How to Improve Diabetic Neuropathy and Foot Ulcers

The prevalence of diabetes continues to increase in the US (and worldwide) each year.  Of all the complications that can arise, diabetic neuropathy is the most common – present in approximately 50% of people diagnosed.  Diabetic Neuropathy can lead to other disabilities such as Diabetic foot ulcers, amputation, gait and balance impairment, and so on.  It’s imperative that we, as clinicians, are equipped to properly identify the risks; and educate our patients and their caregivers to prevent such disability from occurring.

Risk Factors:

how to improve diabetic neuropathy and foot ulcers self check

There are certain risk factors that may be present prior to a diabetic foot ulcer forming.  These include poor control of blood sugar, cigarette smoking, previous foot ulcers and amputations, and most commonly, diabetic neuropathy and peripheral vascular disease.

Diabetic Neuropathy – As mentioned, this is very common among the diabetic population and can be very costly to their health.  Diabetic Neuropathy happens when nerves become damaged from chronic uncontrolled high blood sugar.  This damage can affect various parts of the nervous system that control motor, sensory, or autonomic functions – all of which can contribute to the patient developing a diabetic foot ulcer.  If the nerves that control muscular control of the feet have been damaged, the patient may start posturing their feet in a way that is biomechanically destructive.  This can cause increased pressure on bony prominences and other abnormalities and put their feet at higher risk for forming ulcers. 

Diabetic neuropathy can also be characterized by pain and/or numbness in the legs and feet if the sensory nerves have been damaged.  The pain is often directly associated with the nerve damage itself and is not in relation to an environmental or outward source of pain. 

Numbness, on the contrary, presents other concerns. If a diabetic foot ulcer has started to develop, the person may not feel pain or other sensations usually associated with wounds. This may allow the wound to progress unnoticed, as the patient continues to bear weight over the ulcer.  When autonomic dysfunction occurs, this can lead to changes in perspiration leaving the skin overly dry and prone to cracking.

Peripheral Vascular Disease – Smoking and Diabetes are among the most powerful risk factors in developing PVD.  PVD is characterized by atherosclerotic changes of the blood vessels where the arterial walls gradually harden and narrow as plaque builds up inside.  This restricts blood flow and limits the amount of oxygen and nutrients the blood can carry to that area.  Some studies show an important distinction that PVD in a person with Diabetes mostly occurs in the femoral and tibial arteries. Other risk factors (such as smoking) will affect more proximal vessels.  The nature of PVD makes it easy to imagine why this would put a person with Diabetes at risk for developing a foot ulcer – the feet are not getting the oxygen and nutrients they need to sustain healthy tissue! 

The prevalence of PVD among people with Diabetes is difficult to pin down due to the variability of symptoms. Some people may present as asymptomatic.  A great way for clinicians to help identify the presence of PVD is the Ankle-Brachial Index.  Research has shown this to be highly sensitive and specific when compared to angiographically confirmed disease… and the great news for us is that it doesn’t require any fancy equipment!

For great resources to use in the clinic, check out our ‘Ultimate Guide to Managing the Diabetic Foot’!

Time for healing:      

Wounds often take a longer time to heal for a person with diabetes, and here’s why:

Diabetic Neuropathy – As mentioned above, this could be a risk factor for developing diabetic foot ulcers to begin with, but it is also a major player in the wound healing process.  If the nerve damage is contributing to a sensory loss… the person is going to be at a very high risk to reinjure/reopen the wound site again and again.  They can’t feel it, so it won’t be “a problem” for them until it’s too late.  A vicious cycle! 

how to improve diabetic neuropathy and foot ulcers self check

Peripheral Vascular Disease – Blood flow with good oxygenation and nutrition supply is essential to proper wound healing.  When this is compromised, as it is in people with PVD, the body simply does not have the fundamentals that it needs to move through the wound healing process and repair tissues.  If a more severe lack of oxygenated blood exists, this could lead to ischemia and necrosis of the tissues, which would then need to be debrided… making the wound larger.  In other cases it could lead to gangrene and eventual amputation.

Infection – Diabetic foot ulcers are often at higher risk for infection, which would then prolong the healing process.  When a person has diabetes, they produce certain enzymes and proteins that make the immune response less effective.  So, when a diabetic foot ulcer is present and bacteria enters in, your body is already at a disadvantage in fighting off infection and moving on to healing the wound. 

Prevention is Key!

If you or someone you know is at risk for developing diabetes, it is imperative to take steps toward prevention!  This is sometimes easier said than done. But, making small changes at a time will give you the best results… by far! Don’t take everything on all at once. If you’re a clinician healing your patients and their families, don’t overwhelm them with information – start slow.

Check out this page to get great tips and resources from the American Diabetes Association on how to prevent Diabetes!

But if Diabetes is already present, there are plenty of ways we can still help our patients prevent complications, such as Diabetic neuropathy and foot ulcers. 

