Brownie Therapy

Late for my occupational therapy (OT) observation with Jamie in the Green Therapy Pavilion (CORF), I arrive to find Jamie and Jill, her occupational therapist, preparing to make brownies in the OT kitchen.  Wondering why these gals are going all “Martha Stewart” on me, I figured Why not? Brownies have been a form of therapy for me in the past. Giggling to myself, I settle into a chair to observe.  Jamie, ever the sweet friendly gal, enthusiastically greets me as I slide into the session in attempt not to disrupt.  I’ve noticed in past observations Jamie becomes easily distracted, but Jill keeps her on track by giving her a bag of brownie mix asking her what they need to get started.

How many times have you and I made a box of Duncan Hines brownies?  Do you remember the last time you actually read the box recipe directions?  Can you recite any of them?  I admit I didn’t until I did a Google search.  At best I scan the pictures for how many eggs, how much oil and/or water, what oven temperature it requires, and how long to bake them.  You and I take for granted our automatic grasp of baking a simple box of brownies but the follow-through on these simple steps challenges Jamie’s success.  With her cognitive challenges, distractions come easily for her and her attention to details and thus, follow-through suffers.

Jamie reads the package aloud, noting they will need two eggs, ¼ cup oil and ½ cup of water.  Jill sends Jamie to the refrigerator for two eggs while she herself pulls oil and a measuring cup out of a cabinet.  Next, Jamie reads the first step of the recipe instructions, Preheat oven to 350 degrees.  Jill helps Jamie figure out our dinosaur of an oven in OT.  This oven comes from the dark ages with its knobs and dials!  Jamie turns the knob to 350 degrees with Jill’s guidance and explanation on how to actually turn the oven on with a second knob.  Oven preheating, they move to the next step in the recipe directions. 

“GREASE bottom of pan with shortening or cooking spray.”  Jill pulls out a can of cooking oil so Jamie may spray the pan.  With this task complete, Jill asks Jamie to continue:  Empty brownie mix, egg(s), oil and water into large bowl.  Jamie follows the instructions, though Jill has Jamie review the recipe step again because she forgot to add one of the ingredients.  As I observe, Jamie not surprisingly becomes easily distracted as she asks Jill about her wedding plans, or says how tired she is, or asks her if she watches the TV show “Friends” rather than fully focus on what she’s doing.  Jill gently redirects Jamie’s attention to the task at hand.

Stir until well-blended (about 50 strokes); spread in greased pan and bake immediately. Once Jamie begins stirring, Jill takes the opportunity to answer a couple of her questions.  I notice awkwardness in Jamie’s body as she simultaneously holds the bowl and stirs the brownie mix.  Jamie manages the task fine but the coordination challenge presents itself.

Spread the batter evenly into the pan.  Jamie now struggles with the coordination of holding the bowl while manipulating the spoon to dump the batter into the pan.  Jamie’s upper-body strength or the lack thereof comes into play here too.  Jill notices, and suggests that Jamie hold the bowl a different way, giving her specifics on how to do so. Jamie concedes that’s easier and continues pouring the batter.  Jill asks Jamie to review the instructions one more time to determine the baking time.  She helps Jamie set the timer, then opens the oven door so Jamie can place the brownies inside, cautioning her to be careful.  Once the brownies are in the oven, we move to another OT activity until the timer goes off.  When the timer buzzes, a quick check with an inserted knife reveals the brownies aren’t done.  Jill explains to Jamie they need to bake the brownies a little while longer, in this case, another ten or so minutes. 

Jill later explained to me that Jamie wants to be independent at home which means cooking more of her favorite things on her own.  Additionally, she explained her struggle with following through on task activities, such as a following a recipe, checking on what’s baking, remember she has something baking, etc. to the final outcome:  a warm batch of brownies fresh out of the oven.

What about the brownies, you ask?  Well, what I know for sure is they smelled awesome and I didn’t get any!

