Listen in as I chat with Philip Gonzalez, a critical care occupational therapist. He will help us de-mystify the philosophy of occupational therapy, discuss how nurses cane help their patients make the most of their therapy sessions, and introduce us to verticalization therapy.
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Discussed in episode
Verticalization therapy is a therapeutic approach using equipment, manual assistance, or other various technologies to gradually tilt a patient from supine to 90 degrees in a slow and controlled manner, traditionally accomplished without any hip flexion using tilt tables.
Transcript
Annie: I think we, as clinical nurses, appreciate the important role that occupational therapists play in inpatient care, but don’t have the time to watch and really understand what they are doing with our patients during therapy sessions. For today’s episode, I am going to cross the figurative healthcare aisle and chat with Philip Gonzalez, a critical care occupational therapist. He will help us de-mystify the philosophy of occupational therapy, discuss how nurses cane help their patients make the most of their therapy sessions, and introduce us to a really valuable technique called verticalization therapy.
Philip: My name is Philip Gonzalez. I am an occupational therapist by trade. I also serve as a clinical specialist in a nonclinical role as well. I’ve been an OT now since January 2015. So roughly eight and a half years. Most of my practice has been in ICU, and I love talking about OT’s role in ICU, what we bring to the table, and how nurses and PT and speech and physicians can utilize our services in ICU effectively and efficiently, and what our perspective brings to the team in PlanetCare.
Annie: Philip never saw himself working in an ICU, let alone a hospital, but, when he stepped foot in the ICU during school, he was blown away with the possibilities of what he could do as an occupational therapist and how much their services were needed in the critical care setting.
Annie: I can only imagine, as an occupational therapist, walking into an ICU setting and thinking, my skills and what I can bring to the table are so needed Because I think by the very philosophy of being an occupational therapist, you’re returning people to their occupation. And, as a nurse, that’s kind of on the back burner of my mind.
I’m not really thinking about returning patients to their occupation. I’m thinking about getting them their medications in time about, uh, vital sign parameters. I’m looking at the here and now, but what you bring to the table as an occupational therapist is just so much richer and, so needed in, in healthcare.
Philip: So, and I think one of the caveats to that is, and it’s a common question I get every single day that I walk into a consult or intervention session is, well, I just saw PT. What is an occupational therapist? What do you do? Like, I don’t need a job. Well, and that’s a common question that everyone asks, and even general public sometimes don’t really understand the full scope of what we do as OTs.
So, just a little breakdown. Occupational therapists, we define our profession as the occupations, That we engage in every day. So we occupation specifically is what occupies our time. It can be as basic as our daily self care needs. It can be as intimate as our social interactions with people. It can be The things that we enjoy to, that we enjoy for pleasure, for leisure. It could be our job, obviously, occupation. Um, it can be our financial management, our social management, our skills we need for driving. There’s such a big scope of what occupational therapists address that I think oftentimes gets overlooked because The name occupational therapy immediately alludes to, well, I don’t need a job. Well, your job is to live, and I’ve actually used that line with patients. Yeah, you’re in the ICU right now. Your job is to get through your disease process and recover.That’s what we’re going to focus on.
Annie: I love how you phrase that. I know whenever an occupational therapist comes to see one of my patients, they’ll they’ll check in with me. Is it an OK time to see the patient?
And you know a lot of this is logistical and like does the patient have a test that they need to go to? Are they in the middle of their meal? But what, what is some additional information that would be helpful to you as an occupational therapist from a nurse?
I’m always thinking, like, I’d like to set you up for success when you go to see the patient. What, what can I do to help facilitate a good therapy session?