  • Get blood sugar under control – This seems obvious, right?  But it’s often very difficult for people to do in real life.  There are so many factors that play into this, from food preferences, habits, culture, family support, etc.  It’s important to get as many team member as possible involved to help reinforce the small changes that the patient will need to make along the way.
  • Follow up with appropriate practitioners – Depending on the risk factors identified, ensure your patient is seeing the experts they need.  Some examples are: Endocrinologist for management of diabetes; Vascular Surgeon or Interventional Radiologist for management of PVD; Dietician for nutritional recommendations; Community based support groups for Psychosocial support; and of course Physical and Occupational therapy!
  • Footwear recommendations – Especially if the person is presenting with Diabetic Neuropathy, you want to ensure that they have proper footwear to support their feet and prevent any unnecessary pressure of shearing of their skin.  They may need to wear certain types of socks; and need education on how to properly don them in order to prevent bunching of the material within the shoe.  They may do well with a wider size to allow more room, or they may need specially ordered Diabetic shoes.  The Healthy Feet Store may be a great resource for some patients!
  • Daily self-check/foot inspection – Once this becomes a habit, it will be an invaluable part of your Diabetic patient’s routine.  This can be an effective way for prevention of diabetic foot ulcers through getting the patient to be more engaged in their care.  They will need a long-handled mirror or a mirror they can place on the floor under their feet.  Here are the steps involved:
    • Skin inspection – Look at the skin on the top of your feet, the soles of your feet and in between your toes.  (Use the long-handled mirror for places you are unable to see.)  Observe for: cuts, scrapes, bruises, dirt/grime, blisters, discoloration, or developing calluses.  Anything that is new or abnormal should be noted.
    • Nail inspection – Look at your toenails for uneven edges, broken nails, ingrown toenails, or signs of infection.
    • Sensation – Feel all over your feet for changes such as numbness, increased sensitivity, lumps/bumps, cold areas, tingling or painful areas.
    • Smell – Try to smell the skin for fungal or bad odors. A change in smell or a bad odor can indicate a problem or a possible infection.
    • Hygiene – Clean your feet of any dirt or grime and dry the skin very well. This will help to prevent any possible infections. Wash using warm, not hot water, and do not soak your feet. Apply lotion and rub it in until feet are dry.

As with many different aspects in healthcare, prevention certainly is key!  But more often then not we are seeing patients after their conditions have become chronic and they are already experiencing a host of complications.  It is no different with our patients with Diabetes.  Identifying what is already present and what they are at continued risk for is where we can still play a role in prevention.  We can prevent the progression of their disease or prevent the development of complications by providing education and strategies to make the changes they need to make more attainable.

If you want to learn more about wounds and wound management, have a look at our LIVE or SELF-PACED course, A Comprehensive Guide to Wound Care: Tools for the Everyday Clinician! This course offers 7 Cont-ed units, practical downloadable tools and resources, and is taught by an expert wound care specialist who makes the education accessible to everyone. Check it out!

Like this article? Sign up to our mailing list for a weekly education right to your inbox! We promise to treat your email with the respect and love it deserves 🙂

How to set Therapy Goals for Hospice and Palliative Care

In the acute in-patient rehab world, we don’t often have to set therapy goals for hospice or palliative care. Mostly, we are working away with patients who are medically stable and usually have a prognosis for a good outcome. However, there are times as a Physical, Occupational or Speech therapist that we may encounter patients who are not recovering as we would hope. Your patient and team may have begun talking about transitioning to hospice or palliative care, once discharged from the rehab environment. How do we set appropriate therapy goals for hospice or palliative care?

Hospice Care vs. Palliative Care

So, what does all of this mean anyway? When someone starts having conversations with their physician and other members of their team on transitioning to hospice care or palliative care… how does that affect them, how does it affect their care, and will it change how they receive physical, occupational and/or speech therapy?

These are all questions that need to be answered, so we have a better understanding of how to maintain an appropriate plan of care with these patients.

First things first – in order to know your role in all of this, you need to gain a better understanding of the similarities and differences of these two services. Although many clinicians and healthcare workers use hospice care and palliative care synonymously… they are different.

Both services are provided to people living with serious and chronic illnesses and focus care on providing relief from the symptoms that the illness brings with it, as well as providing relief from the stress of the illness. People who are receiving hospice care, however, are usually at a terminal stage at that point and have a defined life expectancy of less than six months. Read more about Hospice Services.

One major goal of both services is to improve quality of life for both the patient and the caregivers. However, when receiving palliative care, one can still simultaneously receive life sustaining treatments, such as dialysis, insulin, etc. and have other care goals over and beyond improving quality of life. When receiving hospice care, those types of treatments are discontinued, and more weight is placed on providing emotional and spiritual support for the patient during the end of life. Read more about Palliative Services.

With both hospice and palliative care having their goals heavily influenced by improving quality of life, you may see now how our goals in therapy would need to shift away from a rehabilitative perspective.

Physical Therapy Goals:


So, as mentioned previously, the over-arching goals of care will now be shifting to a place where quality of life can be maximized. There are still a multitude of ways that skilled physical therapy services can be useful to patients that start palliative or hospice services.

This could take many different forms and for any mobility goal you make with a patient receiving hospice or palliative care, the first step is finding out what therapy goals are most important to them. These people will still (to a certain degree… depending on their condition) have the ability to strengthen their muscles, improve their balance, build endurance, and become a functionally safe member of their own lives.

For those that are very frail and weak, physical therapy may be needed to facilitate independence with bed mobility and to provide education to caregivers on proper positioning for comfort and to prevent skin breakdown. For patients able to do more, getting out of bed each day to visit with a grandchild or to watch TV from their favorite reclining chair is what keeps them going. Some people will find more value in being able to walk to the bathroom instead of using a bedside commode or bedpan. To them, that would be a very important goal to achieve in order to maintain a good quality of life. The key is to hone in on what they want and need their goals to be and use your skills to get them there. For the mobility aspect of goal making, it is all fairly intuitive and the only adjustment you may find yourself making is to not be as ambitious with the end point you chose – so shoot for walking 25 feet instead of 300 feet.

