My Mother Betty Jo Williams died 12 years ago last month from a Grade 5 sub arachnoid brain aneurysm. She was an apparently very healthy 52 year old woman who was working as an elementary school teacher. My Father found her collapsed complaining of a severe headache. She had applied a bag of ice to her head (at 1am) and immediately went unconscious. My Father, David called for an ambulance and the 2 neighboring towns began to fight over which territory their home was in for the volunteer EMS workers to come. She had a living will and did not want extraordinary measures however she was resuscitated twice as they drove slowly to Utica, NY to St. Elizabeth’s Hospital. A brain CT scan showed the ruptured aneurysm and she never regained consciousness. She was placed on a ventilator in the early hours of August 3, 1998. The only neurosurgeon on call we were told, Dr. Frank Boehm, was on his way. He arrived more than 4 hours after she did and stated that her condition was very grave. He inserted a brain shunt to relieve the rapidly increasing intracranial pressure and gave huge amounts of steroids via IV. Betty Jo initially demonstrated decorticate posturing and rapidly progressed to decerebrate posturing within her first day on the ventilator. Her eyes were fixed and her teeth clenched.

Dr. Boehm demonstrated exceptionally poor bedside manner and a lack of compassion. His female nursing assistant was terse and very curt with her explanations of my Mother’s condition and prognosis. No surgical intervention or hospital transfer were ever offered. She died Wed. Aug. 5, 1998 in the evening after 3 days on life support.

Six months after her death I took a full-time position at St. Luke’s Hospital as a staff physical therapist. I was there about ten minutes when I heard Dr. Boehm’s name come over the PA. I thought that I would never have to see him again. Soon, I will get my wish.

While visiting family in Utica, NY this past weekend my sister, Jessica related this story from NBC-WKTV in which the State of NY FBI and the Assistant US Attorney General’s Office have worked hard to demonstrate his guilt for writing prescriptions for people with no treatment notes, to a woman he lived with and knew she was addicted, and he also profited from the sale of these narcotics!  He is looking at up to 20 years in prison and $1,000,000 in fines and had his medical license and DEA license revoked.  His awful career is finally over.

It seems that Dr. Boehm was suspended in 1994 for 2 years for writing prescriptions for narcotics to his girlfriend, her sister, and his mother. He was allowed to continue practicing neurosurgery as long as a colleague monitored his practice.  Just prior to this, he had hired Terrence O’Rourke RPA in his office.  Terrence had his license revoked due to inappropriate sexual advances and poor professional conduct.  It is too bad that patients are not privy to this information unless they pressed the State of NY to act themselves or they dig deep to really find out the louse they are seeking care from!

What is the scary part for me as a human being requiring care and a health professional providing care is that so many patients now surf the net or talk to friends to get opinions about their doctors. Here is Dr. Frank Boehm’s patient rating.  There is no mention of the 3 cases of malpractice that were filed against him in this past decade, nor the judgments of professional misconduct that he pleaded guilty to in 1994 and has been repeating up until now! What is the recourse for a patient or family who was treated and potentially maimed or killed by this man or the many unsuspecting people that looked to him as an “expert” in his field.  Check out this website for info about him as an expert in his field of neuroscience.  How would the average health care consumer be able to make an informed choice about his skills based on these rating websites that omit the most dangerous and conclusive information about his practice?

I guess the key is to educate our patients and the community on the benefits of physical therapy and demonstrate our concern and commitment through continued education and perseverance to providing optimal care.

I am glad that karma exists and hope that January 2011 brings some much needed karma to Dr. Frank Boehm Jr. and relief to his previous patients and the people in the Utica, NY community that will never again be at his mercy.  It will not bring my Mother back but I am happy for her sake that she is not a “living victim” of his selfish and incompetent choices.

This power point presentation is for a course that I gave with a colleague Erika, for Masonicare Home Health & Hospice in the Fall of 2009. The focus of the talk and demonstration was getting your hands on patients to improve their joint and tissue mobility through progressive mobilization and stretching both active and passive. At the end of the power point is a section on research related to lumbar spine mobilization. I really enjoyed Josh Cleland’s article “Does the Manual Therapy Technique Matter” and encourage colleagues to read Josh’s work regarding clinical prediction rules and the need to use manual therapy techniques in our treatment.

