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A Publication of the Home Health Section
The
Quarterly Report
The Patient’s Side of EMR
by Stephanie Miller, PT, MS, CLT
Does anyone else recall the day of running after your
documentation after a strong wind blew it out of your
hand as you left your patient’s home? I can only assume
the office staff enjoyed receiving my crumpled notes
with the hint of shoe prints on them, telling the story
of victory as I reclaimed my prize from the clutches of
Mother Nature. My how things have changed, right?
From manila folders and binders crammed with paperwork we’ve moved on to notebooks and tablets (that
don’t have pages) and smartphones, and bears oh my!
As a non-techie, I preferred chasing after my fly away
notes versus trying to learn how to type and how to
navigate around electronic medical records (EMRs).
But I quickly came to realize the benefits of this magical invention. I didn’t know how much of a PT box I
was living in. Unless I called another team member or
they called me, I really had no idea what was going on
with my patients outside of the PT realm. What an advancement to have access to every note, every physician
Continued on page 3 »
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Quarterly Report
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1 The Patient’s Side of EMR
5 Maintenance and Medicare:
Applying the CMS Manual
Revisions to Your Practice
8 Guest Editorial: What’s in a
Name?
10 How I Got Here…
12 The RIET Protocol for
Rehabilitation of a Total Knee
Replacement in the Acute Phase
18 APTA Selects J. Michael Bowers
as Chief Executive Officer
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19 Treasurer’s Report
Research Section
21 2014 APTA Combined Sections
Meeting Presentations
28 Results of Physical Therapy in the
Home Care Setting With a NonEnglish-Speaking Patient: A Case
Report
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2 - Home Health Section t APTA
...continued from page 1
order, and every medication my patient was taking! I
quickly began to appreciate the benefits of the EMR.
So what all does the EMR allow us to do? Not everything can be covered in one paragraph and with so
many systems out there, there’s no one standard format
that every agency follows. But the most important thing
I can think of is access to the patient’s full chart. To be
able to look at vital signs from other clinicians and see
continuity of patient education among each discipline
is so important. Being able to compare wound measurements and status among clinicians and the interdisciplinary team is vital to accurately assess progress and
know if you need to contact a physician during your
visit. Locating physician orders at the click of a mouse
to ensure you have signed orders for your treatment or
to follow up on a new treatment or discipline referral
you requested, instead of calling the office to have that
information located, is such a time saver. Being able to
access the patient’s medication list (to determine if unusual complaints the patient may have that day might
be related to medication changes or side effects of medications or not following physician orders about how to
take his/her medications) is important in ensuring the
patient is appropriate for treatment that day. Compliance and/or noncompliance with medications has a
significant impact on a patient’s ability to safely perform
therapy and in the progress of therapy. Having that information at your fingertips is paramount to enhancing
patient outcomes.
Although communication is important in every aspect
of health care, it is of utmost importance in the home
care setting. Rarely do we physically see our coworkers,
physicians, or DME suppliers. Technology today allows
us to enhance the timeliness of communication to the
interdisciplinary team. Through secure email systems or
other communication modules, you can contact your
team members and notify them of patient status changes, visit cancellations, and changes you made to the
patient’s chart, such as updating the med profile. Efaxes
and electronically-signed documents can allow for more
efficient communication with physicians and improved
timeliness of receiving signed orders.
Although there are many benefits to EMRs, as with
any good thing, there are also downfalls. How many of
you have heard your patients say something like, “My
doctor didn’t even look at me during my visit. He just
clicked on his computer screen the entire time.” Hopefully they’re not saying that about you or me, but it is
a valid point, especially for generations who remember
the days before the advent of the computer. Those were
days where you had more eye contact, clinicians were
more hands-on, and when you called an office you got
to speak to a human prior to clicking three different options only to end up leaving a voicemail anyway. Times
have changed and I only foresee things continuing to
move forward technology-wise. So where do we go from
here?
Well, we fully understand the benefits of the EMR. We
use it daily. We may remember the challenges of the
days prior to its arrival. We understand how it makes
things more efficient and more effective and overall
enhances patient outcomes and patient safety. But our
patients don’t, and we have to remember that. We have
to put ourselves in their positions and try to see things
from their view. Or think about when you were at your
last doctor appointment and how you felt when you
were on the other side of the computer screen. Take
those feelings and thoughts and questions and keep
them in mind during each and every treatment and try
to address them and explain them.
The best thing to do is to introduce the computer from
the beginning. On the first call to the patient, confirm
the address, that they’ll have their medications and
insurance cards available as well as any discharge paperwork, then let them know that it may be a lengthy
visit. Let him/her know that you may be asking a lot
of non-therapy questions and may be taking down and
reviewing their medication information, but that it will
give you the best picture of him/her and is necessary in
providing the best care. Let them know that you’ll be
entering their information in the computer system so
that other team members have access to their records
and that once the case is opened, the treatments will
be more directly targeted to therapy needs. After that,
they’re prepared for a long visit, they know you’ll have
your computer out, and hopefully they’ll have all of
their information readily available to allow for a smooth
evaluation.
During routine visits, there are other ways of getting the
patient on board with the EMR. What are we doing on
our computers during daily visits? We’re looking at previous vital signs (VS) values from our notes and other
disciplines. We’re comparing scores for falls assessments,
range of motion (ROM),and manual muscle testing
(MMT) to those from evaluation. We’re emailing status updates to other team members and submitting
information for authorization requests. We’re calling
physician offices and uploading verbal orders to enhance
Spring 2014 - 3
timeliness of starting new treatments or ordering new
referrals. Just let your patients know this. Patients love
to see improvements in their functional status. They
get excited about going back to look at a score during
their rest break after performing a Berg. Tell them that,
although they don’t like doing the stretches, their ROM
improved most over the two week period that they
were most compliant with the home exercise program.
Let them know that you’re sending in information in
a timely manner to the insurance company to prevent
delay in approval of upcoming visits and you’re checking the system to see how many visits they currently
have authorized. If you justify what you’re doing and
talk to them about it so they know you’re not emailing
or texting your friends, it will make a huge impact on
how they view the EMR and whether they choose to
embrace it or call into the office with a complaint.
Now that we know how amazing technology is and the
benefits of the EMR, we do have to address the issue of
how not to get “sucked in.” Have you ever had an email
come through during a visit that you quickly checked
while the patient is on the phone with her daughter
and the next thing you know, you’re five emails in and
remember you’re in someone’s house during a therapy
visit? It can happen very easily and without intention.
No one plans to do their daily emails during a visit,
but sometimes what seems like efficient multitasking,
becomes very distracting and unfair. Setting boundaries
is paramount in this day and age. Allow yourself time
during your day to answer phone calls and check emails
and make a conscious effort not to open your email account during patient visits. Another suggestion includes
using the copy features if your system has it. Used correctly,
this feature will save you time on documentation and
will allow you more face time with the patient. Also,
use rest breaks effectively. While patients are resting, let
them know that you want to give them credit for all of
the hard work that they did and that you want to type
it all down before you start on the next task and forget.
Please don’t ignore the fact that eye contact goes a long
way. Don’t forget to look up as you’re typing in answers
to questions. We know how important non-verbal cues
are, but we can very easily miss them if our eyes are
glued to the keyboard or computer screen.
Now that we’ve covered the benefits of the EMR and
how to introduce our technological advancements to
our patients, it’s necessary to discuss technology with
the interdisciplinary team and the company in general.
It definitely saves time and money by having distance
trainings and meetings and by emailing instead of calling, but sometimes face time with your team is necessary.
4 - Home Health Section t APTA
Have any of you received an email from the nicest
person in your company, yet the tone of it sounded
horrible? Emails can be read different ways by different people and tone can be easily misinterpreted. Try
to keep this in mind and be cautious of reacting during
moments of stress. Smell the roses and blow out the
candles, do your deep breathing techniques, and really
put thought into responses during those situations. It
may have been an innocent message sent in a rush and
with no ill intent. By the same token, please be cautious
of possible tone inferences in messages you also send out
to your team members.
Have you ever attended an on-line training session or
meeting, but instead of paying attention, you were answering emails or completing documentation as it was
in progress? I have. I’m not proud of it, but it can very
easily happen if you don’t set boundaries for yourself.
You are responsible for the information discussed in
those meetings and educational sessions, so try to keep
the time set aside and truly dedicate yourself to them.
Lastly, remember that face time is necessary. For some
important situations, such as staff meetings and team
building, distractions need to be kept to a minimum. .
We are a team. It’s nice to know who you’re emailing,
whose notes you’re reading, and who your patients are
referring to when they discuss the team members they’ve
been treated by. The advent of the EMR improved our
ability to get out of our PT box and be part of a team
and provide great interdisciplinary care. We just have to
be cautious that we don’t allow technology to send us
back into the box.
Stephanie Miller, MSPT is a staff PT at Celtic Health
Care and a member of the Home Health Section. She may
be reached by email at [email protected].
Maintenance and Medicare: Applying the CMS Manual Revisions to
Your Practice
by Eileen Bach PT, DPT, M.Ed, COS-C
You may have heard from your home care colleagues
and in the news, or you may have heard from your
patients that the Centers for Medicaid & Medicare
Services (CMS) in January 2014 released the manual
changes to meet the required actions in the settlement
agreement. The Center for Medicare Advocacy, Inc, a
supporting organization in the lawsuit, offers self-help
packets on their website to help Medicare beneficiaries
pursue coverage for therapy and/or nursing maintenance care. In addition to providing resource materials
and links to CMS announcements and manuals, postings alert Medicare beneficiaries that maintenance care
is covered. “Patients should discuss with their health
care providers the Medicare maintenance standard and
whether it is applicable to them. Health care providers
should apply the maintenance standard and provide
medically necessary nursing services or therapy services,
or both, to patients who need them to maintain their
function, or prevent or slow their decline." Under the
maintenance standard articulated in the settlement, the
important issue is whether the skilled services of a
health care professional are needed, not whether the
Medicare beneficiary will "improve."1
The CMS notice stated “No ‘Improvement Standard’
is to be applied in determining Medicare coverage for
maintenance claims that require skilled care. Medicare
has long recognized that even in situations where no
improvement is possible, skilled care may nevertheless
be needed for maintenance purposes (i.e., to prevent or
slow a decline in condition). The Medicare statute and
regulations have never supported the imposition of an
‘Improvement Standard’ rule-of-thumb in determining
whether skilled care is required to prevent or slow deterioration in a patient’s condition. Thus, such coverage
depends not on the beneficiary’s restoration potential,
but on whether skilled care is required, along with the
underlying reasonableness and necessity of the services
themselves. The manual revisions now being issued will
serve to reflect and articulate this basic principle more
clearly.”
1. http://www.medicareadvocacy.org/medicare-info/
improvement-standard/ ; accessed March 6, 2014
You can find the source documents at the websites listed
here:
The CMS Transmittal for the Medicare Manual revisions, with a link to the revisions themselves, is posted
on the CMS website at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2013Transmittals-Items/R176BP.html?DLPage=1&DLSort=
1&DLSortDir=descending.
The CMS MLN Matters article is at: http://www.cms.
gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/
MM8458.pdf.