Philip: Absolutely. I think handoff communication is key. For me personally, and I can’t speak for all occupational therapists, but when I’m checking in with the nurse, I ultimately want to make sure that there are no changes from the most recent documented event or note that a physician may have entered um, most of the time I will know, The ins and outs of that patient at a greater detail than even some of the nurses unless they’ve been with that patient for an extended period of time. So for me personally, and this is what I often teach a lot of my students to do, is I want you to know the ins and outs of that patient from the start of their hospital stay, their history even prior to their hospital stay, and then what their disease process looks like now. You should know that before even going to the nurse. So when I check in with the nurse, I’m looking at, okay, what is their response to interventions that were provided that morning? What is their response to changes in medicine that the physicians may have initiated?
What’s the plan for the day? If an ICU patient, if they’re, I go back to being intubated, are there plans for spontaneous breathing trials? SATs or SBTs. Um, is there plans to wing sedation if they’re on sedation so that they can participate in therapy? If they’re on pressers, are we holding their pressers?
Do we have room to titrate to participate in therapy if they need it? So when I do that handoff communication with the nurses, I think,
for me, I’m not necessarily asking if a patient can be seen, because I would hope that I’ve already determined they’re appropriate to be seen. It’s more so just clarifying if there’s any changes that would bar me from seeing them in that moment.
Annie: Besides pain management, are there other things we can do to help facilitate a good session like, uh, get family members there, don’t know. I’m just thinking off the top of my head, like, what are there things that, nurses do that you’re like, Oh, thank you so much for doing that.
Philip: Yeah. Oh, no, absolutely. Um, I think the greatest success I’ve found is when nurses kind of prep the patient for the plan for the day where therapy isn’t an option. It’s an expectation.
So when I’ve gone into a room and. The nurses or even physicians have said, Oh, well, you get an easy day today. You get to rest today.
And then I come in the room and try and expect them to participate in an evaluation or an intervention. Well, I’m going to get immediate pushback and say, well, The doctor said I can rest today or the nurse said I can rest today. Whereas if I go into the room and the nurse has prepped the patient from the start of their shift, just as they do with their medicine management, they’re gonna go over in detail what their medicine to look like for the day. That, hey, therapy is part of your plan of care today. It looks like you have so and so coming to come see you. We’ll figure out a time of
when they’re coming to see you. It helps prep the patient for that expectation And know that it’s not going to be a surprise.
I think that’s where it’s been most successful.
Annie: a hundred percent. I think there’s an element of salesmanship that nurses can do to really sell the importance of therapy.
One thing I hear from, um, therapists over and over again is, no patient really wants to work with therapy, that they’re often dealing with kind of grumpy patients who don’t really want to move because they’re tired and they’re uncomfortable.
And so what one thing I personally like to tell my patients, because I’m a really big believer in early mobility and giving patients good, functional outcomes, they’ll say, you know, working with therapy today is just as important as this antibiotic I’m about to give you is just as important as any medication.
So if you decline therapy, you’re declining one of the best interventions we can give you.
Philip: Yeah. And in my experience, what I’ve found is even those patients that are grumpy, that are hesitant and resistant to work with therapy, if I can get them actively engaged and involved with Nine times out of ten, yes, they may be a little tired, but they’ve, one, enjoyed the session, two, actually feel better, feel like a more normal human being and not somebody that is sick and in the hospital and actually can feel the benefits of it the next day.
One of my, one of my favorite things to do as an OT, because we’re assessing ADLs in our sessions anyway, is if I have the opportunity to, and the patient’s appropriate to, is actually get them in the bathroom, get them in front of a mirror, go through their morning hygiene routine.
It does two things: It, one, allows them to feel a little sense of, engagement that they’re able to actively do this, but then two, they’re actually able to see what they look like being ill and want tochange that. Nobody wants to look or feel ill. So when they get in front of a mirror and see that. They’re like, oh, I gotta fix this.
Annie: Oh, I love that. I love that. I always assumed that that was done because, like, oh, it feels so good to have a clean mouth and to feel like you’re getting back in your routine. But I like that. It gives them that, like, added motivation to, um, to actively change their circumstances.
I’ve heard that time and time again that mobility often goes down after ICU, because there are just fewer..
Philip: A 2:1 ratio to a 4:1 ratio.
