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By Jason Dusza, OTR-L, CBIS and Alissa Humes, PT, DPT, NCS, CBIS
Rainbow Rehabilitation Centers

Simple tasks such as getting up from the sofa, walking up and down the stairs, and even taking a shower are activities that most of us take for granted. But when you are severely injured, these simple endeavors become extremely difficult. Parts of your own home may become inaccessible, and simple actions are now daunting and can induce anxiety.

What is Home OT and PT?

Occupational therapy (OT) and physical therapy (PT) have an important role to play in the home and community environment. These roles are very different than those in inpatient and outpatient settings. Providing therapy within the home environment is unique in that it allows the client to practice activities within a familiar setting.

Research has shown that home rehabilitation services can help clients improve or maintain their physical level of function, improve their quality of life, and increase their overall independence.1 Additionally, home care services can also address home- and community-related issues with caregivers in real life settings. This can improve caregiver involvement and allow family to cope with their family member’s new level of function, which may lead to the client being able to stay in their home longer.2

OT and PT each have their own unique approach to home- and community-based therapy that, when combined, can work synergistically to meet the client’s goals in a more holistic and well-rounded manner.

The American Occupational Therapy Association states that OT helps people across their lifespan perform the activities they need and want to do to in order to live life to its fullest. Occupational therapy can help promote better health and prevent or manage injury, illness, or disability through the therapeutic use of daily activities (occupations).3 This can be accomplished in the home by analyzing the environment, recommending changes to better support the client’s needs, goals, and safety, and performing an analysis of the demands of various tasks and activities that are important to the client. Activities such as home management tasks, cooking and medication management can be directly addressed in the setting they are accustomed to instead of being simulated, as they often are in the clinic.

The American Physical Therapy Association describes PTs as health care professionals who work toward reducing pain and improving mobility by examining each individual to develop a plan and start a treatment program. Through this, PTs “promote the ability to move, reduce pain, restore function, and prevent disability” as well as educate individuals on healthier lifestyles.4

A physical therapist is typically brought into the home when a person is unable to leave their house for various reasons such as transportation issues, not having the strength or endurance to leave the home or being unable to enter or exit the home independently. In the home, the PT assists with improving mobility to increase overall independence, whether that be with various assistive devices (walker, knee scooter, wheelchair, cane), strengthening exercises, or improving overall activity tolerance.

A Teamwork Approach

Both the OT and PT have the common goal of meeting the individualized needs of the client, and it has been proven that “working in teams and sharing skills eliminates confusing and exasperating duplication of tasks for the patient.”5 Research and the first-hand experiences of clients has concluded that OTs and PTs working together is a more effective method of delivering care.5 Each therapist will have discipline specific goals on which they are working during each session.

When OTs and PTs work together with a client within his or her home, the therapists are able to combine their skills to truly maximize the client’s independence in an efficient and meaningful way.

Casey’s Background

Recently, one Rainbow client benefited from a successful OT and PT collaboration. Prior to being involved in a car accident on August 20, 2017, Casey was independent and active at home and in the community. He and his wife were hit head on by another vehicle resulting in Casey sustaining multiple contusions, abrasions, and a Lisfranc fracture in his right foot. Casey was unable to bear weight through his right leg for nine weeks due to an open reduction internal fixation surgery and therefore needed various assistive devices to help him move, including a knee scooter, a walker, and a wheelchair. Casey also had a history of Parkinson’s disease. Slowed cognitive processing, memory impairments, anxiety, decreased coordination, and difficulty with motor movements became exacerbated following his surgery, which added additional challenges to his recovery.

Casey’s Therapy Goals

Rainbow’s OT and PT team worked with Casey to identify and develop goals that were meaningful and important to Casey and his spouse. It was quickly evident that Casey’s main goal was to access and use his basement bathroom, as it was the only shower in the home he could utilize. At the time of the initial evaluation, Casey was unable to manage a full flight of stairs due to his physical and cognitive impairments. As a result, he was limited to a sponge bath at his kitchen sink with assistance from his wife.

