How To Make COPD Rehab Effective With Physical, Occupational & Speech Therapy

COPD is likely a condition you have encountered: No matter where you work. The role of the Physical, occupational and speech therapist will vary depending on the stage of the disease, and our goals can be effective at every level! Here, we will delve into the different stages of COPD and examine how each stage can be approached from a therapeutic standpoint.

What is COPD?

Chronic Obstructive Pulmonary Disease (COPD) is a progressive lung condition characterized by airflow limitation and respiratory symptoms such as coughing, wheezing, and shortness of breath. As the disease advances, your patients may experience reduced functional capacity and impaired quality of life.

However, a patient with COPD can still benefit from comprehensive rehab! Symptom management, QOL improvement, and overall wellness are some of the goals that therapists can work on with individuals who have COPD.

Stage 1: Mild COPD

In the early stages of COPD, patients often experience mild symptoms and have minimal limitations in their daily activities.

Physical therapy plays a crucial role in this stage by focusing on exercise training to maintain respiratory muscle strength and overall physical fitness. Endurance exercises, such as walking or cycling, can enhance cardiovascular fitness and improve the body’s ability to utilize oxygen. Respiratory muscle training, including deep breathing exercises and inspiratory muscle training, can help strengthen the respiratory muscles, enhancing lung function.

Occupational therapy in this stage aims to maximize functional independence. Therapists assist individuals in adapting their daily routines and environments to conserve energy and reduce breathlessness. Strategies such as pacing activities, energy conservation techniques, and assistive devices can be employed to optimize occupational performance and facilitate self-care tasks.

Did you realize that CBT can have a huge impact on COPD symptoms? Check out this article here!

Speech therapy may not be the primary focus in mild COPD, but it can still provide valuable benefits. Therapists can address issues related to breath support, vocal quality, and communication strategies. Techniques such as breathing exercises, posture training, and vocal hygiene practices help individuals maintain effective communication and minimize the impact of respiratory symptoms on their speech.

Stage 2: Moderate COPD

As COPD progresses, symptoms worsen, and physical limitations become more apparent. In this stage, physical therapy continues to emphasize exercise training but may also incorporate breathing techniques and airway clearance strategies. Pulmonary rehabilitation programs are particularly beneficial, combining supervised exercise sessions with education, nutritional counseling, and psychological support.

Check out the therapeutic goals for Heart failure cheat sheet right here!

Occupational therapy aims to optimize performance in activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Strategies to modify the home environment, simplify tasks, and facilitate energy conservation become crucial. Education on adaptive equipment and techniques for managing dyspnea during various functional tasks can significantly improve independence and quality of life.

Speech therapy becomes more relevant in moderate COPD, addressing not only respiratory-related speech issues but also swallowing difficulties that may arise. Techniques such as vocal exercises, relaxation techniques, and postural adjustments can help individuals control breath support during speaking, enhancing intelligibility. For individuals with swallowing problems, therapists can provide swallowing exercises, dietary modifications, and strategies to reduce the risk of aspiration.

Stage 3: Severe COPD

At this advanced stage of COPD, individuals often experience severe limitations in physical activities and require more intensive therapeutic interventions. Physical therapy focuses on maintaining functional capacity through exercise training tailored to the individual’s abilities and limitations. Respiratory techniques, including pursed lip breathing and diaphragmatic breathing, help manage dyspnea and improve oxygenation.

Occupational therapy addresses the challenges faced by individuals with severe COPD in maintaining independence and participating in meaningful activities. Assistive devices, modifications to the living environment, and energy conservation techniques are employed to enhance function and promote engagement. Psychosocial support becomes essential to manage the emotional and psychological impact of the disease.

Speech therapy in severe COPD primarily addresses dysphonia, reduced intelligibility, and cognitive-communication difficulties. Therapists work on strategies to optimize voice production, improve speech clarity, and enhance communication effectiveness. Augmentative and alternative communication (AAC) systems may be explored for individuals experiencing severe speech impairments.

A comprehensive approach to COPD rehabilitation that incorporates physical, occupational, and speech therapy can significantly improve the well-being and functional capacity of individuals at different stages of the disease.

By tailoring interventions to address specific symptoms and limitations, therapists can empower COPD patients to manage their condition effectively, enhance their quality of life, and promote optimal overall health.

If you are interested in COPD and the impact of therapy on other chronic conditions, you may enjoy ‘Update your care Plan: Heart Failure!’ This seminar focuses on improving and upgrading your therapeutic approach to HF for best results possible.

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Lymphedema Management And The Role Of The Physical Therapist

Lymphedema is a chronic condition that affects millions of people worldwide. As a physical therapist, you play a crucial role in managing this condition and improving the quality of life for your patients.

To provide the best care, it’s essential to understand the different stages of lymphedema and tailor your interventions accordingly. Here we will delve into the stages of lymphedema and discuss the vital role physical therapists play in each stage.

Lymphedema is usually categorised into three stages – and each stage can be approached with different clinical goals and objectives.

Stage 0: Preclinical or Latent Stage

The preclinical stage, also known as stage 0 lymphedema, is often overlooked but holds significant importance. During this stage, patients may not exhibit any visible swelling or overt symptoms, but they may experience subjective sensations such as heaviness, tingling, or tightness in the affected limb.

As a physical therapist, your role in this stage involves educating patients about risk reduction strategies, emphasizing skin care, promoting regular exercise, and providing self-management techniques. Early intervention and education can help prevent or delay the progression of lymphedema.

Download our (free!) Edema Management Ebook here! Resources to manage swelling in any setting are included!

Stage 1: Mild or Reversible Stage

Stage 1 lymphedema involves mild swelling that is reversible with appropriate treatment. Physical therapists play a critical role in managing this stage by implementing complete decongestive therapy (CDT). CDT comprises manual lymphatic drainage (MLD), compression therapy, exercise, and skin care.

