Analysis and Interpretation: NBCOT study cards

Explain why home exercise programs (HEPs) are an important part of the plan of care

A home exercise program (HEP) is a series of exercises or activities created by the therapist in order to provide continued training and activity outside of the scheduled therapy sessions. Treatment is almost always supplemented with the construction of a HEP to allow for carryover of treatment principles into the home setting as appropriate. This can be simple UE or LE exercises against gravity or with a TheraBand for strength and endurance, fine motor or dexterity exercises with putty for a hand injury or stroke, or task-related activities such as folding towels or making a sandwich. A well-designed HEP will help the patient build on the skills learned in each therapy session so that progression to new activities and tasks can be addressed in each session.

Explain evidence based practice (EBP) and how it influences therapy

Evidence based Practice (EBP) is how clinical expertise is integrated with clinical evidence from systematic research. More simply put, it is based on a combination of research results, clinical expertise, and the client's preferences, beliefs, and values. Therapists are under increasing pressure to justify the services they provide because of reimbursement issues, services provided within the scope of practice, and staffing ratios: EBP is how this is done. The EBP process has six steps: (1) formulating the clinical question, (2) searching for the best available evidence, (3) critically analyzing evidence for its validity and usefulness, (4) integrating the appraisal with personal clinical expertise and client's preferences, (5) evaluating performance or outcomes of actions, and (6) disseminating and communicating knowledge so that the entire profession benefits.

Explain the Bruininks-Oseretsky Tests of Motor Proficiency (BOT-2) and how it is used.

The Bruininks-Oseretsky Tests of Motor Proficiency (BOT-2) is a standardized test used to evaluate fine and gross motor skills, and it can be used with typically developing children and children with developmental disabilities between the ages of 4 and 21. This test has a complete form and a short form, and it ahs four sections with eight subtests that include fine manual control, manual coordination, body coordination, and strength and agility. The short form has 14 items selected from the subtests of the complete form, and it is most often used to screen for further evaluation. The complete form takes 40-60 minutes to administer, and the short form takes 15-20 minutes.

Discuss the types of bone fractures seen in a clinic.

A bone fracture is caused when the force against the bone is greater than the bone can sustain causing it to splinter, fracture, or break. There are multiple classifications of fractures. A closed fracture is when the bone breaks but does not puncture through the skin and protrude through to the outside. An Open fracture is when the bone breaks and punctures the skin protruding to the outside of the body. A comminuted fracture is when the bone breaks in multiple areas. This is often seen in a trauma such as a car accident or in competitive sports. A greenstick fracture is when part of the bone bends and does not fully break. This is often seen in young children because the bones are flexible, softer, and still developing. A spiral fracture is when the bone is twisted or rotated like a corkscrew. An avulsion fracture is when a tendon or ligament is taxed and pulled too hard causing it to pull away and break the bone. An Oblique fracture is a break at an angle caused by the outside force coming at a right angle to the bone. A transverse fracture is when the fracture is perpendicular to the shaft of the bone. A pathological fracture is caused by disease making the bone weak, and the bone can break without warning simply by putting minimal pressure on it.

Discuss the importance of care coordination meetings in healthcare.

A care coordination meeting is a meeting to discuss each patient's care, progress and discharge planning on a weekly basis. These meeting will have various members based on the setting, but they most often include a case manager, therapy nurse, and physician. The focus is determining the length of stay, assessing readmission risk, discussing barriers to discharge (help at home, independence with mobility, and ADLs), discharge locations ( home, SNF, rehabilitation center), equipment needs (oxygen, walker, commode) and current concerns, family and patient questions, patient education, family training, and complications or complaints. Therapy plays a pivotal role because it is the therapist who determines safety and independence with mobility and self-care and has a strong influence on the safest location for discharge. Additionally, in a skilled nursing setting, the care coordination meeting will discuss Medicare and insurance coverage days and the patient's resource utilization group (RUG) level, which is a classification system to determine reimbursement levels for patients in SNFs.

Discuss maintenance and restorative therapy programs and how OT is involved.

A maintenance program is a program that is created by a therapist toward the end of the therapy sessions in order to maintain functional status and prevent decline with discharge from services. Maintenance programs can also be established after the therapist completes a "screen" on a patient in order to address a resident's ability to maintain their functional status or the patient is at risk for functional decline. Screens are often completed in long-term care and assisted living facilities. A screen is a nonbillable treatment intervention to look at strength, ROM, and flexibility as well as functional ability and cognition. It is usually initiated by an incident such as a fall or by staff noticing a decline in functional ability. The screen will determine the need for therapeutic evaluation and intervention or the need for the patient to be on a restorative or maintenance program. A restorative therapy program is a program established by the therapist to prevent decline after the patient has been discharged from therapy services. It is activities, exercises, and tasks created by the therapist and run nursing assistants or nonclinical therapy staff. Activities can include transfers, bed mobility exercises, fine motor tasks, and functional mobility. Restorative therapy aids are in most cases trained by and signed off on by the treating therapist.

Discuss the importance of a multidisciplinary team in healthcare.

A multidisciplinary team is when a group of medical professional come together to work for the betterment and success of the patient's healthcare needs with a collaborative approach. This is how a patient can have the most comprehensive medical treatment possible because the different disciplines' scopes of practice work to complement each other, meeting all of the patient's concerns in a more thorough manner to create the best outcome. A team approach allows for the patient's physical, social and emotional needs to be met. In addition to creating better outcomes for the patient, studies are beginning to show that a team approach allows for more checks and balances to prevent adverse events and higher patient satisfaction. Teams vary based on the setting, but they can include physicians, nurses, aides, floor directors/unit directors, PTs, OTs, SLP, dietary/nutritionists, social workers, case managers, psychiatrists/psychologists, and pharmacists. The therapists on the team (PT, OT, SLP) will typically have a unique and important role because they will have more frequent and daily interactions with the patient than the other members of the team. Often, it is these therapists that notice more subtle changes or concerns because they are treating the patient for 45 minutes or longer everyday whereas other staff see the patient briefly each day, only once a week, or because of shift work they will have multiple days off between interactions with the patient.

Discuss the process of updating a plan of care (POC) and interventions

A plan of care (POC) is the therapy document that is written and signed plan of the patient's care establishing the diagnoses, treatment goals, treatment modalities, and interventions and the amount, duration, and frequency of therapy services. This is written and signed by the evaluating therapist and then submitted to the physician or nurse practitioner for approval. Progress notes are created on the 10th treatment day or the 30th calendar day of the episode of treatment and are submitted to the treating physician. At this time, updates are generally made to the POC based on the patient's progress. Standardized testing is completed to determine if progress has been made since the initial evaluation and to address if the goals have been met or if the patient is progressing on the goals, and the therapist needs to determine the effectiveness of the overall therapy interventions including if the patient has met their highest level of functional potential and if there are still skills that need to be achieved. This is all documented and submitted to the physician for sign-off. Although the POC is most often updated during the progress note, it can be altered and changed at any time during the therapy process if the therapist feels that the goals are not appropriate, the patient's medical status has changed, or the frequency needs to be updated.

