OT for Hip Fracture

What can OT do for a person with a hip fracture or hip replacement? More info in the full post.
Note: this post was written several years ago but still holds true. Just be aware that surgeries and protocols are changing with time and each surgeon will have their own specifics they want followed. I worked at a facility where the surgeons preferred a 2-incision "mini" replacement that carried no precautions, and several who debate whether to use an anterior or posterior approach. Just be up to date on what is preferred by your medical team.

Often, if the hip breaks near the joint's socket, the orthopedic surgeon will perform a total hip replacement (THR). This is also a common elective procedure for individuals w/ degenerative joint disease (DJD). There have been several advances in the operation, and there are new techniques that are less invasive and don't carry hip precautions. If for some strange reason you were pushed into a room with a patient you had no information on, and wanted to know whether this patient had a THR w/ precautions or an ORIF/pinning w/o precautions, the presence of a brace that extends from ankle to groin or a giant triangular pillow attached between the legs is the flashing sign that says "YES, I HAVE PRECAUTIONS."
Don't count on the pt. to remember, as you may not have done a full cognitive eval yet, and it may have slipped even a very intact person's mind after the anesthesia.

For the sake of this example, we'll assume that our subject "M" has a THR w/ the standard precautions (no hip flexion past 90*, no crossing midline w/ operated leg, no internal hip rotation) and the fourth (no active abduction) which is used depending on the location of the fracture and the surgeon.
There will also be a note about weight bearing status. Often, a person electing to have this surgery at a younger age will be allowed to weight bear as tolerated (WBAT). If there is more concern over the stability of the joint or bones, the surgeon will want less weight on that leg. We'll assume that "M" is partial weight bearing, which means that only 50% of her weight on the operated leg. (This saves us from having to explain toe-touch WB with the uncomfortable metaphor of not crushing an egg under your foot; and from non-WB which means that you have to hop. I have done the hopping w/ several... most recently an 89 y.o. female, and progress was slow)

We'll assume that in the OT evaluation, the therapist developed an occupational profile of "M", highlighting her concerns and priorities. We won't go into that in-depth in this post, as I actually want to finish it at some point. But, from my 'chart review,' I see that "M" is an educated woman who was respected at her job and has family support. The report states that she lives in a high-rise, which is good because it probably has elevators, but could be bad if they have rules about adaptations to apartments for safety. She also has vision difficulties, which could complicate ADL retraining.

ADL retraining, or relearning how to do the basic activities of bathing, dressing, toileting, transferring, etc, will be a large part of an OT's treatment for "M." Learning and understanding hip precautions is also a major task- non-medical personnel are not likely to instantly understand hip flexion, adduction, abduction, so this is a key for the therapist to rephrase, review, and demonstrate precautions so that the patient does not forget them and does not pop their hip out. Standard hip precautions often have to be followed for 3 months, so it needs to become second nature. (I once had a gentleman w/ dementia in his 80's that could not remember and understand these. He liked to draw, so I taped paper up on the wall and had him stand and draw cartoons of people obeying hip precautions) Here's some quick ways to simplify the precautions while covering some of the contingency situations:
  • No hip flexion beyond 90*: Don't bend over! Don't try to get anything off the floor without a reacher! Don't lean forward when standing up from a chair. Use the adaptive equipment for dressing. (As a therapist, you can also help by modifying the hospital bed so that the legs don't raise. Often a little button on the foot of the bed or on the outside of a rail)
  • No crossing over midline: Don't cross your legs! Use the wedge or pillows between your legs in bed. Avoid sleeping on your side.
  • No hip internal rotation: Keep your toes pointed up in bed, don't let them turn toward each other. Don't pivot on the operated leg.
How is "M" going to get bathed and dressed independently when she can't bend over? Adaptive Equipment/Devices. A "hip kit" is often recommended, but there are cheaper alternatives to the medical supply stores. Reachers and long sponges can be found at many discount and pharmacy stores. Long handled shoe horns are found at my local Dollar Tree. (I have a handout on how to make dressing sticks, long sponges, and sock aids from household items, but I can't lay hands on it. Will link to it later.) At any rate, an OT will work w/ "M" to help her develop new patterns and procedures for doing her daily tasks w/ devices as needed.

Transfers are often looked upon as "PT territory," but an OT can't expect to work without being comfortable helping people relearning safe transfers. This includes bed to chair, as well as into the tub or shower and to the toilet. Though the "comfort height" toilets are gaining ground, most people (and much of my hospital) has the standard 15" commode. This will not be workable for most individuals w/THR. There are risers for toilet seats, but I have always wondered about their sturdiness. I recommend getting a bedside commode / 3 in 1 toilet, throwing out the catcher/hat/pot, and putting it directly over the commode. In the tub or shower, I always recommend grab bars, and then experiment with different seats to see what works best for the patient. School-based OTs work to get their kids in the least-restrictive environment, I look for the least expansive tub chair that offers the patient the level of safety they need. I have had 1 person w/ THR demonstrate a safe step-in transfer to a tub, but most people will need some sort of seat to swivel into the tub. This is not natural to people, and takes practice.

