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Listening to Your Heart – Atrial Fibrillation

Everyone knows about heart attacks… but have you ever heard of atrial fibrillation? Despite being the most common heart arrhythmia (meaning irregular heartbeat) that is medically treated and being the cause for 1 in 7 strokes, most people aren’t familiar with atrial fibrillation. Surveys have revealed that even those who are aware of it often don’t consider it a serious medical condition. Education is key here, as leaving atrial fibrillation untreated doubles the risk of heart-related deaths and increases the risk of having a stroke significantly. It is estimated that by 2030, about 12.1 million people living in America will have a diagnosis of AFib. Considering how high that number is, it’s time to start paying attention to what it is and how you can mitigate yours and your loved ones’ risk factors!

a fib diagram

What is Atrial Fibrillation?

So what is atrial fibrillation? Atrial fibrillation, abbreviated AFib, is an abnormal heart rhythm during which the top chambers of your heart, called your atria, quiver rather than beat, leading to inefficient movement of blood through your heart. Given the inefficient contraction of the heart, individuals with AFib are at a higher risk for clots. The higher risk of clotting and the decreased ability of the heart to pump blood efficiently is what leads to an increased risk of further heart conditions and stroke should a clot form and travel to the brain.

Common Symptoms

While some individuals with AFib might not know they have it and may experience no symptoms at all, others could experience a number of various symptoms. Pay attention to the symptoms and take action. Consider scheduling an appointment with your doctor if you or a loved one are experiencing any of the following:

Risk Factors

In addition to symptom monitoring, there are a number of risk factors to be aware of related to AFib. Considering the risk of stroke and heart disease increases significantly with AFib, mitigating the risk factors of AFib is crucial. Risk factors include:

If any of these risk factors apply to you or a loved one, consider if your risk factors are modifiable, meaning you have more control over reducing how much of a risk they pose. Focus on lowering your blood pressure, losing weight if appropriate, reducing or eliminating alcohol intake and quitting smoking. Consuming whole, natural foods when possible, incorporating exercise and purposeful movement every day, and staying hydrated can go a long way in preserving your health!

Treatment

If you have already been diagnosed with AFib, it is important to continue to mitigate as many risk factors as you can using the guidance above, in addition to seeking proper medical treatment for your condition. Lifestyle changes, even after being diagnosed with AFib, can greatly decrease the severity and frequency of your symptoms. These lifestyle changes include cutting back on alcohol, reducing caffeine, quitting smoking, exercising regularly, eating a nutrient rich diet, losing weight if required and lowering your blood pressure. When prescribed medications for AFib, especially blood thinners to reduce the risk of clots, it is imperative that you follow the guidance of your doctor and stay consistent with the treatment.

Understanding Your Medications 

Given that AFib is a chronic condition, meaning it doesn’t go away, it is likely that you will be on medication to manage it for the rest of your life. This can be scary and anxiety inducing if you don’t understand your medications or don’t have a plan to stay on track. Meet with your doctor and be sure to understand what medications you are taking, why you are taking them, how long you will be taking them for and what side effects to look out for. You deserve to understand and feel comfortable with your treatment, so be sure to collaborate with your medical team and find support from your loved ones.

heartbeat

Atrial fibrillation – if it’s not taken seriously, it could cause serious problems!

Know the symptoms, schedule regular visits with your doctors, and practice a healthy lifestyle to reduce your risk!

Sources:

Image 1 – https://www.cdc.gov/heartdisease/atrial_fibrillation.htm

Image 2 – https://www.mcrmedical.com/blog/aha-2020-guidelines/

Heart Foundation –

https://www.heartfoundation.org.nz/your-heart/hearthelp/atrial-fibrillation/managing-your-af

CDC – https://www.cdc.gov/heartdisease/atrial_fibrillation.htm

American Heart Association –https://www.heart.org/en/health-topics/atrial-fibrillation/what-is-atrial-fibrillation-afib-or-af

Speech Therapy

We as humans are a community that thrives on the ability to communicate with those around us. With many means of communicating, our voices, the ability to speak, serve as an especially valuable and empowering tool that cannot be taken for granted.

There are certain conditions that threaten to take away our ability to speak and sometimes our ability to swallow or hear, both of which also impact our speech and communication. These communication disorders can be a result of stroke, brain damage, muscle weakness or respiratory distress throughout one’s lifetime. In other instances, communication disorders are congenital, in other words, they are present at birth. Regardless of the cause or duration of the communication disorder, losing the ability to speak or not having the ability to communicate is scary and can result in feelings of helplessness or frustration.

microphone

In the older population, speech therapists, also known as speech-language pathologists, are especially beneficial in the recovery processes following a stroke or in the therapy involved in dementia and other physical disorders. These conditions along with others can result in language and communication barriers. Aphasia, characterized by a difficulty in reading, writing, speaking and understanding language and apraxia, characterized by a difficulty in forming words, are two communication disorders that can commonly result from a stroke. Dementia often leads to difficulty thinking of words, trouble remembering thoughts, or losing attention during conversations. Physical weakness of the vocal cords can also result from multiple sclerosis (MS) and amyotrophic lateral sclerosis (ALS). These disorders have the potential to affect us and our loved ones and deeply impact our independence. Recognizing the value in seeking out speech therapy can help to preserve an individual’s ability to speak and communicate for as long as possible.

In such situations, speech therapy is a remarkable service that can alleviate much of the distress that accompanies communication challenges. Speech therapy is a speech and language focused treatment that can aid in communication disorders spanning the lifetime.

Services include assistance with early language skills, voice and sound production, comprehension, fluency, clarity and expression. The therapist will work with patients to create highly individualized treatment plans and can provide additional techniques for the individual to practice on their own. Speech therapy is most commonly available in hospitals and clinics, but BrightSpring Health Services is one of the few home health companies to offer at-home speech therapy. This has a huge advantage, as it offers the potential to receive therapy in the comfort of your own home, which is important during such a vulnerable time. Recovering from and overcoming a speech disorder can be a long process. It requires patience and support from family and friends, and a speech therapist can aid in the journey to recovery.

elderly patient and healthcare provider

The benefits from speech therapy are undeniable. With the help of a speech-language pathologist, you, your family member, your loved one or your friend will feel better, communicate better, regain more independence, and overall experience an improved quality of life.

Sources:

Image 1: https://tutorbin.com/blog/informative-speech-topics-for-2020

Image 2: https://www.nia.nih.gov/health/obtaining-older-patients-medical-history

Cleveland Clinic: https://my.clevelandclinic.org/health/treatments/22366-speech-therapy

BrightSpring Health Services: https://www.brightspringhealth.com/services/homecare-services/  

Lingraphica: https://www.aphasia.com/aphasia-resource-library/what-causes-aphasia/dementia/

Recognizing Seniors During National Homeownership Month

elderly woman with young child

5 Ways Seniors Can Age at Home During National Homeownership Month

June is National Homeownership Month, a time to celebrate and bring awareness to the various housing and support options available to Americans dreaming of homeownership. It’s also a great time to highlight the options seniors and family caregivers have available to them as they plan for their future continuum of care. This June, get to know the options available to seniors wishing to safely and happily age in place.

The Benefits of Aging at Home

A recent survey by Freddie Mac suggests that the majority of aging adults are planning to age at home in 2022. Of the U.S. adults age 55 and older who responded, 66% intended to age in place. That’s no surprise given the many benefits that aging at home can provide to seniors and caregivers alike – not to mention the emotional value that homeownership brings to adults. Aging in place has shown to dramatically increase adults’ overall happiness, health, and quality of life. With support, aging in place can be a beneficial option, even for a senior who has health issues. Seniors who age at home also have the benefit of decreased risk of exposure to illness compared to their peers in senior living communities. Other benefits of aging at home include:

If you’re not sure what your current options are for aging at home, consider home options that support aging in place.