Annie: yeah, I mean it pretty much all comes down to that. Yeah, yeah, and I think there’s an element of intrinsic motivation that’s needed for nurses to, to mobilize patients, unfortunately, and, and, that’s something that I’m acutely aware of, and something that I address on this podcast a lot is, you know, there’s so many benefits.
Of, uh, mobilization and it’s almost like you have to do it from the goodness of your heart. Not necessarily because you have to do it. Like we have to scan medications. We don’t have any, well, it, it, I guess it depends on the, the culture of the floor that you’re on, but there’s not as much accountability for nurses to mobilize as there is for medications.
Philip: Well, and to add to that too, there’s such a fall prevention dynamic in hospitals where I think we use Alarm systems ad nauseum that actually hinder a patient’s ability to mobilize and mobilize freely. Obviously, we want to make sure falls are prevented so that we’re not adding injury to a disease that’s already a patient is dealing with in the hospital setting. But a lot of times what I find is when patients are a little bit more free to move around or they have a good family support, they’re going to be more successful more often than not. I think when we limit a patient’s mobility because we have alarms set to the most sensitive settings because we don’t want that patient to get up and move around because they look frail, it often leads to further deconditioning because there’s been times where I’ve gone in for an evaluation seeing a 90 year old female or 90 year old patient. Said, you know what? They’re good to go. They can move around as long as they have their walker nearby. They’ve had no losses of balance to get to the bathroom to perform dynamic movement. They’re good. That handoff communication was done to the nurse on shift that day, was done for that night nurse. Well, the next day I come by and I pass by the patient’s room and they’re there with a bed alarm.
They’re not allowed to move. The nurse says, oh, well, they can’t move. They have a bed alarm on. They’re, they’re not safe to move around. I’m like, really? Because I saw them yesterday, and I physically cleared them. And I think a lot of, the times it becomes overly precautionary that ends up impacting a patient’s functional status.
Annie: Most, , floors or units, there’s a sign, you know, X number of days since fall. And, you know, this is a metric that we track so closely, and it seems there’s so much shame involved in being the nurse, uh, of a patient who falls. And I, you know, on the flip side of that, falls can be devastating. But I, I think a little bit more nuanced thinking or reasoning could go into it. I know a lot of, uh, patients are so frustrated by the fact that they’re on a bed alarm.
It’s such, it’s a balancing act.
Philip: You’re caught between a rock and a hard place in those situations, really truthfully, but the question I often ask is does the risk outweigh the reward, or does the reward outweigh the risk? And for me, as a therapist, the rewards of physical mobility and just engaging in your daily activity at a normal rate and Um, pace oftentimes outweighs the risk because anytime somebody enters a hospital, there’s an immediate decline in just the amount and volume of physical activity and daily engagement that they’re going to engage in. The amount of activity that we do at home is far greater than the amount of activity somebody’s going to do in the hospital room and I think oftentimes that gets, that becomes an afterthought. The now we’re trying to build the person up to be able to tolerate their level that the amount of physical activity that they’re going to need to do at home.
Annie: Yeah. Now I have the million dollar question for you. I’d love for you to share. with my audience, what nurses can do to leverage what you do as an occupational therapist when you’re not there. I’d love for you to talk about, the importance of routine. And especially early mobilization, preventing delirium, when you’re not there.
Philip: No, absolutely. Personally, one of the reasons I fell in love with ICU is because there’s a lot of foundational work that can go into a person’s rehabilitation process, what is therapy going to look like in the ICU? This patient is intubated, has been sedated, was on paralytics, they’re barely starting awakening trials, they’re sometimes tolerating the vent, sometimes not tolerating the vent. How is somebody going to come in and do therapy for that patient? On top of, now because of all of the medical management that they’ve had to do, Now they’re fighting delirium, whether it be hyperactive delirium or hypoactive delirium, where they’re just not engaged, and they look like they’re okay, but they’re just spaced out, even though they’re off sedation. Um, so where does OT fit in with those patients? I’d love that question.