In the Next Blog Entry: A Wild Ride - “Mildly off balance by the sudden, disorienting flow and rhythm of the conversation, I struggled to track Jamie’s line of thinking as she jumps around within the exchange.”

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A Ball of a Time

On my first day of occupational therapy (OT) observations at the Green Therapy Pavilion (CORF), I arrive to meet Jill Boeglin, Jamie’s occupational therapist.  Upon Jamie’s arrival for her OT session, Jill introduces us, explaining I’m observing as a new employee learning our services.  We ask Jamie if she’s okay with my observing her sessions to which she replies “sure.”  Jamie by all appearances seems to me like a normal young woman, leaving me to wonder why she’s even in OT.  At this point, I have no background information on Jamie or the OT goals set by her and Jill. 

We walk to the therapy area where Jill selects a large ball similar to an exercise ball and gives it to Jamie with instructions to bounce it with her right hand.  Jamie does, successfully maintaining control of it as she bounces it in one spot without any problem.  Jill gives Jamie a medium-sized ball, asking her to do the same thing again.  Jamie bounces this ball but now I notice her struggle to keep control of its bounce.  Her arm movement appears gangly and stiff while her hand bounces it with heavy-handedness.  Suddenly, the ball moves out of her bounce zone; despite bending over to extend her reach for it, it gets away from her.  Rather than moving herself with it, Jamie simply lets it bounce away while standing in the same spot, making no effort to retrieve control of it.  Jill retrieves the ball, returns it to Jamie with further instructions:  When the ball moves away from you, move with it, moving your feet with the ball to maintain control as you bounce it.  Jamie bounces the ball, and again, the same thing happens after the first several bounces.  She bends at the waist, feet planted where she’s standing, attempting to maintain contact with the ball.  As a result, she loses her balance in the overcompensation from the upper body effort to stay with the ball.  The ball makes its get-away.  Saying “this is hard,” Jamie nonchalantly retrieves the ball.  Once again, Jamie bounces, and once again struggles to coordinate her upper and lower body to work in unison to maintain control of it. 

In later OT sessions, Jamie shows improvement with this exercise, moving from a medium ball to a smaller ball, then a tennis ball.  The tennis ball really challenges Jamie’s gross motor skill coordination.  At one point when the tennis ball bounces away to rest under an immovable object, Jamie goes to it but seems unsure as to how to get to it.  To retrieve the ball, the action would require someone to bend down, even on one’s knees, bend further over at the waist with an extended arm under the object to retrieve it.  Jamie stands as if unsure of what she needs to do to get access to the ball. 

Initially, I think Jamie’s just being lazy, especially since she’s repeatedly stating “I’m tired” during the activity.  When Jamie bounces the ball, the movement appears as if both halves of her body are awkwardly interacting with each other.  One or the other moves, but both struggle to work together to perform the task.  Later, I learn Jamie’s lack of effort reflects her inability to process the physical coordination involved in moving with the ball and getting the ball out of its tight spot. As children, we naturally learn to get on our knees, lower our upper body enough so we can extend our arm under a dresser to reach a toy lodged in the back next to the wall.  We learn this activity unconsciously giving no thought to the mechanics of the effort.  For those with cognitive and physical challenges like Jamie, this activity requires conscious thought and concerted effort in performing this physical coordination.  As we get older and our bodies age, bones creak and joints stiffen, we take greater care and thought into maneuvering our bodies through the task of retrieving something under a chair. Through OT, Jamie learns how to coordinate her muscular movement so both the upper and lower body work in unison to perform the activity. 

Over time, Jamie managed the ball bouncing activity better some days than others, and I definitely saw improvement.  Jill explained and showed Jamie how to move her feet and body with the ball when it tried to get away from her.  One day, Jamie proudly announced she’s been practicing at home which occupational therapists encourage of their clients. This exercise helps Jamie build upper body strength while facilitating coordination between her larger muscle groups.

