simple contact & obstetrics

[Jana OT]

Any thoughts on the use of Simple Contact in this practice setting?

I was allowed to create a new area of treatment a couple of years ago at the request of patients and one of our perinatologists. I work with obstetrical patients in the hospital on extended bedrest in a critical care unit. These patients are admitted primarily due to pre-term labor, premature rupture of membranes, pre-eclampsia, cervical insuficciency, multiple pregnancy, or third trimester bleeding. Patients range in age from 13-45 generally. In the worst case I will have a patient who will be asked to remain in trendelenburg with no bathroom privileges for up to 12 weeks. Classically this patient would have one or two small children already at home she stays home to care for. (I realize this is beginning to sound a bit holistic but rememer I'm an OT working and purpose, meaning, and value as defined by my patients are key components.) As an occupational therapist my job (my passion) is to help that mother adapt to the restrictions, learn new ways to be as independent with self care as possible, gain a sense of control over her life, learn new ways to parent the children she has already, to prevent as much deconditioning as possible and limit the risks of complications such as DVT's. Generally these patients do not feel ill and initially they generally do not complain of back or joint pain outside of contractions. In many cases they feel fine but are required to limit mobility. I also get to follow them on their journey of physical recovery postpartum. It is an amazing and professionally challenging role in the hospital for me. When we first considered the program it meant enormous hours of study and research on my own to develop competency. Frequently pain is an issue with limited ability to treat due to the restrictions of movement in place. In this setting I am constantly reminded that suggestions or actual treatment without each aspect thought out/ researched can spell disaster for my patients and their unborn children.

[Diane]

Hi Jana, welcome to SS. :)
In the worst case I will have a patient who will be asked to remain in trendelenburg with no bathroom privileges for up to 12 weeks. Wow. Sounds absolutely awful for such an unfortunate woman's nervous system. (Not to mention her gastrointestinal system.) Hope she can at least be in side lying for relief. Can she?

I should think moving whatever is safe to move would be hugely relieving.

[Jana OT]

Diane,
Side lying is preferred. Even when our patients are in "supine" they are actually tilted left or right at the pelvis. This prevents obstruction of venus circulation through the vena cava as a result of the weight of the fetus over the structure.

as a side note these individuals have great difficulty with balance immediately postpartum due to changes in proprioception

[Diane]

Side lying is preferred.
So, I get that the really dangerous thing is being upright, not necessarily movement per se? In other words they can move around in bed?

[Jana OT]

Diane,
Although each patients situation is unique, here are some basics.
pre-term labor: position can increase contractions as the weight of the fetus is on the cervix, movement can be problematic through the pelvis and torso, these patients are in supine with pelvic tilt or trendenlenburg and often are on tololytic medications
premature rupture of membranes: approximately 50% of these patients will go into preterm labor, infection is also a fear and antibiotics are given, as far as position they follow the same guidelines as above with the added risk of umbilical prolapse
pre-eclampsia: these patients and some of the most delicate due to the risk of seizure, CVA, kidney, and liver damage, these patients require limited environmental stimulation, patient and family education can be tough, everyone is worried, they all try to crowd in, they turn the radio to some hard rock station or the TV to some power packed action movie, getting the patient to a place where they can focus and listen/ attend to their body is challenging at times, as far as movement these patients have fewer restrictions, they maybe able to get up to the commode or bathroom and typically are able to sit up for meals
cervical insuficciency: for these patients gravity is truly the enemy, their cervix does not tolerate the weight of the fetus and dilates without active contractions, some of these patients are taken to surgery for a cerclage or stitch into the cervix to hold it in a closed position, and may go home on bedrest or modified bedrest, if not they are in tredelenberg for as long as their body will tolerate, hopefully getting the fetus into viability
multiple pregnancy, these patients typically come into due to preterm labor, the challenges are in helping the patient manage pain and discomfort of the sheer weight and size of the gravid uterus, low back pain is a common issue with pregnancy but with multiple pregnancy that increases
third trimester bleeding: these patients have limited activity initially as the reasons for bleeding are assessed, if it is determined that they have a complete placenta previa inwhich the placenta has attached covering the cervix they can be in for a lengthy hospital stay as it is unsafe to go into labor in this condition, these patients feel fine making the process of adaptation difficult, we all move act/ react differently in public than we do in our own homes, once again culture dictates, these women are asked essentially in public, this may contribute to their discomfort

Once again, these are women from 13-40's, from all different levels of education, all different social situations, and varying abilities to make healthy choices in their lives in general. It is a challenging but very rewarding area to work.

[Diane]

OK, thanks for the breakdown Jana. So, looking back to your original question, Any thoughts on the use of Simple Contact in this practice setting?..... which ones do you think it would be ok to help learn ideomotor movement? (Once they have one or two experiences with simple contact, most go on to practice ideomotor movement on their own.)

I'm thinking, even the ones that can't get off their beds could at least contract and relax their bodies ideomotorically while recumbent. That shouldn't put much if any strain on cervixes. Of course it could "pull" on the abs somewhat, but I wonder if it could create as much of a pull as simply rolling over using lats does? (I'm thinking, pull on abs increases intrabdominal pressure.) Probably not..

Granted it would be a bit hard to teach them how with SC if they are already in that position. Probably many confined to such an existence figure it out on their own. :)

Anyway, those are the thoughts I have about it.

[Diane]

One other thought I had, later on, Jana.. are your patients able to safely assume a 4 point kneeling position? They could probably do ideomotor movement that way as long as they remain horizontal, right?

I should think that if pain is an issue, the spine would like to get up, and the trunk up off itself, once in awhile, and nerve roots could always use some flossing. If there is a way to eliminate gravity, i.e. not be upright, but rest and elongate and move the spine in a non-weight bearing way, seems to me quadruped position would be the way to go. Ideomotion/SC would be easy in that position.