For me, it really comes down to the root of my profession, and that’s We are an occupation based profession. Our occupations are the daily routines that we engage in every day, whether it be the routines we engage in at home, the routines that we engage in with people, and the routines that we engage in in our environment.
The more we are able to maintain those routines for patients in the hospital setting, and especially in the critical care setting, it has such a profound effect on a patient’s cognition to help with the delirium management.
One of the first things we do in the morning, and on average most everybody, we get up, we get out of bed, we may take a sip of water if we’re, have cotton mouth from sleeping all night, and go to the restroom. Second thing, after we’re in the restroom, we probably interact with ourselves at the sink, washing our hands, brushing our teeth, washing our face. That is something that is so ingrained into us that it’s an afterthought for most healthy individuals. Well, for somebody who is ill, and critically ill, that goes to the wayside because there’s a disease process that has to be managed.
Well, on top of that, they’re not engaging with their normal routine, so now you’re setting the body itself to fall out of its normal circadian rhythm of what a normal day can look like. So, when we talk about routine establishment in the ICU and how OT can be utilized to help with that, looking at what does a patient’s daily routine look like, and I think one of the best stories I have for this is, it was a neuro patient, came in with a stroke, nurses and physicians were doing the neuro assessments during the day, And patient was very sluggish, very lethargic, not really participating as much as they would like, had a pretty significant stroke, um, but very hard to wake up in the morning, and hard to get a good, true neural assessment.
Well, come to find out, this patient had worked night shifts for the past 20 years. Their, Their, routine was, they slept during the day, they got off of their shift at about four in the morning, they went to bed, they slept until about, Two in the afternoon, they woke up at two in the afternoon, and they were able to engage in their normal activity, go to work, and do their normal job. So, after discovering that, I told the nurses, told the physicians, I was like, hey, come back and do your neuroassessment in the afternoon. Because what I was noticing was, we had a patient that the doctors wouldget one presentation of them in the morning, I would end up seeing them in the afternoon, and they were great.
Annie: Wow.
Philip: So there was such a stark difference in what that patient looked like, well, after finding out that that was their routine, well, yeah, it makes sense. His body hadn’t adjusted to the new expectation of now being up at 6 o’clock in the morning during shift change to be able to participate in daily activity on top of his stroke. And now they’re doing neuroassessments for that, which you’re already dealing with. Cognitive deficits, time differences, you get alarm burnout from ICU, you’re not sleeping in general, wasn’t getting adequacy because he never slept at night normally. Um, so I think having that foresight to really look at a person’s normal routine and how that can be applied into what their hospital routine is going to look like can really be the starting point for, Eitherdelirium prevention or even progressing to delirium management if it’salready been established that delirium is present.
Annie: Yeah. I think it would take a nurse having a team approach, like, talking to aides, talking to techs, like, let’s get up brushing their teeth, ordering breakfast, doing all those, those things because it’s hard for a nurse to do that on a patient’s schedule. Like, I think patients end up being on our schedule. So I think, if , you can sell it as, if you do that work up front of figuring out what a patient’s schedule is, their norm, their usual routine, it’s more work up front, but maybe less work down the line when they’re not as delirious.
Philip: And a lot of the times what I’ll tell nurses and family members too is obviously the burden doesn’t need to fall solely on the nurse to do that, to figure that out. It’s a interdisciplinary model for where you may not find that information out, we may find it out for you guys. But then going back to our handoff communication, ensuring that that communication is handed off to the appropriate channels. There’s a lot of times if I’m working with a patient who is showing signs of delirium, That and family is present all go into extensive education of what they can do for the management of delirium. Oftentimes, it’ll be okay if they’re having visitors. It’s the same visitors. It’s familiar voices. It’s the people that they would see regularly in their home environment.
