Celebrate

Miriam Janove, PT, is an August 2019 graduate of the University of Puget Sound, Washington.

Read her winning Essay below:

Jack (name changed for confidentiality) was admitted to inpatient rehab with a left pontine stroke, presenting with dense right hemiparesis and neglect. Three weeks later, he discharged from inpatient rehab with all his goals met, including transferring and walking with no physical assistance and hemi-propelling a wheelchair up and down ramps. The glow and satisfaction of a physical therapist is palpable when discharging a patient who has met all their goals and returned to all their prior activities. So often, however, we discharge patients who have plateaued below what we deemed as within their capacity at initial evaluation. There may be some structural differences between the bodies of the patients in these scenarios, but more concerning are the disparities in their attitudes and perspectives required for healing, such as an internal locus of control, therapeutic alliance and body awareness. Though physical therapy treatment should be based on therapeutic exercise, including strength, endurance, flexibility and coordination, to most effectively treat our patients, we must empower them to believe in the gains made through their own hard work and to engage fully in therapy.

We spend much of our Doctor of Physical Therapy (DPT) program learning about the structures and functions of the body in order to use evidence-based practice to treat our patients. Recently, we have shifted focus towards examining the impact of illness by discussing the patients’ participation goals using the International Classification of Functioning, Disability and Health (ICF) model. No longer is it appropriate to treat impairments in patients without accounting for the fact that we are working with human beings who have rich and demanding lives. I envision using my current and future studies to support the integration of patients’ humanity into medical treatment.

In Jack’s case, it was essential to account for the privacy that he and his wife value, as well as his wife’s inability to assist physically due to her own medical conditions. Due to their private natures, they were unwilling to ask neighbors or extended family for support. Additionally, he was obese and had a very sedentary lifestyle prior to his stroke, which left his intact side too weak to compensate for his hemiparesis.

Putting patients’ concerns and connections first lays a foundation for success in therapy, but there are several other relevant mental components to fruitful therapy. Locus of control is a concept that elucidates the perception of what impacts the outcomes in one’s life. Someone with an external locus of control believes that they have no direct influence over their own life. This person is likely to have significant difficulty with motivation to engage in therapeutic exercise because their perception is that their own actions will not impact their outcomes. However, someone with an internal locus of control believes that their actions directly influence their life.

Jack arrived at inpatient rehab with an external locus of control. He did not take responsibility for his own healing and did not prioritize exercise outside of therapy time. He had a defeated attitude and was resigned to his new immobility. As we know, therapeutic exercise during physical therapy sessions is insufficient for substantial progress, but despite reminders, he spent his evenings resting instead of exercising.

Though every individual has an innate tendency towards either an internal or external locus of control based on their personality, medical professionals can cultivate an increased internal locus of control in their patients through motivational interviewing and encouragement. Communicating to a patient that measurable improvements in strength, flexibility, endurance or coordination are due to the effort they put into their home exercise program helps foster a greater sense of internal locus of control. This internal locus of control is an asset that serves patients beyond one episode of care as they take ownership of their own health and healing overall.

Gentle encouragement for Jack to participate in the variety of therapeutic opportunities offered on inpatient rehab initially went nowhere. His external locus of control was apparent and he made excuses. As he slowly began to recognize strength gains within his own body, drawing the connection between those improvements and his effort helped him see the control he had over his own healing. After planting the seed, this internal locus of control took on a life of its own, growing exponentially each day as his functional mobility improved, first with independence in bed mobility, then transfers, and finally gait.

Motivational interviewing is a technique I used to build Jack’s internal locus of control. This technique allows medical professionals, including physical therapists, to help guide lifestyle changes by allowing patients to come to conclusions for themselves about their own priorities. By using open-ended questions, active listening and reflective statements, we can draw out our patients’ own reasons to make the changes we have already assessed to be beneficial. Many people resist demands and suggestions from medical professionals, but with motivational interviewing, the patient realizes through their own words that there is dissonance between their goals and their actions. People are more likely to commit to change if they are the ones to come up with the idea.

In talking with Jack, we discovered that his dogs were one of the most important things in his life. When thinking about caring for his dogs, he could see the real-life implications of working to increase his independence in mobility. He realized that his wife would become solely responsible for dog care if he didn’t work hard and improve his function. He wants to be a contributing member of society, and to Jack that means being a contributing member of his household.

Another elusive contributor to good outcomes in physical therapy is therapeutic alliance. This is a quality of the relationship built between therapist and patient, including trust, communication and collaboration. In a systematic review, Hall, et al. conclude that positive therapeutic alliance correlates with physical therapy outcomes including decreased pain, improved function, increased home exercise program compliance and increased satisfaction.1 Soft skills, such as listening and motivational interviewing are integral to building therapeutic alliance with patients who have clear benefits.