Explain progress notes and discharge reports and why they are used in treatment

A progress note is written for each therapy session and is a description of the treatment intervention and the patient response to that treatment. It will also include the start and end time, a progress indicator with regard to the stated goals (if the patient is progressing toward established goals), documentation of pain, and plans and recommendations. A signature from the therapist makes it a legal document. Progress notes can be narrative or in SOAP note form, and they must be clear, consistent, and accurate with the treatment activity. Often, a more detailed exercise log will be attached to the progress note with specific exercises and activities detailed with the amount of weights used or the time needed to complete the activity and number of repetitions. The goal of the progress note is that any therapist could step in and provide and continue treatment that is in line with the plan of care in place and to keep a detailed chronological log of patients progress and success. A discharge summary is completed at the discontinuation of therapy services. It summarizes the therapy sessions, addresses progress toward goals, and makes recommendations. A discharge report will include identifying information in detail (name, age, diagnosis, and precautions), date of evaluation, and discharge with the number of visits, interventions and modalities that were used, summary of goals and their progress, standardized testing results, and recommendations. Again, the document must be signed by the therapist to make it a legal document.

Explain the term sensory diet and how it is created and used in treatment

A sensory diet is an activity plan that provides the sensory input that a person needs to stay focused and organized throughout the day. These plans are generally created based on the results of the sensory profile. Tasks and activities in the "diet" can include activities that encourage sensations and situations that are challenging, increasing alertness, regulating emotions, decreasing unwanted sensory seeking or avoiding behaviors, and working through transitions during work and play. This is a tool most often used with children on the autism spectrum or with sensory processing issues, but it is also being used working with adults dealing with the symptoms and issues of dementia and Alzheimer's disease, including adverse behaviors. Examples of this can be heavy work for proprioception such as lifting, pushing, and pulling items; vestibular input such as spinning and swinging; auditory input such as noise-canceling headphones or music can be played; and olfactory activities such as "scent breaks" in which cotton balls saturated in scents such as orange or peppermint or vanilla can be inhaled for a calming effect. These activities can be done throughout the day and integrated into work or play activities.

Explain why using standardized assessments adds to the validity of the profession of occupational therapy

A standardized test is defined as a test that: - can be administered, scored, and interpreted in a consistent manner without bias - can be duplicated - can be given in diverse settings - will compare function and ability across a variety of populations Standardized tests are considered a fair and objective method of assessing skills, without bias, and there is room for interpretation by the provider of the test. They provide a good measure of a patient's ability, which demonstrates credibility, and they justify that the therapy interventions that are provided actually work. With the profession as a whole moving toward a focus of evidence-based practice, standardized testing is not only needed, but it is crucial to the support and justification of intervention and validating the need for services. Currently, as well as into the foreseeable future, reimbursement from our continually changing healthcare system will become increasingly reliant upon occupational therapy services to demonstrate patient progress through documented, accurate and reliable testing.

Discuss orthopedic interventions for total hip replacement

A total hip replacement or total hip arthroplasty is the surgical removal of the ball and socket and replacement with a metal ball and stem inserted into the femur bone and an artificial cup socket. Surgical approaches can be completed by surgically entering posteriorly or anteriorly, and each approach will require different precautions for the patient. In a posterior approach, the patient will be unable to bend at the hip past a 90-degree angle, cross their legs, or twist the hip inward (pigeon toe). In an anterior approach, the patient is not allowed to step backwards with the surgical leg into hip extension, externally rotate the surgical leg, cross their legs, sleep on the surgical side in a side-lying position, and must use a pillow to support a neutral hip when rolling in bed. These precautions are generally in place for 4-8 weeks depending on the surgeon. The main goal of the hospital OT is to reinforce hip precautions while completing ADLs. The OT will evaluate the patient's ability to care for themselves at home including getting in an dout of bed, functional transfers, toileting, self-care, dressing and grooming and will review the equipment needed for return home post-surgery such as a shower chair, toilet riser, or commode. The therapist will also educate the patient in the use of a hip kit, which contains a reacher, sock aid, long-handled shoehorn and long handled sponge. the home health or facility-based (SNF or rehab) OT will teach the more advanced ADL skills while continuing to enforce hip precautions.

Orthopedic interventions for total shoulder arthroplasty

A total shoulder arthroplasty is the surgical removal of the ball and socket and replacement with a metal ball and stem inserted into the humeral bone and an artificial cup socket. The need for this surgery can be caused by arthritis, fracture or trauma, or a rotator cuff repair. Post-surgery, the patient will likely wear a sling for 4-6 weeks, only taking it off for exercise and ADL activity, and will be told to not participate in activities that require active movement and pushing or pulling of the surgical arm. Each surgeon will likely have his/her own protocols based on the surgery techniques used, and therapy is guided by the specific ROM designated by the surgeon. The hospital OT will be tasked with teaching how to don/doff the sling and sling care, teaching one-handed ADL techniques, and in most cases only hand, wrist and elbow ROM and pendulum exercises. Facility and home health therapists will continue refining single-arm ADLs including dressing, bathing and cooking. At the 6-8 week mark, patients will generally begin seeing an outpatient therapist to begin on strengthening and ROM and start to return to full and normal functioning.

Discuss how a treatment plan is established and documented and how goals are established

A treatment plan is the key part of the initial evaluation process. The evaluation of a patient can be separated into three parts: (1) background information, history, and physical, (2) assessments and testing, and (3) the treatment plan. A treatment plan is a combination of short-and long-term goals; treatment procedures and activity; amount, duration, frequency and anticipated number of visits; and recommendations including discharge equipment and referrals. The plan must have input from the patient and demonstrate evidence and need for the therapy intervention. Goals are established by determining what tasks the patient wants to be able to participate in, what is causing the patient to be unable to complete the task, and how that task can be made possible and attainable. Goals should always be functional, measurable, observable, and attainable in a reasonable amount of time. In most settings there will be short term goals and long term goals. STGs are directly related to LTGs and are the building blocks and often the individual performance components of LTGs. LTGs are the activities and skills that the patient and therapist would like to see the patient master by the time of discharge from treatment.

