The Byways of Health Care
Physical therapists serving populations on farms and in small towns and villages are meeting the challenges of distance, climate, and lack of facilities with ingenuity and patient involvement.
You don't have to be a physical therapist in a rural area to benefit from the lessons learned by the PTs profiled here. Among the highlights:
- Lack of effective safety and health programs contributes to injury rates among patients. PTs can offer programs to help reduce injuries.
- A variety of resources exist-ranging from federally-funded programs and private foundations to local universities-to help support PT outreach efforts.
- PTs sometimes need to be creative in using available equipment and in making equipment modifications.
- Networking with other PTs and using the resources of APTA can help PTs deliver needed services and stay current on issues.
The vast majority of Alaska is rural, with only 1.1 persons per square mile. (The US average is nearly 80.) Even Anchorage, its largest city, has a population of only about 250,000, says Nicole Taniguchi, PT, assistant manager of the Physical Therapy Department at Alaska Native Medical Center (ANMC) in Anchorage. In addition to its rural character, Alaska's size, some 663,267 square miles, and remoteness of many population centers bring health care delivery and transportation challenges that are unlikely in "the lower 48," as Alaska residents refer to the bulk of the United States south of Canada. Much of the remainder of the 49th state's 600,000-plus population lives in "villages ranging in size from about 30 people to 700 or so, or in small towns such as Nome that have a few thousand people," says Pat McAdoo, PT, Med, a retired but actively on-call traveling physical therapist who formerly worked at ANMC.
ANMC is a Level II trauma center and the only hospital in Alaska that serves the whole state. "There are village hospitals and outlying clinics," Taniguchi says, "but when they have patients they're not equipped to care for, they send the people to us; for example, a person with a broken bone who needs surgery is likely to be flown to Anchorage." ANMC's physical therapy department serves both inpatients and outpatients, she says. Taniguchi works with a staff of seven PTs and one PTA who see the full gamut of injuries and ailments: respiratory illnesses such as COPD, TB, and lung cancer are very common, as are diabetes and obesity. Patients also have many orthopedic problems, such as fractures, as well as head injuries, strokes, and traumatic brain injury. Use of motorcycles and all-terrain vehicles (ATVs) is common. Sometimes in the villages, a snowmobile (in winter) or a four-wheel ATV (in summer) is the only way to get around.
"We also have quite a number of occupation-related injuries," Taniguchi says. "A lot of the high-paying jobs are manual and dangerous, such as commercial fishing, working on the Alaska pipeline, and in the airline industry. These workers may be carrying heavy equipment, such as large pallet-like containers, so they can have back or leg strain, or injuries, when equipment breaks or jerks or if something falls on them."
"On the outpatient side, we get a lot of patients with neck and back pain as well as repetitive stress injuries," she says. "Some patients go to our 'back school' to learn ergonomics and body mechanics before they come in for physical therapy."
Northbound To Barrow
Four times a year Taniguchi goes to Barrow, the northernmost point in North America. ANMC provides service there "because it is the only major village that hasn't started its own physical therapy clinic," she explains. The town plans to have a new hospital and its own physical therapy service, but it may take several years to build the facility, Taniguchi says. Meanwhile, to access physical therapy services, Barrow residents must fly or drive on the ice road (a frozen river) to Prudhoe Bay, about 200 miles away. From there, some drive down a dirt highway to Fairbanks.
During her quarterly visit, Taniguchi does evaluations and the indicated interventions, then will re-evaluate the same patients the next time she is there. "I almost always give them an extensive home program," she says. "Usually by the time I see them next, that problem is mostly corrected and they will be ready for discharge. Or, they may need something else." Some of the patient visits are follow-ups of people seen in Anchorage. For example, one patient had surgery for a broken ankle, then needed more help with range of motion. Or a patient with a traumatic brain injury who has finished rehab, but lives in the village where there are dirt roads and tundra, needs high-level balance added to the home exercise program or modifications in a natural setting.
One big challenge in providing physical therapy services in Alaska is finding out about the patients' home environment and preparing them to return to a situation that may not aid recovery unless special preparation is made for their safety. For example, they may be living in the mountains or in a house built on a hillside, or have lots of stairs to climb. "In some of the rural areas, they don't have running water. They have to go out and chop the ice, bring it in, and melt it," Taniguchi says. McAdoo adds, "In these cases, it really takes some ingenuity to instruct people in home programs such as wound care, post surgical care, and avoiding infection."
