Outpatient Neuro Rehab with Emily

Hi! My name is Emily. I am currently completing my doctoral capstone project at an adult day center. I attended the University of Indianapolis (UIndy) and I am graduating with my OTD and MS in gerontology in May! I plan on taking my NBCOT at the end of June. When I graduate I hope to work in either inpatient rehab, skilled nursing, or outpatient neuro. I would also really like to do travel therapy!

What setting are you sharing about today and can you give a brief description of it?          

I am sharing about my experience in an outpatient neuro clinic. The clinic is based out of a large private hospital in Indianapolis. We would see a lot of patients who had spent time on the inpatient rehab floor of the hospital after they had returned home. We would also see individuals who were under the care of a specific team of doctors and nurse practitioners who specialized in stroke rehabilitation as well as concussions.

What is OT’s role in this setting?

OTs role is to help the clients with a variety of neurological impairments regain the ability to participate in their valued occupations. During my treatment sessions I focused on cognition, ADL/IADL completion, fine/gross coordination, strengthening, vision, balance, and transfers.

Did you feel prepared going into this setting based off of your classes? And how did you prepare before starting?

I did feel prepared going into this setting based off of my classes. Classes that prepared me the most for this setting were anatomy and neuro. Additionally, my previous level 2 experience was in inpatient rehab, so I was familiar with a lot of the diagnoses/conditions, assist levels, etc. I also prepared by organizing materials from classes and my previous fieldwork by different diagnoses I was going to see in the outpatient setting. I also received a list of assessments, diagnoses, and common treatment techniques from the facility, so I took a little time to research these.

I also took a little time to relax before starting my rotation. I only had one week between my inpatient rehab fieldwork and this one due to COVID, so I took time to be with family and friends before starting another rotation. I think that it is important for any student about to start fieldwork to take time to be with family and friends because burnout is a real thing even on fieldwork.

What resources were the most helpful during your time there?

I had two CIs during my fieldwork experience. Both of these therapists had years of experience either working in outpatient neuro or in inpatient rehab. They gave me outlines of materials from continuing education classes that they attended. Additionally, they gave me handouts on different assessments that they liked to use, research articles that they found interesting and applicable to the clients we were seeing, and they met with me on a regular basis to discuss any concerns or questions I may have had. I also used free handouts from Seniors Flourish, notes from my neuro and anatomy classes, materials I had collected from health and wellness classes, as well as materials my past CIs had given me. For example, my CI, the Practical Occupational Therapist, from my previous level two writes his own guide books and handouts. They were very helpful. Also I joined several OT groups on facebook as well as followed many OT instagram pages. Having an online OT community is very beneficial, and can help you feel like you’re not alone when you are struggling.

How did you stay organized and manage your time?

I would bring a notebook. During the first few weeks of my fieldwork, I would take notes over treatment sessions, assist levels of patients, and even created problem lists for patients I saw. As fieldwork progressed, I took less notes during sessions. As a therapist, we have to be able to think on our feet and process information in the moment and decide where to take the session next. In order to be able to do this I had to wean myself off of my notes and handouts.

To organize my session, I would try to do an activity for at least 15 minutes. Each activity would correspond to a goal I had for the patient. Each session was an hour long so I tried to do at least 2-4 activities in a session. I would also leave at least 5 minutes at the end of the session to summarize what we did and why we did it, update the HEP, and answer any questions the patient had.

What was your schedule like?

My first patient was at 8 am and I could potentially see patients until 5 pm. Each session was an hour long. However, in outpatient settings clients will cancel, so I would either work on documentation, intervention planning, or would shadow another therapist if one of my patients canceled. Additionally, I would spend some time at the end of the day to review the clients I was going to see in the morning so I was mentally prepared for the next day.

What assessments did you use most?

During their initial assessment I would use MMT, Modified Ashworth, box and block, nine hole peg, goniometer measurements, pinch and grip measurements, and I would complete a brief occupational profile. Depending on their diagnosis and/or results of the initial assessment I would also use the MOCA, ACLS, MET, or the kettle test. If the individual had sustained a concussion, I used RiverMead Post Concussion Questionnaire, I would assess their visual saccades, pursuits, convergence/divergence, and visual midline. I also used the campimetry device to assess visual fields, and I used several protocols on the dynavision for people who had sustained concussions or strokes to determine safe return to driving.