People can tell when someone is genuinely excited to spend time with them. It was enjoyable to work with Jack because he was pleasant, though he was not always cooperative. Motivational interviewing not only helps us understand the driving factors in our patients’ lives; it also helps us see their humanity. This connection builds compassion which supports therapeutic alliance by boosting each therapist to show up with true caring for each and every patient.

By bringing locus of control, motivational interviewing and therapeutic alliance to the forefront of physical therapy treatment, we will improve the care provided to one of the most challenging populations to treat, people with chronic pain. As the United States population ages, chronic pain has become an epidemic, which is beginning to get the attention it deserves. Chronic pain patients are a difficult population to treat because there is no protocol or quick fix. This group is also one of the biggest beneficiaries of cognitively based therapeutic interventions as a major part of their treatment program. We know that thoughts and breathing can impact patients’ blood pressures and heart rates, so it follows that thoughts and breathing also impact patients’ experience of pain.

Interdisciplinary collaboration is an important aspect of treating patients with chronic pain, since cognitive behavioral therapy is outside of our scope of practice as physical therapists. As with any other interdisciplinary work, physical therapists can support the goals and strategies of other therapists. We can use cognitively based techniques, such as mindfulness and visualization, learned from these other professionals, to enhance their practice and our own. Due to a flaccid arm and shoulder subluxation, Jack had shoulder pain. With diaphragmatic breathing and progressive muscle relaxation, his shoulder pain decreased. Another benefit of these activities is that they can be prescribed for times when a patient is too tired to do physical exercise.

As physical therapists, decreasing pain is a daily goal with many patients. Body awareness contributes to increasing patients’ locus of control and decreasing pain. Body awareness can be cultivated with widely accepted therapeutic interventions, such as diaphragmatic breathing and attention to exercise form, which is a form of mindfulness. Though some would argue that mindfulness training and meditation are outside of the physical therapy scope of practice, researchers have found that with proper training, these are effective and important tools within a physical therapy context.2, 3

People throughout the United States are frequently disgusted by the medical system. As physical therapists, we are players in their medical care with an opportunity to build connection and provide patients with caring and compassionate medical treatment. Building faith and trust between patients and the medical establishment improves patient outcomes, but more importantly improves people’s lives. By continuing to educate myself and others about the psychosocial and cognitive components of successful therapeutic relationships, I will help build a physical therapy community which treats the whole person instead of simply treating their body.

References

1. Hall AM, Ferreira PH, Maher CG, Latimer J, Ferreira ML. The Influence of the Therapist-Patient Relationship on Treatment Outcome in Physical Rehabilitation: A Systematic Review. Physical Therapy. 2010;90(8):1099-1110. doi:10.2522/ptj.20090245.
2. Pike AJ. Body-mindfulness in physiotherapy for the management of long-term chronic pain. Physical Therapy Reviews. 2008;13(1):45-56,doi:10.1179/174328808X251957
3. Rundell SD, Davenport TE. Patient Education Based on Principles of Cognitive Behavioral Therapy for a Patient With Persistent Low Back Pain: A Case Report. Journal of Orthopaedic & Sports Physical Therapy. 2010;40(8):494-501

By Jamie Funk, Therapy Recruiting Resource

Scott Langdale is a stand-out leader in our Washington operations. He is one of those dedicated clinicians who quietly goes about doing whatever needs to be done — in his own facility as well as his partner facilities — no matter what it takes and without any expectation of recognition. “We are so lucky to have him on our team,” says Mira Waszak, his therapy resource.

Scott joined our organization when his facility, Beacon Hill, was acquired in 2014. He was a staff therapist at the time but quickly became a Director of Rehabilitation when the position opened up in 2016. He is passionate about developing others and believes that developing others is what great leaders do — they give the people they lead the tools and culture to grow and then get out of their way!

This therapy veteran has been part of many different teams over the years. What sets his current team apart from all the others is their closeness and genuine love for each other. Beacon Hill therapy is extremely supportive of all of the facility departments and has developed outstanding relationships with each one. Because of this close partnership, patient outcomes and satisfaction are excellent.

Scott is quick to praise the nursing team at Beacon Hill: “The thing I appreciate most about our nursing team is how much they appreciate our therapy team. What I mean is that our opinions matter and are taken seriously. We work very well together and there is no us and them.”