MLD, a gentle massage technique, aids in rerouting lymph flow and reducing swelling. Physical therapists may also teach patients self-MLD techniques for daily maintenance. Additionally, prescribing appropriate compression garments and devising tailored exercise programs are integral components of your role in this stage.

Want to learn to Teach your patient Diaphragmatic Breathing? Check out this video!

Stage 2: Moderate or Spontaneously Irreversible Stage

In stage 2 lymphedema, patients experience a moderate increase in swelling that may not fully reduce with elevation or rest. This stage is characterized by the formation of fibrotic tissue, leading to irreversible changes in the affected limb.

As a physical therapist, your role is focused on managing and minimizing the progression of lymphedema-related complications. CDT remains a cornerstone of treatment, but you may need to incorporate advanced techniques such as multi-layered bandaging and pneumatic compression devices. Your expertise in manual techniques, scar management, and exercise prescription becomes crucial in this stage.

Stage 3: Severe or Lymphostatic Elephantiasis

Stage 3 lymphedema represents the most advanced and severe form of the condition. Patients in this stage experience significant swelling, skin changes, and potential functional impairments. As a physical therapist, your role involves implementing complex interventions to manage symptoms, improve lymphedema limb function, and enhance quality of life.

Customized compression garments, lymphatic massage, skin care, and exercises tailored to individual needs are essential components of therapy. Collaborating with other healthcare professionals, such as wound care specialists, may also be necessary to address concurrent complications.

Physical therapists play a pivotal role in the comprehensive management of lymphedema across its various stages. From early education and prevention strategies to advanced treatment modalities, their expertise is indispensable in improving patient outcomes and enhancing their overall well-being.

By understanding the different stages of lymphedema and tailoring interventions accordingly, you as a physical therapist can provide exceptional care and support to their patients, empowering them to lead fulfilling lives despite this chronic condition.

If you found this program development article helpful, you’ll love our popular and engaging seminar on the topic of Edema Management. Check it out and read more right here: Edema Management in In-patient Rehabilitation!

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The Value of Physical Therapy in Wound Care

Wound care is far more than just changing a dressing!  When dealing with wounds, there are many things to consider. 

It’s important to take note of how the wound formed in the first place, in order to prevent further wounds from developing.  It’s also very important to know what type of wound it is – as all wounds are not created equal!  You also want to take note of how the wound may be impacting the way the person is able to move around and function in their environment.  Once you know what you’re dealing with, you can develop a plan to treat it.   There are many different team members that can (and should!) be involved in the wound care process… one of them being Physical therapists!

If you are not sure where or how to start your wound care journey, this course is a must for you: A Comprehensive Guide to Wound Care: Tools for the Everyday Clinician

Let’s explore some of the ways a Physical Therapist can be an effective member of a wound care team. 


The best-case scenario is to stop the wound before it starts!  This is where persistent patient and caregiver education can make a huge difference.  There are many disease processes that put patients at higher risk for developing wounds, such as diabetes, chronic venous insufficiency, spinal cord injury, etc.  Each situation will be different from the next, but providing various tools and resources to these patients is essential.  Many times this will include footwear or positioning devices to provide protection and/or prevent high pressure on bony prominences. 

Direct and Indirect Wound Care:

There are also many ways that a Physical therapist can provide direct wound care or provide an adjunct treatment that would facilitate faster healing through increasing circulation, etc.  Here are some examples of how a physical therapist can affect changes in wounds:

  • Sharp Debridement – Sharp debridement is a component of physical therapy wound management involving the use of forceps, scissors or a scalpel to remove devitalized tissue, foreign material or debris from a wound bed.  Depending on the state you are practicing in, this may require extra training before putting it into practice. 
Pulsed lavage with suction
  • Pulsed lavage with suctionThis is a method of wound cleansing that allows for more control over the pressure of the irrigation used.  This allows for more bacteria to be removed as well as loose necrotic tissue and debris left on the wound bed.  Continued research is needed to identify the exact parameters (or psi) to use for each specific type of wound, but this is a great option for PTs to use in wound cleansing.
  • Electrical stimulation – High-voltage pulsed current (HVPC) can be used to increase capillary perfusion, and therefore increase oxygenation of the wound bed.  This will then encourage granulation and fibroblast activity and speed up wound healing.
  • Ultrasound – Physical therapists use therapeutic ultrasound to deliver mechanical vibrations of a high or low frequency to promote cellular healing.  Physical therapists frequently use therapeutic ultrasound to ease pain, improve circulation, and improve soft tissue mobility. In addition, using ultrasound can assist in wound and injury healing, pain relief, and the reduction of inflammation.
  • Laser – Laser therapy can help to create a more ideal environment for wound healing by promoting an highly oxygenated setting and helps bring more needed nutrition and white blood cells to the area to promote healing.
  • Ultraviolet light therapy – According to reports, ultraviolet therapy is a promising addition to treatment for chronic wounds infected with resistant bacteria because it kills bacteria and speeds up wound healing.  Psoriasis, atopic dermatitis, vitiligo, mycosis fungoides, and hand/feet eczema all benefit from ultraviolet therapy.  Despite the fact that ultraviolet therapy has been shown to be effective in the treatment of wounds and other skin conditions and that physical therapists play a significant role in its application, anecdotal evidence suggests that this treatment method is not commonly used in regular clinical practice.
  • Negative pressure wound therapy – A technique known as negative pressure wound therapy (NPWT) aids in wound healing by removing fluid and infection. The wound is covered with a special dressing (bandage) and a gentle vacuum pump is attached.
  • Lymphatic drainage and compression bandage techniques – In order for a wound to heal, it has to have a certain balance in its environment.  If too many “toxins” are present, the wound will take longer to heal.  This is where the lymphatic system comes in!  If there is edema present with the wound, we must clear the area of the stagnant lymphatic fluid in order for the “toxins” to be flushed out and the wound to get the nutrients to it that it needs. 