The CMS fact sheet is at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/
Downloads/jimmo_fact_sheet2_022014_final.pdf
It is important to understand that maintenance therapy
requires that a qualified therapist designs and sets up a
safe and effective maintenance program that will maintain function and/or prevent regression for a specific
illness or injury. The therapist instructs the patient and
caregivers in the programs and then infrequently reevaluates the program to determine any changes needed.
A qualified maintenance program REQUIRES the specialized knowledge and judgment of the therapist (OT,
PT, ST). The January CMS transmittals defined restorative and maintenance therapy as:
y “Restorative/Rehabilitative therapy (i.e., whose goal
and/or purpose is to reverse, in whole or in part, a
previous loss of function), it would be entirely appropriate to consider the beneficiary’s potential for
improvement from the services.”
y “Maintenance therapy. Even if no improvement is
expected, skilled therapy services are covered when
an individualized assessment of the patient’s condition demonstrates that skilled care is necessary for
the performance of a safe and effective maintenance
program to maintain the patient’s current condition
or prevent or slow further deterioration and the services cannot be safely and effectively carried out by
the beneficiary personally or with the assistance of
non-therapists, including unskilled caregivers.”
Spring 2014 - 5
Additionally the CMS manual revisions included references to documentation that would support skilled
services. Quoting the manuals for Home Health, the
documentation should include, as appropriate:
t “History and physical exam pertinent to care (including response or changes to behavior from previously provided skilled services)
t Skilled services provided on current visit
t Patient/caregiver immediate response to skilled services on current visit
t Plan for next visit based on rationale of prior results
t Detailed rationale explaining the need for skilled
services in light of patient overall medical condition
and experiences
t Complexity of the service performed
t Any pertinent characteristics of the beneficiary or
the home”
CMS also added “Clinical notes should be written to
adequately describe the reaction of a patient to skilled
care. Clinical notes should also provide a clear picture
if the treatment as well as next steps to be taken. Vague
or subjective descriptions of the patient’s care should
not be used. Examples of insufficient terminology to describe need for skilled care – ’Patient tolerated treatment
well;’' ‘Continue with POC;’ ‘Caregiver instructed in
medication management.’” The need to ensure documentation was measurable and objective is identified as
well.
The following case scenarios are created to stimulate
your thinking regarding maintenance therapy and the
answers to the case questions following this article.
Case 1
You are seeing a patient with Parkinson’s disease who
was referred for home PT after a recent neurology appointment where the patient’s score on the Hoehn and
Yahr scale is now rated as stage 4. Your PT assessment
indicates that:
y Mobility impairments in transfers and gait; postural
instability noted
y All needed assistive devices are present in home
(Bathroom)
y Patient performance improves in safety and quality
when cues and feedback are provided during exercises and mobility tasks
6 - Home Health Section t APTA
The patient transfers and ambulates independently. You
design an exercise program along with safety and falls
prevention education and teach the program to patient
and spouse.
1. Would this be a maintenance program?
a. Yes, if the physician identifies the patient
needs maintenance
b. No, the PT program would be considered restorative care
c. Yes, if the PT assessment indicated no
restorative needs
d. No, all patients should receive restorative care for the initial episode.
2. What would be an appropriate visit frequency
and duration for a maintenance plan?
a. Twice a week for 4 weeks
b. Once a week for 8 weeks
c. Twice a week for 1 week, 2 times a
month for 2 months
d. Once a month for 1 month
Case 2
You are seeing a patient whose primary diagnosis is
heart failure and who was referred for home therapy to
improve ambulation and self-care abilities. The patient
lives with adult son. Your PT assessment indicates that:
y Transfers and gait are safe; gait is slow
y All needed assistive devices are present in home
(bathroom, rollator)
y Patient performance improves with feedback provided during exercises and ambulation
The patient transfers and ambulates independently with
walker. You design an exercise program along with safety
and falls prevention education and teach program to patient and son. Both patient and son are independent in
the program, demonstrating full return demonstration
of skills and knowledge in all aspects of the program by
visit two.
3. What would be the key factor in determining a
maintenance program is not needed?
a. That decision is made by your home care
agency
b. The physician referral did not indicate
maintenance
c. The nursing plan of care would cover
any needed teaching and monitoring
d. That there was no skilled need requiring
a PT’s judgment and knowledge
4. Which listed documentation element is most
critical to support whether a maintenance PT
program is needed?
a. Patient’s medical history
b. Frequency and duration of PT orders
Maintenance therapy requires the clinician's knowledge,
judgment and skill for care to be considered skilled; the
service must be so inherently complex that it can be
safely and effectively performed only by, or under the
supervision of, professional personnel. If the maintenance program does not require the skills of a therapist/
nurse because it could be safely and effectively performed by the patient or with the assistance of a nontherapist/unskilled person, then such services are not
skilled and thus would not be covered. It is important
to keep in mind that ALL other required eligibility criteria for home care must be met such as reasonable and
necessary, homebound, skilled and intermittent care.
Eileen Bach is a member of the Home Health Section Publication Committee.
c. Number of exercises and distance ambulated
d. Patient’s response to skilled care provided
Answers
Case 1:
1 c – it is the PT assessment and specific skilled care needs that determine if the PT plan
will materially improve or reverse loss of function (then it would be restorative) OR if the
plan will maintain function or prevent/slow deterioration.
2 c – for a maintenance plan, it would be appropriate to visit twice a week to establish the
plan and complete the teaching to patient and spouse and then infrequently re-evaluate the
plan.
Case 2:
3 d – the unique skills and knowledge of a PT is needed to establish a maintenance
program. The PT assessment including goals and patient needs should be communicated
to the physician.
4 d – the patient’s response to skilled care provided is the only element listed that would
support a maintenance plan. The patient’s need for PT plan adherence and the response
elements such need for reinforcement, modifications, the impact of interventions on status
are examples of how the maintenance program is supported in patient’s response to care.
Spring 2014 - 7
Guest Editorial: What’s in a Name?
by Kenneth L Miller, PT, DPT, CEEAA
The impetus for writing this editorial article stems
from the Home Health Section’s Business Meeting
held at CSM 2014 in Las Vegas. Toward the end of the
Business Meeting, our current President, Cindy Krafft,
asked those present what they thought of the current
name of the Home Health Section (HHS). Prompting
this topic was the fact that the Section on Geriatrics
officially changed its name to the Academy of Geriatric
Physical Therapy.
So, I ask you, what’s in a name? Should the section
go down the same road as the Academy of Geriatric
Physical Therapy and rename itself? Those of you at the
Business Meeting know this precedent was set many
years ago as this would not be the first name change for
the HHS. In fact there have been several name changes
in the organization’s history. Did you know that the
HHS was founded in 1956 as the Public Health Section
of the American Physical Therapy Association?
community may meet, confer, and promote these
interests.3 The goals of the Section are: 1. to conduct
programs devoted to home health issues of interest to
members of the Association; 2. to provide guidance
and advice to the Association regarding the delivery
of physical therapy in the home health setting; 3. to
provide guidance and leadership, at the academic and
clinical levels of physical therapy education, pertaining
to the involvement of Physical Therapists and Physical
Therapist Assistants in the delivery of care in a home
health setting; 4. to promote Physical Therapist and
Physical Therapist Assistant participation in home and
community health planning; 5. to monitor national
legislation dealing with the delivery of health care
within the home setting; 6. to encourage research,
promote the development of new knowledge, and
foster contributions to professional literature; 7. to
provide such services as will further the objectives of
the Section.
So, what is in a name? Merriam-Webster provides
several definitions for the word “name.” The definition I
like most for this discussion is, “a word or symbol used
in logic to designate an entity.”1 Does the name “Home
Health Section,” define or designate our organization’s
identity? Before we consider renaming ourselves, we
should look at our organizational structure and mission
to see if the current name fits and see if the current
name has meaning to the public at large. Additionally,
we should look at the various types of organizations
such as academies, institutes, and societies to see where
the Home Health Section fits if the name were to
change.
Does the name Home Health Section have any
connection to its structure, mission or meaning to the
public at large? I say “no.” The mission to promote
physical therapy in the home and alternative settings
in the community is not reflective in our name. The
current name, “Home Health Section” may not have
meaning to the public at large as to what a section of
the APTA is. How many times have you had to explain
what the HHS is anyway? I believe that a name change
in order to define ourselves is a worthwhile endeavor.
However, the process of changing our name needs to be
carefully planned out.
The Home Health Section's purpose (mission) is to
provide a means by which Association members having
a common interest in the delivery of physical therapy
in the home and other alternative settings within the
If we are to change our name, should we become the
“Kingdom of Home Health”? Or the “Academy of
Home Health Physical Therapy”? Are we the “Institute
for the Advancement of Ethical Home Physical
Therapy Practice” or the “Society of Home Care
8 - Home Health Section t APTA
Physical Therapists?” Before answering this question, we
need to look at what the terms “academy,” “institute”
and “society” mean to the public at large to see what
term fits the Home Health Section, if any. I think
that we can all agree that kingdom is out! According
to Oxford Dictionaries, an academy is a society or
institution of distinguished scholars, artists, or scientists
that aims to promote and maintain standards in its
particular field; 4 whereas an institute is a society or
organization having a particular object or common
factor, especially a scientific, educational, or social one; 5
and a society is a voluntary association of individuals for
common ends; especially an organized group working
together or periodically meeting because of common
interests, beliefs, or profession.6
Knowing that an academy has a strong connection to
academia through scholarly efforts, I believe that the
current construct of the section is not an academy.
However, the section is moving toward publishing a
peer-reviewed journal and has research funding for
scholarly work in place as the goal of the section is to
encourage research, promote the development of new
knowledge, and foster contributions to professional
literature. Were the section to get a peer-reviewed
publication in place with an editorial board, manuscript
reviewers and structure in place as exists for other peerreviewed journals, then I think the section would be
closer to calling itself an academy. The term academy
has name recognition with the general public as being a
leading academic authority on the profession for which
it represents.
Could the Home Health Section be an institute or
a society? I believe that either of these terms is more
appropriate for the current structure, however, I believe
that the term “institute” most accurately identifies the
HHS and its mission of supporting research, education,
and advancing physical therapy practice in the home
health setting. The goals of the section are clear in that
they seek to provide guidance to academic settings,
clinicians practicing in the home health setting, to
promote research and to monitor national legislation
regarding the delivery of health care in the home
setting. I believe that the public at large views the
term institute in a positive light associated with having
authority over the topic it represents. The term society is
also applicable to the Home Health Section, however,
it may lack the connectedness to science, research and
scholarly work (which the HHS supports) and may be
too far removed from the terms academy and institute
and be perceived as a social club. Additionally, the term
society may give the impression that the home health
society is considering itself “high society” which is a
term known to the public. I believe any reference to
ourselves as a “society” has the potential to connect us
to the term “royal” or “high” society and in the current
health care environment, we want to be seen by the
public as altruistic and serving the common good and a
society may be seen as self-serving.
