The responses to that post made some good points. First, impaired cognition is a need for skilled therapy. Usually that falls under the scope of practice of STs and sometimes OTs. Other than safety and family training, it isn't directly addressed by PTs. Second, safety must be addressed no matter what the level of cognition. Even the most confused person must be safe.

Maybe my question should have been, "When is therapy no longer skilled?" It only takes a few visits to rearrange furniture. Appropriate fall measures should be completed. Addressing balance issues is a skilled service but sometimes the only deficit is failure to remember to lock the wheelchair or RW. How many visits does it take to determine whether or not learning will occur? The same is true of way-finding in a facility. It's necessary but not something usually addressed by PTs.

This brings me back to the original question of, "What is skilled therapy?" Or my new question, "When does it reach a point that enough is enough?" Special training isn't required to remind someone to lock a wheelchair or warn of obstacles. CNAs do it all the time. Those patients need skilled therapy to address cognitive deficits but it isn't the purpose of physical therapy to provide it. Keeping patients on caseload month after month to ensure they remain ambulatory isn't a skilled service. It needs to be done but not by physical therapy.

Maybe we hang on to them because they're elderly. TBI patients are frequently referred to as walking wounded. They generally regain physical mobility but remain confused, impulsive and very unsafe. No one expects PT to keep them on caseload once they are walking with supervision. I've had much more confused TBI patients than the elderly patients I've been describing, who I discharged while OT and ST remained involved. It's the same problem, just a different population.

I'm looking forward to the responses to this post.

I've been noticing a disturbing trend lately. More and more facilities are considering the need for supervision as a need for skilled therapy. Back in the day, patients referred to SNFs and outpatient had an obvious need. They had trouble walking. They couldn't transfer. They'd recently undergone total joint replacement. The knowledge and skill of a therapist were needed to treat the impairment.

Last weekend, I worked at a different SNF than usual. I had nine people on my caseload. Six of those were ambulatory with supervision. They didn't need help to transfer. They didn't need help to walk. They weren't falling all over the place. They all had a diagnosis of dementia and required supervision for safety. For two of them, dementia was the admitting diagnosis. I'm not talking about facility residents who've declined in function. I'm talking about people admitted because they can't be left alone.

Physical therapy addresses physical problems. Impaired cognition that prevents the learning and retaining of new information isn't going to respond to physical therapy. No amount of safety training is going to make someone who can't form new memories remember to lock a wheelchair or rolling walker. Admitting someone with the expectation that a PT can improve cognition is ridiculous.

It doesn't require skill to walk with someone like that. Anyone can do that with minimal training. These are people admitted because they can't go home for some reason. They don't need PT, or at least not very much. They need to have someone with them at all times for safety. Training the caregivers would be skilled therapy. Caregivers might come to visit but rarely attend therapy sessions. They have to work.

I don't have a problem with admitting those people. They do qualify to be in the facility, just not on therapy caseload. Medicare A only pays for the stay if there are skilled needs, which usually means therapies. And therein lies the crux of the situation. This is a common situation with TBI patients. Their mobility improves but they can't be left unsupervised. We refer to them as walking wounded. I think that definition needs to be broadened.

The APTA is characterizing us as movement specialists. We are the muscle experts. So please tell me how an elderly walking wounded fits into that description. I don't see it.

Someone was fired last week. The rumor is going around that she was fired because she didn't smile. I don't know if that's true or not but in Texas it is legal. Here an employer can fire an employee for any reason, even if they make it up. Nor do they have to prove it's true. There are no laws preventing it. Maybe the woman smiled. Maybe she didn't. She's still fired.

Last year I was the victim of something similar. I've become very familiar with Texas labor laws. When I've brought the topic up with lawyers, everyone gives me the same answer. It might be legal but it's very unethical. Those same lawyers tell me there are no laws against unethical behavior. You're just supposed to know better.

