Welcome to Todays Workshop! 1 Pl Please ease keep eep in in mi - - PowerPoint PPT Presentation

Welcome to Today’s Workshop!

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Pl Please ease keep eep in in mi mind… nd…

• Turn cell phones to silent
• During breaks and lunch, secure personal belongings
• Temperature, noise, or other distracting issues
• Restroom locations

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CE & Certificate Process

• Sign In & Sign Out

‐ ASHA, State‐Specific Forms

• Participation Waiver
• Program Evaluation (located in manual)
• Certificates

‐ If you leave early… ‐ Call Summit Office (800) 433‐9570, Option 1. ‐ Okay to leave a message if weekend.

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Today’s Schedule

• Morning and Afternoon Breaks
• Lunch on your own

‐ Dining options

• Interaction/Q&A

Latest Advances in

Patient Mobility

Developing Safe and Effective Patient Handling Techniques to Improve Pain, Mobility, Stability and Balance

Jeff Ladinsky, PT, DPT, MTC, CCI Clinic Manager‐South Sebring CORA Physical Therapy Sebring, Florida drjeffladinsky@gmail.com

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Tell us about yourself?

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Course Objectives

• Understand the physical impact of aberrant posture on the

caregiver during patient handling.

• Distinguish myths vs facts of patient handling and the evolution to

the no‐lift environment

• Perform

various patient transfer techniques using less thoracolumbar force to reduce musculoskeletal injury risk to the clinician.

• Recognize the various bariatric body types and its influence on

mobility

• Design appropriate exercise interventions and effective patient

handling techniques

• Choose reliable and valid fall risk assessment tools for outcome

measures

• Distinguish between equipment that may be available for safe

mobilization of this population

• Develop

proper documentation strategies for successful reimbursement. 8

Wh Why this this co course?

• The adult human form is an

awkward burden to lift or carry

• There are no handles
• The body is not rigid
• People are getting larger
• You cannot count on the

patient assisting

• You cannot predict…
• Very susceptible to severe

damage if mishandled or dropped.

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Wh Why this this Cour Course? se?

• Allied Health Care is one
• f the Top 10 high risk
• ccupations despite

most injuries being unreported. 68/10,000 FTEs Vs 33/10,000 FTEs all others

• The greatest risk factor

for musculoskeletal disorders in Health Care Workers is manual handling of patients!

• In an eight hour shift,

the cumulative weight that a health care worker may lift may be equal to an average of

• ne ton!

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Why this Course?

Work‐related Musculoskeletal Disorders (WMSD)

• Musculoskeletal pain ‐

90% of PTs during their careers, 50% experience within 5 years of practice.

• The body part most

commonly affected lumbar (66%), cervical/shoulder (61%)

• PTs working in hospitals

have higher prevalence of WMSD.

• WMSD are associated

with PTs' age, gender, specialty and job tasks.

• Up to 23 % of
• ccupational therapy

practitioners experienced musculoskeletal injuries.

• Muscle strain (52 %) was

most reported injury

• Lower back (32%) was

most injured body part.

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Not Not on

• n my

my pl plane anet…

• The amount of weight

to be manually managed was suggested to be limited to 50 pounds under IDEAL conditions.

Waters T, When is it safe to manually lift a patient, American Journal of Nursing, 107(8), 53‐59., 2007

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Pr Problem wi with NI NIOSH OSH Lift Lift Eq Equation

• The maximum lifting

values were based on boxes or other inanimate

• bjects. In order to

accommodate the added space needed when lifting a person (the the lifter’s spine and the patient) was added.

• Researchers have

reported that no caregiver should lift more than 35 pounds of a patient’s weight – NIOSH Lifting Equation,1993

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Ta Take aw away…

• Patient handling was the

primary factor associated with these injuries.

• Risk Factors for injury

include experience and age

• There have been many

recommendations for changing practice, but the debate about how to reduce and manage the risks associated with musculoskeletal injuries continues

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Wh What at ha have we we done done la lately? ly?

The 1990’s

• “Proper Body

Mechanics” Education including orientation and annual mandatory training)

• Select use of Hoyer lifts

for “heavy” patients

• Staff accepts that an

“aching back” is part of the job Early 2000’s

• Electric/Battery
• perated patient lifts

introduced

• Back Injury Prevention

Programs

• Use of back belts

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Wh Where ha have al all the the back back belts belts gon gone?

Over 13,600 retail employees in over 30 states were evaluated to see the effectiveness of using back belts in reducing back injury claims and low back pain. Conclusions ‐ In the largest prospective cohort study of back belt use, neither frequent back belt use nor a store policy that required belt use was associated with reduced incidence of back injury claims or low back pain.

• James T. Wassell, PhD; Lytt I. Gardner, PhD; Douglas P. Landsittel, PhD; et

al Janet J. Johnston, PhD; Janet M. Johnston, PhD JAMA. 2000;284(21):2727‐2732. doi:10.1001/jama.284.21.2727

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MYTHS vs FACTS Associated with Patient Handling

Myths

• We can train workers to use

proper body mechanics and avoid injury.

• Patients are not as

comfortable or safe with mechanical lifting.

• It takes less time to

manually move patients than to use lift equipment.

