Chronic Conditions and Self-Management

Many people at home or in long-term care have chronic conditions, often related to lifestyle behaviors. Regardless of whether these conditions are the diagnoses for which they are receiving physical therapy, the related activity limitations and participation restrictions can limit their abilities to participate and progress in their therapy. Chronic conditions can affect the person’s physical capabilities, as well as his or her emotions, attitude, and motivation. Many patients with chronic conditions or functional decline lead full and rewarding lives, but doing so requires the active participation of the patient and the physical therapist to maintain the fullest level of function despite the changes. The choices patients make about their health care, exercises, and methods of self-management will largely determine their health-related quality of life (Chapter 1).

Though people with chronic conditions have multiple impairments requiring adaptation of their lifestyles and schedules, the majority still accomplish what they want and need to do each day. The goal is to augment their knowledge about their symptoms and enable them to work within a collaborative, self-advocacy, and self-help model with their health care team to achieve optimal health. Positive self-management involves a combination of positive emotional outlook, active involvement in decision making, and maintenance of a lifestyle that is as optimal as possible. The interprofessional team needs to engage the patient in his or her care decisions. The physical therapist needs to be caring and fully present with the patient. Although the physical therapist can provide the initial stimulus for the process, effective self-management comes only from within the patient. The physical therapist can continue to be a resource and provide interventions as needed, but the goal is for the patient to be his or her own case manager and decision maker, whenever possible, regarding health care and optimal function (Chapter 1).^14,23

In the home or community setting, the person with a chronic condition needs to make several choices. How does he or she decide what will promote optimal function and health? What resources must be employed to meet these needs (e.g., a maintenance program), or does the person have the potential to improve to the extent that he or she can benefit from further professional services? Many people are discharged from the hospital without referral to home care or outpatient physical therapy to manage their chronic conditions. If they are referred to a pulmonary rehabilitation program, for example, what determines when they have completed the program? Financial support by private third-party payers and insurers is limited, influencing patients’ decisions about which avenues to use to move further toward optimal health. Do they go to a health club or the local YMCA? Do they walk in a shopping mall or take yoga classes? Do they continue to pay privately for physical therapy, continue with a long-term pulmonary rehabilitation program, or simply exercise at home? The answers are as different as the people making the decision about what optimal health is in relationship to their personal circumstances. At times it may be a matter of trial and error; perhaps the patient’s choice is not the same as that of a physician or other health care professional, but it is his or her decision and choice. A patient has the right to try, to succeed or fail, and make other decisions. He or she needs to know how to access the health care system if there are medical problems, and learning to do so must be an integral part of the patient education process.

Actively playing a role in decision making (i.e., self-management) empowers patients, making them more motivated, positive, active, and successful than passive patients who do only what the physical therapist and other health professionals advise.23,25 A decrease in the number of visits allowed by third-party payers has forced a necessary change towards patient self-management and empowerment, which has led to improved efficiency and effectiveness in treatment. The promotion of positive self-management strategies for a more active, healthy lifestyle is one of the most important competencies of contemporary physical therapists.

The physical therapist facilitates this process by being caring, supportive, and respectful of patient goals and priorities. This has been referred to as a “healing presence,” which may lead to a beneficial, therapeutic, positive experience for the patient.26,27 The American Physical Therapy Association promoted this practice philosophy with the phrase “the science of healing, the art of caring.”

Cardiovascular and Pulmonary Concerns in the Community

Patients with either chronic or acute conditions present with primary and/or secondary cardiovascular and pulmonary diagnoses at all levels of independence. Patients may have preexisting cardiovascular and pulmonary impairments such as asthma, hypertension, congestive heart failure, and comorbidities such as type 2 diabetes mellitus, obesity, and one or more types of cancer. Most patients will also have risk factors for one or more of these lifestyle-related conditions; thus risk factors need to be assessed and modified accordingly. Patients may have had problems such as hip fractures, joint replacements, CVAs, MIs, or some combination. The cardiovascular and pulmonary impairments related to the impairments and subsequent deconditioning associated with these conditions may be the limiting factor with respect to progression of physical therapy. These concerns need to be addressed so that the individual is able to reach his or her full rehabilitation potential.

