There are two issues with patient preference.  I wouldn't last 10 minutes in a pediatric setting.  Others would last less than that in a hospital.  Just because I have some idea how to treat a patient doesn't mean I should.  It makes sense that I should be assigned patient types I'm comfortable with and knowledgeable about.  It also makes sense that I shouldn't work with a patient I don't get along with.  It doesn't matter what the diagnosis is, sometimes personalities clash.

The other side of that coin is not wanting to work with a patient I know how to treat.  That patient will probably get better treatment from someone else.  No matter how hard I try, it won't be my best effort.  Is that a bad thing?  Part of me thinks it is.  Another part says no, if I know I won't work well with the patient someone else should be the therapist.  

Sometimes it's the patient who makes the decision.  I'm known as one of the "harder" therapists.  I make my patients work.  Not everyone buys into that philosophy.  Someone who was inactive premorbidly isn't going to suddenly change after a stroke. That patient will do better with a different approach.  I can think of 10 different examples of a patient doing better with another therapist than they would have with me in the last week alone.  None of the reasons had anything to do with me specifically.  We wouldn't have been good fits.

It's easy to scoff at someone who says I don't like this kind of patient.  When I say that it doesn't mean I couldn't work with the patient, just that I would prefer not to.  I don't think the issue should be pushed.  If it's not a good fit, let someone else see the patient.  I'm not talking about patients no one wants to work with because of personality or psych issues.  That needs to be sucked up and dealt with. It's rarely a problem in my department. A patient should get the best care possible. Assign the patient to the therapist who will do just that.

As PTs we know exercise comes in many shapes and forms. A good argument can be made that a functional activity is actually exercise.  I progress to working in standing as soon as possible to strengthen core muscles and legs. I probably do forced use exercises with half of my patients on any given day. In each of those examples I'll get strengthening, but none of those exercises were done with the goal of strengthening. All were done with some function in mind.

This may be nitpicking. Everything in PT is function oriented. Does it really make that big of a difference what kind of strengthening exercises I do? Yes, I think it does. Muscles are very specific. They must be trained to perform their particular function. At the same time the muscle must have the strength to be strong enough to practice the functional activity. This is like the chicken and the egg question. Except in this case it doesn't matter which comes first. You have to have both to get the job done.

I tell my patients it doesn't matter how strong a muscle is if it can't do its job. This usually happens when I start forced use exercises. I use weight lifters as my example. As strong as they are, they can't do anything with that strength. I never have to explain strengthening exercises. All I have to say is we're going to do exercises to get stronger. Yet if I want someone to be strong enough to stand, I make him stand. Then I have to go back and work on weight shift, eccentric control and whatnot.

That simple statement made me realize I need to rethink some of the things I do. I need to get back to mat exercises. I have my patients for an hour and a half. Time is not a problem. I can do more facilitation techniques on a patient who is lying down. I can make patients bridge to strengthen hip extensors. Weak hip extensors are a bane of my existence. You can't move through stance properly if you can't extend your hip.

Memo to self, do more exercising. Facilitation of movement patterns is just as important as increasing strength. I must remember that.

It's nice to be recognized. It makes you feel good about what you do. It makes you feel good about your profession. That is the purpose behind PT month, recognition of PTs. The APTA offers banners, T-shirts, pens and whatnot for sale to help us celebrate.  It's too bad no one outside of our department will know anything about it.

Let's face it. PT month, just like OT month and ST month, generally passes without anyone outside of rehab even noticing. The hospital I work at isn't recognizing it. I haven't even received an email acknowledging it. The same isn't true for nursing.  Everywhere I've worked Nursing week is always recognized.  I always know when Nursing week happens because there are posters and emails telling me. One hospital I worked at gave all the nurses and CNAs lunch bags in celebration. 

Okay, nurses are important. They are an essential part of the health care team.  But they aren't the only one the team.  Other disciplines make contributions to patient care yet it seems only nurses get any recognition.  Does anyone know when Dietician month is?  How about Respiratory month?  I'm tired of being forgotten and deemed unimportant.   Nurses aren't the only health care providers, yet they seem to dominate everyone else.

I can get past lack of recognition for PT month.  There are more important things for us to worry about.  However, I wonder if this social slight is a symptom of something more ominous.  Is lack of recognition a sign of how the medical community views PT?  Although medicine is moving toward a patient-centered approach it is currently controlled by physicians.  Everything must go through them.  Right behind physicians is nursing.  Neither one of them could function without other disciplines. It's time the other disciplines are acknowledged. 