I quickly learn OT involves breaking the simplest of tasks down into several steps for greater understanding and performance, which becomes more evident when the time comes for Jamie to make brownies.

Mmmmm, brownies. . . . . . . .

In the Next Blog Entry: Brownie Therapy - “ Wondering why these gals are going “Martha Stewart” on me, I figured Why not? Brownies have been a form of therapy for me in the past.”

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Hoops & Red Tape

Jim began physical therapy (PT) with Ryan in the Comprehensive Outpatient Rehabilitation Facility (CORF) on Wendell Foster’s Campus (WFC) in June 2011.  His PT goals:  climb and descend the stairs at least once with only minimum (25%) assistance; walk eight roundtrips in the parallel bars with little assistance, and walk ten roundtrips with a walker with 50% assistance.  Jim’s commitment is evident because within only a few months, Jim exceeded his initial goals.  As a “person-centered” facility, therapists seek to understand what their clients want to accomplish for their life and together discuss what is involved in that process.  Goals are developed; and our therapists create the “therapeutic plan” that facilitates goal achievement.  A goal can simply be “I want to easily move from my wheelchair into my bed;” a simple task to you and me, yet huge to someone with a physical disability.

But our therapists and more significantly, our outpatients face the hurdles of red tape, hoops and bureaucracy in their efforts to reach their goals.  Therapists in all the therapeutic areas share stories of how insurance, Medicare and Medicaid limit patients’ access to these needed therapies.  For example, Medicare sets a dollar amount on how much one can spend per year on therapy.  Some insurance limits the number of therapy sessions a patient can have within a year.  In one case, a child with significant developmental disabilities would benefit long term from weekly therapy session, but his coverage authorizes only twelve therapy sessions for the year, the equivalent to one appointment per month. Reasons vary for these limitations, and understandably our therapists become frustrated.  For most of our outpatients, therapy is an on-going process, not a set number of visits and “be healed” experience.  For those with developmental disabilities, therapy may be a lifelong treatment.  Just as pharmaceuticals are indefinitely prescribed and accessible to offset serious and/or debilitating health challenges such as high blood pressure and diabetes for most of one’s life, therapy treatment offsets serious physical limitations for those with cerebral palsy, promoting and facilitating healthful and functional independence.

Then there’s the red tape and hoops.  One speech therapist tells the story of how a request for coverage for a patient’s therapy was denied because it lacked appropriate information.  She highlighted with a highlighter the “missing” info within the originally submitted text of the paperwork and returned it.  The request was approved.  Another outpatient challenged an insurance hearing panel’s decision to deny additional PT coverage.  His request was finally approved after a third-party neuro-specialist reviewed his case, and deemed it not only justifiable but a necessary treatment to address his condition.  Hoops.  Red tape.  Bureaucracy.

Jim now stands before these hurdles.  He recently became eligible for Medicare, which places a maximum dollar amount per year combined for both speech and physical therapy.  His supplemental plan has a deductible; once met, it covers 80% of his therapy costs.  Since January, Jim had two physical therapy sessions a week, but recently changed to once a week because he’s closing in on his “Medicare allowable amount” for the year.  Healthcare is a big topic in today’s news, and Jim’s situation isn’t unique.  Our therapists constantly battle “the system” to ensure our outpatients receive the necessary therapeutic treatments and equipment needed to empower them to the maximum functionality in their lives.  To limit opportunities of therapy only strips these individuals’ ability and potential. I wonder how limiting its availability isn’t discrimination against those with disabilities, when opportunities abound for those of us without disabilities to reach our fullest health potential. Therapy offers those with developmental disabilities a chance to overcome limitation, and more importantly hope in the face of physical challenges.  It empowers individuals to become more independent so they may do the simplest of things they want to do.