Discuss how occupational therapy has an important role in health literacy

According to the Department of Health and Human Services, health literacy is the "ability of the individual to access, understand, and use health-related information and services to make appropriate health decisions." Healthcare professionals often recommend treatments and activities for the overall health of a patient that are complex and not easily understood for a nonmedical or uneducated persons. The average American reads at a 6th grade level and with the influx of patients with English as a second language, the ever-changing healthcare system becomes more difficult to navigate for the average person. OTs are unique in that they are skilled in task analysis and are adept at deconstructing tasks and information to a level that is understandable for their patients. If a patient is instructed by their physician to "Eat healthier" after having a heart attack, does the patient understand what that means? the OT can identify that the person does not understand what eating healthy means and can break the task down into understanding food labels, shopping the outside perimeter of the grocery store for fresh products, and identifying correct portion sizes. The OT can create a therapy session around making a shopping list, gathering the items at the store, and prepping and cooking a healthy meal.

Discuss activity and task analysis and what is means to "grade" an activity

Activity analysis is the process that an OT uses to explore the demands of an activity and the range of skills needed to complete the task by breaking it into small steps in order to determine its therapeutic potential. It creates an understanding of what is needed to perform the activity so that the therapist can teach the patient how to complete the activity, and it determines the equipment, material, space, cost and time required to perform the activity. Task Analysis is the process in which a task is broken down into smaller, more manageable pieces that can be taught, practiced, and reinforced step by step, for example, walking into the kitchen, turning on the light, opening the fridge, gathering sandwich components, etc. Grading an activity is the modification of the activity to support the client's performance. Activities can be graded to make the task easier or more difficult, depending on the goal. Activities can be graded by increasing or decreasing the difficulty of a task by altering the number of steps or the complexity of the steps required to complete it, the amount of time given, or the amount or type of cues or assistance given during the activity.

Explain why program design and development are important in occupational therapy

An OT is not limited to traditional settings or areas of practice. Many therapists see a need in their facility or in the community that could be addressed by therapy to meet the needs of a large population. It can be something as simple as a balance and exercise program to prevent falls in a senior center or a modified swim class for children with special needs at the local community center. Once the idea is born, a plan with specific details of the program activities, resource allocations and financial needs, and expected outcomes of the program needs to be documented to present to the community or organization. Program design has the potential to create areas of practice outside of the traditional hospital or clinical settings and create an impact on a larger portion of the population that may not be reached by traditional therapeutic approaches.

Explain an individualized education plan (IEP) and how it impacts occupational therapy treatment.

An individualized education plan (IEP) is a document that is created for children ages 3 to 21 who needs special education services. The IEP established guideline and goals based on federal regulations to accommodate and assist a child who has an established and documented physical, cognitive, or learning disability. The document is created and updated yearly by the child's teachers, therapists, and other paraprofessionals with input from the family, and there is a yearly team meeting to discuss the child's progress and update goals. The IEP remains in place through the child's high school graduation or 21st birthday. The goal is to assist the child to be as successful as possible in school and in their academic career. The role of the OT is to address the impact that the disability has on the child's ability to function and participate in the educational process are successfully as possible.

Discuss the following cognitive evaluations: Saint Louis University Mental Status Exam and the Mini-Mental State Examination

Cognitive testing often falls under the job description of the OT, but it can also be completed by a speech therapist depending on the setting. It is always a good idea to discuss the cognitive evaluations that you choose with the speech therapist on staff because often both disciplines will test cognition to address different concerns and this ensures that you are not both using and administering the same assessment. Saint Louis University Mental Status (SLUMS) Exam: Evaluates attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation. It looks for cognitive deficits and cognition changes over time. It is norm-standardized and used in all settings. There are 11 items in the exam, and scores will indicate normal cognitive function, mild neurocognitive disorder, or dementia. Mini-Mental State Examination: Evaluates orientation, registration, attention, calculation, and language and praxis. It is norm-standardized and used in all settings. There are 30 questions on the exam with scores indicating normal cognitive function, mild cognitive impairment, moderate cognitive impairment, and severe cognitive impairment.

List the common nerve injuries seen in a clinic

Common nerve injuries seen in a clinic are the following: Radial nerve damage: the radial nerve is responsible for sensation on the dorsum of the hand and extension of the fingers and wrist for assisting in functional grasp. Damage is caused by physical trauma or infection. Ulnar nerve damage: The ulnar nerve is responsible for sensation of the ring and pinkie fingers and fine motor control of the hand. Damage is often caused by elbow injury, nerve trauma, infection and increased edema. Median nerve damage: the median nerve is responsible for sensation on the thumb, middle, and ring fingers and flexion of the fingers and thumb for assisting in functional grasp. Most often, damage is related to carpal tunnel injury, but it can also be caused by trauma, edema, and infections.

List the common tendon injuries seen in a clinic

Common tendon injuries seen in a clinic are the following: Carpal tunnel syndrome: the carpal tunnel is the narrow area in the volar wrist where tendons, ligaments, and nerves pass to provide sensation and mobility in the hand and fingers. Carpal tunnel syndrome is when the median nerve is compressed causing numbness, tingling, and pain. Often seen with repetitive hand movement such as with frequent computer use. Often, a carpal tunnel release is surgically completed prior to therapy. Flexor tendon injury: Flexor tendons are found on the volar side of the hand and are superficial to the skin. They are responsible for bending the fingers. Injury is caused when the tendon is pulled out of the sheath and away from the bone by physical sports, diseases such as RA, or deep cut to the palm or fingers. Extensor tendon injury: Extensor tendons are found on the dorsal side of the hand and are superficial to the skin. They are responsible for extending the fingers. Injury is caused when the tendon is pulled out of the sheath and away from the bone by physical sports when the finger gets jammed, diseases such as RA, or a superficial cut to the back of the hand. The most common types are a mallet finger/baseball finger (extreme force causing flexion, such as jamming the finger when catching a ball) or boutonniere deformity ( the finger is bent at the PIP joint, or the thumb is bent at the DIP joint caused by tendon injury or RA).

List the common wrist fractures seen in a clinic (colles' fracture, Smith's fracture, and Distal radius fracture )

Common wrist fractures seen in a clinic are the following: Colles' Fracture: caused when a person falls and tries to catch themselves with the wrist extended. The distal part of the radius breaks causing it to point in a dorsal direction. Smith's fracture: A "reverse Colles' fracture" which is caused by falling on a flexed wrist or an impact to the dorsal forearm causing the distal part of the radius to point in a ventral direction. Distal radius fracture: Caused by falling with the arms extended when a person is trying to catch themselves. A Colles' fracture is the most common type of radial fracture. Distal radial fractures can be intra-articular or extra-articular. In an intra-articular fracture, the broken piece of the radius extends into the joint, whereas in an extra-articular fracture, the broken part of the radius does not extend into the joint itself.

