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Rehabilitation Services: The Road to Recovery

Wander Community Hospital's main campus and take in the elements of the healing environment. Notice the colorful koi milling around in the central pond, darting in and out of the fountain spray. Study the legendary collection of fine art gracing the walls, and the sculptures exhibited throughout the interior landscape of the hospital. Stroll the lush gardens planted with native foliage and notice the subtle elegance of the architecture carried from classic to contemporary construction. Aesthetically, it is a place that promotes healing.

"But when it comes to creating a healing environment, it takes more than a koi pond," says Alain Claudel, director of Rehabilitation Services. "Sure, the pond creates a beautiful environment; the whole building looks wonderful. And it certainly is a reminder to the professionals who work here to match the aesthetic of the environment with our dedication and skill. But it is the people, the patients and the staff, who make this an environment of healing. Anybody who is hired by Community Hospital is here for a reason - because, in addition to specialized skills, he or she understands the tremendous responsibility we have to care for this community and care for them well."

The Rehabilitation Services department provides acute-care and outpatient services in physical, occupational, and speech therapy - with many specialized services from the therapists, most of whom have advanced certifications and/or doctorate degrees. Since December 2006, the department's wound-care services have been augmented by the addition of hyperbaric medicine.

Essentially, physical therapy deals with joints, muscles, and nerves, and anything that can go wrong with them. The physical therapist is there to restore movement. The occupational therapist, meanwhile, is less interested in the systems generating the movement and more focused on getting the patient to move for a specific reason - to perform work functions or simply to re-learn the activities of daily living. Speech therapists, on the other hand, deal with cognitive skills; their expertise also lies in communication and comprehension.

"Like the Olympic rings," says Claudel, "our three disciplines have overlapping circles of treatment. We usually take a team approach, bringing in therapists with different expertise who work together to promote healing. And we definitely consider the patient an important part of that team."

From toddlers to geriatrics, stroke patients to cancer survivors, injured athletes to wounded weekend warriors, Community Hospital's rehabilitation program works to restore what has been wounded, compromised, or lost. Through a wide range of services that includes wound care, hand therapy, swallowing skills, and balance - an extraordinarily comprehensive offering from a community hospital - the rehabilitation therapists know how to make a difference in your attitude, your recovery, and your life.

Hyperbaric oxygen therapy

Hyperbaric oxygen therapy is one of the many things that makes Community Hospital special. It is a treatment in which a patient breathes 100-percent oxygen while inside a pressurized chamber.

In Monterey County, we are at sea level. That means we experience 1 atmosphere of pressure during our daily lives. The hyperbaric chamber, on the other hand, can be adjusted to deliver up to two additional atmospheres of pressure. Coupled with the inhalation of 100-percent oxygen, this results in a dramatic increase in oxygen to the body's tissues. Rest assured, you won't get the same results with a stop at the oxygen bar at the local mall.

Many people associate hyperbaric oxygen therapy with divers. If divers return to the surface of the ocean too quickly, nitrogen in the body can form bubbles that can become trapped in the body, causing pain and a life-threatening condition commonly referred to as "the bends." The oxygen helps flush out the nitrogen, and the pressure in the chamber crushes the bubbles to make them small enough to get through tiny blood vessels and eventually be expelled out of the lungs.

Community Hospital's state-of-the-art hyperbaric oxygen chambers are used not for diving accidents, but rather for selected non-healing wounds, deep-tissue infections, chronic bone infections, injury from radiation treatment, and compromised tissue grafts. The compressed oxygen is dissolved into the blood, which can carry a high concentration of oxygen to damaged tissue. And oxygen is critical for healing. Perhaps the most important feature of hyperbaric oxygen is that it stimulates the growth of new blood vessels, which can then support new tissue growth.