In the end, what is in a name, anyway? Everything! For
my two cents, I would like to introduce a name for
your consideration, “Institute for the Advancement of
Ethical Home Physical Therapy Practice” (IAEHPT), I
believe that above all else, we need to promote ethical,
best practice which will in the end, speak for the name
itself. As an institute, the newly named organization will
remain focused on providing best practice in the home
health industry through its pursuit of a peer-reviewed
journal, scholarly endeavors, and research activities,
legislative advocacy for our patients and profession,
professionalism and being an authority for the home
health industry.
I welcome a healthy dialogue on this topic and hope
that this article stimulates a discussion on whether the
name should change or not. And if so, who are we and
what do we stand for?
Kenneth L Miller, PT, DPT is the clinical educator for
Catholic Home Care where he provides orientation and
competency training to the inter-disciplinary team . He
is Chair of the Section’s Practice Committee and may be
reached at [email protected] or [email protected].
References
1. Merriam Webster Online dictionary. Available
at: http://www.merriam-webster.com/dictionary/
name. Accessed 2/16/14.
2. Home Health Section. Available at: http://
www.homehealthsection.org/?page=8. Accessed
2/16/14.
3. Home Health Section. Available at: http://www.
homehealthsection.org/?page=MissionVision.
Accessed 2/16/14.
4. Oxford dictionaries. Available at: http://www.
oxforddictionaries.com/us/definition/american_
english/academy. Accessed 2/16/14.
5. Oxford dictionaries. Available at: http://www.
oxforddictionaries.com/us/definition/american_
english/institute?q=institute. Accessed 2/16/14.
6. Merriam Webster Online Dictionary. Available
at: http://www.merriam-webster.com/dictionary/
society. Accessed 2/16/14.
Spring 2014 - 9
How I Got Here…
by Theresa Gates, PT
After practicing for ten years in inpatient rehab, I
stepped out into the world of home health as a PRN
physical therapist. Honestly, after a few weeks, I was
asking myself, why didn’t I go into home health sooner?
After three months, the CEO of the home health
agency I was working for asked if I had any interest in
helping her “build” a rehab team. While anxious, I was
so honored and fortunate to have this opportunity that
I grabbed it and started building!
I joined the Home Health Section (HHS) six months
after practicing in home health. I felt in order to manage and lead a rehab team in home care, I needed to
align myself with everything and anything related to
physical therapy home health care resources, colleagues
with experience, education sessions and leaders in the
home care industry. This was 12 years ago, and joining the HHS during this time was exciting as the home
health industry was significantly growing, with home
care agencies and leaders beginning to understand the
exceptional value rehabilitation brings to their patient
satisfaction and clinical outcomes. Attending Combined
Sections Meeting (CSM) for the first time as a Home
Health Section member was a great experience. I was
met with an abundance of support and the opportunities for networking with home health therapists in every stage of experience from newbies like me, to home
health physical therapists who were owners of their own
home health agencies. It was here that I realized I wasn’t
utilizing the Home Health Section as much as I could
to help gain knowledge and relationships.
Over the years, I increased my involvement with the
section by attending various education sessions, both
online and on-site presented by section members and
leaders. I decided after two years of being in the home
health setting, and a HHS member, it was time to chal10 - Home Health Section t APTA
lenge myself and present at APTA-CSM, representing
the Home Health Section and industry. I have always
encouraged therapists who work for me to find opportunities to present on areas that they find exciting,
yet challenging. Presenting on home health topics both
at CSM and at National Association for Home Care
(NAHC) has been a great experience. While getting
involved in educating colleagues on the home health
industry is professionally rewarding, it has helped me to
stay abreast of the most current home health regulatory
and clinical information. The extent of opportunities to
network with HHS members all around the country has
directly influenced my ability to provide on-going education and leadership within the home health industry.
I felt it was time for me to contribute back to the HHS
by becoming more active within the leadership of the
HHS. I wanted to serve HHS members and help members fully utilize the benefits the HHS has to offer. I applied for the HHS Secretary position as a candidate for
the 2011 elections. While I felt I was travelling down
new territory again, I was confident that I had the support and encouragement from the HHS leadership and
members.
I have been the HHS Secretary and the Chairperson
of the Membership Committee for over two years and
it’s been an amazing journey. My predecessor, Kurt
Baumgartel, mentored me through the whole transition
process and I STILL call him from time to time with
officer questions and he doesn’t hesitate to provide the
support.
I have to say, one of the most unique opportunities,
and somewhat unexpected, in serving the HHS members as the Secretary has been the direct contribution
I have been afforded in providing back to the HHS in
professional growth and development of the section. It
is amazing how many quality-driven resources, educational presentations and conference programming sessions the organization has developed over the last few
years. As an officer with the Home Health Section, our
job is to “lead” the section members, to help steer and
guide the amazing initiatives, ideas, and strategies from
our members into fruition. There are HHS members
who provide their time and dedication serving on one
of our committees, representing the HHS members as
well. It is through our members’ input and involvement
that we are able to grow the HHS to a level that brings
value and opportunities to the home health industry as
a whole.
I hope I was able to provide you with a glimpse into the
potential available should you decide to become more
active with the Home Health Section. If you haven’t
done so in a while, please take the time to navigate the
HHS website and see the amazing growth. And while
you are on the website, go ahead, reach out to one of
the section committee chairs, leaders or officers and get
involved! I am confident there is some initiative, committee, or task force that will assist you in making a
contribution that brings value to the entire HHS.
Theresa Gates, PT is the Founding Owner and CEO of
Beyond Home Health Care Services, LLC. a home health
agency in Jacksonville, Florida. As an executive in the home
health industry, Theresa has extensive experience in all aspects of home care business development to include quality
management and performance improvement, operational
management, and cost-effective care coordination. She is a
licensed physical therapist for over 20 years and currently
serves as secretary for the American Physical Therapy Association’s (APTA) Home Health Section and chairperson
of the membership committee for the home health section of
the APTA. She has been a course presenter at the state and
national level on the topics of rehab therapy utilization,
clinical program development, OASIS, staff retention and
clinical outcomes. Theresa is a national home care consultant, providing education and consulting services for home
health agencies in the areas of quality assurance, staff retention and development, due diligence, clinical management,
operational assessments and therapy utilization management. Theresa can be reached at tgates@beyondhomehealth.
com.
By being involved in the Home Health Section, I have
received much more than I have given and I only feel
compelled to share this opportunity for involvement
and growth with you!
Congrats to Robyn Lovecchio, PT
Winner of the iPad Mini drawing at CSM
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WKHLU\HDUROGWZLQER\V'DOWRQDQG'LOORQDQGGRJV6DOO\DQG&LDUD
11 - Home Health Section t APTA
Spring 2014 - 11
The RIET Protocol for Rehabilitation of a Total Knee Replacement in
the Acute Phase
by Scott Johnson, PT
The methods for rehabilitating a total knee replacement (TKA) during the acute phase (two weeks) have
changed over the years. Initially, patients receiving a
TKA remained in the hospital for many days, often
longer than a week. Rehabilitation consisted of gentle
range of motion and encouragement to sit up in chairs
frequently throughout the day. As the length of hospital
stays shortened, the emphasis shifted to returning to
normal activities of daily living as soon as possible. This
approach focused on increased ambulation distance,
high level strengthening and attempting to resume normal life immediately.
This may sound appealing and has been a popular marketing strategy for encouraging joint replacement, but
may not be what is best for the patient initially recovering from a TKA. Instead of focusing on a speedy return
to activities, we should be striving for the highest possible quality of functional tasks.
Pain relief and return of function are typically the patient’s main goals following a TKA. To achieve the longterm goal of function, we must initially focus on shortterm goals of edema control, range of motion and quad
control. These principles are especially critical during
the initial phase of recovery from the trauma of surgery.
After the initial recovery the body should be able to
handle increased activity and tolerate the surgical leg in
a dependent position (standing, sitting, walking) more
often. Once the patient is responding without excessive
swelling and demonstrates adequate knee ROM, physical therapy can progress into strengthening and gait
quality. Ultimately, the final phase of rehabilitation aims
to incorporate high level balance, proprioception and
functional strengthening. The time frames can vary as
each patient will react and recover at different rates. Ultimately, the patient’s response with swelling will guide
progress through the protocol.
Edema Control
In order to control the initial edema, activity is limited
to minimize the dependent position of the surgical leg.
We instruct our patients not to sit with the surgical leg
dependent for more than 5 or 10 minutes. Ambulation
should be limited to household distances, roughly 50 to
75 feet at one time. Excessive standing should be avoided, i.e. standing to cook, cleaning the dishes, folding
the laundry, etc. All of these activities tend to increase
edema in the operative limb. Once swelling begins in
the lower extremity, it is challenging to reverse and can
jeopardize the patient’s outcomes. Effects of swelling in
a TKA include:
t Decreased muscular contraction in the muscles
surrounding the joint. (Protective Shut Down)1
t Stiffness
t Pain
t Poor Proprioception4
Table 1. Description of the acronym RIET: Rest, Ice, Elevation and Therapy.
Rest
y
y
y
$YRLGRSHUDWLYHOHJLQGHSHQGHQWSRVLWLRQIRUH[WHQGHGSHULRGVRIWLPH
/LPLWDPEXODWLRQWRVKRUWKRXVHKROGGLVWDQFHV
$YRLGVLWWLQJZLWKVXUJLFDOOHJGHSHQGHQW
Ice
y $SSOLHGWRWKHNQHHZLWKDQDSSURSULDWHVNLQEDUULHU±WLPHDQGIUHTXHQF\ZLOOGHSHQGRQKRZWKHLFHLVDSSOLHG
&RROLQJPDFKLQHYV,FH
Elevation
y /HJLVSODFHGRQ/58SLOORZLQWKHUHFRYHU\URRP
y /HJLVSODFHGRQ/58SLOORZDVRIWHQDVFRPIRUWDEO\WROHUDWHGWDNLQJEUHDNVDVQHHGHG
Therapy
y
%HJLQQLQJGD\RIVXUJHU\WKURXJKKRVSLWDOGLVFKDUJHFRQWLQXLQJWKURXJKKRPHKHDOWKDQGRXWSDWLHQWHDUO\DQG
FRQWLQXHGSDUWLFLSDWLRQLQWKHUDS\LVUHTXLUHG
12 - Home Health Section t APTA
Edema control can give patients an advantage and a
head start with rehabilitation. Edema control has been
used for decades utilizing Rest, Ice, Compression, and
Elevation (R.I.C.E.). We developed a specific acute total
knee protocol focused on edema control and knee range
of motion. We named the protocol the RIET protocol,
stemming from the old acronym RICE (Table 1).
The main concept of the RIET protocol is to focus on
edema control and attempt to regain as much AAROM
of the surgical knee in the first two weeks. Patients are
asked to limit activities in a dependent position; they
get up and ambulate to the bathroom or from room to
room as needed. They are asked to work with therapy in
order to obtain independence with gross mobility and
their ADLs, as well as perform motion exercises at least
four times per day. When they are not performing one
of these activities, they are to elevate their surgical limb
and apply ice to their knee.
