By Tracie Hunnicutt, MS, CCC-SLP; Julie Clement, OTR; and Susan Adix, PT
Patients enter inpatient rehabilitation facilities for countless reasons, but always share a common goal—independence. Each patient may define independence differently, but the ultimate goal for all is to recover function in the skill sets that allow them to return to their chosen activities at home or in the community. The foundation for successful recovery of function is task specificity. Research has shown that physical rehabilitative therapy focused on task-specific training produces more meaningful functional improvements than therapy based on high-intensity repetitive exercise alone.1 This is true regardless of age or diagnosis, and is particularly relevant for patients who are recovering from a neurologic event. When the neurophysiologic goal is to impact plasticity, it is critical that the activities chosen for therapy are the very same activities that patients will be returning to at home or in the community. Task-specific practice results in greater cortical representation and reorganization in recovering neuro patients.1 In patient populations other than neuro, task specificity may not be necessary to impact plasticity, but can and will incrementally improve both patient performance and confidence.
Functional therapy begins with a skilled therapist invested in developing an individualized care plan suited to the patient’s needs and interests. The joint nature of the care plan should start during a thorough patient history, where both skill and intuition are necessary to identify what is important to the patient, and what therapy tasks can most closely resemble the patient’s desired activities. Physical therapists, occupational therapists, and speech language pathologists all spend a large portion of their work day adjusting tasks or manipulating the surrounding environment to simulate a patient’s home and community activities. This can present a challenge during the inpatient portion of a patient’s recovery in both acute care and inpatient rehabilitation settings, which are hospital-based and designed with patient safety and ease of function as priorities. The contrast between what the environment demands from a patient in a hospital versus the demands of home and community is vast, and can be a surprise and a risk to patients who are not prepared.
From this clinical need arose a new treatment tool—Realistic Environment Applied Learning, or REAL Therapy. REAL Therapy is a community simulation environment with ready-made functional therapy tasks available to patients and clinicians from the moment they enter the room. Because the environment is task-specific, and does not require modification by the therapist, the entire time spent in therapy can address the physical and cognitive demands of real-life activities performed by the patient. REAL Therapy is comprised of various modules that each have a unique clinical focus. Modules were designed to address some of the most common community-based locations patients visit upon discharge. Available modules include a grocery store, restaurant, deli, laundromat, and a car transfer/gas station area.
The grocery store module is the most versatile and commonly used area of REAL Therapy. Opportunities for functional therapy tasks abound, and physical therapists, occupational therapists, and speech pathologists alike utilize this module daily because of the variety of tasks that can be performed. The grocery store includes standard grocery shelving with a height of 72 inches, stocked with realistically weighted items. There is an area with fruit and vegetables that must be hand selected and weighed, as well as a bakery. A freezer with cold storage contains commonly refrigerated items. There are shopping carts and baskets, a working checkout counter, a register, and an ATM.
Some of the common physical tasks include dynamic balance activities such as pushing a shopping cart, carrying a shopping basket, reaching for objects on high shelves, reaching for objects on low shelves, reaching for objects at the back of shelves, opening the glass door and selecting items from cold storage, picking up heavy or bulky objects, retrieving items from a shopping cart and placing them on the checkout counter, bagging items, and carrying bags out of the store. Some of the common cognitive tasks include creating and executing a shopping list, locating difficult-to-find items, reading labels, calculating totals, money management, operating a credit card machine, staying within a budget, using memory strategies to recall short lists of items, and identifying obstacles and safety hazards.
This module is used frequently because it represents an essential community location that up to 84% of geriatric adults visit regularly.2 Community-based locations specific to food and medical care are among the most commonly visited sites for older adults. Therefore, task-specific practice with a skilled therapist is likely to be a precursor for greater success and safety when patients are functioning in these locations post-discharge.
The restaurant is another module with a variety of applications depending on the patient’s individual needs or preferences. There are various settings within the restaurant, each with its own challenges to the patient. There is indoor booth-style seating for one table and outdoor seating/patio furniture for another, complete with a table umbrella.