Home Options For Aging at Home

Multigenerational Living

Multigenerational living has increased within the U.S. over the last several years thanks to its value in helping both seniors and family caregivers who want more housing security. Living in a multigenerational living structure allows a family to combine financial resources for the benefit of the whole family. Since multigenerational family structures allow for a senior to have their own space within the home, seniors have the flexibility to reside in both common areas and personal spaces which has been shown to decrease senior loneliness, increase their overall quality of life, and foster a sense of independence. Another great thing about multigenerational living is that a senior can receive care at home whenever they may need it. Regardless if you’re living with a family caregiver or not, aging at home is easier with a home caregiver. If a big family has a busy schedule, seniors and family members can be assured that their needs are being met with a home health care and hospice care provider to ensure the proper administration of medications, help with personal care, or provide general housekeeping tasks.

Downsizing

Downsizing to a smaller home to better suit a senior’s needs is always a considerable option. For seniors, maybe that means buying a newer home with upgrades and improvements. Perhaps a factor for downsizing is the wish of being closer to family members – or they want to be closer to the city, so transportation is easier. Many seniors want to downsize to a single-level home, or they just don’t want the burden of maintaining a lawn. Whatever the reason, downsizing a home to suit a senior’s needs is always a sustainable option when deciding to age at home. Besides the obvious benefits of downsizing your home, it also brings the possibility of increased independence all around. Less space means less house to maintain and an increased likelihood of having more senior-friendly features like a walk-in bathtub, wider doorways, or even a ramp for easier accessibility.

Home Modifications for Health & Safety

Seniors planning to age at home successfully should always have a home health inspection conducted. In order for a senior to have the best quality of life, they should have access to a safe environment. During a home health inspection, an inspector would look for any potential risks of falling, slipping, tripping, and other immediate risks. Oftentimes, a home inspection also accompanies suggestions or strategies for improving the health and safety of a home. The most common home modifications for seniors include:

Financial Considerations For Aging at Home

Planning Continuum of Care

Before making any substantial changes or plans for aging at home, It’s important to know the options available to seniors wishing to age happily and successfully at home. So the first step is to identify how the senior plans to include support for their continuum of care. Thankfully, the Medicare program provides financial help and assistance to seniors looking specifically for at-home health care and hospice services including medical equipment and supplies, disease and end-of-life care, skilled nursing, and more. Additionally, if you’re a veteran, there’s financial support available for housing, living expenses, and healthcare, just to name a few, and can be extremely valuable in planning your continuity of care. Similarly, if you’re disabled or collect social security, there are specific programs available to ensure you’re able to successfully age in place.

Mortgage and Loan Options

Whether you plan to stay in your current home or buy a new home, there are many mortgage and loan options available to seniors looking to age in place. If a senior homeowner is experiencing financial difficulty, there may be ways homeowners can ease that burden. Before making any extensive plans, seniors need to be aware of their current financial situation and the amount of equity they have, if any, in an existing home. To get a better understanding of your financial wellness, get your updated credit score and see if you prequalify for a mortgage or loan program, and make the best decisions for your housing and support needs.

Utilizing a Home Equity Line of Credit (HELOC) is a great way to pay for costs associated with home modification or improvements.

Home equity loans or lines of credit are great because of their low-interest rates and give seniors the ability to use their home’s equity to borrow funds for any home improvement projects. The downside is that if your financial situation changes dramatically in the future, you could be at risk of losing your home.

Another popular choice for seniors to consider is a reverse mortgage, which can be a great option for seniors needing financial assistance. Similar to using a HELOC, a reverse mortgage, or a Home Equity Conversion Mortgage, take the home’s equity and disperses it back to a homeowner through monthly payments. As long as the senior is living in the home, payments received from your lender never have to be paid back. However, the loan must be repaid if you ever decide to leave or sell your home.

Regardless of where a senior chooses to age in place, knowing the housing and support options available are the best way to a happy and successful quality of life for the future.

Men, June means it’s time to take charge of your health!

young father and son

The month of June is Men’s Health Month and is dedicated to bringing awareness and providing education regarding all things health for the male population. With chronic disease and sedentary lifestyles on the rise, it is more important than ever to stay properly informed of how you can take steps to preserve your own health. Oftentimes, it can be as simple as making small changes to your daily routines that can prevent illness and preserve your quality of life in the long run.

Leading Health Concerns and Risk Factors

While men and women both share many of the same leading causes of death, studies have shown that men have a higher morbidity and mortality rate than women from coronary heart disease, hypertension (high blood pressure), diabetes and cancer, four of the top ten leading causes of death in our country. Though many factors, including genetics, come into play with these diseases that are not always avoidable, many of the biggest risk factors are preventable, including smoking, alcohol consumption, lack of physical activity, obesity, and high-risk behavior.

Statistics have identified men as being more likely to smoke, drink higher amounts of alcohol, partake in risky behaviors, and put off checkups and medical care, all of which put you in a much higher risk category for chronic disease. Recognizing the risk factors that are most at play for you and reducing their presence in your own life can have a monumental impact on the quality of your life.

statistics graphic

Health Issues Unique to Men

In addition to being at higher risk for universal health issues that can affect everyone, there are several health concerns that are unique to men. These include prostate cancer, benign prostate enlargement and low testosterone. Sometimes signs and symptoms don’t present themselves until it’s too late, and because men are more likely to skip the doctor visits, these diseases can go unnoticed for some time despite treatments being available. Regular checkups and screenings are imperative for men, as they can often identify disease early, even before symptoms occur, making it more likely that treatment will be successful.

Making the Change

Lifestyle changes can be hard but living with chronic disease that could have been prevented is the unfortunate alternative. When you’re ready to consider evaluating some of the risk factors for disease that exist in your own life, start by making a list. Once you’ve made a list, pick one to three things that you can change right away. The change can be as small as drinking one more cup of water each day to as big as hiring a personal trainer or nutrition coach!

Remember, a huge key to success is starting with something you know you will be able to stick to in order to build a strong habit. Reducing risk factors, improving your nutritional choices, and increasing your daily activity levels has a long list of benefits. These include better sleep, improved cognition, less weight gain, decreased levels of depression, and lower risk of heart disease, stroke, type-II diabetes, hypertension, Alzheimer’s and several types of cancers. You have the ability to dictate your quality of life for the rest of your life, starting with the changes you make today.

Use this checklist below as a pocket guide to make sure you’re hitting your health goals and share with the men in your life!

References

Image 1 – https://www.minorityhealth.hhs.gov/omh/content.aspx?ID=10238

Image 2 – https://bppn.org/june-is-mens-health-month/

American Heart Association – https://www.heart.org/en/healthy-living/fitness/fitness-basics/aha-recs-for-physical-activity-in-adults?gclid=CjwKCAjwyryUBhBSEiwAGN5OCPrs7yMioBQ6DkruGXplfE6urx91CVQEadSrYxoZHVUrPIkkmpOs0BoC6z8QAvD_BwE

CDC – https://www.cdc.gov/healthequity/lcod/men/2016/all-races-origins/index.htm

National Library of Medicine – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5756802/

My Health Finder – https://health.gov/myhealthfinder/topics/doctor-visits/regular-checkups/men-take-charge-your-health

June 12th: Women Veterans Day

June 12, 1948. A day that changed the course of history with the passing of the Women’s Armed Services Integration Act. This act would allow for women to serve in an official capacity in the Army, Navy, Marine Corps, and Air Force.