One example is a patient with coronary artery disease, who is fully independent in his or her day-to-day activities but not at a maximal functional level because of limited education on how to further improve function. Another example is a patient who cannot resume his or her prior level of independent function after an acute bout of illness or hospitalization because of limits resulting from primary and/or secondary cardiovascular and pulmonary dysfunction. Both of these examples illustrate the resultant decrease in such patients’ tolerance for, and ability to independently perform, activities of daily living. Because of these decreases, patients must acquire continued support to maintain their safety and improve their level of function. Those with the least ability to care for themselves after an acute bout of illness transfer into nursing homes or alternative long-term care, and those with higher levels of function move into assisted living facilities or return home with assistance and therapy. Such patients may present with decreased strength, endurance, and balance, leading to decreased independence, mobility, and activity level. Returning home with a decrease in independent functioning may be associated with negative emotions, which may further decrease appetite, activity level, motivation, and social/community interactions (Chapter 1).

Nursing homes, assisted living facilities, and senior housing offer residential services for those who can no longer care for themselves. Some facilities offer multiple levels of care within one system, ranging from independent living apartments to skilled-level care. For residents who live in independent apartments when they are well, the facility can offer temporary increased support from a skilled level of care with physical therapy and nursing support upon discharge from the hospital. The goal is for the patient to return to the least level of care with the highest level of independence. Physical therapy services can be utilized at all levels of care to improve independence and tolerance for daily activities to improve patient safety in the community. Patients living in residential facilities should be screened periodically to determine their readiness to benefit from further physical therapy intervention and enable them to live to their fullest capacity.

Functioning depends on the ability of the patient to maintain all of the components of oxygen transport to support activity. One example is a patient who fell in the parking lot of a hospital where she had been attending a pulmonary rehabilitation program. She was fitted with a long leg cast and discharged home. She reported being short of breath with sit-to-stand transfers, and soon she was hardly able to ambulate across the room with the standard walker she used before. When the physical therapist observed this patient using her bronchodilator metered-dose inhaler, she was using it improperly. After she was instructed on how to use the bronchodilator therapy effectively before activity, the patient’s transfers and her walking ability improved markedly. She was able to coordinate her breathing with her activity, and her endurance further improved. Case reports and professional experiences such as this provide important information for the physical therapist to use in conjunction with the findings of research studies when planning and prescribing interventions for patients at home using evidence-based practice.²⁴

Long-Term Care Facilities and Nursing Homes

Practicing in a long-term care facility as a physical therapist opens up an opportunity to work with an interprofessional health care team to carry out therapeutic goals during other tasks of the day. Aides, generalist and specialist nurses, respiratory therapists, occupational therapists, speech therapists, dietitians, and on-call physicians all interact with patients each day and are able to remind and encourage patients to follow through on their exercise and activity goals. In order for this to happen, it is necessary to communicate the importance of the patient’s active participation throughout the day.

Therapeutic goals and treatment plans for patients should be designed with solicited input from the patient and family or significant other. Clear and achievable goals must be developed and revisited as the patient progresses or regresses in therapy. If the patient’s goal is to transition to a more independent living facility (i.e., home or an assisted living facility), then the plan would be more aggressive than if the goal were to maximize function within the current living facility. In order to achieve the patient’s goals, a holistic approach to care that is mindful of cognitive, psychological, and pathophysiological impairments should be used. As goals and interventions are determined, quality-of-life issues need to be considered in order to comprehensively address each patient’s needs. To increase patients’ ability to achieve their therapy goals, therapy sessions may need to be scheduled based on the time that is thought to be most efficient in relation to the patient’s medication schedule and other events of the day, rather than the most convenient time that fits into the therapy schedule.

The patient’s ability to participate in therapy may be driven by multiple system impairments. Nutritional concerns are a priority. It is important to monitor whether the patient is losing or gaining weight. Poor denture fit and the impact of medications on taste and appetite can affect the patient’s ability to eat. The patient may be depressed, also limiting appetite. The patient may not want to drink because of difficulty getting to the bathroom independently. Determine whether the patient is taking a diuretic and whether he or she has urinary incontinence. Patients who have difficulty managing urination because of frequency or urgency may be less likely to drink sufficient fluids, increasing the risk for hypovolemia, hypotension, decreased cerebral perfusion, and falls.²⁸

Patients with severe breathing problems, such as those with heart failure or COPD, can become extremely short of breath doing even such simple tasks as eating. Nurses and aides, as well as family and friends, can make observations about these occurrences. As much as 30% of can be attributed to labored breathing, which places considerable metabolic demand on the patient simply to breathe, let alone the challenge of pausing breathing to eat. A nutrition consult can be initiated to assess the patient’s caloric intake and supplement this intake if indicated.