Since my last post in June 2009, I sustained a tear of my right posterior tibialis tendon and spring ligament allowing to experience first hand the pros and cons of being a patient.  I utilized a cam rocker boot initially for a conservative approach in an effort to scar the partial thickness tear together.  During the Fall of 2009 while working simultaneously in homecare, inpatient, and outpatient physical therapy I felt the eventual collapse of the mid foot and the constant ache and discomfort that the malalignment caused.  My 38 years of living with flat feet with hyper mobile excessive pronation that had never been painful… suddenly became very painful and I was able to identify that I was experiencing adult acquired flat foot deformity with a Stage IIb Posterior Tibialis Tendon Dysfunction.  I was unable to stand barefoot without severe right foot pain and a sensation that my foot was not able to provide me a sense of structure or support for the rest of me up the chain.  I continued to work on my feet all fall some days up to 12 hours and this was only possible with the constant use of a lace-up ankle brace, new foam/cork orthotics, and daily doses of Aleve.

I thought that I was managing life and this injury ok while to work and take care of my 2 children, home, etc. when I attempted to cross a street in November without the  brace on and a car was approaching.  My brain told my legs to hurry across the street and my right ankle would not work.  I suddenly panicked as I felt like my tibia was resting on a peg that would not move.  I wanted to plantar flex and push off and the foot would not cooperate.  I quickly realized how limited my function had become over the last 5 months….. I did not go kayaking, run/walk on uneven ground, limited stair climbing, didn’t run, limited my gardening, avoided going on our sailboat….all out of fear of pain and falling.  I had subconsciously limited my function and accompanying that loss of function came instant weight gain and depression.  I had to make a change.

I researched the mid foot reconstruction and potential surgeons.  January 5, 2010 I met Dr. Jonathan Deland at Hospital for Special Surgery in New York City.  He quickly diagnosed my right foot with Stage IIb Posterior Tibialis Dysfunction.  I had plain film radiographs of both feet in standing.  Prior to the films I told him that I felt as if my right navicular and talus were on the floor.  Sure enough…the radiograph showed that the right talus and navicular rather than being parallel to the ground were severely angulated towards the ground, the calcaneous was in significant eversion, and the first ray was hypermobile and elevated, shortened Achilles tendon due to the everted calcaneus.  All compensations due to a ruptured right post. tib tendon and spring ligament.

My foot surprisingly looked just this photo, “too many toes sign” and all….

His office called me and nine days later I was in the operating room from 5pm to midnight.  Seven hours of reconstruction for an injury that I had lived with for 6 months.  He performed a right gastroc belly lengthening, calcaneal wedge osteotomy with 2 screws to fixate, lateral column rebuild, first ray osteotomy with a right iliac crest graft, spring ligament repair, and flexor digitorum tendon transfer into multiple areas of the degenerated posterior tibialis tendon.  I was treated with a popliteal block, spinal, and epidural anesthesia.  I was in the hospital for 5 days and received exceptional care.  I am recuperating at home with a cast on my right lower leg and ambulating right non-weight bearing to all settings.  I am on Coumadin with twice weekly INRs.  After taking Percocet and Lyrica for 6 weeks I am beginning to come out of the narcotic haze and anxious to get moving.

One task to pass the time while laying in bed with my leg elevated, has been to scan my Great Grandmother Alma’s letters to her husband, Eddie while she was a patient at the Galen Sanitarium in Montana from April 1926 to March 1927.  She was brought there emergently due to the scare of Tuberculosis.  She had 5 sons and 1 daughter and had recently lost a daughter to childhood illness.  My maternal grandfather was 5 years old when his mother was taken away.  She was only able to visit with her husband occasionally and no children were permitted to visit.  The usual internment for TB was 300 days.  I became fascinated reading her letters which began optimistically about her recovery and her plans for the future and then sunk into despair and paranoia that possibly her husband had left her for another wife and that she may not see her children again.