It’s not somebody different every day that’s coming in, asking what’s going on, and talking to them, and then, because often times our patients with delirium may not, one, know who they are, where they are, what’s happening, what’s going on. There’s a lot of confusion that goes associated with that. So even routine can be as simple as, Hey, if we’re going to have visitors, let’s, Try and make it the same visitors pretty consistently, showing up at the same time, leaving at the same time, introducing themselves every day, describing what has happened, just establishing that familiarity is just routine establishment in general. And then looking beyond that, you’re also able to, if they’re expected to be in the ICU room for an extended period of time, looking at modifying their environment to be more familiar to home. So bringing pictures that are familiar, bringing smells and scents if they’re able to smell if they’re not, um, trached or orally intubated. But bringing things that are familiar blankets, pictures, um, music. I love the use of music in intervention sessions. Um, one of the stories that I love to share is a patient, a trauma patient that, was a traumatic brain injury. So side story is that this patient, young kid, 16 years old, if I remember correctly, motor vehicle versus pedestrian, pretty severe traumatic brain injury, as well as a lot of orthopedic injuries.
The progression for a traumatic brain injury is youhave some comatose stages, some minimal response statuses, they progress to like an agitation phase and then they’re able to progress beyond that and work more on higher level cognitive skills. So a lot of the times when therapy is consulted, it’s either when they’re comatose and doctors don’t really know how to get them stimulated, or it’s when they’re beyond the agitation phase or the There’s still a lot we can do, I just wish we were consulted sooner.
So fortunately for this patient, we were consulted early enough during the comatose stages where we were able to help them progress beyond being comatose through routine establishment, sensory stimulation at consistent intervals.
Well, typically happens when a patient wakes up from a coma that’s a traumatic brain injury is there’s a lot of confusion, agitation, and flailing. Sometimes some thrashing that nurses, sometimes obviously for obvious reasons for safety, the immediate go to is utilizing pharmaceutical intervention to calm them down.
Annie: Yep.
Philip: In those situations is consult, make sure therapy is consulted. We are able to provide a patient with physical activity levels that in layman’s terms can wear them out so that now you’re not having to add sedation on top of a traumatic brain injury of somebody who’s just starting to come out of being comatose and then mess with their sleep wake cycle and mess with their daily routine.
So with this story in particular what we found that worked phenomenally for this patient was the use of music and specifically Musicals. So he was a theater kid that loved the musical Hamilton. When we found that out we decided to try it in therapy. We sat him up edge of bed. He was thrashing, flailing, which is what we expected. The moment we turned on the music, he immediately stopped and started kind of just rocking back and forth and self soothing.
So we relayed that information to the nurses and any time he was having bouts of agitation, um, and becoming just a little bit more unruly in the bed to where he was either bucking the vent or trying to pull at stuff or just thrashing, they would turn on his music and it was an almost an immediate switch and he would just instantly calm and self soothe because it was something that was familiar to him. It was something that was routine to him.
Annie: There is soemthing magical about music. Music is so therapeutic for a patient.
And um, one of the first things I do when I notice a patient’s delirious is I’ll call up a patient care services and I’ll say, can I get a iPad for this patient? And I’ll ask the family members, like, what kind of music do they like to listen to?
And it’s, honestly, it’s pretty easy, but it’s so beneficial for the patient too. And it’s kind of even nice for me to be in the room and be able to listen to this music with them.
Philip: Yeah. And so I think just going back to it, it goes back to just that routine establishment leveraging those skills of trying to figure out what that patient’s routine is allows in the ICU.
Annie: Absolutely. Absolutely. Before we go into verticalization theory, um, I wanted to talk about how to promote an independence with patients. And one thing that I’ve become aware of in myself since I’ve become a mom and I see it now in myself as a nurse is that I want to just do things for my patients or my son, because it’s easier that way.
I see my son struggling to put on a shoe and I have to stop myself from just doing it for him.
And just allowing that moment of struggle to happen, and I was wondering if you could shed some light on some ways that nurses can, promote independence of their patients, whether it be with, with family or with, , specific tools, I’d love for some, you know, very specific nuggets that you can give us.