Ineffective sleep can be a problem after surgery, trauma, or CVA. Multiple factors may be involved, but sometimes the problem is simply the fact that the required positions for sleep are driven by joint precautions or the need for joint and skin protection, rather than what is comfortable for the patient. Nurses and care staff can help by being receptive to positioning options that may increase the patient’s chance for effective sleep but that still meet the criteria for joint and skin protection. If the patient has difficulty waking in the morning or has headaches or difficulty following directions, sleep apnea or other sleep disturbances need to be considered. A wide range of issues—incontinence, anxiety, depression, chronic pain, a busy environment outside the patient’s door—may contribute to sleep deprivation and should be addressed.

Functional gains may be achieved sooner when physical therapy is incorporated into the patient’s daily living with the help of the nurses and aides. This can improve physical capabilities by aiding the learning process, as well as increasing the number of repetitions performed for motor planning. For example, if the patient is taught to use ventilatory strategies with movement, such as inspiring when extending the trunk (Chapter 23), this should be communicated to other caregivers and encouraged during movements that extend the trunk, such as dressing. If the goal is for the patient to walk to meals, the physical therapist and caretakers can have the patient transition from walking as far as he or she can toward the dining room for one meal each day, then walking to two meals each day, and finally, to all meals. The next progression would be to set more functional goals, such as walking to daily activities, to social settings, to the car, and so on; thus walking is no longer associated only with therapy. In-services for nurses and care staff that help reinforce physical therapy interventions can be conducted individually and in formal classes. Instruction can be incorporated into the staff competencies upon hire and annually. One-on-one therapist/aide education sessions should not be replaced by the competencies; rather, they should occur as needed when unique patient needs arise. Educational opportunities such as this can help to make patient education more consistent.

When all facility programs collaborate to follow through with therapeutic goals, the patient’s progress can be realized sooner. It may be helpful to make the activity department aware, for example, of patients who need extra time or help with oxygen in order to participate in activity programs. Events such as an open house for staff in the physical therapy department would allow staff members to visit and ask questions about physical therapy and to better understand what role they can serve. Offering educational materials about the physical therapy profession and patient information pamphlets may help the staff to better understand what physical therapists do for patients.

In many long-term care facilities, not all patients are on the present physical therapy caseload. Other staff members of the facility may have helpful input and suggestions for additional patients who may benefit from physical therapy. In addition to chart reviews and discussing patients with the staff, it is also helpful to screen for patients in the dining rooms, activity sessions, and halls.

Monitoring Cardiovascular and Pulmonary Status in the Long-Term Care Facility

Because of short hospital stays, patients in long-term care facilities may be less medically stable than patients in the past. With this increase in patient acuity, it is particularly important to monitor each patient’s response to activity. Many long-term care and subacute facilities now provide pulse oximeters and portable electrocardiogram monitors because of increased patient acuity. In addition, physical therapists need to be competent in monitoring blood pressure and heart rates. Auscultation is highly recommended as a clinical competency (Chapter 15). When patients present with acute changes in their status, it is important to utilize any methods of telemedicine available to communicate their medical status to their primary care practitioner. Telemedicine can range from a formal program for AICD-pacer monitoring, for example, to using a secure Internet connection to send video or audio portions of a physical examination.^29,30

During the initial evaluation, vital signs and oximetry are taken with the patient in supine or semi-Fowler’s position for baseline, then in sitting and standing positions if orthostatic measurements are indicated. It is helpful to take the baseline resting blood pressure readings on both arms to ensure they are comparable. The arm with the higher reading should be used for recording and monitoring. If the two readings differ by more than 10 mm Hg on multiple recordings, cardiovascular pathology needs to be ruled out.

Vital signs and oximetry need to be evaluated before each physical therapy session and after intervention to assess the physiological response to exercise. Blood pressure and pulse should increase proportionally in relation to the activity (Chapter 18). An increase of 20% to 30% or 20 to 30 beats above resting heart rate would be within normal limits, with a recovery time of 5 to 10 minutes. These responses can be affected by medication; therefore it is vital to know what medications the patient is taking and to understand their impact on the vital sign response.

Many patients without primary cardiovascular and pulmonary diagnoses have abnormal responses to exercise, either as a result of a preexisting but undetected dysfunction or a more recent change. Each patient must be observed closely and measured objectively to be sure he or she is responding to exercise predictably. One example is a patient who was markedly deconditioned and obese prior to total knee arthroplasty. After the surgery, with short distance ambulation, she demonstrated a dramatic increase in HR without arrhythmias, an appropriate blood pressure response, and an increase in the work of breathing and accessory muscle use. If only the heart rate or the blood pressure had been used to determine therapeutic intervention limits, the exercise response may have been misinterpreted. Patients’ response to exercise and intervention should be interpreted using their overall vital sign response. It is imperative to communicate the vital sign and exercise response to the primary care practitioner with as much information as possible to avoid inappropriate medication changes.

