EXPERT > Doctor In The House

Independence Through PT

By Dawn Nakamura
Interviewed by Melissa Moniz
Wednesday - December 19, 2007
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Dawn Nakamura
Physical Therapy Clinical Specialist at Rehabilitation Hospital of the Pacific

What is physical therapy and what do you do?

As a physical therapist, our job is to increase functional independence by improving a patient’s motor recovery, range of motion, strength, coordination and balance, as well as trying to decrease their pain.

Being that there are so many neurological disorders, which are the more common ones you see?

The disorders that we commonly see at the REHAB Hospital are strokes, brain injuries and spinal cord injuries. Other neurological disorders that we treat, but are not as common, are patients diagnosed with GuillainBarre and Parkinson’s disease.

Aphysical therapist works on balance and coordination with a patient in REHAB’s therapy pool

With the understanding that it differs depending on the case, what is the average length of time you see a patient?

Stroke patients usually stay 10 to 14 days, however, it does depend on the severity of their impairment. The brain injury and the spinal cord patients typically stay a little longer, but it really depends on their prognosis and their functional abilities. We also need to consider their discharge disposition and their social support situation.

Can you talk about the most common forms of treatment for neurological disorders?

It depends on the outcome of the evaluation. Based on the results of the evaluation, we could work on either their motor recovery, their strength, their balance, etc. For patients with hemiplegia (paralysis of only one-half of the body) or hemiparesis (weakness in only one-half of the body), we actually encourage weight bearing and use of their affected side. Some of the treatment techniques we use include Neuro-Developmental Techniques with co-treatments with other disciplines as needed, Body Weight Supported Gait Training and pool therapy. The ideal situation for treatment, though, is to be able to treat the patients immediately upon discharge from the acute hospital.

Have there been any medical advancements which have made your job easier, or any new machines used now to help with the physical therapy treatment?

Currently at REHAB we have a pressure-mapping system called the X-Sensor, which allows us to prescribe the most appropriate seating system for patients who having w/c seating issues. It allows us to see a 3-dimensional picture of the patients’pressure areas when seated in various seating surfaces, and to prescribe the most appropriate seating surface.

We also have the Bioness L300, a functional electrical stimulation unit that assists patients who have foot drop as a result of a neurological disorder. It works through a wireless remote and allows the patient to walk with greater foot clearance on the impaired side. Because the remote is wireless, the patient actually controls the stimulation by unweighting their foot from the ground. This allows the system to turn on and off by the position of the foot. Another treatment option we have is the Body Weight Supported Gait Training, which we call Lite Gait. It actually suspends the patient and offers partial support of their body weight, and we can have them go over the treadmill and then assist them. Because the apparatus is supporting the patient’s body weight, the therapist’s hands are free to work with the patient and assist them with walking. It allows the therapist to get lower and concentrate on advancing the patient’s leg, and also gives the patient a sense of support and safety. Before the Lite Gait was introduced, the PT might have had to have another person or two to assist or use the pool as another option.

Do you do a lot of treatment in the water?

Yes, pool therapy can be very beneficial for patients with neurological impairments as long as they meet the criteria for entering the pool.

Can you describe how pool therapy helps?

Pool therapy can help by providing body weight support for the patient. It’s the same principle as the Lite Gait, where it gives them body weight support. The water also provides stimulation and resistance, which allows them to work on strength training. The pool can also help with improving balance, postural awareness, range of motion, endurance, normalizing tone and decreasing pain.

Is physical therapy ever painful?

It depends on the diagnosis. Sometimes people who have experienced a neurological disorder have what’s called neurogenic pain, where the cause of pain is because of their disorder. Normally we try to avoid increasing pain in therapy, but sometimes it can’t be helped. We work as a team with the nurses and MDs to try to coordinate and time pain medication to allow the patient to maximize their therapy participation. We also can use modalities that can help ease pain.

Generally, do most of your patients leave your care still needing more therapy?

Well, for us, we’re just part of a continuum of care. Most of our patients come to us from the acute hospitals and then we work on getting them more functionally independent so they can return home or to a safe environment. Most of the patients continue on to outpatient therapy, or they have home therapy. With many neurological disorders, the rehabilitation and recovery time can be up to a year or longer, so the patients continue to work toward progressing with their motor recovery, strength, endurance, balance and coordination, which in turn improves their functional independence.

So if a patient isn’t progressing, do you keep working with them until they reach a level so that you’re comfortable with them leaving?

We want to make sure that it’s a safe discharge, so we want to get them as functional as possible. What we also do is caregiver training. We try to ensure that the caregivers are trained appropriately, so they can help care for the patients. Each patient receives caregiver training with therapy and nurses prior to discharge.

What happens if they’re released and they don’t have anyone who can care for them?

In those situations the case manager assists us and we have different placement options. We try to make sure they are returning to a safe environment.