The problem isn't cost.  It costs practically nothing except a few minutes of someone's time to send an email to all employees acknowledging October as PT month.  I think the problem is mindset.  No one would deny the importance of physical therapy.  It just doesn't seem like we're that high on the medical hierarchy.   The solution is simple.  Either recognize everyone somehow or don't recognize everyone.  Instead recognize the team.  Instead of celebrating every individual month or week, recognize everyone at the same time.  That makes everyone equally important on the health care team.

I'll enjoy breakfast tomorrow.  I just hope someone brings some good coffee.

The first question I asked was why she was on a rehab unit in the first place. The most she's done so far is 1.5 hours in one day of PT and OT combined. That was with me giving her no other option. She clearly doesn't want to do therapy. She obviously isn't meeting criteria. We've had patients who did very little previously. Her stay will be as brief as those were.

I also want to know what I'm expected to work on with her.  She doesn't want to do anything. Even with a translator to explain things she refuses to do anything. Ethically I can't physically pull her out of bed and drag her down the hall.  Passive exercise is the only thing possible if she won't work with me. This isn't a completed confused and disoriented patient. Her dementia prevents her from understanding what has happened and why therapy is important. It doesn't impair her ability to know what she will and won't do.

What's really frustrating is that her impaired functional status is completely effort dependent. She can transfer and ambulate with CGA if she wants to. I did it with her. Based on that treatment I have no goals for her.  She needs CGA for safety. Yes, her endurance isn't very good but she wasn't doing much of anything before she came to the hospital.

I'm back to the original question. What am I supposed to do with her? I know there is a cultural element to this. That doesn't change the situation. She is on rehab and I am supposed to provide therapy.  What is left to work on when the patient won't participate and I can't physically do it for her? Ethically I know I can't force her to do something she doesn't want to do. Therapeutically I know she can't stay in bed. 

I've run into this when I've worked in acute care.  It's much easier to handle. If the patient doesn't want to work with me, I move on to the next one. I document lack of participation and assess the patient as a poor rehab candidate. I'm not sure what happens to those patients but I would guess either they return to a setting where they are taken care of or find their way to custodial care via an SNF.

I'm ready to pull my hair out. I have to drink a cup of coffee just to work up the energy to go into the room and make an attempt. Today I completed 15 minutes of therapy. Tomorrow won't be much different. She will discharge on Thursday to an SNF. I understand she isn't going to do much with me. Nonetheless, I keep thinking there is something more I can do to change that. 

Then came the one I had to think about. What would I like to see the APTA focus on?  Given enough time and space I could have written a thesis. I only had a paragraph. I've complained about several things.  I've found fault with the system. I've discussed the disappearing work ethic.  Those are real problems, but not ones the APTA can address. 

After thinking for a few minutes, I decided the answer was to back off on Vision 2020 and concentrate on getting all practicing PTs and PTAs ready for 2020 to happen.  I don't think most therapists have a clear idea what 2020 is all about.  I know many who are content to let it happen around them while they continue to practice as usual.

Evidence based practice (EBP) is a good thing.  The APTA can push it as much as it wants.  EBP won't happen until practicing therapists of all educational levels and training are familiar and comfortable with it.   Doing a computer research search is something that must be taught.  Separating good research from bad is another skill that is generally lacking.

The same is true of direct access.  Direct access is a good thing.  The truth is if it happened today, the profession of PT isn't ready for it.  There are some excellent OP therapists out there who would be fine.  There are some others who are close.  From my experiences working outpatient, I would say the majority of OP therapists aren't anywhere near ready.  I'm not talking skill level, although that could be a problem.  I'm talking about the additional knowledge necessary to practice autonomously.  

I could go down the list of Vision 2020.  PTs are being promoted as musculoskeletal specialists and neuromuscular experts.  We have unique knowledge and skills which enable us to make those claims.  That's true.  But everyone has different levels of those skills.  I think it makes more sense to get everyone generally practicing the same way.  We have to move away from doing something because that's the way it's always been done.  We must go beyond doing the same thing every time because it's a comfortable treatment.

