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Patient Centered Care isn’t just taking good care of our patients. It is a holistic philosophy of including the patient and their family members in as many decisions and system/facility improvements as possible. It means offering choices whenever possible, thereby giving our elders more control over their lives.

This approach may include asking for their input on anything from what kind of furniture they would like to replace the old furniture in the front lobby, to what we should ask them on a discharge survey, to simply when they would like to go to bed at night. We are still in our infancy with implementing this philosophy, but here is what we have accomplished thus far:

Long-Term Care Residents

• We invited six LTC residents to help plan our Nursing Home week in May. They offered suggestions and picked the theme for each day, the activity and the special food to be served.
• We have added an “Activities Calendar Planning” day to our Activities calendar and have begun including LTC residents with the planning of their monthly events.
• We have included LTC residents on our Dining Experience Performance Improvement Plan (PIP) to get their feedback on what they feel would improve their dining experience.

Rehab Patients

• We created a PIP for the first 24 to 48 hours, as this has been an area where we either shine or fail to impress.
• We invited a prior patient and his spouse to meet with us and get their feedback on their experience and collaborated on which areas we needed to improve.
• Therapy is offering a choice to new patients of what time they would like to be evaluated (before lunch or after lunch).
• Therapy is also asking each new eval if they would like to make a friend while rehabilitating. We then introduce them to another patient who also expresses an interest in meeting someone.

Through our patient-centered approach, we are able to improve the quality of life for residents and ensure they feel not only well-cared for, but also valued and significant.

By Park Manor Rehabilitation Center, Walla Walla, WA

Utilizing Heart Rate Variability Biofeedback in a Patient With CVA to Improve Psychophsyiological Coherence

By Amanda Call, MA, OTR/L, Draper Rehabilitation and Care Center, Draper, UT

At Draper Rehabilitation and Care Center, we treated a 74-year-old female patient who sustained L hemispheric hemorrhagic CVA. She presented with a host of symptoms, including R hemiplegia, dysphagia, aphasia, R neglect, malnutrition, HTN, pain, muscle spasms, constipation, depression, anxiety, neuropathy, GERD, nausea/vomiting, hyperlipidemia, and R foot and coccyx wound.

The patient spent approximately two months in a rehab hospital, followed by two months in another SNF, then came to AVR four months after her admission to the hospital. She was six months post-CVA at the time of this intervention and was reaching a plateau with therapies because of difficulty regulating her emotions, which caused increased tone and aphasia.

As the therapists involved with the case brainstormed ideas to address the barriers preventing the patient’s progress, the patient’s ability to self-regulate emotions and physiological states came up as a common barrier that was limiting progress and functioning. At this time, OT learned about heart rate variability biofeedback and theorized that the patient might benefit from this intervention to facilitate self-regulation skills. She suspected that teaching the patient to control heart rate and breathing would help with emotional regulation as well as improving tone and aphasia, which would allow her to progress with her therapy goals and become more independent.

Literature Review

“Heart rate variability is a measure of the naturally occurring beat-to-beat changes in heart rate.” (McCraty et al 2004). When an individual’s respirations and heart rate are at an optimal frequency, this is referred to as coherence. Coherence is “the maintenance of a physiologically efficient and highly regenerative inner state, characterized by reduced nervous system chaos and increased synchronization and harmony in system wide dynamics” and “is conducive to healing and rehabilitation, emotional stability, and optimal performance” (McCraty et al 2004).

Research studies suggest that “individuals with brain injury and impaired self-regulation often display HRV patterns with reduced HRV” and speculate that interventions which address HRV “could directly enhance the ability to self-regulate.” (Kim et al 2015).

A study of individuals with severe brain injury found that there was an association observed between HRV coherence and improved emotional control, attention, life satisfaction, self-esteem and self-awareness and concluded that “HRV biofeedback has promise as an effective, cost-efficient method for improving self-regulation in individuals with severe brain injury” (Kim et al 2015).

An additional study of individuals with chronic brain injury found that there was an association between HRV training and the regulation of emotion and cognition and that “individuals with severe, chronic brain injury can modify HRV through biofeedback” (Kim et al 2013).

Intervention

OT facilitated seven treatments utilizing heart rate variability biofeedback training during a period of three weeks. Interventions were completed using a computer-based system that tracked heart rate using a pulse oximeter and created a visual representation of heart rate variability on the computer screen. The visual representation was in the form of a line graph and a bar graph, but the system also allowed for the feedback to be given in the form of a variety of games. This patient preferred to receive feedback through the games.

This intervention was used as a preparatory activity for ADL tasks such as toileting. At the beginning of this intervention period, intervention focused on discussion of toileting because toileting was a task that caused significant fear for the patient, resulting in increased tone, difficulty communicating and difficulty problem solving to complete the task.

As the patient improved her ability to modify her heart rate variability, intervention progressed to toileting in the therapy gym, then in the patient room and with her CNAs. Furthermore, as the patient became better at regulating her physiological states while using the program, therapists began encouraging her to apply the strategies during ADL tasks. For example, if the patient became upset or frustrated during toileting, the patient was encouraged to close her eyes and picture the biofeedback games.

Example of game available in emWave Pro™ program. As patient coherence improves, the rainbow extends to the pot of gold and gold coins can be earned.

Results

During the three week period after initiating the intervention, the patient showed improvement in the following areas of OT functioning: View here: HeartMath – Draper

As the efficacy of medical treatments increases, the average life expectancy has also increased. Geriatric populations are getting older. The life expectancy of a person born in the United States in 1900 was 49 years, which has significantly increased to 78.8 years as of 2014.