Physical Therapy in Home

Treating patients at home poses many challenges, one being the responsibility to help the patient return to the level of function before his or her illness. Gaining sufficient information from the prior level of care can expedite the care in the home. Some areas unique to home care are the need to continually assess and adapt treatment to the patient’s living space, observing and anticipating safety concerns, and identifying creative ways to improve the patient’s functional independence and quality of life.

Continuity of care is an essential component of quality health care, given the trend toward earlier and earlier hospital discharge. At minimum, acute care physical therapy addresses mobility, including safety, transfers, and household-distance ambulation as the patient recovers from an illness or procedure. Breathing exercises and positioning may be used in conjunction with functional mobility to facilitate movement and recovery. Patients are often unable to extrapolate their inpatient education to all of their home setting situations. Ideally, on discharge from acute care, patients should receive a home exercise program to help them with decision-making principles as well as exercises for them to perform. Decreased endurance due to recent insult/injury and bed rest during hospitalization and possible change in medication may compromise the potential of the patient to regain his or her premorbidity level of activity and function without appropriate follow-up care. A postacute exercise program designed for the specific needs of the patient and a complete review of the hospital stay should be communicated to the physical therapist in the community.

A patient’s successful recovery from acute or long-term loss of independent function is often dependent on the availability of able caregivers. Patients who have a caregiver to help them can discharge home, rather than to a facility. Caregivers are often family, friends, or paid workers who provide this service. Caregivers should be educated to measure vital signs and monitor for changes in physical status, appetite, and behavior as part of their responsibility as the caregiver. Children with chronic illness whose parents can provide care, with or without nursing staff, often return home successfully. These children tend to integrate smoothly into the community, attend school, participate in recreation, function well, and report a high quality of life. Adult sons and daughters are often the caregivers of their parents. In such cases, these adult children may have children of their own, whose needs they are responsible for. This “sandwich generation” is often torn between caring for their aging parents and for their own children.⁴ It is important for physical therapists to be sensitive to the needs of the patient and the limitations of the caregiver when determining the patient’s safety at home. Many older adult patients remain independent at home, some of them amazing even the most seasoned clinicians with their inventiveness and the extent of their support systems. The physical therapist serves an integral role in teaching patients and families how to manage the impact of disease and elevate each patient’s quality of life to the fullest extent.

Although a physical therapist makes numerous adaptations when treating patients at home, many physical therapy interventions performed in these settings are comparable to those prescribed for outpatients of similar ages and conditions. Activities to improve safety, strength, endurance, transfers, ambulation, and tolerance for activities of daily living (ADLs) are common, and often traditional methods such as supervised repetition of tasks (i.e., transfers and ADLs) are used as they would be elsewhere. Theraband products or nontraditional physical therapy equipment (e.g., water bottles as weights) may be indicated and prescribed based on the patient’s needs and abilities. For patients whose activity tolerance waxes and wanes as a result of their chronic condition, water bottles or similar household objects can provide an inexpensive and readily adjustable tool to meet the patient’s needs of any given day.

Education is especially important in home care. It can be directed to the patient, family, and caregivers and is especially important in ensuring the patient’s safe and independent functioning when the physical therapist is not present. Safety and medical issues can arise unexpectedly. Patients and caregivers must be familiar with the signs and symptoms that indicate a change in their condition (e.g., weakness, discomfort/pain, shortness of breath, changes in secretions, increased fatigue, inability to perform ADLs, depression, and loss of appetite). The physical therapist should gauge the patient’s and/or caregiver’s ability to interpret the medication schedule, understand the prescribed parameters for oxygen use, and recognize when to rest versus when to exercise. The therapist also needs to determine the patient’s ability to self-monitor his or her sign and symptom response to activity (Chapters 17 and 18) both during therapy and during independent activities. Patients and their caregivers need to be able to monitor their cardiovascular and pulmonary status to prevent overexertion and accidents. Because of potential limits in learning, it is important to check the reliability and validity of each patient’s self-assessments. Caregivers and family members can be taught how to monitor the patient’s blood pressure, heart rate, and respiratory rate; they can also be taught to observe for changes in shortness of breath, amount and color of secretions, presence of dizziness or lightheadedness, color changes such as cyanosis or flushed skin, diaphoresis, changes in balance during ambulation, and changes in mental status—and to report such changes promptly to the physical therapist or physician. Patients and caregivers need to know how to manage signs and symptoms, as well as when to call 911 rather than simply calling the physician’s office. If there are concerns about the patient’s judgment and reasoning, which may cause gaps in the patient’s learning, the physical therapist should adapt the education format accordingly.^14,31,32

