We recently had another patient who seems to have fallen between the cracks in our wonderful health care system. He was initially in therapy for a variety of medical reasons and then a fracture was discovered in the mid-spinal region. Therapy was held per MD request for about two weeks. When therapy requested orders to resume activity, none were given. Then the insurance company decided it was not going to pay for the patient's stay any longer since he was not making progress with therapy.

The patient was not able to walk more than 10 feet with an assistive device due to pain, and with the MD not giving resume-activity orders, he got weak and had to have more assistance with transfers. The day the patient left, he explained to me his home environment. I knew there would be trouble at home if this man left but away he went. It was like sending him home "against therapist advice." (Is there such a thing?)

The patient was upset that therapy was not involved in the decision-making process about going home. He could obviously see the benefits we offered him but apparently the insurance company couldn't care less about the person's function and how he would be able to move around in a home environment. It reminds me of when Medicare Part A refuses to purchase any ADL equipment for the bathrooms, specifically for THA patients who are at a high risk for dislocation.

They would rather have a patient dislocate a recent surgery than provide a high-rise commode and a bath bench. There is a lot I do not understand about our insurance industry, beginning with how in the world someone decided a patient should be in ARDs, RUG categories, COT etc. and not give the patient what he needs to be safely discharged to home? Maybe "Obamacare" has a point; I don't know, but the current system has failed too many of my patients.

After reading a patient's chart and looking at the eval, I usually have a plan formulated in my head on what I am going to do with that patient. Sometimes it does not go as my well as my meticulously thought-out plan and I feel like running right into some of the rooms screaming, "Leeroy Jenkins!" ("World of Warcraft" players will recognize this).

There will always be those patients who can hide their dementia very well and other patients who claim they can do more than what their body will allow them to. Most of the time, I can accommodate for these things and usher along a patient who thinks all I do is force him out of bed to move his legs.

For joint replacements there are sets of exercises we all do with the patients, then I break protocol and begin their functional descent into "real-life" therapy. Can they carry a grocery bag (or other items) while pushing a walker or using a cane? Are they able to use a flashlight and maneuver around a room in the dark? How about climbing a ladder to change the smoke-alarm battery? These things are very functional for someone who is supposed to go home, but what do I bill it under?

In a home assessment, I usually delve into the bedroom, bathroom and kitchen -- the three rooms most people are likely to go. But what about the laundry room, feeding the animals, gardening and trying to get between the pews at church with an assistive device? I attempt to replicate some of this as best I can at the facility with the patients but sometimes it does not work. And there are times when no matter what I have planned for patients in my head, they will take me in another (better) functional direction. One patient showed me how she picked up flat pieces of paper on the floor with her reacher without breaking her THA precautions. Another patient perfected the log roll from supine to stand in one smooth movement without violating his back precautions.

Even though I have a plan in my head, there are times I have to wing it because the patients have already thought out their difficulty and accommodated for the deficit. By the time I get there, all I can do it go through the monotony of supine, seated and standing LE exercises. It is the patients who haven't formulated their own plans that keep me motivated enough to show different functional ways to move around without feeling helpless.

The police, fire department, EMTs and MDs are a few of the professionals that seem to be on duty all the time. In therapy, we are not and in most cases we do not make truly independent decisions. This might be due to the training and thought processing that has been taught.

We consult with the nurse or other health professional before seeing patients in a hospital setting and a SNF. When X-ray and blood draws are needed, we are asked to step out of the room so they can do their procedure, and it seldom works the other way around. We cannot change a person's diet or medication, and in some cases we do not even have the authority to get him to participate in exercises.

In outpatient, a therapist cannot refer a patient to a different MD that might be better for the patient's condition. Therapists cannot write a prescription for an assistive device or adaptive equipment so insurance companies will pay for it. Yet insurance companies will require us to complete a wheelchair-seating assessment before they even think about providing one for a patient. Where is our authority to dictate to the insurance companies that we know what equipment the patient needs prior to discharge?

The higher education in therapy has given little credence to insurance companies and an LPN can still tell a DPT to leave a patient alone because the patient needs rest. Therapy does not dictate length of a patient stay and despite a therapist's knowledge and assessment of a patient diagnosis, we cannot act on that assessment unless we have approval from insurance and in some cases, the MD.