• Lifting equipment is not

affordable or cost‐effective. Back belts are effective in reducing risks to caregivers. Facts

• Research shows that relying
• n body mechanics alone is

insufficient to prevent injuries.

• Patients feel more secure

with mechanical transfer devices.

• Takes longer to round up

team for manual lifting.

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MY MYTHS vs vs FA FACTS Associa Associated ed wi with Pa Patient Handl Handling ng

Myths

• If we invest in

equipment, workers will not use it.

• Lifting patients is the only

high‐risk patient handling task.

• Injuries to healthcare

workers can be prevented by careful screening of candidates before hiring.

Facts

• Studies show that

investment in policies and equipment can be recovered in 2‐5 years.

• Engaging staff in selecting

the equipment promotes using it.

• Training is key to success.

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Myths Associated with Safe Patient Handling

• All lifting devices are

equally effective.

• Use of mechanical lifts

eliminates the risks involved in manual lifting.

• If a facility has a no‐lift

policy, healthcare workers (HCW) will stop lifting

Worker safety Encourage patient independe ‐nce SAFE PATIENT HANDLING Patient safety

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2000’ 2000’s…and s…and bey beyond! nd!

Lift free Workplace No‐lift policy is an administrative control that assures workers that proper equipment for lifting will be available and safely maintained. In order for this type of program to work, there must be attitudinal change to successfully address and reduce the manual handling burden Consistency must be adhered to avoid gaps.

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Nur Nurse and and Heal Health Car Care Wo Worker Protecti

• tection
• n Act

Act of

• f 2015

2015 (H (H.R .R.4 .4266)

• Requires OSHA to develop and implement a SPHM

(safe patient handling and mobility) standard that will eliminate manual lifting of patients by nurses within two years of the legislation’s enactment.

• Requires employers to purchase, use, and maintain

equipment within two years after the establishment of the standard. It also requires employers to train health care works annually on proper usage of equipment.

• SPHM programs provide early mobility therapy which

gets patients up and moving, as soon and as often as possible, leading to decreased mortality, length of stay in hospitals and unplanned readmissions.

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Where is this bill today?

• Introduced to Senate by sponsor Senator Al

Franken, R‐ Minnesota.

• Read twice and referred to the Committee on

Health, Education, Labor, and Pensions in 2015.

• Referred to the Subcommittee on Workforce

Protections in 2016.

• Senator Franken left office in early 2018 and the bill

died as the congressional session ended at mid year.

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The The irr irresis sistib ible le fo force meet meets the the im immovable object…

• bject…

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Re Remember… “Patient Handling” “Patient Lifting”

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Manual nual Pa Patient Handl Handling ng

Defined as the transporting or supporting of a patient by hand or bodily force, including:

• Pushing
• Pulling
• Carrying • Holding
• Supporting of the patient or a body part

Lifting occurs when one carries a patient from a lower to a higher position

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TEN COMMANDMENTS for reducing risk during patient Handling/mobilizing

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Thou shalt:

1.

Push rather than pull 2. Stand in a stride position and prop one foot up for prolonged standing 3. Shift your position often for prolonged standing 4. Use teamwork/machines for Heavy Loads 5. Slide the Load if possible 6. Never twist with a Heavy Load 7. Keep the load close to you 8. Never hold your breath 9. Plan the lift before you lift 10. Lift with your Head not with your back.

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I‐ Pu Push ra rather than than Pu Pull

The same amount of force is needed to push as to pull Pushing recruits more phasic muscle groups Neutral pelvis is easier to achieve with pushing

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II II‐ St Stand and in in a st stride position position and and pr prop

• p one
• ne foot
• ot up

up fo for pr prolong

• longed

standing anding

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Your foot goes where?

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III III‐ Shift Shift yo your position position oft

• ften

Fatigued side can switch off Foramen opening Larger cone of stability

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IV IV‐ Use Use Te Teamwork fo for Hea Heavy Loads Loads

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V‐ Sl Slide ide a Load Load if if Possible ssible

The wheel was invented between 5500 and 3000 BC We urge you all to use this device as often as possible

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VI VI ‐ Nev Never( )T )Twist wi with a Hea Heavy Load Load

35 Cervical Curve Cervical Curve Thoracic Curve Thoracic Curve Lumbar Curve Lumbar Curve

Definition of Twist:

(We’ll get to that in a few moments)

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VI VII ‐ Keep eep the the Load Load Cl Close

• se to

to Yo You

If… We have… External force = Internal force‐‐‐‐‐‐‐‐‐‐‐‐Equilibrium External force > Internal force‐‐‐‐‐‐‐‐‐‐‐‐Trunk towards flexion External force < Internal force‐‐‐‐‐‐‐‐‐‐‐Trunk towards ext

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Internal Force External Force

VIII III‐ Nev Never Hol Hold Yo Your Br Brea eathe the

Can raise the BP to unsafe levels Orthostatic Hypotension Can be a sign that the load may be too heavy

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IX IX‐ Pl Plan an the the Lift Lift Be Before Yo You Lift Lift

Assess the object to which is to be lifted Plan the pathway to follow Prepare the area Perform

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X ‐ Lift Lift wi with Yo Your Head Head and and not not Wi With Yo Your Back Back

Not all lifting situations will be ideal The body is more forgiving

• f bad lifts if the good lifts

far outnumber them

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Why Lift With The Legs?