Once Casey’s main goals were identified, the team discussed how each discipline would address, prioritize, and organize therapy in order to meet Casey’s overall goal. Both OT and PT complemented each other throughout the therapy process by targeting different aspects of the goal unique to their discipline.

For example, the OT evaluated Casey’s upper body strength and range of motion to assess whether there would be any physical barriers to complete showering tasks. They assessed the bathroom for fall risks, provided recommendations on adaptive equipment to utilize, and completed a simulated shower for practice.

The PT focused on improving Casey’s independence with his walker, scooter, and managing stairs, as this was a main barrier to accessing the lower level basement. Throughout this process, OT and PT remained in communication by frequently updating each other on progress, concerns, and successful techniques that were working for Casey so that each therapist could implement the same strategies in a consistent manner.

Remaining consistent in the therapeutic strategies used with Casey was important due to the cognitive deficits present such as memory impairments, difficulty with complex commands, following instructions, and increased anxiety, especially with new tasks. All these deficits made it challenging for Casey to carry over new techniques. Therefore, OT and PT attempted to utilize the same cueing and education techniques as well as overall physical instruction during each discipline’s session.

In addition to individual sessions, the OT and PT also completed multiple co-treatment sessions in which both therapists worked with Casey at the same time. This allowed the therapists to problem solve together, improve patient safety, and decrease Casey’s anxiety during tasks that were more difficult for him.

For example, during one of the co-treatment sessions, Casey worked with both therapists to simulate the process of transferring from his knee scooter to the floor prior to trialing this complicated task at the stairwell. Casey had reported significant anxiety over practicing on the stairs, but this simulation allowed him to master the skill needed in a safe and comfortable setting prior to completing the move on the actual staircase. This strategy was developed after both therapists worked closely with Casey’s spouse who helped by locating items within their home that could be utilized as well as helping to problem solve through various barriers that they came across. Casey’s spouse had also previously received PT following the same accident and was able to offer many helpful suggestions based on her experiences in therapy.

During individual sessions, PT continued to work with Casey on improving techniques to manage the staircases and practiced transferring from his scooter to the steps. Once Casey completed the entire process of transferring from his scooter to the staircase and going up and down the stairs, OT began the next step towards meeting his goal by working with Casey on using the bathroom.

The OT team first worked with Casey on completing transfers from his wheelchair into and out of his shower while maintaining his weight-bearing precautions. He was educated on the proper use of his shower chair, grab bars, and the hand-held shower to improve safety and independence. He then completed a simulated shower to improve carryover and reduce anxiety prior to completing a real shower. Once Casey demonstrated safe techniques and reported confidence with these tasks, he was able to meet his main goal of taking a full shower after many months. He continued to complete showers successfully with his spouse’s supervision.

Reaching Casey’s Goals

Casey is an excellent example of how OT and PT teams can work together in the home, utilizing their individual skill sets to maximize a client’s function as well as help the client meet the most challenging goals they have at home. Ultimately, Casey could put weight on his foot without having to wear a boot, which resulted in him being able to go up and down stairs without any issue. However, during the months he was unable to do this, occupational therapy and physical therapy helped him regain his ability to perform an everyday activity that most would take for granted—taking a shower.

References

  1. Armstrong J, Sims-Gould J, Stolee P. Allocation of rehabilitation services for older adults in the Ontario home care system. Physiotherapy Canada. 2016; 68(4); 346-354; doi:10.3138/ptc.2014-66.
  2. Warner G, Stadnyk R. What is the evidence and context for implementing family-centered care for older adults? Physical and Occupational Therapy in Geriatrics. 2014; 32(3); 255-270.
  3. American Occupational Therapy Association. 2018. About Occupational Therapy. https://www.aota.org/About-Occupational-Therapy.aspx
  4. American Physical Therapy Association. 2015. Who Are Physical Therapists? http://www.apta.org/AboutPTs/.
  5. Smith S, Roberts P. An investigation of occupational and physiotherapy roles in a community setting. International Journal of Therapy and Rehabilitation. 2005; 12(1).