When not working, Scott loves to spend time with his family. His favorite Disney character is Goofy, because he puts his heart and soul into everything he does, doesn’t take himself too seriously, and he truly wills the good of others — sounds a little like Scott!

It is no surprise that serving as a director of rehabilitation is a demanding job, and with all the noise, chaos and drama that comes his way each day, Scott mindfully decompresses and reflects on his day during his drive home with no radio on in the car. Each evening after dinner, he takes the time to journal about his day and think about what he did right, what he could improve, or any work issues that are on his mind. This keeps him focused and keeps work at work, allowing him to enjoy his time at home with his family.

To help build morale and culture with his team, Scott has some great tricks. He makes sure he has a small gift for each employee when he does their annual performance review. He also makes sure they have facility T-shirts and hoodies, knowing how much our therapists love shirts. The team also has an off- site rehab team lunch at least once a quarter.

Scott keeps his passion for his field alive by mentoring student therapists as often as possible. He also maintains a willingness to try new things. “There is always something to learn,” he says. “The one thing I know is that I don’t know everything. Everyone I meet or interact with has a story to tell. If I treat them as a person instead of a thing, I am always amazed at how much they will teach me.”

Over 250 therapy leaders gathered in Newport Beach to create a Therapy Leadership Experience powered by love! The theme of this year’s experience resonated throughout our amazing two days together spent in learning, loving and leading. Beginning with an optional yoga session in the outdoor amphitheater each morning and continuing with healthy meal and snack options combined with fresh flowers and an indoor/outdoor ambiance, the tone of the event centered on wellness.

The WELL Project Team provided context to the idea of creating a wellness movement with the goal of not only helping ourselves, but also leading by example to positively impact all with whom we come in contact. Leaders provided written notes of gratitude, WELL Commitments and ideas for inspiring wellness among one another. Our Therapy Director, Mary Spaeder, provided a beautiful reminder about our ability to choose our response to all that we face in life and leadership, while reinforcing the use of tools and techniques such as heart rate variability training to help us build our resilience.

We experienced an awesome opportunity of interacting with some of our great organizational leaders. Barry Port, Bev Wittekind, Soon Burnam, Clay Christensen, Debbie Miller, Tyler Douglas and Spencer Burton all spent valuable time sharing thought-provoking lessons on leadership and learning. Following the recommendation of our 2018 Summit Leaders, Mike Dalton joined us to stimulate our thinking about life and leadership.

The learning and sharing of best practices for enhancing outcomes-based care of our LTC residents, outpatient program development, therapy utilization techniques and tools, business development, clinical program development and the inner workings and considerations for functioning in a Patient-Driven Payment Model environment were central to our 19 different Think Tank Sessions and over 40 Poster Sessions presented at the event. We invited CMS Leader, John Kane, who shared brilliant insight and led a dynamic Q and A session allowing our leaders to get a close-up view of the rationale behind a PDPM and the CMS perspective on hopeful outcomes from the reimbursement system.

Ultimately, we left the experience more enlightened and overflowing with joy and love for an organization that values our growth and supports our passion for learning.

As Mary so beautifully shared during her opening remarks through the words of Rabindranath Tagore:

I slept and dreamt that life was joy
I awoke and saw that joy was service
I acted and behold, service was joy

The 2019 Experience calls us to continue our quest toward Joy in Leadership and the unexpected power of leading with love!

Thanks to Alan Gibby for lots of great photos! Click here for Part 1 … and Part 2

Got Joy? The therapists, nurses, residents and IDT members at Mt. Ogden Nursing and Rehab do, and they are sharing these joyful moments through messages and photos. How will you inspire a WELL movement like DOR Brooke Stanley and her team did?

Roger Pavon has been part of the California Southland family for over 20 years and was one of our original pioneers who traveled via the “Southland bus” and “Southland jet” to help our affiliate operations in San Diego and Northern California. Roger was instrumental in helping implement in-house therapy with the then-named Northern Pioneers operations.

“Roger and his wife, Grace, have three beautiful kids who grew up with us at Southland. He is a humble, loving, passionate therapist who knows how to bring out the best in every patient. My mom could not smile anymore by the time her Parkinson’s had advanced, but the moment we brought her in for outpatient services at Southland in 2017 and she saw Roger, she smiled for the first time in months with tears of joy in her eyes,” said Mary Spaeder of her appreciation of Roger.

Roger became interested in physical therapy after his grandmother had a stroke. He witnessed and took part in her rehabilitation and was inspired to help other people make positive changes in their lives. His favorite part of being a therapist today is helping people regain their mobility and improve the quality of their lives physically, mentally and emotionally. Even after over 20 years of being a therapist, Roger finds his work extremely rewarding.