Especially impacted are children; early intervention gives them a chance to manage and overcome long-term limitations their developmental disabilities create.  Therapy increases a young patient’s chance and ability for greater independence and mobility so he or she may thrive into their adolescence and adult life. Early intervention also develops a mindset of “where there is a will, there is a way”; they can do whatever they want with determination.  They learn at a young age not to give up on themselves when many around them, seemingly including the healthcare system, have already given up on them from the get-go.  They learn how to get around any limitation to achieve anything that any one of us can do in our daily life.

One little boy I observe proves the power of early intervention and its worth in my next PT and speech outpatient observations.  Goals can be simple:  “I want to play T-ball this spring” and “I want to eat at Chuckie Cheese.”   This observation introduces me to a six-year-old boy who started physical therapy shortly after birth and speech therapy when he was one.  I learn how important early intervention is, and my entire perception of physical and speech therapy and its value in the life of a young child drastically changes, as does my life and my outlook on it, when I meet a little boy named Nicholas.

In the Next Blog Entry: Against All Odds: “Nicholas was taken to an Evansville hospital’s neo-natal care unit for more intensive care for his medical needs.  He wasn’t expected to survive . . . . . he proved doctors wrong . . .”

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I’m Gonna Take That Mountain!

In my physical therapy observations at Wendell Foster’sCampus (WFC) in the Green Therapy Pavilion, I watched Ryan encourage Jim as he walked back and forth between the parallel bars, even gently pushing him to “keep on keeping on.”   I saw Jim’s determination and his exhaustion.  I sensed he didn’t like doing it, but I see in Jim a will, a determination to do it anyway.  What I didn’t see in Jim was what Ryan saw in him:  his potential to do more.

Before starting physical therapy (PT), the physical therapist conducts a client evaluation to determine and rule out physical problems, assess pain and discomfort, muscle strength, and range of motion from any joint in your body – ankles, knees, shoulders, elbows, etc.  The evaluation assesses the need for equipment to assist in the recovery and/or mobility of the client, adaptive space needs, etc.   Finally, it also determines the course of therapy treatment and the frequency of sessions needed to facilitate goal achievement, healing and/or rehabilitation.  Ryan gets a good sense of what Jim (and any of his clients, for that matter) is capable of doing as a result of this evaluation, in addition to his observation of Jim’s progress since starting therapy.  So at my next observation with Jim, I was stunned when Ryan announced Jim was going to climb the stairs!

The PT area includes a staircase that ascends nine steps up to a landing then turns left to continue up another nine steps to a larger landing resembling a loft area.  Ryan explains Jim has previously done the stairs exercise which strengthens his leg muscle and builds endurance.  This particular exercise requires the help of a PT assistant.  I sit on a bench off to the side of the stairs and watch, holding my breath to the point my body forces me to breathe as I watch Jim take one wobbly step up at a time.  Ryan spots Jim, lightly holding his waist belt from behind for balance and support as he goes up while a PT assistant stands in front of Jim on the ready in the event of a misstep.  Once upon the landing, they let Jim catch his breath for a minute before he begins his descent of the nine steps he just climbed, with spotters in place as before.  Jim does “take this mountain” twice during this session.  Both Jim and I breathe a deep sigh of relief upon his final step onto the floor.

Another activity involves Jim walking the length of the PT area with a walker.  This exercise requires three people:  Ryan who offers the majority of support to Jim by holding on to the waist belt while another person ahead of the walker helps Jim steady the device. A third person, for which I’m volunteered in this session, follows with Jim’s wheelchair so he may sit for rest breaks and as a safety precaution.  Jim travels a few round trips back and forth across the PT room, and despite these exhausting exercises, Jim never complains.

Jim shows up for each appointment twice a week; many patients who have the opportunity don’t.  Jim never quits.  Many patients do.  Jim is obviously pooped by the end of his session.  Ryan teases Jim that he probably enjoys a good nap after his PT sessions.  Jim confirms he does.

But soon, I learn Jim’s access to physical therapy is jeopardized by red tape, bureaucracy, and ironically, the health industry itself.

