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June/July 2002

Return to Work Revisited

John Turner, MS, ATC, LAT, and Kate Hughes, PT, MS, OCS, in their article in the April 2002 issue ("Getting Back to the Daily Grind") do not mention job accommodation strategies, including the consideration of assistive technology devices in return to work (RTW) plans. Why do Turner and Hughes fail to mention the development, implementation, and evaluation of job accommodation solutions, in particular considering how assistive technology devices might be used by the client in the job setting, as part of a RTW plan? They mention that reintegration-the outcome of RTW plans-may include modifications to the work environment or placement of the person into another job, but they make no mention of how assistive technology devices are being used at the job site as an accommodation. RTW plans that do not consider job accommodation in achieving RTW outcomes are narrowly defined. RTW plans must move beyond medical models to achieve the outcome of reintegration. Practitioners may want to investigate the use of job accommodation strategies, in particular the application of assistive technology devices in the job setting, when developing, implementing, and evaluating RTW plans. R.L. Grubbs, MA, MEd

Assistant Professor
Assistive Technology Specialist
Texas Tech University Health Sciences Center, Lubbock, Tex

In the article, "Getting Back to the Daily Grind," we attempted to present an overview of key concepts critical to RTW success. We did mention "modification of the work environment," but did not expand on that statement due to article length constraints. Our article was meant to be a general overview, and did not explore work modifications in depth. Certainly, entire books have been written on subjects specific to modifications in the work environment, such as ergonomics and assistive technology. We appreciate Mr Grubbs expanding on our general overview, and regret that the constraints of the published article did not allow us to specifically address assistive technology.

John Turner, MS, ATC, LAT
Kate Hughes, PT, MS, OCS
TIRR Rehabilitation Centers, Houston

Singer Should Not Be Silenced

I think people with disabilities and their families should be able to listen to Professor Peter Singer's contributions to the issue on the choice of life and death. This is obviously a difficult area. It seems to me that there does need to be a certain quality of life to make it worth living. The editor's message in the April 2002 issue, "Not Dead Yet," represents some opinions of people with disabilities, but those opinions are probably just as diverse as all of society's. Everyone has the right to an opinion, but we cannot have an opinion without information and discussion.

Frank Potter
Vocational Rehabilitation Counselor
Dubuque, Iowa

Chest Physical Therapy Still Beating

Thank you for your editor's message in the March 2002 issue, "Getting to the Heart of Chest Physical Therapy." I agree that chest physical therapy is underutilized and patients suffer because of it. I have worked in spinal cord rehabilitation for many years and have been a strong proponent for chest physical therapy as part of our treatment.

At the Seattle Veterans Hospital, the PTs on the spinal cord injury (SCI) unit are currently the ones who are performing chest physical therapy. Because respiratory failure is the leading cause of death in the SCI population, I feel it is one of the most important aspects of our rehab program. We perform postural drainage, chest physical therapy, suctioning and/or mechanical insufflator/exsufflator (MIE), assisted cough techniques, and respiratory exercises with the appropriate patients. Our physical therapy department was instrumental in resurrecting the use of the MIE on the SCI unit after many years of disuse. (Mary Massery presented this equipment at the American Physical Therapy Association SCI section annual conference in 1999). We have utilized this equipment for almost 2 years with excellent results. Respiratory therapists (RTs) and nurses are also being trained and are utilizing this equipment with postural drainage techniques as a way to prevent respiratory complications. There has been a tremendous amount of energy invested in educating and training our RTs and nursing staff regarding respiratory care and prevention. We have found, as you stated in your article, that respiratory therapists and nurses do not receive the same extent of training that PTs have. Our RTs and nurses have historically been quick to utilize mechanical devices and are not comfortable with the hands-on approach that a PT has been trained to perform.

Because of the significance of respiratory failure and high incidence of death in SCI, we train patients, families, and attendants in all aspects of respiratory care. Many of our patients are trained to utilize postural drainage, chest physical therapy, and MIE on a regular basis after discharge to prevent respiratory complications. Respiratory complications and further hospitalizations are more costly in the long run than adequate care and training with patients to prevent or minimize respiratory problems. In my experience, the most qualified individuals to perform skilled respiratory treatments are physical therapists or physical therapist assistants. I strongly advocate the resurrection of chest physical therapy and encourage our national association to continue to bring this issue to the attention of its practitioners.

Sandy Symons, PTA
Spinal Cord Injury Unit
Seattle Veterans Hospital, Puget Sound Health Care Systems, Seattle

Thank you so very much for your wonderful editor's message ("Getting to the Heart of Chest Physical Therapy") in the March 2002 issue. This could not have come at a better time. I am a PT with 6 years' experience, with 31¼2 of those at the Burke Rehabilitation Hospital in White Plains, NY, where we had a pulmonary rehab unit. In school, I blew off most of the cardiopulmonary coursework due to lack of interest and being told by upper classmen and clinical instructors that that was the job of RTs these days.

To my surprise, when I went to work at Burke and found out we had a pulmonary rehab unit as part of our rotations, I began to look at things a little differently. Fortunately, I had an incredible supervisor on that unit who had an invaluable wealth of pulmonary knowledge and experience, which she shared and taught to our staff. After a while I even began to like pulmonary work and pursued some continuing education coursework with one of the masters of the area, Mary Massery. My supervisor trained us so well, and we could see the transformation of patients from when they were admitted to the time of discharge.

She also put the fear of God in us, telling us that if a patient of ours developed pneumonia, it was our fault. I can tell you very few of our patients did. We did share part of this (a very small part) responsibility with respiratory therapy. However, I can tell you from my experience that trying to get RTs to do bedside chest physical therapy once a day was like pulling teeth from a pit bull. They were very happy going from room to room measuring pulse-ox levels and changing oxygen tanks. We, on the other hand, would be sweating at the end of a session. If we relied on respiratory therapy, all of our patients would have developed pneumonia. I then began doing a lot of work in stroke rehab and translated all of my pulmonary knowledge to poststroke rehab. How can you treat a stroke patient without addressing his or her cardiopulmonary system? But still, I find the majority of PTs are clueless or do not care.

At my current job, we were having a discussion last week about a patient I felt needed chest physical therapy. When I asked how I go about getting an order written, I was looked at like I was from Mars! I responded, "Why the strange looks?" I was then told, "We don't do that here-it's respiratory therapy's job." At that point, I had to refrain from vulgarity and screamed, "We are the only ones who can do it the correct way." I don't even know if the doctor knew what he was writing because obviously it had not been requested in a long, long time.

I feel that PTs who just try to rule chest physical therapy off as something respiratory therapy does is writing us off as a profession, and illustrating their sheer laziness and lack of motivation. We need to reclaim this for our profession and make people realize we offer so much more than just clapping. How can you demand that someone perform exercise if they cannot breath efficiently? If we educate our colleagues, they will see there is so much more to cardiopulmonary treatment than just the old thought of clapping. I have never felt so rewarded as a professional as I have after a very good pulmonary treatment session. As Mary Massery states, "If you can't breath, you can't function." I need not say more.

Vincent J. Orlando, Jr, MS, PT
Glasco, NY
PS. Sports physical therapy to me is quite boring anyway.

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