While it took until 1948 for women in service to be recognized by law, women have been making invaluable contributions during war times through much of American history. From sewing uniforms, to providing medical services, to forming all-female units to help fight the war, women were integral members of the military as early as the Revolution and continued to serve in the Civil War and the World Wars. Today, they are legally and rightfully permitted to serve in the Armed Forces and continue to be a vitally important component.

Female soldier standing in field filled with American flags

Despite women being the fastest growing group of veterans, with approximately two million residing in the United States today, they experience a disproportionate amount of challenges compared to their male counterparts both during their time in service and upon returning to civilian life. At present, they continue to face a higher risk of harassment and sexual violence during service, homelessness following their duty, difficulty finding employment, and social bias upon reintegration to society. The Armed Forces have always been and remain a male biased organization and the struggles for women because of this bias continue to negatively impact our female veterans. The Center for Women Veterans (CWV) was established in 1994 to address

some of these disparities between women and men in service. The CWV continues to be a leading organization whose mission it is to ensure that female veterans are treated with respect and equality. While there are scattered efforts across the nation and within communities to address the needs of female veterans, we are far from a point at which we should be satisfied. Women’s Veterans Day was first recognized just four years ago on June 12, 2018. This day was established to highlight female veterans and the struggles they face in hopes of addressing them with lasting solutions. We, as a society informed of the struggles these brave women face, must continue to raise awareness on their behalf.

To the women that have served this country and to those that continue to serve, we see you and we thank you.

Group of soldiers saluting with focus on female soldier

For more information regarding the resources available to you as a female veteran, you can visit the National Veterans Foundation’s website for a categorized list of resources depending on your specific needs. https://nvf.org/women-veteran-resources/

References:

VAntage Point – https://blogs.va.gov/VAntage/89813/origin-women-veterans-day/

U.S. Department of Veterans Affairs – https://www.va.gov/womenvet/resources/index.asp

VAWnet – https://vawnet.org/sc/challenges-specific-female-veterans National Veterans Foundation – https://nvf.org/women-veteran-resources/

Cropped image of military service member holding PTSD block letters

Post-Traumatic Stress Disorder: Awareness, Recognition, and Support

What is Post-Traumatic Stress Disorder?

Life is full of events that cause challenge, fear, or even sometimes pose a threat to us. Those serving in the military are even more susceptible than the general public to these events due to the high-stress, high-risk nature of their occupation. Often and commonly, individuals react to the situation at hand and are temporarily unsettled by these events before returning to normal daily living. In other cases, the event that is experienced can have long-lasting, life-altering negative effects and this is known as post-traumatic stress disorder. The National Institute of Mental Health (NIMH) defines post-traumatic stress disorder, commonly referred to as PTSD, as a disorder that develops in individuals who have experienced shocking, scary, or dangerous events who continue to feel stress or fear even after they are safe from the original event.

Signs and Symptoms

While it is common for individuals to be temporarily disrupted by a trauma, especially during combat, PTSD diagnosis is less common and requires an individual to experience symptoms for more than a month and in a great enough capacity to interfere with work and/or relationships. Symptoms are categorized into four subgroups: re-experiencing, avoidance, arousal and reactivity, and cognition and mood symptoms. Below are some examples of each.

Re-experiencing

Avoidance

Arousal and Reactivity

Cognition and Mood

Treatment Options

Whether you recognize these signs or symptoms in a loved one or perhaps in your own behaviors, you are not alone and there are many treatment options available. Treatment by a mental health provider can open up the door to options such as medication or psychotherapy, or a combination of both. The medications that have been studied and utilized most extensively are antidepressant medications which help to mitigate anger, worry, sadness and numbness. Additional medications can be sought out and explored to help alleviate other symptoms such as trouble sleeping and nightmares. Psychotherapy, also referred to as “talk therapy”, can be done one-on-one or in a group setting. Along with specific and individualized therapy goals, treatment should aim to educate individuals about their triggers and symptoms and prepare them with strategies to manage them when they occur.

PTSD can be incredibly isolating and takes a toll on the lives of many individuals in our community. While it may be hard to imagine living without the symptoms, recovery is possible. In congruence with medication and therapy, there are steps you can take on your own to facilitate recovery. Exercise can be a useful tool to improve both physical and mental health, as it is proven to reduce stress and improve mood. A strong support system of family and friends, as well as the veteran community, can be key to recovery. Involving loved ones in your life and engaging in a community that can relate to your experience can help to alleviate the loneliness associated with PTSD. While working with your therapist to build skills to reduce symptoms, consider partaking in activities that previously sparked joy and interest.

Caring for someone with PTSD can take a serious toll on those providing support as well. If you are a family member, friend or loved one of someone with PTSD, it is imperative to

prioritize your health and seek care and support for yourself as well. Look into local support groups within your community or virtual platforms to connect with other individuals in similar positions and keep regular checkups with your doctor. Make sure to set aside time to sleep, exercise and eat while you are offering care. You are not alone in offering care; seek out professionals and encourage the individual you are caring for to get further treatment. The better you care for yourself, the better you will be able to offer support.

Looking to the Future

Research has been underway for years looking into both the mental and biological components of PTSD, and new research directions continue to develop as scientists acquire new information. A subgroup of research studies called clinical trials seek to study if new tests, prevention measures, or treatments are effective. While clinical trials are an excellent method to further scientific knowledge, individuals should be aware that new information is the goal and there is no guarantee of successful treatment. If you are interested in learning more about current clinical trials or being involved in one, you can visit clinicaltrials.gov for a current list of National Institutes of Health (NIH) studies being conducted across the country or visit the NIMH’s Clinical Trials webpage for information about partaking in a study.

Resources for Veterans and Caregivers

Seeking treatment can feel overwhelming and lonely initially, and it is important to know that there are many organizations that are in place to help you find the support you or your loved one may need.

If you are a veteran with PTSD, the Veterans Crisis Line is available to you and your loved ones. You do not need to be enrolled in VA benefits or health care to access the 24/7, 365-day-a-year support that this line offers. Veterans Crisis Line: 1-800-273-8255 and press 1

If you are a caregiver for a friend, family member, or loved one dealing with PTSD, the VA offers caregiver support in the form of a helpline as well as a caregiver program. To visit the website, go to caregiver.va.gov or call the helpline to speak to someone directly. Caregiver Support: 855-260-3274

The Substance Abuse and Mental Health Services Administrations, abbreviated SAMHSA, has a free and confidential hotline for individuals and family members facing mental health and/or substance abuse disorders. This hotline is also referred to as the Treatment Referral Routing Service and provides referrals to treatment centers, support groups, and community-based programs. The hotline is free, confidential, 24/7, 365-day-a-year and is available in Spanish and English. SAMHSA hotline: 1-800-662-HELP (4357)

Additionally, the National Alliance on Mental Health (NAMI) has a Monday-Friday, 10am-10pm, ET. informational helpline as well as an email address, helpline@nami.org, to

provide support and resources to individuals in need. The NAMI is NOT a hotline, crisis line, or suicide prevention line. NAMI helpline: 1-800-950-NAMI (6264)

Thank you to our veterans and their community caregivers.

We see you, and we support you.