Pain management

Generally, patients who receive palliative care or hospice care experience pain at some point in time. There are several different ways pain management can be approached in physical therapy, depending on the source of the pain. A diagnosis such as Cancer could be the culprit. Normally, physical therapists practice with the utmost caution when considering the use of modalities in the presence of a cancer diagnosis, often siting it as a contraindication altogether. However, in cases where the goal is to improve quality of life, a pain management goal is certainly appropriate to include as part of the physical therapy they receive. And it is also appropriate to consider interventions such as modalities to treat the pain, even if “traditionally” it would be avoided. Of course this would still need to be discussed with the rest of the team, including the patient, in order to ensure everyone is on the same page… but it could be the one thing that takes the edge off enough for them to enjoy daily life.

Download our modalities cheat sheet, and other cancer-related resources right here!

Pain (or discomfort or restlessness) could also occur as the patient gets nearer and nearer to the end of life. In this situation, modalities would not be the answer. However, physical touch can be a powerful tool for pain relief and decreasing anxiety, among other things. In physical therapy, there are many manual therapy skills we can use to help comfort these patients and decrease their pain. Soft tissue massage, myofascial release, manual stretching, gentle joint mobilizations are among a few that can be easily and effectively included in the plan of care for these patients. And as with many other interventions, passing these skills onto caregivers is paramount in order for the benefit to continue on between therapy sessions.

The wording of this type of goal may specifically state the inclusion of caregiver training. An example could be: ‘Patient will exhibit no physical signs of pain or discomfort while lying in bed through caregiver training of [insert manual technique].Read more about pain management strategies in the cancer population.

Occupational Therapy Goals

Basic Activities of Daily Living

Occupational therapy in many settings centers around basic activities of daily living, such as grooming, bathing, dressing, toileting, etc. As with the mobility goals that physical therapy will be focusing on… the ADL goals may be shifted fairly naturally after the patient expresses what is going to be most meaningful to them. Some patients will want to feel like themselves and be as self sufficient as possible in order to perceive their quality of life as being “good”. Others will only want to be able to feed themselves and therefore may need training on the use of adaptive equipment or may require caregiver education on what types of assistance or cueing they will need in order to continue being successful with participation in this task. Depending on what else is going on with each patient’s medical condition, eating may be one of the only activities that these patients take pleasure in at this stage in their care, so ensuring they can still have a certain level of control over this task would be meaningful to many of these patients.

Instrumental Activities of Daily Living

Some of the usual IADLs that occupational therapy would be incorporating into the plan of care are things like cooking/meal prep, medication management, light cleaning, etc. These types of therapy goals, for many of the patients receiving palliative care or hospice care may not be a priority to them, as other things will take precedent. Family or caregivers will often be stepping in to take over these types of activities in order to help support them through this time.

But outside of the more commonly worked on IADLs, the occupational therapist can explore some other ways of incorporating these goals into palliative or hospice care. This is an area that occupational therapy shines!

hospice and palliative therapy goals

Getting to know these patients and families and figuring out what is most meaningful to them in their day to day life is what occupational therapy is all about! They may find that something like being able to use their cell phone (or tablet, or a family member’s device) will enable them to stay in touch with family more frequently or enable them to join and participate in a virtual support group. Many older adults are tech savvy and can navigate through a smart phone – search the internet, work facetime or skype, and add/play appropriate applications. But there are still many others who have not even attempted this “new” technology.

Having this type of goal and spending the time working through the “how to’s” would be extremely beneficial in providing emotional support and allowing them to enjoy this difficult time, as long as they are open to learning the basics. And as with anything, caregivers can certainly be incorporated into the goal in order to fill in the gaps if the patient isn’t fully understanding.

Therapeutic use of self

This may not necessarily be a goal in occupational therapy, but it certainly is a useful tool to use at anytime throughout caring for someone… and especially as they enter a stage where they would need palliative or hospice care.

In the rehab world, this type of intervention can get lost or forgotten in the midst of all the dumbbells, weighted dowels, theraband, and UBE’s. Treatment gets funneled into making the patients stronger so they can do things more on their own… (which is important)… however, sometimes the benefits of how we can use ourselves and our own experiences and feelings to connect with people is lost. Providing emotional support and encouragement will, by itself, provide an improved quality of life… but it will also help the occupational therapist to knock down some walls and find out what is most important to these patients.

Speech Therapy Goals


Depending on the person’s medical condition, they may or may not have developed some degree of dysphagia. Normally when this is identified in speech therapy, there would be goals to improve the function of the swallow and progress the patient to the most “normal” diet they can be on. Since palliative and hospice care therapy goals are not going to be rehabilitative in nature, the speech therapist can look at a few different things when it comes to their recommendations of diet level.