What conditions/diagnoses did you see most often?

Conditions and diagnoses I saw were SCI, stroke, Parkinsons, and concussions. Additionally, the outpatient clinic I was at also had an amputee clinic so I also saw a lot of individuals who had lower limb amputations.

What did a typical session look like?

It really depends on the patient. I saw patients with a variety of neurological conditions and various degrees of abilities. I would usually try to break my session up by 15-30 minute increments. The activities I chose were based on the specific needs of the client. Activities we did during the session included IADLs (cooking, driving with the use of a driving simulator, housekeeping) balance training (standing, weight shifting, yoga, tai chi), transfer training, therapeutic exercise, dressing, practicing use of adaptive equipment, vision activities (often utilizing the dynavision, hart charts, brock string) cognitive activities (games, kitchen tasks, dynavision, metronome), and fine/gross motor coordination.

How did you stay client-centered and occupation-based?

As OTs, we are very good at activity analysis. When deciding interventions to use during sessions, I would usually observe them completing an occupation and then base my interventions off of my observations as well as the information I collected from the initial evaluation. For example, I had a patient who had a stroke who loved to cook. Because of their stroke, they had a hard time opening containers, reaching for objects on a shelf, stirring things in a bowl, maintaining their grasp on kitchen utensils, and even processing the steps needed to complete the cooking activity. I broke down what they were having difficulty with and why. Based on this I decided what interventions would be appropriate for them. During our sessions we worked on scapular AROM, UE strengthening, fine motor coordination, gross motor coordination, and cognition. Some example of activities we did were reaching for objects on a shelf over and over again with proper form, turning various sized lids multiple times, the Envelope Task (which worked on the clients ability to follow directions), using a tripod grasp to pick up pegs, using a gripper to pick up pegs, and stirring various objects in a bowl.

Did you have to do a project or in-service? Could you share what topic you chose?

I did have a project. The site I was at used the Multiple Errands Test (MET) with many of their patients. The purpose of this test is to determine how the impairments in executive performance impact the client’s ability to function in a natural context. The test has you complete multiple tasks throughout the hospital. The patient has to complete 12 tasks, and the tasks created have to follow a certain set of criteria. I made sure that the tasks that were being done followed the conditions. I also modified their scoring sheet based on research that I completed to that it was easier to understand. Additionally, I discussed the purpose of the MET to the interprofessional team during their weekly rounding.

What was your favorite part of this fieldwork experience?

My favorite part of this fieldwork experience was being able to build meaningful relationships with my patients. In outpatient, you see your patients for weeks to months. I was able to see a lot of my patients make amazing progress during my time there. Additionally, the amount of collaboration that occurred between the different professions at this site was awesome. It was really cool to see how PTs, OTs, ST, NPs, and MDs could all work together for their patients.

What was your least favorite part of this fieldwork experience?

In outpatient settings, it is often up to the therapist to decide when it is time to discharge your patient from outpatient services. This conversation can get very emotional because your patient can feel like they haven’t made enough progress to be discharged yet, but you know that they have plateaued with their progress. It can be heartbreaking, but you have to remember that it is unethical for you as the therapist to continue treating a patient if they are not making any progress.

What is something you learned that you will take with you for the rest of your career?

It is so important to keep learning and keep an open mind to learning opportunities. During fieldwork, there were many challenging situations I faced, but I tried to think of these situations as learning opportunities. If I struggled with a patient, I researched different interventions and talked to my CIs, other OTs, and other members of the outpatient therapy team. I learned that I won’t always have the answer for everything, and that’s okay, but I need to take the steps to learn the answer and prepare for the next time I may face a similar situation.

What advice do you have for a student about to start in this setting?

Be flexible and open to learning. You’re not going to know everything and that is okay. Your CI is there to help you and guide you through this learning experience. Some of your treatment ideas won’t go as planned, and you need to be able to grade and adapt activities in the moment. In class we have minutes to days to plan activities and how we would grade or adapt an activity. In the real world, you have seconds. Don’t freak out though! You are prepared to do this, your CI is there to help you learn, and your professors will be there to support you as well. If you are struggling with something, speak up! The longer you let an issue go, the worse it is going to be.


Links:

Instagram: @emilylugo88

Resources

Seniors Flourish

The Practical Occupational Therapist

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