The Opportunity of Being a Fitness Forward Clinician in a Hospital Setting

Dr. Julie Brauer // #GeriOnICE // www.ptonice.com

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Julie Brauer discusses workout ideas for acute care patients, including those who are confined to bed, able to move at the edge-of-bed, and those who can transfer & ambulate with assistance.

Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog.

If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

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JULIE BRAUER Good morning crew. Welcome to the PT on ICE daily show. My name is Julie. I am a member of the older adult division. Excited to be talking to you all this morning about a few workout ideas for your hospitalized patients. All right. So what we're going to dive into this morning is first, we're going to talk about why it is so incredibly important to bring a fitness forward approach to our medically complex sick older adults in the hospital. and then we're gonna dive right into how to do it. So I am going to give you three different workouts. They're simple. They only consist of three exercises and they're going to be for three different individuals. FITNESS FORWARD ACUTE CARESo the individual who is the bed level patient, so they are not ambulating, they are not transferring. Then I'm going to give you a workout for the individual who can sit edge of bed, so who can tolerate those positional changes, but again it's not someone who is transferring or ambulating. And then lastly for the individual who is able to transfer out of bed. Okay, Let's dive in. First and foremost, team, what I think we can all agree on is that patients are being sent home sicker and sicker and sicker. Insurance is denying acute rehab left and right. And once patients do make it to acute rehab, if they're lucky enough to get there, they're only getting enough days to just barely make them functional. We have to agree that these patients need to get as strong as possible and they need to do it as quickly as possible. If we can agree on that, then we have to realize the massive opportunity we have in the acute care setting to bring a fitness-forward approach. Now, I know what a lot of you are thinking. Fitness in the hospital What the heck? No way. It doesn't belong there. I don't have the equipment. They're too sick. That's for down the road. I want you to come along with me and get a little curious. I want you to be open minded and perhaps shift that perspective. Think about it this way. You are a fitness forward clinician. You are working in the hospital setting. You have hundreds and hundreds of patients handed to you on a silver platter. All these patients are in one place, door after door after door, literally right in front of your eyes. And they are just waiting for you to walk in, inspire the hell out of them, and guide them to the land of wellness and fitness. You do not have to hope that these patients who need you walk into your clinic doors. You do not have to hope that your Facebook marketing or your Instagram post is seen by your target avatar. They're all there waiting for you. You literally have a captive audience. Literally, these patients are in their hospital rooms. They are in their hospital beds. They have alarms on. They are tied to lines and tubes, et cetera. They're all there at your disposal. Team, the patients who need you the most, the ones who are medically complex and sick, They are waiting for you. They are handed to you on a silver platter in the hospital. Do not waste this opportunity. We have to realize that ankle pumps and glute sets, walking to the door and back, doing 10,000 tenettis a day, are not going to get the job done. Those are not going to increase our patient's reserve and resiliency, so they don't end up back on your caseload in a week. Fitness forward therapy is absolutely critical for these sick folks. Okay, so we've gotten curious. We're starting to shift our perspective. The most important thing that comes next is, well, how the heck do we do it? So let's dive into three different types of workouts we could do. WORKOUTS FOR BED-LEVEL PATIENTS Workout number one, this is going to be for your bed-level patient. So this is an individual who is in the ICU, perhaps, or they are in inpatient rehab. They cannot tolerate positional changes. Maybe their vitals go totally wild when they try to sit up. The alarms are going off, the nurses are running in. Vitals go wild, you gotta lay them back down. Perhaps they're incredibly orthostatic when they do sit up. Their blood pressure absolutely tanks, and you have to lay them back down. or they may have significant fear or pain. They just refuse to get out of bed. Hell, this could be the patient who, you know, your last session should hits the fan. You went way over time and now you have barely any time with this human. You do not have the time that it's going to take to get this person up and out of bed. Okay, so think about a couple of those scenarios that you may walk in to your patient today and this perfectly fits that description. This workout is for them. Okay, so what are we going to do? This individual supine is pretty much all they got. The bed is all they got. What we're gonna do is turn that bed into a workout machine. The hospital bed turns into a home gym. What do you need? You need a Sally tube slide. So what is that? You've seen