List the common wrist fractures seen in a clinic (Barton's fracture, scaphoid fracture, and distal ulna fracture)

Common wrist fractures seen in a clinic are the following: Barton's fracture: caused by falling on an extended and pronated wrist. A Barton's fracture is a distal radius fracture with a dislocation of the radiocarpal joint. It can be dorsal or palmar. These are most often surgically repaired with an open reduction and internal fixation. Scaphoid Fracture: A break in the scaphoid bone, which is the carpal bone at the base of the thumb. This is most often injured when you fall on the palm of your extended hand. Distal Ulna fracture: these injuries are seen at the distal end of the ulna articulate with the bone in the wrist. This is usually not an independent fracture and is seen in addition to a distal radius fracture. It is usually injured when there is too much rotation of the wrist or an extreme force against the ulna. There is most often a significant ligament injury as well.

Explain coordination and discuss how and why you would evaluate coordination and what you would do to test coordination in a patient.

Coordination is the ability to complete smooth, accurate, and controlled motor responses on demand. Coordination encompasses gross motor skills, fine motor skills, and hand-eye coordination skills. This can be the UE moving smoothly to create gross or fine dexterity movement for handwriting, or it can be how the body moves through space organized and not tripping or bumping into objects in the environment. Bilateral coordination is the ability to use both sides of the body together in a coordinated way. This is seen in tying shoes, using a knife and fork, and running. To test UE coordination, therapists will often have the patient try to button and unbutton an item or use the finger-to-nose test. In this test, the patient sits across from the therapist and takes the top of his index finger to the tip of the nose and then moves the finger to the therapist's finger that is held in front of the patient. In the LE, a therapist would use a heel-to-shin test or have the patient walk along a straight line. In the Heel-to-shin test, the patient will raise one leg and with their heel touch their opposite knee and drag the heel along the shin toward the ankle and then slowly back up to the knee.

Explain how eligibility for services is determine and how prioritizing/justifying need for services is documented

Determining eligibility for services is the key for reimbursement with insurance companies and Medicare, and it is based on medical necessity. Medical necessity refers to healthcare services that a therapist provides using clinical judgement that would allow a patient to be successful in managing, treating or recovering from an illness, injury or a disease and its symptoms. When medical necessity is established, the patient's insurance will determine eligibility. This is usually based on if therapy services will improve or restore functional ability or prevent the patient from getting worse. Once a physician has initiated a referral for therapy, it is up to the therapist needs to show that the judgement, knowledge, and skills of a licensed therapist are required to prevent the worsening of a condition; improve, correct, or cure a symptom or condition; increase function,; or decrease the deficits resulting from a documented dysfunction. Throughout treatment, the therapist needs to continue to justify need by documenting a clear picture of the treatment sessions including progress on goals, updates to the plan of care, and the direction in which the treatment is heading on the road to discharge from service.

Discuss documentation techniques

Documentation of therapy encounters is a significant part of the day for a working therapist. Documentation is required for every therapy session and must follow the rules established by the facility and regulatory organizations. Most documentation is electronic, but some facilities are still using handwritten notes. All handwritten entries are to be written in blue ink and will include original signatures. This is to easily identify an original note and not a copy of the original. Notes can be written in SOAP format or as a narrative note. SOAP stands for subjective, objective, assessment and plan. A narrative note is a description of the therapy session documenting the sequence of events as they happened making sure to identify as much specific and descriptive information as possible. Subjective (s): document what the patient states are the limitation, concerns, problems and deficits. Objective (o): document all measurable, observable, and quantifiable data Assessment (a): document the professional opinion and judgement regarding patient limits and strengths, goals and barriers, progress and rehabilitation potential. Plan (p): document ongoing plan to reach the goals established at evaluation.

Explain early intervention programming

Early intervention programming is a service provided by the government for children from birth to the age of 2 with developmental delays or specific health conditions or diagnoses in order to help them, catch up in reaching developmental milestones to be successful in school and eventually become a functional member of society. Services are delivered at no or low cost to the child and are provided under the Individuals with Disabilities Education Act (IDEA). Under IDEA part C, occupational therapy is considered a primary service, which means that the OT can be the only service provider the child has or can act as a service coordinator or member of an evaluation team. As a service coordinator, the OT provides client-centered, occupation-based services to the child and family by encouraging bonding between the child and family, educating the family, promoting achievement of milestones, patterning routines and play, adapting the environment so the child is successful with tasks, and encouraging the family to be advocates for their child. As a service coordinator, the OT can assist the family through the Part C early intervention assessment, intervention, and `transition process.

Define the difference between functional mobility and gait training and why one is not under the scope of practice of an OT

Functional mobility is a person's ability to move around in his or her environment. This can include ambulation with and without a device, transferring from surface to surface (chair to commode) and bed mobility. Gait training involves analyzing the pattern of how a person walks with a detailed focus on step length, stride length, speed, trunk rotation and arm swing. This is within the physical therapy scope of practice. Functional mobility is within the scope of practice of occupational therapy, whereas gait training is not. External reviewers will deny gait training services when provided by an OT. Functional mobility in occupational therapy will teach a patient how to safely ambulate in their environment during a functional task for increased independence and safety during ADL activity. It is well within the scope of OT practice to address areas that impact functional performance and safety, regardless of mobility level.

Describe the process of grip and pinch strength testing

Grip and pinch strength testing is an important part of therapy evaluation in an outpatient setting. It helps to establish a baseline for treatment, grade tasks, determine what tasks a patient can or cannot functionally complete, monitors progress, and helps set realistic and attainable goals for therapy. These tests are often used when a patient is referred to therapy after and upper extremity (UE) or hand surgery, tendon or nerve damage, stroke, cerebral palsy (CP), multiple sclerosis (MS), Parkinson's or osteoarthritis (OA). Grip strength is measured using a hand dynamometer. The patient is to sit in a low-back chair with forearms on the arms of the chair and feet flat on the floor. The wrists should be just over the end of the chair's arm, thumbs facing upward. Patients will position their thumb around one side and their fingers around the other side of the handle and squeeze. When the needle stops rising, read the measurement from the dial and record the results. The outside dial usually registers in kilograms and the inner dial in pounds. A pinch test is administered from a pinch gauge, and it measures the tip pinch ( thumb tip to index fingertip), key pinch/lateral pinch (thumb pad to lateral aspect of the middle phalanx of index finger), and palmar pinch/three-jaw chuck pinch ( thumb pad to the pads of the index and middle fingers).

Discuss common wrist fractures seen in a clinic.

