Sunday, July 05, 2015

Toilet Training in Rehab is a Disaster

Rebecca Dutton
Home After a Stroke
June 26, 2015

A friend in rehab fell twice while transferring to the toilet.  I was in this hospital so I know how toileting is managed in this institution.  When I told my PT doing squats improved my balance when I pulled my pants up at the toilet she said she was glad PTs do not toilet training.  OTs evaluate how clients get on and off the toilet, but not how clients handle clothing in the bathroom. Aides are the ones who deal with toileting.  Aides have large caseloads so they get everyone to therapy on time by doing everything for their clients.  Aides are doing what parents do to get their children out of the house in the morning.  Aides and parents do things people could do for themselves IF they had enough time.  Here is why stroke survivors need training to be safe when toileting.

One challenge is handling clothing.  It took me three weeks for my standing balance to improve enough for me to feel safe when I pulled my pants up over my hemiplegic (paralyzed) hip.  I had to twist my trunk to allow my sound to reach the front and back of my hemiplegic hip.  Small weight shifts while rotating my trunk were enough to throw me off balance.  When my skin was damp after a shower or a vigorous therapy session it took repeated tries to get my pants all the way up.

Toileting is also a balance challenge because it requires repeated turning in small spaces while  attention is divided.  Managing a cane, the door, and the toilet interferes with my ability to monitor what my feet are doing and how far from vertical I am.  After I walk into the bathroom I have to turn 180 degrees to close the door.  I want privacy when I use bathrooms in the community (e.g. doctor's office, friend's house, restaurant).  I am facing the door I just closed so I have to turn 180 degrees to walk to the toilet.  When I get to the toilet I have to turn 180 degrees so I can sit down.
I turn again after I stand up to flush the toilet. The last 10 seconds of this video shows why I do not want to be sitting when I flush the toilet.

PTs walk clients in large unobstructed paths in the gym where clients are required to think only about controlling their body.  OTs know about divided attention, but they do not evaluate gait or standing balance in the bathroom because ambulation is PT's domain.  Requiring 24 hour assistance with toileting often leads to a nursing home.  This is a severe consequence.  Different disciplines need to stop worrying about stepping on each others toes.  Therapists need to stop worrying about embarrassing clients by asking them to uncover a private area of the body.

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