Philip: So I’m laughing because I come from a Hispanic background and a Hispanic family, and we’re, we are culturally notorious for when our family members are ill, we take care of them. We do the things for them, we help them along the way, um, and I’m laughing because, um, At this point in my career, if I’m working with a patient and having them do something, reach for something and a family member reaches to help me, I will slap their hand out of the way. And it’s almost reactionary that I end up having to apologize afterwards. Um, because it does.
What happens is when I’m sitting a patient up that’s edge of bed that I know is going to be physically, um, more debilitated, it’s going to require greater assistance. I want that patientto struggle. I want them to feel their body systems activating, to know what those motor pathways feel like, so that we can get muscle engagement, so we can get nerve, muscle recruitment, nerves firing, so that we can feel those joints articulating.
Well, if a family member, if I’m going to sit the patient up on the edge of the bed and the family member all of a sudden grabs her legs and swings them to the edge of the bed. So, I have to catch myself sometimes and I always go into the explanation of why, but most of the time, more often than not, family members laugh because they think it’s funny.
I said, if it was my family member, I want them to do this. I want them to do it on their own because our goal is to recover.
For example, I had a bilateral lung transplant patient the other day. They were, I think, three days post op, um, multiple attempts at phalene extubation. Mostly because their disease, they, a lot of my experiences with patients that require lung transplants also end up with an anxiety component of it. Um, so there’s just an ability to deal with having new lungs and figuring out what it feels like to breathe. Well, she’d been in bed, she’d been sedated, they had started weaning sedation, she was still intubated, she was alert, oriented, appropriate, husband was present. And I went in. Thinking, okay, well, she’s actually going to be pretty significant level of assistance. She’s a post operative surgical patient, has four chest tubes, has the vent, has her IVs. We’re probably going to maybe get to chair position in the bed. If I’m lucky, maybe get to sitting edge of bed. So I had my tech come in and help me just in preparation to sit her up edge of bed. Well, surprisingly, She was able to lift her legs against gravity, raise her arms, she ended up swinging her legs over to the edge of the bed with me just providing a little bit of trunk support, and had I done that for her, and actually in that case Islapped my text hand away, because he was gonna help.
Annie: So much hand slapping!
Philip: I know. I was like, no, hey, let her, let her, let her try. Let me see what she, let me feel what she’s doing. I was able to realize, I was like, oh, she actually moved to the edge of the bed, sat up on her own,was able to support herself, um, maintained her sitting edge of bed on her own. And this was three days after her bilateral lungs.
Annie: Wow.
Philip: Luckily, she’s able to tolerate it, fatigued out, which was expected, but Had the husband helped me or had the tech helped me, well, we wouldn’t have given her the opportunity to really feel what that feels like. So not only
feel what that feels like from a surgical standpoint, but feels what that feels like for a breathing standpoint. Because those are things that I think about too, is if I’m moving the patient and he’s breathing, quote unquote, heave hoing them to the edge of the bed because they’re going to require that level of assistance. Well, I’m taking away the person’s ability to coordinate their breath control during them actively performing their movement. Which it’s important for patients who have just had new lungs put in to figuring out what their breath control is going to look like with activity. Because historically with activity these patients have gone short of breath rather quickly because their lung capacities have been diminished for so long that now when they have new lungs, they are still learning what that feels like.
Annie: I love that explanation that you just gave and I, I think it’s, it might take some explaining to do. Right? Like sometimes I feel like, like kind of an ass, like letting my patient struggle putting their legs up on the side of the bed. That’s, that was one thing I had to give up. Like I used to automatically put my patient’s legs up on the bed and then I decided a few years ago, I’m going to stop doing that and I’m going to let them try and they struggle and then the family members sitting right there and they’re watching this struggle and it’s hard for them to watch that, you know, they’re identifying that patient, their family member, a loved one as ill and how dare you let that patient struggle.