That is something the APTA can address.  It's time for them to step up and help fix this discrepancy.  The APTA can't keep using Vision 2020 as a buzz word.  It's time to help PTs and PTAs move forward.  Sponsoring courses, home study and onsite, would enable practicing therapists to learn the skills needed to move forward.  If the APTA wants more members it should revisit the cost of membership.  Maybe separate state and national membership so that one is possible without the other.  Belonging to sections can get expensive. How about a discount for multiple memberships?  Or, CEU credit for volunteering for a section or state chapter?  These are some thoughts. 

I could go on.  The point is the level of difficulty involved for an average therapist to aspire toward 2020.  For it to work everyone must not only buy into, but be ready for 2020.  Yes, there is a level of individual responsibility and cost involved.  At the same time the APTA is in a position to help those willing to help themselves.

One of her examples was body weight assisted treadmill training. Anyone who has seen or worked with those treadmills will agree they are bulky and not very user friendly. Dr. Craik suggested that by participating in the development phase we could address some design flaws. I have to agree with her. I love those machines, but using them is labor intensive and time-consuming.  Just getting an adequate fit of the harness can take half the treatment.

Another example was the use of electric stimulation on the brain. She pointed out that much of the research is done statically. Yet, humans are dynamic creatures. We are constantly moving in some fashion. She suggested performing therapy during the stimulation sessions. Think of the impact that would have on neurological patients. What if the electricity stimulated a body part to move on command? That could ultimately lead to more rapid changes in motor learning. 

PTs are movement specialists. We can't rely on other disciplines to incorporate movement into practice.  Engineers know how to make machines move. What we need are machines that incorporate the two concepts into one piece of user-friendly equipment. Over the years I've been exposed to various machines and equipment.  It seems like the one's developed by therapists are not only more effective, but easier to use. There's a reason for that.

One of the mottos of my department is to make do with what we have. We end up using things in ways probably not anticipated by the developers. That probably happens in departments all over the country.  There needs to be a way of sharing those ideas with each other. We also need to communicate our unique needs to manufactures. They won't build something if they don't know we need it.

There are many good pieces of equipment out there that are underutilized. The obvious reason is cost.  The second reason has to be they are too complex. No matter how good a piece of equipment is, it won't be used if it is too complicated. I wonder how much equipment is gathering dust for that very reason.

 I would love to tell some manufacturers what I think of equipment. Maybe it's time PTs start doing that.  Most companies have sales reps that are available to visit facilities. Talking to sales reps might be a good place to start. If they're not selling equipment or constantly getting called back for training the message will eventually get through. It's a place to start.

Last week I had the pleasure of hearing Rebecca Craik, PT, PhD speak. She gave her perspective on the past and future of physical therapy.  As she is the editor of the Physical Therapy Journal she is in a position to talk realistically about what's ahead for us.  I can sum her 90 minute lecture into two sentences.  The profession of Physical Therapy is making good strides in preparation for Vision 2020.  The individual therapists who make up the profession are not.

That sounds harsh.  A few years ago our profession made decisions about where it wanted to be positioned by the year 2020.  Based on those decisions action plans, such as the DPT, evidence based practice and specializations were put into place.  Increased emphasis was placed on direct access.  Whether these goals are reached in time is yet to be seen.  But, as Dr. Craik pointed out, the changes were made.

According to Dr. Craik this is not true of individual clinicians.  We have a lot to do to prepare.  That includes being flexible and embracing the changes.  Consider that less than 10% of practicing therapists are DPTs.  The number of certified specialists is less than 10, 000 nationwide.  Admittedly there has been resistance to changing, particularly concerning the DPT.  This resistance is probably a big piece of why clinicians aren't ready. 

The reality is the profession has changed.  Dr. Craik pointed out that practice has become more like research.  She also pointed out the lack of research.  Currently there is a disconnect between research and clinical practice.  What we need, said Dr. Craik, are more clinical oriented researchers.  We the clinical know what needs to be researched.  Who better to do it? Not all research has to be theoretically based.  We also need research that support our treatments and defines the best practice for each. 

It's easy to get caught up in everyday life.  It takes time and money to get education or prepare for certification.  My department is probably typical.  No one else is interested in getting a DPT.  No one else is willing to do the work to get a certification.  Generalize that to the entire population of PTs and part of the problem is evident.  Advanced degrees and certifications aren't reasonably for many people. 

What about evidence based medicine?  Only two of us in my department can actually explain it.  A third, a new grad, knows what it is.  The rest have no interest.  Evidence based practice isn't difficult to understand.  It could be learned in a CEU format either in person or online. I don't think I've seen even one course offered on the topic, only included with another topic.  Including evidence in our education is important. But it doesn't do  any good if no in the class understands the significance of the evidence.  One of my future goals is to do a class for the facility.  And I will, if I ever get the time to actually do it.