I looked through the Texas practice act. It covers every kind of professional behavior; charging, documenting, conflict of interest, interaction with patients etc., except ethicality. It says PTs are to behave in a professional manner. The APTA does have a code of conduct. It touches on ethical issues although it's somewhat vague. Nowhere could I find anything concerning enforcement of ethical behavior.

I don't know who acts as the ethics police for physical therapy. Physicians have a process in place. I couldn't find anything specific for nursing but they spell things out much more clearly. Apparently we're just supposed to know better. I'm here to tell you, that isn't true. Some people either don't know, don't care or don't think it applies to them.

Maybe ethicality falls under professionalism. I can see that argument. A professional should behave in an ethical manner. I can think of a few PTs I've worked with over the years who did nothing overtly wrong but didn't behave in a professional manner, although I'd say they were ethical. I worked under a manager who was blatantly unethical but was professional in appearance.

We need a better definition of both for our profession. Which brings me back to my original question of who functions as the ethical police for physical therapy? To whom do we report unethical behavior? More importantly, how do we enforce it? I have no clue. I think we're generally a very ethical bunch but there's always someone who takes advantage of a position for personal gain or wrongly uses information.

This is going to become a larger problem as we continue to grow as a profession. The more responsibility we take on, the more careful we must be.

One of the presentations I attended at CSM discussed ways to increase motor learning by empowering the patient. They gave an example where one group of patients was asked to help decide which picture to hand in the waiting room prior to assessment. The other group just did the balance test. The patients who participated in picking the picture did much better.

The speakers went on to give other examples, including giving patients choices about which exercises and allowing them more freedom to make mistakes. It makes sense. Providing them with choices gives them some control. With control comes ownership.

The flip side was using phrases like "I want you to" and "I need you to." Obviously sometimes you have to use them but it's context as much as vocabulary. "I want you to do a hand exercise. Which one would you prefer?" is an example. Pretty simple but many in the room were surprised. There was discussion about how to change behavior in the clinic that surprised me.

I know I'm more likely to buy into something if I'm included in the decision process in some way. Same with understanding why I need to do something. If I see the purpose, I'm more willing to try. But this goes beyond that. By including those individuals in the decision, they were being validated. They were being told their opinion mattered. How often does that happen to someone in the healthcare system? It's pretty much someone else directing what happens.

I've been doing my own mini-experiment since I've gotten back. I try to exclusively use choice words. Twice we've had to make a decision about where something went in the department so I've asked all the patients for an opinion. I don't know that they're doing better but they seem to be enjoying therapy more.

Now that I'm home from CSM, I've had an opportunity to process all of the information. Most of the presentations were excellent. Those that weren't purely theoretical had a common theme. We have to maximize what we do because we're spending less and less time with patients. We have less time to spend because there isn't money to pay for our services.

More than ever, the underlying theme was get as much as you can as quickly as you can. Prioritize what you do. We no longer have the luxury of waiting on return of function to work on recovery. Now it's see what you have. Assess the length of stay and do the best you can. Among the unintended consequences is the difficulty in getting more heavily involved patients mobilized earlier and into acute rehab.

The problem isn't therapists. Payer sources aren't funding longer lengths of stays. They aren't giving us the number of treatments we need to accomplish our goals. In their zeal to cut costs, payers have forgotten that home is less expensive than long-term care. If we had more time acutely, or even subacutely, more patients could return home. That means no more paying for long-term care. I can't imagine another week of inpatient rehab is more expensive than months and months of nursing home care.

Money also affects staffing. Cutting staff levels means spending less money. Now fewer therapists must see more patients. Those that are heavily involved, in the ICU, or difficult to mobilize are the ones most frequently skipped. Sadly those are also the ones who need therapy the most. They don't demonstrate immediate gains, which creates the impression the therapy isn't helping.

We're getting better and better at what we do. Brains can only repair themselves so fast. Often they need more than seven to 10 days to reorganize. No matter how hard I, or anyone else tries, we can't speed the process along. The same is true of musculoskeletal injuries and disease processes. Yet somewhere along the line, someone decided that's all the time that's needed.