"In the evaluations," Taniguchi says, "we have to ask questions designed to find out what their homes are like. For example, 'How many stairs do you have to climb? Do you have running water/indoor plumbing? Are there relatives or neighbors nearby who can help you or take care of you?' It can be a challenge to make sure that even though they want to go home, it is a safe environment."
Climate, weather, and geographic features may affect a PTs ability to travel to see remote patients, as well as how the patients get to Anchorage and how long they stay, Taniguchi says. Extreme weather is not unusual in Alaska. In Barrow, for example the temperature can get down to -60 degrees in winter with the wind chill. In other parts of Alaska, such as the southeast coast adjoining British Columbia, it's a maritime, humid climate with frequent fog. Special situations such as volcano eruptions can ground airplanes. In winter, travel is mostly by plane, or sometimes snowmobile. Many places can only be reached by plane or, in summer, by boat.
On top of that, air travel is very expensive in Alaska. Taniguchi notes that "from Anchorage, it costs as much to go to Barrow as it does to go to Washington, DC. That extra cost can affect the plan of care when patients seek less expensive options or choose not to travel at all. "For example, a patient with diabetes needed to come to Anchorage for a blister on his foot and decided to save money by taking the ferry rather than flying," she says. "The ferry was delayed a week, and by the time he got to the hospital, the blister had become infected and spread throughout his foot, requiring additional treatment."
All of this means that patients as well as clinicians may end up staying places longer than intended, either in hospitals or in the villages. McAdoo is one of several Alaska PTs who travel to the remote villages on temporary assignments, and she says, "Patience and flexibility are needed to work here. I take a sleeping bag, extra food, and a change of clothes, because I may be sleeping on the floor in someone's home or in the clinic."
The high cost of transportation also affects shipping and whether PTs can get needed equipment. "At times we have to make do with what's available, or find a substitute," says Taniguchi. "For, example, a patient in a remote village may need a bath chair but can't afford to have it shipped. The insurance or Medicare will reimburse for the equipment, but not the shipping costs. So it's often easier just to tell the patient to put the fish cooler [ice chest] in the bathtub and sit on it. Just about everyone has a fish cooler."
Taniguchi previously worked as a PT aide in a large hospital system in Sacramento, California. "We had a lot of skilled nursing facilities and assisted living homes in the state," she says. "At ANMC, we have pretty much everything in terms of medical care, but skilled nursing facilities and extended care facilities are rare in Alaska, especially outside of Anchorage and Fairbanks. Some of the larger villages have elder care centers that are designed to keep patients near their family, but there is no licensed nurse on site." McAdoo also formerly worked in urban areas, most recently in Anchorage for 18 years prior to her retirement, and before that in Chicago. "Cities are different partly because the pace of life is faster. But the main difference is the lack of a community intimacy," she says. "In the small towns, everybody knows everyone else, and everybody knows everything about you."
The "everyone knows everyone else" mindset carries over into professional life for many physical therapists practicing in Alaska. As Taniguichi puts it, "we have a lot of networking going on here-we have to keep in touch with each other in order to survive professionally." PTs in Alaska rely on resources from the American Physical Therapy Association, she adds. And McAdoo comments, "APTA membership is so good that way. If you find something you're not familiar with, you can call one of your APTA member friends and ask questions, whether they're in Alaska or some other state."
Back to the 'Lower 48'
If that other state is Oklahoma, the challenges of being in a rural area are less weather-related and more related to the vastness of the topography and the occupation of farming and ranching. Oklahoma is one of 27 states awarded an AgrAbility project by the US Department of Agriculture's National AgrAbility Project. The purpose of Oklahoma's AgrAbility Project is to assist farmers and ranchers who are injured or disabled in overcoming barriers so that they can continue working in agriculture. The state AgrAbility project provides outreach through university extension programs. Outreach services include on-farm assessment of the farmer, farm tasks, and farm equipment," says Millee Jorge, PT, EdD, dean of the School of Physical Therapy at Langston University in Langston, Oklahoma, and a partner in the Oklahoma AgrAbility Project.
Farming is one of the most dangerous occupations in the Unites States, according to National Safety Council data. More than 700 farmers and ranchers die in work-related accidents yearly, and another 120,000 agricultural workers have disabling injuries from work-related accidents.1 The fatality rate is about 22/100,000 compared with 6/100,000 for other occupations, and one-tenth of amputations occur in people working in agriculture. In Oklahoma, 25% of farm workers report having a long-term disability.
