February 6, 2012
An Awakening
A pretty neat thing happened at work last week. I was writing up notes at lunch time in the rehab gym while eating my lunch. Out in the hallway, a young man was playing the piano brought out from the solarium and several patients and staff were listening to him play. Inside the gym, a gentleman was working at the upper body ergometer.
Having music in the gym is not untypical; often a gym will have a system playing music from the radio. But what we heard this day was classical music played live and rich, resonating throughout the rehab floor. This is a good thing, because music is found to have a calming effect. Not only that, music, unlike speech, is a whole brain activity. This will become important in a moment.
As I'm writing up my notes, I hear the gentleman at the ergometer say, "I've had a stroke!" I look over at him, he pedaling away, in no apparent distress. I see no new symptoms of a stroke, in fact, the initiation of speech is new for this man. "oh wow! I've had a stroke!" I slide over to him, "you want to talk about it?" He exhibits word finding problems, stuttering and perseverating on one of the words he can grasp but I can tell it's not quite adequate to express what he really means.
A cerebral vascular accident (CVA or stroke) is a type of traumatic brain injury where blood supply is cut off from a portion of the brain, either due to a burst or blocked blood vessel. It is strongly related to heart disease. Following a CVA, affected tissue areas of the brain, like any part of the body that is injured, exhibit swelling. As that inflammation goes down, patients often begin to get function back that they had lost. Forcing the engagement of this process too early is found to have more detrimental effect upon recovery than if we allow the brain to rest 3-4 days.
For my friend in the gym, what I was likely witnessing was post-ischemic recovery of brain tissue. With music playing in the background, more areas of the brain were stimulated, which would increase blood supply to the cortex (or outer covering of the brain). This would allow alternate blood flow to reach affected areas of the brain, and with it memories, words, and capabilities that the brain may have lost.
I can only imagine for someone like this, what his recent experiences must be like. He's in the hospital and may not understand why? Amnesia of the event may lift like a veil, and memories of the precipitating event may flood in, along with the emotions surrounding the event. A realization of the extent of the loss of prior function or the gratefulness to realize that they have survived such a dangerous experience may be overwhelming. With it may come relief and a clearer insight as to the why people have been pushing, pulling, prodding, moving him from one place to another, along with a sense of purpose that these things will help with recovery.
It was a big moment and really neat to see. I informed the attending physician and the speech therapist regarding their patient's breakthrough. I think he'll be alright now. Rather than floating through his therapy as though he is lost, he will likely engage his therapy with vigor and purpose, speeding his recovery.
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February 3, 2012
Unfamiliar Terms in Medical Charts
As part of every physical therapy evaluation and treatment requires that we look up a patient's medical history. Do this enough and you begin to see patterns emerge. It seems that most people who are ill and end up in the hospital have hypertension, diabetes mellitis, and hyperlipidemia. This triad is known as metabolic syndrome - avoid getting these diseases and you likely cut your risk for being hospitalized.
Then there are terms in the medical history that I've never seen before. These require that I pull out my medical dictionary or, even quicker, go on line and look up the definition. The first of these is Eaton-Lambert Syndrome. Lambert-Eaton syndrome is a disorder in which faulty communication between nerves and muscles leads to muscle weakness. This is a diagnosis that physical therapy can work to improve.
Then there is the term balanitis. My colleagues and tossed this one around, trying to take the root of the word and find a reasonable definition: could it be a swelling of the balance? Is our patient an "uber balancer"? Maybe he's a superhero. Well, my coworkers and I were way off. Unfortunately for the patient, the disorder is much less glamorous and intimate. It does involve swelling, but it involves the foreskin of the penis. There's something you wish you didn't know about a person. I doubt my patient would want me to know either. This is why we have HIPAA laws. As Elaine from the show http://www.amazon.com/exec/obidos/ASIN/B000VECAEE/ref=nosim/fingertips-20 once said, "I don't know how you guys live with those things."