In the Next Blog Entry:  Hoops & Red Tape: “. . . .the red tape and hoops. . . . a request for coverage for a patient’s therapy was denied because it lacked appropriate information.  She highlighted with a highlighter the “missing” info within the originally submitted text of the paperwork and returned it. . . . .”

We want to hear from you!  Please share your responses and comments by clicking below on “Comment” – you may post them anonymously or using your gmail.com profile name.

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Let’s Get Physical!

Tall, stocky and ominous in his build, Ryan Kizer is one of three physical therapists in the Green Therapy Pavilion (CORF), and the only male in the department.  He performed his clinical at Wendell Foster’s Campus (WFC) while finishing up physical therapy school, fell in love with the work at WFC, and returned after graduation to begin his physical therapy career. 

After introductions, permission requested of and granted by Jim to observe his therapy sessions, Jim and Ryan get to work.  Upon arrival, and with Ryan’s assistance to stabilize his balance, Jim mounts a stationary bike to spend anywhere from six minutes as a warm up to twenty minutes as part of building endurance.  Watching Jim transfer from his wheelchair to the bike reveals the balance challenges and weakness of his legs, as well as the mental effort he must exert to move them when and where he wants them to move.  In this transfer, Jim expends focused energy to lift his right leg over the stationary bike centerpiece to sit in the seat, then to place his feet into each pedal.  For this session, Jim is on the bike for approximately six minutes to open the range of motion in his hips, knees and ankles as he pedals, and to warm up his legs for the other strengthening exercises Ryan will have him do later in this session.

Ryan often involved Jim in deciding the day’s exercises designed to strengthen his leg muscles, increase his endurance level, and develop muscle coordination between movements.  Each session may consist of one major movement exercise, such as repetitions of walking within a set of parallel bars or walking back and forth with the assistance of a walker.  These activities might be followed with two or three muscle strengthening exercises, such as squats, side steps, and/or knee bends.  Sometimes, Ryan simply stretches Jim’s muscles.  He’s always by Jim’s side helping him mind his balance and physically spotting him with a hold on a waist belt worn around Jim’s mid-section. 

Walking the parallel bars wouldn’t seem like any big deal but if you’ve depended on a wheelchair as your main source of mobility, it’s a big deal!  Jim has some use of his legs, so one therapy goal includes regaining better steadiness and mobility on his feet with the use of a walker so he can move about within his home a little easier.  The parallel bar exercise not only gets Jim on his feet, but helps him practice the motor skill movement of putting one foot in front of the other, as well as coordinating movement of his hands grasping the bars with feet movement.  This exercise also helps him be more aware of his core balance to increase greater stability on his feet. He holds both bars, one in each hand, and Ryan moves backwards while in front of Jim with a hand lightly on his waist belt to help him maintain and regain balance if he wobbles in his efforts.  Two or three round trips later, the exhaustion is evident in Jim and on his face as he sits in his ever-waiting wheelchair to rest, despite having a minute-long breaks between roundtrips.

I thought Jim doing this parallel bar walking exercise was a big challenge for him; but what Ryan would ask Jim to do in the next PT session baffled my mind!  One, I never would’ve dreamed Ryan would ask Jim to do this next PT exercise which I equate to his “climbing a mountain”; and second, I realized I completely underestimated Jim and what he’s was capable of doing, and willing to do to better his mobility, reminding me again to not underestimate people’s potential or their determination!

In the Next Blog Entry: I’m Gonna Take that Mountain:  “I sit on a bench off to the side of the stairs and watch, holding my breath to the point my body forces me to breathe as I watch Jim take one wobbly step up at a time. . . .”

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A Softball Great Goes Down

Once upon a time, I was “prescribed” physical therapy (PT) thanks to a softball injury. 