What if someone created an intervention to completely reverse the effects of a stroke? What if it took two weeks for the intervention to be effective? How would payers respond? I'd like to think they would make adjustments in their reimbursement structure but I doubt it. It would be too expensive. What if that intervention was physical therapy? PT can restore lost function after stroke. With adequate therapy, many stroke survivors can return to some level of their previous lives. Most don't get adequate therapy because it's too expensive.

SAN DIEGO -- Just like my fellow ADVANCE blogger Lauren, I'll be attending the APTA Combined Sections Meeting in San Diego. CSM happens this week so I'm already in my hotel. I've registered and picked up my materials. I attended my pre-conference workshop on item writing. I'm ready for things to begin.

Unlike most of my fellow therapists, the warm weather and sun aren't making much of an impression on me. Houston was almost the same temperature when I left. I'm not complaining. It's a bit of a walk from the hotel to the convention center so warmer weather is appreciated. Lots of people were outside enjoying themselves earlier.

I'm just glad to be here. I need to regroup and remind myself there is more to life than my little SNF. The presentations are usually the latest and greatest, things I've never heard before. I've already planned my schedule, including which booths to visit in the expo hall. I promised to bring back pens and post-it pads. Both will be plentiful in there.

Everyone might have different agendas but we're all here to learn and improve as therapists. The unofficial head count this morning was just under 11,000. It was 8,000 two years ago in New Orleans. That's a lot of people who take their profession seriously.

For me there's an added bonus. I'm around people who understand what I'm talking about when I get excited about neuroplasticity and motor learning. There are people here who've forgotten things I haven't learned yet. That's a good yardstick to remind me of where I am in skills and knowledge.

Because I ride horses competitively, I spend many hours taking lessons. Just like my patients, I'm trying to learn and master motor skills. Sometimes I get it right, sometimes not. This morning it hit me how similar my learning experiences are to those of my patients. I heard myself saying exactly the same thing to a frustrated patient that frustrates me when I hear it. He was doing no better at the time than I was.

Despite the fact I'm riding a large, moving animal with a mind of its own, I have the advantage over my patients. My neuro, visual and somatosensory systems are intact. Errors on my part are usually due to misunderstanding the instructions whereas even if my patients understand perfectly, they may not be able to do what I want. Either way, we both end up frustrated and no further along.

The same things that annoy me probably annoy them. I don't like being talked to as if I'm stupid. Nor do I appreciate exaggerated demonstration and pointing out obvious mistakes. I know I was wrong. The thing that annoys me most is telling me two or three different methods and acting surprised when I'm confused about what was really wanted.

Yes, I'm sad to admit I did all but one of those this morning with my patient. If I don't learn anything like that, I shouldn't expect it of my patients. Now I'm wondering how many times I wasted a session because I wasn't paying attention. Frustration means try something else, not a new explanation. After I realized what I was doing, I shut up and let him try to figure it out for himself. He did a little bit better.

I'm going to work on remembering the problem might not be lack of understanding of the task. The problem might be lack of skill to complete it.

Yesterday I heard something that's still bothering me. I was evaluating a woman. Her husband told me the following. He couldn't tell me when the problem started, just that for the past few weeks she couldn't sit up without leaning on something. He had been taking care of her at home and calling a grandson to help move her. Finally he couldn't do it anymore so he took her to the hospital, where she stayed three days before coming to us.

It turns out the hospital did nothing for her. They didn't run any tests or scan anything. She was seen for therapy one time. According to the husband, the purpose of the hospitalization was so she could go the SNF under Medicare part A. Her status at admission was exactly the same as prior to her hospitalization. This is wrong is so many ways. I don't deny she belongs where she is. It's how she got there.

The hospital admitted her solely for the purpose of qualifying her for a SNF stay. That is bad. While there, they didn't seem to work up any of her problems. They accepted her poor functional status as baseline and sent her to therapy at the husband's request. Turns out the woman became unresponsive while getting into a car maybe three weeks before hospitalization and then became total assist for care. That is just as bad.