• Spinal muscles have to
• vercome upper body

mass + any load at the UEs

• Physiologically are

endurance muscles. Therefore, do you want a Toyota Corolla pulling a boat?

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Material Handling for the Smart Person

…In Three Easy Steps

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1 – Bec Become a Py Pyrami mid, not not a sky skyscr craper aper

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Base Base of

• f Support

Support

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2 – Head Head is is lik like a baseball baseball catc catcher

45

3 – NEVER, NEVER, EVER EVER x (∞) TW TWIS IST

Is simply when your hands and feet are not positioned or going in the same direction

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The The Fo Forc rces ar are st strong wi with this this

• ne!
• ne!

VI VI ‐ Nev Never( )T )Twist wi with a Hea Heavy Load Load

48 Cervical Curve Cervical Curve Thoracic Curve Thoracic Curve Lumbar Curve Lumbar Curve

Tr Tree Root

• ot Sy

Syndrome

THE CURE!

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Casc Cascade ade of

• f chaos…

chaos…

Decreased functional mobility Decreased ability to perform mobility ADLs Disability

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Con Consid ider eratio ions fo for Mo Mobilizing ng

• Inability to lift trunk with HOB @ 45*
• Perceived exertion with

Supine‐sit > “HARD”

• Not able to move extremities

against gravity

• Unable to scoot up in bed
• Prolonged bed rest >72 hours
• Three or more staff members
• Significant change in medical
• r orthopedic stability
• Pain > Seven
• Fear and/or anxiety

Dionne, M: Dionne’s Safe Patient Handling and Bariatric Rehab. Course Manual 2017.

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Medi Medical cal Conditions Conditions Af Affecting cting Saf Safe Pa Patient Handlin Handling

• Weight bearing
• Strength
• Cooperation and

Comprehension

• BMI

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Medi Medical cal Conditions Conditions Af Affecting cting Saf Safe Pa Patient Handlin Handling

• Pain
• Orthopedic conditions
• Prior Falls
• Poor skin integrity
• Postural hypotension
• Weakness, paresis
• Respiratory
• Amputations
• Stomas
• Tubes/drains

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GAI GAIT BEL BELTS TS

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Gai Gait bel belt

Feedback in detecting falling:

• 1. Auditory
• 2. Visual
• 3. Proprioceptive
• Which is the weakest for

purposes of guarding?

• In which direction do most

bariatrics fall?

• Do not hook belts together! Use

sheet if necessary

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Gai Gait bel belt

Feedback in detecting falling:

• 1. Auditory – complete
• disadvantage. Will not be able

to redirect

• 2. Visual – we have to accelerate

to the falling mass then redirect

• 3. Proprioceptive – Redirection

can occur at the initiation of the fall Don’t put your spine on the line!

Dionne, M: Dionne’s Safe Patient Handling and Bariatric Rehab. Course Manual 2017.

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Reminder ‐

The human form is an awkward burden to lift or carry

• We have no handles
• The body is not rigid

WE NEED TO PROTECT OUR SPINE!

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LAB LAB TI TIME

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Si Sit‐ to to‐St Stand and Cr Cross

• ss Gr

Grip Techni chnique que

• Takes up soft tissue

slack

• Block the leg
• Have the patient place

their hands on the transfer surface and squeezed (Adduct) their arms against yours

• Drop down, flex elbows

to generate force

Dionne, M: Dionne’s Safe Patient Handling and Bariatric Rehab. Course Manual 2017.

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Si Sit to to sta stand

• Cross grip with pronation on

hand away from the guarded side

• Patient MAY grip at the

elbow but not higher!

• Patient to ADDuct arms to

reduce telescoping trunk

• Blocking the tibia creates a

fulcrum.

• DO NOT use back extension

to complete the lift. Rather, elbow flexion to draw the patient over his knee.

Advanced Mobility DVD tall short.avi https://www.youtube.com/watch?v=IrIyd91HP1U

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Fo Forward Sl Slide ide

• Place a sheet below the

patient’s waist

• Position patient’s feet in

front (knees approximately 70*)

• Have patient BB the spine

to move hips forward as much as possible

• Place sheet below your

waist to avoid lumbar spine recruitment

• Step back to mobilize

Dionne, M: Dionne’s Safe Patient Handling and Bariatric

• Rehab. Course Manual 2017.

61

Backw Backwards Sc Scooting

• oting
• Internally rotate legs

and place sheet under thighs

• Position the feet

directly below the knees and tip the trunk forward

• Wrap sheet below

lumbar spine

• Free hand used to

balance as you sit or step back

Dionne, M: Dionne’s Safe Patient Handling and Bariatric

• Rehab. Course Manual 2017.

62

La Lateral sliding sliding

• Tuck sheet under shoulder.
• Bring the sheet around and

tuck under the opposite arm.

• Cross over the torso,

leaving the shoulder/arm free.

• A second sheet may be

passed under the knees, again, tuck under thigh.

• Place sheet below your

lumbar spine and take up the slack.

• Step back or squat, using

free hand to balance.

Dionne, M: Dionne’s Safe Patient Handling and Bariatric Rehab. Course Manual 2017.