Yesterday, I stumbled across Laennec's cirrhosis. I know what cirrhosis is, but I had never heard of Laennec's. This type of cirrhosis is related to over consumption of alcohol. The patient who had this in their diagnosis presented with swollen abdomen and really skinny arms and legs, appearing almost like malnourished individuals in impoverished countries.
And finally, while I was checking out a CT report on a patient with CVA, they were found to have encepholomalacia, a degenerative softening of the brain, usually due to a brain injury. But it was the location of the problem, the "opercular region of the temporal lobe" that threw me. We learn brain and spinal cord anatomy in PT school. We learn general functions of the brain regions and how they impact function. But when someone starts getting into the particulars of brain anatomy, I need a review.
This is why blogging is important to me, because it helps me brush up on areas where I have gaps in my knowledge. Better yet, I acquire practical knowledge in the context of my job and how the condition presents in a particular patient. This helps me learn rather than simply memorize facts out of context, which is what much of PT school felt like. I believe this process helped me become a better massage therapist, and I believe it will help me be a better PT clinician, as well.
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January 30, 2012
Palliative Massage
I had a patient on my list in the cancer and palliative care ward, her diagnosis: anemia. I checked prior level of function and her lab values - she was dependent in bed mobility. As a PT intervention, I can perform range of motion exercises, teach her rolling skills so that she may assist her caregivers, maybe sit her on the edge of the bed to improve stamina and trunk control for sitting unsupported, a necessary precursor to walking.
The patient was lying in bed, sleeping, her breathing loud and labored. Her husband was there and seemed to shrink into the corner when I arrived. Something struck me as NOT right here. My instincts said, "let her rest," so I went to speak with the nurse to get the scoop on why a patient who might be weakened by anemia sounded so bad. The nurse simply stated that the patient was usually agitated and thrashing against her covers, that this was the calmest she had been in a while. I kept trying to glean from the nurse whether I should leave her be and let her rest, but the nurse wouldn't say. She did jump to action, however, when I mentioned the patient's breathing seemed labored. I wrote my note, deferring treatment to let the patient rest.
Back at the nurse station, I got the full story from the Hospice nurse. It's a torturous history: loss of a daughter to leukemia, then a grandson in a car accident, then the diagnosis of ovarian cancer just days preceding the death of her father. This poor woman, who for all appearances looked healthy except for the labored breathing and her forgotten husband in the corner of the room, deserved some respite. As my instincts had told me, something, indeed, was NOT right. And then the Hospice nurse suggested the obvious, something to soothe the patient: massage.
I entered the room and encountered the husband gently cleaning his wife and changing the bed pad. She was awake now and moaning. I jumped in to assist him, holding her steady, soothing her as best I could. He gently cradled her to roll her again to clean her other side, I taught him what strategies I knew. And when we were finished, I performed massage on her arms and legs. She remained calm during this time, exhibiting Cheyne-Stokes breathing. She stopped breathing for what seemed like forever, then a breath, then a second, a modest pause and then a third. I said to her, "keep breathing," praying, "God, don't let her die on me." Her husband hugged the corner, almost shyly, watching from across the room.
As well intentioned as my ministrations were, I felt like an intruder. This should be his time with her, and if she was going to die, it was not my place to be there. She stopped breathing again, but then resumed, a pattern emerging that so long as it didn't change, I could stay and finish my work. I left the lotion for him, and began to rearrange furniture. I put the chair by the bed: "sit." I had him hold her hand, and I began to work on him: shoulders, neck, scapulae, paraspinal musculature. In all this, I wondered, who might be taking care of him?
This was a risk I took. This was possibly outside of my scope of practice and certainly not a billable service, working on the family member of a patient. But I believe it was the right thing to do. I'll work late to make up the time, reporting that I was on break time, if it becomes an issue. But I told no one (until now*). Only his wife, who cried out and flung her arm wide, may know of my attempt to lend her spouse some small strength for the final hours of her life. This tragedy is not hers alone; he, too has lost a daughter, a grandson, his second father, and now his best friend and life companion as he watches on helpless to do anything. Could anyone begrudge this man a human kindness at such a critical time?
