Life Advice From Senior Citizen

 Here are nuggets of wisdom my patients have shared with me over the years. All quotes shared with permission. 

“Go with the flow in life.” -Dolores, 91

Addressing Uncomfortable Health Topics as a Therapist

By David Garner MOT, OTR/L, AC

As therapists (PT, OT, SLP) we wish the best life possible for our patients. Sometimes we see them making unhealthy decisions that may impede their recovery. How can we approach these topics with respect in a way that is educational without being judgemental? Topics I'm referring to including losing weight, quitting smoking or drinking, and other counterproductive lifestyle choices. For many people these behaviors may involve addiction or anxiety. They likely know they should change, but it's hard. Perhaps they have tried in the past and were met with poor results. 

We are not generally experts in these areas, but we can educate our patients about healthy life choices as well as resources that may support their success. It can be awkward to bring up these topics with patients. So here is what I have found to help me approach the subject respectfully without any awkwardness. 

Begin by ensuring the conversation takes place in a private setting. Some patients care more about this than others. Begin the conversation by acknowledging their own experience. For adults that are overweight or smokers, they have probably heard the message a thousand times that they need to change. You are probably not the first to communicate this to them. I say something like, “You are probably aware that ____ negatively impacts your health.” 

Next, I will emphasize how this issue currently impacts their recovery. For example, smoking severely impairs tissue healing, also it exacerbates neuropathy symptoms. They may be much more motivated to succeed if they understand how the unhealthy practice impedes their recovery and return to PLOF.

Lastly, I will let them know I’m sharing for the purpose of allowing them to make educated choices. My goal is not to place judgement or shame. 

If they seem interested, I will share resources or educate them on medications available that may aid their goal so they can discuss with their doctor. Community and online resources may be beneficial. The key is to provide support, not pressure. 

The Drowning Journal Technique

Journaling is a widespread practice, yet many people feel it is not for them. There is a stereotype, especially among adult men, that it is juvenal or feminine. Research has shown that it is an effective coping mechanism for people of every gender and at every stage of life. Additionally, it does not look the same for everyone. The classic trope that one needs a dedicated diary where they gush about there deepest feelings in paragraph after paragraph of vivid ink is untrue. There is no right way to journal.

Let me repeat that, there is no correct way to journal. Each person does it their own way. Here is how I define journaling. The act of writing down things that clog or stick in your mind. The primary use for journaling in my view, is to help control and focus ones thoughts. Writing paragraphs is perfectly fine. Many people feel they do not have time for that. Here, I want to share a simple technique that is quick but impactful. It can be used in almost any location, private or public. 

When would you use this technique? When you feel you are drowning emotionally. When thoughts are stuck in your mind. When your thoughts are racing or overwhelming. When you are having trouble focusing your thoughts, or when you are having difficulty relaxing. You can use it at any time.

All that is needed is a writing utensil and a surface to write on. Alternatively, you can do this on a digital device, but I prefer paper or a white board. The technique begins by simply writing down the things that are racing through or clogging your mind. Start with one- to two-word descriptions (e.g. finances, pain, car trouble, sickness, stress, my mother, my job, etc). Do not write them in a list. Instead, write each word over top of the former. When you are done, it should be difficult or impossible to read any of the words you wrote. You have just drowned your problems in ink.

As I write my problems over top of each other. I like to turn the page all the way around, writing each word at a slightly different angle. Then I end up with a large circular blot of scribbles. I will sometimes write the same thought down multiple times if it is especially persistent in my mind. When I am done, I feel more calm. Because none of the words are discernable, it is entirely private. You can simply throw the piece of paper away along with your worries. At least it makes me feel better to think about it like that.

To be sure, it does not fix all your problems. But this exercise will calm your mind and allow you to focus or relax. It helps to just put your thoughts down on paper. It only takes 1-2 minutes. It slows the frantic thoughts jumbled in your mind. It works kind of like Dumbledore's pensive in the Harry Potter series. Although sadly we don't have a magic wand to solve our problems. At least afterword, you can relax or focus on whatever is at hand. 

An alternative for those with disabilities who cannot write is to turn on a recording device and speak aloud the things that are crowding your mind. It is very therapeutic. 