It's time for clinicians to wake up and get moving.  The PT profession is moving forward.  Either we adapt, make changes and go along for the ride.  Or, we get left behind.  The ripples of change are beginning to develop.  It's easy to continue with business as usual.  When those ripples become waves some of us will be lost in the undertow. 

His complaint isn't unique. I've heard it from other patients. I suspect many people with physical impairments have the same complaint. For some reason, people equate physical impairment with cognitive impairment even though there is no direct relationship. One can be present without the other. People also equate cognitive impairment with aging. Decreased cognition is associated with aging, but not every older adult is cognitively impaired. 

Using baby talk with a cognitively intact adult is wrong. Period. So is assuming someone is cognitively impaired based solely on physical appearance. Had the nurses taken a few minutes to speak with my patient instead of speaking to him they would have realized their mistake.  It might be easier to do that but that isn't respectful of the patient. 

I would attribute this to working on a neuro unit where many of the patients are cognitively impaired.  That might be part of it, but I hear the same thing on medical and orthopedic floors.  That assumption can't be made based on appearance alone. Nor should someone talk at a patient because it is quicker or easier. 

PTs spend more time with our patients than almost any other discipline. We get to know them and they get to know us. A PT is willing to take the time to talk to someone before making judgments about cognitive impairment. I greet every patient as though they have no cognitive impairments even when I suspect they do. To me it's a matter of respect.  If a patient is cognitively impaired, I adapt accordingly. No matter how severe the physical deficits are the patient is still a person who should be treated with dignity. That means speaking to the patient and not at the patient.

When I worked in OP settings, my new evaluations would fill out a medication list.  I looked for those same drugs.  Their presence could affect exercise tolerance and therapy.  Since pain is one of the primary reasons patients seek OP therapy, I expected I would see OTC pain meds.  I now know that over 100,000 hospitalizations occur annually due to GI complications associated with OTC anti-inflammatory or aspirin use.  That figure assumes normal use and dosages.  Too much Tylenol can cause liver damage.  Too much aspirin can contribute to decreased clotting.

Anti-depressives are another commonly prescribed drug.  MAO inhibitors can elevate resting BP.  Others are associated with drowsiness and slowed response time. Wellbutrin and Zyban can cause insomnia.  Any of these side effects will directly affect performance during therapy.  The danger of mixing benzodiazepines and alcohol are well known.

Lasix is commonly prescribed for any patient who retains fluid.  Overuse of lasix leads to dehydration, which in turn increases the demand on the cardiovascular system.  Dehydration can also cause orthostatic hypotension.  Less blood volume means it takes more effort to pump the blood upward resulting in a drop in BP when attempting to stand. 

Compliance with meds is also important.  I've lost count of the number of stroke patients I've seen who were non-compliant with anti-hypertensives or stopped taking their Coumadin for some reason.  Inconsistency with other cardiac meds can also have disastrous results.  Failure to control blood sugars via insulin is another common problem.  Every OP setting I ever worked at kept orange juice and hard candy on hand for patients with low blood sugars.  High blood sugar is associated with many diabetic complications. Many of us have worked with patients who haven't taken their pain meds prior to therapy.  We all know how difficult that can be.

PTs aren't pharmacists.   We don't need to know the many details involved in pharmacology.  We do need to know the side effects and possible interactions of commonly prescribed meds in our treatment populations.  That knowledge enables us to monitor our patients more effectively. 

First, my horse died a few weeks ago.  He'd been sick, looked to be recovering then went bad quickly.  Training that horse was the main thing that kept me in this area.  If I don't have to make arrangements for a horse, I can live anywhere.

Second, I had a run in with a petty co-worker.  We weren't communicating very well.  When I asked to meet with her and the manager, I was told how rude and disrespectful I've been to her.  She was offended that I would even mention this to our manager and felt it was an insult to her skills as a therapist. All I said was we were having trouble communicating and I wanted to clear it up before patient care was affected.

Third, I will be finished with my classes this January.  I can take the geriatrics exam anywhere.  If I decide to pursue my PhD, I can do so in Dallas or in St. Louis where I'm originally from.  That's a tough call.  Dallas would be warmer (and closer) but I miss many things that are only found in St. Louis.