Range of Motion
The “therapy” in the RIET protocol focuses heavily on
knee ROM secondary to the concern of production
and maturation of scar tissue. Following the trauma
of a total knee replacement the body will immediately
lay down the precursors to scar tissue.5 Therefore, we
recommend to our patients to immediately begin motion exercises on the day of surgery. We ask the patients
to perform 4 exercises, 4 times per day for the first 2
Table 2.&RPSDULQJ$$520RISDWLHQWVUHFHLYLQJD
7RWDO.QHH5HSODFHPHQWIROORZLQJWKH5,(73URWRFRO
YHUVXVWKH³WUDGLWLRQDOUHKDELOLWDWLRQ´1RQ3URWRFRO
RIET
Protocol N=39
NonProtocol
N=24
0-5 Degrees Knee
Extension
85 Degrees or >
Knee Flexion
weeks (See Fig. 2, pg. 17). These exercises are instructed
to the patient and family members with multiple treatment methods incorporated: active ROM as able, active
assisted ROM with use of a strap approximately 5 feet
long (straps are given to the patients to use during their
hospital stay), contract-relax methods and over-pressure
as needed. The patients are encouraged by both PT and
nursing to perform their exercises faithfully throughout
the day. Focusing primarily on motion exercises is intended to assist the patient in gaining strength, endurance and balance at any point during recovery, but there
is only a certain period of time to regain motion.
Outcomes
We implemented the RIET protocol in 2009. In the
first quarter we recorded TKA AAROM at hospital
discharge and compared the use of the RIET protocol
versus non protocol with patients from a single surgeon
(Table 2).
In 2011 the hospital questioned the efficacy of using
the CPM machine. The question was posed to one of
our surgeons, “Why are we using CPM machines on
our TKA patients?” The surgeon’s response indicated
he was utilizing the CPM machine more for elevation
than for the motion it provided. He also reported that
the machine really did not need to be on, just placed
in full extension. However, despite the CPM machine
being placed in full extension, the patients’ knees were
RIET Protocol Vs. Non Protocol
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SRVLWLRQDQGOLPLWURWDWLRQ
Spring 2014 - 13
not resting in full extension while in the machine. Also,
many nurses were sharing their dislikes with the weight
and maintenance of the machine. Subsequently, we
designed an alternative elevation device that focused on
knee extension at rest. After many prototypes we settled
with a product we now call the LRU pillow (Fig. 1).
We were still unsure if the use of the LRU pillow would
yield the same results as the CPM machine, which
was the gold standard at our institution. Performing
a prospective study,2 as well as, a retrospective review3
comparing the CPM machine with the LRU pillow we
discovered that we were yielding better extension and
flexion results at hospital discharge when using the LRU
pillow (Table 3).
We shared our outcomes at one of our orthopedic sectional meetings, requesting their blessing to create a
unified TKA protocol that all patients would follow at
our hospital. We received their approval and immediately began instructing all necessary disciplines (nursing, physical therapy, and occupational therapy) on the
RIET protocol, as well as, the use of the LRU pillow.
Since then we have opened a new hospital and began
1. No physical therapy intervention
2. Initiate outpatient PT immediately
3. Initiate home PT immediately, followed by outpatient PT
Problems identified with option #1:
t Noncompliance or inadequate attempts with
home exercise program
t Discontinuation of edema control, i.e. icing, elevation, limited activity
t Development of deviated gait patterns, etc.
Problems identified with option #2:
t EDEMA: The patients are active in the community early during their recovery phase in order to
initiate outpatient PT. This ensures the patient’s
surgical leg is in a dependent position which
encourages swelling. The patient then has a hard
time achieving edema control, leading to problems regaining knee range of motion, emergency
room visits with increased pain and increased
visits to their surgeon’s office.
Table 3. &RPSDULQJ$$520UHVXOWVRISDWLHQWVUHFHLYLQJDWRWDO
NQHHUHSODFHPHQWDWKRVSLWDOGLVFKDUJHXVLQJWKHFRQWLQXRXVSDVVLYH
PRWLRQPDFKLQH&30DQGWKH/58SLOORZ
treating TKA patients in March of 2012. We were
CPM-free, using the LRU pillow exclusively and were
able to educate all staff members on the RIET protocol
(Table 4).
Physical Therapy after Hospital Discharge
The length of stay in an acute hospital setting for a patient receiving a TKA is rapidly becoming shorter. Our
average length of stay for a patient receiving a TKA is
two nights. This places a much higher responsibility
on rehabilitation beyond the patient’s hospital stay. If a
patient returns home there are three options regarding
continuation of physical therapy:
14 - Home Health Section t APTA
In an attempt to resolve these problems, or at
least reduce them, home health PT is ordered
for two weeks following a patient’s acute hospital stay. The RIET protocol is continued
and appropriate PT intervention at this stage
of recovery is performed. Pain scores and
AAROM numbers are tracked (Table 5, pg.
16).
We discovered that continued activity limitations beyond the hospital stay for two weeks
(with proper PT intervention) yielded much
better results than no PT or immediate outpatient PT. Proper PT intervention consisted
of continued patient education on edema
control, use of the LRU pillow, continued
education and assistance with various methods of knee ROM, home safety and ADL
training as appropriate. The no home health group was
sent immediately to outpatient PT. It was evident that
allowing the patient to start outpatient PT and resume
activities resulted in significant reduction of knee ROM
likely due to increased swelling of the knee. Therefore
it was our conclusion that patients should limit their
activities beyond their hospital stay (ambulation only
household distances, standing only briefly and avoid sitting with surgical leg dependent) for the first two weeks
or until the patient follows up with their surgeon (typically 10-14 days).
Table 4.$$520RXWFRPHVDVZHOODVDYHUDJHSK\VLFDOWKHUDS\YLVLWVGXULQJDFXWHKRVSLWDOVWD\IRUSDWLHQWVUHFHLYLQJ
DWRWDONQHHUHSODFHPHQWLQ0DUFKWKURXJK'HFHPEHURI$OOSDWLHQWVIROORZLQJWKH5,(73URWRFRODQGXWLOL]LQJWKH
/583LOORZ
90 Deg.
Or >
Avg. Knee
Flexion
ž
Avg. PT
Tx’s
ž
0D\1 ž
-XQH1 ž
-XO\1 ž
$XJXVW1 ž
6HSW1 ž
2FW1 ž
1RY1 ž
'HF1 ž
Average
97%
88%
99%
116º
4
2012
0-5 Deg (Ext)
Full Knee Ext.
0DUFK1 $SULO1 It is our belief that other than quad control, strengthening exercises are not important acutely. Acutely we are
concerned about the window of opportunity to regain
knee motion. Extension should be a high priority and
flexion will be regained as long as swelling is controlled.
Exercises are performed faithfully with clear expectations given to the patient. Outpatient PT, two weeks
later, can then focus their plan of care on strengthening,
gait training and higher-level balance activities because
the first hurdle of excellent ROM and quad control is
complete.
Medical and rehabilitation programs are dynamic;
however, there is one factor that has not changed…
human physiology. Despite the advancements of medi-
cal technology, the body still requires time to heal. In
summary, early intervention should focus on edema
control, proper positioning at rest with use of the LRU
pillow and frequent knee motion exercises allowing the
initial healing response of inflammation to resolve with
limited sequelae. Increased edema will increase pain and
limit the patient’s ability to achieve adequate ROM.
Proper PT intervention and keeping the patient home
will assist with edema control and increase knee ROM
which will allow for outpatient PT to immediately focus
on strength, gait, proprioception, etc. Of course, every
patient is different, and discharge needs may vary. However, through trial and error we believe TKA patients
will benefit from following this program.
Spring 2014 - 15
Table 5. &RPSDULQJ$$520RISDWLHQWVUHFHLYLQJ
WRWDONQHHUHSODFHPHQWVDWZHHNVSRVWRSXWLOL]LQJ
KRPHKHDOWK37YHUVXVLPPHGLDWHRXWSDWLHQW37
EH\RQGKRVSLWDOVWD\
Full Knee
Extension
Knee Flexion >
100 Degrees
No Home
Health PT
Home
Health PT
References
1. Riann M. Palmieri-Smith, PhD, ATC, Jennifer Kreinbrink, James A. Ashton-Miller, PhD and Edward
M. Wojtys, MD. Quadriceps Inhibition Induced
by an Experimental Knee Joint Effusion Affects
Knee Joint Mechanics During a Single-Legged
Drop Landing. Am. J. Sports Med. 2007; 35; 1269
originally published online Jan 23, 2007; DOI:
10.1177/03635465062964
2. Jerele, Jennifer MD, Johnson, Scott PT, Lawless,
Matthew MD. Effects of the LRU Pillow on active
assistive knee range of motion and pain scores following a Total Knee Replacement surgery. Publication Pending.
3. Jerele, Jennifer MD, Johnson, Scott PT, Lawless,
Matthew MD. The Effects of the LRU Pillow versus
the CPM Machine on Active Assistive Knee Range
16 - Home Health Section t APTA
of Motion at Hospital Discharge. A Retrospective
Review. Publication Pending.
4. Young A, Stokes M, Iles JF: Effects of joint pathology on muscle. Clin Orthop 219:21-27, 1987.
5. Hardy, MA: The biology of scar formation. Phys
Ther. 1989 Dec; 69(12): 1014-24.
Scott Johnson is a physical therapist at Miami Valley Hospital in Dayton, Ohio. He has worked in an acute care setting for eighteen years with a focus in orthopedics. For the
past six years he has been the Acute/Outpatient Orthopedic
Service Line Specialist. In this role he facilitates the rehabilitation continuum of care for total joint replacements
including teaching pre-operative education classes, evaluating and treating post-operative total joints during the acute
hospital stay, facilitating home health total joint protocols,
and ensuring the transition to out-patient physical therapy.
Fig. 2 - Exercises for Knees
Heel Props: Place heel of affected foot on
a tightly rolled pillow or towel. Tighten
the muscle in the front of thigh. Hold for
5 counts. Repeat 10 times. Attempt to get
your knee as straight as possible.
Towel Pulls: while seated or lying flat, place
a towel or a sheet around the ball of your
foot. Pull towel toward you, lifting heel in
the air. You may use hand to push down on
your thigh to stabilize. Hold for 5 counts.
Repeat 10 times.
Heel Slides: While seated or lying flat, slide
your heel toward your body. To help you
bend the knee further, place a towel under
your thigh or around your ankle. With both
hands pull towel toward your body, sliding
the heel closer to your buttocks. Hold for 30
counts. Repeat 3 times.
When, and only when, you can lock your
knee fully straight, you may begin Leg Lifts.
Leg Lifts: While seated or lying flat, bend
your non-operated knee in towards your
body. Keeping your operated leg straight,
lift your heel off the bed approximately 18
inches. Repeat 10 times.
Spring 2014 - 17
The American Physical Therapy Association (APTA)
announced on February 3rd that J. Michael Bowers has
been selected as its new chief executive officer, effective
February 28, 2014.
Bowers comes to APTA with recent experience as the
CEO of the American Association for Marriage and
Family Therapy (AAMFT). He worked at AAMFT
in a variety of leadership positions for more than 25
years, developing expertise in
many aspects of
association management, including advocacy,
governance, volunteer development, financial
management,
and member
relations. While at AAMFT, he led the effort to achieve
universal licensure for marriage and family therapists,
and also improved the association’s financial position by
overseeing the purchase and full payment for a headquarters building.