References

NIH – https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd#part_2241 SAMHSA – https://www.samhsa.gov/find-help/national-helpline https://www.caregiver.va.gov/Tips_by_Diagnosis/PTSD.asp https://www.veteranscrisisline.net/

NAMI – https://www.nami.org/help

Image – https://www.heroesmile.com/intersection-of-ptsd-and-veterans/

Elderly couple with dementia putting together a puzzle

Alzheimer’s and Brain Health Awareness Month

June is Alzheimer’s and Brain Health Awareness Month. This month, take time to discuss the importance of brain health with your friends, relatives, and elderly adults in your life—especially those who may be at risk for dementia and cognitive impairment. Taking steps to improve brain health early on can often reduce the risk of Alzheimer’s and other cognitive disorders.

What Is the Prevalence Of Alzheimer’s Disease?

Alzheimer’s disease affects an estimated 6.5 million Americans. As the most common form of dementia, Alzheimer’s is a progressive disorder that destroys brain cells and causes the brain to shrink. It is most common among adults over the age of 65.

Memory loss is the primary symptom of Alzheimer’s disease. Alzheimer’s can also affect a person’s concentration, judgement, and decision-making ability, leading to problems with carrying out essential daily tasks like bathing, getting dressed, and cooking. Many people with Alzheimer’s often require hospice care so they can get help with performing these activities.

The Importance Of Early Screening

Alzheimer’s disease is a progressive condition that develops gradually over time. There is no designated screening test for Alzheimer’s, though your doctor can review your medical history and perform an evaluation to determine your risk.

Ways to Improve Your Brain Health

Maintaining optimal brain health is key to reducing your risk of dementia and Alzheimer’s disease. If you are caring for Alzheimer’s patients, you can work with them to improve their brain health and reduce the severity of certain symptoms.

Eat Healthy, Nutritious Foods

Leafy greens, fatty fish, and almonds are some of the many foods that contribute to good brain health. Foods like these are loaded with nutrients, including vitamin E and omega-3 fatty acids, that are shown to boost brain health and delay the progression of Alzheimer’s. Eat a higher amount of healthy foods like fruits, vegetables, fish, poultry, and nuts to improve your cognition.

Stay Social

Socializing with others on a regular basis can stimulate your memory and attention, strengthening neural networks to improve overall brain function. Being social can reduce feelings of loneliness and isolation, boosting the quality of life in people with Alzheimer’s. Go dancing, join book clubs, and attend social events at community centers. Many hospice care providers can help you find social activities geared toward older adults and seniors.

Exercise Regularly

Physical activity offers a wide range of benefits for cognition and brain health. It improves your circulation and blood flow, boosting your memory and problem-solving ability. It can even help ward off anxiety and mood disorders, including depression. Schedule exercise into your daily schedule, even if it’s only a 10- to 15-minute walk. Better yet, join exercise classes for seniors, such as water aerobics and yoga.

Challenge Your Brain

Learning new skills and challenging your brain can lead to the formation of new connections between brain cells, which reduces your risk for cognitive problems, including Alzheimer’s. Play board games with your relatives and other seniors in the community, or take classes that teach you a new language or how to cook a certain cuisine. You can even download and play brain games on your smartphone, such as Wordle, Lumosity, and Candy Crush.

Hospice Care With AT Home Care

AT Home Care is a leading provider of home health and hospice services throughout Virginia—including hospice services for people with Alzheimer’s disease. Fill out our online form today to learn more about our services.

Senior woman walking on outdoor trail

5 Things To Do On National Senior Health and Fitness Day

Staying fit and healthy year-round is essential for a fulfilled lifestyle. But as people age, it becomes increasingly more difficult to remain active and feeling your best. ​​If you have been struggling with your health or fitness lately, then May 25th is the perfect day for you. This year, May 25th is National Senior Health and Fitness Day, and to kick off the celebration, here is a list of our favorite things you can do to improve your well-being on this inspiring day, and throughout the year.

Get Active Outside

As the weather starts to turn in May, now is the perfect time to dust off your walking shoes and get outside. For seniors, low-intensity activities are safer and easier to do on your own. They still promote increased heart health and strength while putting reduced pressure on your joints and muscles. Some activities can include walking to the park with your family, doing lawn work, or riding a bike. These are all great ways to get outside and get active, and the best thing is, seniors of all ages can enjoy them without pushing themselves to their limit. The bottom line is as long as you are getting outside and moving your body, you’re taking steps in the right direction to leading a healthier life.

Get Active Inside

We all know the weather can be very unpredictable at times, especially during the spring months. At times, it can go from rain to sunshine within the same hour. That’s okay because there are plenty of ways that you can still stay active indoors, no matter if you’re living independently or in a community living setting. For example, yoga and dancing are great options because they work all parts of the body, are low impact, and can be performed indoors. If you need something a bit more tangible to do, look into using resistance bands when doing some basic exercises. These bands are much safer than weights and will not take up nearly as much space.  While you might have to get a little more creative if you’re working with less space indoors, there are plenty of ways you can get your body moving inside even just by walking up and down the stairs. Your local gym or YMCA also may offer a dedicated space for activities such as swimming to get active while still staying indoors.

Schedule Your Health Screenings

Maintenance is key to living a long and healthy life. The best way to maintain your health is by staying on top of your regular health screenings. If you find yourself in the situation of not having been to the doctor in a while, now would be a great time to schedule an appointment. Keep in mind that your health goes beyond just your normal primary care. Scheduling a cleaning with your dentist, getting new prescription eyeglasses from your optometrist, and getting a head-to-toe skin check at your dermatologist are all commonly skipped areas of health maintenance. If you can’t remember the last time you addressed these areas of your health, use today to take that step in scheduling your health screening appointments so you can ensure you live the longest, healthiest life you can.

Eat A Healthy Meal

I’m sure you have heard the saying that “food is your fuel”. The food that you put into your body plays a major role in how you feel and operate on a daily basis. Don’t wait, start eating some healthy meals today! To begin, try and get your daily serving of greens, whole grains, and protein. While they are all important, eating an adequate amount of protein each day can help prevent the muscle breakdown that most seniors will face as they age. Another thing to keep in mind is the roles that certain foods have. For example, if you’re having a hard time with digestion, try eating more fiber as it helps food move through your digestion system. Lastly, staying away from processed foods and sugar as a whole can make a world of difference for your overall nutrition.

Meet With Your Friends/Family

Happiness is a foundational building block of your health, and don’t let anybody tell you anything different. Make time to visit with friends and family today; even if it’s only for a half-hour. Grab a coffee, eat lunch at your favorite local spot, or even invite company over. Not only does seeing your loved ones show that you care, but it also allows a space for happy memories to be created. In addition, being happy has been shown to fight stress, reduce blood pressure, and may even extend your lifespan. Take the opportunity to get out of the house, enjoy some great company, and reap the benefits that come along with it.

AT Home Care Thanks You

Even though AT Home Care acknowledges the importance of our seniors every day, National Senior Health and Fitness Day gives the larger population an opportunity to shed light on the importance of their health and wellbeing too. No matter what you do on this day, the memorable lesson is that you’re acting upon the matter and seizing the opportunity to better yourself.

We are looking forward to seeing how you participate this year. We hope you enjoy National Senior Health and Fitness Day 2022.

Evidence-informed Home Health Management
of Total Hip Arthroplasty

By: By Babatope Olusina, PT, DPT and Olaide Oluwole-Sangoseni, PhD, DPT, MSc.

