Collaboration between the various disciplines is key, and physical therapists and occupational therapists make an effective co-treatment team
By Mike Le Postollec
Pressure from Medicare and other insurers to quickly transfer patients to less expensive, lower levels of care has caused therapists to treat patients with much greater levels of impairment than before.
For this reason, collaboration between the various disciplines is key, and physical therapists and occupational therapists are a common and effective co-treatment team. Aside from the obvious benefit of an extra set of hands, OT/PT teams can cut down on overall treatment time and offer patients a more holistic approach to therapy. Benefits of co-treatment aren't limited to the patients. By working together, PTs and OTs can gain a broader perspective on treatment and a better understanding and appreciation of each other's role on the rehab team.
"Patients...can see the goals from both disciplines come to fruition...(and) PTs and OTs can see what the other [professional] does and how important it is to work together." explained Toni Thompson, MA, OTR/L, senior OT at Shriners Hospital for Children, Tampa, FL.
When Do OTs and PTs Co-treat?
At Shriners Hospital, therapists provide ongoing treatment for a primarily inpatient population, including children with cerebral palsy, spina bifida, upper and lower extremity amputations, and other conditions with an orthopedic component. Although co-treatments are not always appropriate, Sandy Smith, MS, PT, director of rehab services, said that OTs and PTs work together when patients' impairments cross over several disciplines.
"Our powered mobility training program requires participation from the total team, including physical therapists, occupational therapists, speech pathologists and seating specialists," she said. "The OT will continually assess upper-extremity function and fine motor control for switch access, while the PT evaluates positioning. Postoperative therapy in lower-extremity temotomies is another time when our goals converge, because we're all trying to improve trunk control, balance and upper-extremity function through weight bearing while the patient is in long leg casts."
Therapists at Mt. Sinai Hospital, Chicago, also co-treat often, usually for patients with traumatic brain injury, stroke, spinal cord injuries or highly involved orthopedic problems. Ibrahim Arowolo, PT, senior therapist at Mt. Sinai, says that the patient's level of impairment usually determines whether the rehab team will decide to co-treat.
"If a patient is deconditioned and has sustained some type of injury, I'll start the beginning of ADL training, things like eating, dressing, grooming and basic hygiene," continued Dominik Zaravia, OTR/L, who co-treats with Arowolo at Mt. Sinai. Arowolo would help facilitate these activities by working on the patient's mobility, transfers, balance and gross motor control, and other skills that provide the foundation for ADL.
A Complementary Relationship
Although traditionally, OTs focus on ADL and fine-motor skills while PTs work on gross-motor tasks and ambulation, most impairments will cross over these areas.
"It's too simple to say that OTs work on upper extremities and PTs work on lower extremities," Smith explained. "Even though the patient's condition affects a specific muscle group or joint, they could benefit from receiving interventions from both disciplines, because if the patient doesn't have enough trunk strength or the ability to weight bear through the upper extremity, they won't be able to transfer, walk or do other things that PTs work on."
Thompson offered the example of a patient who came to Shriners with cognitive damage, quadra-membral amputations and hypersensitivity in the residual limbs.
Although one of this patient's primary goals was ambulation, he could not tolerate handling an assistive device with the upper extremities.
"While we were waiting for the prosthesis, the PT and I began working on some gross-motor work and desensitization of the upper extremities so the patient would be able to tolerate handling when he was ready to walk," she said. "Through co-treatment we were able to decrease the hypersensitivity and increase his familiarity with both of us and the environment. It made it less traumatic for the patient, and more successful."
Therapists at Mt. Sinai will sometimes adopt treatments that typically fall under the other discipline to get the patient the full range of services he needs. While part of Zaravia's OT treatment may include upper-extremity range of motion (ROM) activities three times a day, due to limits on reimbursement or other issues, the therapist may only be able to see the patient twice daily, so Arowolo may incorporate the ROM activities into his PT sessions.
If the patient needs three sessions of gait training each day, Zaravia may handle the third round in his OT session, even though ambulation is traditionally a PT treatment.
"There are times when we'll have to consult each other about our [individual] goals," Zaravia said. "If I need to have a patient stand up to work on an OT activity, I'd have to wait for [Arowolo] to assess that patient first to see if he needs an assistive device before I initiate treatment. So when [Arowolo] and I began working together...I learned things from his PT perspective and vice versa, and I think that broadened our views of the patient and gave us a more holistic approach."
Bringing PT and OT Together
While the therapists who spoke with ADVANCE did note that there is a "learning curve" to OT and PT interactions, Smith believes that facilities can help foster a good relationship between the disciplines.
"Some places may have separate PT and OT departments, and I think that might inhibit sharing," she said. "But in our facility we're under the same department, so the opportunities to share are ongoing.
"I think that when therapists take a lot of personal responsibility for their patients, they may get tied up in what they're doing, so it takes a special effort to get the other disciplines involved."
Allied health schools can also work to establish interactions with OT and PT students, Thompson said.
"I was in an OT program only a few years ago where we only had one course with PT students, and I think (it created) a separatist attitude," she said. "It'd be helpful if PT and OT students had more courses together, so that they'd understand each other better and not look at treatment as just a PT or an OT thing." *
Mike Le Postollec is an ADVANCE contributing editor.