63

Rollin lling

• Tuck sheet under shoulder,

leaving about one foot of sheet

• n rolling side.
• Bring the sheet around and

tuck under the opposite shoulder.

• Cross over the shoulder/arm
• A second sheet may be passed

under the knees, again, leaving a foot of excess. Tuck under thigh.

• Bring the sheet around the
• pposite knee. Tuck under

thigh

• Place sheet below your lumbar

spine and take up the slack.

• Step back or squat, using free

hand to balance.

Dionne, M: Dionne’s Safe Patient Handling and Bariatric Rehab. Course Manual 2017.

64

Ceph Cephalic/Ca lic/Caudal Slid Slidin ing

• Twist the sheet and pass

it under the patient’s knees

• Pull cephalically so the

sheet is near the gluteal fold.

• 2 person – place sheet

around cephalic hip

• 1 person – stand at head
• f bed, sheet below

lumbar area

• Use friction reducing

surfaces if possible.

Dionne, M: Dionne’s Safe Patient Handling and Bariatric

• Rehab. Course Manual 2017.

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Wo Work = Fo Forc rce x Di Distance ance

• Shorten the resistance

arm

• Lengthen the force arm
• Move fulcrum as close

to patient as possible

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1st Class Lever 2nd Class Lever 3rd Class Lever

Effort Effort Effort Load Load Load Fulcrum Fulcrum

Wh Why Do Do Patien tients ts Fall? ll?

Falls

Medical Issues

Musculoske letial

Meds

Environ‐ ment

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Should You Be Aware…

• On average, a person

loses a small portion of their overall balance every year starting from about the age of 20 mostly due to decreasing levels of activity, not aging.

• Inactivity causes the

balance system to weaken much like a muscle that isn't used.

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Body Body Follo llows Head Head

• For every inch of Forward

Head Posture, it can increase the weight of the head on the spine by an additional 10 pounds.

• Most attempts to correct

posture are directed toward the spine, shoulders and pelvis.

• All are IMPORTANT, but,

head position takes precedence over all others.

• The entire body is best

aligned by first restoring proper functional alignment to the head

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The The eff effects of

• f the

the movemen movement pa pattern ern during during fo forward bending bending in in people people wi with and and wi without

• ut lo

low back back pain. pain.

• Individuals with low back

pain moved with a stereotyped strategy at their lumbar spine and hip joints.

• On average, people with

LBP have reduced lumbar ROM, proprioception, and move more slowly compared to people without LBP.

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Wh Why do do the they fa fall?

Medical Disorders Metabolic Neurological Orthopedic Visual Fear

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Why do they fall?

Falls

Medical Issues Musculoskeletial

Meds

Environment

75

Why do they fall?

Drugs!

• Ototoxic
• Side effects
• Combinations/Poly‐

pharmacy

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Why do they fall?

Falls

Medical Issues

Musculoskeletial

Meds

Environment

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Environmental Influences

• Improper footwear
• Improper or Poorly

used ADs

• Lighting
• Floor surfaces
• Trip hazards
• Furniture?

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Wh What at Cons Constitut titutes a Fall… ll…

Most people think they have to hit the ground to “count” that as a fall.

A fall can be as simple as a loss of balance, hitting the walls at home, grabbing furniture or a rail going up stairs It is simply an unexpected event in which the participant comes to rest on the ground, floor,

• r lower level that may or may not be

accompanied by injury

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Fa Fall Ri Risk sk Assessm Assessmen ent To Tools

• Use of quick, reliable, and

valid fall risk screens to identify high‐risk patients and to trigger further fall‐ related assessments and interventions is important for each clinical practice setting.

• They can play a crucial

first step in implementing an effective and efficient fall reduction program

• Different types of setting

(e.g., acute care,

• utpatient, and extended

care), should probably use different assessment scales.

• Acuity of illness and

medication changes will affect mobility, physical status, and cognition

• Will vary considerably

within and between shifts.

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Fa Fall Ri Risk sk Assessm Assessmen ent To Tools

• Use of quick, reliable, and

valid fall risk screens to identify high‐risk patients and to trigger further fall‐ related assessments and interventions is important for each clinical practice setting.

• They can play a crucial

first step in implementing an effective and efficient fall reduction program

• Different types of setting

(e.g., acute care,

• utpatient, and extended

care), should probably use different assessment scales.

• Acuity of illness and

medication changes will affect mobility, physical status, and cognition

• Will vary considerably

within and between shifts.

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Fa Fall Ri Risk sk Screening Screening Tool

• ols

‐STRA STRATI TIFY FY Sc Scale ale‐

Answer all five questions below and count the number of "Yes" answers

• 1. Did the patient present to hospital

with a fall or has he or she fallen on the ward since admission (recent history of fall)?

• 2. Is the patient agitated?
• 3. Is the patient visually impaired to

the extent that everyday function is affected?

• 4. Is the patient in need of especially

frequent toileting?