Osteoarthritis is a degenerative joint disorder that affects the articular cartilage, underlying bone, and surrounding soft tissues. It is the most common form of joint disease in the United States (US), with an estimated prevalence of 27 million people,1 with an occurrence of about 10% in men and 13% in women, over the age of 60 years. 2 Hip osteoarthritis accounts for about 70% of total hip arthroplasties (THA) that are performed in the US due to severe pain, which limits the individual’s functional mobility and negatively affects his/her activities of daily living (ADLs), eventually limiting his/her participation in work and leisure activities. 3 Other indications for THA include but are not limited to trauma and osteonecrosis of the femoral head.4

THA is the surgical replacement of the natural hip joint with a prosthesis. 3 The first THA procedure was completed in the US in 1969 and as the procedure has grown in incidence, the technique has evolved and its efficacy has improved. 2,4 A 2010 prevalence study estimated 2.34% of individuals over the age of SO years in the United States have had THA, corresponding to 2.5 million people (1.4 million women). 4 A detailed breakdown of their study revealed a prevalence of 0.58% at age SO years, increasing to 1.49% at sixty years, 3.25% at seventy years, 5.26% at eighty years, and 5.87% at ninety years of age.4 The original or more popular technique is the posterior or posterolateral approach, with its associated precautions (no hip flexion above 90 degrees, no adduction beyond the midline, and no internal rotation of the surgical hip joint).

In the 1980s, an anterior approach was developed and gained popularity because of improved early outcomes in terms of pain and early functional recovery. 5 Hip hemiarthroplasty is the surgical removal of one of the components of the hip joint, most often the femoral head. Although it is less invasive, the Physical Therapy assessment and management will follow a similar path as for a THA.


Home health physical therapists (HHPT) are part of the multidisciplinary team-approach called upon to manage these patients upon their return home. Orthopedic surgeons seek the involvement of physical therapists (PT), as movement specialists, to facilitate the recovery and rehabilitation of THA patients to maximize their return to full function and participation in the activity. In consultation with the orthopedic surgeons, our home health agency established protocols that can be customized to fit the individual patient’s desired outcomes and surgeon’s preferences. These protocols guide the first few weeks of in-home rehabilitation before the transition to outpatient physical therapy. As a HHPT with a weekly caseload of about 50 percent of total hip and total knee arthroplasty patients, I recognize that no two patients’ status post-THA is the same.


The Medicare home health Conditions of Participation (CoP) require that a comprehensive assessment of each patient be performed by the admitting clinician to start the episode of care. This assessment includes the patient’s past medical history (PMH); a complete review of the patient’s medications, including any changes in dosage and patient’s response; and the integumentary assessment, all of which go into the process of formulating the patient’s plan of care.

Because most home health patients have multiple diagnoses, the evaluating PT incorporates the patient’s past medical/surgical history and the patient’s prior level of function into his/her physical therapy plan of interventions. A detailed assessment of the patient’s home is an essential aspect of the initial visit, as safety hazard/fall risks can be identified, and safety education and recommendations can be immediately communicated to the patient and their caregivers. The purpose of this case report is to highlight the physical therapy management of a THA in the home health setting with a focus on adapting exercise program based on pain and muscle fitness indices.

Case Presentation:

The patient is an 81-year-old female, retired nurse admitted to HHPT following right THA revision with weight-bearing as tolerated precautions. She resides alone in a single level house in a 55+ Age-in-Place community. Before this surgery, she was fully independent with all of her functional mobility, occasionally using a standard straight cane for ambulation. She was independent with all activities of daily living (ADL)s and was active in her community, participating in group exercise sessions every week.

Past Medical History:

Her PMH was significant for multiple comorbidities: hypertension, atrial fibrillation, type 2 diabetes mellitus, anxiety, neuropathy, general osteoarthritis, vertigo, history of lumbar laminectomy and fusion in 2017, reflux disorder, cystocele with prolapse, and recent urinary tract infection. Initial THA was performed in 2002; she had a dislocation in 2017, which resulted in persistent hip joint pain afterward.

Current Medications included:

• Apixaban, PO, 2.5mg, 1 tab, twice daily
• Diltiazem, PO, 240mg, 1 tab daily
• Norvasc, PO, 5mg, 1 tab PRN, if diastolic is above 90mmHg
• Pepcid, PO, 10mg, 1 tab Q 8 hours
• Xanax, PO, 0.5mg, 1 tab daily
• Tramadol, PO, 50mg, 1 tab Q 6 hours
• Purelax PO, 17gram/dose, 1 tab twice daily
• Potassium Chloride, PO, 20mEq, 1 tab twice daily.
• Tylenol Extra strength, PO, 500mg, 2 tabs Q 8 hours

The patient stated her goal is to return to walking independently without the walker.

Objective Examination and Assessment

Physical Status:

On examination, “Nanette”(a pseudonym) was alert and oriented to person, place, and time, and able to follow a multi-level command. She presented with hypomobility of the hip joint and weakness of the proximal muscles of the surgical lower extremity. She required contact guard/minimal assistance to assist her right lower extremity into the bed during bed mobility assessment. She required close stand-by-assistance of the therapist for sit to/from stand and bed to/from chair transfers due to She was dependent on a rolling walker for ambulation, with forward-flexed trunk posture over the device, using a 2-point antalgic gait pattern. The Timed Up and Go test (TUG) was performed, with the “Nanette” requiring 36 seconds to complete. 6 A time greater than 20 seconds is indicative that the patient is dependent on transfers and confirms homebound status. 6 The family had hired a private duty company to provide personal care assistance for several hours during the day to assist her in the first 3 weeks.

Integumentary:

Because the initial home PT evaluation was on the same day as the nursing start of care (SOC) visit, PT evaluation referred to the nursing integumentary assessment. However, the physical therapist assessed the surgical incision on each subsequent visit, per our agency protocol, performing dressing changes when needed. The status of the wound was documented and presented at the interdisciplinary case conference with the registered nurse as required.

Pain:

Per Medicare CoP, Nanette’s pain was evaluated on the initial examination and all subsequent visits, using a numeric pain rating scale (0-10) and verbal description. She rated her pain at level 5/10; her goal was to be pain-free by discharge. The expectation was a gradual decrease in the pain level, and any movement in the other direction and/or a new type of pain warrants additional evaluation.

Clinical Impression:

Based on the hypomobility of the hip joint and weakness of the proximal muscles of the hip and pelvis, the International Classification of Functioning, Disability and Health (ICF) model diagnosis of M25.651 or 652 (stiffness of hip joint, not elsewhere classified) was made.

Plan of Care

It was determined that Nanette would benefit from a skilled PT intervention frequency of 2 times per week for 4 weeks. Her exercise prescription consisted of joint mobilization, ROM and strengthening exercises, instruction in a home exercise program (HEP), functional mobility training (including bed mobility, transfer, and gait training), balance reeducation, equipment training, safety education, to progress to independence in all areas (Figure 1).

Figure 1: Physical Therapy Plan of Care

Since the pain was the chief complaint, it was used as one of the outcome measures. Pain medication was to be taken an hour before the PT session. The patient’s pain level was expected to decrease to level 1/10 at discharge.

  1. Therapeutic exercises on the day of the examination consisted of:
    • Isometric contraction of the quadriceps and bilateral gluteal muscles sustained for 5 seconds or until fatigue.
    • Isotonic exercises, including hip abduction (in standing), hip/knee flexion (in supine via heel slide) and knee extension (in sitting), ankle dorsiflexion and plantarflexion (in supine), up to 15 repetitions or until fatigue, using BORG rate of perceived exertion (RPE) score with a target score of 14 on the 6-208 scale.8 The PT’s focus was on increasing muscle endurance using a high repetition approach. The patient’s positioning during exercise was modified in sitting and standing due to a history of chronic acid reflux; she was unable to tolerate supine lying.
    • Exercise progression/upgrade included gradual addition of hip flexion, abduction, and extension in standing for muscle strengthening-an upgrade of knee flexion, ankle dorsiflexion, and plantarflexion in standing using gravity and bodyweight resistance. Exercise intensity was based on RPE, and the type of exercise was the final two weeks to include external hip rotation in the supine position.
    • Home Exercise Program (HEP): The patient was instructed to perform the aforementioned exercises as her HEP 2-3 times daily on the days that the PT is not scheduled, to maximize her progress and to progress her towards her stated goal. Nanette’s adherence was crucial to her overall recovery, stated personal goal, and physical therapy outcome. HEP adherence was monitored through direct open-ended questions and requested demonstrations during subsequent visits. Nanette was provided education to encourage cooperation with the overall plan of care.