Manual lymphatic drainage (MLD) is a gentle, stretching massage that helps move lymphatic fluid out of swollen limbs by stretching the skin. It is not the same as a traditional massage. In order to facilitate the flow of lymphatic fluid, MLD focuses specifically on the lymph vessels. Your unaffected areas receive therapy first, allowing the fluid to “decongest” the area or move out of the affected area. MLD helps open the leftover working lymph gatherers and move protein and liquid into them, as well as to assist with accelerating lymph liquid course through the lymphatics.  A multi-layered compression bandage complex used in conjunction with manual lymphatic drainage techniques will further facilitate the movement of lymph out of the area of the wound, which will allow for the wound healing process to move forward.

  • Exercise In many instances, weakness and/or diminished mobility worsen wounds. An exercise program will be created by a physical therapist so that the person with a wound can move around their environment as safely as possible without risk of injury. Physical activity and exercise can sometimes speed up the healing process by improving circulation to the area and relieving pressure around the area through frequent repositioning.
  • Scar management – There are several techniques a Physical therapist can use to help manage scars after a wound has healed.  These include massage, myofascial release, cupping, stretching, taping, IASTM, and desensitization. 

How do I get started in wound care?

Don’t delay!  Wound care is already within your scope of practice as a Physical therapist!  You can start with the basics and go from there.  There are several training courses to become more skilled as you gain more confidence.  A Comprehensive Guide to Wound Care: Tools for the Everyday Clinician is a great one to start with.  This course will give you all the necessary knowledge and tools that you can use with your patients right now!  This course not only with give you the confidence to start treating wounds, but will also allow you to have more informed discussions with the team and become part of the decision making process for what to include in the plan of care.

How do I become a specialist in Wound Care?

If you’re looking to continue your wound care journey, there are several options out there for Physical therapists to become certified specialists.  Check these out and see what you would need to do to qualify and apply for these certifications.

Board-certified Wound Management Clinical Specialist

Certified Wound Therapist

Certified Wound Specialist

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Personality Changes After Brain Injury: What a Clinician Needs to Know

One of the most intimidating issues for caregivers, families, and the person affected by brain injury is: personality changes.

Personality changes are reported by family, friends, and caregivers to be the biggest contributor to caregiver burden and burnout – even more so than continence issues or mobility issues. How often have we heard that this person is ‘no longer themselves’ after their injury? Here, we are going to examine whether personality changes with brain injury – how we can adjust our expectations – and tips for therapists and families to navigate this tricky field.

How common are personality changes after brain injury?

A study published in the Archives of Physical Medicine and Rehabilitation found that 59% of persons with severe brain injuries demonstrated changes in personalities as rated by their significant other. That’s pretty significant! So what does the clinician need to know?

What kind of changes to personality might you see post brain injury?

Poor Frustration Tolerance

When a person is tired or stressed, new situations, or when they are in a bad mood, they may have trouble with their ability to handle frustration. A person who has had a traumatic brain injury (TBI) may become more likely to lash out in anger and become physically or verbally aggressive.

Trouble following through with tasks

People who have suffered a TBI  may have difficulty staying focused or paying attention. Attention is the foundation of all other cognitive skills. Having trouble paying attention can frequently result in additional issues and challenges, such as: a greater propensity to become distracted, difficulty completing tasks, difficulty switching attention from one task to another, difficulty remembering and learning new information, difficulty maintaining lengthy conversations or focusing on one conversation when multiple people are talking.

Poor self-awareness in social situations

Poor self-awareness in social situations

Everyone has issues with self-awareness to some degree;, but people who have experienced a TBI  are not truly adept at assessing our own capacities. Damage to brain structures that allow us to self-monitor can make it harder to be aware of oneself after a TBI. It can be difficult for people with TBI to adjust their perception of what they can and cannot do because they may lose the ability to self- monitor how well they perform everyday tasks. Self-awareness difficulties following a TBI are thought to be primarily caused by damage to the brain itself, but emotional coping and adjustment issues can also have an effect on self-awareness.


Family members of people who have a TBI often say that the injured person has a “short fuse,” “flies off the handle” easily, is irritable, or has a quick temper. Studies show that up to 71% of individuals with TBI have issues with increased irritability. The person with the TBI might scream, use bad language, throw things, slam doors, slam fists into things, or threaten or hurt family members or others.



After someone experiences a TBI, one of the most common issues is anger. When someone with  a TBI struggles with anger, a number of factors often come together. Often times, people with TBI are angry because of the injury itself and/or the issues that may have arisen as a result, such as physical disabilities, the loss of a job, friends, money, and control over one’s life. Also, people who had anger challenges prior to their injuries could continue to have magnified issues after.  People who are unfamiliar with the survivor’s injury are often quick to assume that the person can control how they are reacting, when in fact, they cannot.   To put it another way, the brain regions that normally prevent a person from acting or feeling irate have been damaged and cannot perform their duties as effectively. This means that the person’s tolerance for anger is lower, making it easier and more intense for them to get angry. We can tell that the brain injury is directly responsible for this impulsive anger when:

  • Anger episodes may be in response to minor events.

  • The person experiencing the anger episodes is surprised, embarrassed, or distressed by them.

  • Anger is often made worse by physiological stress, such as fatigue, pain, or low blood sugar.

Need help understanding how to navigate these tricky areas? Check out this course


Aggression  following a TBI is more common than you might think. Research in The Journal of Neuropsychiatry and Clinical Neurosciences conducted a study in 2009 to evaluate 67 individuals who had suffered a TBI for the first time. Within 3 months of the injury, over 28% of them displayed post-TBI aggression (primarily verbal). In most cases, the aggression was associated with the onset of depression among other psychosocial problems. When things don’t go as planned or when there are disagreements with family or coworkers, they are frequently cited as having a short temper. Outbursts of verbal or physical aggression may outburst when this is associated with poor behavioral control.

Read this real life story about Hope, an OT and wife of a person with TBI

How can we help patients, families, and ourselves to deal with personality changes post brain injury?

family with tbi

There are three main ways to assist with managing personality changes post TBI:  stay present, calm, and don’t argue; provide structure; and make a plan and meeting their needs.  Keeping those things in mind is definitely easier said than done, but it’s important to remember that recovering from a brain injury is a process, meaning the person will continue to evolve and change and we, as the caregivers/professionals, have to evolve and change with them. 