Feel better.

David F. Garner OTR/L

The Survey of Spiritual Needs (SOSN)

Developed by David Garner MOT, OTR/L with contribution by LaVoy Garner M. Div, CC

Description: 

The Survey of Spiritual Needs is a short, seven question survey to assess for spiritual distress, depression and patient needs and wishes related to these issues. This survey can be completed in two to five minutes. It is intended for adult and older teen populations with abstract reasoning skills. 

Purpose:

Screening for spiritual needs can be conducted by any healthcare personnel including patient care technicians and certified nursing assistants.  The SOSN is a brief survey that will enable any healthcare professional to assess for spiritual distress and disruptions in spiritual engagement thoroughly yet quickly. It will also enable the examiner to identify solutions to help their patient re-engage with this occupation and begin to resolve present distress. It will enable the examiner to connect the patient with other appropriate resources and determine if further screening is necessary. No prior training is required. 

Settings:

This tool is intended for use in any setting. While spiritual distress is more common in overnight medical facilities, it can impact health in every setting. Spiritual distress rarely resolves on its own when a patient is discharged back home. It can persist as can any disease. It may be less visible, but can still pose a barrier to returning to a prior level of function and independence. It can also impact caregivers also.

Many patients live alone. They may have a short stay in a hospital where they only interact with staff for a few days. Following that, they may require weeks or months of regular visits by home health staff or to an outpatient setting. Thus, they may form a more intimate bond with staff in the outpatient setting. Occasionally, these patients are so lonely, they schedule outpatient visits even on major holidays because they have no one else to visit. In such circumstances, the outpatient staff may be the best resource to notice and screen for spiritual issues.

This rationale can be extrapolated to any setting where healthcare workers serve including home health, prisons, schools, and independent living centers as well as more traditional settings such as hospitals and nursing homes. It is even applicable to telemedicine. Spiritual distress can impact a person at any stage of life and in any situation. Therefore, medical staff should be prepared to screen for it in all settings and refer to local spiritual care resources.

Definitions: 

- Spirituality: this is a broad term that may be defined differently by different people. No attempt should be made to define it too narrowly while completing the survey. The primary definition used in the SOSN is “a concern for or sensitivity to things of the spirit or soul, especially as opposed to materialistic concerns.”

- Spiritual distress: 1) “a disruption in a person’s belief or value system.” Can often be accompanied by emotional distress. 2) not currently feeling at peace. 

- Spiritual and religious occupations: 1) “Engaging in religious or spiritual activities, organizations, and practices for self-fulfillment”; 2) “Finding meaning or religious or spiritual value; engaging in spiritual contemplation”

Recommended Contraindications for Use:

Alert and Oriented to less than 2.
Moderate to severe cognitive impairment such as indicated by:
    Brief Interview for Mental Status score less than 13.
    Mini Mental State Examination score less than 21.

Severe aphasia or physical limitations that impair communication including speaking or writing.

Instructions: 

This survey can be completed in less than five minutes but may take longer if the patient/client is talkative. It is recommended to allow them time to talk if they desire. Active listening without judgment is the best approach.

Before beginning the survey, consider the environment and any aids that will help communication. Is the environment quiet and private? Are they hard of hearing? Do they need a translator? For some patients/clients it may be easier for them to read the survey and fill in answers. If so, utilize glasses, large print and a well lit room as needed. To create a large print version of this survey, simply copy the below questions into a word processing program and print in a plain, large font that is at least 16 to 18 points. 

Survey:

Name_____________________________  Date____________  Patient Number __________

State: “You seem stressed. Would it be ok if I asked you some questions about that?” If they are agreeable, proceed to ask the following questions. If not, let them know you are willing to listen if they change their mind. 

1) Are you at peace?

2) Do you feel unhappy or distressed? 

    If the patient responds “yes” ask: Would you like to discuss those feelings with someone?

3) What are your sources of hope, strength, and comfort?

4) What spiritual practices or religious practices do you have?

   

    If the patient responds other than “none” ask: 

Do you need assistance with that?

AND

Do you need items or reading material for that?

5) Are there any ways we (the staff) can support you better?

6) Would you like help connecting with someone important to you?