  1. Functional mobility training included bed mobility training with safety instructions given to ensure the patient adhered to the THR precaution during supine to sit and sit to supine mobility. Transfer training included regular sit to/from stand, toilet transfers, shower and tub transfer training, and, later, car transfer training in preparation for discharge. The patient received gait training with the rolling walker, with verbal and visual instructions provided to address the deficits and impairments noticed during her initial examination. This patient received instructions for postural reeducation, and to increase stance time and the amount of weight-bearing in her right LE. As her pain subsided 2-3 points, and her right LE muscle strength improved, she was progressed to the use of a standard cane first on level surface, and later on uneven surfaces. Just before discharge, the patient was progressed to gait training without an assistive device.
  1. Balance reeducation in standing started with transitional weight-shifting patterns in the sagittal and coronal planes. The verbal emphasis was on maintaining upright trunk posture, increasing stance time on the surgical leg, and improving the amount of weight-bearing. The first progression of this was to perform the same activities without upper extremity support. The next progression was the use of transitional stepping patterns in the sagittal and coronal planes. These activities were performed to improve the muscle stabilization action around the replaced hip joint, as well as improve the patient’s confidence in the ability of the surgical hip to sustain her weight. This is essential in the progression of gait training from a walker to a cane, and eventually to ambulating without a device.

  1. Patient Education Patient education was a multi-pronged approach. The patient demonstrated a high level of health literacy; therefore, patient education was a multi-pronged approach. The PT provided education about Nanette’s THA precautions, with emphasis on observing these precautions as she goes through her day-to-day activities. Nanette’s precautions included avoiding turning towards the affected side, sitting in a low chair, and during supine to/from sitting, as these are some of the times when a patient is most likely to break the precautions. Safety education was provided in direct correlation to the safety hazards identified during the initial examination visit and other sessions. Nanette had area rugs in her walking path and a narrow path to her side of the bed. The PT provided suggestions and education regarding fall risks and prevention. Her bed was rearranged to allow a wider path to fit the walker. Area rugs were removed throughout the home. Also, caregivers (daughter and paid caregiver) were provided with education on a variety of topics, including Nanette’s home exercise program, signs, and symptoms of a deep venous thrombosis (DVT), pain medication management, the application of cold modalities for pain management, and if and when to seek medical attention. Researchers have suggested that there is an emergency room visit rate of about 13.4% in the first 90 days following THA, and the most frequent reasons are swelling (15.6%) and uncontrolled pain (12.8%).7 A study by Saleh et al documented these same common surgery-related reasons accounted for emergency room (ER) visits in about 35% of patients.9 These studies underscore the role of home health professionals in patient education regarding the careful assessment and management of swelling and pain in this population, as well as identifying patients that need to be referred to the ER for further evaluation immediately. This PT utilizes Wells’ Criteria for DVT10 as a clinical tool whenever there is concern about a possible DVT.

Outcomes

The patient achieved independence with her bed mobility by the first session of week 2 (3rd visit), and independence with her sit to/from stand and chair to/from bed transfers by the end of the second week (4th visit). She demonstrated independence with her shower stall and tub transfers by the third week (6th visit) and independence with car transfer in the 4th week. The patient progressed to gait training with a standard cane by the 3rd week. She had progressed to independence with gait training on level and uneven surfaces, including on her inclined driveway and to her community mailbox, which is about 450 feet away from her front door, with a numeric pain score of 0/10. Her functional score improved from 36 seconds at initial evaluation to 12 seconds using the TUG test. This score correlates with independence in all transfers and activities of daily living. Her right hip muscle strength had improved to 3+/5, and the patient demonstrated independence with her HEP. Nanette had achieved pain-free status by the final visit.

Discussion

This patient presented with several impairments that created limitations at the body function level as well as at the activity and participation level, 11,12 as laid out above with the ICF model.


The HHPT used his/her expertise to provide an individualized, person-centered, evidence-informed treatment in the management of this patient. The plan of care was based on the interdisciplinary protocol developed by the surgeon and the home health agency, to help achieve the goals she stated as important to her. Nanette was motivated to return to driving and get back to her normal social life with her friends in the 55+ Age-in-Place community where she resides. The patient had multiple episodes of elevated blood pressure that warranted the notification of her primary care physician (PCP). To err on the side of caution, our home health agency policy requires physician notification for any systolic above 150 and diastolic above 90mmHg. Although her PCP decided not to take any immediate action, her blood pressure was carefully assessed at the start of each visit and response monitored throughout the interaction. The patient had a medical history of anxiety, which sometimes played a role in her exercise response and feedback to the therapist, especially related to her RPE rating and response. She required frequent reassurance, and it was well managed afterward.


Further, consistent with her medical history, constant adjustments had to be made based on observations and findings at the beginning of each visit. Some of her exercises were modified, considering her history of back pain and surgery to avoid aggravating old symptoms. She received a reiteration of education regarding home safety and community re-entry in the last week of the HHPT visit.


Nanette was discharged from home health nursing services in her second week and was discharged to outpatient therapy upon completion of her 8th and final visit. She planned to start driving, first inside her community, once she was released from home health services. An anonymous satisfaction survey was mailed to her by the agency after discharge, and she expressed her satisfaction to the therapist on her last visit, showing how quickly she was progressed to independence with physical therapy. This case report demonstrates a successful progression of an individual with a posterior approach THA from acute care to return to community living through a three-week course of HH services.

About the Authors

Babatope Olusina, PT, DPT, Certificate of Advanced Competency in Home Health (APTA Home Health Section). He is a member of the APTA and Home Health section. Dr. Olusina now works for a home health agency in Richmond, VA, but previously owned and ran a Contract Therapy Staffing Company.

Dr. Olaide Oluwole-Sangoseni, PhD, DPT, MSc, GCS, is an associate professor of physical at Maryville University of St. Louis. She is a Board Certified Geriatric Specialist and a home health PT. Dr. Sangoseni is an advanced physical therapy clinical specialist degree in neuro-orthopedics from the University College London, England. She is an APTA credentialed clinical instructor. She can be reached at osangoseni@maryville.edu.