Physical tasks for this module include getting into and out of a booth with limited space, pulling out chairs to sit down and repositioning closer to the table once seated, raising or lowering the table umbrella, reaching across the table to receive food from a server, and identifying a space to place any necessary assistive devices (ie, walkers, wheelchairs, canes, etc) while at the table. Common cognitive or communication tasks for this module include reading a menu, making menu choices that consider dietary restrictions or special needs, communicating with wait staff, verbalizing an order, participating in conversation and socialization during a meal, estimating a bill, calculating a tip, completing and signing the check, and time management.
The deli module includes a glass-faced display case from which patients can view and select their food options. There is a metal tray line in front of the display case followed by a drink and condiment station. This module demands more from the patients from a mobility standpoint, and is less flexible in terms of the ability to modify the physical tasks that can be performed.
Common physical tasks for the deli include standing and reaching into the display case to obtain food, placing items on the tray, pushing the tray down the line as it gains an increasing amount of weight, moving the tray to the drink station, obtaining the desired drink and condiments, carrying the tray, and getting into and out of seating. The deli has an elevated barstool-type seating area, and the restaurant module seating may also be used. Where the deli lacks some flexibility in physical modification of tasks, it is particularly useful in the patient’s ability to problem-solve in a challenging, less forgiving environment.
Cognitively, the patient must determine if he or she has the ability to perform the necessary tasks, or if it would be safer to request help with the physical components of this setting. Elements of the deli environment, such as bilateral upper extremity use to open the case and obtain the food or propelling and carrying the tray, may require the assistance of another person, as they cannot be easily modified. Cognitive tasks in the deli include visual scanning, sequencing food choices (ie, salad, main dish, dessert, drink), making food choices that are compliant with dietary needs, estimating cost, money management, and identification of barriers or safety hazards.
The laundry module can represent a community-based laundromat or a home-based laundry room. This module includes a top-loading washer, a front-loading dryer, an ironing board, and an elevated folding table that also has a place for hanging clothes. Common physical tasks in the laundromat include picking up large piles of both wet and dry clothing, picking up heavy containers of detergent or fabric softener, loading and removing clothing from the washer, bending to load and remove clothing from the dryer, carrying a laundry basket, folding clothes, ironing clothes, and hanging clothes. Common cognitive tasks in this module include sorting and organizing clothing, calculating how much detergent or fabric softener to use, and time management. If this module is being used to simulate an actual laundromat, there is an available change machine to include the money management portion of the activity.
Car Transfer / Gas Station
In addition to the grocery store, the car transfer/gas station module is one of the more frequently utilized areas of REAL Therapy. Safe and effective car transfers are often one of the keys to a patient’s continued community involvement, as well as access to necessities and medical care following hospitalization. The inability to perform this task has been linked to decreased quality of life, increased burden of care, and the possibility of institutional living.3 In certain patient populations such as spinal cord injury, correct execution of car transfers is even more critical to prevent pain and injury that could compromise a patient’s overall independence.4 The REAL Therapy module features a car transfer simulator. The simulator is the front end of a car, with working doors, handles, locks, seat belts, bench or bucket seats, gas pedal, brake, steering wheel, and a behind-seat wheelchair loading area. The car simulator is height adjustable, so that therapists may match the simulator to the type of car, truck, or SUV utilized by each patient.
When utilizing the car simulator, patients must perform a variety of physical tasks that include approaching the vehicle, opening the car door, getting into proper position for the transfer, turning and lowering themselves into the car seat, bringing their legs into the vehicle, repositioning in the seat if necessary, and buckling the seat belt. One of the more challenging aspects of car transfers is the management of assistive devices during the transfer. Patients who are learning to get in and out of a vehicle often need and depend upon assistive devices, but find that there is limited space between the car door and seat. They require instruction from a skilled therapist for proper placement and utilization of devices such as wheelchairs, power wheelchairs, walkers, hemi-walkers, canes, sliding boards, crutches, etc. Another aspect of managing those assistive devices is ensuring that the caregiver or family member is trained and able to lift and/or stow the devices in the car. The car simulator has behind-seat space specifically designed for practicing this skill. Caregiver training for proper body mechanics will help prevent both injury and broken equipment.