As "M" progresses through the continuum of care from acute hospital, to skilled nursing, to home health (more likely than outpatient in her case), she will continue to work on more advanced skills that she had previously engaged in, such as cooking, car transfers, showering, etc, which OTs call IADLs. Hopefully someone will be able to visit her home as she gets near to discharge so that they can advise on home recommendations. That includes placement of grab bars, moving furniture, adaptations for low vision- anything to make "M" safer and more independent.


OT Bag: Ancient Egypt

I spent last year practicing in a great school system with a terrific and experienced group of OT practitioners. One of the ideas that they had is that each person creates a themed bag of activities, which you keep for a week and then pass on. It's great, since you get 2 months worth of activities for just developing one plan. This is what was in a bag I created for April/May on Ancient Egypt.

I really enjoyed learning about Ancient Egypt when I was young, entertaining (briefly) the notion of being an archaeologist and code cracker and discovering long forgotten things. I thought it would be a good topic for our kids, in an adapted way. My interest was renewed when I found this great book on sale at Ollies for $4:

It came with these nifty hieroglyphic stamps and phonetic instructions so you can make words. This would have made a great cotreat with a speech therapist because sounding out the letters for their names was really hard for most kids. Usually, I would circle on the sheet which stamps were needed instead of having the kid determine whether they had a short or long vowel in their name or a SH instead of an S. It was still a visual perceptual challenge for the kids to scan among the stamps for the correct pieces.

I included other items so that there was variability for ages and activities needed to achieve goals. There were Egyptian "medallions" in bird shape on card stock to practice cutting and tying; coloring sheets that could be used with pyramid crayons; and a pyramid that required cutting, folding and taping to construct. 
We had a game at the office that requires you to move a marker through a maze using a magnet underneath the maze board.

Some of the items that I included didn't work out as well. I made my own cryptogram about King Tut on a website, but failed to notice that there weren't many letters that repeated, so it was very laborious for the kids. I had pages on complete and incomplete Pascal's Triangles (I enjoy dorky math type things) for kids to do simple addition and color in the even and odd numbers with different colors (try it, it makes a pattern!). However, even the older kids I worked with struggled mightily with the simple addition concepts and did not know odds/evens, so this did not go anywhere. The complex folding and taping required for the pyramid construction was also pretty hard for most. However, judging by what I read on other blogs and the IEPs I saw from other districts, I think that my kids on caseload (who were being mainstreamed) were generally lower functioning than  others getting OT, so these items may work for you with your kids in a graded manner.

Overall, I enjoyed making this bag and trying to instill a little love for learning about ancient Egyptian culture with my kids, though it didn't necessarily work out as planned.  


Salary, Hourly, and Contract- understanding different types of employment

Occupational therapy is a great field with so many opportunities to work with different populations and in different settings. I always tell students that you have such flexibility that you can literally work as much (or as little) as you want. If I could have cloned myself a couple of months ago, I would have been able to work 80 hours a week. The other side of the coin is that I also now work only 2 days a week and still have financial security. To navigate this world, it is helpful to know the different types of employment that are available. Here are some descriptions and pros/cons to different types of employment.

Salaried employment is what most people think of with a "typical" job. You are paid a set amount per year and usually after a short probation period have an expectation of job security. Promotions may be available more readily, and most management positions are also salaried. Typically, you can negotiate for a raise at your annual review and may get a cost of living raise during this period as well. Salaried workers usually get benefits such as health insurance, life insurance, paid vacation days, and 401K eligibility/matching. CPR and other necessary certifications may be provided and reimbursed at your employer. Continuing education may be reimbursed and days off for education may also be paid. In an OT world, you may need to spend extra time outside of "typical" hours doing work tasks. There may be meetings during lunch times and you may need to stay late to see patients or do paperwork. There may be additional job responsibilities (the infamous "other duties as assigned") like participating in committees, representing the facility at meetings, etc.

Hourly employees may make more money than salaried employees and may be able to opt out of purchasing certain benefits in order to increase their pay. Part time employees will often be paid hourly .Typically, you will not be asked to work overtime because then you will be paid more, and bosses try to avoid that sort of thing. :) You will likely have to keep very close track of your time in, time out, and lunch times to ensure that you are paid accurately. Hourly OTs may still earn paid time off, but will accumulate it gradually as they work each hour. Depending on the employer, hourly employees may not be guaranteed a certain number of hours each day or week, and may also be the first person "furloughed" if someone is looking to cut costs.