It seems to me they could have at least run some tests and done a CT scan to see if maybe something had changed. After all, she was in a hospital. Granted the onset was weeks before admission, so the primary problem might not be treatable but the secondary issues could have been addressed. Sadly, no one I've mentioned it to seems surprised.

Ironically, that same day I evaluated another person. According to the family this person fell at home, was admitted and discharged 30 minutes prior to qualifying for a SNF stay. The SNF admission was a week later as self-pay. At time of discharge, assist for mobility and ADLs was needed. At the time of assessment, I found no deficits. There probably was a need at discharge.

Obviously in the first case, the husband should have taken her to the hospital immediately. In the second, I don't think a SNF stay was really needed since the person improved so much in just a week. By now, I'd be struggling for reasons to continue care. Nonetheless, both of these examples demonstrate the wrong way of doing things.

One of our residents has a well-known grandson. For several years, he starred as one of the Chandlers on the soap opera, "All My Children." There are autographed pictures of him throughout the facility from his last visit. When I started working there, I was told he occasionally drops by to visit his grandmother.

Today was the day he stopped by. Now granted, a soap opera actor isn't on the same level as say a DeNiro or Jack Nicholson. I doubt he's won any awards for his acting. There is one thing all soap opera actors and actresses have in common. They are very attractive. Call me small-minded but I wasn't going to miss the opportunity.

Yes, he was every bit as attractive in person. When we got to the dining room, he was sitting at a table with his grandmother and several old ladies. He was laughing and flirting with them. They were eating it up. Here was this very attractive, younger man treating them like they were the young women they once were. He did more for their morale than anything I've ever witnessed.

He was very patient as he posed for pictures with us "not-so-old" ladies. Yep, he flirted with us, too. It was every bit as exciting as meeting the beer wagon Clydesdales at a horse show a few weeks ago. Not only did I get pictures with the horses, I got kisses.

There's an old saying the squeaky wheel gets the oil. In healthcare that translates to the patient who complains the loudest, is the most uncooperative or makes the most unreasonable demands, also gets all the attention. Often this means other patients are ignored. It never fails to amaze me how this happens over and over again.

Last weekend was a good example. I worked at one of my part-time jobs. On Friday, I received a call to give me a heads-up about a patient on my schedule. Seems he was very difficult. He would only participate in therapy at times of his choosing and would only do what he wanted to do. As a result, the department was running around in circles trying to accommodate him. The phone call to me was to warn me a specific time had been scheduled and give me the background information.

I wonder what would happen if we said no to those people. What if instead of bending over backward, we listed the options and told them to pick one. In this case, the man survived having his therapy in the morning instead of the afternoon.

We've all had patients like this. It may take four or five attempts to complete the treatment. Meanwhile, we spend the day running all over trying to squeeze others in around the multiple refusals. I'm not sure why. In my experience, even when these people participate in therapy they rarely do enough to make the treatment worthwhile.

I don't remember being taught I must make multiple attempts to accommodate difficult patients. Nor do I remember being told I should. Facilities want to avoid complaints because they fear it will affect utilization. They pander to those individuals who complain, which frustrates staff and encourages the behavior. I think that the word "no," said in the most pleasant of voice, would be just as effective.

A few weeks ago, we had a man who refused to get out of bed to go to meals, which is the facility policy. He demanded that food be brought to him. My suggestion was to stop bringing him food. Tell him to go to the dining room if he is hungry. Once he realized we weren't going to bring him food, he might be more willing to get up. I was told no, that wouldn't be right. He might starve. None of the other residents were allowed to eat in their rooms, though many wanted to. So all this did was create resentment.

PT departments are chronically understaffed and overworked. They don't have time for such nonsense. There's a difference between someone who is confused, scared, demented or in severe pain refusing therapy compared to a manipulator. I realize this may be one of the few ways those people can control their lives.