• 5. Does the patient have a combined

transfer and mobility score of 3 or 4? (calculate below)

Transfer score: Choose one of the following

• ptions which best describes the patient's

level of capability when transferring from a bed to a chair: 0 = Unable 1 = Needs major help 2 = Needs minor help 3 = Independent Mobility score: Choose one of the following

• ptions which best describes the patient's

level of mobility: 0 = Immobile 1 = Independent with the aid of a wheelchair 2 = Uses walking aid or help of one person 3 = Independent

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Fa Fall Ri Risk sk Screening Screening To Tools ‐ST STRA RATI TIFY Sc Scal ale‐

Total score from questions 1‐5:

• 0 = Low risk
• 1 = Moderate risk
• 2 or above = High risk

STRATIFY Scale for Identifying Fall Risk Factors. http://www.ahrq.gov/professionals/systems/hospital/fallpx toolkit/fallpxtk‐tool3g.html

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Fa Fall Ri Risk sk Screening Screening To Tools ‐Schm Schmid id Fa Fall Ri Risk sk Assessm Assessmen ent‐

Quantifies the degree

• f risk for falls based
• n five areas
• Mobility
• Mentation/cognition
• Elimination
• Prior history of falls
• Medications

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Fa Fall Ri Risk sk Screening Screening To Tools ‐Schm Schmid id Fa Fall Ri Risk sk Assessm Assessmen ent‐

• Schmid Score
• > Score 0‐2 = Low risk
• > Score > 3 = High risk

Assess fall risk upon

• Admission
• Transfer to another level of

care

• Whenever there is a

significant change in a patient’s status or after a fall incident

• Daily or every shift

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Fa Fall Ri Risk sk Assessm Assessmen ent To Tools ‐Mo Morse Fa Fall Sc Scal ale‐

• The MFS consists of six

items: history of falling, presence of secondary diagnosis, use of an ambulation aid, i.v. therapy, type of gait, and mental status.

• The predictive sensitivity

was 83% and the specificity ranged between 55% (Morse et al. 1996, Eagle et

• al. 1999).
• The inter‐rater reliability

was 96%

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Tim Timed Get Get up up and and Go Go Te Test (TU (TUG)

“TUG test is a valid tool for screening balance deficits that lead to increased fall risk in senior citizens.” ‐Nightingale CJ, Mitchell SN, Butterfield SA. Validation of the Timed Up and

Go Test for Assessing Balance Variables in Adults Aged 65 and Older. Journal of Aging and Physical Activity. 2019; 27: 230‐233

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Egr Egress ss Te Test

• Patient clears hips 1‐2 inches from bed and returns

to seated position. Two reps of sit to stand are then performed.

• If successful, patient stands and marches in place

for 3 repetitions

• If successful, patient steps forward and back with
• ne leg then the other

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Egr Egress ss Te Test

The test is stopped at any point where the patient cannot perform the task safely. The patient is always directly in front of the bedside so returning to seated position is possible. Passing the Egress test does not mean that the patient is independent, only that safe means to egress from the bed have been determined. Mechanical conveyance is appropriate if the patient cannot perform the steps of the Egress test.

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Origins of Obesity

• Genetics ‐ not due to

heredity: we have had the same genes for thousands of years!

• Metabolism of Nutrition

‐ food influences the way

• ur bodies secure, collect

and discharge energy (e.g. sugar, salt, fat)

• Environment –

Community may influence an obesogenic environment

90

The The Obesog Obesogenic enic En Envir vironm nmen ent

• Social – Sedentary

behaviors including inactivity and smoking

• Cultural – Obesity is

viewed differently among cultures

• Medications ‐

antidepressants, antipsychotics, anticonvulsants, antihypertensives

91

Obes Obesity ma may le lead to to…

• Orthopedic issues:

arthritis, osteoporosis and joint immobility

• Obesity cardiomyopathy:

decreased lean muscle mass and increased fat mass causing decreased systemic vascular resistance and increased circulating blood volume, resulting in increased cardiac output.

• Obesity hypoventilation

syndrome: displacement

• f the abdominal

contents causes increased work of

• breathing. Respiratory

muscle fatigue is exacerbated by lack of

• sleep. Combined with

hypoventilation and diminished ventilatory drive, the patients develop severe hypoxemia.

• Obstructive sleep apnea

92

Obes Obesity ma may le lead to to…

• Central abdominal fat ‐

associated with changes in blood glucose removal, insulin resistance, and increased sympathetic activity

• Cancers ‐ esophageal,

colon, rectal, liver, gallbladder, pancreatic, kidney, breast, uterine, stomach and ovarian cancers, as well as non‐ Hodgkin’s lymphoma and multiple myeloma.

93

Body Body Com Compositio ition Measur asuremen ement

• Components include fat, lean tissue and bone
• Used for identifying possible at‐risk patients for not
• nly obesity, but obesity‐related conditions
• Used for following prevalence, trends and possible

determinants of pathological consequences of

• besity.

94

Wo Would BM BMI be be an an accur accurate in indicator of

• f obesity
• besity fo

for…

• Athletes
• Persons during puberty
• Orthopedic deformities

(scoliosis, kyphosis)

• Pregnant

Dionne’s Safe Patient Handling & Bariatric Rehabilitation Seminar Manual

95

Field Field met methods

• ds incl

clude ude BM BMI

BMI = weight (kg)/ height (m) ^2 BMI = ( Weight in Pounds / ( Height in inches x Height in inches ) ) x 703 May overestimate bodyfat in athletes and others that have a muscular build May underestimate bodyfat in older people and others who have lost muscle

96

Acc According ing to to their their BM BMIs, these these guy guys ar are ove

• verweight?