In an outpatient clinic, much of the occupational therapy caseload will be made up of hand injuries and UE deficits, even if the therapist is not a certified hand therapist. These are the most common injuries and interventions seen in a clinic. Treatment interventions for wrist fractures will include but are not limited to the wrist generally being in a cast for 6-8 weeks prior to therapy. On assessment when the cast is removed, there is a possible need for splinting to further immobilize or for pain management. The patient's ROM, strength, sensation, dexterity, and edema are assessed. A functional activity assessment is completed. Treatment sessions would include physical agent modalities (PAMs); pain management; edema and wound management; retrograde and scar massage; fine motor; dexterity; strength; monitoring of the neck, shoulder, and elbow for pain or stiffness; active assistive and passive ROM; and modification and task analysis of the home, workplace and ADLs.

Discuss worker health programs, and define the terms work hardening and work conditioning.

In the outpatient setting, a therapist will likely see many workers' compensation and workplace injury patients. When someone is injured at work, they are frequently sent to therapy to address the injury and functional deficits that are keeping them for their jobs. Treatment sessions will include work simulation activities and strengthening and conditioning activities to get injured workers back to work as quickly as possible. The facility may also have a contract with local businesses to complete work readiness evaluations during a preemployment screening. Screens and evaluations may include a functional capacity evaluation, which is a standardized and peer-reviewed evaluation tool that measures strength, endurance, physical demand, work level and positional tolerance. This may be done preemployment, or it can be used to determine return-to-work status including identifying if a patient can return to full duty or needs to return with modified or transitional duty. Work hardening is a program designed to return the employee to work by completing activities that include real or stimulated work activities in line with their job. The goal is to improve and restore physical, behavioral, and vocational functions so that the person can return to active duty at his or her place of employment. Work conditioning is more general and goal oriented to address deficits in strength, ROM, endurance, joint mobility and functional abilities with the same intent: to get a patient returned to full duty at work.

Discuss the key legislation that impacts therapy services

Legislation can have a major effect on the treatment of your patients, and it is important to stay abreast of new rules and laws throughout your career. The American Occupational Therapy Association (AOTA) website is always the most up to date with current laws and regulations. Rehabilitation act of 1973 (Section 504): The rehabilitation act is a federal statute created to protect people with disabilities from discrimination based on their disability. Section 504 requires schools to meet the needs of students with disabilities in the same that they would for children with no special needs. Accommodations can include extended time on tests or assignments, adaptive equipment, alternative and flexible seating, behavioral or educational contracts and peer to peer counseling or teacher aides. Americans with Disabilities Act of 1990 ( ADA): The Americans with Disabilities Act (ADA) is a civil rights law that protects people with disabilities against discrimination in all areas of life. This includes all areas open to the general public in public and private businesses, schools, parks, places of employment and public transportation.

Explain metabolic equivalent (MET) levels and how it is used.

MET levels describe the intensity and amount of energy that a person will use during an activity. One MET is the amount of energy that a person uses per unit of body weight during 1 minute of rest. MET levels are most often used in cardiac rehabilitation settings. Patients who have had a heart attack or heart surgery need to carefully work back into a typical and normal activity level. Therapists will use MET levels as a guide to ensure that the activity does not exceed what the patient's heart can tolerate during the healing process. MET: 3 and under Intensity: Light activity Activity: sitting, reading, grooming, dressing, hygiene, crafts, and basic ADLs Met: 3-6 Intensity: moderate aerobic activity Activity: walking briskly, hiking, dancing, housework, resistance exercises while sitting, up to 10 lbs. Met: 6 and above Intensity: vigorous and intense aerobic activity Activity: Running, competition sports, swimming

Describe how strength testing is completed in a therapy evaluation and why it is important.

Manual muscle testing (MMT) and the use of a dynamometer (for pinch and grip) are the most common methods to measure strength in a therapy evaluation. We do this to evaluate the strength of a muscle or muscle group to determine the ability to move against gravity and with resistance in the full and available ROM. Muscles can be graded into six categories: zero (0), trace (1), poor (2), fair (3), good (4), and normal (5). In the zero category, no muscle contraction can be felt. In the trace category, the muscle contraction can be palpated but you may not see active movement. In the poor category, movement is available but only with gravity eliminated. In the fair, normal, and good categories, full ROM is seen against gravity. Further strength is identified in the good and normal categories because the muscle can sustain movement and hold its position with resistance in addition to moving against gravity. Each category can be adjusted by using a (+) or (-) system, and it is designated below. Normal Abbreviation: N Number: 5 Gravity: against ROM: Full Resistance: maximum Good abbreviation: G Number: 4 Gravity: against ROM: full Resistance: moderate Good- Abbreviation: G- Number 4- Gravity: against ROM: full Resistance: less than moderate. Fair plus Abbreviation: F+ number: 3+ Gravity: against ROM: full Resistance: minimal with breaks. Fair abbreviation: F number: 3 gravity: against ROM: full Resistance: none Fair minus Abbreviation: F- number: 3- gravity: against ROM: >50% Resistance: none Poor plus abbreviation: P+ number: 2+ gravity: against ROM: <50% resistance: none Poor plus Abbreviation: P+ Number: 2+ gravity: eliminated ROM: full Resistance: minimal with breaks Poor Abbreviation: P Number: 2 Gravity: eliminated ROM: full Resistance: none Poor minus Abbreviation: P- number: 2- Gravity: eliminated ROM: <full Resistance: none Trace Abbreviation: T Number: 1 Zero Abbreviation: 0 Number: 0

Discuss how group treatment is used as a treatment modality.

OTs have been using groups since the beginning of the profession in order to facilitate learning and support positive interactions. Group treatment is task and activity based and is used for enhancing and mastering skills; increasing strength or physical ability; and increasing comradery, communication, and social skills while recovering from illness or injury. There are many benefits to running groups for occupational therapy interventions. Groups are often seen in mental health settings using trust- and team building activities, as well as simulated role play to elicit increased communication skills,. emotional regulation, appropriate social interactions, and teamwork among group members. In pediatric settings, children can be seen in groups to foster appropriate interactions between children and to initiate play strategies and self-regulation. Groups with parents and children are often used so that therapists can assist the parents and children are often used so that therapists can assist the parents in modeling appropriate behaviors and interacting in public with multiple sensory inputs. In a rehabilitation setting, groups often include ADL groups, exercise groups, family training and teaching patients how to use adaptive devices and electronics.

Explain proprioception and discuss how and why you would evaluate and test proprioception in a patient

Proprioception is how we identify our body position in space. The sensory receptors in our skin, joints and muscles help provide information for motor movement and postural control. When a patient has deficits in proprioception, they will likely be labeled as "clumsy" or they will be at a high risk for falling. There are no standardized tests for proprioception, but there are two ways that therapists can test it. The therapist can stand behind the patient so they can't see you and what you are doing. The patient will then be requested to close their eyes, and the therapist will position one UE (including the hand, wrist and fingers) in a position and have the patient attempt to copy the position with the opposite limb. The other testing option is to have the patient close his eyes and the therapist will move his limb into a flexed or extended position and back into neutral. The patient will then be asked to identify if the limb was flexed or extended after the movement has ended. Proprioception is documented in the evaluation as either impaired or intact.