For more information on these strategies see this article:  Agitation and Brain Injury (TBI):  How to Manage

It’s also important to have the person with the TBI continue to receive therapy in some form to assist with self-awareness and improving overall insight. This can come in form of physical, occupational, or speech therapy in a structured clinic setting or also from a neuropsychologist who is well versed in managing people who are recovering from a TBI.  If therapy is not possible at the moment, there are a wealth of resources available online to assist you. 

For more information on tips to improve social skills in something with an acquired brain injury, see this article:  Social Skills Post ABI – this took is a game changer!

As a loved one of the person with the TBI, it’s key that you adjust your expectations and almost ‘grieve’ who the person was before their injury.  It’s important to meet them where they are in that moment, and not where you want them to be, or where you think they should be.  Self-care is very important – seeking out therapy for yourself is just as important as therapy for your loved one.  It’s ok to need some help with adjusting – no one is expected to seamlessly transition after a major life altering event. 

The entire family is affected when someone sustains a TBI. According to research, caregivers of people with TBI may experience feelings of burden, distress, anxiety, rage, and depression.  And interestingly enough, personality and behavior changes are stated by caregivers to be the largest things that contribute to caregiver burden. Recognizing how stressful this situation can be and seeking support services are important if you are caring for a partner, spouse, child, close friend, or other relative who has a TBI.

As a caregiver, you will probably find it challenging to obtain sufficient and appropriate services for your loved one. It’s important to know that you will need to continually advocate for your loved one, as well as yourself.  Staying well informed and grounded are going to be the most important things that will help you continue assisting your loved one with managing their brain injury

Interested in becoming a CBIS? Check out the Certified Brain Injury Specialization (CBIS) Training

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What Are The 5 Treatment Strategies For Pusher Syndrome

When your patient has pusher syndrome, it can be exhausting… to say the least!  They have an overwhelming compulsion to push themselves over, and in the beginning of their rehab journey, it seems like nothing will stop them from this incessant pushing. 

So why do they do it? 

Pusher syndrome can be categorized as an impairment in body orientation perception.  When a patient who has pusher syndrome is sitting upright, in midline – they feel as though they are leaning (approximately 18 degrees) toward their unaffected (strong) side.  So, in order for them to feel like they are sitting straight, they push themselves toward their affected (weak) side to get themselves to what they think is midline.  And, as we have all seen… they often overcompensate! 

Also, if a patient has other impairments happening concurrently, such as visual, proprioceptive, and motor impairments, this makes knowing the correct body orientation even more difficult. 

Let’s explore this a bit further and see how we might be able to help!  Who does this affect and how can we stop the pushing, once and for all!

Want to upgrade those stroke skills? Check out Inpatient Stroke Rehab: 14 Strategies to Get Your Patient Home!

Who gets Pusher Syndrome and who doesn’t?

Any patient can experience pusher syndrome after a stroke, no matter where the stroke occurred in the brain.  Depending on the source you look at, there is a wide variety when it comes to the exact number or percentage of patients that pusher’s occurs with.  However, a consistent finding is that pusher syndrome is more prevalent when the stroke occurs in the right hemisphere vs. the left.  This could be due to uprightness being controlled more by the right side of the brain.  Pusher syndrome also requires more time for recovery when the stroke occurs in the right hemisphere.  So, knowing that any of our patients could be experiencing this phenomenon… let’s make sure we are prepared to help them overcome it!

5 Strategies to Help our Patients Overcome Pushing

Strategy #1: Re-orientating them to true vertical

First thing’s first – since they have a skewed perception of vertical, we want these patients to relearn where they are in space.  There are several different ways to achieve this.  If their vision is mostly intact, we want to provide visual feedback in the beginning.  Teach them to use their eyes, when their bodies and brains are sending them mixed signals.  Place a mirror in front of them, use vertical lines on the mirror or in the environment for them to line up with, use yourself as a guide by sitting in front of them and having them match your posture.  These are great forms of external attentional focus, which we know is going to produce better motor learning and retention! 

Read this article to find out more about motor learning!

pusher syndrome

When reorienting someone with pusher syndrome back to vertical, make sure you start with their head and eyes.  If they are not able to hold their head in midline due to spasticity or weakness, orienting their body to midline is going to be a difficult task.  The same applies if your patient has a field cut (or other visual impairments).  Addressing these things first is of utmost importance in order to have success in pusher syndrome rehab. 

In the beginning of the rehab process, when pushing is strong, simply placing them in front of a mirror may not do the trick.  You may need to give them physical support. 

Our first instinct, with pusher syndrome, is to sit on their weak side (the side they are pushing toward)… and push back!  But this is the opposite of what we should do!  Remember, they feel as though they are leaning toward their strong side, so we want to provide a sense of security for them… so they don’t have the urge to push.  We want to provide support from their strong side.  This seems counterintuitive, but we need to retrain their brain that they will not fall, even though they feel like they are leaning.  This could come in several forms.  You could position their strong side next to a wall, so they see and feel that even if they are leaning in that direction, there is no way they will fall… because there is a wall there. 

You could also place large bolsters or the tall end of a wedge next to their strong side.  This would give them the feedback of support, but still allow you to position yourself in front of them or on their other side if needed.  You could also have them weight bear through their elbow onto the object you’ve placed next to them, so they have to actively lean toward the side they want to push away from.  Whether they are positioned next to a wall or bolster, you want to have your patient with pusher syndrome attempt to lean outside of their base of support toward their strong side, all while educating and verbally and visually orienting them to midline.  This could look like rolling a large therapy ball toward their strong side or reaching for various objects.