There are more job opportunities now than previously.  It probably wouldn't be too difficult to find another job if I decided to leave the city.  There are plenty of hospitals and whatnot here in Houston.  A re-assignment wouldn't be difficult either.  Besides, my company has a branch in Dallas as well.

I like what I'm doing.  If I move, I won't be able to recreate this position somewhere else.  I'd have to prove myself all over again.  It doesn't matter how good you were.  It matters how good you are.  Of course I could find something I like better.   I could find something completely different.  I might not find anything and decide to stay put. 

Something, in addition to my attitude, has to change.  Moving has the appeal of something new.  Staying is comfortable, but will require me forcing some changes which might not be possible.  One of the benefits of being a PT is the ability to change jobs easily.   In the short term I won't be making any changes.  I'll focus on my next class (pharmacology) and research my options.  I will also talk to my manager.  The problem is I'm undecided if fixing things where I am will fix everything.

Consider this situation.  The census in my unit has picked up dramatically.  Everyone is carrying a full load and then some.  Because of the three hour therapy rule and the amount of documentation, it isn't always possible to complete everything in 8 hours.  So, many of us are putting in the extra hours.  Does staying late to finish our work make us workaholics or responsible professionals? 

The answer to that depends upon what is considered to be more valuable.  If it is more important to leave work on time, we are workaholics. What if leaving on time means paperwork wasn't completed?   That bothers me because I was taught to never leave paperwork undone.  If for some reason I don't make it in the next day, it might not get done.  Or, if a patient discharges unexpectedly, it might not be possible to track down the chart later on.  If I start my day doing paper work for yesterday, it's possible I might forget something.  And, if I'm doing paperwork, I don't have as much time to prepare for my day.

If it's more important to finish everything then we are dedicated professionals.  We're doing what needs to be done to fulfill our job requirements.  No one wants to get home later.  That cuts into family and leisure time.  No one is looking for more work to do.  Sure, notes I write late in the day probably aren't my best effort, but all the important information will be included.

Or, consider a person who has the same load as I do, the same documentation as I do, but manages to get everything done and leave on time.  How is this possible?  That person must be cutting corners somewhere.  I would hope treatments aren't being cut short.  You can only shave so much time off note writing and still meet the requirements for reimbursement.  I suspect that person is skipping all the other "little" things that should be done but aren't absolutely necessary.  Today I finished late because I had three conversations with physicians.  I scheduled a translator for a patient.  I redid my schedule for tomorrow twice to accommodate changes in patient schedules.  I attended stroke rounds.  And, I ordered a BSC for a patient who was finally ready to use it.  None of that had to be done, but it was nice when done.

I fail to understand why so much emphasis is placed on not working as hard. Neither my co-workers nor I would be considered workaholics.  We simply like to be thorough.  Maybe someday someone will explain that to me.  Maybe that same person will also explain why it's okay to stop doing the little extras that routinely come up.  In the meantime I'll be working hard rather than hardly working.

That got me to thinking.  Perception influences therapists as much as it influences patients.  I work on a rehab unit.  The therapists have the perception that our patients are there to get three hours of therapy aimed at improving function.  We know the therapy can be difficult and tiring. Because of our original perception about the patient, we believe this is acceptable to the patients.  Our treatment plans and goals are based on these perceptions and expectations. 

Today I evaluated a patient who didn't want to work with therapy. He agreed he was on a rehab unit and was there for therapy. Among other things, he was upset that all three disciplines came to see him in one day.  He thought it was too much.  He adamantly refused his afternoon treatments stating he would "do something" tomorrow.  

He told me he didn't think he would have to do so much. He thought he could get better by lying around. He didn't understand why three different people came to see him. He also thought he should be able to work at his own pace on what he wanted to do. His idea of therapy was getting into a chair for a little while, then returning to bed. 

It's pretty obvious where the perceptual problem is with that patient.  His response to me was based on what he perceived therapy/rehab to be. When the truth was explained to him he agreed to participate, but wasn't happy.  It wouldn't surprise me to see him make little progress.  He doesn't strike me as someone willing to work for anything. 

This is a glaring example of something that probably happens more than we think.  I expect neuro patients to have problems with perception physically and plan treatments accordingly.  What I don't do is factor in other perceptions that might influence therapy.  A patient who perceives his or herself to be weak will expect to be treated as if that is the case.  A person who has been treated as an outpatient will expect rehab to be similar and vice versa.  Patients who are in pain often perceive the pain as a limiting factor. The same is true of fatigue, nausea and just about any other reason patients refuse therapy.  When I look at things from this angle I can see why patients refuse therapy to watch a favorite TV show.  It might not be that they think therapy is unimportant.  It might be that they don't perceive therapy as more important.  They don't have the perception that time is valuable and accommodating a TV show (or anything else) might not be possible.