them if you've been in the hospital. They're yellow, they're plastic. Individuals and the staff will use them to transfer patients because it decreases friction. You need that and you're gonna need a wedge or a slide board. and a gait belt. So three pieces of equipment, sally tube slide, a wedge or a slide board, or and a slide board, and a gait belt. Okay, so what are the three movements that we're going to do? We are going to do a modified pull-up, we are going to do a modified leg press, and we are going to do a modified rope climb using the gatebell. Okay, so how do we set this up? You get that sally tube slide underneath them. For our modified pull-up, you're going to tilt the bed. They are going to reach to the bed rail that's above their head and they are going to pull themselves up. That sally tube slide is going to allow them to slide and we're going to add some gravity onto them so we get them to a degree of a vertical pull. For our leg press, you're going to set that on the slide board, sometimes the wedge on top of the slide board at the bottom of the bed. We're going to tilt that bed again. They are going to kick and press to do a leg press, and then they'll slide back down, and then they push again, slide back down, etc. For our rope climb, you're gonna use that gait belt. You're gonna tie it to the foot bed rail. You're gonna tie that gait belt on there, and then they are going to grab onto it. They are going to pull themselves as much as they can to get to an upright, long sitting position, and then slowly let themselves down. Okay, so that's how those three exercises with the equipment are gonna be set up. Now, how do we dose this? Remember, this is an individual who has very low tolerance. We are just trying to get that blood flowing. We are trying to do very short bouts of activity and they're going to need a lot of rest. So how I would set this up is an EMOM, maybe an EMOM for six or nine minutes. Minute one, we're going to do that pull-up. I'm going to have them work for 20 seconds, and then I'm going to give them a full 40 seconds of rest. What am I doing during that time? Taking their vitals, right? Watching to see that they are responding okay to the exercise. I'm going to want to know what their blood pressure is, their heart rate, their oxygen saturation. Minute two, they're going to do that leg press, 20 seconds, and then they get 40 seconds of rest. And then lastly, they're going to do that rope climb for 20 seconds, 40 seconds of rest. What is beautiful about a workout like this is that many times what you will find after you're able to increase the intensity with them in the bed where their vitals are staying at a reasonable level, they're not going wild, then you sit this individual up and you will find all of a sudden their blood pressure actually stabilizes here. And now they're someone that you can safely get out of bed. Okay, there's your bed level workout for that individual. WORKOUTS FOR EDGE-OF-BED Next, now you have someone who can tolerate a little bit more. We're going to do a combination of a bed level exercise and sitting edge of bed. So they can tolerate positional changes. This is for that patient who can transfer out of bed, but it totally exhausts them. One rep and they're absolutely toast. This is for the patient who you know would thrive at acute rehab, but you really need to build their tolerance. You need to be able to say to those acute rehab liaisons, hey, this patient can tolerate multiple sessions of therapy per day. So we're going after endurance here. All right, so what do we need for this one? We need a heavy TheraBand or a resistance band. And that's it. One piece of equipment. So what we're going to do is we are going to do a AMRAP here. A 15-minute AMRAP. As many rounds as possible. Three exercises. Why are we doing that? Because we want to show, hey this individual tolerated 15 minutes of non-stop work. What are our three exercises? First, we are going to do a resisted bridge. How do you set up a resisted bridge in a hospital bed? You take your TheraBand and you anchor it one side of the bed rail to the other side of the bed rail. Now, when they go to bridge up, they have some resistance there. You can do it double leg, you can do it single leg. Exercise number two, we are going to do repeated supine to sideline to sit transitions, all right? And then exercise number three, while they're sitting on the edge of the bed, they're gonna scoot laterally to the foot of the bed and then to the head of the bed, okay? So those are your three exercises. How are we gonna dose this? Again, the goal is endurance. So we want them to be doing only enough repetitions to where that RPE at the end is only like a four to five. We don't want them to be seven, eight, nine. Remember this is endurance we want them to be able to sustain for 15 minutes total because that is going to be the buzzword that helps get them to acute rehab. So for that entire 15 minutes you're going to do as many rounds of those three exercises and you're going to try and keep the rep scheme to as many that keeps that RPE about four to five. That you're going to go ahead and document about why this person is perfect for acute rehab because they can tolerate 15 minutes and then you are going to progress them from there, try and get to 18 minutes the next time you see them and then get to 22, etc. Okay, that's your second patient.

