Rehab strategies for patients with chronic conditions A complete, patient-centered approach to e ff ectively treat challenging patients
Andy McCormick • Clinical faculty for APTA Geriatric Residency Program 2014 • tDPT Regis University 2009 • MSPT University Alabama at Birmingham 1996 • MEd Auburn University (Exercise Physiology, minor Biomechanics) • Board Certified Geriatric Physical Therapy 2013 • Board Certified Orthopedic Physical Therapy 2001 • Certified Strength and Conditioning Specialist 1996 • Advanced Credentialed Clinical Instructor APTA 2014 • Tennessee Physical Therapy Association Clinical Instructor of the Year 2018
Andy McCormick • Developed and implemented Phase 4 Cardiac Rehabilitation Program featuring interval circuit training which lead to significant improvement in functional abilities and decreased fear of activity • Developed and implemented advanced Cardiopulmonary Rehabilitation program for SNF which lead to a system-wide reduction in re-hospitalization of 30% • Significant improvements in breathing capacity, endurance, gait speed and tolerance and SOB index • Successfully integrated manual therapy techniques into acute and subacute settings leading to significant functional improvements for patients
Learning Objectives 1. Classify patients with chronic conditions, prevalence, pharmacological considerations and the therapists role in improving functional status 2. Select the appropriate outcome measures to codetermine baseline function and show improvement, including appropriate documentation of performance and expectations 3. Recognize common breathing substitution patterns and e ff ectively improve these patterns to increase functional endurance 4. Utilize alternative treatments for common pathologies associated with the medically complex patient to improve balance and mobility 5. Implement e ff ective soft-tissue and joint mobilization techniques with confidence across a wide spectrum of patients and complaints 6. Incorporate appropriate corrective exercise to maintain improved airflow changes gained through manual therapy
My goals 1. Reduce or resolve your fears in working with the chronically ill 2. Encourage you to “raise the bar” on yourself and your patient; use your skills and don’t let YOUR mind limit YOUR outcome 3. Create consistency in your thoughts, attitudes, beliefs and approaches with your patients 4. Educate regarding the impact of the mental state on performance and outcomes in the medically complex patient 5. Improve your confidence in applying manual therapy techniques in the complex medical patient
• Visual refractive • Depressive • Hypertension errors disorder • Hyperlipidemia • Osteoarthritis • Coronary atherosclerosis • Diabetes • Fibromyalgia • UTI • Back pain • Malaise/fatigue • Cancer • Anxiety • Joint pain • Parkinsons • Obesity • Major depressive • Alzheimers disorder • Respiratory problems • Bronchitis • Dementia • Hypothyroid • Asthma • CVA
• Heart disease a ff ects ~ 47% of US • 647,000 die (1 in 4 deaths) • Diabetes a ff ects ~ 9.4% os US; 0.55% to 8.6% (type 1 and 2 respectively) and 25.2% of geriatrics • 79,535 die (7th leading cause) and 252,806 die as secondary cause • Anxiety a ff ects ~ 18.1% of US • <40% seek treatment • Parkinson’s a ff ects ~1.2% of US • Cancer risk for the lifetime is ~ 42.05% men and 37.58% women • COPD a ff ects ~ 14.5% of US • Leading cause of death of women in US
Classification “the action or process of classifying something according to shared qualities or characteristics”
What should we classify? Things that DIRECTLY impact treatment decisions Cognitive Sensory Motor
Evaluation and Assessment Evaluation and accurate assessment is the ESSENTIAL INGREDIENT in providing correct care for all patients “What else can it be?”
Demonstration Sit<>stand (Strength)
Evaluation Accurate classification for treatment • Pertinent history • MI, cancer, COPD, pneumonia, CHF • Surgery (CABG, stent, filters, pacers) • Rehabilitation (Cardiac, pulmonary) • Specific leading questions OUTCOME MEASURES & TREATMENT GOALS directly impacting movement • Exacerbation • Fatigue • Anxiety • Fear avoidance • Shortness of breath
• How many exacerbations of your COPD have you had this year? On average how intense were they (1-10 scale)? How many times did you to go to the hospital? • Do you feel tired most of the time? What things make you tired? How long does it take to recover? • Are you anxious when you do …..? If so how much? What do you do to decrease your anxiety? • Are you afraid to fall? Are you afraid to walk outside? Are you afraid to become short of breath? • How short of breath do you become when you do …..? How often are you short of breath? How long does it take to recover?