Discuss how a therapist would assess range of motion (ROM) and why it is important

Range of motion (ROM) is the measurement of movement around a specific joint or body part. This is assessed by a therapist using observation, palpation, and the use of a tool called a goniometer. ROM can be assessed actively (AROM) or passively (PROM). AROM is when the patient actively contracts the muscles to move through ROM independently. PROM is when the therapist moves the patient through the full ROM without the assistance from the patient. The goal is to look for the presence of pain during the movement and the actual range of movement that we measure in degrees. When ROM is limited, it can affect the patient's functioning and cause pain. We look at end feel during this process. End feel is when the movement is stopped or resisted when passively moving the joint through the end of its ROM reaching its limit. End feel can be soft, firm, or hard. Soft end feel is seen in knee and elbow flexion where there is soft-tissue approximation. Firm end feel is when there is a normal stretch and is seen in finger extension and arm pronation. Hard end feel is bone to bone and is seen in elbow extension.

Discuss the following cognitive evaluations: Short Blessed Test, and Montreal Cognitive Assessment

Short Blessed Test: Evaluates cognitive concerns in the areas of orientation, memory and concentration to determine cognitive changes associated with dementia. It is norm-standardized and used in all settings. There are six items on the exam, and the scores will indicate normal cognitive function, minimum impairment, minimal to moderate impairment, and severe impairment. Montreal Cognitive Assessment: Evaluates the ability to process and understand visual information, executive function, language, short-term memory recall, attention, concentration, working memory and awareness of time and place. It is norm-standardized and used in all settings. There are 16 items in 8 categories on the exam, and scores will indicate mild cognitive impairment and Alzheimer's disease.

Discuss the common tendon and nerve injuries seen in a clinic.

Tendon and nerve injuries can be a result of disease, trauma and surgery. This can be because the structure itself has been cut, overstretched, crushed, pinched or compressed. When there is damage to the tendons and nerves in the hand, a patient can lose sensation and the ability to move the worst functionally either due to wrist drop or inability to extend the wrist as well as compromised muscle tone in the shoulder, arms, and hand affecting functional movement and ADLs. Patients also often complain of pain, numbness, tingling, and hypersensitivity. Therapeutic treatment will likely include splinting, PAMs, vibration and sensory modalities, tendon gliding exercises, environmental modification, adaptive equipment , edema and pain management, wound care if there was a surgery, establishing a home exercise program, fine motor and dexterity activities, ROM exercises, and exercises that will increase the use of the hand and UE. These are the most common injuries seen in a clinic.

Explain the Allen Cognitive Level Screen (ACLS)

The Allen Cognitive Level Screen (ACLS) is a standardized screening assessment of functional cognition developed within the framework of the cognitive disabilities model by OT Claudia Allen. The patient's learning and problem-solving abilities are evaluated during the performance of three visual motor tasks of increasing complexity. The screen consists of learning three visual motor tasks using leather-lacing stitches and it can be completed in 20 minutes. This test was developed for use with adults with psychiatric disorders and dementia. The patient is tasked to complete three stitches: the running stitch, the whipstitch, and the cordovan stitch. Scores are numbers that correspond to the specific levels of supervision and care that are needed to function in daily life. Scores range from a low of 3.0 to a high of 5.8 and can indicate the need for 24/7 supervision for safety to complete independence and the ability to learn new tasks.

Discuss the key legislation that impacts therapy services (continued)

The American Occupational Therapy Association (AOTA) website is always the most up to date with current laws and regulations. Individuals with Disabilities Education Act of 1997: This act states that every child has a right to free and appropriate education and states that children with disabilities can be educated with their nondisabled peers. It requires every state to have policies and procedures in place and allows for assistive technology for children ages 3 to 21. Assistive Technology Act of 1998: Provides state funding for assistive technology through programming to ensure that technology- related assistance and devices are available for people with disabilities. The developmental Disabilities Assistance and Bill of Rights Act of 2000: Provides grants, protection, and advocacy groups for people with developmental disabilities including funding for university-based and affiliated programming.

Explain the Barthel Index (BI) and how it is used.

The Barthel Index (BI) is a standardized test that uses an ordinal scale to rate a patient's ability to complete self-care and mobility in ADLs. the BI was one of the first standardized tools to assess ADLs, and the FIM was created to be a more comprehensive test based on the BI. The goal is to determine the level of independence that each patient has without the use of verbal or physical help or cues. It assesses the levels of independence in 10 ADL tasks with a score range of 0 (dependent) to 20 (independent). These areas include dressing, feeding, grooming, toileting, bathing, bed/chair transfers, walking, stairs, bladder, and bowels. With a score of greater than 85, the patient will likely reintegrate into the community independently and could live alone. A score of less than 40 would indicate significant deficits in ADLs and mobility, and the patient would be unlikely to return home and would need 24/7 care. Score 0-20 - level of disability: total dependence Score of 21-60: - level of disability: severe dependence Score of 61-90: - level of disability: moderate dependence Score of 91-99: - level of disability: slight dependence Score of 100: - level of disability: independence

Explain the Battelle Developmental Inventory and how it is used.

The Battelle Developmental Inventory is an assessment for infants and children through age 7. It is a flexible, semistructured assessment that uses observation of the child and interviews with parents and caregivers. The test has 5 global developmental areas and 13 categories to evaluate strengths, and deficits in personal-social, adaptive, motor, communication, and cognitive skill sets. This test is aligned with the federal requirements for the Office of Special Education Programs and the Head Start Program, and it indicates readiness for school or a need for special education services. The test can be completed 60-90 minutes.

Explain the Beery-Buktenica Developmental Test of Visual-Motor Integration (Beery-VMI) and how it is used.

The Beery- VMI is an assessment for ages 2 and up. The short form is geared for ages 2-7. It is a norm-references, standardized assessment used to assess deficits in visual perception, fine motor skills, and hand-eye coordination. It focuses on the patient's ability to integrate visual and motor skills, but it is also a top assessment to be used as an outcome measure to test improvements in visual-motor integration skills after handwriting interventions during treatments. The core of the test is copying 30 geometric forms with 2 subtests designed to look at visual abilities without the fine motor component and then fine motor skills without the use of visual perceptual skills. The test takes 10-15 minutes to complete.

Explain the Borg Rating of Perceived Exertion and how it is used.

