Clinical Practical Perspective for the Treatment of the Injured Worker

As highly educated and trained Physical Therapists, we are experts of movement and functional performance of activities of daily living, both within the home and the work place. Our ability to assess the quality of movement and contributing factors of compensatory patterns of musculoskeletal injuries is unparalleled in the healthcare field. Our specialized skill set allows us the ability to paint a picture leading to successful outcomes for all injuries, whether caused by poor posture, body mechanics, repetitive overuse, or trauma. With this in mind, we have an even greater opportunity to impact work related injuries. It is, however, very easy to overlook the specific job demands, impairments and functional limitations of our individual patients, thereby making their case seem like any other.

In order to paint a full picture in a worker’s compensation case, we must hold a full understanding of their job demands. Utilizing intake forms which provide a thorough history incorporating job specific questions, such as a Functional Job Demands Form, can allow us to gather information pertaining to a patient’s job demands including lifting, pushing/pulling, reaching, carrying, and the weight and frequency to which the tasks must be performed. This alone however, will only give us a “snapshot” of the patient’s physical job demands throughout their work shift. Job descriptions can often be obtained from the patient’s employer or from the Dictionary of Occupational Titles (DOT), however, these descriptions are typically more generalized to the overall position and may not be specific to the individualized demands of the job. Therefore, an on-site visit to the workplace is recommended in order to obtain a complete appreciation and understanding of the worker’s duties needed to fully rehabilitate your patient back to their prior level of function.

On-site visits allow us the “real and most accurate” means of visually assessing a worker to their job. If possible, it is ideal to schedule a site visit within the first two weeks of care in order to apply this information into the treatment plan as soon as possible. The information collected from the Job Demands Form at the evaluation can be an essential tool in alerting you in advance what you should look for on your visit. It is strongly recommended to have the patient accompany you to the visit as their presence offers additional knowledge and means of measurement by looking specifically at them in their work environment, as well as to be able to capture billable time under Physical Performance Test or Measurement Coding. Studying the patient’s work station, posture, work site set up, ergonomic situation, physical job demands, and rate as to which they are needed to perform their job tasks, will allow you to better conclude functional goals, work simulation tasks, and determine potential modifications to prevent future injury.

As job site visits do require time out of the clinic, training another licensed professional such as a Licensed Athletic Trainer, Exercise Physiologist, or a Physical Therapy Assistant on how to properly complete a Job Site Analysis can be of great value as you will have the ability to remain in your clinic while still being able to paint the full picture of how a worker was injured. The data collected directly by you or another designated individual can also allow you to establish more functional tests as you perform progress notes to update their physician and case manager as to how they are doing. With a more functionally based progress note we are not only able to objectify our patient’s progress with comparable data as to how far they have come with our typical measures of ROM, MMT, and pain, but more so apply the functional data from which we have gathered regarding their job specific functional limitations and impairments. The combination of these efforts will allow you to best understand, simulate job tasks within the clinic environment, problem solve, and ultimately determine when a Work Conditioning/Work Hardening (WC/WH) program is appropriate for preparation of their full return to work at their previous level of function.

Job simulation is imperative in successfully returning the patient to work safely and efficiently and therefore is a key component to all WC/WH programs as they give you a full appreciation of the demands in which each individual patient needs to undergo throughout the course of their work shift. Following the completion of WC/WH, a functionally based discharge summary is recommended to test and measure the progress and/or limitations that may still be present at the time of discharge. This information is of great value as it will assist and facilitate physicians in more accurately and specifically determining work restrictions/modifications or disability ratings as they return our patient back into the work environment.

The detailed documentation that stems from the Job Demand Analysis, Functional testing and WC/WH will not only assist us as therapists, but also the patient, the physician, the case manager, employer and payer. Pro-actively offering in-depth communication with the case manager and payer will help them better understand the patient’s need for therapy, thereby the need to deny visits and claims will not be as likely to occur. The employer will also benefit from pro-active communication as it shows the high level of involvement invested in the care of their employee. By showing the value of your services through the worker’s treatment, you may even open the door for future opportunities for on-site work including educational seminars, stretching programs and ergonomic training. Becoming further involved with the employer may also lead to additional therapy opportunities to becoming the preferred provider of choice by the employees and their families.