Having this light bulb go off for me has made me aware of the need to fully explain how the unit works.  When I run into someone who doesn't want to do something I will ask specifically why. If it's a matter of perception (RWs are for old people, etc) I can try to address it.  I feel like I have a whole awareness of how patients experience the world. The class was well worth the time and money. Not only did I learn new treatment techniques, I also gained a new context  for working with patients.

I didn't know exactly what to do when that happened. I didn't want to correct her in front of the patient and family. It wasn't like that particular piece of information mattered in the big scheme of things. Still, it was incorrect which bothered me. I'm not about to say I know everything about strokes or pushers. However, I had just completed a paper examining pusher syndrome with 17 references. In this case, I know my information was accurate. Given the circumstances I made the decision to let it go for the moment. Still, it bothered me.

I'm sure I'm not the only one who has run into this. It's happened to me a few times, though never in front of a patient before. No matter when it happens, it's difficult to know what to do. Sure, I could just let it slide. But that really isn't a good idea. All that does is perpetuate incorrect information being spread. Just because it doesn't make a difference this time doesn't mean there won't come a time when incorrect information will effect a treatment decision. I've done that a few times. Most recently it involved a relatively new grad who didn't want to put ice on a TKR post-op day one. Her reason was the ice would accelerate formation of scar tissue and therefore impair therapy.

I just finished a class project that involved looking at available health-related information and rating it on accuracy. The point of the assignment was to make us aware of how much of what's available to people is incorrect, biased or out of date. We were made aware of this to help us with patient education and assist with finding information for our patients. PTs and OTs are one of the few healthcare disciplines that actually spend meaningful time with patients. As a result, we're often asked questions about things unrelated to therapy. We need to be able to provide accurate and truthful information in return. That's why this situation bothered me.

The solution to my problem was simple. I pulled the OT aside and explained what my research had found. She was surprised but glad for the new information. My problem was solved. I've also heard doctors give incorrect information, almost always about something therapy related, or, and this really kills me, telling someone who isn't ready for gait therapy I will be by to get them up to walk. I'm not suicidal. I'm obviously not going to correct an attending physician. I realize the doc meant well but it just made my job more difficult by setting up an unrealistic expectation. Which is another reason accurate information is important. Part of my job is educating the residents who pass through the unit. This is one of the areas I stress.

It's never easy to tell someone they're wrong. Yet, because we provide so much education and do so much teaching it's important we be correct in what we say. Not everyone takes it well when told they were wrong.  Just like not everyone handles confrontation, though mild, well. This may be another example of me being picky. It wouldn't be the first time. Nonetheless, while no two situations are exactly the same, there are times when something needs to be said. I have one piece of advice for those, like me, who have to do something.  Say it with a smile. Negatives are easier to take when presented nicely and in a friendly way.

Obesity is defined as an increase in body weight beyond the limitations of skeletal and physical reinforcement. Morbid obesity is defined as excess body fat that has an adverse effect on health.  (The Free Dictionary, 2009)  There is a general consensus that the rate of obesity is continuing to climb in America.  Obese patients are a common part of practice today.  Research concerning PT and obesity is necessary to determine evidence for the best practices.  In this case, though, I think the researchers asked the wrong question.

PTs are trained health care providers.  They view obesity as just one of a multitude of possible co-morbidities.  It would be expected that their opinion as a whole would be neutral.  I think a more telling question would have been to ask how those PTs felt about treating obese and morbidly obese patients.  I think the answers would have been somewhat different.   It's already been established that obesity is associated with poorer outcomes and longer length of hospital stays.  The same relationship is probably true between obesity and PT. 

For example, an obese person s/p a total joint replacement is going to be at a disadvantage. The increased weight on the joint will increase pain.  More muscle strength will be needed for the limb to move so the limb will require additional strengthening.  The extra weight will cause fatigue more quickly.  The overall therapy will take longer to get the same results.  The added days will cause the insurance company to pay more.  Progress in therapy will be slower.