The Borg Rating of Perceived Exertion is a scale that is used to measure how hard you feel like your body is working during physical activity. This scale allows therapists a reference point in order to grade tasks for patients to successfully complete tasks and attain goals. Exertion description: none Borg Rating: 6 Examples ( for most adults <65 years old): reading a book, watching television Exertion: very, very light Borg rating: 7 to 8 Examples for most adults <65 years old: tying shoes Exertion: very light Borg Rating: 9 to 8 Examples for most adults <65 years old: folding clothes Exertion: fairly light Borg Rating: 11 to 12 Examples for most adults <65 years old: walking through the grocery store Exertion: somewhat hard Borg Rating: 13 to 14 Examples for most adults <65 years old: brisk walking Exertion: Hard Borg Rating: 15 to 16 Examples for most adults <65 years old: bicycling or swimming Exertion: very hard Borg rating: 17 to 18 Example for most adults <65 years old: highest level of sustained activity Exertion: very, very hard Borg rating: 19 to 20 Examples for most adults <65 years old: finishing kick in a race.

Explain the Developmental Test of Visual Perception (DTVP-2) and the Motor-Free Visual Perception Test (MVPT-4) and how they are used.

The Developmental Test of Visual Perception (DTVP-2) is a standardized test with high reliability and validity used to test visual perception and visual motor integration skills. It is used with children ages 4-10. The test takes 45 minutes to administer. There are 8 subtests that include hand eye coordination, proprioceptive, copying, figure ground, spatial relationships, visual closure, visual motor speed, and form constancy. The test has been normed through age 75, and it has also been a helpful tool with TBI patients, right hemisphere stroke patients, and patients with dementia. The motor free visual perception test (MVPT-4) is a standardized test of visual perception. It can be used for ages 4-70. It tests the areas of visual discrimination, spatial relationship, visual memory, figure-ground, and visual closure. There are 36 cards with a 2D figure on them and choices form a to d to choose the item that most closely matches the example. The test takes 10-15 minutes to administer. It is most often used in the pediatric setting and as an indicator for driver recertification after stroke or head injury.

Discuss the Function in Sitting Test (FIST) and the 30-second sit-to-stand assessment

The Function in Sitting Test (FIST) is a criterion-referenced standardized test created to assess seated bedside balance and stability after stroke or brain injury. It has 14 items and it is scored from 0 to 4, with the numbers indicating (0) dependent, (1) needs assistance, (2) UE support, (3) verbal cues/increased time, and (4) independent. The patient sits on the edge of the bed with hands in the lap and with the feet supported. The patient is given sternal nudges, asked to scoot, pick up an item from the floor, sit with eyes closed, lift feet from the floor, reach for items, and shake head yes/no while maintaining balance. The 30-second chair test evaluates leg strength and endurance. The patient is seated in a chair with a straight back without armrests with a seat 17 inches high and asked to complete as many sit-to-stands as he can without using his arms in a 30-second time frame. Scores are based on age for both men and women and a below-average score indicates a risk for falls.

Explain the Functional Independence Measure (FIM), where it is used, and how it is scored.

The Functional Measure (FIM) is a standardized test that is used in order to address the physical, psychological, and social functioning of a patient. There are 18 categories in this test broken into motor and cognition sections, and it takes approximately 60 minutes to administer. It is used primarily in skilled nursing facilities (SNF) or in an acute rehabilitation setting in order to assess a patient's level of disability during the evaluation process and to monitor changes in the patient's status in response to treatment interventions. Each item on the FIM is scored on a scale form 1 to 7. The higher the score, the more independent the patient is in performing the task. A core of 1 is total assistance with a helper. A score of 2 is maximal assistance with helper. A score of 3 is moderate assistance with a helper. A score of 4 is minimal assistance with helper. A score of 5 is supervision or setup with a helper. A score of 6 is modified independence with no helper. A score of 7 is complete independence with no helper.

Discuss the Glasgow Coma Scale and when it is used

The Glasgow Coma Scale is a neurological scale used to determine the level of consciousness in a brain-injured or comatose patient. The test measures the motor response, verbal response, and eye-opening response in a patient. Behavior: eye opening -spontaneous eye opening= score of 4 - eye opening to speech= score of 3 - eye opening to pain=score of 2 - no response = score of 1 Behavior: best verbal - oriented to time, place and person=score of 5 - confused =score of 4 - inappropriate words=score of 3 - incomprehensible sounds= score of 2 - no response= score of 1 Behavior: best motor - obeys command=score of 6 -moves to localized pain= score of 5 - flexion withdrawal from pain= score of 4 - abnormal flexion (decorticate)= score of 3 - abnormal extension (decerebrate)= score of 2 - no response= score of 1 Total score: - best score= 15 - comatose client= 8 or less - totally unresponsive= 3

Explain the Hawaii Early Learning Profile, how it is used, and what areas it covers.

The Hawaii Early Learning Profile is not a standardized test, but a curriculum-based assessment used to identify needs, monitor growth and development, and create goals and a plan of care for treatment. It is an observation-based assessment for children birth to age 3 with an additional section for ages 3-6. It can take up tp 90 minutes to administer test. This test supports federal requirements for part C of the Individuals with Disabilities Education Act and Early Heard Start programs. The assessment is divided into seven domains: regulatory/sensory organization, cognitive, language, gross motor, fine motor, social-emotional, and self-help. Each domain is divided into strands, and each strand has a number to further specify the area. Domain 6.0 is self-help/behavioral skills, and strand 6.115 is putting both shoes correctly on each foot. Each of the strands is made up of skills, and each skill is built on the previous skill. The test is given at evaluation, monthly during treatment. and again at discharge or transition through the system. The test is scored as a (+) if the skill is present, a (-) if the skill is not present, a (+/-) if the skill is emerging, and as a (N/A) if it is not applicable.

Explain the Katz Index of Independence in Activities of Daily Living and how it is used.

The Katz Index of Independence in Activities of Daily Living is used to assess functional status and the ability to perform ADLs independently. The test is not standardized, and there is no formal reliability or validity research, bnut it is a common test used in multiple settings. The index ranks performance in six areas: bathing, dressing, toileting, transferring, continence, and feeding. Patients are given a score of yes/no for independence in each area. A high score of 6 points is possible. A score of 6 identifies independence, a score of 3-5 is partially dependent or moderate assistance needed, and a score of 2 or less identifies dependence in the activity and severe functional impairment.

Explain the Kohlman Evaluation of Living Skills (KELS) assessment and how it is used.

