Disclosures Rehabilitating Pre- and Post-liver I have nothing to - PowerPoint PPT Presentation

9/30/2016 Disclosures Rehabilitating Pre- and Post-liver I have nothing to disclose transplant Patients Michelle Oberst, PT, DPT, GCS, CEEAA Alicia Rivas MS, OTR/L Objectives Role of Therapy in Acute Care � Understand the role of physical therapy with pre- and Physical Therapists (PT) and Occupational Therapists (OT) post-liver transplant patients are trained in the medical model to provide detail � Understand the role of occupational therapy with pre-and assessments and interventions (activity modifications, post-liver transplant patients strengthening, neuromuscular re-education, trunk � Understand common physical therapy interventions stabilization, balance activities) after illness and injury. � Understand common occupational therapy interventions � Identify when to consult therapy services 1

9/30/2016 Occupational Therapist are… Physical Therapists are… � Experts in assessing and promoting independence with Biomechanical experts activities of daily living (ADLs) and daily life roles � Experts in assessing cognition and perception as it relates to safety in ADLs and mobility Assess and promote proper movement strategies and safety � Interventions focus on adapting the environment, with bed mobility, transfers, gait and stairs. modifying the task, and educating the client/family � Goal: to increase participation in and performance of ADLs and iADLs (instrumental activities of daily living) Provide Interventions that will maximize performance of the � Model of Human Occupation (MOHO) explains how oxygen transport system, musculoskeletal and neuromuscular human occupation is motivated (VOLITION), organized systems; titration of activity in response to changes in (HABITUATION), performed (PERFORMANCE) and influenced by the environment physiological status Areas of Occupation Gastrointestinal Social ADLs IADLs Work Leisure Participation Metabolic Musculoskeletal Bowel & Safety Employment Leisure bladder procedures/emer Community seeking participation mangement gency response Employment Bathing, Care of Leisure Hematologic Psychological interest/prusui Family showering others/pets exploration ts Complications of immobility Community Job Leisure Dressing participation Peer, friend mobility performance Financial Feeding management Cardiovascular Integumentary Functional Health mobility maintenance Hygiene and Home Respiratory Inflammation Grooming management Sleep/rest Meal prep Winkelman C, Higgins PA, Chen YJ, Levine AD. “Cytokines in chronically critically ill patients after activity and rest.” Biol Res Nurs. Apr 2007;8(4):261-271. Bloomfield, S. A. (1997) “Changes in musculoskeletal structure and function with prolonged bed rest.” Medicine and Science in Sports and Exercise. 29 (2), 197-206. Sexual activity Shopping 2

9/30/2016 Impairments Ascites and Edema � Deconditioning � Makes sitting up uncomfortable � Hepatic encephalopathy � Difficulty getting center of gravity over base of support to achieve standing � Pain/discomfort � With extra weight and fluid status will see fluctuation in � Ascites activity tolerance � Balance � Lower extremity edema makes legs heavier to move, rub � Sleep deficiency together, and patients more uncomfortable � Depression/apathy � Frailty Fried’s Frailty Index Malnutrition, Cachexia and Sarcopenia Unintentional weight loss � Sarcopenia- loss of muscle mass Self-reported exhaustion � Cachexia- loss of both fat and muscle mass Low physical activity � Sarcopenic obesity- disproportionate loss of muscle mass Weakness (grip strength) in the presence of increased adipose tissue mass Atrophy, overall physical activity � Adversely affects survival and quality of life � ≥3/5 = frail � Each 1 unit increase associated with 50% increased risk of Dasarathy S. “Consilience in sarcopenia of cirrhosis.” J Cachexia Sarcopenia Muscle. waitlist mortality 2012;3(4):225-37. Fried LP, Tangen CM, Walston J, et al. “Frailty in Older Adults: Evidence for a phenotype.” J Gerontol A Biol Sci Med Sci 2001; 56:M146-M156. Lai, J.C.., et al. (2014). “Frailty Predicts Waitlist Mortality in Liver Transplant Candidates." American Journal of Transplantation 14: 1870-1879 3