[Jana OT]

Diane,

I appreciate your bravery! Its nice to get feedback. I wasn't sure what to expect. When I posted and honestly I assumed that I may get a bit of trash talk in response from Barrett. His silence is deafening. There are few therapists that work in this setting and even fewer OT's. It was an uphill battle to design/ develop/ and implement a new program with such critical patients. A fresh set of eyes so to speak is helpful. I have to say I do enjoy the challenge. Our nurses on the unit now request therapy services on admission.

I had not considered quadruped that may be an option. As for the abs you are on track its valsalva manuers we have to avoid.

[Jana OT]

Diane,

"Granted it would be a bit hard to teach them how with SC if they are already in that position. Probably many confined to such an existence figure it out on their own."

My problem with this is that our patients are in a critical care unit, staff in and out, throughout the day and night.... there is no real privacy. Of course we knock to enter etc. but there's a stream of people they have never met. The cultural tendency to be "polite" in the ways that individuals hold their bodies is in place. It is a difficult place for most to follow their bodies cues for ideomotor movement in front of what must seem to the patient as an audience. This is especially pronounced in our patients who are more shy, reserved, or modest in their normal daily lives.

[Barrett Dorko]

Simple Contact is always used in the same fashion and for the same reasons. The patient in pain secondary to an abnormal neurodynamic will indicate that as I described several times in class. Special circumstances of immobility do not change this.

You go to the patient as you can. If they are unable to come to you then you find them where they are. Deform the skin and wait/inquire about the characteristics of correction. Change contact(s) as dictated by the patient's response.

Anybody simply reading this along with other freely available (and free) writing here and on my site wouldn't have to attend my course and endure my presence.

[Diane]

Hi Jana,
I appreciate your bravery! What bravery? :angel: No bravery was required, I'm a general moderator (and frequent poster) for somasimple, which is quite extensive. Feel free to look around, explore, post your thoughts on this or that. Barrett moderates this particular forum, as it is his own.
(I think if you get to know him better he'll seem less scary.. :))

The cultural tendency to be "polite" in the ways that individuals hold their bodies is in place. Sounds like you got the basic idea from the SC class. :thumbs_up I should think that the women you work with would lose most of their fear of how they "appear", given how much personal privacy they've had to relinquish; they'd probably be willing to do something "effortless" like ideomotion to acquire pain relief (for the pain that is secondary to mechanical deformation).

its valsalva manuers we have to avoid. Hmmnn. Then it should be safe for them to move however they want/can as long as
1. They do not get vertical
2. Do not hold their breath when they move.
What do you think?

[Jana OT]

Barrett,
I do understand the material as you presented. I listened intently as also listened to my body and sat quite comfortably cross legged in the chair, moving, stretching, turning without considering the motion. I may not be familiar with physical therapy scholars but I understood the concepts presented. As a last minute substitute I really did not know I was going to be attending the course. Most of my reading and internet time has been spent learning the obstetric world so that I could feel competent in my interactions with those patients that I see. The internet has always been a great source for me. I can research topics I need to and juggle caring for my children. I agree with you amoung therapists the internet seems to be under-utilized.

It is possible that I wasn't clear in my initial post. My question or hesitation as it may be with this population is that having my patient implementing ideomotor movements might be dangerous to the patient. I don't know this to be a fact, just pondering the possiblities. Most of the women I see do not feel any different. They do not feel ill or compromised physically... at least not when the are initially admitted. My point being, if they do not know there motor limitations and engage them in free movement... would this put the patient at risk? It seems obvious from your lecture that placing limits on that movement defeats the exercise. Further, if that is the case, I'm back where I started with a patient who is in pain due to mechanical deformation and I still don't have a technique to assist them in correction.

I don't have the answer and I'm not fishing for a particualr answer. As you had suggested this is a good forum to get feedback for these and other clinical issues. As for enduring your presence... I stand by my opinion that if you lightened up a bit and possible entered a course with the notion that there are therapist seeking knowledge you might make it possible for more of your students to hear what you are saying without feeling attacked. Just my humble opinion.

[Barrett Dorko]

Thanks so much for the advice.

Ideomotion does not require anyone move in a way that is excessively bizarre or impolite. While on the treatment table the vast majority of correction occurs beneath the surface, invisibly but palpably.

Diane,

I agree. Bravery is not required here.

[Jon Newman]

Although there may be more, two general ways to decrease a person's experience of pain (especially that due to mechanical deformation) is to decrease the mechanical deformation in the nervous system or increase the system's tolerance for mechanical deformation (or both). One of the important attributes a PT (or OT) possesses is knowing when a particular movement might otherwise be unhelpful. If someone is in a straight knee immobilizer (for a tibial plateau fracture) for instance then encouraging or allowing them to bend their knee, even if such movement might be pain relieving, may not be the best move on the part of the PT if the MD doesn't want the person's knee to bend. I say "might be pain relieving" because we can't know whether it is pain relieving until the person actually moves that way.

Jana, if you are unsure of what safe movement is for your clients it seems to me that your best bet would be to talk to the MD in charge--especially considering the specialized field you are in.

[Diane]

the vast majority of correction occurs beneath the surface, invisibly but palpably. I would concur with that.

I wonder if therapists who don't do much handling of tissue (i.e. therapists who are not "manual " therapists) are aware of all the busyness that goes on that can be palpated? By that, I mean, if they don't palpate much or ever, how would they know about it? No one has to answer that, it's mostly a rhetorical question. :)

[Jon Newman]

Hi Diane,

One way someone might come to know this (without direct palpation) is by a patient's self report of the characteristics of correction.

[nari]

...which is my way of thinking, because I do not palpate much at all. The patient's experience would tell me more, I suspect.

Nari