7) Would you like to talk to a chaplain or a mental health professional? (Any preference for chaplain: Catholic, Protestant, Jewish, Muslim, other?)

Closing: Thank them for their honesty and courage in sharing with you. 

Further steps: 

It may be beneficial to share the results of this survey with the patient’s case manager and the treatment team. However, if they indicate they do not wish the results to be shared their wishes should be respected unless suicidal ideation is suspected. If indicated in question two, make recommendations to social work or psychiatric services for follow-up. Also if indicated, assist the patient as needed to participate in spiritual practices or connect with spiritual/religious community, mentor or chaplain services of choice. If Chaplain services are available at facility, refer patient to them if indicated in question seven. Consider further assessments such as those below. If suicidal thoughts are suspected, consider screening for suicidal ideation with the questionnaire below. Consider repeating the SOSN as follow up.

Further assessments and resources:

Article Recognizing Spiritual Distress by Joy Freeman.

Patient Health Questionnaire for Depression and Anxiety (the PHQ-4). Less than 3 minutes. 

H.O.P.E. Questionnaire (HOPE) for spiritual assessment by Gowri Anandarajah and Ellen Hight. 10-15 minutes.

Spiritual Distress Assessment Tool, (SDAT) by Monod SM. 15 min assessment.

Suicidal Ideation Questionnaire to screen for suicidal thoughts. 2-5 minutes.

Smiley-Face Assessment Scale A faces scale for assessing mood. 1 minute. Explanation: This is a scale similar to the Wong-Baker faces scale for pain that is designed to assess the current mood and emotional state of persons with decreased cognition. It utilizes five faces from frowning to neutral to smiling. Each face correlates to the moods of, very sad, somewhat sad, neutral, somewhat happy, very happy. This scale may be more practical for patients with limited communication or cognition than the SOSN or other spiritual or emotional assessments listed above. It was developed by the New York Museum of Modern Art’s Alzheimer's Project. You can find the scale and the research behind it in the publication MeetMe produced by the Department of Education, The Museum of Modern Art, New York in 2009 on page 89. Link MeetMe_FULL.pdf (moma.org).

Vibration As A Modality In Occupational Therapy

By David F. Garner OTR/L

Nancy was a 74-year-old female who had a total left hip replacement. During the first few sessions of occupational therapy at the skilled nursing facility, her participation in therapy was greatly limited by 8-9 out of 10 pain. She refused sessions because of pain. She was taking the maximum doses of pain medicine and due to other issues, was unable to take muscle relaxers. After an assessment, I determined much of her pain was due to muscle tightness and cramps in her thigh and low back secondary to post-surgical guarding reaction. 

In our third session, I tried our vibrating massager to see if that would relieve her pain. After 10 minutes of vibration set to 60 Hz, her pain decreased from 9/10 to 4/10. She then participated more easily in dressing tasks. For each subsequent session when her pain was high, she was brought to the gym a few minutes early and used the vibrating massager on herself. Sometimes, she would stay after and continue treating herself. Vibration also has many other benefits. It is a modality missing from many clinicians’ bag of tricks.

Vibration has uses across the lifespan for a variety of ailments. (see this article) The body responds positively to biomechanical stimuli. It is believed vibration provides similar stimuli which promote beneficial responses in the body. Before the prevalence of modern electric vibrating massagers, tuning forks were used for decades to relax muscle trigger points and increase stimulation. In fact, vibration as a medical treatment is over 200 years old. Jean-Martin Charcot noted that whole body vibration reduced Parkinson’s symptoms and invented a chair to treat patients. Vibration is useful when other modalities such as heat and e-stim are contraindicated. Additionally, some facilities are unwilling to provide heat or electrical modalities. Vibration is a safe, cheap, and highly portable alternative, but should be considered a secondary substitute to other modalities for some conditions. 

Vibration is a modality any client or caregiver can easily purchase and be taught to apply without a therapist present. There are virtually no negative side effects except for those who are sensitive to vibration (such as vibratory urticaria), yet many numerous benefits. Quality units can be purchased for around $100. 

Now, let’s address terminology. I avoid the term vibrator because of the connotation of sex toys. I prefer the phrase vibrating massager or simply massager. I often use the vibrating massager in the gym where others may overhear conversations. So, I like to avoid language that might sound like I’m discussing a private topic in public. 