As your patient with pusher syndrome progresses, and the pushing is less strong, you want to wean the amount of support you provide, so they can adjust the amount they are pushing (and eventually abolish it!).  This may mean placing their “pushing hand” on something mobile like a rolling stool or rolling table during their transition from sit to stand – this almost eliminates the possibility of them pushing as the stool moves instead of them!  And with practice, your patient will learn to modulate how much pressure they put through that hand. 

You can also have your patient with pusher syndrome sit backward in a chair.  The support they are relying on in this strategy is more medial and the chair back itself can serve as a vertical environmental reference.  During this phase of pusher syndrome rehab, you can now have your patient attempt to actively reach outside of their base of support toward the strong and weak sides.

Strategy #2: Provide knowledge of results

So, how do we know if our patient with pusher syndrome is understanding our education and training?  How do we know if they are going to carryover the skills we are teaching them?  We need to allow our patients to *safely* fail.  That’s right!  We need to find out if they know what is happening.  Even during that very first meeting, during our evaluation… we can push back against their push and ask, “What will happen if I let go right now?”  If your patient says, “I will fall over!” – this is a good sign!  They have more awareness that something is not right and will be more engaged in finding a solution with you.  If they say, “Nothing,” try to gently show them that they will fall over if you let go.  They may get it right away, they may slowly learn this with repetition, or they may never gain this awareness. 

Those patients with pusher syndrome that never learn that they are pushing… are going to be your trickier patients. 

Strategy #3: Utilize different positions and functional activities

Daily routines and activities require us to get into all sorts of different positions throughout a normal day.  So, we want to make sure that we are training our person with pusher syndrome to match what they would need to do in daily life.  But utilizing different positions and functional activities, this will provide various versions of proprioceptive and visual input to help retrain the misperception of vertical. 

One school of thought is to initially facilitate weight shifting or weight bearing toward the strong side in order to allow the person’s brain to habituate.  Here are a few examples of how you can facilitate this.

When having your patient with pusher syndrome lie prone, make sure their strong arm is down by their side (to prevent pushing) and rotate their head toward weak side.  Similarly, when propping them in prone on elbows position, do not allow their strong arm (elbow) to extend and instead facilitate weight bearing/leaning through the elbow.  You can also hold their weak elbow straight and provide manual approximation to facilitate a weight shift toward their strong side.

When working in quadruped, you can have their weaker side resting on a slightly higher surface to facilitate more weight bearing on the strong side, then also complete active assisted weight shifts in all directions.  When in tall kneeling, try to have their affected side resting on a slightly higher surface, similar to what you will do in quadruped. 

Now, you might be thinking… we’re trying to orient them to true vertical!  Why would I put them on an uneven surface on purpose?  That’s a great question!  You would think that we would want to use a level surface all the time for them to know what level is.  But… we want them to learn that they are able to lean toward their strong side, lean on their strong side, and move to their strong side without falling.  We want to habituate them to moving in that direction again.  This will all contribute to them relearning where midline is. 

Gait training can happen a few different ways.  If you are using a body weight support system, you can adjust the straps of the harness to offset the pushing.  So make the straps slightly looser on the strong side in order to facilitate more weight bearing toward that direction.  If you are training over ground, it would be a great idea to utilize an assistive device that provides bilateral upper extremity support, such as a platform walker or EVA walker.  This will not only provide more stability, but will allow you to integrate both sides of the body and avoid the pushing behavior. 

You may also need two (or more) people to assist with over ground walking, depending on how strong your patient’s urge to push is!  The first helper should stand on the strong side, in order to provide the patient with visual and tactile feedback that they are not going to fall in that direction, even though they feel as though they are leaning over.  The second helper should stand on the weak side (the side they are pushing toward) as a safety precaution in case the first helper is not able to manage the pushing from the strong side.

Strategy #4: Complete bed mobility and transfers toward both sides!

If we want to make a right turn… we don’t make three lefts – we make a right!  So why are we always wanting to train our patients in one direction?  I know in the beginning of rehab, we normally start by transferring toward someone’s strong side (as it usually allows them to be more successful).  In pusher syndrome, you may choose to transfer toward their weak side first (since they are already prone to moving in that direction). 

However, you must eventually train them to move in all directions!  Remember – we need to reorient them to true vertical… so they don’t continue to push.  If they only ever move in one direction, they will not be aware of the “mistakes” they are making.  Transferring/rolling/etc. toward the strong side will definitely take more time with a patient with pusher syndrome… but it’s worth it!  Even though it’s tempting, don’t rush through the transfer… let them work it out!  In the long run, they will be able to do more of these tasks independently and relearn midline faster! 

Strategy #5: Use outcome measures

We all know that these patients usually take longer to meet their goals and therefore need more time in rehab!  And sometimes it’s hard to get the time we need.  Outcome measures can assist you in showing the small increments of progress that you might need to highlight for insurance companies to approve the time you need! 

Here are a few to check out:

Burke Lateropulsion Scale

Scale for Contraversive Pushing

For more information about pusher syndrome and these outcome measures, visit – Pusher Syndrome – Physiopedia (

What is my patient’s prognosis if they have Pusher Syndrome?

The good news is, that most patients who have pusher syndrome are able to achieve the same type of outcomes as those without pusher syndrome.  However, this does not mean that we want to leave it unchecked.  A patient with pusher syndrome will take significantly longer to achieve those outcomes.  And with the limited amount of time we have in acute and subacute rehab settings, we must set our patients up for success in every way possible!

What else can I do?

Continue to educate yourself on pusher syndrome and other stroke interventions!  The more skilled and intentional we become with our interventions, the faster our patients will reap the benefits!

If you’re interested in learning more, check out Inpatient Stroke Rehab: 14 Strategies to Get Your Patient Home.

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Starting Your Own Therapy Business? Here are 5 Financial Tips to Keep in Mind

Opening a therapy business can signal the start of an exciting chapter in your professional life. But, as an entrepreneur, you’ll need to handle various moving pieces of the business and ensure that finances are always under control. In this article by ARC Seminars, we’ll explore all the steps you should take to get your therapy business up and running.

