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Toni Talks about PT Today

Functional Matters

Published January 14, 2009 2:45 PM by Toni Patt
We have a new lunch table topic at work. Another therapist and I had seen the same patient a week apart. She performed the initial evaluation. I performed a re-evaluation a few days later. Our objective values were about the same. She put the patient on caseload. I didn't.  Her reasoning was that the patient needed to get out of bed and nursing wouldn't do it. My reasoning was lack of functional goals. The patient was an elderly lady who lives at a nursing and is dependent for all mobility and transfers at baseline. The restorative staff lifts her out of bed every morning and returns her in the evening. That stopped when she became hospitalized.

This isn't the first time I've had this discussion. My position is a therapeutic intervention must somehow correspond to a functional goal. A patient with a new onset of a CVA may be a dependent transfer when evaluated but has the potential to progress. Therefore a functional goal can be assessed. A patient who has been dependent at baseline, is dependent at initial evaluation and does not have the same potential. While I agree being out of bed is therapeutic, a total lift transfer is not. The exception is a new low level brain injury who needs to be out of bed for coma stimulation. The few transfers are therapeutic because monitoring and assessing is taking place. 

The purpose of therapy is to increase function and independence. For that to happen, the patient must be able to participate in therapy. Particularly in a rehab setting, there must be teachable moments and carryover to create improvement. Providing training to a dependent patient's family is also functional because the family has the potential to learn. Knowledge of body mechanics is vital to prevent caregivers from becoming injured. The transfer is functional because the family is being taught.

A dependent transfer is not a skilled intervention. It does not require the special skills of a patient. Almost anyone can perform such a transfer with a little training. There has to be more emphasis on interventions only a skilled PT can perform. This is one of the arguments in support of the PATIENT. We provide a skilled service because we are the only ones who can do what we do. I can't charge for a non-skilled activity because it isn't something only a PT can do.

I know my co-worker meant well. She was thinking of what was best for the patient. I'm not saying the patient doesn't need to get up. I'm saying it isn't a skilled service and therefore the patient is not appropriate for caseload. We are PTs. We have special skills and training. We need to be careful how we use those skills.  Many, many years have been dedicated to separating ourselves from other disciplines and moving away from the idea that all we do is get patients out of bed. 



 I hope you read this...we went to PT school together at SLU!!! good job and nice peice of writing!!

mary delrossi-bishop, SAR/ Public Health Nurse - PT RN BSN January 19, 2009 8:39 PM
Philadelphia Area NJ

I do agree, for the most part, with the comments made in this blog. I would like to comment that PT's do more than just transfer patients. If this person went to the hospital is it not posible that she may have had a change in activity tolerance and postural tolerance. This could result in seating and positioning changes, changes in ability to assit with self care, changes in ability to sit on the toilet. An extended hospital stay could have resulted in muscle shortening from being bed bound and resulting increased pain. Lastly, is this person who was in the hospital and mostly immobile more at risk for respiratory complications. As PT's are we not able to formulate exercise and activity programs to minimize risks of secondary comorbidities. I realize that low level patients do not have many independnet goals. However, I do believe that many PT's miss oppertunities to provide care believing the level of care is unskilled and a nursing issue. Nurses and Rehab use different models to administer care. I hope as PT's we can see beyond transfers.

Josh Walbert January 17, 2009 9:54 AM
Philadelphia PA

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