Other professions often go to court and have a legal precedence to what their profession can accomplish. I have met one therapist who went to court and was crucified because of poor handwriting in the chart. We do not even have a licensure compact agreement like nurses do where they can easily glide from state to state with limited interruption in their services. We are not on duty 24/7 and can relax on our days off. Officers, nurses, MDs and EMTs often have a duty to stop at an accident scene to render aid while those with a therapy degree can simply cruise on by listening to music. Even a lawyer would probably stop and pass out cards to secure clients, but not a therapist.

Years ago, I was new to an area and began to secure employment as a per-diem PTA. One of the first places I worked was a hospital. After educating them on the per-diem pay scale, I was hired to work almost every weekend. I explained to HR that I needed full-time work since I had a family but no insurance to cover them and that I would be looking for full-time employment while I worked.

Two months passed and finally I found a SNF who hired me full time. I spoke with the therapists at all the per-diem places I was signed up for and 99 percent of them wished me good luck with my full-time employment and kept me on as a per-diem PTA. The hospital and the therapists I worked with were upset. Naturally so, but since they had the luxury of having insurance by working full time and no children to cover for health care needs, they did not seem to understand my situation. So we parted ways but not as BFFs.

Move ahead several years and this hospital is hiring for a full-time PTA. I apply and there is no response. A month passes and the opening is still not filled, so I apply again. I receive a notice shortly thereafter essentially informing me I will never be hired by their health care system because I did not adequately inform them about my departure as a per-diem therapist. My only wish is to write down the hospital's name, the therapists I worked with and the HR tyrant who blacklisted me so other therapists will be aware of this.

Everyone once in a while, we will see angry patients. It might be from the circumstances they are in, the bed, food or not being able to move about in familiar surroundings. Most of the time the anger is not because of us, but it can often be aimed at us in therapy.

Recently I had a lady throw her FWW at me. Fortunately my cat-like reflexes dodged the blow and I retrieved her walker and set it back up next to her. She stared at me for a minute, then turned away and did not acknowledge me when I tried to speak with her. I am not sure what she was trying to accomplish but she didn't do therapy that day, so I guess she won.

Another patient a few doors down would come for therapy, endure the activity and say, "Thanks for nothing" after we were done. She would make her snide comments throughout the sessions to every therapist who approached her to work. With enough coaxing, she agreed but reluctantly.

Then there are the patients who are just as angry but make funny comments that get us all laughing in the gym. Most of their comments are directed toward me and I laugh right along with them. The floor-to-ceiling transfer pole we have set up usually gets the most laughs and is commented on by both the men and women. That is fine as long as the patients can take their minds off being angry and not throw anything else at me. But at least I know I am still quick.

As I was doing some research, I discovered that some state boards have already adopted APTA precepts or at least have it on their agendas to do so. Being a non-member of the APTA, I will soon have to abide by their rules if state boards continue with this course of action.

I wonder why some state boards do not take the time to write their own rules rather than merge with ones that are already written. And since the majority of those who practice therapy are not members of the APTA, state boards are ensuring we will follow the rules set forth by the national organization by a de facto standard.

I wonder how long it will take for state boards to mandate we have to join the APTA in order to be licensed in their state. I better not give them any ideas.

I was asked to help during a PT evaluation. I enjoy assisting the PT during this process because I can ask appropriate questions when it is over and I get a "firsthand" look at what the patient is capable of when he initially comes to the facility.

There have been times when I know a patient has performed remarkably well per the eval but then when I see the patient he acts like it is the first time he has ever moved out of bed. Assisting with the eval can also refresh some of the things I have forgotten about like tactile discrimination, nerve-root distribution and different ways to manually muscle test a patient's strength.

The part that is frowned on is having two people of the same discipline in one room. This is costly for a company if we both need to be there for any length of time. But since PT aides have been "let go" and nursing personnel has been cut back, sometimes there is no alternative but to have me and a PT in the same room.

For those of you who study state board rules and regulations, I have a question for you. If the PT is in the process of evaluating the patient (she has not completed the evaluation) and requests my assistance, am I able to put my hands on the patient even though the eval is not finished? Or am I just splitting hairs with this one?

We had a patient come to us and there were no therapy orders on the admission paperwork. We asked, faxes were sent to the MD and surgeon but there was no response. A week later the immediate need for an evaluation from all disciplines was demanded when orders finally arrived. Emphasis on demanded.