9/30/2016 Impact of Frailty Short Physical Performance Battery � Balance Test � Decreased physiologic reserve and resistance to stressors � Feet Side by Side � Increased risk of post-surgical complications and the need for extended care. � Semi-Tandem Stand � More than doubles the risk of morbidity and mortality from surgery � Tandem Stand and cardiovascular conditions. � Strongly predicts waitlist mortality in liver transplant candidates � Gait Speed Test Afilalo J, Alexander KP, Mack MJ, Maurer MS, Green P, Allen LA5, Popma JJ, Ferrucci L, Forman DE (2014). "Frailty assessment in the cardiovascular care of older adults". Journal of the American College of � Chair Stand Test Cardiology 63 (8): 747–762. Makary MA, Segev DL, Pronovost PJ, et al. (June 2010). "Frailty as a predictor of surgical outcomes in older � 5 x sit to stand with arms patients". J. Am. Coll. Surg. 210 (6): 901–8. across chest Lai, J.C.., et al. (2014). “Frailty Predicts Waitlist Mortality in Liver Transplant Candidates." American Journal of Transplantation 14: 1870-1879 Guralnik JM, Simonsick EM, Ferrucci L, et al. “A short physical performance battery assessing lower extremity function: Association with self-reported disability and prediction of mortality and nursing home admission.” J Gerontol 1994; 49: M85-M94. Image of test available from Google image search for SPPB. Physical Therapy Objectives in Pre- Treating Patients with ESLD Transplant Patients � Daily functional assessments, activity tolerance information � Assessment Questions: correlated to vitals, lab values, medications � Patient physiologic reserve- past and present � Providing psycho-social orientation, motivation, self-efficacy � Ambulatory enough to be listed? � Family education � patient’s MELD score does not always correlate with function � Environment management � Family able to realistically continue care for the patient? � Identify and minimize barriers to mobility � Is patient already listed and will stay admitted until organ � Preventative medicine- Carefully monitored activity available? � Sleep disorders � What is the patient’s hemodynamic and 02 response to activity? � Steroids osteopenia, hyperglycemia, and muscle wasting � Motivation � Pneumonia � Delirium, mood affect � Discharge Options � Endurance, fatigue � Balance 4

9/30/2016 Interventions Exercise � Can increase skeletal muscle volume � Bed mobility and strength � Transfer training � Increase physical activity � Gait training � Increase exercise capacity � Stair training � Improve insulin resistance � Balance exercises � Can prevent or minimize sarcopenia � Therapeutic exercises � Education re: energy conservation and safety Toshikuni N et al, “Nutrition and exercise in the management of liver cirrhosis”. World J Gastroenterol 2014 June 21; 20(23): 7286- � Caregiver training 7297 Lai, J.C.., et al. (2014). “Frailty Predicts Waitlist Mortality in Liver Transplant Candidates." American Journal of Transplantation 14: � Equipment recommendations 1870-1879 Occupational Therapy Pre-transplant Equipment Ascites and Edema Frailty and weakness � Impaired lower body � Impaired balance dressing/bathing � Impaired functional mobility � Impaired bed mobility Poor endurance/activity tolerance � Impaired toileting � Falls and injuries � Back pain � Loss of independence in ADLs � Shortness of breath � Loss of independence in iADLs � Loss of meaningfull roles � Skin breakdown Encephalopathy Lactulose � Attention deficits � Frequent bathroom trips � Hypereflexia/impaired motor � Accidents planning � Skin breakdown � Impaired sleep patterns � Loss of freedom to leave home � Inability to manage medications � Inability to manage finances � Unable to work Brown, J., Sorrell, J H., McClaren., & Crewel,J.W. (2006). Waiting for a � Unable to drive liver transplant. Qualitative Health Research, 16(1), 119-136. 5

9/30/2016 Impact of Liver Disease on ADLs and Participation � Treating Patients with ESLD � Assessment questions: � Baseline and current level of ADL/iADL function � Baseline and current cognitive functioning � Home environment setup/barriers � Access to durable medical and adaptive equipment � Motivation � Meaningful roles, routines, hobbies � Discharge options Scott, P., (2011). Occupational therapy services to enable liver patients to thrive following transplantation. Occupational Therapy in Health Care, 25:4, 240-256. Occupational Therapy Objectives in Pre- transplant Patients So you had a liver transplant… “individuals in the prolonged transplant pipeline must learn either independently or with assistance, to cope with the serious limitations and restrictions to performance of ADLs and participation in valued occupations” � Education about changes in role performance � Adapting ADL/iADLs tasks � Conserving energy � Durable medical equipment � Adaptive equipment � Medication management � Caregiver education � Education and preparation for later stage disease and potential transplant � Recommendations for home and out patient services Scott, P., (2011). Occupational therapy services to enable liver patients to thrive following transplantation. Occupational Therapy in Health Care, 25:4, 240-256. 6