References

  1. Lespasio MJ, Sultan AA, Piuzzi NS, et al. Hip osteoarthritis: a primer. Perm J. 2018;22:17-084. DOI: https://doi.org/10.7812/TPP/17-084
  2. United States Bone and Joint Initiative: The Burden of Musculoskeletal Diseases in the United States (BMUS), Fourth Edition, 2020. Rosemont, IL. Available at http://www.boneandjointburden.org. Accessed on June 15, 2020
  3. Siopack JS, Jergesen HE. Total hip arthroplasty. West J Med. 1995;162:243-249, 1995
  4. Kremers HM, Larson DR, Crowson CS, et al. Prevalence of total hip and knee replacements in the United States. J Bone and Joint Surgery. 2015: 97(17): 1386-1397
  5. Wang Z, Hou JZ, Wu CH, et al. A systematic review and meta-analysis of direct anterior approach versus posterior approach in total hip arthroplasty. J Orthop Surg Res. 2018;13(1):229. Published 2018 Sep 6. doi:10.1186/s13018-
    018- 0929
  6. Centers for Disease Control and Prevention: National Center for Injury Prevention and Control. STEADI Tools. https://www.cdc.gov/steadi/pdf/
    TUG_Test-print.pdf. Published 2017. Accessed on June 20, 2020
  7. Kelly MP, Prentice HA, Wang W, Fasig BH, Sheth DS, Paxton EW. Reasons for ninety-day emergency visits and readmissions after elective total
    joint arthroplasty: results from a US integrated healthcare system. J Arthroplasty. 2018;33(7):2075-2081. doi:10.1016/j.arth.2018.02.01 O
  8. Williams N. The Borg Rating of Perceived Exertion (RPE) scale. Occupational Mede.2017; 67(5):404-405, https://doi.org/10.1093/occmed/kqx063
  9. Saleh A, Faour M, Sultan AA, Brigati DP, Molloy RM, Mont MA. Emergency department visits within thirty days of discharge after primary total hip arthroplasty: a hidden quality measure. J Arthroplasty. 2019;34(1):20-26. doi: 10.1016/j.arth.2018.08.032
  10. Wells PS, Anderson DR, Rodger M, et al. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med. 2003 Sep
    25;349(13):1227-35.
  11. Klapwijk LC, Mathijssen NM, Van Egmond JC, Verbeek BM, Vehmeijer SB. The first 6 weeks of recovery after primary total hip arthroplasty with fast track [published correction appears in Acta Orthop. 2018 Feb;89(1):140]. Acta Orthop. 2017;88(2):140-144. doi:10.1080/17453674.2016.1274865
  12. Bahardoust M, Hajializade M, Amiri R, Mousazadeh F, Pisoudeh K. Evaluation of health-related quality of life after total hip arthroplasty: a case-control study in the Iranian population. BMC Musculoskelet Disord. 2019;20<1>:46. Published 2019 Jan 31. doi:10.1186/s12891-019-2428-0

Evidence-informed Home Health Management
of Total Knee Arthroplasty

By: By Babatope Olusina, PT, DPT and Olaide Oluwole-Sangoseni, PhD, DPT, MSc.

Osteoarthritis (OA) is a degenerative joint disorder that affects the articulating bones, the articular cartilage, and surrounding soft tissues. Other causes of joint pain and degeneration include rheumatoid arthritis (RA), osteonecrosis, post-traumatic degenerative joint disease, and other pathologic conditions. While joint pain is usually the first sign that prompts the decision to seek medical attention1, other symptoms soon develop, including but not limited to joint hypomobility and muscle weakness. The progression of the disease results in the development of functional limitations such as difficulties with transfers, gait abnormality, stair management, and completing activities of daily living (ADLs), eventually having negative impacts on work, pleasure, and quality of life.

The knee joint is the largest weight-bearing joint in the body, and chronic knee pain has been listed as a “leading cause of musculoskeletal disability in the United States (US)”. 2 Total knee arthroplasty (TKA) is the surgical replacement of the natural knee joint with a prosthesis. It was the first performed in the US in 1968, and with ongoing advances in the technique and materials used, significant progress has been made in its effectiveness and success rate. A 2010 prevalence study of TKA by Kremers el al3 estimated 1.52% in the entire US population, and 4.55% in those over the age of 50 years, have had TKA. Prevalence is higher in women as compared with men, and it increases with age. Inacio et al4 projects that the number of TKAs performed in the US will increase by the year 2050 to a prevalence of 2.58%, amounting to 2,854 procedures per 100,000 US citizens. Partial knee replacement is often performed when the degenerative changes are confined to a particular compartment of the knee and mostly in the younger patient. The PT management is similar to that of a TKA, as described later in this study.

Physical therapy (PT) plays a major role in the initial conservative management of the knee pain before TKA, not only for pain management but also to improve function and decrease the limitations afflicted by the condition. Following a TKA, the home health physical therapist is part of the multidisciplinary team approach that manages the patient upon discharge home. Our Home Health Agency (HHA) has developed protocols to manage these patient populations effectively. Based on previously established protocol with the referring Orthopedic Surgeon, a registered nurse (RN) completed the initial visit, performing a comprehensive assessment of the patient, including the past medical history (PMH), assessment and care of the surgical incision, medication review/training, and the OASIS elements. This HHA also has established protocol with other Orthopedic Surgeons where the PT is the admitting clinician. The initial PT evaluation consists of a detailed musculoskeletal assessment of the patient,
a review of the patient’s PMH, gait and balance evaluation, and a home safety evaluation. A PT plan of intervention is formulated to address noted impairments and functional limitations, with the patient’s self-stated goal as the endpoint.


The purpose of this case report is to highlight the physical therapy management of TKA in the home health setting.

Case Presentation:

The patient is a 50-year-old female office worker referred to home PT and Nursing following a right TKA revision due to instability and eventual failure of hardware. She resides with her husband in a single-level house, with 8 entrance steps, and she was fully independent with all of her functional mobility, including ambulating without an assistive device, but she was limited by right knee pain and the knee “locking up”.

Past Medical History:

Her PMH was significant for multiple comorbidities: Significant for Hypertension, Diabetes Mellitus, Hyperlipidemia, Asthma, Anemia, Cervical spine stenosis, Elevated Hemoglobin, Ehlers-Danlos syndrome, Depression, Metabolic syndrome, and Premature Ventricular Contraction (PVC). Her past surgical history is significant for Bilateral TKA, Anterior cervical discectomy with fusion, and Caesarean Section.

Medications:

Objective Examination and Assessment

Physical Status:

During her initial evaluation completed on 12/26/20, Valerie presented an alert and oriented to person, time, and place, and able to follow multi-level commands. She presented with hypomobility of her right knee (flexion ROM of 81 degrees and extension at negative 6 degrees) and weakness in her right quadriceps and hamstring muscle strength (2+/5 on the Manual Muscle Testing grade). She had difficulty with her bed mobility requiring close stand-by assistance, and she required supervision for her transfers. She was dependent on a pair of axillary crutches for ambulation using a 2-point gait pattern. She also used an antalgic gait pattern and exhibited poor arthrokinematics in the right knee. Her balance was assessed with the Timed Up and Go test (TUGT)5, with a score of 17 seconds; this identified her as having a high risk of falls.

Integumentary:

The patient’s right knee surgical incision was covered with “Aquacell”, a non-removable dressing on the day of PT evaluation. It was removed by skilled nursing during the subsequent visit on 12/29/20. PT assessed the patient’s surgical incision during all follow-up visits, for signs and symptoms of infection. This is part of agency protocol that all clinicians will assess surgical incision and document appropriately; coordination of care is performed weekly with the RN case manager.

Pain:

The patient’s pain level and description were assessed and documented during the initial PT evaluation and subsequent visits. The PT provided education to the patient and her husband regarding pain management strategies with her prescription analgesics, cryotherapy, and movement.

Clinical Impression:

Based on the hypomobility of her Right knee joint and the weakness of her right hamstring and quadriceps muscles, the International Classification for Functioning, Disability and Health (ICF) model ICD diagnosis of M25.661 (stiffness of right knee, not elsewhere classified), was made.

Plan of Care

PT determined that patient will benefit from skilled intervention with a frequency of 3 times per week for 3 weeks, per previously established protocol with referring surgeon. The intervention included therapeutic exercises (including a range of motion [ROM], strengthening exercises, and joint mobilization), functional mobility training (including bed mobility, transfer, gait, and stair training), instruction in-home exercise program, balance reeducation, safety education, equipment training, patient and caregiver education, and training, to progress her to independence in all areas.