Monitoring Cardiovascular and Pulmonary Status at Home

Because patients discharge to home in more acute states than they did in the past, physical therapists need to have a high level of clinical reasoning and measurement competencies commensurate with the needs of patients now being managed at home. Patients who are postoperative or who have had a recent decline in function may experience difficulty with breathing or endurance when performing ADLs. Without home-based physical therapy, the patient’s full return to their premorbidity status can be jeopardized.

In the home-care setting, the physical therapist tends to be independent without the advantage of the health care team close by, even though support is available through nursing and home-care agencies. The physical therapist needs to be prepared to evaluate patients and their progress with minimal consultation and information from the management team. This specialized practice area requires foremost that physical therapists have the ability to practice independently. They often need to handle emergencies and crisis situations. As in other areas of health care, home-care practice requires physical therapists to have annually renewed health provider CPR certification. Knowledge about policies and procedures for handling emergencies, infection control, and safety is essential. Home-care physical therapists evaluate the need for referrals to other health professionals such as social workers, nursing staff, and occupational therapy. Unfortunately, problems such as abuse and neglect are not uncommon, particularly in the older adult population; thus health professionals in home care must be alert for such evidence. If the patient’s condition declines or new conditions have arisen (for instance, the patient shares that he or she has been falling), the physical therapist may need to do preliminary medical screening and decide the appropriate intervention, including notification of the patient’s referring provider. The patient’s status needs to be monitored in relation to changes in diet, bowel and bladder habits, and mental status; such findings need to be included in frequent updates and reports to the referring practitioner. Home care is a challenging practice setting that requires astute clinical reasoning and observation skills.

By using equipment such as portable pulse oximeters (Figure 41-1) and blood pressure cuffs, along with physical examination (Chapters 6, 15, and 32), the physical therapist can do much to determine a patient’s ability to safely perform exercise in the home setting, although there are limitations to the depth of such monitoring and examination. In rural and underserved areas, limited resources may restrict the use of 911 service to life-saving situations only. However, with advances in communication technology, patients and home therapists can gain access to care better than ever before. Advances in chronic disease management in relation to acute changes in status, maintenance care to avoid acute conditions, and research into chronic disease impact and management have come as greater bandwidth has improved the quality of visual and auditory communication.²⁹ According to the National Research Council Report in 2000,³³ the Internet is often used for health information websites but is only beginning to be explored for its potential value in clinical decision making, patient education, and clinical outcome improvement—all possible because of the sharing of resources by professionals, “immediate” access to specialists, and more timely adaptations in medication doses, among other advances.

Multiple articles have found limitations in health literacy can decrease a patient’s ability to understand¹⁴ prescription instructions, exercise programs, and appointment schedules. For example, in independent studies, Harmon and colleagues¹³ and Sorensen and coworkers³² noted that patients often do not adhere to their antihypertensive medication prescription regimen for a variety of reasons: a poor understanding of the importance of the medication, limited symptoms of hypertension, and a dislike of the side effects, complicated dosing rules, and financial constraints. This underscores the importance for physical therapists to clarify whether and how patients are taking their prescribed medication; only then can therapists determine whether their patients are sufficiently medicated to safely participate in an exercise program. Furthermore, ongoing communication between patients and their prescribing clinician needs to be fostered on a more frequent basis than is available through office visits.

The use of webcams has great potential as a communication tool for monitoring home-based exercise. This emerging resource provides patients with access to specialists that physical distance may preclude while also allowing more frequent patient interviews than would be possible with only face-to-face meetings. Webcam interviews are more revealing than phone conversations because they convey the patient’s nonverbal, as well as verbal, communication. In this way, the webcam interview is similar to an office visit—perhaps even better because the patient’s level of attention, or inattention, to self-care can often be more evident when the patient is in his or her own home.30,34,35 Webcams can be used by physical therapists to access patients for review and upgrade of their home exercise program. In one study, pulmonary rehabilitation programs performed in an outpatient setting were compared with home programs with telemedicine access, and no statistical difference in outcomes was found.³⁶ Because of the convenience of the webcams, few patients in the study disliked them, but concern was raised about the potential for increased isolation. This concern would need to be addressed if webcams are to be used as a primary means of communication instead of face-to-face meetings. However, the use of a webcam in addition to vital sign response as a way of communicating a patient’s response to exercise can help the home physical therapist to advocate for the patient’s need for medical examination or medication adjustment more clearly than a phone call.