The person who coordinates admissions missed something (important) and then demands we suddenly jump because orders were received. The patient is not aware of this aspect of health care and probably thought therapy was not coming. Nursing did not get the patient up enough and was not sure what to do with him. Therapy knew what to do but was not able to do the job they were trained to do because no orders were received from the doctor. The MDs most likely thought therapy was involved because the patient was seen by therapy in the hospital and why would those orders change in the SNF?

I spoke a while back about facilities having standing orders for all therapy disciplines when entering a SNF. In this instance it would have worked. Therapy could evaluate and assess the needs of the patient at admission and professionally determine a course of action without a delay in treatment. This patient has lost a week with us. I wonder if the insurance company cares about this delay? Will therapy get an extra week because someone didn't check the little box that says therapy can evaluate the patient? Probably not.

A patient came to the nursing facility with a weight-bearing restriction of TTWB. Hospital notes indicate he walked between 25 and 50 feet while there. The day I saw the patient we were only able to gait about 10 feet before I noted the increase in weight to the involved LE.

We worked on upper-extremity exercises as well as lower-extremity strengthening in lieu of increasing gait distance. This posed a problem with everyone involved with his care. When questioned, I related what I perceived as too much weight bearing on the involved lower extremity. Stairs were impossible due to this, safety became an issue when nursing walked him to the bathroom and lack of strength and stability during activity deemed him a fall risk as well as impaired healing to the surgery site.

The push for increasing gait distance was felt throughout the therapy department. We pushed back, stating the patient is not consistent enough with the surgeon's order of TTWB. That calmed the storm for a while, but it was still brewing just outside of the parallel bars, waiting to come back at us stronger than before.

Because of the surgeon's order and our assessments of the patient and his lack of strength, he was saved from being discharged to home. Once the surgeon's order is changed to full weight bearing, the patient will most likely be sent home with inadequate follow-up care for balance, strengthening and safety. He will amble along in his home, drive his car, go shopping etc. without the benefit of continued therapy. He is a fall waiting to happen (again) because he chose the wrong insurance company.

While working on a patient who still required a mechanical lift, I practiced sitting balance on the mat table and use of the slide board multiple times. It was successful to a degree. The obstacle for success was that no carryover from the nursing department occurred.

And to make it worse, the sling used for the patient remained under him throughout the day. When nursing was asked about the sling still under the patient, the reply was that it is easier for them to do it that way when getting him back to bed. Now, I am not a genius about skin integrity, but I have seen wrinkles on a bed produce wounds on an immobile patient. Imagine the thickness of a sling being under someone and what that can produce in the realm of wounds.

Apparently this didn't seem to be an issue with anyone but me. The sling has stayed put and my feeble attempts to change that are met with scorn. Somehow the sling is replaced when therapy is done (I don't replace it after therapy) and the patient has mentioned it can get uncomfortable at times if the seam is in the wrong place.

Where to go from here? Do I continue the silent sling protest by not replacing it or should I hide it somewhere in his room? Another thought is that maybe the sling is under him in case he requires medical attention and a fast transfer back to bed is needed. I am not sure what to do. The needs to protect the skin from damage and make the patient comfortable are paramount but so is ease of transfers. Maybe we will get to the point of using the slide board more consistently and safely so the sling will become a non-issue soon. I sure hope so.

I recently attended my first "live" conference in more than 10 years. It was one of the most informative and action-packed adventures I've had. I was able to connect with people, collect numbers, share experiences and sample some new technology that is available to those who need it (and are able afford it).

This conference was not what you would think. It had nothing to do with physical therapy and yet I learned more in this conference in two days than I ever expected. The focus of the conference was about educating and empowering students with disabilities and for those students to take charge of their education, speak up at IEP meetings and learn how to navigate the governmental systems put into place for their own "good."

While at the seminars, I learned about some pioneers in the disability rights movements. I thought it strange that in history class years ago I learned about Martin Luther King Jr., Cesar Chavez, and Mohandas Gandhi but I never heard of Ed Roberts and Judy Heumann, who were instrumental in defining changes within the government to allow people with disabilities more rights. And as recently 1990, the Americans with Disabilities Act was signed into law and had amended changes that were to take effect in January 2009. Imagine if any other group had to wait that long for civil rights legislation to be passed.

I did meet an ST and a PT who were peddling goods for large companies like they were at a medieval faire. The products were new and would benefit a lot of people but the price was prohibitive for most families who attended. I do not know which is worse, having therapists push a corporation's products because they are "rehab experts," or the corporation itself that develops a product to assist with accommodations and then doesn't make the product readily available to everyone who needs it.