Firstly, determining what the least restrictive diet for that person will be may look slightly different than the usual recommendations in rehab. Speech therapy recommendations may be more on the conservative side when trying to rehab, in order to decrease risk of aspiration, etc. But depending on the patient’s medical situation and prognosis, a more liberal recommendation may be appropriate in order to provide more pleasure with eating… even if increased risk is present. This would certainly be on a case by case basis and after discussion with the patient and team.

hospice therapy goals

If everyone is in agreement that they can move to the less restrictive diet, the SLP could shift the therapy goals to focus on all the appropriate strategies to make eating as safe as it possibly can be during hospice or palliative care. These strategies aren’t anything new… but they will be more the focus vs. trying to improve the actual swallow. These goals, like many listed here, can be met ‘through caregiver training’ depending on the patient’s ability to participate and understand.
If it’s still determined in speech therapy that the diet would have to be on the more restrictive side, the therapist can tap into all their experience they’ve gathered along the way to make certain diet textures more “palatable” so that they still may enjoy eating throughout this time. Mixing various foods, adding gravy/sauce (depending on the recommended texture), using food molds if it’s the visual appearance that turns them off to it… among other things!

The speech therapist could also consider making one or two exceptions if there is just that one favorite food they want to eat. So they would be on one diet level for all regular meals and snacks, but are allowed to have their one favorite food. This would take some careful assessment and a certain degree of training and modification of that food as appropriate… but may be a really great way to improve quality of life for them.

Cognition and Communication

No matter what the patient’s medical condition, they need to be able to communicate with their loved ones and caregivers. And with some patients, the form their communication takes may evolve as their condition declines. In speech therapy, this may pose a great opportunity to present various levels of communication strategies to the patient and caregivers. Having a variety of strategies readily available (even before they may need them) and presenting a list of “what if” scenarios would be invaluable to keep effective communication flowing. These may be very difficult conversations for all parties to enter into, but we are in a unique position to pass along our skills and prepare the patients and caregivers for the progression the disease process and what that could mean to how they are able to understand, be understood, and communicate basic needs.

A simple example would be if someone’s level of alertness waxes and wanes and that in turn affects the volume and clarity of their speech. Providing alternate forms of communication would be key – if they can still write, suggest a dry erase board; if they aren’t able to write, suggest a picture board. These may be obvious to us, but they certainly wouldn’t be to the patient and caregivers. And knowing that the patient’s medical status will progressively get worse, having approached this in a proactive way will help decrease anxiety felt by both the patient and family. They won’t have to wonder what to do if the “what ifs” happen… because you have prepared them!

The Right Next Step

The suggestions above are certainly not all inclusive of the ways physical therapy, occupational therapy, and speech therapy can shift their way of thinking about goals in order to meet the needs of patients receiving palliative or hospice care. But hopefully, you are starting to break out of the bubble you may have been working (and thinking) in!

There are many ways to provide these skilled services even if we know that in the end we aren’t making the patient “better”. Here are some simple steps to take after you find out that palliative or hospice care may be involved in the near future.

Step 1:

Stay positive. Don’t write your patient off, simply because they have a poor medical prognosis. Their life is not over… and you can still make a huge difference in how they continue to live! We aren’t out to perform miracles, but we certainly can bring much more hope, comfort, and quality to someone’s life that we think we can… simply by providing the skills we have!

Step 2:

Take part in a team meeting – early! And make sure the patient and family/caregiver are there. The care team needs to know what the goals of the patient are and everyone needs to be on the same page so that the progression of care and any processes that need to be put in place happen seamlessly.

Step 3:

Keep an open mind. There may be several different instances throughout the time you care for these patients that you need to shift your way of thinking and adjust your goals. But there is always some level of benefit you can bring to the patients themselves and to the caregivers.
So, take the time and listen to what your patients are saying and see what they may be going through. Make sure to formulate your goals in a way that will also achieve the over-arching goal of improving and maintaining good quality of life. Your patients and their caregivers will look to you for comfort, advice, and guidance – and it’s awesome that we can use our skills to provide what they need in what can be a quite desperate time.

“Have a heart that never hardens, and a temper that never tires, and a touch that never hurts.”

Charles Dickens

To learn more about how to collaborate as a team on the care and therapy goals of patients with cancer, including those receiving hospice and palliative care, check out our comprehensive, 3 CEU webinar, ‘Cancer Care: A Collaborative Approach’.

Like this article? Sign up to our mailing list for a weekly education right to your inbox! We promise to treat your email with the respect and love it deserves 🙂

Cognitive Impairment and Heart Failure: The Shocking Truth

Cognitive impairment might not the first thing we think about when treating patients with congestive heart failure and anemia.  But you may be surprised to find out- these disease processes can often be causes of memory loss and cognitive impairment.  Therefore, it’s essential that we fully learn how these patients can be affected as a whole, so we can provide them with the most well rounded and effective plan of care possible!

Click here to download some great heart failure resources!

Correlation between Congestive heart failure and Anemia:

Anemia is present in approximately one third of patients with congestive heart failure.  There are multiple factors that can contribute to these conditions co-existing, and it’s hard to say in general terms if one is causative of the other.  Firstly, they do have several risk factors in common, such as chronic kidney disease, Diabetes Mellitus, inflammation, advanced age and exposure to toxins such as chemotherapy. 