Continue reading "Palliative Massage"
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January 26, 2012
Solving Communication Barriers
I love working in New York City. There are so many wonderful, beautiful people here from all over the world. There is no doubt that, not only in NYC, but everywhere in America, diversity is increasing. This is a good thing, because I believe that a variety of viewpoints is enriching.
However, there are pitfalls. For me, language is a barrier. While I managed to wend my way through college, changing majors 3 times and finally finishing after 6 years, I managed to dodge the foreign language requirement. I speak English and can only count to 10 in six different languages, including Mandarin. Many of the patients I encounter in our hospital speak Russian, a language for which I only know "yes" and "no." This makes performing physical therapy evaluations difficult and frustrating for both me and the patient.
I may have found a solution. By utilizing several standardized scales for things such as pain and rate of perceived exertion, patients can report what is happening in their bodies. By using picture flash cards, I can figure out much of the information I need to gather about their living situation, the assistive devices they use, and mobility barriers such as steps into the home. Recruiting a few co-workers with foreign language skills, I can fill in the rest of my cards with a few key questions in a yes/no format.
No matter your knowledge and experience base, no education is wasted. Those graphic design skills I picked in my undergraduate major have served me well. When I owned my own business, I designed my own logo, business cards and forms. I can still use those skills to design flash cards in a variety of languages to carry with me during patient interviews: Spanish, Russian, Cantonese, and Creole. I can even use my counting skills to help patients monitor their exercise reps. Of course, a smile and a gentle touch (learned during my massage therapy training) need no translation.
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January 23, 2012
Yoga Injuries
I just ran across an old article in the New York Times regarding Yoga injuries from July 2010, When Yoga Hurts. The following quote from the comment field caught my attention:
Any time you’re forcing your body to do things it doesn’t want to do, you’re running the risk of damaging tissue. This will be exacerbated by the desire to be just like those flimsy little 22 year olds who are gifted with wonderful flexibility.
I discovered yoga when I was 17. A friend lent me a paperback book from the 1960s and I remember being somewhat horrified, yet fascinated, by the grainy black and white photos of an man contorting his body in ways I never knew possible. Why I chose to read the book, I don't know, but the concepts fascinated me. I began to systematically follow the asanas and got to about page 189 when my friend wanted her book back. My transformation was already underway.
I believe one of the reasons I took to yoga was because I owned a "flimsy" 17 year old body and found it easy to achieve many of the poses. Within 3 to 6 weeks, I was able to make physical changes that made me both stronger and more flexible. For years in my teens, I felt frustrated and rudderless, and the mental and emotional clarity provided by yoga was just what I needed.
In 1991, I was involved in a car accident. My doctor told me to immediately stop doing yoga. Physical therapy to treat whiplash and subsequent Alexander Technique classes, improved my posture and corrected some of the anomalous ways that I used my body that I picked up from my Yoga practice, such as standing with my feet together.
Sadly, I left yoga behind for the most part, dabbling a bit as a massage therapist, in a class offered at a local hospital and later with a former client who was a new instructor. What I miss about it is ability to revel in my body, rolling around on the floor in a open space, and the clarity of mind that yoga offered me.
But is with the New York Times most recent article about yoga injuries, such as strokes, neck injuries, spinal injuries, etc., that I may have stumbled upon my original yoga book: B. K. S. Iyengar's seminal Light on Yoga, published in 1965. Flipping through the pages through the Amazon site' Look Inside feature, I stumble upon Iyengar's description of standing on page 64:
People do not pay attention to the correct method of standing. Owing to our faulty method of standing and not distributing the body weight evenly on the feet, we acquire specific deformities which hamper spinal elasticity. [When standing properly,] our hips are contracted, the abdomen is pulled in and the chest is brought forward. One feels light in body and the mind acquires agility.
What a beautiful concept. What I remember about this first book was the clear step-by-step instructions about how to achieve the poses, the process. And it was the tweaks once inside the poses that were described that helped advance the position. Effects of the pose on the body are a nice addition, but it is the notes that are available for those too weak or too sick to go back to the most basic positions that I felt helped make this book safe for those teaching themselves yoga. The message basically says, if you are not able to do this, go back to page one and master this before you try to move forward.