“On behalf of the APTA Board of Directors, I am
thrilled that Michael will be joining us as CEO, and I
look forward to working with him,” said APTA President Paul A. Rockar Jr, PT, DPT, MS. “Throughout his
career, Michael has proven himself to be an innovative
and visionary leader who cares deeply about members
and staff. He also exhibits a passion for the types of
quality of life issues that are so important to missionbased organizations like APTA and to the physical
therapy profession.”
18 - Home Health Section t APTA
Bowers will succeed Bonnie Polvinale, CMP, who has
been serving as Interim CEO since June 2013.
"I couldn't be more excited or honored to join the staff
of APTA in advancing physical therapy,” Bowers said.
“My commitment to members and the organization is
to work collaboratively, with all my energy, to achieve
outcomes that matter for patients and for the profession."
During his tenure
at AAMFT, Bowers
presented testimony
in 22 state legislatures, the US House
of Representatives,
and US Senate, and
he has appeared on
CNN and NBC
Nightly News. He
was instrumental in AAMFT becoming a part of the
Substance Abuse and Mental Health Services Administration Minority Fellowship Program, and having marriage and family therapy recognized as a core mental
health profession. He also led AAMFT to its highest
student membership in the organization's history.
Bowers is trained as a marriage and family therapist and
has bachelor’s and master’s degrees from Harding University in Searcy, Arkansas. He has prior experience as a
therapist in the justice system and also as a minister. In
addition, he is an active member of the American Society of Association Executives.
Bowers lives in Alexandria, Virginia, where he and his
wife participate in the music community as singersongwriters.
Treasurer’s Report
by Chris Chimenti, PT
The 2013 end-of-year profit/loss statement has
been finalized (see Page 20) and was discussed
during the Home Health Section Business Meeting at CSM 2014 in Las Vegas, NV. Those who
were present during this discussion appeared to
understand and appreciate the Section’s current
financial position. I hope to convey a similar sentiment through this brief article.
2013 Income- The Section budgeted for an
income of $144,000. Actual income totaled
$158,055, resulting in a positive income of
$14,055. The “big ticket items” related to this
positive variance were royalties (Career Center,
APTA Learning Center) and registration (CSM
Pre-Con, CSM, and webinars).
2013 Expense- The Section budgeted for expenses
in the amount of $146,815. Actual expenses totaled $179,993, resulting in an “over” expense of
$19,123. Expenses that exceeded original expectations were conference exhibit display (shipping/
storage), printing (new and improved Quarterly
Newsletter), and travel (sponsorship for various
Section leaders to attend NAHC, CSM, and Student Conclave).
By now, you may be concerned about the Section’s spending habits. This is a natural reaction.
But please don’t be alarmed, Section leadership
has a financially responsible approach here. The
APTA Investments Held For Reserve Policy suggests
the Association maintain 40-55% of the annual
income budget in reserves. The Section has budgeted an income of $154,700 for 2014. Therefore,
we should maintain somewhere between $61,800
(40%) and $85, 085 (55%) in reserve. At the conclusion of 2013, the Section had an investment
reserve of $146, 112 through our Vanguard account. As you can see, we currently hold a financially healthy position.
As members, you are our primary focus. We are
here to serve you. Section leadership feels it is far
more important to invest in member benefits,
than to continue to further accumulate reserves
beyond that recommended by APTA. With that
said, we are proud of the fact that we have pledged
$37,500 to The Foundation COE for Health Services/Health Policy Research campaign. The Section
will donate $7,500/year for the next five years
beginning this year. By doing so, we are optimistic
the interests of home health therapists will be represented in the associated research efforts.
It feels good to be part of a section contributing
directly to the clinical excellence taking place in
patients’ homes across the country. A strong financial position can only help to ensure these efforts
will continue going forward.
Chris Chimenti is the Director of Therapeutic Services at
HCR Home Care in Rochester, NY, where he manages a
group of over 50 therapists across a three-county region and
serves as a member of the Senior Leadership Team. Chris
has over 14 years of experience in the home health setting.
He is an accomplished speaker on the topics of home health
practice, clinical research, and joint replacement rehabilitation. He previously served the Section as Research Chair for
a period of 6 years. Currently, he serves as Treasurer and a
member of the Executive Committee. Chris can be reached
by email at [email protected].
Spring 2014 - 19
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ϮϬϭϯzĞĂƌŶĚ^ƚĂƚĞŵĞŶƚŽĨ&ŝŶĂŶĐŝĂůWŽƐŝƟŽŶ
ASSETS
Current Assets
Checking/Savings
First Security Bank Checking 77,171.88
Vanguard Investment Acct 146,112.11
Total Checking/Savings
223,283.99
Total Current Assets
223,283.99
TOTAL ASSETS
223,283.99
LIABILITIES & EQUITY
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Vanguard Wellington Fund 104,175.00
Opening Bal Equity
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223,283.99
TOTAL LIABILITIES & EQUITY
20 - Home Health Section t APTA
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Research Section
Presentations Report
2014 APTA Combined Sections
Meeting Presentations
by Matt Janes, PT, DPT, MHS, OCS, CSCS
The 2014 APTA Combined Sections Meeting in Las Vegas,
NV was another great success for our section as well as the
entire professional association. Each year, CSM continues
to grow and this year was no different allowing the Home
Health Section to highlight informative and clinically relevant research. The research committee approved nine different studies to be presented at CSM in the form of 3 posters
and 6 platform presentations. Researchers presented a variety
of relevant topics and findings that could be applied immediately into clinical practice. Abstracts for each presentation are
represented below. The Section would like to thank all of the
authors and coauthors that contributed to each study affording the opportunity to enhance and expand our knowledge
of physical therapy practice. Home Health research submissions are open for CSM 2015 in Indianapolis, IN until June
2nd. Information regarding submission requirements can be
accessed at http://www.apta.org/CSM/submissions/
Matt has 10 years of experience in the home health setting and
is an accomplished speaker on the topics of home health practice,
clinical research, and orthopaedic rehabilitation. He has been
involved with a variety of professional activities at both the state
and national level. Matt currently serves as Research Chair for
the Section and can be reached via email: matt.janes@gentiva.
com
2014 APTA Combined Sections Meeting (CSM)
PLATFORM
Title: Does score on a multifactorial falls risk assessment identify homecare patients who fall?
Authors: Amy Miller, PT, DPT, EdD; Emily Eaves, PT, DPT; Elizabeth Reibson, PT, DPT; Alison Slachta, PT, DPT; Janet
Roberto,PT, DPT
Purpose/Hypothesis: Falls remain a primary preventable reason for re-hospitalization in the homecare population. Use of a
multifactorial falls risk assessment is a process-based quality improvement measure included in the Outcome Assessment and
Information Set (OASIS-C). Agencies may satisfy this criterion through multiple tools, however the goal remains to provide
meaningful falls screening and assessment that will lead to the most appropriate falls intervention plan. The purpose of this
study was to describe and compare patients who fell and did not fall, and examine the ability of the falls risk assessment included in the McKesson electronic documentation system to identify patients who fell.
Number of Subjects: 409 subjects
Materials/Methods: A retrospective data analysis was performed on patient records from a hospital home health provider.
Information regarding client demographics, Falls Risk Assessment score, and selected OASIS-C information was gathered for
all patients who received home care between July 1, 2011 to June 30, 2012 and sustained a fall (n=264). The same data was
Spring 2014 - 21
obtained for a sample of non-fallers discharged over a randomly selected one month period (n=145). Descriptive data was analyzed for both groups and compared using t-tests and Chi square analysis. Likelihood ratios for the threshold score of ≥ 10 on
the Falls Risk Assessment were determined.
Results: Those who fell differed from non-fallers in age, number of medications, total Falls Risk Score, history of falls, and
presence of cognitive/behavioral impairment symptoms. The mean falls risk total score was significantly different (p=0.0002)
for the group that fell, mean = 18 (SD 5.7) compared to those who did not fall, mean = 14.5 (SD 6.1). Using a system selected
threshold of ≥ 10, 93.6% of the individuals who fell and 80% of those who did not fall were identified at risk for falls. A positive likelihood ratio (LR) of 1.2 (95%CI: 1.1-1.4) and negative LR of 0.001 was calculated for the threshold score of ≥ 10 on
the Falls Risk Assessment. An ROC analysis using other thresholds did not change tool discrimination in this sample.
Conclusions: Homecare patients who fall differ from non-fallers however, the examined Falls Risk Assessment categorized
nearly all homecare patients at high risk for falls. These data do not support the isolated use of the Falls Risk Assessment to predict falls. Though a statistically significant difference in mean total scores was found, the low positive LR, close to 1.0, indicates
using a threshold of ≥ 10 will minimally change confidence in falls risk and is not discriminating enough to help guide clinical
decision making.
Clinical Relevance: Home health agencies are positioned to positively impact their patients through appropriate identification
and interventions to reduce falls. Results of this study help guide home care agencies on selection of appropriate falls assessment tools or combinations of tools.
PLATFORM
Title: Efficacy of a Home-Based Exercise Program in the management of CHF: An Evidence-Based Multi-Disciplinary Approach
Authors: Kenneth Miller, PT, DPT; Veronica Southard, PT, DHSc; Peter Douris, PT, DPT, EdD
Purpose/Hypothesis: The Purpose was to determine the efficacy of a multi-disciplinary home program consisting of specific
education and home-based individualized combined aerobic and resistance training exercise program for persons with heart
failure.
Number of Subjects: A total of 765 subjects were screened for the study. At the conclusion, there were 10 subjects accepted
of which 8 subjects completed the first phase. Of the two that did not complete phase 1, one subject was rehospitalized and
another subject withdrew from study for reasons unrelated to the study. Three subjects were in the experimental group and
five subjects in the control group. Compliance was low as noted by only 1 of the 8 subjects completing the activity logs for 12
months. Of the remaining subjects 3 complied with activity logs and answering phone interview questions for 6 months.
Materials/Methods: This study was a randomized, two group, experimental group (combined aerobic and resistance training)
and control group (usual care), pre-post test design measuring the effects of a home-based combined aerobic and resistive training program with subjects between 60-85 years of age with chronic heart failure. The subjects were evaluated at baseline and at
4 weeks for falls history, hospital re-admission history, endurance using the 2MST, quality of life using the MLHFQ, strength
using the 30 second chair stand test, and comfortable gait speed for functional ability. In addition to postage paid monthly
logs, the subjects received follow up phone calls for falls,hospital re-admissions and MLHFQ at 6 months and 1 year
Results: Since there was such difficulty obtaining subjects, percent changes were calculated based on those participating in the
study. Overall there were improvements noted in the experimental group in the 2MST (53%), Gait speed (36%), MLHFQ
(110%) and the Physical Dimensions (276%) and Emotional (35%) subsets of the MLHFQ and 30s STS (125%) over controls.
Conclusions: The small sample size does warrant in depth statistical analysis. This may serve as a pilot however for future work
with a subset of subjects with CHF in different practice settings such as in an outpatient facility or with the same practice setting looking at improving compliance.