Farmers do not typically retire at age 65. Many work well into their 70s with known health and physical problems such as cardiac, musculoskeletal, and neuromuscular impairments. Common diseases and health conditions affecting farmers and ranchers include osteoarthritis; tendonitis; carpal tunnel syndrome; chronic low back pain and neck pain; peripheral nerve damage from exposure to toxic chemicals and fertilizers; respiratory ailments such as farmer's lung, asthma, COPD, and bronchitis; or skin problems from exposure to weather extremes such as frostbite, heat exposure, sunburn, and skin cancer. Farming accidents such as tractor rollovers may result in traumatic brain injury, spinal cord injury, or amputation of a limb.
State AgrAbility projects work with the USDA's Cooperative Extension Service to provide education, on-farm technical advice, and other assistance to farmers and ranchers with disabilities and their families to allow them to continue their occupations. The National AgrAbility Project, based at Purdue University in West Lafayette, Indiana, provides technical assistance and professional training for the state projects, and produces and disseminates resource information.
One goal of the national project is to prevent secondary injury to farmers, ranchers, and others working in agriculture who have disabilities. There is a need for health and safety education for farmers and farmer workers with known physical impairments and disabilities to prevent secondary problems. The on-farm assessment that is conducted by physical and occupational therapists working in AgrAbility projects allows for analysis of factors that can contribute to the development secondary injuries and facilitates discussion of strategies and adaptive equipment and assistive technology that can prevent secondary injury.
Even though rehabilitation professionals and others may perceive that agricultural workers with disabilities are at higher risk for further injury, Jorge says, there has been little documentation of increased incidence of injury among farm workers who are disabled.
Rehabilitation professionals such as physical therapists should be familiar with the resources available through the Breaking New Ground Resource Center in Purdue's Department of Agricultural & Biological Engineering, Jorge says. The program was founded in 1979 when a farmer who sustained a spinal cord injury asked for assistance with returning to work in agriculture. The resource center has provided state-of-the-art information and resources on rehabilitation technology for people working in agriculture.2
The advances in rehabilitation assistive technology permit physical therapists working with farmers and ranchers with physical disabilities to conduct on-farm assessments and develop a plan of care that supports farmer access to barns and outbuildings, fields, livestock, and farming equipment. Physical and occupational therapists work with personnel from the state's Department of Rehabilitation Services and Vocational Rehabilitation to make referrals and advocate for people with disabilities to continue working in agriculture.
Recommendations for farm equipment modifications may include changing hand-controls or foot controls to facilitate operation of machinery, power lifts to access tractors, specialized seating, step extenders or additional steps to help get into the tractor or truck, and changes to hand tools to facilitate use of one-handed tools.
A couple of clinical case studies illustrate the type of physical impairments and ailments that farmers and ranchers may have, and types of interventions that have been accomplished through AgrAbility, Jorge says. (Names are changed to protect patient privacy.)
"Tad" is a 44-year-old rancher with degenerative arthritis of both hips.
The progression of his disability eventually required the use of a wheelchair. For 2 years he was unable to actively work on the ranch. Through the assistance of the Oklahoma AgrAbility Project he was referred to the Department of Rehabilitation Services and received funding for a necessary surgical intervention of bilateral hip arthroplasty. He underwent physical therapy and was able to resume his rancher responsibilities: He rides horses and herds sheep; he is able to access his farm fields and safely walks without assistive devices on uneven terrain, handles farm animals, and uses farm machinery and equipment. Because he has had bilateral hip replacements, it is very important for him to take care to prevent secondary injury associated with the arduous work of ranching.
"John" is a 38-year-old farmer who sustained a thoracic spinal cord injury when his tractor rolled over and pinned him underneath. He uses a wheelchair for mobility on uneven terrain and can stand and walk for short distances. He wanted to return to cattle and wheat farming at his family homestead after his injury. He was referred to the Oklahoma AgrAbility Project and was evaluated by the physical therapist and physical therapy students from Langston University. An extensive on-farm assessment was completed and recommendations were made for a mechanical lift for his tractor and mechanized opening and closing of the shed doors. John has resumed farming and has received education on preventing secondary injury such as skin breakdown while spending time out in his fields in his tractor.
As the examples indicate, physical therapy plays a major role in rural America and makes a difference in health and quality of life for patients-not only in the Oklahoma AgrAbility program but in Alaska, Missouri, and other states.
Nicole Taniguchi graduated in 2001 with a Masters in Physical Therapy from Samuel Merritt University, formerly known back then as Samuel Merritt College.