Flashback to 1995. I made a great hit off a low slow pitch, and as I headed to first, BAM!  My right leg fell out from underneath me; I hobbled in excruciating pain the rest of the way to base.   I later learned I pulled, possibly tore the major set of muscles in my thigh, including the groin.  The doctor told me PT was my best bet to recover the strength and flexibility while healing.  In my first PT appointment, they put me on a treadmill to walk.  Um, how will that help?  I wondered, but I didn’t ask, I just did what I was told.  After fifteen minutes, I’m then asked to do another ten, only this time, walk backwards, at a really slow pace.  Say what?  Again, I did what I was told.  I never asked and they never volunteered the info to me.  My physical therapy lasted three sessions, and I considered it a waste of time.  So upon arriving at PT for my observation, I admit I had skepticism.  Some folks with developmental disabilities can’t walk, I thought to myself, what will they do since they can’t do the treadmill?

Meet Jim, my first PT client observation who works with Ryan Kizer, a physical therapist in our comprehensive outpatient rehabilitation facility (CORF).  Jim lives in one of four handicapped-accessible rental homes sitting on the periphery of and owned by Wendell Foster’s Campus (WFC).  I first see Jim slowly moving himself into the physical therapy area in his wheelchair using one hand and his feet.  As I watch him, I am reminded how I take for granted my own mobility, agility, and ability to do so much.  I’m generally a grateful person, but since starting at WFC, that gratitude has deepened daily for all that I have and am physically, mentally, emotionally, and spiritually.  As in Jim’s case, it can all be taken away from you in an instant.

At the young age of 34, Jim suffered a broken neck and severe head trauma in a car accident while living in San Francisco.  His injuries left him in a coma for two days.  Jim’s head injury and its resulting effect can be seen in his face and cranial area; you can also hear its impact on his speech which is understandable with great effort on Jim’s part, but slurred.  From the hospital he moved into a rehabilitation facility for six months where he received physical, occupational and speech therapy.  He returned to Kentucky in 1984 but had no therapy since his return.  Jim moved into his Campus home three and a half years ago, and began physical therapy in June 2011. By the time I arrive to observe in January 2012, he’s been in PT for approximately six months.  Upon introductions, Ryan explains who I am and why I’m there, and Jim graciously agrees to my observation of his PT sessions.  Jim appears as a mild-mannered man, with a dry sense of humor evident during his therapy.

Jim’s therapy differs drastically from my own personal experience; but then I didn’t have the same physical challenges to overcome as Jim does.  In hindsight, I realize what a cry-baby I was when I had my leg injury.  Yes, it hurt terribly and I hobbled for a few days, but it was a big deal because I made it a big deal, when in fact, it was simply an inconvenience, temporary at that.  With Jim’s blessing, I will watch Ryan put him through a physical ringer of a PT workout over several sessions as they work together towards Jim’s physical goals.  And no treadmills were involved.

Upon starting PT with Ryan, Jim hadn’t walked with a walker in twenty-eight years; therefore, his legs were weakened.  In addition to strengthening muscles, Jim wants to easily transfer himself from his wheelchair to a couch, bed or toilet.  His head injury also impacted his perceptual awareness of his body and balance, creating challenges in his efforts to stand and walk.  These are a few of the issues Jim and Ryan began addressing upon starting PT twice a week last June.

I soon will learn how amazing the human body is, how determined the soul can be, and how powerful physical therapy is as a treatment in overcoming physical challenges.

In the Next Blog Entry: Let’s Get Physical! - “I thought Jim doing this parallel bar walking exercise was a big challenge for him; but what Ryan would ask Jim to do in the next PT session baffled my mind . . . . ”

We want to hear from you!  Please share your responses and comments by clicking below on “Comment” – you may post them anonymously or using your gmail.com profile name.

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Blog content is copyrighted property of Wendell Foster’s Campus for Development Disabilities and Carolyn Smith Ferber and/or other blog authors).  Content may be used, duplicated or reprinted only with the expressed authorization of the Wendell Foster’s Campus.  Permission for use, duplication or reprints may be made to wfcampus.org@gmail.com.