Vibration frequency measurements vary between models. Some models list their frequency settings in hertz (Hz), a measure of pulses per second, while others list them in revolutions per minute (RPM). Some list them as vibrations per minute which is the same as revolutions per minute. Either is fine so long as you know the purpose of each setting. Muscle relaxation takes place around the 20-60 Hz or 1200-3600 RPM range. Higher ranges can also induce some relaxation however this lower range is most effective. Muscle contraction is stimulated best by the 90-130 Hz or 5400-7800 RPM range or higher.

There is research going back decades on the benefits of vibration therapy. Several studies and articles are linked below. Further research is certainly needed, however. The body of research on this topic leaves a lot to be desired. The dearth of available studies means it is difficulty to provide robust evidenced based guidelines for frequency of vibration, duration of treatment or number of treatment sessions for most conditions. The guidelines provided below are often based off of one to two studies and some clinical judgement. Clinical experience will aid the therapist in finding best practices.

Uses for Vibration as a Modality

·       Myofascial pain due to soreness/tightness: Begin by applying in the relax range to the muscle belly. Apply for 10-20 minutes. Use can reduce pain by up to half and last up to 72 hours. It may be less effective for chronic pain or large muscle groups. However, since it is a easily accessed and cheap therapy, patients may be willing to try and see if it offeres any relief. Medication alternatives are usually worth trying. 

·       Hypertonia and spasticity: Vibration reduces tone when applied to muscle belly of high tone/spastic muscles. Apply in the relax range to agonist muscles and in the contract range to antagonist muscles to stimulate reciprocal inhibition. Effectiveness can be improved by applying sustained stretch lasting 5-10 minutes during vibration treatment. 

·       Hypotonia/Flaccidity: Applying vibration in the contract range to the muscle belly excites muscle tissue causing contraction. It can be applied for at least 5 minutes and has similar effects to electrical stimulation. The effects including promoting neurogenesis and strengthening muscles. It may take a few sessions to see results. For clients who have also lost sensation, the vibration stimulates flaccid muscles and promotes the activation of sensory receptors. 

·       Scar tissue mitigation: Use of a percussion massager has similar effects to traditional manual scar massage techniques. It can break down scar tissue, increase blood flow, alleviate pain, reduce itching, and improve healing including minimizing scar tissue formation. Some may be more likely to use a massager at home than traditional manual massage techniques. It may be contraindicated for scars over bony prominences. 

·       Hyperesthesia: Use of low frequency ranges have been shown to reduce tactile defensiveness and hyperesthesia. Begin at 1-2 seconds and increase per client tolerance. If a client struggles to tolerate it at the lowest frequency, try placing a sponge or folded towel between the massager head and skin to reduce transmitted vibrations. A sonic toothbrush may be less intense than a full-size massager. Apply in addition to texture desensitization exercises.

·       Neuropathy: Use of vibration provides increased circulation, reduced pain, and high stimulation to the nervous system promoting regeneration. Whole-body vibration for neuropathy is effective. But this is not practical for many patients. A vibrating ball or massager can provide similar benefits when held in the hand or against the foot. Portable vibrating foot plates are also available for use while seated. A sonic toothbrush may be more appropriate for the facial region for this condition. Vibration can be applied in the relax range for 10-12 minutes per day or every other day.

·       Low arousal/unilateral neglect: Vibrations in the low-frequency range can provide an excellent alerting stimulus. It can provide high sensory input to hands/arms/chin to increase alertness and attention to specific regions. Explain what you will be doing before contact. Introduce for 2-3 seconds, then slowly increase the time of contact to determine client response. Application up to 5 minutes to neck muscles at the start of the session can improve attention to the neglected side.

·       Tremors: There is some evidence that vibration can reduce the severity of all tremor types. Product reviews on Amazon.com for vibrating tools corroborate this, but results vary. Either high or low frequencies can be effective with results lasting several hours. However, one may not see results for a few weeks initially. It seems to be most successful if applied to the hands or arms affected for 10-20 minutes three or more times a day. The best results are seen immediately after, so completing a treatment session before meals is useful. Reasonably priced balls like this can be purchased as well as more expensive devices.

