HPFW CLASS NOTES.docx

Week 1: Theories, Vitals

Health Belief Model:

• Taking action on a health behavior depends on individuals perceptions of its cost and benefits
• 6 constructs
  • Perceived:
    • Susceptibility, severity, benefits, barriers
  • Cue to action
  • Self-efficacy (health motivation)

Transtheoretical Model:

• 5 stage cyclic stages of behavior change

Preparation: within 30 days planning

Action: doing it for at least 6 months

Social Cognitive Theory:

• Learning occurs in a social context
• Behavior is influenced by personal, environmental, and behavioral factors
• 5 primary constructs:
  • Psychological determinants of behavior
  • observational learning, environmental determinants of behavior
  • self-regulation
  • moral disengagements (following)
  • (perseverance)
• 4 methods:
  • Mastery experience (sternest, set your patient up for success. Have your patient do something they feel confident in- achieving small goals. Mastery in their life while achieving things
  • social modeling (mentorship, addiction recovery, if someone did it, you want to too)
  • improving physical and emotional states (can you do something to make someone sleep/feel better, help someone with fatigue by making sure they sleep well- performance will go up)
  • verbal persuasion (least strongest, saying that someone should exercise)

Self-determination Theory

• Meeting basic human needs: competence, autonomy (free will, involved in decisions- give then a choice, helps motivation), relatedness(feeling connected) - facilitates behavior change
  • Motivation
    • Intrinsic (personal reason, what you really want to do- more powerful
    • Extrinsic (rewards, prize money)

Resilience Theory

Pain:

• Pain is an unpleasant sensory and emotional experience
  • It is whatever the patient says it is and exists wherever and whenever the patient say it does
• Self-report: of pain is the most reliable indicator or pain
• Each patient should be screened for pain on admission and asked is they have pain
• A pain screen is a quantitative rating of intensity of pain and is reported using a standardized instrument that has demonstrated reliability and validity

Week 2

Unit 2: Healthy People 2030 and moving, Pre-Post-exercise vitals

Prevention:

• Chronic conditions are often attributed to behaviors

Health:

• A state of complete physical, mental and social well being-

Healthy people 2030

Vision:

• A society in which all people can achieve their full potential for health and well being across the lifespan and live long, healthy lives

Mission:

• To promote, strengthen and evaluate the nations efforts to improve the health and well-being of all people

5 goals for Healthy People 2030:

• Attain healthy, thriving lives and well-being, free of preventable disease, disability, injury and premature death
• Eliminate health disparities, achieve health equity, and attain health literacy to improve the health and wellbeing of all
• Create social, physical and economic environments that promote attaining full potential for health and well-being for all
• Promote healthy development, healthy behaviors, and well-being across all life stages
• Engage leadership, key constituents, and the public across multiple sectors to take action and design policies that improve the health and well-being of all

355 core objectives divided into 5 topic areas

• Health conditions
• Health behaviors
• Population groups
• Setting and systems (healthcare falls in it)
• SDOH
• Leading Indicators of Health (LIH) are a subset of high-priority objectives that are selected drive action to improve health and well-being

5 key areas of the framework

• Health disparities
• Health equity
• Health literacy
• Wellbeing
• Social determinants of health

Social Determinants of health

• Economic stability (income)
• education access and quality (clean schools, good curriculum, dropout rate
• Health care access and quality (quality of the care, is the doc office too far)
• Neighborhood and built environment (safety, parks, or in city, opportunity for recreation, water and air quality, noise, smoke, food desert of places to find food)
• Social and community context (support systems, interactions with people, service groups)
  • Include age, gender, social status, and social support
  • Social risk factors are the adverse social conditions that may lead to poor health

Physical Therapist Role

Biopsychosocial Model

• A person’s health status is determined by the interplay of the biological, psychological and social domains

ICF Framework:

• International Classification of Functioning, disability and health
• Used by PTs to prevent, minimize, or eliminate impairments of body functions and structures, activity limitations, and participation restrictions by optimizing movement

Role of PTs

• Prevention
  • PTs can facilitate behavior change to reduce risk factors in the individuals with whom they work with
• Movement Specialists
  • PTs collaborate with physicians and other health care providers and fitness professionals to promote active lifestyles and reduce risk behaviors
• Consider the APTA vision statement, “transforming society by optimizing movement to improve the human experience”
  • Optimal movement:
    • Purposeful, efficient- especially in terms of energy expenditure- and reduces risk of injury or onset of impairment or disease
  • Quality of life:
    • Improves with the ability to move well

Transformation

Physical Therapists can facilitate transformation of society through the typical practice of working with patients in rehabilitation after onset of injury or illness or after surgery

Education:

• Educating patients. Clients to enhance health and wellness

Improving physical literacy to promote optimal movement

• Include the components of motivation, confidence, physical competence, knowledge and understanding

Identifying community resources available to the client to support a healthy lifestyle, advocating for community systems and resources to support-health enhancing behaviors and environments

Advocating for reduction in health disparities

Starting and Stopping Exercise/ Testing

Starting exercise:

• Initial screen/evaluation; physical activity readiness Questionnaire for everyone (PAR-Q) and or provider clearness
• Absence of:
  • Angina or angina like symptoms
  • Shortness of breath, wheezing, leg cramps or claudication
• Signs of poor perfusion:
  • Light headedness, confusion, ataxia, pallor, cyanosis, nausea, or cold and clammy skin

Stopping exercise:

• Onset of angina-like symptoms
• Drop in SBP >or equal to 10mmHg with an increase in work rate or if SBP decreases below the value obtained in the same position prior to testing
• Excessive rise in BP: systolic pressure >250 mmHg and or diastolic pressure >115mmHg
• Shortness of breath, wheezing, leg cramps or claudication
• Signs of poor perfusion: light headedness, confusion, ataxia, pallor, cyanosis, nausea or cold and clammy skin
• Failure of HR to increase with increased exercise intensity
• Noticeable change in heart rhythm by palpation or auscultation
• Individual requests to stop
• Physical or vernal manifestations of severe fatigue
• Failure of the testing equipment

Normal Response to Exercise

HR:

• Increases with progressive workloads at a rate of around 10 bpm per MET

SBP:

• Increases with increasing workloads at a rate of around 10 mmHg per 1 MET

DBP:

• Normally no change (or slight decrease)

Pulse OX:

• Should remain stable

RR:

• Increases with progressive workloads

Post exercise:

• SBP typically returns to pre-exercise levels (or lower) by 6 minutes or recovery

Week 3

PT’s in Primary Care

• Physician shortage may reach 120,000 by 2030
• Capabilities model:
  • work at their full level of training, share responsibilities, get the right patient to right provider, timely
  • identify recourses- match them to patient
• Barriers:
  • Hight copays, Medicare lack of recognition (policy)
• We don’t want to replace but help within our scope to triage and refer
• Important to know IP team members roles

PT’s in the ER

• Gait training
• Assistive device fitting
• Discharge needs assessment/ disposition planning
• Vertigo
• Early neurologic assessment
• More

Our Value in Emergency Care

1. Wait time (1/2 with PT involved) less and shorter length of stay (LOS)
2. Decreased hospital admissions, less LOS and $ (falls, mobility)
3. Less readmissions for falls and MSK disorders.
4. Increased patient satisfaction; value in care and education provided.
5. Patient Outcomes: LBP; less immobilization, meds, improved function.
6. MD acceptance and value on education, safety, prevention, gait training,
   pain alternatives and D/C planning. Network! Advocate!
7. MSK Dx: as effective, Dx concordance, time efficient, less referrals.
8. Good interrater agreement with physicians.
9. Evidence Based guide: judicious imaging, meds, early mobility
10. Opioid crisis and alternative Rx’s for pain.
11. Cost: $ PT as extra service vs type of service.
12. Still, we decrease : less time, imaging, referral, meds, return to work

Primary Health Services Enhancement Act (H.R. 5365)

• Position The APTA strongly urges Congress to pass the Primary Health Services
  Enhancement Act (H.R. 5365). This bipartisan legislation would expand patient
  access to essential PT services to children and adults who receive care at
  rural health clinics and federally qualified health centers, also known as
  community health centers (CHCs). H.R. 5365 was introduced by Reps Ron
  Kind, D-Wis, Diana DeGette, D-Colo., Jackie Walorski, R-Ind., and Don Bacon R-
  Neb.
• Background CHCs provide primary health services to more than 30 million
  people in over 12,000 rural and urban communities across America, including
  nearly 3 million Medicare beneficiaries and one in five Medicaid beneficiaries.
  These facilities provide a lifeline to communities in need of essential health
  services whose barriers to health care include, cost, lack of insurance, distance,
  and language. Presently, CHCs offer a range of health services, including
  access to physicians, advanced practice nurses, dentists, clinical
  laboratory, emergency medical, behavioral health, and COVID-19 testing
  and vaccine distribution. However, CHCs are restricted in how physical
  therapy services are provided and reimbursed.
• Pain Management and COVID-19 Between 2015 and 2018, 73% of CHCs reported
  an increase in opioid use disorder, and 69% reported an increased number of
  patients addicted to prescription opioids. This abuse is widespread in rural and
  medically underserved areas where CHCs are often the only option for medical
  care. COVID-19 has caused health, social, and economic stress that has
  exacerbated the opioid epidemic. This legislation would afford Medicare and
  Medicaid beneficiaries greater access to their physical therapy benefit.’’

*we are not reimbursed (main point)

Posture:

• Observing your patients when they aren’t looking

Seated Posture

• Switch sitting positions often
• Take brief walks around your office or home
• Gently stretch your muscles every so often to help relieve muscle tension
• Don't cross your legs; keep your feet on the floor, with your ankles in front of
  your knees
• Make sure that your feet touch the floor, or if that's not possible, use a footrest
• Relax your shoulders; they should not be rounded or pulled backwards
• Keep your elbows in close to your body. They should be bent between 90 and 120
  degrees.
• Make sure that your back is fully supported. Use a back pillow or other back
  support if your chair does not have a backrest that can support your lower
  back's curve.
• Make sure that your thighs and hips are supported. You should have a well-
  padded seat, and your thighs and hips should be parallel to the floor.

Weist Circumference

Android Fat Distribution

• Excess upper body/visceral fat (central fat) associated with metabolic complications
• HTN T2DM, CVD, dyslipidemia, sleep, apnea

Gynoid Fat Distribution

• Lower body fat associated with reduced metabolic complications
• Hips area

BMI (weight in kg / height in m^2)

• To test for quick/ convenient but no distribution for muscle mass, bone density, body type, fat distribution, racial or gender differences

Anthropometric Measures

• Height/Weight
• BMI
• Circumference
• Body fat composition

Body Fat Percentage Calculation by Skinfold Measurement

• Better estimates body fat percentage +/- accurate as around 1/3 of fat is subcutaneous
• Variations with age, sex, race, training
• Other options:
  • Densitometry
  • DEXA scan
  • Bioelectrical impedance
• Body density formula
  • 1.109380 – (0.0008267 × sum of three skinfolds) + (0.0000016 × [sum of
    three skinfolds]2) – (0.000257 × age)
• Jackson-Pollock 3-site formula
  • Women: triceps, suprailiac, thigh
  • Men: chest, abdomen, thigh

Week 4