The problem is more acute in an inpatient setting.  Whenever I have an overweight or obese patient I know I'm going to have to work harder to mobilize that patient.  I usually don't have help so I'm going to have to do it myself and my fatigue level will decrease.  Two weeks ago I worked with a CVA patient who tipped the scales at 534 pounds.  I had orders to mobilize her.  With the assist of the CAN, I got her to the EOB.  She had right-sided weakness and fell to the left.  Even with my whole body weight sitting on the bed I couldn't keep her from falling over.  I had to elevate the HOB as high as possible and have her lean on a bed rail.   We never got beyond sitting EOB. 

Let me be clear.  I'm not complaining about that patient.  Working with patients like that is part of the territory.  What I am doing is using her as an example of the difference in treatment the extra weight made.  I would be very interested in the opinions of PTs concerning the actual provision of care to an obese person.  I would also be interested in knowing how many facilities have purchased bariatric equipment in adequate numbers.  In my experience as soon as someone goes into the bariatric w/c you will need another one.  The rest of the time the chair will sit and gather dust.  I would also like to know if facilities have changed staffing patterns to accommodate the obese.  Finally I would like to know how many therapists who work with obese patients are concerned about potentially injuring themselves while providing therapy.   I worry about that all the time because I am a single income person.  If I don't work, I'm out of luck so to speak.

The research in this article is a good start.  It answers one question but asks dozens more.   Clearly more research is needed on the topic.  Maybe someone could survey obese patients about how they perceived therapy in addition to surveying therapists.  I'm sure that would have interesting results.  From the answers to these questions will come changes in practice patterns and educational offerings. 

References
The Free Dictionary. (2009) Retrieved from http://medicaldictionary.thefreedictionary.com/morbid+obesity

Sack, S., Radler, D., Mairella, K., Touger-Decker, R,. Khan, H.  (2009)  Physical therapists' attitudes, knowledge and practice approaches regarding people who are obese. Physical Therapy, 89, 804-815.

That's the problem.  The Neuro docs want the patients mobilized every day even if it is only ROM exercises.  Because of caseload demands and staffing patients who only perform bedside exercises usually aren't seen daily.  Those that receive PROM are seen even less.   No one in the Rehab department has a problem with this.  Bedside exercise, especially PROM isn't a skilled service.  A tech or nursing assistant can be trained to do them.  Exercise only becomes skilled when additional skills such as facilitation or motor learning training is performed.  Moving a body part passively through its ROM doesn't require skill, just a little training and education.

The doctors have a valid point.  Their patients should be moved around daily and out of bed if at all possible.  The problem is who should be doing it.  As a PT, I am expected to provide skilled services.  If I perform an evaluation on a patient who isn't responsive, I may still do PROM exercises.   I usually do this as part of my ROM and strength assessments since I'm moving the limbs anyway.  I'm also assessing how the patient tolerates the movement and looking for pain responses and changes in arousal.  Those actions make that a skilled treatment.  If I come back the next day and the next and perform PROM I haven't really performed a skilled service unless there is a status change.  If I return once or twice weekly, I can include an assessment as part of my exercises which is skilled.  If the patient is waking up or cleared for out of bed I can change the POC.

Performing PROM one to three times weekly is generally accepted as adequate.  An argument can be made that the rules are a little different in a hospital, particularly an ICU.  That could be true sometimes.  But, if we as therapists, say PROM is an unskilled service in one circumstance, it should be in all circumstances.   We need to be consistent.  The exception might be a new stroke patient the therapist wants to follow a few days to monitor arousal.  PROM would be appropriate for that period of time. 

There is another part to this conflict.  If PT doesn't do the PROM, who does?  The obvious answer is nursing, or more specifically, the nursing assistants.  Bath time is an excellent time to move someone around.  So is turning for repositioning.  Nursing, however, doesn't feel that way.  I've yet to meet one nurse or nursing assistant who had the first idea about PROM.  To them it is a huge mystery.  It becomes the same argument as whose responsibility it is to get patients out of bed.  Just like the out-of-bed tug of war, if PT doesn't do it, it doesn't get done. 

The result is our conflict with the Neuro docs.  If PT doesn't do the PROM, it won't be done.  It isn't feasible for a limited staff of therapists to perform PROM on 20+ patients on a daily basis.  They barely make it through their caseloads when they divide the PROM treatments up throughout the week.  It's not realistic to expect administration to create a position just to perform PROM on ICU patients.  Nursing isn't about to add something else to their to-do lists.  The conflict will go on.