Thursday, December 24, 2015

Don't believe the hype -OR- Have you been lowballed? -OR- Clinician fulfilled prophecy

Bottom line: 
What the therapist predicted: very little
What the survivor achieved: a lot

Let me tell you about a stroke survivor I worked with a year or so ago. I'll call him "Sam."

I was working in a skilled nursing facility. The physical therapist (PT) did Sam's evaluation.  The PT then told me Sam would be added to my caseload. 

I read the PT evaluation and it was pretty shocking. One thing stuck out: The "long-term goals" were one thing: "bed mobility." 

There it was. The best that Sam was expected to do was to be able to roll around in his bed. He wouldn't be able to stand. And walking was beyond belief.

The day Sam was to have his first treatment I went to the nurses station to read his chart before I met him. Nursing facilities often have a cluster of patients in wheelchairs right around the nurses station. It's where all the action is.

As I began to read Sam's chart I asked one of the nurses to point Sam out to me. She pointed to a gent in a wheelchair. "That couldn't be him"- I thought. If he could not get around the bed, how did nurses get him in a wheelchair?  The nurse: "That's him. He came in yesterday." 

This was the guy who's long-term goals were "bed mobility."
That day he took his first step. Two weeks later he was lapping the facility several times, without an AFO, and beginning to walk outside. Yes, we were both a "hot mess" by the end of treatments, but it was fun. Sam would get called out by staff "Amazing! Keep going Sam! Lookin' good!" In fact, some of the folks with dementia thought it was some sort of conga line so by the end of our walk we'd have a parade! 

P.S: There may be several reasons for the physical therapist lowballing expectations. Maybe Sam was exhausted by the experience of being transferred from hospital to skilled nursing. Maybe his meds had changed. Maybe he was admitted so late that by the time the therapist got there he was asleep and the therapist had to wake him and he was very tired. 

Or maybe: 

Some clinicians are so concerned with deficits that they miss potential.


Tamara said...

Good point that some clinicians are too focused on deficits, they forget to look at potential. I feel the same thing has happened a lot in my case the last few years, with one physiatrist and my current physiotherapist as the exception. Most therapists seem to work with their own one size fits all model. But at 42 years old I'm willing to work much harder than someone 82 years old. I have so many good years ahead of me. And I don't want to live those with an ugly walker and orthopaedic shoes. I want to be a sexy survivor! :-)

Peter G Levine said...

I know! I agree... I just read this journal article that said that outcomes are much better for stroke the greater the number of survivors that come through the door of their facility. Some clinicians just don't have the experience to make the prediction relatively accurate. And my argument is that, that prediction actually effects the final outcome. i.e. If the PT does not think the guy will walk, the PT may waste days being cautious Vs. being more aggressive.

granny survivor said...

I suffered a massive right brain ischemic stroke. My husband was told I might die, but I was fortunate to qualify for the "new"miracle drug, T-pa. No one had ever survived the use of this drug at this trauma unit before, so the neurologists had no precedent for my recovery. They are ( were) car mechanics who had "fixed" my brain problem, my motor ability returned near 100% so they assumed very thing else was also cured. Therefore no one took into account my young age, my stubborn tendencies, etc. I was discharged in 7 days to my home with a general script for PT. no OT and no SLP, let alone any type of neuropsych evaluation. When I ran into brick walls cognitively, I didn't understand why I was having trouble. Just trying to organize my pills for the week exhausted me. I didn't know why. No one had considered the possibility of permanent brain damage in a stroke survivor treated with T-pa, so my concerns were dismissed as "female hormonal " problems and the neurologist referred me to my on/gym. I eventually became suicidal and deeply depressed. I found myself a LCSW and a psychiatrist, and began therapy or counseling. After 10 years of my own self designed rehabilitation program including participating in some musical groups and vocational training, I can now say, I think I am 95% back to my pre stroke abilities. No thanks to anyone but myself and my kind and empathetic husband and family.

Peter G Levine said...

granny survivor: sounds just about right!

Dogon Sirius said...

I was told by several therapists at the hospital that I would likely never walk without a cane, and one of those damned four pronged hospital canes to boot. Stuff that. Being fully able bodied has nothing to do with balancing and becoming centred. Now a year and a half later, you can barely notice my limp on a good day. I may even sometimes use a stylish cane I bought, despite it becoming a hindrance when traversing stairs, it's good to carry around a stick just in case you need to whack someone with it - ha!

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