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January 19, 2012
24 Hours In The ER
I've begun watching BBC America's 24 "Hours In The ER". Not only do they tell the saga of individuals admitted to the ER, they also interview hospital staff, from doctors and nurses to technicians. I've only seen 3 episodes, but I'm hooked.
It's the little touches, the unvarnished truths regarding human nature, and the trouble that people make for themselves that make this show for me. I guess I can relate, since working in the hospital has exposed me to the best and the worst in people. One detail in "24 Hours In The ER" is a sign on the wall that says roughly "please be polite (or patient or kind), we are trying to help you."
I know that now one is at their best when they are in the hospital. That goes for both patients and their very distressed families. Nurses are pulled in so many directions, handling not only mundane tasks, but also attending to crises and the idiosyncratic demands of a few patients. It amazes me they haven't snatched all the hair out of their heads. More often than not, all employees in a hospital are patient, caring, and hard-working. Every person and the work they do, from doctors to house-keeping, play vital roles in keeping the hospital operating smoothly and seamlessly.
I have found that I use those words from that sign, "please understand, we're trying to help you," when patients become agitated because of the things I ask them to do as part of my job as a physical therapist. These words help calm people, and, if they do not, it falls to me to find out why a patient becomes upset. An example, a patient with a blood clot in his leg refuses any kind of PT intervention. He is vehement that he knows he should not move (which only creates more opportunity for blood clot formation) and that I trying to kill him. We give patients 3 opportunities to refuse PT intervention services before taking them off our treatment list, just in case they are having a bad day or a have a change of heart as they feel better. This individual becomes verbally abusive and I wouldn't put it past him to begin throwing things at me if I darken his doorway again.
Later, I found out through his wife that his father, terminal with lung cancer, had been diagnosed with a blood clot in his leg. Faithful to his generation's willingness to follow doctors' orders, he dutifully performed his exercises. The blood clot broke free, became an embolism, traveled to his lung and lodged there. He died the next day. That episode is the basis for his son's fear and hostility. It is these kinds of emotional stories that "24 Hours In The ER" tells so well.
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January 16, 2012
Women and Sleep Apnea
Women may be under-diagnosed with sleep apnea because they tend not to exhibit the classic symptoms that men do. A "typical" sleep apnea patient is a middle-aged, overweight or obese male who snores. Women present with insomnia, morning headaches, mood disturbances or other symptoms, many of which are non-specific.
According to sleep study experts, for every 2 to 3 men who are diagnosed with sleep apnea, one woman can also be diagnosed. However, in reality, the diagnosis is 1 in 10. When should women see their doctor? Symptoms may include:
Difficulty maintaining sleep, un-refreshing sleep, chronic fatigue, lack of energy, snoring, frequent nighttime urination, awakening gasping, daytime sleepiness, awakening with a headache, or edema (swelling) of the feet.
Pregnant women, over-weight or obese women and women who are or have transitioned through menopause are more likely to have sleep apnea. Women also have sleep disorders secondary to life-style stresses and hormones.
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January 14, 2012
Remaining Engaged
I've gotten into the habit of waking to work listening to my Ipod. And while I don't play it so loud that I can't hear what's going on around me, I do recognize that I don't see the little things that the city has to offer, people don't say hello or smile, I find myself less engaged in the community.
My Ipod has 251 songs on it. This sounds like a lot. But over 4 to 5 months, I've pretty much heard everything on it and I'm getting pretty tired of the play list. One night, leaving work, I decided not wear my headphones, instead, going "commando" so as to enjoy the night and the breeze.
Standing in the street next to the curb was a woman, crying out for help. She needed a bathroom (and a little help stepping up onto the curb). Supporting her under the arm, I led her into the lobby of the hospital to the ladies rest room. She had waited so long to go that she was crying in pain, tears running down her cheeks.
It was a small gesture, really, helping someone in need. If I had been wearing my headphones, would she have called out to me? Would I have been as receptive to help? Is this the same for all of us who tune into a world of our own choice? Is it the case for so many who walk down the street, eyes on our cell phones?