1. Create a Business Plan

The best way to get off on the right foot will be to create a business plan which will provide some much-needed structureto your business. Here are the following aspects to include in the plan:

  • Information regarding the type of mental health practice you’ll run which can include a specialized clinic, generic out-patient services, etc.
  • Research your target customers, their pain points, purchasing behaviors, and more relevant information.
  • The cost of buying property, equipment, labor, and the expected revenue predictions for at least the first five years. 

2. Seek Required Funding 

Those planning to practice from a physical location should start their property search early and meet with lenders to discuss the probable financing options. TMC Financing explains that one of the key factors will be a good down paymentwhich can range between 25-30%, along with a strong credit score.

Your business plan will play a key role when negotiating with lenders, hence, ensure all calculations are accurate and achievable. A well-written business plan will significantly increase your chances of getting approved.

Another way to fund the business is to enter into a partnership with fellow professionals to split the costs and gain leverage to seek better interest and repayment terms.

3. Invest in Digital Solutions

While reporting requirements vary by state, as a medical establishment, you’ll need to adhere to local and federal level guidelines to remain compliant at all times and avoid fines. To achieve this, consider investing in the following types of software:

  • Electronic Health Record Systems: as reported by, EHRs are all-inclusive software that provides the functionality of safely storing patient records. Additionally, it makes it easy for the business to retrieve records during appointments and update them in real-time.
  • Billing Software: Billing software will leverage the power of automation to share prompt invoices to patients or their insurance providers, resulting in positive cash flow for the business. Additionally, this will help to accurately calculate monthly revenue expectations. 
  • PDF Editing Software: if you plan to send any confidential information through email or other digital channels, you must be able to encrypt it for the patient’s safety. PDFs are the most easily encrypted, which means you can add a password to the file before sending it. The recipient can then use editing software to make changes or add comments to the file before returning it to you or to their other specialists. This may help them to get the support they need faster without compromising their confidentiality. 

4. Hire Help

Trying to run the business as a one-person show will be unfeasible, hence make room in your budget to hire the following professionals:

  • Administrative Assistants: look for admin assistants with experience in healthcare who understand the importance of confidentiality and know the best practices to manage patient records.
  • Medical Assistants: depending on your specialization, hire medical assistants who can help with prepping procedures, sterilizing equipment, and conducting tests.  

If you find there are rehabilitation-specific areas in which you would like additional training in order to be more confident, schedule a class with ARC Seminars. Or you can encourage your nursing staff to attend one of their nursing courses for additional training.

5. Establish a Limited Liability Company

Registering your practice as a limited liability company will provide some much-needed protection from business-related liabilities. This is because an LLC is considered a separate legal entity from the owner. Hence, in case of a lawsuit, your personal assets or finances will be protected from all claims. For added protection, consider purchasing liability insurance, as it will help pay for the cost of hiring attorneys, court filings, and other related expenses.

If your business is a partnership, you can opt to register it as a limited liability partnership which provides similar benefits.

Keep Your Finances Under Control

Starting your own medical practice or business can be very exciting, but it’s important to stay on top of your finances as you proceed. Keeping these tips in mind will help you keep a strong hold on finances at all times and ensure the long-term survival of your practice. Don’t shy away from taking help when needed, whether it be working with a financial advisor or hiring talented staff. 

How to discuss return to Sex and Intimacy After Stroke

Bringing up the topic of sex after a stroke with your patient can be an intimidating prospect for many clinicians. At what point after this traumatic event is it appropriate to bring up something as sensitive as intimacy?

Although stroke is a serious medical event that requires extensive recovery, it is possible – and probable! – to return to sexual activity post-stroke.

Of course – individuals should discuss any physical, cognitive, and emotional changes with their doctor and rehab clinicians in order to get an accurate overview of any restrictions or limitations, and risk factors that may need to be observed. 

It is important to take precautions when returning to sex post-stroke to ensure that there are no additional complications. 

The medical team can provide guidance about appropriate physiologic changes, frequency of sexual activity, and risk for pregnancy or sexually transmitted infections.

 However, when our patients in rehab present post stroke, it falls into our role as a rehab clinician to make a safe space for sex and intimacy to be brought up!

What is my role as a rehab clinician in addressing return to intimacy post stroke?

The main role of the rehab clinician is to create a safe space and area of discussion for our patients.

Read our article about examining the rehab clinician’s role in addressing sexuality here!

Rehab for intimacy post stroke may address:

Physical changes


After experiencing a stroke, individuals may experience a variety of changes to their physical abilities- such as weakness, numbness, or unilateral paralysis. These physical changes affect the ability to perform sexual activities, such as kissing and intercourse. Additionally, it may be difficult to move or position oneself comfortably, which can make sexual experiences less enjoyable.

There are many ways to incorporate intimacy into a relationship even when physical sensation and desire may have changed after a stroke. 

While physical intimacy may not be feasible for all couples, it is important to recognize that intimacy can be fostered in many different ways. Participating in activities together, such as taking a walk in the park, going out for dinner, or even just cuddling can increase connection. It is also helpful to understand that different people have different boundaries, and it is important to respect them. Everyone should feel comfortable expressing their desires and boundaries to each other.

Encourage your patients to experiment with new positions and techniques that are comfortable and enjoyable.


sex stroke

When it comes to bringing intimacy back into a relationship post stroke, communication is key. Partners should take the time to talk about the changes in sensation and desire, as well as any difficulties with positioning or movement. One way to start is by discussing past experiences in the relationship and finding ways to recreate those fond memories. In addition, focusing on activities that don’t involve physical contact can be helpful, such as playing board games or watching a movie together.

Acknowledging the difficulty of the situation, being thoughtful and honest with each other, and reaching out for help from professionals are all important steps to take. Additionally, activities such as massage, cuddling, talking, and other forms of physical contact can be beneficial. It is important to remember that both partners should be able to express their needs in order to find solutions that work for the relationship.


intimacy sex

Compensatory techniques can be used to minimize the impact of stroke-related disability and facilitate a return to sexual activity. These techniques include adapting the environment, using assisted devices, and positional aids. 