For patients with heart failure, the use of AICDs and biventricular pacemakers is more common because of advances in morbidity and mortality (Chapter 32). Emerging technology is available in some areas to allow the cardiologist not only to monitor a patient’s heart rate and rhythm, but also to measure discrete changes in fluid retention that are evident before activity-limiting symptoms.^37,38 Changes in a patient’s clinical examination, combined with interview questions regarding diet and bowel and bladder function, can help a clinician monitor changes in fluid retention and lab values. In cases in which a patient often presents with such symptoms, more sensitive monitoring should be used to better control the patient’s disease if possible. No data point stands alone, so even when advanced telemedicine options are available, the AICD-communicated data should be analyzed in relation to the physical examination and the patient’s interpretation of his or her symptoms.³⁹

Regardless of whether or not telemedicine resources are available, physical therapists must continue to use their clinical reasoning skills and their patient’s vital sign measurements and convey the information accordingly to achieve best-practice principles and to be the best advocates for their patients. An example that illustrates the importance of this concept involves a patient who was being monitored for his primary diagnosis post-CVA in a home-care setting. The patient demonstrated a new-onset profound fatigue and reported that his knees felt as though they would buckle. The patient had been progressing in his exercise program in each prior session without symptoms, but he had not been monitored. Once the patient expressed the feeling of weakness, however, the physical therapist recorded his vital signs at rest without symptoms and then again after the next walk with symptoms. The patient’s blood pressure and heart rate dropped during the exercise. The physician was informed of all signs and symptoms as they correlated to the activity and the new presentation of weakness, which prompted the physician to order a blood test. The results showed that the patient did not have an appropriate blood level of digitalis. Medication was adjusted and the patient’s signs, symptoms, and functional level improved. Had the physical therapist not checked the vital signs and instead continued to challenge the patient to work past his symptoms, serious consequences may have resulted. As another possibility, if the physical therapist had called the physician without objectively recorded signs to support the patient’s symptoms, the physician may have had insufficient information to determine the best course of action and the patient may have continued to be untreated.

Special Monitoring Considerations for Patients on Oxygen

Oxygen therapy is usually prescribed for hypoxemia (low levels of oxygen in the arterial blood) or to relieve myocardial work such as in cases of severe myocardial infarction.

Typically, arterial blood gases are drawn at rest with no patient activity (unless specifically noted, as in an exercise test with a blood gas), so it is not a likely resource to use in the home setting. Generally, Medicare guidelines specify that a patient with an SpO₂ of 88% or less during activity or recovery be placed on home oxygen. This value is on the steep part of the oxyhemoglobin dissociation curve (Chapter 4). Because oxygen consumption increases proportionately with exercise, a patient may desaturate if oxygen transport is compromised to the extent that it is unable to compensate or respond appropriately to increased demand (Chapter 18). For example, if a patient is on oxygen at rest and the SpO₂ is 90%, he or she may desaturate because the red blood cells need to give up more oxygen to supply the exercising muscle. The patient will be short of breath, and oxygen saturation recorded with an oximeter will be abnormal. A drop below 90% is of concern.

The pulse oximeter reading is an indirect measure of arterial oxygen saturation. For otherwise healthy people, this value is at least 97% at rest, and it is clinically acceptable to maintain oxygen saturation at 90% or higher. This saturation corresponds with maintaining PaO₂ generally above 55 mm Hg; below 55 mm Hg, a dramatic drop in oxygen saturation is associated with a small drop in PaO₂ (Chapter 4).

Best practice in physical therapy requires a pulse oximeter for patients at home or in other facilities. If the facility or home-care agency does not have an oximeter, the medical equipment supplier can provide one.

Patients on oxygen at rest need to have their arterial saturation assessed. Oxygen is a drug, and thus needs to be ordered and prescribed appropriately. The prescription should be written with sufficient flexibility so that it can be adjusted to the patient’s needs. A prescription is written to account for a range of liters of oxygen that is estimated to maintain a level of acceptable saturation. For example, the prescription may state to titrate the patient’s oxygen to 4 L/min to maintain SpO₂ over 90%. This is true even for people who retain carbon dioxide and whose oxygen is carefully titrated to prevent a suppression of the hypoxic drive to breathe. Strategies are used to limit risk for CO₂ retention and increase ventilation, thereby improving signs and symptoms and reducing risk for desaturation (Chapters 29, 30, and 43).