As I lay here recuperating I admire Alma’s resolve and determination in her first letter to her husband, Eddie, upon arriving at the Galen Sanitarium:

“I divided my mind into three parts and labeled each one.  The middle path of it is ‘road to health, happiness, and hope.’  Down this path are ‘gratitude’ for you to work for me and love me, for Mother to shoulder my responsibilities and to love my kids, and for the chance that I have to get well.  I want contentment and the resolve to help all I can.  The left hand path is labeled ‘this way madness lies.’  Down this path are loneliness, worry, willfulness, and self-pity- to be absolutely shunned.  The right hand path is labeled ‘comparison’ when I get to feeling sorry for myself and mine.  I resolutely turn to this path and think of those whose troubles are worse than ours and it’s the middle path that I am going to travel and I forgot to mention that at the end of that path is ‘home.’  Don’t worry–keep a stiff upper lip, as you can–keep well and stand by.  Help Mother all you can and be patient.  Keep my little kiddies good for me and write often.”

What a clear vision she had on April 2, 1926 when she wrote this and what a tough journey she had over the course of that year to heal and return to her family.  Here is a link to a story about the Sanitarium where she resided.

More to come on healing…..

Greetings from our Annual Conference,
I haven’t attended since Boston 2005. How good it is to see our colleagues doing poster presentations, publishing their work, and continuing to contribute to our growing body of evidence. I currently work in acute care and home care and am really enjoying getting some new ideas into my PT tool box and being pushed to remember those tricks I have long forgotten to use.

After listening to loads of information about how our patients recover from hip fractures, it was amazing to think that based on research patients begin to gain mobility and strength at 2 months post op and recover full function by one year. However Dr. Kathleen Kline Magione PT, PhD, GSC referred to Dr. Magaziner (1990) while reporting that 40-60% of patients post hip fracture fail to regain pre-fracture mobility and to return to community activities. The pilot programs and studies looked at putting patients on aggressive strengthening programs for one year. I was excited to hear their information and perspective and also saddened that most of the conversation about hip fracture recovery dwells on reimbursement. Ten years ago, patients were in the hospital for 14 days on average, where I work it is now 3 and then off to acute/sub-acute rehab based again on where the payor decides. We see them in homecare about post op week 3 to 4 and are “encouraged” to treat them in 8 to 12 visits and pay attention to HHRG scores, HMO auth., homebound status, etc. and then listen yesterday and realize that true strength acquisition will happen in 4 to 6 months!!! Even when I send my patients to outpatient PT for further strengthening…. by 6 months, to my knowledge most patients are done with all of us and on “their own.”  How can we stop them from falling and re-injury if we don’t get them far enough to be successful on their own.

Dr. Mangione referenced Home care episodes of care (Fitzgerald et al 2006) in 1996 at 48 days for an episode of care and in 2001 it was 26 days, not treatment sessions!!! Now I imagine that the average length of stay in home care is less than 2001, it can only be due to reimbursement and staffing pressures. Where does that leave our patients if they don’t have social support or ability to travel to an outpatient setting for continued supervision to return them to their previous level of function or better? Our system is broken as many have stated.

With all of this great research showing that older adults can do more strengthening over a longer period than we have offered ( I know that I am guilty), who is lobbying on Capitol Hill to show them that our patients are really losing out on recapturing their lives pre-fracture levels of activity, self-esteem, and dignity!!!!

Dr. Mangione stated that high intensity training is associated with clinically meaningful improvements whether performed in the home or the clinic setting (APTA, All Things Hip June 11, 2009). She discussed at length the idea of “dosing” our exercise. Her study Home Based Interventions (Mangione, 2005) force production, endurance, and balance were addressed. She used the shuttle mini clinic http://www.shuttlesystems.com/mcindex1.htm

for leg press, hip abductor, hip extensors in standing, and unilateral standing planar flexion. They utilized 3 sets of 8 reps at 100% of 8 RM, 2x/wk for 10 weeks. Intensity was adjusted every 2 weeks. She reported clinically meaningful change mPPT score- 3.6 points, fast gait speed- 0.1m/sec., and 6 min. walk distance- 35 meters. More importantly as she reported the patient was happy with their progress resulting in improved function.