What's the worst thing that would happen if one of these people missed a treatment or two? It wouldn't be any worse than what happens to the patients who miss therapy because the therapist is running around trying to accommodate the squeaky patient.

When I started my current job, I was given a request. Help Jenny (not her real name) walk again. Jenny had a devastating stroke four months prior to that and was just beginning to wake up. At first they didn't think she'd live. Then they didn't think she'd wake up. She fooled them all. When she became my responsibility, she was awake, following one-step commands and moving her left side.

So I did what they asked. I got Jenny walking. I don't think anyone believed I could do it at first. There were times when my tech and I practically dragged her down the hall. Other times, I didn't think I'd ever get that knee working. I spent almost as much time thinking about what I was doing as I did actually doing it. Finally three months later, Jenny walked to the dining room with SBA.

We kept working. Jenny became MI for almost everything except sit-to-stand. We reached the point where her nervous system had no more to give. Jenny had started cruising through therapy so I signed off. Prior to doing so, Jenny and I had a talk. I'd noticed that she'd gained some weight. It was making transfers and walking more difficult. I was concerned that her post-stroke body couldn't manage her pre-stroke weight.

That was about two weeks ago. This morning I checked on her. She was in the dining room sitting in her wheelchair. It turned out she wasn't walking to meals anymore. In fact, she isn't walking much at all anymore. The restorative aides tell me she's having trouble getting out of her chair. They have to lift her up. They tell me she spends most of her time in bed drinking sodas.

The good news is that Jenny beat the odds. She's alive with a decent quality of life. The bad news is all that work was apparently for nothing. Jenny is happy to rely on her wheelchair. Yes, she can do many things independently but her goal was to walk to the bathroom. We achieved that goal and then some.

I'm torn about how I feel. Getting her walking was a major accomplishment. How she moves around the facility now is her choice. I shouldn't be surprised. Many patients lose some mobility once discharged from therapy. After all that work, I guess I expected something more.

I don't know about anyone else but I can't wait for Christmas to come and go. Things need to get back to normal, or what passes for normal. I'm not a holiday person. I don't go out of my way to celebrate them. Holidays are actually my favorite days to work. No one else is there so the day is peaceful and productive. The patients are appreciative that someone is there, so they seem extra cooperative.

This year I got into the spirit of the thing by having some of my patients help trim the tree. Hanging ornaments is a wonderful balance activity. We also did candy canes. I helped cut and tape the holiday chain that drapes from one of our walls. I gave money toward the manager's present. But that's as far as it goes. I will celebrate by taking treats to all the horses in the barn. My spoiled ponies will get a little extra but everyone will get something. That's my kind of giving.

I like to choose who and what I give, not have it made a requirement. This year we're having a holiday lunch at a nearby Mexican place. Rehab employees, who are new to all of us, from our sister facility will be joining us. Even though I generally skip parties, that seemed acceptable until we were told to bring a Secret Santa gift. We're going to pool the gifts and draw numbers. Since when did Secret Santa become mandatory?

Half the fun of Secret Santa is figuring out something for your person. Even if they provide ideas, it's still up to the giver to make the selection. I like to give gift cards to favorite stores or restaurants. Even in smaller groups, it's still fun to find out who had whom. To do that now means buying a generic card under the limit amount or trying to think of a generic present. The idea is making me less inclined to even bother.

Maybe you should just call me Scrooge. It wouldn't be the first time.

One of my favorite patients died last weekend. It wasn't unexpected. She'd been gradually deteriorating for the last few weeks. It was obvious by looking at her that she wasn't feeling well. She'd begun talking about stopping dialysis because it made her feel worse. Yet every day she was ready and eager for therapy. Even on her worst days, she wanted to at least try.

I feel very fortunate to have known her. Her daughter stopped by the department today to thank me for working with her mother. She told me her mother looked forward to our morning coffee before therapy. I was lucky. I was at work when the ambulance came so I had the chance to tell her goodbye. I don't always get that opportunity.