97

98

Obl Obligator tory St Stats

• Estimated that 1 out of

every 3 people in the US are obese

• Over 2/3 of Americans

are overweight or obese

• Overweight children are 5

times more likely to remain this way into adulthood

• 30 percent of young

people in the U.S. are now too heavy to qualify for military service.

99

Consequences Consequences

• Obesity and overweight

together are the second leading cause of preventable death in the United States – over 300,000

• Multiple factors including

cardiovascular and pulmonary disease, sleep apnea, cancer and type II diabetes and OA are conditions strongly linked to obesity

• $190.2 billion or nearly

21% of annual medical spending in the United States is related to obesity.

• Patients of size will spend

almost $2000/year more on medical expenses due to more medical complications.

• Higher costs for disability

and unemployment benefits.

• $4.3 billion are lost due to
• besity‐related job

absenteeism and decreased productivity.

100

Disease Risk* Relative to Normal Weight and Waist Circumference 3

101

Ph Physio iolo logy of

• f Metabolism

bolism

• Ingestion is when food

enters into the body; and

• Digestion occurs when

nutrients from food are extracted in the gastrointestinal tract.

• Absorption is the process

through which nutrients are passed into the blood stream

• Excretion, is when

indigestible and unabsorbable products from food are eliminated.

102

Hippocampal Dysfunction Decreased inhibitory controls by satiety cues Increased Appetite Responding to Food Cues Excessive Intake of Food

Possible Dysfunction of How Overeating May Affect the Brain

103

Evaluation topics for Bariatrics

• History
• PMHx including weight

loss attempts

• Social Hx
• Prior Fx Level
• Medications
• Phentoermine
• Diethlproprion
• Phendimetrazine
• Orlistat (Alli)

104

Barrier Barriers to to Heal Healthcare:

• Lack of privacy
• Impaired

mobility/decreased physical capabilities

• Limited transportation,

embarrassment

• Fear of the

inaccessibility of the environment 24‐27.

105

“Obese Frail”

• Proportions of fat and

lean muscle mass changes with age

• Studies have shown that

aging patients lose lean tissue mass and strength (sarcopenia)28.

• Decline in muscle quality

and muscle density due to lipid accumulation29

• An increase in visceral

adipose tissue, and a decrease in bone mass

106

EV EVAL ALUATION TION

Past Medical/Surgical History

• Presence of comorbid

conditions such as diabetes, coronary artery disease, hypertension, hypercholesterolemia, sleep apnea, obesity hyperventilation syndrome

• Prior surgeries or

interventions for obesity management

• Prior or current orthopedic

conditions or surgeries

• Any other relevant past

medical or surgical history

Prior Functional Level

• Baseline ambulation, including

distance and symptomatology

• Assistive devices if applicable,

including use of wheelchair or power scooters if not ambulatory

• Home environment,

modifications, e.g. ramp, stair lift, and any potential barriers to returning home

• Sleeping arrangements (i.e. head
• f bed elevated, sleeping in a

recliner chair) and any use of a home oxygen delivery system, including bipap or continuous positive airway pressure

• Prior or current exercise program

107

Baria Bariatric ric Body Body Ty Types

from Dionne’s Safe Patient Handling & Bariatric Rehabilitation Seminar Manual

• Apple Pannus
• Apple Ascites
• Pear Abduction
• Pear Adduction
• Gluteal Shelf

108

Apple Apple Pannus nnus

• Mobile umbilicus
• High waist to hip ratio

demonstrating inferior abdominal drift

• May tolerate flat postures

including prone

• Better breathers as weight

below chest wall

• Fall risk if log roll to sidelying

then sit if panniculus is anterior

• f the COG
• LEs ABducted

109

Apple Apple Asci Ascites

• Immobile umbilicus
• Intolerant to flat postures
• Supine to sit via roll to

elbow supported sidelying technique using LE as a counterbalance

• Weight on chest wall.

Poor oxygenation due to CHF is common.

• LEs Adduction
• Increased risk of LE

cellulitis

110

Pe Pear ABducti ABduction

• n
• Unable to achieve

femoral contact due to excessive medial tissue

• Perineal care issues

dominant

• Not able to logroll

easily due to heavy LEs. Long sit from supine.

• Stand via knee

extension then trunk extension

111

Pear shaped ADducted

• Most of the tissue bulk is

below the waistline and lateral aspect of the thighs.

• Usually can fully adduct

knees until contact is made.

• Because of the lateral

placement of the adipose tissue, easier hygiene and pericare are easier

• Observed mobility

pattern includes supine to long sit. Tissue bulk allows for logrolling

112

Gl Glut uteal eal Shelf Shelf

• Large gluteal mass
• May need support

under low back in supine

• Decreased

tolerance in supine

• Impaired sitting

due to LBP

• Increased

resistance to rolling as COG is posterior to back wheels of WC

113

In Indicatio tions fo for Rx Rx

Pain

• Should be assessed as

with any other patient population

• Care should be taken to

address patterns of pain associated with long term stress on the weight bearing ROM May be limited by tissue accumulation around

• joints. Patient positioning

during ROM measurement may need to be adjusted Circulation Peripheral pulses may be difficult to assess, and the patient may have lower extremity edema due to immobility and venous stasis

114

In Indicatio tions fo for Rx Rx

• New weakness
• Decline in functional

mobility

• Decreased endurance
• Loss of balance

115

Str Streng ngth th te test sting

• Should include

functional movement patterns and manual muscle testing.