Though patients may have oxygen established by another professional before the therapy evaluation, it is important to review a few parameters with the patient and caregiver during the course of physical therapy. First, ask patients to tell you their actual oxygen use versus what was prescribed. Next, ask whether they were instructed to adjust the level of oxygen with activity and whether they know how to adjust the dose. If they do adjust the oxygen level, what criteria do they use to determine that they need to adjust the dose?³¹ Gaps in health literacy and awareness of risk factors can make it difficult for patients to manage their home oxygen safely.

Safety Considerations in the Home Setting

Any evaluation of a patient in a home setting involves an assessment of the patient’s home layout and safety concerns. The risk for injury is increased if a patient needs to perform household tasks that trigger signs and symptoms such as overexertion. Several questions can help establish ways of adapting a patient’s activity intensity and the physical environment, while also engaging the patient in decision making (Box 41-1). Home-care agencies often provide the support of a social worker to help patients identify resources available to them. A physician’s referral may be needed, and the service is generally covered under Medicare. Although these guiding questions are not exhaustive, they provide a basis for part of the assessment and evaluation.

Exercise and Activity at Home

For patients managed at home, the baseline tolerance for activity and exercise is often low, particularly in those with primary and secondary impairments of the cardiovascular and pulmonary systems. Establishing an exercise program with these patients can be challenging, especially when the patient is inactive or has attempted exercise before with unsuccessful or unpleasant results. Exercise is then less likely to be effective as a therapeutic intervention, and another approach may be necessary to address the patient’s need for increased activity for functional and health reasons.

The physical therapist needs to consult with the patient so that exercise is incorporated into daily activities and interests that the patient enjoys, such as playing with grandchildren, gardening, walking, or visiting family and friends (which may involve walking to and from the car, as well as several transfers).

The frequency and intensity of these activities may be minimal initially and increase commensurate with improvement in conditioning. The patient’s program is progressed accordingly in conjunction with feedback from the patient. Self-monitoring (perceived exertion and heart rate) and input from the patient should be encouraged. Some patients purchase their own oximeters and use them to monitor their saturation at rest and during activity.

The physical therapist ensures that patients can perform the exercises and ADLs safely and independently (with the appropriate device or caregiver support) while properly and accurately monitoring their own condition and modifying the intensity or distance appropriately with fewer and fewer prompts from the physical therapist. Once patients do this reliably, they or she can pursue activities of their choice, which hastens progression of therapy goals. Also, patients who actively participate in their own rehabilitation will more likely be effective in generalizing the skills learned to their daily life.

Home Oxygen

Home oxygen devices include oxygen concentrators, tanks, and liquid oxygen systems (Figure 41-2, A, and Chapter 43). Multiple extensions of oxygen tubing may be needed to enable patients to navigate throughout their homes—for instance, going to the bathroom, maneuvering in the kitchen, and walking to the living room (Figure 41-2, B). Although the presence of oxygen in the home is a safety concern that the home-care physical therapist needs to address, long tubing allows for proper oxygen delivery. Compensated flow meters measure the amount of oxygen that reaches the patient, and problems such as kinks are shown by a reduced flow reading. Some portable oxygen systems, particularly demand oxygen systems, may not deliver the amount expected (Figure 41-2, C). Thus a pulse oximeter is needed to ensure that the patient’s arterial saturation is acceptable. Patients are taught to coil the tubing or use a similar strategy to minimize the risk for tripping. To minimize the need for long lengths of tubing, some patients use more than one tank or concentrator.

Patients with sleep apnea may use nocturnal nasal continuous positive airway pressure (CPAP) (Figure 41-3) or biphasic continuous positive airway pressure (Bi-PAP), which provides varying levels of ventilator assistance at night. A Bi-PAP machine allows the patient to rest and assists ventilation by providing pressure support on inspiration and exhalation. The patient is encouraged to use the machine at night in particular. Although the patient may have difficulty adjusting to the nasal CPAP, he or she will adapt to the assistance and appreciate its benefits.