I must say that the experience lightened my heart. It was the end of a long day at work, on my feet all day, and I was tired. I was ready to go home. But taking an extra 5 to 10 minutes out of my evening to help someone energized me for the rest of the night. She got relief, but I believe I got much more.
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November 11, 2011
Massage in the Context of Physical Therapy: Part 3
Last week I was assigned a patient who was being discharged home, who I had not worked with before. As a PT, the responsibility of initial evaluation, re-evaluation, and discharge documentation falls to us because it is beyond the scope of PTAs. This patient, again, was relatively young, and had a diagnosis of spinal stenosis. Spinal stenosis occurs when the space within the spinal canal or around the nerve roots becomes narrowed.
She was not having a good day. Maybe because it was the first day of rain following a particularly warm and dry spell. She had pain radiating through her gluteal region and down her thigh to her knee. She could not walk standing upright and walking aggravated her pain to 8/10. I felt terrible, we were sending her home in this condition. I advised her about sleeping positions that might settle her pain, a towel roll under her waist in sidelying, a bed pillow between her legs, knees to ankles, to maintain a neutral spine. This settled her pain to a 6/10, but it went right back up to an 8/10 when we walked again.
I taught her stretches and reviewed her core stabilization exercises, issuing her theraband so she could perform her exercises at home. Her pain improved to a 6/10 again, and again, it jumped up to 8/10 with walking. I was running out of ideas. And then the light bulb turned on: massage.
I positioned the patient side-lying, pillow between her legs and proceeded to work, explaining which muscles were where and what they were used for. The gluteus maximus, the big muscle we recognize as out bottom is the powerful muscle we use to propel the body forward during walking. Gluteus medius (and boy was it tight) was used for balance. Gluteus minimus, which sits higher and deeper into the bony crest is also used for balance. Tensor fascia lata hooks into the broad band of connective tissue on the outside of leg that goes to the knee (also tight and painful, full of trigger points. I explained the position of the sciatic nerve, sandwiched between tight muscles, it could get pinched and send pain down the leg to the big toe. Its typical presentation: pain in the middle of the butt cheek. "That's it, right there!" she said, and I used the broad tool of fist to soften the larger muscles rather than the smaller, pokey tool of my fingertips.
I couldn't leave the task without checking the joints above the region of pain. They said in PT school, "Always address the joints above and below the problem." I knew this already from my experience as a massage therapist. Quadratus lumborum was tight and full of trigger points. The QL is a tough muscle to work all the knots out; definitely impossible in one session given the woven configuration of its fibers, allowing for the twisting motion of the lumbar spine. (Anyone out there with tips for releasing QL humanely in one session?? I'm open to input.)
With my treatment time up, I knew I wasn't done, but it was the best I could do. The patient sat up. She felt freer and more flexible. Her pain was reduced. The proof in the effectiveness of the treatment: she was able to walk back to her room with her pain staying down to a 4/10.
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October 20, 2011
Massage in the Context of Physical Therapy: Part 2
Sometimes patients present with challenges where massage therapy is just the thing they need. For example, I was working with a patient who had broken his foot and was having to learn how to walk without bearing any weight through the cast. Being relatively young (anyone under the age of 50 - funny how that number keeps changing), you would expect him to be given crutches and send him on his way. However, he broke his foot because he passed out from a previously undetected heart condition. So the doctors had put in a pacemaker just under the skin of the opposite shoulder (it is protocol for pacemakers to dwell in the left shoulder). He had finally been cleared to a weight-bearing-as-tolerated status in the left arm. Initially, he was non-weight bearing until enough scar tissue knitted around the appliance to hold it in place. Not only that, the incision site was quite painful, which discouraged any use of the left arm anyway.
As you can imagine, this scenario creates quite a dilemma for walking. Initially, I tried fitting him for a hemi-walker, but he was too unsteady. So we used a standard walker for stability, but it was too painful and required too much energy to pick up, after all, this patient was ambulating by hopping on one foot. Using a rolling walker was the solution to this problem. However, by this time, the patient was exhibiting learned non-use of the left arm, and fear avoidance behavior with the belief that pain meant damage was occurring.