Where do we go from here? I know that I have to push my geriatric patients harder and document their improved function and improved objective tests through the TUG, BERG, Tinetti, DGI etc and keeping trying to make a difference for each patient, one at a time. I am convinced that we home care therapists have to improve our image and get our communities (social, medical) to realize that home care physical therapy intervention can be meaningful, productive, supportive, and empowering for our patients and their loved ones.

The following PowerPoint was presented for continuing education at Visiting Nurse Services of Connecticut to provide information about manual therapy techniques to improve knee mobility in the home setting.  Please feel free to provide a comment.

As reimbursement tightens and productivity standards increase we as physical therapists have to provide quality patient-centered care in an efficient professional manner. That goes for our documentation. If we are providing manual therapy techniques to our patients to improve mobility and function, we must accurately document what we provide. The following are commonly used terms I use in my homecare and acute care documentation to substantiate my work.

-Skilled passive range of motion to knee into flexion and extension to tolerance.
-Anterior to posterior tibial glides grades I, II, III with progressive passive to active assistive knee flexion to tolerance.
-Prone alternating contract relax to quadriceps and hamstrings with progressive skilled passive flexion to tolerance.
-Prolonged deep friction massage or transverse friction massage to entire peripatellar region, primarily to lateral retinaculum region with passive medial lateral patellar mobilization.
-Prolonged caudal patellar glides with progressive passive knee flexion.
-Prolonged cephalo patellar glides with progressive passive calf stretching with anterior to posterior proximal femoral and tibial glides for improved knee extension.
-Prolonged proximal fibular head mobilization anterior to posterior with rotation in moderate knee flexion in hook lying.
-Prone knee extension with foot off of bed with posterior to anterior proximal posterior tibial glides grades I to IV for improved knee extension.
-Soft tissue massage to quadriceps belly for improved relaxation prior to joint mobilization.
-Skilled passive stretch to calf to tolerance with progressive knee passive extension and over pressure at distal femur and proximal tibia.
-Hook lying position for knee flexion with full hip flexion and washcloth under knee with patient providing increased knee flexion with hands at mid anterior tibia with increased bouncing at knee creating an increased flexion moment at knee to tolerance. Mulligan Mobilization with Movement (MWM).

These terms and phrases drive my treatments as they are the “bread and butter” techniques I use for every patient with a total knee replacement when I see them anywhere from 4 to 20 days post- operatively whether they are coming directly from the hospital or a rehab facility back home. The focus must be on proper pain control, early edema reduction and progressive mobilization coupled with proper assistive device use for optimal gait pattern. As the edema and pain reduces the patient is instructed in a proper quad set and progressive straight leg raise and then they work on it on their own. We need to guarantee that the patient has proper technique on the CPM (if using) and with therapeutic exercise. However the bulk of my treatments in the home focus on manual therapy techniques to improve their function and then I want the patient to “work the knee” on their own for progressive strengthening and mobility. Then depending on mobility and strength, they are encouraged to go to outpatient physical therapy within 2 to 3 weeks. I have established relationships with outpatient physical therapy practices in my area that are “hands on” and I know that our philosophies are similar for the patient. I try very hard not to have my patient go to a clinic that is so busy they don’t see the therapist and they spend hours with a teenager watching them. My father recently had a TKR in the Cooperstown, NY area and the orthopedists prefer to do surgery and send their younger (45-65 years) patients directly home and go to outpatient PT as soon as possible. When I asked if he could have homecare initially and quickly transition to outpatient physical therapy, the surgeon’s PA stated, “Oh we don’t use homecare physical therapy. It is not very good and we just send patients to outpatient PT.” I was disappointed as this is my area of work and I feel that as therapists we can bring all of our “clinic tricks” to the home setting by being creative and innovative.

By providing quality care in the home one patient at a time with evidenced-based practice, we will change the negative mind-set of homecare and make a difference for our patients and the community.

The following PowerPoint was presented for continuing education at Visiting Nurse Services of Connecticut to provide information about manual therapy techniques to improve knee mobility in the home setting.  Please feel free to provide a comment.