It appears that in some cases, congestive heart failure can lead to anemia and in others the opposite is true.  There are many complex mechanisms that go into the domino effect of each of these scenarios, but in simplified terms… if a person has congestive heart failure that leads to things like renal dysfunction, inflammation, nutritional deficiencies, or blood loss or if they are on a medication such as an ACE inhibitor or beta blocker… these things can then lead to anemia.  On the flip side, if a person has anemia (due to any number of reasons) – this would cause the need for an increase in their cardiac output in order to get the needed amount of oxygenated blood to all the tissues and organs that need it.  This, in turn, can overwork the heart and lead to congestive heart failure.

heart failure

The combination of anemia, chronic kidney disease and iron deficiency in patients with congestive heart failure occurs often, and is associated with progression of these disease process, cognitive impairment, and poor prognosis.  So, although you could surmise for each specific case you encounter that one diagnosis may have led to the other, it is still unclear whether anemia leads to advanced congestive heart failure and worse outcome or if anemia is merely a sign of more advanced disease.  But the bottom line is, they coexist often and have effects that we don’t always think about.

Prevalence of cognitive impairment in those with heart failure

cognitive impairment heart failure

Causes of memory loss and cognitive impairment have also been clearly associated with congestive heart failure.  One study identified patients with heart failure who had anemia as having a greater than four times more risk of cognitive impairment compared to the heart failure patients who did not have anemia.  And if you remember… one third of patients with heart failure also have anemia.  This is a huge number of patients that are at risk for having cognitive impairment that very well may slip through the cracks without receiving cognitive assessment or intervention.  Patients with heart failure usually have so many medical care needs, that cognitive impairment may (unfortunately) be the last thing the team is worrying about.  But it should be one of the first things on the list!  If physicians and other clinicians are trying to implement new treatments, new medications, new lifestyle changes, etc. the patient with cognitive impairment will not be taking all the instructions in as well as they may appear to be.  And in order to more effectively address all these other aspects of care, we must evaluate for and intervene when cognitive impairment may affect carryover of education on the disease process and treatment.

Screen and Identify early

Two different screening processes would be useful to initiate with all patients with congestive heart failure.  

  1. Since anemia is quite prevalent in those with heart failure, we would want to identify if it is present or not in order for the anemia itself to be treated (and also to give us insight into what we may find during our cognitive assessment).  Simple blood work would be able to identify if these patients are also experiencing anemia and therefore be at a higher risk for cognitive impairment.  After discussion with the care team, this could be something that would be incorporated into a clinical pathway and could be included in a physician order set for congestive heart failure right off the bat!
  2. As mentioned before, a Speech Language Pathologist referral is not something you would think of first when caring for people with heart failure, but given what we now know about the correlation between heart failure, anemia and cognitive impairment, it would be worth discussing with the team how to make it standard to screen cognitive function in these patients.  This may not need to be initiated by the Speech therapist themselves but could be a step in the process of the multidisciplinary evaluations that occur in the early stages of forming the care plan.  The physical or occupational therapist could include in their assessment any number of standardized cognitive assessments in order to more accurately refer these patients to the Speech therapist so a more comprehensive cognitive assessment can take place when needed.  These assessments could include the Brief Cognitive Assessment Tool – short form (BCAT – SF), the Saint Louis University Mental Status exam (SLUMS), or the Mini-mental State Exam (MMSE).  Any of these options (and others not listed) will provide a quick and easy way to identify, objectively, if cognitive impairment is present and if further assessment is needed.   Caution should be used when simply relying on observation of functional activity and conversation with the patient to use as your screening process, as patients often learn how to compensate for deficits and can “cover up” the severity of the impairment.  They may seem ok and be able to carry on simple conversation and routine daily tasks without difficulty.  Using an objective measure is always the way to go – so talk to your team and figure out which one would be the best fit for your needs!

Find a few of the suggested outcome measures here.

Circle back to function

Functionally speaking we will already be looking at certain things during our regular assessments, such as their ability to complete activities of daily living and perform their basic care needs, manage their medications and any other tasks that they would normally complete.  These tasks may warrant “the usual” intervention by the therapy team but may also warrant support and education to the caregivers as these patients may require more support from a cognitive standpoint than they did previously. 

During bathing and dressing tasks, depending on the severity of cognitive impairment, the person may have difficulty with sequencing the steps involved, they may be forgetful and perseverate on one aspect of the task, they may not have the ability to initiate basic hygiene needs, or be able to recognize if things have been completed thoroughly.  This would be a great opportunity for the Speech Language Pathologist to coordinate with the Occupational therapist in order to institute the appropriate strategies and increase carryover of skills from one session to the next.  

The same types of principals would apply to instrumental activities of daily living, but especially with medication management.  Mishandling of medications or non-compliance with medication recommendations is one of the leading causes of rehospitalization and patients with heart failure often have new medications they are dealing with or have frequent adjustment of the medication they are currently on.  Combine that with untreated cognitive impairment and you have a rehospitalization waiting to happen!  It is important to provide strategies to these patients for them to not only take the right pill at the right time but also to teach them what the pills look like out of the bottle!  Their pill box is bound to spill at some point… so putting together a visual aid so they can identify their pills and reorganize them accurately, will be a very useful thing for them to have.

There are countless examples of how cognitive impairment can affect a person’s daily life, but getting the caregiver involved is key.  The patient with congestive heart failure may have been a person that previously was able to complete everything on their own and is currently pretty good at compensating for the cognitive impairments they have.  This would be a patient that the family will most likely not identify as someone needing help.  It will be our job to advocate for the patient and really educate them and their caregivers on everything that may have changed and what they may now need assistance with.  This could range from setting up the pill box once per week, to helping them get dressed and undressed in the morning and evening, to staying with them overnight.  It will all depend on their individual need.  The American Heart Association has really great resources for patients, caregivers, and clinicians.  You can find them here.