Documentation

Functional outcomes consistent with the ICF have become as important as outcomes associated with limitation of function and structure (Chapters 7 and 17). Both short- and long-term goals are linked to functional outcomes that enable patients to be safe and as mobile, functional, and independent as possible in the care setting in which they live. The Guide to Physical Therapist Practice (published by the American Physical Therapy Association) defines practice patterns within the cardiovascular and pulmonary areas to use as a reference to establish goals and treatment plans.⁴⁰ Goals for patients with cardiovascular and pulmonary conditions, primary or secondary, are typically more detailed than, for example, being able to walk a specific number of feet with a particular device. Goals should also include quantifiable measures of quality—for example, rating of perceived exertion, dyspnea scores, and demonstration of symptom management during functional tasks.

Documentation needs to show progress toward the functional outcomes that the physical therapist has developed with the patient. The cardiovascular and pulmonary systems need to be optimized for the patient to reach maximal outcomes. When functional outcomes are met, the patient is reassessed to determine whether he or she can accomplish more or whether active therapies in the home or long-term care setting need to be replaced with a maintenance program. Patients with chronic conditions should be reexamined periodically to determine whether changes in their disease warrant further therapy. Patients may also progress to a higher level of function that could be managed at an outpatient level of care.

Documentation is the basis for reimbursement. Third-party payers read therapist documentation to determine the examination findings, evaluation, and plan of intervention for the patient. These notes are their primary means of determining a patient’s overall status, including functional outcomes and quality of life. For patients who require long-term physical therapy, thorough and accurate documentation is vital to communication with third-party payers to increase the likelihood that patients will be able to receive the services they need. Teamwork that includes the patient in the decision making and goal planning has become a focus of optimal management in recent years.²³ Written and verbal communication is vital to the exchange of information and the targeted and timely progression of care to meet patients’ ongoing and often-changing needs. One rule of thumb must always be remembered: “If it wasn’t written, it wasn’t done.”

Support for People in the Home or Community

An important part of achieving optimal health upon returning home or settling into a new living facility is having the necessary social and emotional supports. Hospital stays or new functional limitations can often cause patients to think of themselves only as patients, solely defined by their medications, symptoms, and diagnoses. Family and friends can help prevent this. Close social ties help to keep patients connected to memories and situations that define them as individuals.

Support can also be found with people who have similar diagnoses or limitations. Support groups and networks are often formed in the community and, increasingly, on the Internet. Such groups can be important resources for patients, regardless of the support they receive from family and friends. Peers in these groups may be the only people who fully understand what the patient is going through; support from these peers, as well as the opportunity for the patient to support others in return, can help inspire physical and emotional gains.

Peer groups, in person or over the Internet, can be valuable resources to help patients with chronic conditions make choices concerning their health and life situations.41–46 Many websites and blogs offer free information or may request a nominal fee for membership for patients, health professionals, and supporters to receive newsletters and information in the mail. They host grassroots efforts such as conferences and informational sessions on self-care management and patient empowerment. These support groups publish newsletters that discusses research and provide tips from people living with chronic conditions to help share evidence-based information. These organizations inform people that they are not alone and steer them towards resources that can help with decision making as they strive for optimal health.

Many patient-friendly websites are available for people with COPD and other common chronic conditions, all of which are easily accessed through various search engines or by exploring the links sections of related websites. Box 41-2 lists examples of websites that may be helpful to people with chronic conditions and their families or caregivers.

Therapeutic Goals for Home-Care Patients with Cardiovascular and Pulmonary Dysfunction

To be independent at home, patients with cardiovascular and pulmonary dysfunction should strive toward achieving all of the following:

Summary

The physical therapist can promote optimal health for patients with chronic and short-term illnesses who live in various community settings. A patient’s path to optimal health involves patient education on effective methods of self-monitoring during activity, adherence to medication regimen, and use of multiple available resources to achieve a higher functional level. Education methods using shared decision making²³ can improve patient risk factor reduction, nutrition, and overall functional level more effectively and efficiently than methods in which the patient is not actively part of the solution. People living with chronic conditions can live more safely and independently at home if given sufficient education in a format in which they can understand the goals and expectations before them. As health professionals, physical therapists recommend modifications of patients’ home environments and offer tools to use to best achieve their functional independence and fit their lifestyle based on the best available research. Patients’ participation in such recommendations is vital to improve the degree and longevity of their progress toward optimal health. If patients are to be successful in living independently in the home setting, they need to be independent in their judgments and activities. Physical therapists must respect patients’ choices and decisions, while sharing their own experience, therapeutic judgment, and expertise. The home setting can be a particularly rewarding practice experience, although at times it can be challenging. One thing is certain—if you ask a patient where he or she wants to be, the answer is almost always the same: “There’s no place like home!”