The simulator also has the ability to assess the driver’s brake reaction speed with a reaction time tester. Drivers are given instructions to attend to an illuminated light box with red and green lights. As the green light changes to red, the timer starts and the patient depresses the brake. Reaction speeds are generated and may be compared to age and gender norms as a means of basic biofeedback to the patient. Information from various studies has revealed that in some patient populations, reaction time is a useful metric in determining when it is appropriate to return to driving.5 While this decision is ultimately made jointly by the physician and patient, the data generated by the reaction time tester can be valuable information and a means to build insight and confidence for patients and families.
Other elements included in the car transfer/gas station module are an ADA-compliant flooring surface that simulates asphalt, a 6-inch curb typical of those found in parking lots, and a weighted gas pump.
While the benefit of REAL Therapy for patients is clear, the group of people who may be the most invested in REAL Therapy are the rehabilitation clinicians. The amount of time they spend trying to modify the environment to suit the needs of each patient can become direct patient care time. There are also endless possibilities of treatment ideas, so there is less time spent planning and organizing, and more time spent doing. REAL Therapy also removes the necessity of explaining to the patient how the therapy tasks they are doing are applicable to their real-life activities, as the connection is very clear. Rather than moving weights on a shelf to simulate groceries, the patient walks into a grocery store. Rather than move from one chair to another, the patient gets into a car. This immediately makes sense to the patient, increasing their buy-in and willingness to work with therapy.
REAL Therapy is the manifestation of a treatment philosophy that focuses on returning a patient to function. With the move to shorter lengths of stay across all healthcare settings, it is important that physical rehabilitation therapists immediately focus on the patient’s desired activities and begin task-specific training as early as possible. In addition, the evidence base supports functional, task-specific training to achieve better patient outcomes and perceived independence. When used in conjunction with a protocol for therapeutic patient outings into the community, there is an even larger impact on patient confidence and ability. As the rehabilitation industry and we as therapy professionals move forward, REAL Therapy and functional, task-specific treatment may be the key to efficient service delivery and excellent patient outcomes. RM
Tracie Hunnicutt, MS, CCC-SLP, Therapy Manager, received her training as a speech-language pathologist at Texas Tech University Health Sciences Center. The early part of her career was focused on the care of traumatic brain injury (TBI) patients with an emphasis on community re-entry. From this setting, she developed a strong foundation in functional therapy as a tool to return patients back to school, work, community, and home activities. Hunnicutt is currently a medical speech language pathologist in inpatient rehabilitation at HealthSouth Rehabilitation Hospital of Arlington.
Julie Clement, OTR, received her training in occupational therapy at the University of Texas Medical Branch. She specializes in helping patients increase independence with Activities of Daily Living (ADLs), functional mobility, and Instrumental Activities of Daily Living (IADLs). Clement is a Neuro-IFRAH certified therapist, and has completed more than 200 hours of continuing education related to neurological evaluation and treatment. She has been the OT Team Lead at HealthSouth Rehabilitation Hospital of Arlington for the past 12 years.
Susan Adix, PT, received her training as a physical therapist at the University at Buffalo. She began her career in outpatient physical therapy at HealthSouth Arlington, working primarily with orthopedic and neurologic patient populations. In 2006, Adix transitioned into inpatient rehabilitation, where she focused her professional development on the care of neurologic patients. Adix has assisted in the development of the REAL Therapy Gym and is currently the PT Team Lead for a staff of more than 30 physical therapists and rehabilitation techs. For more information, contact [email protected].
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