With all the things these patients are going through, the first step in providing the best care possible is making sure to identify where the impairments lie.  Now that we know how highly correlated cognitive impairment is with congestive heart failure and anemia… we can’t unknow it!  We must act.  Talk to your team and make a plan.  These are simple (but important) steps we can all take to improve our skill and improve the care we provide!  

To learn more about the (not so obvious) aspects of heart failure, check out our short (but information packed!) webinar – Update Your Care Plan: Heart Failure.

Interested in more clinical tips, articles, and resources for your practice? Sign up for our bi-weekly mailing list below! We promise to treat your inbox with the respect and love it deserves 🙂

Rehab for Cancer Pain: What’s the best treatment?

Cancer treatment brings with it many layers of personal, family, social, financial, and (the obvious) health issues that the person and their loved ones are left to sift through.  The healthcare team pulls together to provide as much support to as many of these areas as possible.

As a Physical or Occupational Therapist working with someone who is undergoing cancer treatment, you want to make sure that you are also providing appropriate interventions to address some of the physical cancer symptoms that may come up either during a primary diagnosis or with metastasis.  One of these symptoms is cancer pain.  There are many different avenues a therapist can go down to treat pain, depending on what its source is – manual therapy, positional release, exercise, and modalities are among a few.  

Click here for a great guide to using modalities with cancer!

Cancer Related Pain:

Reports of pain from people with a cancer diagnosis can be quite common at every stage of the disease.  Pain is, more often than not, an indicator that something is not quite right.  It’s a way for our bodies to tell us something. 

Abstract, Background, Glitter, Pain

Among cancer symptoms, cancer pain is one that certainly cannot be ignored on a day to day basis and can become quite debilitating before, during, and after cancer treatment.  One meta-analysis in 2016 found that out of 63,533 patients, 66.4% in advanced, metastatic, or terminal stages of the disease reported pain; 55.0% reported pain during cancer treatment; and 39.3% still reported pain after undergoing curative treatment.  When looking at cancer pain severity in 32,261 patients, 38.0% reported the pain to be moderate to severe.  (Read the full article here) So, as anyone can see… this is not a small problem we are contending with!  Chronic pain, from any etiology, can have a massive impact on a person’s ability to move around, to mentally focus, and to maintain a good quality of life.  


How can we help?

There are so many ways that therapists can treat pain.  Here we highlight a few of the more practical and easier to incorporate interventions.  And as always, we would never want to put our eggs in one basket.  These interventions would be used in conjunction with others – not in isolation.

  1. Manual Therapy – The power of human touch!  Massage has shown to decrease cortisol levels and increase the amount of natural killer cells in the body.  What a great boost for the immune system, while also tackling the debilitating sensation of pain.  Now because cancer pain is something that seems to stick with the person throughout the course of cancer treatment (and even after), this may be a great opportunity to educate this person on ways to incorporate this into their life, even after therapy stops.  Showing their caregiver the techniques that seem to work the best and possibly setting them up with a local spa for a weekly or monthly appointment would be a great place to start!
  2. Exercise – Get those “feel good” juices flowing!  Therapists are going to incorporate exercise into the plan of care for obvious purposes anyway – strengthening.  But exercise also has powerful pain-relieving qualities as well!  Now, we wouldn’t expect our patient with cancer pain to experience “runner’s high”, but many forms of exercise can produce changes in the brain that can contribute to a decreased sensitivity to noxious stimuli.  Endorphins are released and our endogenous opioid system is activated which will improve the perception of pain and decrease overall stress.  
  3. Modalities – That’s right… I said it!  Despite popular belief in the clinic, many different modalities can be safely used to treat cancer pain.  Our first reaction is usually, “Well, they have cancer, so these things are contraindicated.”  And, that may be true… depending on the circumstance.  But we owe our patients the chance to benefit from this aspect of the treatment we can provide.  Electrotherapy (aka – electrical stimulation, TENS, etc.) has been shown to be effective in reducing pain that originates from many different sources.  Incorporating it into your plan of care for someone newly diagnosed, for someone already undergoing cancer treatment, for someone with metastasis, or someone who has recovered can be extremely pivotal in helping them improve function and quality of life.

Electrotherapy will cause Metastasis: Fact or Myth?

Well… it is not a simple answer unfortunately.  There is not enough research to say for certain that electrotherapy is not safe for treating cancer pain.  But there’s also not enough evidence to say that it is unequivocally safe either. 

The general consensus in the therapy community is that the use of electrotherapy directly over or in close proximity to a malignancy should be avoided.  The theory is that the current produced will promote the spread of cancer cells to other parts of the body.  The use of electrotherapy on a body part distant from the site of cancer would be considered a precaution, not a contraindication.  And, that sounds like good advice… in general terms.  However, our plan of care and the interventions we choose are not one-size-fits-all.  Our patients are not carbon copies of each other.  Each person’s situation is going to call for a different approach to cancer treatment and treatment of cancer pain.  If we see the person as a whole and we involve all the appropriate members of the team in this decision, there can be very useful indications for electrotherapy in this population.