Clinical Relevance: The significance of this study suggests that with the appropriate cohort this protocol will add to the existing knowledge base of using resistance exercise and aerobic activity for this population. Furthermore, the low compliance seen
in this study suggests further research is warranted to determine ways of improving compliance.
22 - Home Health Section t APTA
PLATFORM
Title: Improving Function after Hospitalization in Older Adults with Co-Morbid Conditions
Authors: Kathleen Mangione, PT, PhD; Emily Dupaul, MPH; Jessica Hamilton, PT, DPT; Kristin Brumbach, PT, DPT; Erica
Nardi, PT, DPT; Janet Roberto, PT, DPT; Natalija Dementovych, MD; Andrew Rosenzweig, MD
Purpose/Hypothesis: Hospitalization is a profound contributor to functional loss in older adults, especially those with multiple comorbidities. This pilot compared the effect of non-standardized usual care (UC) PT to a progressive multicomponent
(PMC) PT program in these individuals. We hypothesized that the PMC intervention would lead to better outcomes through
a Medicare-covered 60 day episode.
Number of Subjects: 14 patients were randomized, 11 (5 UC, 6 PMC) completed the 60-day episode.
Materials/Methods: The inclusion criteria were ≥ 65 years of age, referred to home health PT after hospitalization, had ≥ 3 comorbidities, and previously ambulatory without human assistance. Exclusion criteria were acute lower extremity fractures, joint
replacement or amputation, cardiac surgery, moderate dementia or referred to hospice. UC was left to the discretion of the PT.
The average number of UC visits was 6±3.1. The PMC intervention was provided 2x/week for 8 weeks and included progressive resistance exercises, gait/balance training, ADL training, and mobility training. Interventions were provided by home care
staff PT. A blinded research PT measured outcomes including the
Short Physical Performance Battery (SPPB), modified Physical Performance Test (mPPT) and Six- Minute- Walk Test
(SMWT) at 0 and 60 days.
Results: The average age was 82±6.7, 55% were women and mean BMI was 27.7±2.7. There were no statistical differences
between groups, although the pilot was not powered to do so. The PMC group showed clinically important changes in all outcome measures (1 point in the SPPB, 5.9 points in the mPPT, 60 meters in the SMWT) and statistically significant improvements in the mPPT. The UC group only showed a one point change in SPPB scores.
Conclusions: This study is the first to evaluate a novel, multi-component home PT program. Due the small sample size, there
were no between-group differences, but the within-group effects suggest the PMC intervention had a clinically meaningful impact.
Clinical Relevance: The PMC intervention fits within the current Medicare reimbursement scheme and can be delivered
by non-research, clinical staff. Patients were able to tolerate the intensive program and showed meaningful gains in multiple
measures. Future analyses may show improved outcomes and decreased costs via decreased readmissions and utilization of resources.
PLATFORM
Title: The Effects of Combination of Resistance Training and Aerobic Exercise on Cardiovascular Status, Strength, Balance,
Gait, and Function in Community-Dwelling Older Adults with Knee Osteoarthritis (OA)
Authors: Wendy Anemaet, PT, PhD, GCS; Amy Hammerich, PT, DPT; Sade Alade, PT, DPT; Steven Brentin, PT, DPT; Tim
Burch, SPT; Jenni Carlos, PT, DPT; Erin Carpenter, PT, DPT; Masa Chalupa, PT, DPT; Rachel Cornish, PT, DPT; Leslie
Cresswell, PT, DPT; Alex de la Paz, PT, DPT; Michael Flores, PT, DPT; Anna Friedman, PT, DPT; Leesa Henderson, PT,
DPT; Kelley Lindstrom, PT, DPT; Megan Moberg, PT, DPT
Purpose/Hypothesis: The purpose of our study was to determine whether a program consisting of aerobic training alone or
a combination of aerobic and resistance training improves cardiovascular, strength, balance, and gait in community-dwelling
adults over age 55 who have knee OA. Knee OA is one of the most prevalent musculoskeletal disorders in the world. Individuals with OA have a decreased ability to perform activities of daily living, as well as impaired ability to participate in recreational
physical activity. It is well established that exercise may be beneficial to offset the functional limitations and pain resulting from
OA, however which type of exercise is “best” has not yet been determined.
Number of Subjects: Subjects were recruited from the Denver, CO metro area through fliers and contacts at local senior independent living communities and churches and randomly assigned to one of two research groups: aerobic training (CVT)
(n=27) or a combination aerobic and resistance training (CMB) (n=23) There was also a control group that did not receive the
intervention (n=11).
Spring 2014 - 23
Materials/Methods: Aerobic (treadmill or bike): 5-10 minute warm-up, followed by 30 minutes at approximately 65-75%
of predicted maximal heart rate; followed by 5 minute cool down. Resistance: 3 sets of 8 repetitions at 80% of their 1RM for
paraspinals, hip abductors, plantar flexors, knee extensors, hip extensors, dorsiflexors, and abdominals. Each group attended 2
sessions a week for 8 weeks; either doing 2 aerobic sessions (CVT) or 1 aerobic and 1 resistance session (CMB).
Results: Significant within-group differences from pre-test to post-test were found in STS (p = 0.040, F=4.476) and FSST
(p<0.001, F=18.963). Significant between-group differences were seen in OLSP: (p=0.008, F = 5.333). Significant differences
in strength were found in both experimental groups for all muscles tested from pre-test to posttest, with the exception of knee
extensor strength (TE: p=0.000, F=21.98; TF: p=0.002, F=10.42; HER: p=0.000, F=22.79, HEL: p=0.000, F=19.37; HAR:
p=0.000, F=45.22; HAL: p=0.000, F=33.75, PFR: p=0.003, F=10.08; PFL: p=0.005, F=8.58, DFR: p=0.000, F=44.11; DFL:
p=0.000, F=44.44). Furthermore, significantly different improvements between groups were also observed in HEL (p=0.047,
F=3.29), HAR (p=0.018, F=4.38), HAL (p=0.035, F=3.62), and DFL (p=0.006, F=5.87). Both experimental groups demonstrated improvements in VO2 from pre-test to post-test, but were not significantly different. However, the CMB group did
show a significant difference when compared to the control for VO2 (p=0.43, F=3.418, 95% CI: 0.22-16.38).
Conclusions: Community-dwelling older adults with knee OA who engage in either aerobic or a combination of aerobic and
resistance training programs should show functional improvements.
Clinical Relevance: Physical therapists could use either aerobic training or combination aerobic and resistance training to improve balance, sit to stand, strength, and aerobic capacity in older adults.
PLATFORM
Title: Joint Mobilization in Acute Total Knee Arthroplasty for Improvement in Pain and Range of Motion
Authors: Cathy Stucker, PT, DScPT
Purpose/Hypothesis: The overall goal of this investigation was to determine if the addition of grade I-II oscillatory joint mobilizations to the tibiofemoral joint would improve range of motion (ROM) and pain during rehabilitation provided in the home
following total knee arthroplasty (TKA). It was hypothesized that the addition of joint mobilization to the standard rehabilitation regimen would improve ROM and reported pain in the acute TKA patient.
Design: Prospective cohort study with repeated measures.
Setting: Home health care.
Participants: 48 adults (18 males, 30 females) who were randomly assigned based on referral to the home care agency from the
acute hospital following TKA. Ages ranged from 46 to 86.
Main outcome measures: Knee flexion and extension ROM, pain report, joint effusion, and quad lag with straight leg raise.
Background: Rehabilitation following TKA typically involves exercise, cryotherapy, and modalities. Manual therapy techniques have included patella mobilization and incision mobilization. The use of oscillatory joint mobilization has not been
investigated for this patient population.
Methods and Measures: Forty-eight subjects who underwent unilateral TKA were randomly assigned to the mobilization or
non-mobilization group when they were admitted to home care for rehabilitation. Time points for measurement included the
initial visit which occurred on the third or fourth day post-op, and the discharge visit from home care which occurred approximately 3 weeks after home care admission. ROM was measured utilizing a longarm goniometer, and pain was reported utilizing an 11-point numeric pain rating scale (NPRS). Knee joint effusion was measured mid-patella utilizing a tape measure. All
participants were instructed in a standard exercise and pain control regimen.
24 - Home Health Section t APTA
Summary of Use: Improvements were noted for both groups in knee flexion and extension ROM, however knee flexion ROM
was not found to be statistically significant between the groups at discharge from home care (x=115.25°±7.54° for mobilization group and x=112.12°±6.43° for non-mobilization group). Knee extension ROM was found to be statistically significant at
discharge for achieving at least 0° of extension or hyperextension, which has been determined to be a successful outcome following TKA. Mean discharge knee extension ROM for the mobilization group was in hyperextension (-.79°±1.44°) compared
to mean discharge knee flexion ROM for the non-mobilization group in slight flexion (x=1.17°±2.26°). Knee ROM measurements in this study were found to be consistently higher than other comparable studies which provided similar rehabilitation
with the exclusion of the mobilizations.
Importance to Members: The most significant finding was the successful achievement of knee extension ROM with 96%
of the mobilization group. Other test measures were not revealed to be statistically significant between the mobilization and
non-mobilization study groups. Oscillatory joint mobilizations would be a beneficial addition to acute TKA rehabilitation programs.
PLATFORM
Title: A Systematic Review of the Most Appropriate Fall Assessment Tool to Predict Falls in the Home Care Setting for the Geriatric Population
Authors: Dianna Holdren, SPT; Ashley Jacobi, SPT; Alicia Meyer, SPT; Alexandra Pauley, SPT; Tracey Collins, PT, PhD,
MBA, GCS
Purpose/Hypothesis: Each year 1/3 of adults age 65 and older falls. In 2000, direct medical expenses for nonfatal falls among
older adults totaled $19 billion and may reach $54 billion by the year 2020. Many falls occur in the home, it is important for
healthcare providers to effectively screen patients at risk of falling. To decrease medical costs and improve mobility in the geriatric population, appropriate fall risk assessments should be used. Therefore, the purpose of this systematic review is to document
the most appropriate fall risk assessment performed in the home care setting among the geriatric population.
Number of Subjects: Studies which included subjects 65 years and older who received physical therapy in the home.
Materials/Methods: Studies were identified through existing reviews, searching four electronic databases (PubMed, Cinahl,
ProQuest, and ScienceDirect), and screening references for studies through January 2000. The search terms used included
“home care” OR “homecare services” OR “home nursing” OR “housecalls” OR “home visit” AND “fall risk” AND “assessment.” Inclusion criteria consisted of peer-reviewed studies published January 2000 to present, human subjects 65 years and
older, English language, and full text. Exclusion criteria included middle aged, young adults, cognitive disorders, dementia,
delirium, and manuscripts. Intervention: Fall risk assessment tools used in the home setting, particularly the Berg Balance Scale
(BBS), the Tinetti Performance Oriented Mobility Assessment (POMA), the Timed-Up-and-Go (TUG), and the Functional
Reach (FR)
Results: Seven studies met inclusion criteria. Two of the seven articles measured the BBS, four of the seven articles measured
the POMA, two of the seven articles measured the TUG, and one of the seven articles measured the FR.