  1. Patient has a diagnosis of Ehlers-Danlos Syndromes (EDS)6, a connective tissue disorder with joint hypermobility as one of its primary symptoms. Her therapeutic exercises, especially her ROM, were modified acccording to her symptoms and feedback. Therapeutic exercises prescription and progression was developed based on the phase of her rehabilitation, described as follows:

Days 1-10 acute phase (with emphasis on ROM, isometric and isotonic exercises)

Days 11-21 the sub-acute phase (with progression to advancing ROM, strengthening exercises, and joint mobilization)

Home exercise program (HEP) – the patient was instructed to perform her HEP 2-3 times daily. HEP was upgraded from Phase 1 to Phase 2 as the joint effusion and pain decreased, the right LE muscle strength and coordination improved.

  1. Functional mobility training – The therapist provided verbal and visual instructions to the patient to quickly teach bed mobility and transfer techniques to progress her independence in both areas. Gait training with a pair of axillary crutches, emphasizing the proper use of the 2-point gait pattern and ensuring the crutches support the right LE, was performed. PT emphasized the need to increase right knee flexion ROM during the non-weight bearing phase of gait and facilitate full knee extension at heel strike. She was started on gait training with a one-handed device by the end of the second full week and progressed to independence by the end of her 3 weeks of home PT.
  1. Balance reeducation – transitional weight-shifting patterns in the anteroposterior and lateral directions in standing, facilitating increased weight bearing on the surgical leg. Later progressed to using a narrow base of support (BOS) in a modified tandem position, where she initially required contact guard assistance and later progressed to supervision level.
  1. Patient education: PT provided detailed instruction to the patient and her husband regarding pain and joint effusion management, signs and symptoms of DVT and infection at the wound site, and edema management. Patient education was specific to the home exercise program. Several studies have identified pain, fear of DVT, and edema as the most common reasons patients visit to the emergency room. (5-7) Therefore, our agency emphasizes patient education regarding symptoms management and patients’ expectations of their recovery roadmap. Safety education was provided, emphasizing the patient safely navigating her house with 2 cats and 2 small dogs underfoot. Her husband was instructed to, and he ensured a clear path to the bathroom from her bed, and he provided assistance that patient required for her first few shower transfers. During her fourth HHPT visit on 1/4/21, the patient reported feeling sick, dizzy, and nauseous after completing her supine and sitting exercises. Her vital signs were initially checked at the time of the therapist’s arrival, and they were within normal for the patient. She was assisted back to the couch, and her vital signs were re-checked; her blood pressure was now 91/53 mmHg, pulse was 94 beats per minute, and respiratory rate was 20 per minute, and her oxygen saturation was 98%. Further, the patient was diaphoretic and quite anxious. The PT re-assured the patient and provided moving air to cool her down. After about 5 minutes in a supine position with her lower extremities elevated, she reported feeling “somewhat better”. Her vital signs were re-checked – BP was 91/59 mmHg; pulse at 93 beats per minute; respiration at 16 per minute, and oxygen saturation at 98%. The patient’s surgeon’s office was contacted and informed about the incident. Her primary care physician (PCP) was also informed per the patient’s request. Both physicians agreed with the therapist that the patient did not require emergency care because her oxygen saturation remained within normal range, and she recovered in terms of her subjective feeling. PT ruled out possible Pulmonary Embolism (PE) using Well’s Criteria and ruled out possible DVT. She subsequently missed the next scheduled session on 1/6/21; even though she reports feeling better, she asked for another day to rest before resuming PT. She had a follow-up appointment with her primary care physician on 1/11/21 and was started on an iron supplement for postoperative anemia.

Outcomes

The patient completed 8 of 9 planned HHPT visits, and she had progressed to independent bed mobility and transfers by her third visit on 12/30/21. By the end of the 3rd week her progress was as follows:

Discussion

The patient’s plan of care was developed based on a combination of her impairments following her right TKA, functional limitations, and goals. She made steady progress towards her stated goals of independence with all of her functional mobility and all of her ADLs, without pain and locking up of her Right knee joint. The patient regained full AROM of her right knee joint and regained muscle strength to engage in her regular activities. She progressed to and demonstrated independence with all of her mobility and planned to resume telecommuting the following week once cleared by her surgeon.

During HH services, the patient was diagnosed with postoperative anemia by her PCP, which is common among surgical patients.7 Following the initial incidence, her vital signs and symptoms were monitored more frequently. Her surgeon and PCP were contacted to report her symptoms, and because the patient was discharged from home health skilled nursing services on 12/29/21, the PT provided education to the patient regarding the possible drug interaction of her iron supplement prescribed by her PCP. Ferrous Sulfate can bind to Doxycycline in the Gastrointestinal tract, which may decrease their absorption and bio-availability. They should be taken 3-4 hours apart to avoid or minimize this interaction. The therapist also provided education to the patient and her husband regarding food rich in Iron to complement her medication.

Several studies have identified the common reasons for visits to the emergency room after TKA. (7-9) A study reported 15.6% of ED visits were for swelling, and 15.8% were uncontrolled pain.8 Another study reported that among patients who had ED visits after THA and TKA, the primary diagnosis in 17.84% was pain.9 To decrease unnecessary visits to the ER, our agency has developed a comprehensive education program for post-op THA and TKA patients. PTs share the information with the patient on the first visit regarding the red flags of infection and possible DVTs; and education regarding pain and edema management. The same information is reviewed on the 2nd and 3rd visits until the patient can verbalize the previously provided information.

This case report highlights the effective management of a TKA patient in the HH setting while incorporating the patient’s unique PMH and postoperative complications. Her exercise program and joint mobilization were modified to accommodate her Ehlers-Danlos condition and her vital signs more closely monitored with the postoperative anemia. Her exercise program was progressed from the initial set more suited for the immediate acute phase to more advanced exercises in the sub-acute phase. She was progressed to independent ambulation without an assistive device on a level surface and with a one-handed device on uneven surfaces.

About the Authors

Babatope Olusina, PT, DPT, Certificate of Advanced Competency in Home Health (APTA Home Health Section). He is a member of the APTA and Home Health section. Dr. Olusina now works for a home health agency in Richmond, VA, but previously owned and ran a Contract Therapy Staffing Company.

Dr. Olaide Oluwole-Sangoseni, PhD, DPT, MSc, GCS, is an associate professor of physical at Maryville University of St. Louis. She is a Board Certified Geriatric Specialist and a home health PT. Dr. Sangoseni is an advanced physical therapy clinical specialist degree in neuro-orthopedics from the University College London, England. She is an APTA credentialed clinical instructor. She can be reached at osangoseni@maryville.edu.

References

  1. Zhang Y, Jordan JM. Epidemiology of Osteoarthritis: Clin Geriatric Med.2010 Aug: 26(3): 355-369
  2. Jette DU, Hunter SJ, Burkett L, et al. Physical Therapist Management of Total Knee Arthroplasty: Physical Therapy. 2020 Aug; 100(9): 1603-1631
  3. Kremers HM, Larson DR, Crowson CS, et al. Prevalence of Total Hip and Knee Replacement in the United States. J Bone Joint Surg Am. 2015 Sep 2; 97(17): 1386-1397
  4. Inacio MCS, Paxton EW, Graves SE et al. Projected increase in total knee arthroplasty in the United States- an alternative projection model. Osteoarthritis Cartilage. 2017; 25: 1797-1803
  5. Centers for Disease Control and Prevention: National Center for Injury Prevention and Control. STEADI Tools. https://www/cdc.gov/steadi/pdf/TUG Test-print.pdf. Published 2017.
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