For a week and a half I worked with this patient to strengthen both legs and increase reliance on the left arm during ambulation, and increase his walking distance. I had to find a balance between performing exercise without creating heart palpitations or extreme dips in blood sugar, as this patient was also diabetic, both conditions that could create syncope (passing out) and falls. And yet, the left shoulder pain persisted, relieved only by ice. It was time to whip out my secret weapon: massage.
What I found in shoulder was a great deal of tension in pectoralis major attachment toward the humerus - cross fiber friction combined with massage with the grain of the muscle to stretch and ease discomfort where appropriate. The patient also pointed out pain at the top of the shoulder, the first head of the trapezius. Working with the trapezius naturally led me into the neck where the scalenes were tight and splenius capitis and cervicis along with the other cervical intercostals were tight and painful. I mobilized the scapula (shoulder blade) which, of course has pectoralis minor attached to the corocoid process, and leads right down into the anterior chest to the location of the pacemaker. I had to avoid the pacemaker placement because scar tissue massage would run counter to the necessary healing process of its placement. However, the increased pain and sense of pulling the patient was feeling was due to an overgrowth of scar tissue and muscle splinting that was counterproductive to the patient's recovery.
Following massage, the patient noticed an immediate decrease in pain and an increase in range of motion. This improvement continued into the afternoon and was noted during his occupational therapy as a marked improvement in functional tasks such as donning a shirt. OT took advantage of this through stretching and strengthening into the new range which the patient had not been able to tolerate previously.
My reward for utilizing this skill: "Thank you for fixing my arm," and a box of chocolates.
In my next post is another example of how I incorporate massage therapy into my physical therapy treatment.
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October 14, 2011
Massage in the Context of Physical Therapy: Part 1
I don't get the opportunity to utilize my massage skills much anymore. Mostly, I work on co-workers at lunch who have sinus headaches and neck cricks. Many ask me if I still perform massage services, or if I've retained my license. One went so far as to ask me if she could commission me to work on her and her husband on a regular basis. The answer to all of these questions is no.
It's not that I don't love massage anymore. In fact, I miss it. There is nothing I enjoy more than engaging the body, listening with my hands. I allow myself to flow into the natural rhythm that is muscles releasing to the cues given by a knowledgeable hand. As a physical therapist, massage is within my scope of practice, so there is not need for me to retain my massage license. But, honestly, at the end of the day, I'm tired. I have no desire to work evenings or sacrifice my precious weekends, necessary for "recharging my batteries" for another week of work.
Now if I worked in out-patient physical therapy, opportunities to perform massage would be plentiful. In fact, during a short stint in March, I observed in an outpatient setting, nearly every client started their session with a heat or ice pack and some massage. Personally, I felt this wasn't the right way to utilize precious therapy time, but it made the clients feel good and the extra 15 minutes allows the therapist to finish with their over-lapping client. Unfortunately, it skews patient perspectives about what physical therapy is - everybody remembers the massage, heat packs, and e-stim, none of which are considered skilled therapy.
Working in an in-patient setting, opportunities to perform massage are much more limited. Because massage is considered a less-skilled therapy and garners a lower cost CPM code, it is only acceptable to perform massage therapy infrequently. Physical therapy has a CPM code for manual therapy, which encompasses a wide variety of bodywork techniques. Many massage therapists are trained in bodywork therapy that elevates their skills beyond efleurage, petrisage, tapotement, and kneading.
Bodywork skills that I trained for include craniosacral therapy, visceral manipulation, lymph drainage, trigger point therapy, and myofascial release, all of which are considered manual therapy. Rarely do I, or did I ever, perform straight massage therapy. Aspects of bodywork have always been interspersed with the basic Swedish massage that I learned in massage school.
In my next post, I'll share how I incorporate massage therapy into my physical therapy treatments.
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October 13, 2011
Happy Birthday Fingertips
Fingertips Blog started today in 2003, making it 8 years old.
Happy Birthday Fingertips!
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