When asked who on his team he admires the most, Roger said, “I admire each and every team member I work with because each person contributes something special that makes our team what it is.” Roger doesn’t have a specific professional mentor at this stage in his therapy career, but he is a life-long learner and likes to listen to podcasts and read books by motivational leaders like Louise Hay, Dandapani and Wayne Dyer.

Roger’s favorite Disney character is Peter Pan, “because he is carefree and adventurous, and doesn’t grow up. We don’t stop playing because we grow old; we grow old because we stop playing,” Roger says. Roger does plenty of playing himself — his favorite outdoor activities are snowboarding, stand-up paddle-board, and spending time at the beach and in nature. His favorite core value is Love One Another. As he explains, “Love is God and God is love!”

Roger believes that the biggest thing that leaders and resources in our organization can do to support our therapists is to appreciate them. “It is said that a person who feels appreciated will always do more than expected,” he explains. Roger Pavon, you are appreciated!

Did you know….

Jacob Barnes is the Therapy Program Manager at Park Avenue Health & Rehabilitation Center in Tucson, Arizona. Inspired by his Occupational Therapist mom, he began volunteering at Northwest Hospital in Tucson when he was 14 – only to be offered a paying job when he turned 16. After becoming bored with work in hospital transportation, Jacob trained to become a Patient Care Technician and ultimately, the hospital paid for him to complete the Physical Therapy Assistant program at Pima Community College.

This proven Ensign leader has an obvious talent for creating outstanding Animoji’s, but his hidden talent is crossing his eyes – while keeping one eye straight. He hasn’t revealed this talent to his 5 and 2 year old sons yet – but it will be interesting to see if they have inherited this strange but amazing ability! A Pittsburgh Steelers fan, Jacob spends his down time hanging out with his family, studying Jujitsu with his son, and when he gets the chance, scuba diving with his wife in places that include Jamaica, Mexico, Hawaii and California.

Some of Jacob’s biggest accomplishments as part of the Ensign family (so far ) have been being part of a successful IRO visit and also getting to be part of the Park Avenue Award. The Park Avenue Award is specific to Arizona and is modeled after the Southland Award. Not only does Jacob feel honored to be a therapy leader for the facility that inspired this award, he loves being part of the selection committee for subsequent awards.

Jacob also represents us at career fairs and therapy conventions. His best advice to recent therapy graduates is to be a sponge and learn everything possible from the therapists, nurses and other healthcare professionals we are surrounded by. Finally, whatever you do in your career, make sure you are having fun!

This new special award, in essence, emulates the spirit and incredible human being that Natalie was.

Natalie was a PT at Legends Euless when it was transitioned by Ensign in the 2016 Legends acquisition. At the time of transition, the DOR decided to leave and remain with the outgoing company. Natalie stepped up to become the DOR. She had not been a manager before, but she worked diligently to learn what she needed to do to lead her new team with a new company and new systems. Natalie truly evolved as a leader, showing ownership for her department, love for her team and compassion for her residents. In fact, Natalie’s facility was leading in best therapy metrics ever and leading us in Keystone when she found out right before last year’s DOR conference in California that she had breast cancer. While this would have stopped many people in their tracks, Natalie persevered. She took the initiative to work from home on days when the treatment kept her down, never giving up hope and never letting her family or her team down. She completed her chemo treatments the first week of January, 2019 and we were all relieved and excited for her! Unfortunately, what we didn’t know was that the chemo had taken its toll. A rare reaction to the treatment had done serious damage to Natalie’s heart. On March 5, 2019, Natalie reported to work in spite of feeling horrible. She used a facility walker to attend the morning meeting before her team sent her home. She went to the ER where the damage to her heart was eventually discovered but irreparable. We lost Natalie in the early morning hours of March 7, 2019. While Natalie was enduring treatment, her ADOR Kim Graybeal readily stepped up and filled in the gaps. She attended meetings, triple checks, assisted with staffing/scheduling and held the team together in moments of fear, chaos, and uncertainty.

When Natalie passed, we knew there was really only one person who could help the Euless team make such a difficult transition. Kim Graybeal has eased the burden with grace and dignity. She carries Natalie’s memory in high esteem and continues to hold their team together in ways that few others could. In spite of the huge void left by our beloved Natalie, we award Kim with the first annual Natalie Blascienski Award to recognize how she has stepped up in the face of adversity, shown leadership in times of turmoil, and displayed unconditional love to her team, her facility, and to Natalie and her family—many traits that Natalie possessed. Please join me in congratulating Kim Graybeal, DOR of Legend Euless, as we honor her with this prestigious award.