• Adjustment of hand

placement may be necessary

• Substitution patterning

may suggest needing to modify testing position

• Rhabdomyolysis should

be considered in the differential diagnosis in the weak postoperative patient. 116

Examination

Vital Signs

• Pulse oximetry may not

be accurate due to adipose present in fingers

• Palpation of pulses may

be difficult

• Increased arm

circumference may give an elevated BP if too small a cuff is utilized

• Anthropometrics –

height, weight and BMI Cuff Size Arm Circumference Regular (12 x 23 cm) Less than 33 cm Large (15 x 33 cm) 33 to 40 cm Thigh (18 x 36 cm) < 41 cm

117

Auscult Auscultati tion

• n

Heart sounds may also be difficult due to the distance between the chest wall and the

• heart. Alternative ‐ patient can

be placed in left side lying or in a sitting position bringing the heart closer to the chest wall

118

Pa Palpation

May be difficult due to the presence of adipose tissue

• ver bony landmarks
• Patients with apple

ascites obesity will demonstrate a rigid and immobile abdominal wall with an immobile umbilicus.

• Patients with apple

pannus obesity have mobile abdominal tissue

Dionne M. One size does not fit all. Rehab Manag. 2002;15(2):16‐19.

119

Po Postural Assessm Assessmen ent

Each body type will have a different effect on function

• Apple Ascites body type – may use accessory

muscle for breathing causing hypertrophy, cervical convexity, elevated clavicles and a flexed trunk

• Results may include dyspnea, CO2 retention due to

expiration effort.

120

Po Postural Assessm Assessmen ent

• Apple pannus may demonstrate lumbar lordosis
• Pear abducted body type demonstrate abducted

femurs

• Pear adducted body type demonstrate adducted

femurs

121

Skin Skin In Integrity grity

• Increased risk for skin

breakdown due to poor blood supply to adipose tissue, high glucose levels and higher body temperature.

• Every pound of fat has
• ver one mile of blood
• vessels. Additionally, fat

cells have mitochondria – increased metabolic heat. This may lead to increased perspiration and moisture leaving the skin at high risk for irritation, breakdown, and ulceration.

122

Skin Skin In Integrity grity

• Compare skin mobility

bilaterally

• Look for ulcers, tears,

infection in the skin folds

• Skin color
• Friction or shear points

123

Skin Skin In Integrity grity

• Increased risk for pressure

ulcers and ulceration within skin folds, particularly around the neck, under the breasts, around the abdomen and in the groin and perianal areas

• The patient should be

placed on a mattress with special pressure relieving qualities.

• Care should be taken to

avoid lines and tubes positioned within skin folds.

124

125

Skin Skin In Integrity grity

• Surgical wounds are at

greater risk for wound dehiscence due to diabetes, hypoproteinemia, decreased blood flow and tension at the wound edges.

• Abdominal binders may

assist in decreasing stress

• n the incision may help

to decrease the patient’s report of pain.

126

Functi Functional

• nal Mo

Mobility

Bed Mobility/Transfers

• Medical/functional

dependent people (medical instability requiring constant monitoring) usually do well with foot egress

• Side access

recommendation for medically stable individuals

Foot vs. Side Exit

127

Gait Assessment

• Larger base of support
• Increased time in

weight bearing

• Decreased step length

which leads to decreased gait speed and cadence.

• Note the equipment

weight limit.

128

Endur Endurance nce

• Assess aerobic capacity

based on the patient’s prior level of function, pain, muscle strength, range of motion, balance

• r certain

cardiorespiratory conditions.

• During the examination
• f endurance, baseline

and activity vital signs are

• btained for screening

purposes and to help develop an appropriate exercise prescription

• The Rate of Perceived

Exertion (RPE) scale

• The six‐minute walk
• 2‐minute step test
• TUG test
• 5 rep sit/stand test

129

Bed Bed Mobility bility

• Friction reducing sheets
• Airflow mattresses

130

Bed Bed Mobility bility

• Trendelenburg/Reverse

Trendelenburg Positioning How about this?!

131

Bed Bed Mobility bility Techni chnique que

Apple Pannus Patient

• Tend to tolerate supine

well as long as pannus is mobile.

• Utilize supine or prone

flat spin technique to side exit from bed

132

Apple Apple Asci Ascites

• Intolerant to

supine and prone due to CO2 and fluid retention.

• Semi‐fowler

position is the preferred posture.

133

Pe Pear Shape Shape ABduct ABducted

• Difficulty with rolling due to

increased proximal LE tissue mass.

• Supine to long sit to short sit

134

Pe Pear shaped shaped ADduct ADducted

• Usually do well with rolling

techniques

• Can also utilize long‐to‐short

sitting technique

135

Pe Pear shape shape wi with gl glut uteal eal shelf shelf

• Posterior tissue

bulk tilts the pelvis anterior in supine

• May benefit from

an air mattress to allow for the heavy part to sink and lighter trunk to remain elevated

136

Gai Gait Trai aini ning ng

• Includes stairs, corners
• Appropriate assistive device

needs to take weight into account

• If WC needed then seating

assessment may be needed

• Gait training equipment for PWB

137

Me Menta ntal Br Break? eak?