Weigh the Risks and Benefits:

Firstly, as mentioned above – talk to the team, including the patient and their caregivers!  You need to have a clear understanding of “the big picture” before making any decisions.  Based on the lack of evidence neither for nor against the use of electrotherapy for cancer pain, a big deciding factor would be knowing what stage the cancer is in, if they are currently undergoing cancer treatment, and if there are already known areas of metastasis.  If they are newly diagnosed in an early stage and medical treatment aims to cure, you may choose other routes of pain management in order to avoid any chance of electrotherapy having adverse effects. 

However, if the person is in later stages and already has metastasis, electrotherapy may be something that you would want to consider, especially if the medical prognosis is poor.  Now, these statements are not meant to say that it doesn’t matter if cancer is spread in a person that already has metastasis.  All of these patient’s lives are equally valuable.  But we cannot put on blinders to the benefits it may bring them and the improvement in quality of life they may experience with the decrease in pain… simply because we are afraid of the “what if?” You want to consider how intense their cancer symptoms (especially cancer pain) are and how those symptoms are affecting their quality of life, and what the patient’s overall goals of care are. 

Ways to incorporate this treatment:

Here are some scenarios meant to provide food for thought.  There is no cookbook we can follow, unfortunately.  But if we take each patient with all the different factors in their individual situation and consider if this intervention would be useful to them, after weighing the risks and benefits and speaking to both the patient and their Oncologist… we will always come to the right conclusion!

  1. The patient with early stage cancer and good prognosis.  I mentioned above that this may be a patient you would take in a different direction with pain management.  However, like everyone, this patient’s scenario will need to be looked at on an individual basis.  They may receive curative treatment, but may have other sources of orthopedic pain that have flared up because of bouts of immobility or having to sit for hours in one position to receive chemo treatments.  This would be a great opportunity to explore the option of electrotherapy for these secondary sources of pain.  It would also be good to keep it in mind if they have lingering pain after their cancer is no longer active.
  2. The patient (at any stage) who is at the end of their rope because they have tried everything to relieve the pain they have, but nothing is effective If the severity of the pain they are feeling is at such an intensity that it is drastically affecting their quality of life, then a consideration of the use of electrotherapy is in order!  Again, this would be something you need to be in good contact with their Oncologist about in order to properly assess if the benefits outweigh the risks.  But if you can give them relief and they can start to enjoy living again, this treatment can be just as powerful as the cancer treatment itself!
  3. The patient who now has incontinence from pelvic floor dysfunction after surgery.  This affects different people in different ways.  Some will take it in stride and accommodate fairly well, and some cannot deal with this new impairment that came along with their cancer diagnosis and treatment.  A person’s outlook on incontinence may or may not have to do with the age of the person, or how active they are, or even just their own preconceived notions of the stigma they attach to it.  This may be a pain management issue or a muscle re-education issue… but either way, it would be worth evaluating if electrotherapy has a place in the plan of care.  How much is this effecting their daily life?  Where are they in their cancer treatment?  What is the prognosis?  Answering these questions will certainly help inform the next step in your decision.

It is undeniable that a cancer diagnosis and cancer treatment brings with it many obstacles people have to continuously overcome.  With all the ways that therapists can assist people in getting back to the lives they want to live after their lives have been horribly disrupted… we need to always make sure to look at the person as a whole and look at their entire situation prior to discounting any of the tools we have at our disposal.  So, should we use electrotherapy to treat cancer pain?  I would say, it depends… but hopefully now you have more confidence to consider it when it would indeed improve your patient’s overall condition.

To find out more about caring for the person with cancer, check out our jam-packed, practical, and compassionate webinar, Cancer Care: A Collaborative Approach! This short but powerful webinar is sure to give your practice the boost it needs!

Interested in more clinical tips, articles, and resources for your practice? Sign up for our bi-weekly mailing list below! We promise to treat your inbox with the respect and love it deserves 🙂

The Surprising Link between Loneliness and Heart Failure

Feeling lonely?

You aren’t the only one! But you may be surprised to learn about the very significant impact of social isolation and loneliness in people with Congestive Failure.

In the last few months of 2020, we can certainly reflect back on how this year’s events have contributed to feelings of social isolation and loneliness throughout many different groups of people.  To some degree, we have all had to change our daily routines.  Whether it’s avoiding seeing and touching the people and places we love, rescheduling trips, being newly unemployed, or having to fully quarantine because of sickness or possible exposure… the lack of contact with other humans and inability to participate in the social aspects of our lives is taking its toll.

To learn more about how physical touch affects our well-being, read this insightful article!

Even before we experienced a global pandemic, and were forced to continuously adjust to the “new normal”, people were perceiving feelings of social isolation for all kinds of reasons.  Some may appear more obvious, such as stressful life changes or the passing of a loved one, a long-standing history of depression or other mental health issues. 

But what about all the people that appear “okay”?  The ones that aren’t “officially” depressed?  

Interactions with certain populations of people with other various medical diagnoses, may not automatically lend themselves to the thought… “I can’t imagine the loneliness they must feel.”  People receiving care from a medical professional, whether as an inpatient or outpatient, are constantly surrounded by people… but what we don’t think of is that these interactions are often stressful, not comforting.  They’re not meaningful in the same way a visit with family and friends is.  These people cannot return to their usual routine and often have to implement many big changes at a moment’s notice. 

One of the populations that we wouldn’t think of first as being affected by social isolation is people with Congestive Heart Failure.

How badly are people with Heart Failure affected by social isolation?