The average PEDro score for the seven articles reviewed equaled three. Two out of the seven studies found that the BBS may be
predictive of falls when used with another fall risk assessment to definitively predict the risk of falls in the elderly. The POMA
is cited in four of the seven studies, as a screening tool to predict falls, yet may not be able to detect mild impairments in the
elderly. The POMA is considered a suitable fall screening assessment. In two of the seven articles, the TUG is cited as being the
second most suitable, behind the POMA, in assessing fall risk. The TUG is appropriate for frail older adults. The FR is cited in
one of the seven articles as being able to predict falls when used in combination with other fall risk assessment tools.
Conclusions: With the variety of tests to assess balance in the home and multiple factors attributing to falls, there is still no
single test that can be considered most appropriate in predicting falls. More diagnosis specific research is needed within the
home care setting.
Clinical Relevance: The most appropriate fall risk assessment tool used by PTs in the home health setting to predict falls in the
geriatric population needs to be supported in the literature.
Spring 2014 - 25
POSTER
Poster #3001
Title: The Development of a Comprehensive Older Adult Screening Tool to Detect Decline in Community Dwelling Older
Adults
Authors: Hammerich AS, Anemaet WK, Brown K, Evens K, Kohnen J, McCluskey R, Peloquin C, Watkins D
Purpose/Hypothesis: Functional decline is a loss of independence in activities of daily living. For community dwelling older
adults this functional decline often results in the need for assistance, increased use of health care including hospitalizations and
emergency room visits, increased need for institutionalization, social isolation, and death.
Detecting individuals at risk for functional decline and intervening to prevent the decline is imperative to improve quality
of life throughout the later years of life and to prevent undue strain on the community’s resources. The first step in preventing functional decline in older adults is identifying those at risk. Several studies have looked at methods of detecting risk for
decline on an annual basis using short, simple tools performed by physicians or nurses. However, the process of functional decline is a complicated and dynamic one and the timeframe for affecting functional decline is small. Therefore a more comprehensive tool that is performed on a more frequent basis may aid in more accurate prediction of persons at risk for decline.
The purpose of this study was to develop a community-dwelling older adult screening tool to detect risk for decline in older
adults and implement it every three months with adults aged 55 years and older over the course of a year to determine its feasibility and usefulness in detecting decline.
Number of Subjects: 20 older adults
Materials/Methods: Subjects were recruited from underserved populations in the Denver metro area. After signing an informed consent they underwent assessment of cognition, visual acuity and depth perception, posture physical function, balance, psychosocial measures, nutrition, gastrointestinal function, incontinence, strength, bone mineral density, pulmonary
function, flexibility, physical activity, and pain. Subjects then recorded on a calendar each day they felt well, each day they were
ill and with what illness, and any medical or health related appointment, hospitalizations, and emergency room use. Subjects
were reassessed every 3 months to determine changes in status. Statistical analysis was performed with SPSS version 21 and included descriptive statistics, ANOVA, Kruskal Wallis, and correlational analyses.
Results: This study examined 11 females and 9 males ranging in age from 56 to 89 years with a mean age of 72.95 years,
Functional and health status changed in most of the subjects over the course of the year. Data showed strong trends for relationships between many of the measures and percentage of days well or unwell and medical visits. Each assessment lasted approximately 75 minutes.
Conclusions: This comprehensive assessment for community dwelling older adults may be an effective way to detect decline
early in this population. Further studies are needed to determine if it can be shortened and if it can be used to target interventions to prevent decline.
Clinical Relevance: This study provides some possible early indicators of decline in community dwelling older adults which
may assist therapists in implementing preventative measures.
POSTER
Poster #3002
Title: Making it HIRT So Good: Using high intensity resistance training to improve function in an older adult with a six year
history of prolonged mechanical ventilation
Authors: Falvey J
Background/Purpose: Resistance training (RT) is emerging as a promising intervention for improving function in persons
undergoing mechanical ventilation. Chiang et al (2006) demonstrated that RT for patients undergoing prolonged mechanical ventilation (PMV) in a post-acute setting increased functional independence, lower extremity strength, and ventilator free
time. However, much of the research describing RT interventions is carried out within inpatient hospital settings. There is a
paucity of literature describing how high intensity resistance training (HIRT) may benefit patients after discharge in the home
setting. This case report examined: 1) if physical therapy including HIRT is feasible and safe for a homebound patient with 6
year chronic ventilator dependence, and 2) if HIRT can facilitate meaningful functional gains during a home health episode.
26 - Home Health Section t APTA
Case Description: A 62 year old female with end stage COPD and PMV for 6 years participated in an initial 8 week program
of high intensity resistance training. Her medical history included chronic hypoxemic respiratory failure, hypertension, and
hypothyroidism. She had never participated in formal physical therapy over the last 6 years. Patient was seen 22 visits over 8
weeks for HIRT, with intensity titrated to fatigue at 1 set of 8-12 repetitions. High intensity UE exercises were added in week
4. Interval aerobic training performed during some sessions, but poorly tolerated.
Outcomes: Patient was assessed with 30 second chair rise test (CRT) for LE strength, 8 foot up-and go to assess home mobility
(environmental constraints prohibited full TUG), and the 2 minute walk test to assess functional endurance. She scored 0 repetitions on 30 second chair rise test, 107 seconds on 8 foot up and go, and walked 16 feet on the modified 2 MWT allowing
seated rest breaks, with Borg 17/20. Her goals for therapy were to be modified independent with toilet transfers to/from bedside commode. At 4 weeks, patient had improved 30 second CRT to 2 reps, 8FUG to 40 seconds, and 2MWT to 28 feet. At 8
weeks, 30 sec. CRT was 5 reps, 8FUG was 28 seconds, and 2MWT was 46 feet, Borg 14/20. She achieved independence with
toileting tasks to/from bedside commode across room using a cane.
Discussion: HIRT was well tolerated for this patient, and contributed to significant functional gains in LE strength, aerobic
capacity, and functional independence. While further research is certainly needed to optimize exercise prescription, it appears
that HIRT is a feasible option for therapists to utilize with patients undergoing PMV. This case report helps build on current
research on physical therapy for the critically ill, and identifies the role home health PTs can play in continuing gains made in
acute care settings. Importantly, the gains occurred within a home health episode of care, which has practical implications for
current PTs and allows an immediate translation into clinical practice.
POSTER
Poster #3003
Title: The Challenges of Researching Patients with CHF in Home Health Using Resistance Training
Authors: Southard V, Miller KL
Purpose/Hypothesis: The incidence of Chronic Heart Failure (CHF) continues to increase as people are living longer. Persons
with CHF generally exhibit shortness of breath and/or fatigue with minimal exertion and exercise has been found to be an effective treatment. Given the variability of presentation of the patient with CHF, it is important that the exercise prescription be
individualized. Elastic resistance bands have been found closely related to dumbbells in muscle activation and perceived exertion. The purpose of this report is to describe the barriers when researching home health subjects with CHF and provide alternative strategies to address the challenges.
Description: The research plan followed subjects with CHF for 12 months. The experimental group was given resistance exercises using theraband based at 30-60%of their 1 repetition maximum (1RM), for a period of 4-6 weeks, and then was followed
by telephone and monthly activity calendar the remaining time. A control group received usual care. This study had dual Institutional Review Board (IRB) approval. Challenges were discovered in the inclusion criteria. The first barrier was age, which
included subjects 60 to 85. Potential subjects (n=251) were excluded due to the upper age limitation. Some subjects wanted
to participate, but the delay in getting the New York Heart Association (NYHA) Class and approval from MD precluded their
participation. Remarkably, the majority of the MDs agreed that resistance exercise was a good idea, but it was arduous to get
the necessary information in writing to start the program. Implicit barriers were related to the physical therapists (PT’s) being
fearful of offering such a dynamic program to their patients, (n=251) despite training sessions and familiarization with methods that needed to be employed. In short, after screening 765 potential subjects, 10 were accepted into the study and only 8
completed the first phase, in which they were d/c from home PT and expected to continue with the exercises and monitoring
by the researchers.
Summary of Use: The major barrier was the time element. Having the NYHA class at initial evaluation would have saved time
and allowed for these patients to participate in the study. The positive outcome was that 13 staff therapists now are comfortable
with resistance training CHF home based patients using the methods they were instructed in. The PT’s have also incorporated
5 more outcomes into their practice. In summary, too many constraints created by the inclusion criteria mitigated the anticipated number of subjects.
Importance to Members: When preparing a research proposal, it is paramount to consider time since the length of time on
program in home health is continually declining. Strategies to avoid these barriers and improve success in recruitment will be
provided. The significance of this report suggests that with retooling, protocols such as this will provide the opportunity to extend the evidence base of resisted therapeutic exercise and aerobic activity for this population.
Spring 2014 - 27
Research Section
Case Study
Results of Physical Therapy in the Home Care Setting With a NonEnglish-Speaking Patient: A Case Report
by Chris Mitchell, Student PT, Joseph Lattuca, MSPT, Andrew Opett, DPT, OCS
Introduction:
Cultural competence is a highly sought after skill in
today’s health care industry within the United States,
which is famous for its melting-pot cultural diversity.
Cultural differences can pose great barriers to patient
care, most notably the factor of language differences.
Cultural disparity in health care has been well described,
with data showing minority groups suffer disproportionately from cardiovascular disease, diabetes, asthma,
cancer, and many other conditions.1 In addition to
cultural differences in health care, there is also large
variability in health care literacy. This can affect patient
choices, participation, and outcomes significantly. Patients may find it more difficult to understand what
the information on their prescription means, or how to
appropriately follow instructions given by health care
professionals due to either to professional language or a
language barrier. Patient satisfaction has also been found
to be greatly reduced when dealing with a language
barrier.2 Many daunting factors influence the delivery
of health care, especially for those who don’t speak the
prominent local language or are economically disadvantaged. Therefore, it is essential for health care workers
to use a multi-dimensional and professional approach
to deliver their services most effectively to those who
need them. The purpose of this case report is to report
the results of physical therapy in the home setting with
the adversity of a language barrier between provider and
patient.
Case Description:
The patient is a 65 year-old Ukrainian-speaking female
who was admitted to the hospital for right femoral
Open Reduction Internal Fixation (ORIF) and hardware removal. The patient originally suffered a fall in
the Ukraine, four months prior to the admitting procedure, while visiting family. Subsequent ORIF surgery
was performed to repair a fractured right femur. This
surgery failed to achieve satisfactory stabilization of the
fracture and a second revision surgery was performed
within the following month. During this revision procedure, the femoral artery was severed and the patient suffered a severe hemorrhage, which complicated the completion of the orthopedic procedure. The patient then
flew back to the United States for the admitting surgery,
28 - Home Health Section t APTA
which was performed three months after the revision
surgery. The right femur was successfully stabilized with
a 95-degree blade plate and a revision of the thigh scar
with a complicated wound closure. Past medical history included chronic headaches, hypothyroidism, and
hypercholesterolemia. Medications include Synthroid,
Metoprolol, Oxycodone, Ergocalciferol, Amitriptyline,
Atorvastatin, Enoxaparin, Levothyroxine, and Tylenol.
Examination
A physical therapy examination was performed in the
patient’s residence one month after admitting surgery
and six days after she returned from inpatient care,
which included physical therapy services. The patient’s
daughter was present at this session to provide translation between the physical therapist and patient. The patient’s husband was also present during the evaluation.