As longevity increases, an important factor to consider is an individual’s quality of life. Quality of life is multidimensional and has been measured by the CDC using the health-related quality of life (HRQOL) and the Healthy Days Measure.

The HRQOL measures quality of life considering physical health, mental health and an individual’s ability to perform activities of daily living (ADLs). Another questionnaire used by the CDC is called the Healthy Days Measure, which asks individuals how their last 30 days have been affected by different factors such as pain, sadness, anxiety, sleep and energy.

Studying the Happy Feet Effect

About five or six years ago, Pinnacle Rehabilitation and Nursing had a program called Happy Feet. Residents were brought to the nurses’ station, and then music was played while residents were assisted down the hall to the dining room, either walking or riding in the wheelchair according to their abilities. This program has not been implemented in the past four or five years.

At Pinnacle Nursing and Rehabilitation, we recognize the importance of quality of life and hope that the care the residents receive has a positive impact on their quality of life. The purpose of this study is to see if the implementation of Happy Feet will improve the residents’ quality of life and to see if the number of residents coming to the dining room increases.

To evaluate the effectiveness of Happy Feet on the residents’ quality of life, the residents were asked subjective questions from the HRQOL and Happy Days Measure prior to Happy Feet and then 30 days later. Initial surveys were taken the week of April 17, 2017, and ending surveys taken the week of May 22, 2017. Happy Feet intervention occurred Monday through Friday in the interim. Attendance in the dining room for brunch varies with changes in census.

On April 21, there were 12 residents in the dining room, and 10 regularly attended breakfast and would be in Pinnacle a month later. Of the 10 regular residents, eight were cognitively able to answer the first question and six were able to fully answer the questionnaire. Questions were asked such as: Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?

Results

Regarding general health of the eight residents surveyed, on average the health improved from good to very good. On average in each survey, the number of “not good” days decreased.

In the healthy days questionnaire, in all areas the number of unhealthy days also decreased. There was a significant change in unhealthy days related to pain, worry and amount of sleep. The last question asks how many days they felt full of life, and on average this amount went up from 11.7 to 15.8 days.

When the first survey was completed, 12 residents were attending the dining room, and after the second survey, there are now 16 residents at brunch in the dining room.

Conclusions

We cannot say definitively that we improved the quality of life of all the patients who participated in Happy Feet. However, on average, there was an improvement in all areas. Also, during Happy Feet, the residents were usually smiling or expressing that they were having a good time, the staff enjoyed having a change in their day, and we feel it improved the culture in the building. Additionally, the number of residents attending the dining room at brunch increased. Residents also reported that they enjoyed doing Happy Feet and would like to continue to participate in it on their way to brunch.

By Maresa Madsen, DOR, and the Pinnacle Therapy Team, Pinnacle Nursing and Rehabilitation, Price, UT

View Full Poster Here: Happy Feet Effect on Quality of Life – Pinnacle

At Parklane West, we posited the following problem/question: Would our physical therapy patients feel the Alter-G treadmill will benefit them long-term after the initial use? We hypothesized that they would, due to research about the Alter-G treadmill provided to each patient before initial use.

Project Overview

Our definition of initial use is that it follows completion of the first trial in Alter-G and is before the second use. Our population includes participants ages 65 and older, and we used convenience sampling to choose patients for the trials. All patient data was used; no data was discarded.

Patients were informed of the risks and benefits of using the Alter-G treadmill as well as the process of getting in and out of the treadmill. Visual demonstrations were given upon request. The patient tried the machine for a single trial before using it for multiple sessions.

After the initial session, patients were given a survey on whether they feel it would benefit them long-term, along with their personal subjective feedback after their first trial in the machine. Information was then analyzed.

Variables/Research

Controlled variables

• The same Alter-G machine is used
• The same survey is given to each patient
• The survey is given after initial use in the machine

Independent variable

• The amount of weight taken off the patient in the initial use of the treadmill

Dependent variable

• This might call for future research based on weight taken off
• Measurement will be on yes or no satisfaction rate

Materials

Survey for Initial Use in Alter-G Treadmill

Do you feel the Alter-G Treadmill will benefit you long-term after your first use? Circle one.

YES/NO/UNDECIDED

Explain why: __________________________________________________

Data/Observations

Fifteen patients agreed to participate and be surveyed following initial use and before second use. Here are the results:

• 11 felt it would benefit them long-term
• Two felt it would not benefit them long-term
• One reported nausea after initial use, two reported increased back pain after initial use, and another patient reported feeling confined
• Two were undecided

Results

• 73.33% felt the Alter-G treadmill would benefit them long-term after just one use, as indicated above by the blue area
• 13.33% of patients felt the Alter-G was not going to work in their rehabilitation process, as indicated by the green area above
• 13.33% were undecided, as indicated above by the yellow area

Conclusion

A majority of the patients participating in physical therapy at Parklane West felt the Alter-G treadmill would benefit them long-term. They came to this conclusion due to the elimination of gravity, which allowed them to extend the amount of time they were able to walk and to increase their speed compared to when walking with gravity.

Further research would need to be conducted to include follow-up surveys at one, three and six weeks of Alter-G treatment sessions to further justify initial research. In addition, further research regarding the amount of weight taken off in initial use will need to be conducted for comparison on satisfaction rates.

By Heather Smith, DPT, PT; Rosa Benade, COTA; Jennifer Henderson, OTR, DOR, Parklane West,

San Antonio, Texas