So I think coming to that situation with this explanation of they need not only for strength, but your point to coordination and learning how to use their. Their bodies, new functionality, is such a great thing to explain and kind of allow everyone to step back and let the patient do what they can.
I wanted to give, you time to talk about verticalization therapy. This is how I met, Philip, was at NTI this year. He was demonstrating verticalization therapy.
it’s something that really caught my eye. I think it’s so dramatic to see this bed, tilting up, you know, to be vertical and, And besides that, I’ve seen verticalization therapy for neuropatients in the past. And when I saw it listed in the expo, I was like, I’m there.
But anyway, long winded way of me saying, Philip, specializes, or is very, uh, knowledgeable about verticalization therapy, and I’d love for you to, you know, introduce this this topic to my audience.
Philip: Absolutely. So kind of going back to my role as a clinician, I also serve as a clinical specialist for a company that manufactures a ICU bed that can reverse Trendelenburga patient all the way to an upright position. , yes, it is a passive activity, but the benefits that you reap from the body being in an upright position are profound. Um, and that can be done with a bed. It can be done with a tilt table. It can be done with manual techniques. As I’ve mentioned, I heave ho the patient to the edge of the bed to sit them up and eventually stand them. Um, the idea of verticalization therapy really is to just Use the tools, the means, the mechanisms that you have to get a patient in an upright position. Um, there’s so many physical, logical benefits from it that we Again, take for granted because as people, we’re designed to be upright. We’re upright all day for the most part. We’re either sitting up in a chair working, we’re on, if we’re healthcare providers, chances are we’re on our feet walking around.
If we’re engaging in our daily activity, we’re up and we’re moving. We are upright probably 80 percent of the day. Maybe 70 if we’re sleeping good enough hours, but the majority of our day is probably in an upright position So what happens when somebody is ill, is sick, and is in the hospital? Well, Most of the time they’re gonna be in a hospital bed for an extended period of time They’re probably gonna have an opportunity to get upright for 50 percent of the day, 40 percent of the day.
Sometimes if it’s an ICU patient, maybe even just 20 percent of the day It’s such a dramatic difference of what the human body that person may have normally been used to, that you end up with functional impairments from that. You end up with physiological impairments from that.
You end up with deconditioning, all the things that we know happens in ICU because of prolonged bed rest. So I think what’s important to talk about is why that happens first. So it’s interesting enough because a lot of the study that goes into what verticalization therapy looks like was initially studied by NASA. So, and the reason why is because what NASA notices is that these astronauts coming back from space, they’d often come back with significant Muscle atrophy, decreased bone density. They’d have a horrible tolerance to getting up out of the chairs. They’d end up passing out most of the times, um, the first few steps that they took once they returned to earth.
And they wanted to figure out why. So the problem is, is how do you recreate a microgravity environment? On a planet where there is a set amount of gravity. Um, so what they ended up doing was they tested it by placing these astronauts or these participants in their studies in a prolonged bed rest position with the head of the bed actually tilted a little bit downward. And what that did was that created Maybe not the perfect environment, but it allowed them to be able to study the effects of limited gravity, on the body. Because what happened was instead of gravity going through the body from a head to toe manner, a top down manner, it ended up going from like a chest to back manner as the patient was laying down.
So now the whole body system is not feeling the effects of gravity. It’s going straight through and out the other end versus going from the top of our head down through our spine down through our muscles. We’re not getting the weight bearing.
So it goes into our conversation about why vertical therapy is important because it It goes into what weight bearing looks like through our body, what does loading musculoskeletal system look like, what does loading our cardiovascular system look like, so when we place patients in a bed rest position, we all know this as ICU practitioners, is true. They’re gonna decondition, they’re gonna lose strength, they’re probably gonna lose some muscle mass on top of the disease process where they may be intubated, sedated, maybe not have adequate nutrition on tube feeds, not have feeds at all for a little bit until things are managed, whatever the case may be. You look at the cardiopulmonary system and the cardiovascular system, they may end up with a little bit of azoplasia because their blood vessels actually have become accustomed to being in a dependent position that you move to an upright position. They don’t have the baroreceptor response to support blood flow back up to the heart and to the brain.