Contract employees will likely make more money than salaried or hourly employees, but they are even more costly to the employer than it would seem from that knowledge. If there is a contract company, they are getting paid an extra fee from the facility for that employee. It's a very expensive proposition. It's important to remember that if this facility had any other options other than hiring a contractor (also known as a traveler) that they would have taken it long ago to save money. So there is a potential that you could be walking into a bad situation in one way or another, although you may also just be covering for an extended leave such as a maternity, sabbatical, or medical leave. As a contractor or traveler, all you are getting from the facility is your money. There will be no trainings, no benefits, and they're not going to want to have you taking many days off. You may be able to get these benefits through your contract company, they may also provide relocation assistance. If you have a continuing relationship with them, your contract company will do the heavy lifting of actually finding you placements instead of you looking for job after job, and will help you get through licensing procedures as needed. It's also a good way to see new areas of the country and a variety of practice areas. From the viewpoint of the facility, they will want you to be able to hit the ground running, maintain a higher productivity, and function without assistance. If there's a rehab tech, they are probably helping someone else. If there's a difficult patient, they might be on your caseload. If there's something else that needs done, it may well be shuffled to your schedule. You will be guaranteed a certain number of hours per week, likely for a set time period of a few months to a year. This is often not a good fit for a new graduate who may need more support starting out and is still learning the field. This can certainly be a full-time long-term gig if you live in a metro area or are willing to travel, but there is a degree of insecurity between placements. Contract companies vary with how much they require their employees to do above the actual OT work, as well as what benefits and placements they provide. In an odd twist, some facilities actually employ their entire therapy staff through a contract company instead of having on-site management and hiring. In this case, you operate more as an hourly employee.

Working prn (as needed) or OPT (occasional part-time) involves hourly pay at a high rate like a contractor. You may have a higher productivity standard and will likely not get very much assistance from the staff (both because you're expected to operate independently and because people won't know you as well). Your employers will want you to spend your time efficiently, and so you won't likely be asked to go to meetings or rounds. Similar to contract employment, you are filling a shortage. There is no guarantee of hours per week or continued employment from one day to the next. If you are with a large system such as a brand of nursing homes or hospitals with multiple facilities, you can get frequent calls and make it work as a prime gig, but it's a risky move. This is much better as an option for moonlighting. Many school system OTs have a prn job for summers or weekends to supplement their other pay. Again, this is rough to do as a new graduate (especially if you're balancing multiple facilities or different practice areas) and since you're not going to get staff support, you need enough experience to be independent with what's being asked of you.

There's a lot of flexibility in OT employment and knowing these options can help you make decisions on the jobs that are out there. Check out the "students" label and some of the Greatest Hits entries if you are curious about other facets of finding your OT job.


Keeping Organized

I was lucky enough to be invited to contribute to a couple of OT Month pieces. One was on Abby's awesome pediatric OT blog and the other was for AOTA. In these, I shared some of the organizational tips that I use to try to keep life together. Here is a more elaborate and visual demonstration of some of the best.

My dad teaches high school seniors and as part of his unit on college prep always advises that the kids keep 2 calendars- one for the whole semester and another for the coming 4 weeks. I found this magnetic dry erase calendar at Sam's Club back in 2003 (?) for about $8 and have been using it religiously ever since. I only have to update a week at a time and get to use all the different color markers for coordination. It lives on the fridge and helps keep everything straight.

My high-tech method for the calendar is using Google Calendar, which I'm sure comes as no surprise to anyone who knows of my Google product allegiance. I love that it's integrated with my phone and google account on the cloud. Also, it's easy for my husband and I to add things to each other's calendars so we stay updated, and I can add additional calendars (WVU sports!) so I have other events automatically on my schedule. 

I love these accordion files for organizing all my different papers. I have 3 that I use for different collections of stuff. This one is labeled to keep track of my continuing education for the past five years (required in case of audit in my state), my various licenses, and papers needed for my early intervention renewals.

I got this finance organizer at the dollar store to keep track of my receipts so that I actually had them come tax time. I didn't write in the amounts because I want to reuse it and keep track of all my finances on a computer spreadsheet. You could also use a small coupon file for this same purpose.

In a super-useful variation of the accordion file, this one is broken down for all the days of the month. Especially beneficial when I was in the school system last year as I could place several copies of the relevant evaluation, a prior written notice, and a blank sheet for notes clipped together on the day for the IEP meeting. When I would get an email asking me to screen a child, I could throw the screening papers in the folder on the day I would next be in the school. Very handy when you have multiple sites to coordinate. I got this idea from the book Getting Things Done, which is the only productivity book that I've ever read and very useful.

Speaking of Getting Things Done, one of my favorite apps is Due Today which is based on the methods outlined in the book. You can check out my interview with Stephanie Yamkovenko on the AOTA website to see all the reasons I love this app (one of only a mere handful that I have actually paid for). On the shot, you can see that I have different priority colors, due dates, overarching projects (lots to do in the "baby" category, obvs), contexts, etc. I don't have any notes for these but they are helpful too. Subtasks also help to break up the large pieces and figure out what to do first- you can see that I need to get a cream colored shirt but only if the coral skirt fits. 

Do you have any great methods to stay organized that work well for your business or family? Feel free to share in the comments!


Role Checklist

Cheryl's Role Checklist:
Daughter 198X
Friend 1986
Neighbor 1986
Sister 198X
Student 1989
Teammate 1993
Volunteer 1996
Employee 1999
Roommate 2002
Fiancee 2004
Wife 200X
Professional 2007
Mom 2013

Baby boy and mom are doing well after a mostly uneventful delivery in the middle of a fine April night. We are all adjusting to one another and trying to find our balance. I appreciate all the thoughtfulness from my OT tweeps and real-life friends as well. 

Class of 2025?