This correlation may be largely unnoticed in the heart failure population, with other pressing care issues requiring attention, especially in the acute stage.  Congestive heart failure is a major reason for hospitalization and rehospitalization, and the social isolation/loneliness continues to grow.  

Recent statistics from the Centers for Disease Control show approximately 6.2 million adults in the United States have heart failure.  And in 2018, heart failure was listed on over 370,000 death certificates.  This is quite a large group of people!  Knowing that social isolation negatively impacts quality of life and mortality gives us an advantage in addressing these issues.

So how does loneliness affect health for those with heart failure?

One study, published in 2018 by the Journal of the American Heart Association, highlights how the health of patients with heart failure can be negatively impacted by how they perceive their own social isolation.   (Read the full article here.)

In this study, participants were screened to assess their perception of loneliness and social isolation.  They were ranked at low, moderate, or high perception of these subjective feelings and then they were compared in terms of risk for hospitalization, Emergency Department visits, outpatient visits, and risk of death. 

social isolation and heart failure

When comparing the moderate group to the low group, the moderate group had a 16% increased risk for outpatient visits, but were not at more risk for Emergency Department visits, hospitalizations, or death compared to the group with low perception of social isolation.  However, the group with a high perception of social isolation was found to be at a 26% increased risk for outpatient visits, 57% increased risk for visits to the emergency department, 68% increased risk for hospitalization, and greater than 3.5 times increased risk of death.  

Those are powerful numbers! 

The good news is, if we can identify these patients early on and continuously monitor them throughout the time that we provide care, we will be able to decrease their risk for needing medical care and their risk for death through providing outlets and resources to improve how they perceive their connection to the rest of the world.

For some handy clinic tools you may find helpful with your heart failure population, check out our free resources here!

What tools are available to help identify the risk for people with HF?

The Patient-Reported Outcomes Measurement Information System (PROMIS®) Social Isolation Short Form was used in the study mentioned here.  This is a simple questionnaire that can be incorporated into any assessment.  It has a few different versions – the full form being 14 items with ‘sometimes, always, never’ sentences such as…

I feel isolated even when I am not alone…12345
I feel that people avoid talking to me…12345

It has a few different short-form versions that easily act as screening tools when caring for someone with heart failure.  Click here to download these tools and start using them today! 

The UCLA Loneliness Scale is also available.  This scale was developed by a psychologist and has 20 questions answered on a 4-point rating scale (never, rarely, sometimes, always).  The questions are very similar to the ones listed above, such as, “How often do you feel alone?” and “How often do you feel like you are “in tune” with the people around you?” 

This scale has been used in research of different groups like homeless youth, teen mothers, and low income families. However, it can certainly be generalized for use with patients with heart failure if it’s a better fit in your process for screening for feelings of social isolation!  There is also a 3-item version of this scale- a great adaptation for a quick screen.

There are many other options available depending on how you choose to build this into your process. 

Other tools include the following:

  • Lubben Social Network Scale
  • Duke Social Support Index
  • Steptoe Social Isolation Index
  • Berkman-Syme Social Network Index
  • de Jong Gierveld Loneliness Scale
  • Cornwall Perceived Isolation Scale
  • Campaign to End Loneliness Measurement Tool. 

But no matter what you choose to use… the important part is that you identify where they are in their perception of loneliness and social isolation so you can take the right next step.

What’s the next step?

After you identify a person to be at an increased risk, it’s important to start educating them about what their perception means!  Now, you don’t have to throw all the statistics at them… that would be a bit daunting :).  But make sure they understand what a huge impact how they feel has on their health. 

Get them engaged in their care related to heart failure, and re-engaged in the social aspects of their life!  Help them to better understand the disease process they are experiencing, so they don’t feel like they are going through it alone. 

With any medical condition, the amount of information given to patients at one time can be overwhelming, especially if related to a new diagnosis.  There are loads of patient and caregiver friendly free downloads on the American Heart Association website that may help the information be more understandable and accessible to them. 

Another great resource for patients and caregivers who are experiencing higher perceptions of social isolation is support groups.  Family and friends can’t always understand what a person with heart failure is experiencing. This lack of understanding could be a main cause of the feelings of loneliness and social isolation.  Being a part of a support group can be a great way to feel connected to people who truly understand the same things you are experiencing. 

Support groups can come in many shapes and sizes.  Traditionally, one would go to a location approximately once per month and participate in a meeting of some sort.  These are still extremely meaningful to be a part of, but unfortunately are not very easy to attend these days.  Luckily, there are many virtual and online options! 

If someone is seeking more information and is not yet ready for too much interaction, there are online forums where they can browse information on their own, ask questions via email or instant message, and gradually get more involved as they feel comfortable. 

For people who need more interaction, Facebook is an excellent way to hook up with the right communities.  There are many public and private groups for any subject you could imagine!  And with everyone having to stay indoors more these days, this is a great way to get connected and stay connected!

So, remember… there are many people and various populations out there that could be experiencing these feelings, and it’s not always obvious!  Putting a screening tool in place to identify patients at risk is of utmost importance in order to adequately support them and help them to recover physically, mentally, and emotionally! 

To learn more about the (not so obvious) aspects of heart failure, check out our short (but information packed!) webinar – Update Your Care Plan: Heart Failure.

Interested in more clinical tips, articles, and resources for your practice? Sign up for our bi-weekly mailing list below! We promise to treat your inbox with the respect and love it deserves 🙂