes.  BMC Musculoskeletal Disorders 2011, 12:123doi:10.1186/1471-2474-12-123
5. BWST vs. HEP.  For those that missed it, part of the LEAPS trial has been published with the report that there is no difference between early gait training with BWS and a progressive HEP – so don’t feel bad if you don’t have a BWS system (we don’t either). Duncan PW, Sullivan KJ, Behrman AL, Azen SP, Wu SS, Nadeau SE, Dobkin BH, Rose DK, Tilson JK, Cen S, Hayden SK; LEAPS Investigative Team.  Body-weight-supported treadmill rehabilitation after stroke.  N Engl J Med. 2011 May 26;364(21):2026-36.
6. Urban elderly, fall reduction, and adherence:  For the residency I’ll be at Augustana in downtown Minneapolis 4 days a week.  One of the things that drew me to the program is that it is urban and there is more variety in the patient population.  When I read the title of this article I wanted to read more.  It is interesting that over half attended all the onsite sessions but only one person reported exercising at home all 12 weeks (I would be interested to see what  was the overall percentage of adherence to both), and even more interesting is that if they lived alone they were more likely to attend, but if they were depressed they were less likely to attend all the classes (I’ve requested this article, haven’t received it yet).  Stineman MG, Strumpf N, Kurichi JE, Charles J, Grisso JA, Jayadevappa R.  Attempts to reach the oldest and frailest: recruitment, adherence, and retention of urban elderly persons to a falls reduction exercise program.Gerontologist. 2011 Jun;51 Suppl 1:S59-72.

We have some changes going on at work, and I hope to have some good research and posts out of them soon – stay tuned!

In the past few weeks, three medications have been linked to increased risk of fractures in older adults – levothyroxine (for hypothyroidism), proton pump inhibitors (for GERD), and bisphosphonates (ironically prescribed to treat osteoporosis).

Additionally, it was reported recently in Circulation: Heart Failure that people with heart failure are at risk for vertebral fractures, with an increase when combined with a-fib.

A few thoughts with all this recent news on fractures (and seeing patients with one or more):
First, I’m glad this information is out there, and hopefully patients and their physicians and pharmacists will assess “are all these medications needed and in this dose considering the side effects?” Second, this is a reason to take a good medical history and know what your patient is taking. This segues into #3, which is the importance of weight bearing exercise which can help reduce the risk of fractures. I wish my patients and our community at large were more adherent to physical activity recommendations, but that is a research project for later.

Photo credit: Omeprazole, originally uploaded by idleman

Thanks to Monique Serpas PT, I read an interesting article about insurance covering exercise programs. I think this should be covered or at least supplemented. Here is why, and the possible problems:

Why: more cost-effective for everyone (providing the insured does the program), better for the health of the insured (versus medications and side-effects, especially with polypharmacy), reduced disease burden not only for the country/ community, but also for the individual and their family as they age.

Problems: Adherence (how many of us join a gym but don’t make good use of it?); motivation – ties into adherence, but unless there is either a tangible reward or punishment (better health/ function, or money) I suspect there is less likelihood of participation; insurance company buy-in – because they know the stats on adherence to exercise (why pay for something most won’t keep doing?); lack of education – like Monique said in the comments, there is a lack of education and knowledge on how to lose weight or be more active safely.

Group Health (an HMO in Seattle) does this – they underwrite a good portion of EnhanceFitness for their participants, with good (published) results. I’d like to see other insurance companies do similar structured pilot programs and see what happens.

photo credit: Senior couple on cycle ride, originally uploaded by SCA Svenska Cellulosa Aktiebolaget