Her family, who was very supportive, decided we were not doing enough for her and began a slow campaign to question the nurses about whether we knew what we were doing. Fortunately the nurses and therapy get along well enough to support one another when it comes to patient care and family members. The nurses assured the family we were good (the best in the area) but it did not seem to appease the family. The patient's husband finally asked, "Are the therapists doing everything possible to ensure my wife's recovery?"

There is only so much therapy can conquer when it comes to stroke rehab. Other factors weigh in, such as the extensiveness of the stroke, time elapsed between home and hospital, and the body's ability to recover after a brain injury. This did not seem to make a difference with the family. They wanted progress, and they wanted it now.

The family wanted therapy's estimation of discharge to home and questioned each one of us separately at different times about the progress she was making. Obviously the family was angry about the injury but to ask whether we were doing everything possible hit a nerve in me. Can a family really believe we would not do everything possible to get people well? Do they think we would not work hard with her and delay recovery? I wonder if they questioned the MD that way at the hospital. Probably not since she was not expected to live and now that the life-and-death situation is over they can focus on other aspects of her care, like why she is not improving faster.

The benefits of co-treating with another discipline (OTs and STs) will allow a patient to receive an intensive therapy session without getting so fatigued that he will not participate later in the day. Usually I am working on safety and static or dynamic balance activity while the other discipline is working on another aspect of therapy. This can be overwhelming to some patients because they are receiving multiple tactile and verbal input to maximize functional activity.

The downfall is that for the rest of the day the patient is not doing anything with therapy, especially when only two disciplines are involved and we have co-treated for an hour. That means for 23 hours a day the patient receives no input from us. Could this be bad planning on our part? Or is it that we reviewed the patient's function and made an accurate assessment that the benefits of co-treating have outweighed the risks of the patient being virtually idle for the greater part of the day? This is a difficult dilemma and may not be easily answered except by a constant reassessment of the patient's condition.

There are some patients who demand two therapists are involved so a safe transfer can be made or the patient's energy level may be too low to allow several sessions throughout the day. As the patient improves, we can separate the sessions and space them out accordingly and hopefully see the patient in the morning and afternoon. But then we also have to consider MD appointments, hairdressers and activities coming in to see the patient. So there will be some days when the only way for all disciplines to effectively see a patient is to co-treat.

Recently I told a patient I was going to place a safety belt on her and reached in to attach the belt. She instinctively hugged me as my arms were around her. This was awkward to say the least. I have told male patients that I am going to place a belt around them and some will stick out their hand so I shake it and proceed with placing my belt. But a hug? What am I supposed to do?

Do I hug back? Do I simply continue with what I am doing and step back? I know this may have been weird for her too because she may have misheard me (is that possible from two feet away?) or she saw me "leaning" into her and did what came natural for her. But I am a virtual stranger to this lady, who I met the day before.

She was cognizant, well aware of her surroundings and understood all of my instructions. I want to know why she hugged me. Maybe it is my good looks? No, that can't be it. Maybe I was kind, possibly. More than likely she was used to it - she taught school at an elementary level. Maybe she flashed back and thought I was one of her pupils. Whatever the reason, it was still strange for me to receive a hug uninvited.

A while back, I wrote about how new technology is assisting with patients in the rehab field. I even thought about going back to school to learn more about engineering technology. Then I seriously thought about how this technology is changing the field of therapy. If we use technology to increase a patient's independence where do we fit into the grand scheme of things?

Maybe therapists will fade and engineers will fill the gaps to set the patients up in the machines they designed. Will the skills some of us learned in school and through CEUs become obsolete because the newer technology will pinpoint where a deficit is? There will need to be someone to set up the equipment and place a patient in the machines but is setting a patient up absolutely therapeutic in nature? Will it take the skills of a therapist to tell a patient to push, pull, bend and straighten on a machine? Maybe, maybe not. Could an exercise physiologist tell a patient to do that? Or an ATC? Yes, they should be able to determine where the joint alignment needs to be for the machine to be most effective.

So when dealing with machines, new assistive technology and the like, how do we determine where the therapeutic skills come into play? We know when we do PNF, NDT, etc. we are dealing with a special skill set for palpation, facilitation and patient response to the activity. With machines it is different. We can look at a computer screen, then at the patient, but it seems we would become more detached from the patient the more we use technology to assist a patient to achieve independence. What do you think?