Patients die. Depending on the setting, it can be a regular occurrence. Both SNFs and ICU are places with higher death rates. ICU patients die because they're very sick or critically injured. SNF patient populations tend to be older with medical co-morbidities. Sometimes their bodies just wear out. I've had patients die before. It's not surprising. In many cases it's more like a permanent discharge. One patient leaves and is replaced by another.

This lady was special to me. I got to know her. Her death is a reminder to me that our patients are human.

I don't know about anyone else but I can't read medical news with an unbiased outlook. A few days ago "Yahoo!" posted an article about a man who'd awakened from a month-long coma. The first thought that entered my mind was concern about why he wasn't wearing a helmet. He'd obviously had a hemicraniectomy so needed to be wearing a helmet. My next thought was to disregard the entire story since the coma was medically induced and therefore not a true coma.

I drive people crazy with this. I usually don't say anything aloud unless someone asks me about it. There are numerous movies I can't watch because I'll be so distracted by the medical inaccuracies, I won't pay attention to the movie itself. The same is true of TV shows, news feeds, magazines and the like. I spent half of "Forest Gump" trying to figure out how they were able to make the bilateral knee amputee so realistic.

Several years ago, I worked in a department that watched a soap opera at lunch. Any time one of the characters was in the hospital, we roared with laughter. I don't know which was funnier -- the butchered medical conditions, nonexistent recoveries or lack of residual deficits except for amnesia from the most devastating of head injuries. Entire conversations occurred with a trach in place. Once there was an oxygen tube that ended in mid-air.

But one thing annoys me more than anything else. Where is the mention of physical therapy? The story about the coma man mentioned him taking his first steps but said nothing about the physical therapist who helped him. I seriously doubt the man got out of bed by himself or that the nurses took it upon themselves to help him. For every story about someone overcoming a devastating injury, there is probably a PT pushing that person along who never gets mentioned.

My friends either humor me or ignore me. They don't care whether or not the man has a helmet. Nor do they care that a C-something quadriplegic can't use his hands. They have no concept of what I do or why I get annoyed that PTs are the forgotten discipline in the news.

In a recent blog for ADVANCE, Jason Marketti talks about having several per diem jobs to help him afford large purchases. That reminded me of when I used to do the same thing. I can remember when most of my coworkers worked a few extra days. No one did it regularly, or if they did, not for very long. That isn't true today. Almost every therapist I know has a second job to help pay bills. I know two PTAs who work a full-time job and both weekend days every week. I don't know how they avoid burnout.

I don't know what changed. Things are certainly more expensive. Salaries haven't kept up with the cost of living. Starting salaries might be higher but the raises are much less. I can remember when I could expect a 3- to 5-percent increase. Now, 1 or 2 percent is more common.

It's also harder to find extra work. I've been looking. There are a few supplemental positions advertised but not many. Maybe facilities cut out weekend coverage as a cost-saving measure. Depending on the setting, working weekends is the expectation. Five or six years ago, I was a manager. Finding weekend coverage was an ongoing struggle because no one wanted to work extra. That doesn't seem to be the case now.

My friends who work contract tell me they aren't working regularly. Some are lucky to get 40 hours a week. Facilities aren't using contract help like they once did. Now they make do if someone is off instead of finding coverage. Meanwhile the people who would have filled those openings struggle to make ends meet.

I wonder how this is affecting patient care. I can't imagine patients are getting the same care if weekend therapy no longer exists. I wonder how SNFs and rehab units are making their minutes without weekends. Ironically, the research is supporting better outcomes with more consistent therapy at every level.

There are so many different elements to this equation it's hard to separate them. The reality is most PTs and PTAs work two jobs by necessity, not by choice. Lately, those second jobs are becoming hard to find. I don't mind working extra. Back at the "evil empire," I enjoyed my weekends because I did something completely different. Now I will take whatever is available.