We must never lose sight of providing value in all of our services and painting a full and comprehensive picture for any patient’s injury. It is important that we understand and incorporate a patient’s specific job demands into their Plan of Care so we may better return them to work in a safe and timely manner. Although utilizing a Functional Job Demands Form or obtaining a job description of a patient’s duties can be adequate tools in gathering information, performing an on-site visit will give us a full appreciation of the worker’s tasks and assist us in creating a well-rounded Plan of Care, including job specific functional testing and WC/WH programs when appropriate. By incorporating all of these pieces into the worker’s compensation case, we have the ability to show the true value of our services, unparalleled in the healthcare field, while returning the injured worker safely back into the workforce.

Dysphagia: Diagnosis, Treatment and Controversies

Have you ever swallowed and had food “go down the wrong way”? For an estimated 15-40% of adults over the age of 60 this is a constant concern. Dysphagia is simply defined as any difficulty or inability to swallow. It is not a disease, but a disruption of a normal process. Problems at any point during the swallow can result in difficulty swallowing. A person with dysphagia may have a delayed, incomplete or absent swallowing response. Potential causes include obstruction, nerve and muscle problems and miscellaneous issues such as trauma, medications, poor dentition and poor mouth care. Dysphagia can have a dramatic impact on an older person’s nutritional status including development of malnutrition, unintended weight loss, dehydration, and other nutrition deficits.

Warning Signs of Dysphagia

Dysphagia sometimes goes undetected because the signs and symptoms may be confused with other problems or conditions. Warning signs include:

· Coughing, gagging, choking, weak cough, frequent throat clearing or hoarse voice

· Poor control of head, mouth or tongue

· Difficulty chewing, moving food around or pocketing food in the mouth

· Delayed or absent swallow reflex

· Complaints of food sticking in the throat

If signs of swallowing problems are identified, referral should be made to the appropriate health care professional(s) to screen for dysphagia and assess for problems with dentition, pocketing of food in the mouth, pooling of liquids, suspected aspiration, risk of unintended weight loss and malnutrition. The EAT-10: A Swallowing Screening Tool may be used for screening, and a bedside swallow evaluation may be completed to determine need for further testing.

Diagnosis and Treatment

Tests may include a fiber-optic endoscopic evaluation procedure (FEES test) or video fluoroscopic swallowing study. Diagnosis of the type of dysphagia depends on the origin of the problem:

· Oral Dysphagia: Difficulty initiating a swallow due to difficulty chewing, manipulating food in the mouth or propelling food to the back of the throat.

· Pharyngeal Dysphagia: The food bolus penetrates the larynx due to a delayed swallow reflex, incomplete closure of the larynx or residues remaining in the pharynx after the swallow.

· Esophageal Dysphagia: Food does not move easily through the esophagus due to esophageal dysmotility, structural blockage, stenosis or strictures due to gastro-esophageal reflux disease (GERD).

Once the type of dysphagia is diagnosed, treatment goals include: promoting a safe swallow to reduce risk of choking and/or aspiration of food and fluid into the lungs; maintaining good nutritional status and adequate hydration; facilitating independent eating and swallowing; enhancing the enjoyment of eating and quality of life.

The interdisciplinary team and the patient work together to determine the most appropriate strategies for each individual. Traditional treatment strategies include: swallowing exercises and techniques to improve ability to gather food particles together, thermal stimulation, changes in food/fluid temperature, good oral care to reduce aspiration pneumonia, alterations in food texture and/or fluid consistencies, alternating sips of liquid with food, proper positioning to ease swallowing, close monitoring and intervention during meals and snacks, and/or adaptive equipment such as modified cups or straws.

Controversies in Dysphagia Management

Puree or mechanical soft food or thickened liquids are often recommended to treat dysphagia and prevent aspiration pneumonia. The thought is that cohesive foods tend to be easier to control in the mouth and easier to swallow, and thickening liquids slows the time it takes for the fluid to move through the mouth and esophagus and allows better control of the swallow. However, many experts now believe that evidence does not support diet modification for reducing aspiration pneumonia. Several studies demonstrate that positioning and/or modification of dietary consistency or texture does not reduce aspiration events in persons with dysphagia. As a result, the standard of care for dysphagia management may be changing, especially for management of older adults in skilled nursing facilities.