The high concentration of oxygen also improves the efficiency of white blood cells, which helps clear up infection, enhance the performance of oxygen-dependent antibiotics, and reduce edema (swelling) that sometimes gets in the way of healing. "Hyperbaric oxygen therapy can be used for certain non-healing wounds," says Dr. Ed Johnson, medical director of Wound Care Services and Hyperbaric Medicine at Community Hospital. "But we also treat patients who have compromised skin grafts or flaps.

"A bad crush injury to the leg, for instance, can become swollen quickly. But we can reduce the swelling right away, which allows blood flow to become unrestricted. Because this high concentration of oxygen can pass through the bloodstream in the liquid phase, it can get into small spaces, even where tissue might be crushed.

"Hyperbaric oxygen therapy can also stop the progression of gangrene infection, because the anaerobic bacteria do not like oxygen. By halting the production of the bacteria, white blood cells are able to get in there and clean things up." In many instances, hyperbaric oxygen therapy supplements traditional treatments such as surgery and antibiotics.

Pain management

Let's say you bend over to pick up a sock and your back goes out. You wait a few days and think you are getting better, but then everything seems to go backward. You hurt more than ever.

When pain persists, it may be a matter of learning to manage it with methods such as heat or cold therapy, mindful meditation, or massage. But often, through some investigative work into the source of the pain, whether it be the postures, activities, or injuries compromising your muscles, it is possible to mitigate pain with "trigger-point" therapy or other therapies.

Trigger-point therapy is a hands-on approach designed to identify spasms in the muscles and then work to release them by putting pressure on the source to alleviate pain. The pioneer of this therapy was cardiologist Janet Travell, physician to presidents John F. Kennedy and Lyndon B. Johnson and the woman credited with discovering that left-arm pain signals a heart attack.

"The spasm," says Joy Colangelo, occupational therapist at Community Hospital, "impinges on the nerves which travel through the muscles, causing pain to radiate in a certain pattern. Knowing these patterns leads the therapist to the source, revealing the culprit of the pain. Dr. Travell was a master at this."

Whether it is the way you drive, sit, stand, or hold physical or emotional tension, or an old injury that predisposes you to pain, it's important to realize that your throbbing muscle is simply trying to solve the problem.

An irritable muscle is usually a sign that you're using the muscle for the wrong job, asking it to do something outside its job description. With some posture adjustments, allowing the correct muscles to come into play, the sore muscle no longer has to compensate.

Swallowing therapy

Chances are, you take it for granted, downing everything from peanut butter milkshakes to 8-ounce Porterhouse steaks without a second thought. But swallowing, that vital exercise essential to enjoyable eating, can be compromised. Some 15 million Americans suffer from swallowing disorders that may be the result of a head injury, stroke, aging, diet, or possibly even medications.

In general, the American diet is basically soft. "We have 30 to 40 swallowing muscles in the neck, and we should be grinding nuts and dried meats and grains to keep them strong," Colangelo says. "If people do that, they tend not to develop swallowing disorders."

Most of the people seeking swallowing rehabilitation have suffered a stroke. The therapy in this case may include exercises to help strengthen the swallowing muscles and the introduction of a diet easily swallowed.

After about three weeks of therapy, most swallowing muscles will return to use. That helps the patient avoid a lot of medical procedures.

In addition to muscle strength, body positioning when we eat is very important to the way we swallow. Case in point: Remember the old mantra about eating a square meal? Well, it was developed at West Point, says Colangelo, and it's not about the food we eat but rather about how the body should be positioned at square angles when we do eat. That's the reason we shouldn't be standing or lying down when we eat.

Osteoporosis therapy

Some 44 million Americans, or 55 percent of those 50 and older, have osteoporosis. A bone disease that compromises the skeletal structure, osteoporosis can leave the body vulnerable to a fracture or unable to support itself. While medications are available, prevention is considered the most viable approach to avoiding fractures.

Nevertheless, there are various treatments that can slow the progress or mitigate the effects of osteoporosis.