• Exacerbations of Chronic Pulmonary Disease Tool (EXACT-Pro) • Beck Anxiety Inventory (BAI) • Fear Avoidance Beliefs Questionnaire (FABQ) • Fear of Falling Avoidance Beliefs Questionnaire (FFABQ) • Fall E ffi cacy Scale International (FES-I) • Activities-Specific Balance Confidence Scale (ABC Scale) • Modified Medical Research Council (MMRC) Dyspnoea Scale • Shortness of Breath with Daily Activities Questionnaire (SOBDA) • Dyspnea Management Questionnaire (DMQ) • Modified Borg • Patient Specific Functional Scale
Exacerbation COPD patients with severe exacerbation are at greater risk for cardiovascular disease … probably due to the high prevalence of arterial hypertension and diabetes mellitus Quality of life (CAT Test) and glucose control are predictors for increased CVD risk Mekov et al. Cardiovascular risk assessment in COPD patients with severe exacerbation. European Respiratory Journal 2016;48: PA1134
Fatigue • “Do you feel tired most of the time?” (Yes increases 10 yr mortality 55%) Hardy et al. J Am Geriatric Soc 2008 • Vital Exhaustion Questionnaire (> 9 increases relative risk 2.57 for IHD) Prescott et al. Epidemiology 2003 • Walking Impairment Questionnaire - PAD (Stair climbing < 8 all cause mortality) Jain et al. J Vasc Surg 2012
Lab Values • Hemoglobin < 7 gm/dl • Hematocrit < 15-20% • PaO2 < 60 mmHg • Potassium < 3 or > 6 mEq/L Academy of Acute Care Physical Therapy Laboratory Values Interpretation Resource 2017 Update
Anxiety A general term for several disorders that cause nervousness, fear, apprehension and worrying. These disorders a ff ect how we feel and behave and can cause physical symptoms
Anxiety CBT reduced anxiety and fatigue, improved social functioning and better health-related quality of life Freedland et al. Cognitive behavior therapy for depression and self-care in heart failure patients: A randomized controlled trial. JAMA Intern Med 2015;175(11):1773-1782. CBT demonstrated “a significant 17% reduction” in perception of dyspnea in patients with COPD Livermore et al. Cognitive behavior therapy reduces dyspnea ratings in patients with chronic obstructive pulmonary disease (COPD). Respir Physiol Neurobiol 2015;216:35-42. CBT, exercise and anxiolytic use was associated with changes in depression and anxiety Tully et al. A dynamic view of comorbid depression and generalized anxiety disorder symptom change in chronic heart failure: the discreet e ff ects of cognitive behavioral therapy, exercise and psychotropic medication. Disability and Rehabilitation 2015
Cognitive Behavioral Therapy • Depression - O’Hea 2009 CHF • Anxiety & depression - Cully 2010 CHF , COPD • Emotion/anxiety - Karbasdehi 2018 CHF • Chronic fatigue, self-e ffi cacy - Tack 2018 Type 1 DM • Psychological distress - Ires 2019 MS & Parkinson’s • Mood, anxiety, sleep, negative feelings - Dobkin 2019 Parkinson’s
Cognitive Behavioral Therapy Psychological problems are based in part on: • Faulty or unhelpful ways of thinking • Learned patterns of unhelpful behavior Patients can learn better ways to cope, relieve their own symptoms and become more e ff ective in their lives
Cognitive Behavioral Therapy • Can learn to recognize distortions in thinking that create problems • Can learn to reevaluate thoughts in a di ff erent light • Gain a better understanding of behavior and motivation of others • Use problem solving skills to cope with di ffi cult situations • Increase confidence in oneself
Cognitive Behavioral Therapy Modifies dysfunctional emotions, behaviors and thoughts • Focus on solutions • Encourage the patient to challenge cognition • Change destructive patterns of behavior • Face fears • Learn to relax and calm the body • Prepare for challenges
Cognitive Behavioral Therapy • Not motivational, educational or negotiation • Ask “loaded” questions that you know the answers • Use analogies and examples that are generally known and understood
Lab Battery vs generator
• “Why do you think you need to rest?” We need to establish “baseline thinking” so we can change it • “How long have you been resting?” They will say only a short time, but we know it has been progressively longer and longer so make them acknowledge this • “Is it fair to say you are doing less than… ?” Establish history of progressive weakness to help them recognize rest hasn’t helped • “Is rest really helping you feel stronger?” This helps them begin to understand that rest isn’t helping as much as they think
Recommend
More recommend