WORKOUTS FOR AMBULATORY PATIENTS The third patient, this is an individual who can transfer out of bed all right so they only need a little bit of help they can transfer out of bed but when they get really fatigued their can their performance is really inconsistent so this may be where the physicians or the case managers are like hey they can transfer out of bed like they're high level, they can go home. But you know that when they get fatigued, their knee buckles, or they really lose that eccentric control, their balance starts to go out the window. You know they need acute rehab in order to improve their tolerance so that they are able to do safe transfers throughout the day. Mimicking when someone throughout their day is going to have high and low levels of fatigue, you want to know that that consistent performance is safe. So, what are we gonna do here? In this workout, what we're gonna do, three exercises, we're gonna do an overhead press, a standing march, and then a stand-step transfer, okay? So that overhead press, what do we need? You are gonna get that toiletry bucket that every patient is given, you're gonna dump all the crap out of it, you're gonna take a towel, you're gonna roll it up, you're gonna soak it in water. That makes that toiletry bucket now have some load. This is what we're going to use for the overhead press. It's going to be done sitting on the edge of the bed. Next is going to be the standing march. This can be a standing march that doesn't have any load to it. You can have your arms on the walker for upper extremity support or you can use something like a bedside commode bucket. clean that you put a bunch of weights in like ankle weights load it up and they can do a one-handed uh carry or a hold while they march okay and then with the stand step transfer you just need their assistive device and a chair set up next to the bed all right so in This type of workout, what we are wanting to do is we are wanting to really increase the intensity of those first two exercises, the overhead press and the standing march, and then have them do the transfer because we want to show Hey, this is what it looks like when this person is under fatigue and then tries to do a transfer. You want to prove to those acute rehab liaisons, balance gets really poor. I have to jump in and I have to give them some support in order for them to not lose their balance when they do that transfer. So you're showing the deficit here. So in those first two exercises, you want intensity to be really high. So comparatively to our first imam, it's going to be the same exact thing, but work and rest is going to be reversed. So you are going to have them work for 40 seconds, and then you can give them only 20 seconds of rest. and that 40 seconds, you want it to be sprint effort, okay? You want them to be working at RPE 789. You want them to really, really push it. So similarly, you can do this for 6, 9 minutes, 12 minutes, 15 minutes, and the goal here is that when they get to that stand-step transfer, they're under fatigue, you are going to see what happens. Then you can document and show acute rehab, hey, This is all the assist that they need. This is how their technique breaks down when they are under fatigue. That is going to be the buzzword that you're going to be able to use to advocate for them to get to acute rehab. You're going to also use that and progress them to just try and build that endurance. So let's say acute rehab is still like, screw you, we're not letting you in. Now you have a baseline workout. You continue to hammer in on improving their endurance so that when they get to that transfer, they have stability. SUMMARY All right, three workouts for you. That bed-level patient who cannot get out of bed, supine's all you got. You turn the bed into a workout machine. You got your second workout for that individual who can tolerate transfers, transitionals, and can get to that edge of bed. And then the third, you got a workout for someone who is able to get up and transfer out of bed. I have multiple reels that I've made about each of these individually. I'm going to put them together and post it. You will have that soon so you can get a visual of what all this looks like with my actual patients. And I cannot wait to hear how you guys use some of this stuff out there in the clinic this week. All right, to finish this off, we've got courses coming up. We want to see you guys out on the road. We would absolutely love to see you. We got tons of spots left in Missouri. That is this weekend. Alex will be out there. That course is going to be absolutely amazing. We got multiple courses coming up in February. I will be in Minnesota. It's going to be a freaking blizzard. I cannot wait. And then our online courses are going to be starting up in March. So we'd love to see you online or on the road. All right, y'all, that's all I got for you. Get out there, bring that fitness forward approach to your hospitalized patients. I cannot wait to hear about it.

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