The patient reported she was very motivated to return
to her prior level of independence and was willing to
be fully compliant with therapy. Vital signs were measured with blood pressure reading 122/72 mmHg, heart
rate of 96 bpm and O2 saturation of 96%. Prior to the
initial fracture, the patient was independent with all activities of daily living (ADL), ambulated and performed
all transfers without assistive devices (AD). Upon examination, numbness and tingling was reported over
the right lateral thigh and knee. This area included the
entire length of the incision and distal to the lateral area
of the knee until the head of the fibula on the right side.
The patient reported 4/10 pain on the Numeric Rating Scale (NRS) and “pressure” over the right anterior
knee and right lateral thigh over the incision area. The
incision was healing with no complications with steristrips remaining along its entire length. Prescribed pain
medication was reported to be successfully controlling
symptoms. A functional assessment was performed and
the patient was stand by assist to contact guard with all
ADLs, transfers, and during ambulation, which was performed with a rolling walker with non-weight bearing
(NWB) of the right LE. While ambulating, the patient
held the NWB right lower extremity into hip flexion
and knee extension to maintain the non-weight bearing
status. Right patellar mobility was decreased in all directions and changes in soft tissue mobility were noted
throughout the proximal and lateral aspect of the right
lower extremity. Patient education included instruction
on passive range of motion exercises for right knee extension and flexion, including hold time and frequency.
A Timed Up and Go (TUG) test was performed using
a rolling walker on a carpeted surface and right lower
extremity in NWB. The TUG time was 34 seconds and
indicated the patient was at risk for a fall.
Evaluation
The patient presented with non weight bearing status
for 2 ½ to 3 months per surgeon’s orders, hip and knee
range of motion (ROM) deficits, right lower extremity
numbness, tingling and pain status post ORIF of right
femur. These impairments were linked to the functional
limitations of ambulation, sit to stand and surface-tosurface transfers. Prognosis was reported as good based
upon the patient’s prior level of functioning, success of
revision surgery, motivation and willingness to be compliant with therapy, with anticipated goals of 110o of
knee flexion, TUG score of 20 seconds, reported pain
of 1/10 on the NRS and an expected outcome of independence with all functional mobility. The treatment
plan is to include passive, active-assist and active ROM,
strengthening, functional mobility training, and patient
and caregiver education.
Intervention
The greatest challenge to the success of the treatment
sessions was communication through the EnglishUkrainian language barrier. Proactive steps were taken
by the therapists to learn simple phrases and words
in Ukrainian to establish a base of communication. A
translation application on the therapists’ documentation tablet was also utilized. Both parties were able to
speak short phrases and words into the application
on the device to be translated into the other’s primary
language. The patient and her husband also owned a
Ukrainian-English translation dictionary, which they
used to proactively learn English words and phrases.
These measures resulted in improvement of the patient
and her husband’s English speaking skills with over-all
improvement in communication between parties. With
the exception of the first two visits, no human interpreter was present during the treatment session. After three
sessions no translator service was used until discharge,
where care was taken to ensure correct understanding
and clear communication of the situation.
Due to the location and invasive nature of the patient’s
admitting diagnosis, early rehabilitation was addressed
as close to a Total Hip Arthroplasty (THA) protocol as
possible. Case specific differences that were taken into
consideration from typical THA protocols included the
extended NWB status, secondary to surgeon orders, and
clearance to adduct and internally rotate past neutral
and flex greater than 90o at the hip.3 Patient interventions included passive, active and active assist ROM
and strengthening exercises in supine including heel
slides, quad sets, gluteal sets, and ankle pumps. These
exercises were progressed to the sitting and standing
positions as tolerated. Visual aids, such as illustrations
of the exercises with numbers of repetitions and sets,
were provided to ensure total understanding through
the language barrier. Based upon the posturing of the
non-weight bearing lower extremity during ambulation,
there were early concerns about knee flexion ROM, specifically with rectus femoris length. These concerns were
addressed with stretching, such as supine heel slides and
seated self-applied active assist knee flexion with her
sound lower extremity, and activity modification, which
specifically included education on ambulating with a
neutral hip position and knee flexion to prevent further
rectus femoris activation and potential shortening. Ambulation, transfer, self-care and caregiver training and
education were all performed with the help of previously mentioned lingual tactics. Scar tissue mobilizations
were also provided to encourage ideal incision healing.
Interventions were advanced when the patient’s reported
pain and activity tolerance improved within reasonable
standard THA guidelines.3
Results
For pain, ROM and translator assistance results refer to
Table 1. For functional mobility results refer to Table 2.
Table 1
Visit Number
Pain (0-10 Scale)
R Knee Flexion ROM (Degrees)
Translation Assistance
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Spring 2014 - 29
Table 2
Functional Mobility Status
Initial Status
Final Status (6 weeks later)
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Discussion
As seen in Table 1 and Table 2, measurable improvements were made in ROM, reported pain levels, standardized measures and functional mobility assistance.
Since the focus of ROM was knee flexion values, total
knee athroplasty (TKA), which has similar rehabilitation focuses, was used as a comparison. While clinically
significant knee flexion ROM values for TKA are lacking in the literature, comparisons can be extrapolated.
Minimally clinical important differences (MCID)
between preoperative measurement and postoperative
measurement are not well established. The strongest predictor of postoperative TKA ROM has been found to be
preoperative TKA ROM, equating to 1.7o of post measurement to every 10o of pre measurement. 4, 5 Since no
measurements were taken prior to the initial incident,
comments on possible significance of results are inappropriate. It has also been shown that knee flexion of
67o is necessary for swing phase of gait, 83o needed for
ascending stairs and 90o to descend stairs.6 The patient’s
knee flexion ROM values did not achieve these values
before discharge.
With regard to NRS for pain, it has been found a
decrease of 1 units or 15.0% of reported pain to be
MCID.7 It has also been found that patient reporting of
pain with a NRS is somewhat reliable and can indicate
real change, especially with high reported initial pain
levels.8 The literature suggests to convert pain into percentage changes for better insight into patients’ pain.9
With these suggestions we can show her reported pain
decreased to only 25% of her previous reported pain,
from 4 to 1, achieving the anticipated goal and can be
considered a reliable and significant reported change.
TUG score values are well documented within the
health care literature. Both of the patient’s scores are
indicative of a high risk of falling within all population
types. The patient did not meet her anticipated goal
of a TUG time of 20 seconds. TUG scores have been
found to increase with use of assistive devices and nonweight bearing statuses increase instability during the
30 - Home Health Section t APTA
testing.10 Both of these factors were exhibited by the
patient and could have contributed to her time. Despite
the lack of a change in fall-risk, her 11 second improvement is greater than or equal to all population types
minimal detectable change, which is 11 points or less.
None of these population types had a non-weight bearing status, however.11 While functional mobility testing
can show minimal detectable change and differences,
assistance levels lack literary review and standardization.
The patient did meet her expected outcomes of independence with all functional mobility.
The limitations of this case report include an inherently
small sample size of one patient. This makes it difficult
to extrapolate the results of the physical interventions
to the greater population. A separate physical therapist
conducted the initial visit, as was protocol by the home
agency. The patient was also only seen for six visits lasting one hour each, which may not have been enough to
elicit clinically significant changes to the knee flexion
ROM and outcome measure. The most limiting factor
was the surgeon order to discharge patient from physical
therapy services until clearance to full weight bearing.
With the combination of available technology, visual
aids, proactive and open interactions with the patient
and her family, therapy was effectively delivered with
less outside assistance each subsequent visit, save the
last. The treatment team decided it was in the patient’s
best interest to have a Ukrainian translator service available for the discharge session to ensure total and complete understanding of the situation.
With increasing cultural diversity in the United States,
the health care industry must successfully adapt delivery of its services on an individual basis, considering
linguistic and cultural factors, in order to ensure the
greatest patient outcomes. The problems of health care
literacy, delivery and access to services for low-income
groups, and language barriers in health care are well
documented, but clear solutions are lacking. The com-
bination of a translator, translator service, translation
tablet applications, visual aids, and proactive efforts
from the therapists, patient and the patient’s spouse can
provide effective and measurable outcomes. Adoption
of a multifaceted approach to the delivery of health care
can be an effective treatment plan to implement in the
future.
References
1. Betancourt JR, Green AR, Carrillo JE, AnanehFirempong II, O. Defining Cultural Competence: A Practical Framework for Addressing
Racial/Ethnic Disparities in Health and Health
Care. Public Health Reports. July – August 2003.
118. 293-302.
2. David RA, Rhee M. The Impact of Language as
a Barrier to Effective Health Care in an Underserved Urban Hispanic Community. Journal of
General Internal Medicine. April 1997. 12. 123.
3. Beagan C. Brigham and Women’s Hospital Depart of Rehabilitation Services Physical Therapy.
Total Hip Arthroplasty/ Hemiarthroplasty
Protocol. Available at: http://www.brighamandwomens.org/patients_visitors/pcs/rehabilitationservices/physical%20therapy%20standards%20
of%20care%20and%20protocols/hip%20-%20
thr%20protocol.pdf. Accessibility verified January 4, 2014.
4. Stratford PW, Kennedy DM, Robarts SF. Modelling Knee Range of Motion Post Arthroplasty:
Clinical Applications. Physiotherapy Canada. Fall
2010. 62(4). 378-387.
5. Anouchi YS, McShane M, Kelly Jr F, Elting J,
Stiehl J. Range of Motion in Total Knee Replacement. Clinical Orthopaedics and Related Research. 1996. 331. 87-92.
6.
Dennis DA, Komeistek RD, Stiehl JB, Walker
SA, Dennis KN. Range of Motion After Total
Knee Arthroplasty: The Effect of Implant Design
and Weight-Bearing Conditions. Journal of Arthropalsty. 1998. 13. 748-752.
7. Salaffi F, Stancati A, Silvestri CA, Ciapetti A,
Grassi W. Minimal Clinically Impoartant Changes In Chronic Musculoskeletal Pain Intensity
Measured On a Numerical Rating Scale. European Journal of Pain. August 2004. 8(4). 283-291.
8. Krebs EE, Carey TS, Weinberger M. Accuracy
of the Pain Numeric Rating Scale as a Screening
Test in Primary Care. Journal of General Internal
Medicine. October 2007. 22(10). 1453-1458.
9. Sloman R, Wruble AW, Rosen G, Rom M. Determination of Clinically Meaningful Levels of
Pain Reduction in Patients Experiencing Acute
Postoperative Pain. American Society for Pain
Management Nursing. December 2006. 7(4).
153-158.
10. Yeung TSM, Wessel J, Stratford P, MacDermid
J. The Timed Up and Go Test for Use on a Inpatient Orthopaedic Rehabilitation Ward. Journal
of Orthopaedic & Sports Physical Therapy. July
2008. 38(7). 410-417.
11. Rehabilitation Measures Database. Rehab Measures: Timed Up and Go. Available at: http://
www.rehabmeasures.org/Lists/RehabMeasures/
DispForm.aspx?ID=903. Accessibility verified
December 20, 2013.
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