Freezing of movement: difficulty initiating movements common with Parkinson’s and other conditions can be a major barrier to life. It can affect gait but also upper extremity movement. Vibration stimulation can reduce freezing symptoms in some people at least partially. Vibration should be applied similarly to use for tremors. 

·       Tissue healing: Vibration applied around healing tissues (but never on top of open wounds) has been shown to speed recovery. One study even found it to be more effective than electrical stimulation. It can be applied at 35-45 Hz for 10-30 minutes per day for best results. 

      Insomnia/sleep hygiene: There is evidence that vibration applied in the relax range before sleep can improve the quality of sleep and reduce insomnia. It has similar relaxation effects to massage including reduced stress and anxiety and more relaxed muscles by stimulating the parasympathetic nervous system. Apply to feet or high muscle tension areas for ~10 min as close to bedtime as possible. 

There are some precautions and contraindications for the use of vibration per manufacturers. Some recommend avoiding use of massagers on or next to a healing fracture that has not been reinforced with implanted hardware. However, many studies have shown benefits with no major adverse effects at 35-50 Hz and there are vibration devices prescribed to promote bone healing. Avoid using massagers near an electrical implant like a pacemaker. Never use on a limb with a suspected DVT (usually indicated by swelling, pain, and warmth) or with a patient at risk for blood clots. Patients who have been on blood thinners and do not currently have a clot are likely safe. Consult with the patient's physician. Never use on open or sutured wounds/incisions, bruises, burns, tumors. Also avoid areas of unexplained swelling and swelling related to infection. Do not use with patients who have a history of adverse reactions to vibration such as swelling or vibratory urticaria (indicated by itching, swelling and redness). It is quite rare and less than 1000 people have been diagnoses with it in the United States. Check your model's instruction manual for specific warnings.

Some patients may experience side effects including minor to moderate itching following treatment. This is a common side effect and not necessarily indicative of an adverse reaction. If the patient can tolerate the side effects, it is generally safe to continue treatment. Stop the session early if irritation or pain occurs. Consult with the patient's physician as needed. Note, some doctors discourage use of vibration during post-surgical recovery, however, recent research finds it is beneficial rather than harmful. It has similar benefits to post surgical massage. The decision to use it should be considered by the treatment team.

Overall, vibration is one of the safest modalities so long as the above contraindications are heeded. Nearly all patients will enjoy the relaxing sensation and wish for it to continue longer than time allows. Redness can appear on the skin after use due to friction of the head on skin. A bit of lotion or massage oil applied to the skin before treatment will minimize this. When documenting I typically record the location of application, purpose, frequency, and duration as well as patient response. It can be charged under therapeutic activity or neuromuscular re-education.

Selecting A Tool

There are numerous electric massagers available.  Some have a percussive action with a reciprocating head (sometimes called massage guns). Others simply vibrate at a given frequency, typically higher than the percussion type. Percussive massagers have gained a lot of popularity in recent years in the world of sports. Both have many benefits. The percussive action of a massage gun can be too harsh for many applications. There are some additional considerations with percussive massagers. Many models have a plunger head that travels back and forth 1-1.5 cm or more. For those with plenty of muscle mass, that is beneficial. It may be counterproductive for the geriatric population who often have low muscle mass meaning the massage gun could be painful. Additionally, they are contraindicated for people with low bone density. Some models combine vibration with mild percussion. The head only travels a few millimeters. These models may be appropriate for patients with low tissue mass. The vibrating massager (without percussion) is the most versatile for therapy purposes. 

Vibrating tools come in many designs, some with two or more heads. Massagers with a single large head tend to have the most versatility. The head diameter should be at least 3.8 cm (1.5 inches) at its widest. Smaller heads are useful for targeting muscle knots but can be painful for other purposes. Thus, a larger head is more adaptable. Many models have an angled form factor while some are straight. An angled head enables one to easily reach their own back. The straight design can be more ergonomic if being used by a therapist, but either design is useful. See Figure 1 for an example.

Many models are battery powered which offers portability and convenience. Corded designs are usually cheaper, and you never have to worry about the battery dying mid treatment. Power supply depends on the therapist's preference.