Swallowing abnormalities are common in older adults but do not necessarily require modified diet and fluid textures, especially if these restrictions adversely affect food and fluid intake. Some individuals with dysphagia may request regular food and/or liquids because they don’t like the diet that is ordered. In nursing homes, all decisions on texture and consistency-modified diets should defer to the person (and/or family) after medical advice on the risks and benefits have been provided. If the individual and/or the family refuse recommended treatment, the facility should document that they have educated the individual and/or family, and request an adjustment of the physician’s orders and care plan to honor informed choice.

Developing a Care Plan for Dysphagia Management

Even though the standard of nutrition care for dysphagia is changing, and new recommendations may be released in the future as new evidence is made available, texture modifications, fluid consistency alterations, and proper positioning continue to be the standard of care for dysphagia treatment in many healthcare settings.

The interdisciplinary team, including the RDN and SLP should work together to individualize the care plan for each patient. The RDN should complete a thorough nutrition assessment that includes medical factors affecting food/fluid intake, nutrition-focused physical assessment with emphasis on condition of the teeth and oral cavity, nutritional needs, weight history, evaluation of lab tests, risk of malnutrition, dehydration and unintended weight loss, food habits/preferences, ability/willingness to adhere to consistency modifications. A physician’s order should reflect the results of the evaluations and specify food texture and fluid consistency needed. In nursing facilities, quality of life and an individual’s right to make choices about their care are important considerations, and all decisions regarding diet orders for dysphagia should default to the individual. Their right to refuse recommended treatment should also be respected.

Once treatment has been implemented, regular monitoring and evaluation should include assessing weight over time to identify unintended weight loss, monitoring hydration status, evaluating food/fluid intake, assuring proper feeding assistance and positioning, assuring foods provided are of the appropriate consistency, and monitoring for signs and symptoms of swallowing problems. If intake of foods and fluids is very poor and/or nutritional status is highly compromised, enteral feeding should be considered if consistent with the goals of care.

Older adults with dysphagia can still enjoy mealtime with the right interventions and treatment – and quality of life and enjoyment of food should continue to be the focus.

Cat With Thickened Bladder – Understanding The Causes and Treatment

If you find out that you have a cat with thickened bladder, you need to understand the underlying cause. For example, this can be due to infection that has moved up the tube that connects the bladder to outside the body (urethra), or from crystals that have turned into either struvite or oxalate bladder stones. Until the cause is known, only guesswork can take place.

You may not know it, but somewhere in the neighborhood of five percent of all felines will encounter urinary tract infections or other urinary problems sometime in their life. The cat with thickened bladder issues is just one type of problem among many. As your cat gets older the condition may become chronic, in that there are recurrences of the problem.

The symptoms of thickened bladder, cat, often present when your cat is urinating. Owners may begin to notice that your cat is straining, in pain, leaking urine or urinating outside of the litter box. A cat with thickened bladder issues may also pass urine that has blood in it or urine that is somewhat whitish in nature. Even the observation that your cat is spending more time in the litter box than usual can be a sign (not to mention the infection causing bacteria that is in the box that comes in contact with your cat).

If your cat is not voiding at all then you need to make an emergency call to the veterinarian. If your cat is having difficulty, call your emergency veterinary center to see if immediate action is needed at the moment of if you need to visit an emergency center.

Thickened bladder cat problems can be caused by many things. They may be the result of infectious agents such as viruses, bacteria, fungus, or crystals. Other causes may include trauma to your cat or ingestion of certain toxins. As you can see from this list, being able to determine the cause is something that only your vet can do.

Diagnosis of thickened bladder cat problems is often done through lab tests. Blood and urine tests are normally the first course of action as they can reveal a lot of information that can either rule in or rule out infections and crystals. Some animals may need X-rays or other procedures in order for the vet to rule out bladder stones or urinary tract blockage. Whatever the cause, early treatment is always best and offers the best prognosis for full recovery.

Treatment options for cat with thickened bladder can include a change in diet to dissolve struvite stones, surgery to remove large or oxalate stones, antibiotics to kill any infection, or even natural supplements to restore the urine and help sooth the bladder. Once you get the urinary system working properly, the body with little or no help should be able to keep the bladder in good health.