"Our treatment program," says Community Hospital's Marta Lynch, occupational therapist, "includes physical and occupational therapy and dietary consultation with a clinical dietitian. We address issues of posture, strength, balance, and gait. Our goal is to facilitate movement, prevent falls, and help protect the spine. We're trying to help patients so they don't injure themselves, and particularly so they don't fall and break a hip."
On a practical level, the focus is on how to live everyday life with osteoporosis, how to engage in routine activities functionally and safely. For instance, what is the best way to pick up a laundry basket? Weed the garden? Get out of a car?

Based on a doctor's referral, one-on-one treatment programs are customized for each patient. Therapies may include home safety and fall prevention suggestions, upper body strengthening, and weight-bearing exercises, as well as calcium supplements and other dietary recommendations.

Wound care

The body is a miraculous agent of healing and restoration. But sometimes a wound just won't heal. Wound care management, says Community Hospital's Stephanie Ruskell, physical therapist and certified wound specialist, requires looking at the whole person - his or her circulatory system, sensory system, nutritional needs, and anything such as diabetes that could possibly contribute to why this wound isn't healing as quickly as it should.

"Our job," says Ruskell, "is to create the perfect environment for the wound, which means keeping it clean and moist and controlling the bacteria that could set in. Our concern is any wound that has not healed quickly; a chronic problem would be a wound that has persisted for more than 30 days."

Most important, says Barbara Dangerfield, hospital physical therapist and certified wound specialist, is to address the underlying cause of a wound. Many patients believe that to treat a wound they simply need to put something on top of it. But if the problem lies beneath the skin, the best topical care may not heal the wound.

"If a wound is not healing," says Ruskell, "it could be because the veins are not getting the blood back to the heart, so the blood pools at the site and creates a wound. In this case, we wrap the wound; it's all about compression, compression, compression."

An equally important part of wound management, says Dangerfield, lies in understanding the impact that chronic wounds have on people's lives. People become embarrassed, socially isolated, and incapacitated. "Our goal," she says, "is to make them comfortable and to help enhance the quality of their lives."

Vestibular treatment

The phenomenon is not uncommon: Someone drifts off to sleep, wakes up in the morning, sits up in bed, and suddenly the room starts spinning. And they didn't have anything to drink the night before. Really.

It may be benign paroxysmal positional vertigo. And you can blame it all on ear rocks. Yes, ear rocks.

Our ears house "rocks" made of calcium carbonate. When those get displaced for some reason, it can lead to vertigo.

"It can cause dizziness, nausea, and vomiting," says Community Hospital's Eric Folkins, physical therapist, doctor of physical therapy, and orthopedic clinical specialist. "It is treated by relocating the displaced rocks in the inner ear. We usually can treat it very successfully, with up to 95-percent improvement in just one or two visits."

Folkins also works with patients experiencing general balance problems. These patients feel unsteady and off-balance, as if they are the ones spinning, not the room. Folkins investigates their history, assesses their somatosensory (muscles and joints, particularly the ankles) system, and determines the source of the problem.

"To strengthen an impaired vestibular (inner ear) system or just to improve balance," Folkins says, "we have patients perform various exercises such as walking down the hallway, turning their head side to side or up and down, balancing on one leg or on a piece of foam. We have great outcomes; a lot of times people walk out of here the same day feeling great."

Hand therapy

There are 27 bones in the hand, supported by a very complicated ligament-tendon structure that provides an amazing ability to deal with our world. The hand is integral to how we care for ourselves and others, how we drive and play ball, and how we create art and communicate with others. And it is usually our first line of defense in protecting ourselves.

It's no wonder that to specialize as a hand therapist requires a minimum of five years' therapy experience and thousands of hours of direct hand therapy.
"There aren't too many of us," says Amy Britton, hospital occupational therapist and certified hand therapist. "We deal with everything from post-surgical patients and fractures to burns and laceration repairs to arthritis. We teach patients how to manage symptoms and learn to live with them so they can function in everyday life without causing more trauma to the joints."

Her focus, says Britton, is on function - the things a patient needs to get through a day of caring for self and family, performing on the job, driving, or managing a home.