Assistive devices can play a crucial role in helping stroke survivors resume sexual activity. Devices like sexual aids, lubricants, and inflatable cushions can help address physical limitations by enabling individuals to maintain comfortable positions while engaging in sexual activity. Some assistive devices can also help with communication, such as visual aids that depict body parts or assistive apps that allow partners to communicate desires and needs. 

Healthcare providers can educate patients and their partners about the available options and help them choose the devices that best fit their needs and preferences.

Resources for your patient

Fortunately, there are a variety of resources available to individuals who are looking to get back into a sexual relationship after a stroke. Websites such as the American Stroke Association provide tips and advice on how to handle such conversations and activities with respect to physical abilities and comfort levels.

 Additionally, therapists specializing in couples and family therapy can assist in creating a safe space to discuss communication hurdles and help build intimacy – outside of physical activity. With support, couples can work together to find ways to expand passion, sex and intimacy post stroke.

 Resources for the healthcare provider

There are also resources to you, as a rehab clinician, to develop your skills in addressing this area! CE courses, such as this course from Sex, Intimacy, OT ( If you would like to become more versant in this field, seeking out further training is a great idea.

Even without further certification, however – your role is always to be open and a safe space for your patients post-stroke. As rehab clinicians, we may find ourselves making the first indelible impression on the person as to whether they are returning to a full life after a stroke, which includes sex and intimacy. Therefore, we should display compassion and empathy for this conversation – despite our level of comfort with this sensitive area.

Want to level up your approach to Stroke Rehab? Have a look at our course, ‘In-Patient Stroke Rehab: 14 strategies to get your patient home!” for an in-depth, highly practical approach to stroke care and rehab.

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The Value of CBIS to your Clinical Practice

CBIS certification has raised the industry standard for educational pursuit and knowledge acquisition. Importantly, it has numerous benefits for the individuals who seek the certification.

1. It will enhance your clinical practice!


Becoming a Certified Brain Injury specialist will connect you to a wider network of other professionals in the brain injury rehab field. Currently, there are over 7,000 CBIS’ practicing here and internationally- and they are all linked through the attainment of this credential! Being a part of this network can help you problem-solve various challenges that can pop up in practice, learn about resources and tools helpful to practice, and initiatives that you may not otherwise have known about. 

Once you become a CBIS, you automatically gain a subscription to the Journal of Head Trauma Rehabilitation, which will help you to stay super current on the best brain injury rehab and resources that are upcoming in the field. 

Staying up to date on the evidence is not always easy- read this for three ways how!

And of course – there is the focus that requires to maintain your Certification status! In order to maintain the CBIS credential, you must take 10 hours worth of continuing education per year related to ABI practice. Those resources must be from current material – published or presented within the preceding three years. This means that once you gain your credential, you are forced to stay current and on top of new advances – sealing your status as a specialist!

2. It makes you a more well rounded clinician

The CBIS specialist course and exam does not only discuss Traumatic Brain Injury (TBI) but also non-traumatic brain injuries (NTBI) – which can sometimes be missed in BI practice. The Certified brain injury specialist course and exam also requires the learner to be versed in mild, moderate and severe injuries – and even touches on disorders of consciousness. This makes us, as clinicians, step outside of our comfort zones and learn more about populations and conditions that we perhaps might not normally have examined. 

Brain injury-serving organizations value hiring and training CBIS certified staff, because it allows them to work with and promote clinicians who understand the unique needs of persons recovering from brain injury and staying abreast of current resources in the field. By becoming more well-rounded, you are also establishing your own value as a clinician- go you!

3. It will empower you to develop programs/problem solve

As a certified brain injury specialist – your knowledge goes beyond management and treatment, and expands into advocacy, visibility, accessibility and systemic issues. This places you in a great position to develop brain injury specific programs for your facility, hospital, clinic or community! You will be able to examine the programs from a larger scale and perspective and look beyond your own practice, into the issues facing the brain injury community.

You will also be able to examine barriers to supportive programs where you work, and have knowledge and resources to be able to roll out initiatives and education in your clinic. This will help empower your colleagues on a larger scale, and create more effective outcomes for all clinical staff and patients. 

 Become a CBIS… and super-charge the way you work!

4. Make you a more effective educator/advocate

The act of studying, staying up to date, and being part of a network of like minded clinicians will have another side effect – it will naturally make you a great advocate. You will have the tools you would need to educate patients, family members, and your own colleagues, about what is supportive, appropriate and what is the most cutting edge in terms of interventions and treatments. 

Also, you can further advocate and educate by initiating or running a local brain injury support group – another aspect discussed in the CBIS Training course! Facilitating a group where those who have lived with brain injury can share successes, challenges, resources and more will be an incredibly empowering and positive addition to your clinic or community. 

Obtaining your CBIS really sets you apart from your peers and shows that you are committed to keeping your clinical skills with the ABI population sharp. It can inspire confidence in your patients and their families and give you the tools you need to assist your patients recover. 

Interested in becoming a CBIS? Check out the Certified Brain Injury Specialization (CBIS) Training

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How to Use Evidence Based Practice in Occupational Therapy

Evidence-based practice (EBP) has become the gold standard for healthcare professionals, including occupational therapists (OTs). It’s a phrase we hear constantly – at school, at work, at conferences – and we all know the importance of testing and examining the efficacy of what we are doing. 

But with so many other demands on us, how do we make sure that we are constantly integrating EBP into clinical practice?

What is Evidence Based Practice?

EBP is the process of using the best available evidence combined with clinical expertise to make decisions about patient care. It helps Occupational Therapists to provide the highest quality of care to their clients, both by informing clinical practice and by providing evidence to back up therapeutic interventions. As OTs, using evidence-based practice will also ensure we are following the latest standards of care, while also considering the individual needs and preferences of their clients.

Why is EBP central to good OT practice?