138

Can Can Assis Assistiv ive Eq Equipment Hel Help?

Among injuries for which lifting equipment use was reported, almost 83% of these injuries occurred when the equipment was not used. About 18% of patient handling injuries

• ccurred when lifting

equipment was used.

• CDC. Occupational Traumatic Injuries among Workers in Health

Care Facilities — United States, 2012–2014. MMWR 2015; 64(15); 405‐410.

139

Specialty Specialty Eq Equipment

Bariatric Beds

• Stryker Secure 2
• Max weight 500#
• KCI Barimaxx 2
• Max resident/patient

weight 1000 lbs

140

Bari Bariatric ric Beds Beds

• Hill Rom Triplex
• Sizewise Lowboy

141

Surf Surfaces ces

• Hill ROM Pressure

Release

• Sizewise Big Turn

142

Baria Bariatric tric Mobility ility

143

Bariatric Mobility

144

Baria Bariatric tric Mobility ility

145

Ceilin Ceiling Lifts Lifts

• Medcare Ceiling Lift
• 625 lbs capacity
• Arjo Maxi Sky
• 600 lbs capacity

146

Po Portable Lifts Lifts

• Apex – 400 lbs
• Hill Rom Viking XL – 660

lbs

147

Ai Air Tr Transfer Devices Devices

148

Baria Bariatric tric Toile iletin ting

149

Documentation

It’s how we get…

$$$$$

150

Importance of Documentation

• Serves as a record of patient care, including a report of

the patient’s status, and outcome of physical therapy intervention.

• Is a tool for the planning and provision of services and

is a communication vehicle among health providers and payors.

• Tells others about our abilities, our unique body of

knowledge, and the services we provide as rehabilitation specialists.

• Demonstrates compliance with federal, state, payer,

and local regulations.

• Is useful for research purposes including outcomes

analysis.

151

Common Causes of Denial

• Lack of evidence in

regards to medical necessity for the therapy services provided

• Lack of evidence in

regards to professional skill(s) provided to a patient

152

CMS Definition of Medical Necessity

• Interventions must be considered

under accepted standards of medical practice to be a specific and effective treatment for the patient’s condition.

• Interventions must be of such a level
• f complexity and sophistication or

the condition of the patient shall be such that the services required can be safely and effectively performed

• nly by a qualified therapist.
• There must be an expectation that

the patient’s condition will improve significantly in a reasonable (and generally predictable) period of time,

• r the services must be necessary for

the establishment of a safe and effective maintenance of program.

153

Complexity of the Treatment Intervention or the Condition of the Patient

• Document any co‐

morbidities or complicating factors that may impact the patient’s treatment interventions

• r progression.
• Note: Simply because a

patient has a deficit (ie: lacks ROM/strength) does not mean they require skilled intervention.

• If discharged to an HEP,

will the patient decline or will they continue to improve?

154

Con Conveying ing Skill Skill in in Documen Documentation

Therapist

• Adjustments
• Progressions
• Special Techniques
• Assessment
• Analysis
• Modifications

Assistant

• Adjustments
• Progressions
• Special Techniques

155

Usi Using Out Outcome

• me Me

Measures as as a To Tool fo for Goal Goal Wr Writing

• This can support the need for

further therapy intervention

• Documents complications and

safety issues

• Eg. How NWB is effecting

patient’s ADLs and how can it’s complication be reduced?

• Specifically notes how the

patient has deviated from their PLOF and show that therapeutic intervention is necessary

• Objective measures

Kansas University Standing Balance Scale

Patient performs 25% or less of standing

• activity. (Maximum assist).

1 Patient supports self with upper extremities but requires therapist assistance. Patient performs 25‐50%

• f effort. (Moderate assist).

1+ Patient supports self with upper extremities but requires therapist assistance. Patient performs >50% of

• effort. (Minimal effort).

2 Patient supports self independently with both upper extremities. (i.e. walker, parallel bars, crutches). 2+ Patient supports self independently with 1 upper extremity. (i.e. cane, parallel bar, 1 crutch). 3 Patient stands independently without upper extremity support for up to 30 seconds. 3+ Patient stands independently without upper extremity support for up to 30 seconds or greater. 4 Patient independently moves and returns center of gravity 1‐2 inches in one plane. 4+ Patient independently moves and returns center of gravity 1‐2 inches in multiple planes. 5 Patient independently moves and returns center of gravity in all planes greater than 2 inches. e.g. able to grasp and move object, throw ball.

156

Therefore …

What is the patient’s functional impairment What did you have to do to address the deficit(s) What was the result of your intervention? What has to be done on the next patient encounter?

157

Documen Documentation Barrier Barriers

1 Lack of Time 2 Choosing the appropriate

• utcome

tools 3

Linking

• utcome

scores to goals

4

Writing functional goals

5

Document ing skilled care and medical necessity

6

Document ing progress and discharge

• utcomes

158

KEY KEY WO WORDS

Added, progressed, facilitated, assessed, provided, VC, MC, modified, reviewed/educated, demonstrated, trained

159

160

Thank you for coming!

161