"You really have to understand the biomechanics and the anatomy of the hand," she says. "It's all about balance. When you disturb one part with a fracture or other injury, the whole hand is incapacitated, and so is your day."

Lymphedema program

Lymph nodes are part of the body's immune system, responsible for fighting infections and filtering the blood. But when the lymphatic system becomes overloaded because of damage or disease, the fluid can accumulate and lead to a condition called lymphedema, a swelling of the affected area. Although lymphedema most commonly affects the arms and legs, it can develop anywhere in the body.

Primary lymphedema happens when the lymphatic system is not fully developed, which may or may not be caused by a genetic factor. Secondary lymphedema occurs in response to damage to the lymphatic system by an external source such as surgery, radiation, or the removal of lymph nodes.

"To treat lymphedema," says Community Hospital's Lucy Gomez, physical therapy assistant, "we use comprehensive physical therapy. Included in that is a massage technique that directs the fluid up and out of the limb toward the heart."

If the lymphedema is significant, patients wear a multilayered bandage or compression garment over the area, helping to move the fluid out of the limb.

"We also perform Lebed exercises, a new technique developed to help with lymphatic flow," says Community Hospital's Wendy Neglay, physical therapist and doctor of physical therapy. "We educate patients about proper skin care so their skin doesn't dry and crack. The lymphatic system not only deals with fluid but is part of our immune system, so any openings in the skin can put the patient at greater risk for infection. We teach patients how to perform self-drainage and how to put on and care for their compression sleeve."

Neurophysiologic testing and neurological rehabilitation

It sounds like something that could have been in George Orwell's book 1984. Nerve conduction. Velocity. Electromyography.

Neurophysiologic testing entails assessing the function of the peripheral nervous systems and the muscles, using nerve conduction velocity tests and electromyography. The scope of the practice is to provide test results that enable physicians to determine if nerves or muscles are the culprit of a patient's troubles.

The four primary conditions under consideration are: nerve entrapment, resulting in conditions like carpal tunnel syndrome; radiculopathy, manifested in pinched nerves in the neck or back; polyneuropathy, which creates tingling and numbness in the feet; or myositis, disease in the muscles themselves.

"Neurological rehab comes into play when somebody suffers a stroke or among patients with MS (multiple sclerosis) or ALS (Lou Gehrig's disease)," says Claudel. "In these cases, we get all three of our disciplines involved: our speech therapists to deal with articulation; our occupational therapists to look at functions, especially the hands; and our physical therapists to work on balance, strengthening, and retraining motor functions. We work well together."

Pelvic floor therapy

You've heard the hushed tones, the nervousness, the embarrassment. Women gathered together talking about how their bodies have changed and wondering why. Men silently agonizing over the whereabouts of the next restroom. Maybe you've even seen the commercials and advertisements about how you don't have to suffer from incontinence. No more rushing to the restroom. No more worrying when you cough or sneeze.

Pelvic floor therapy deals not only with incontinence, but with any abnormality or condition causing chronic pain or reduced muscle tone, says Community Hospital physical therapist Jil Johnson. Various events can weaken or cause dysfunction of the pelvic floor, including aging, pregnancy, childbirth, chronic constipation, or surgery.

Common candidates for pelvic floor therapy are post-radiation patients, women who have had children or undergone uterine or ovarian surgery, men after prostate surgery, and anyone following back surgery.

"I spend a lot of time," says Johnson, "assessing the sacroiliac joint, which connects to the pelvic floor and lower back. And I am able, through internal or external work, to reduce many symptoms of lower-back pain."

Therapy, she says, also involves education on the anatomy and function of the pelvic floor, as well as dietary effects on bowel and bladder function, pelvic floor exercises, and other treatments to address abnormally high or low muscle tone.

"Biofeedback," says Johnson, "is a large part of therapy. Biofeedback has to do with body awareness, targeting certain muscle groups, and learning how to use them effectively."

For more information about Rehabilitation Services programs, please call 625-4835.

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