9 times out of 10, a patient that has been intubated, sedated, and paralyzed, I go to try and sit up the first day. I anticipate their blood pressure may bottom out.
So the concept of Verticalization therapy and early verticalization therapy is to try and mitigate the effects of. Bed rest primarily. Allow a person to get in an upright position as much and as often as possible so that down the road we’re not dealing with somebody who has been in bed for two weeks now.Strictly supine with the head of bed maybe greater than 30 degrees if we’re lucky. And now we go and try and see them for therapy and they can’t tolerate any activity.
So fortunately enough, there’s equipment out there that can do that. Um, ceiling lifts, beds that go vertical, tilt tables, standing aids,both electrical and non manual, or both electrical and manually powered, therapies, and what that does is it allows a patient to get upright. So what we’ve learned from this whole process is what verticalization therapy does is from a pulmonary standpoint, it allows patient’s lungs to be in a better biomechanical position, to pull better volumes, to have better VQ matching throughout the entirety of their lungs, to allow the diaphragm to offload off of their chest if they’re a patient who has a larger body habitus, and maybe a little bit of hypoventilation syndrome. Or a patient that has a little bit of CHF that can’t tolerate Lean Supine. It allows better mechanics for the lungs to breathe easier.
From a cardiovascular standpoint, it allows that sensory input to the vascular system to know when it’s appropriate to, uh, Provide a little bit of extra support to pump that blood back up to the heart and obviously up to the head so that they’re not bottoming out from a blood pressure standpoint.
It allows the musculoskeletal system to feel their golgi tendon apparatuses have that weight bearing a little bit of that stretch reflexes to at least initiate some firing so that the muscles aren’t becoming completely wasted for not being used, um,
it allows profound cognitive stimulation. Um, one of I think main talking points, especially if I’m working with patients that either have a little bit of like a hypoactive delirium or they’re a traumatic brain injury that’s having a difficult time being aroused,or if they’re a stroke that’s having a difficult time being aroused. Being in an upright position has such a profound effect on the central nervous system that sometimes it’ll wake a patient up.
I’ve had a stroke patient at one of my hospitals that I got handoff from the nursing. Oh, he’s not arousable. Can’t wake him up. Got handoff in the doctor’s notes. Not arousable. Can’t wake him up. He was a pretty dense stroke. And me and the PT on that particular patient, we decided to go see that patient together. Because we decided we were going to be brave and sit them up and see what they did. And I wanted to have extra hands to help out. The moment we sat them up, patient woke up. Well, went beyond that, well the patient was able to walk. Yet for the, yet for the last two days, while the patient was in bed, they were having a hard time getting him awake, keeping him awake, participating in the day. But being in that upright position had such a profound effect on his central nervous system that it allowed him to maintain a greater alertness.
Annie: How can nurses advocate for something like this? I think just having in the awareness that verticalization therapy is a thing, is half the battle, right?
Like, I, you don’t know what you don’t know, and before I was at and TI, I didn’t really know that verticalization therapy was a thing and there was a name for it.
So, my hope now is that listeners who hear this will know that it is an option to bring it up to, therapy and the physician team if they think their patient can benefit from it.
Philip: Absolutely. And even if you’re not sure, oftentimes it doesn’t hurt to advocate for a therapy consult. and let the therapist come in and decide and make recommendations and go from there.
Annie: Yeah. I, I don’t think I’ve ever seen a physician say no to a PT/OT consult.
Philip: Right. Exactly.
Annie: So I really thank you for, you know, taking the time to introduce occupational, or I should say reintroduce occupational therapy to nurses.
Philip: It’s been a pleasure speaking with you today. I love, love educating about my profession and what I bring, what I bring personally and what OTs bring to the table in the acute caresetting and in ICU so, thank you.