Lastly, look for a model that has at least two modes for more versatility. Look at the instruction manual to find the frequencies of each mode. On some cheap models, the lowest frequency can be close to 100 Hz. This is not ideal for relaxing muscles. Check that the lowest frequency is in the 20-60 Hz or 1200-3600 RPM range and highest frequency is approximately 90-130 Hz or 5400-7800 RPM.

 

Versatile models: 

Magic Wand Plus HV-265 (settings between 2700-6300 RPM)

Prosepra PL021 (settings between 3000-6000 RPM)

Wahl 4120 (settings between 60-120 Hz) 

Pado Purewave (settings between 1500-3700 RPM). Model offers vibration and percussion separately or together.  

TOLOCO EM26 (seven settings up to 3200 RPM). Model is a massage gun offering percussion massage only. 

ARK Z-Vibe (one setting at 7000 RPM). Model is most useful for increasing arousal or attention to specific body regions.

Phillips Sonicare 1100 (one setting at 400+ Hz). Model is a sonic toothbrush. Intensity is much lower than massagers. 

 

 

 

 

 

 

 

 

 

 

 

 

 

Triangle Breathing: An Easy Relaxation Technique

 Triangle Breathing for Relaxation

Deep Breathing is a well-known tool that can help calm your mind, lower heart rate, and reduce stress. For a more in-depth article see this link. A lot of research has been done around this psychobiological hack. Here is a brief review of some of the literature. 

1."Psychological/behavioral outputs related to the above mentioned [physiological] changes are increased comfort, relaxation, pleasantness, vigor and alertness, and reduced symptoms of arousal, anxiety, depression, anger, and confusion." - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6137615/

2."Students reported having perceptions of decreased test anxiety, nervousness, self-doubt, and concentration loss..." - https://www.tandfonline.com/doi/abs/10.1080/10401330701366754

 

The problem with the term deep breathing is its ambiguity. The technique explained here attempts to rectify that. This method will provide a simple approach that is easy to remember, and easy to teach to the cognitively impaired. It is a simplified version of other popular deep breathing exercises.

 

It is best to perform this technique when lying flat on your back, especially right before sleep. A dark room and eyes closed is ideal. However, it can be done at anytime, anywhere and in any position. My technique involves exhaling all the air before you start. Then simply breathe in a full, deep breath over several seconds, hold that breath for the same number, then exhale slowly for the same number. A triangle is used to visualize the three steps. Each step should last the same amount of time. For example, you will inhale for 5 seconds, hold breath for 5 seconds, then exhale for 5 seconds.

 

To begin, you will need to exhale all the air in your lungs. Simply breathe out.

 

Next, picture a triangle. (When teaching this technique, it can be helpful to draw a triangle to look at.) Use an equilateral triangle in which each side is the same length. 

 

Start by looking at the highest point. As you descend one side, breathe in slowly, over the course of a few seconds. Five or six seconds is a good place to start. If you have breathing challenges or decreased endurance, 3 seconds may be best. You can raise a finger for each second to help you keep your place. As you master this technique, you will be able to count only in your mind. 

 

As you reach the second corner of the triangle, stop breathing in and hold your breath. Now you will begin your count over again. Hold your breath as you count to the same number you used breathing in. If you cannot make it the first try, that is ok. Don't force yourself to hold in a breath so long its uncomfortable. Simply restart at the beginning and breathe in for a shorter period.  

 

As your count ends on side two, begin visualizing the third corner of the triangle. You will transition to exhaling your breath. As your gaze ascends the third side of the triangle, exhale slowly. Keep count as you did before to the same number. 

 

Once you reach the peak of the triangle, you have finished round one. You will repeat the exercise several times in a row. If you need to pause between episodes of triangle breathing to breathe normally, that is ok. Simply start a new round when you are ready. I recommend repeating the triangle breathing technique for 3-8 cycles. The more repetitions you do, the more effective it will be. Some people will simply repeat the technique for 5-10 minutes continuously. Others may only do a few repetitions. It all depends on how anxious or stressed you are, and how much time you have to complete the exercise. This technique is flexible to suit your needs.

 

Stay relaxed!

 

By David F. Garner OTR/L