Evidence-based practice has become a cornerstone of occupational therapy. As OT as a profession moved toward a higher level of academia and science, testing and proving interventions became key to establishing OT as a vital health profession. 

As with many professions, clinicians can become comfortable and settled in a certain way of practicing – and this can take the edge out of our treatments. It is important that practitioners understand not only the importance of evidence-based practice, but also how to realistically integrate it into the therapeutic process. 

How do I include evidence based practice in daily occupational therapy?

First – get clear on your goals. Understand the importance of staying current with new research and continually updating your knowledge and skills. When you are creating your care plans, it is essential to ensure you are basing your decisions on the best available evidence. This means looking at research studies that have been conducted on the topic and considering their results. It also means staying up-to-date on the latest evidence; for example, reading journal articles or listening to webinars.

However, OTs should consider their own clinical expertise and patient preferences when making decisions – your experience and clinical expertise are also a form of evidence based practice!

Research Articles

It is clearly important to be up-to-date on the latest research. This includes the latest clinical practice guidelines, current research, and the best available evidence.

To ensure that you are using the best evidence-based practice, you should have a working understanding of the research process and its components. This includes being able to find, appraise and interpret evidence while also applying it to clinical practice. 

When evaluating a source of evidence for use in occupational therapy practice, there are a few key criteria to consider. Is the article peer-reviewed? Are the authors reputable? Was the sample size appropriate?

Look for high-quality research studies. Look for research studies that are randomized, controlled trials with a large sample size and minimal bias

Consider the author’s qualifications, the study design, and the results of the study. Furthermore, it is important to look for evidence of peer-review and to be aware of any potential conflicts of interest. 

Finally- it is important to consider the generalizability of the results and to make sure that the study results adhere to current ethical guidelines. 

Scholarly articles are a great source for evidence-based practice that have been reviewed and evaluated by peers. Additionally, articles from reputable journals and organizations are also a good source of evidence. 

Peer and Team Collaboration

Additionally, it is beneficial for OTs to consult with other professionals, such as physicians and nurses, to get their perspectives on evidence-based practice. By utilizing a team approach and keeping up-to-date with the latest research, OTs can be sure that they are providing the highest quality of care to their clients.

Clinical Expertise

Additionally, it’s important to consider the individual needs of your clients and critically evaluate the evidence for interventions. 

Three ways to include EBP in your daily practice

1. Subscribe to a journal – that is relevant to your practice!

Knowing that remaining current on literature is the most reliable way to stay on top of what is being examined in your field. Although not every assessment and intervention that you complete in a day is likely to be included in the journal – it will examine issues and treatments that are current in your field and may give you food for thought for future, contemporaneous treatments. 

Reading a journal will also expose you to treatments that are outside of your ‘typical’ practice and encourage more expansive thinking when it comes to approaching your client base and their needs.

Ensure the journal you subscribe to is one that you are interested in and that is accessible to you! Some articles can be overwhelming – and that’s where our next steps come in.

2. Critically reflect and analyze your own practice

Make sure that you are regularly stepping back, asking yourself what your plan of care is going to include, and why. Even for discrete therapy sessions – take a critical reflection on why you chose the intervention, and whether the person is receiving the intensity/repetitions/and so on to ensure the treatment is at an effective level.

Joining or starting a journal club can assist with self reflection, and encourage some inter-disciplinary feedback and learning too. Disease specific journal clubs are a great way to niche down into an area of interest but also appreciate the approach of other clinicians in that space; whereas discipline specific journal clubs can help explore many different conditions and OT interventions that are relevant to your practice!

Join our club here

3. Take a course!

Wading your way through understanding Evidence based practice is not easy. Thankfully, we have a course for that! Learn more about how to critically understand and appraise evidence, how to set up your own research, and much more, with our course “Evidence Based Practice for the Everyday Clinician

Check out Evidence Based Practice for the Everyday Clinician here!

Here, you will:

– Learn to find the most relevant evidence

– Be able to appraise and critically consume evidence

– Know how to formulate your own questions and find evidence to support or refute practice

– Understand variables, data, and analyses

– Have a blueprint as to how to start and manage your own research

Appreciate the true ‘power’ of EBP!

Including Evidence based practice as a daily part of your clinical life can make a huge difference to you, your patients, and your team. Try these techniques to make it an intuitive part of your life!

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Learn How to Maintain your CBIS Certification

So you have done your prep course, studied your head off, and passed your Certified Brain Injury Specialist (CBIS) credential exam – Congratulations!

Now as a practicing CBIS, what do you need to do to maintain your certification?

What do I need to do to maintain my CBIS?


In order to maintain your credential, you have to do 10 hours of continuing education per year related to acquired brain injury.  That education has to be a mix of at least two different mediums – webinars, live courses, journal articles, etc.  For example, you can’t do 10-hour long webinars and count them all – you have to have a mix. 

Once you complete your 10 hours of education, you have to complete your recertification application, and pay the recertification fee ($70) – that’s it! 

Having and maintaining your CBIS really encourages you to keep up with current research related to ABI, new evidenced based initiatives,  and makes you stay at the top of your clinical game. 

Can I use a mixture of resources to maintain my CBIS?

Yes!  You need to obtain the necessary CEUs from at least 2 different mediums such as webinars, journal article reviews, attending conferences, etc.  This ensures that you’re always expanding your ABI knowledge from a variety of different sources.  

Where can I find high quality CEUs to help maintain my CBIS?

Allison provisional brain injury certification and CBIS journal club

ARC Seminars offers a variety of live and pre recorded CEUs (check our courses) that can help you maintain your CBIS credential.  Also, offer a free journal club that counts for 1 hour towards your recertification!  All CEUs have to be acquired brain injury related.  Keep in mind any courses taken prior to obtaining your credential do not count towards your recertification (which includes the CBIS exam prep course itself).

Are there are free resources to help maintain my CBIS?

Yes, here is a link to download our FREE CBIS Starter Pack, which includes lots of great information about the CBIS credential, as well as some excellent clinical resources for immediate use.

Watch the video below for more information!

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