The Kohlman Evaluation of Living Skills (KELS) is a standardized assessment used to determine the safety of a patient when reintegrating into the community to live independently. It is a criterion-based assessment that covers 13 living skills in the following 5 main areas: self-care, safety and health, money management, transportation and telephone, and work and leisure activity. Each section of the KELS is divided into method, equipment, administration procedures and scoring. Items are scored as the patient being independent or needs assistance. The KELS is most often uses to assess the senior population or patients post stroke or traumatic brain injury (TBI) in a rehabilitation or SNF setting, but it can be used on any patient from adolescent to late adulthood. It takes approximately 45 minutes to complete the assessment. The test is somewhat outdated with the last update performed in the early 1990s, so the pictures are dated and the Internet as a source is not addressed, so using options other than a phone book to find telephone numbers and writing a check for paying bills are key components of the assessment.

Discuss the Peabody Developmental Motor Scales (PDMS-2), its components, and how it is used.

The Peabody Developmental Motor Scales (PDMS-2) is a standardized and norm-referenced test used to assess gross and fine motor skills in children from birth to age 5. It takes 60 minutes to complete the entire test, but each component can be administered individually in 20-30 minutes. There are six areas of the test. Test area: reflexes what the area tests: addresses how the child automatically reacts to environmental events. This component is only given to children ages 2 weeks through 11 months because most reflexes are integrated after this age. Test area: stationary What the area tests: looks at the control of the body within the child's center of gravity and his ability to retain equilibrium Test area: locomotion What the area tests: looks at the child's mobility and how they move from one place to another. This can be crawling, walking, running, hopping and/or jumping. Test area: object manipulation What the area tests: addresses the child's ability to catch and throw items. This component is only given to children ages 1 and older. Test area: grasping What the area tests: this looks at the child's ability to use his hands. It starts with basic activity such as holding an object, and it progresses to manipulating in both hands and completing buttons and fasteners. Test area: Visual-motor integration What the area tests: addresses a child's hand-eye coordination and visual perceptual skills. This component moves from basic reaching, grasping, and passing items across the midline to copying and drawing.

Discuss the Rancho Los Amigos Scale and when it is used.

The Rancho Los Amigos Scale (RLAS) is also a neurological scale and it is used to assess individuals after a closed head injury and is based on cognitive and behavioral presentations as they emerge from their coma. It tracks the levels of awareness, cognition, behavior and interaction with the environment. Level 1: - response: none - assistance needed: total Level 2: -response: generalized - assistance needed: total Level 3: - response: localized - assistance needed: total Level 4: -response: confused -agitated - assistance needed: maximal Level 5: -response : confused inappropriate - assistance needed: maximal Level 6: - response: confused appropriate - assistance needed: moderate Level 7: - response: automatic appropriate - assistance needed: minimal Level 8: - response: purposeful appropriate - assistance needed: stand by

Explain the Routine Task Inventory and how it is used.

The Routine Task Inventory is a part of the Allen Battery group of tools along with the ACLS developed within the framework of the cognitive disabilities model by OT Claudia Allen. It is an evidence-based, semi-standardized assessment that looks at how the degree of cognitive disability interferes with everyday tasks using observation of task behavior. The therapist needs to observe the patient completing a minimum of four tasks from each area citing specifics about the task and duration of the activity. These areas include physical ADL, community IADL, communication, and work readiness. It can take several days to complete this assessment. Scores are associated with the Allen Scale of cognitive Levels 1-6, and a mean score is calculated for each subscale.

Explain the School Functional Assessment (SFA) and how it is used.

The School Function Assessment (SFA) is a standardized criterion-referenced assessment that measures school-related functional skills of elementary school children grades K-6. The assessment is completed by one or multiple school professionals (therapists, teacher, etc.) that see the child regularly and can observe the child during activity; it can take several days to administer. The SFA has three components: participation, tasks supports, and activity performance. In the participation section of the test, the student is observed interacting in six areas: general, or special education classroom, playground or recess, transportation to and from school, bathroom and toileting activities, transitions to and from class, and mealtime or snack time. Participation in each setting is scored on a 6-point scale with 1 being participation extremely limited and 6 being full participation. The task section looks at supporrt being given to the student during tasks. The task support has four areas: (1) physical task support: assistance, (2) physical task support: adaptations, (3) cognitive/behavioral task support: assistance and (4) cognitive/behavioral task support: adaptations. Supports are measured on a 4-point scale with 1 being extensive assistance or adaptations and 4 being no assistance or adaptations. The activity performance section addresses travel, maintaining and changing position, recreational movement, manipulation with movement, using materials, setup and cleanup, eating and drinking, hygiene, clothing management, functional communication, memory and understanding, following social conventions, compliance with adult directives and school rules, task behavior/ completion, positive interaction, behavior regulation, personal care awareness and safety. This is measured on a 4-point scale with 1 being does not perform and 4 being performs consistently.

Explain what the Semmes-Weinstein Monofilament test is for and how it is adminstered

The Semmes- Weinstein monofilament test is a sensory assessment that is used to test for nerve compression syndrome, peripheral neuropathy, thermal injuries, and postoperative nerve repair deficits in the extremities. The tool has multiple monofilaments in different sizes. Green is equivalent to normal sensation, blue is equivalent to diminished protective sensation, red is equivalent to loss of protective sensation, and the red striped lines means that sensation is untestable in that region. Testing begins with having the patient rest that extremity being tested on a table and having them close their eyes and say "yes": when they feel something. Each test has a guide of where to test on the patient and the order of testing. Generally, the testing will move from digit one to digit five, distally to proximally, anteriorly to posteriorly and then the volar palm and dorsal hand are tested, and the anterior then posterior forearm for the UE. The therapist will press the filament at a 90-degree angle against the skin until it bows and will keep it in place for 1.5 seconds.

Define the ROM parameters of the lower extremities (LEs), ankle, and back and the end feels for each joint

The following are the normal ROM parameters for each joint in the LEs, ankle, and back: Back extension 0-25 degrees firm end feel back flexion: 0-90 degrees firm end feel back lateral flexion 0-25 degrees firm end feel hip extension 0-30 degrees firm end feel hip flexion 0-100 degrees soft end feel hip abduction 0-40 degrees firm end feel hip adduction 0-20 degrees firm end feel knee flexion 0-150 degrees soft end feel ankle inversion 0-30 degrees hard end feel ankle eversion 0-20 degrees hard end feel ankle plantarflexion 0-40 degrees hard/firm end feel ankle dorsiflexion 0-20 degrees frim end feel

Define the ROM parameters of the UE and neck and the end feel for each joint

The following are the normal ROM parameters for each joint in the UE and neck: Neck rotation 0-80 degrees firm end feel Neck flexion: 0-50 degrees firm end feel neck extension 0-60 degrees firm end feel shoulder flexion 0-150 degrees firm end feel shoulder extension 0-50 degrees firm end feel shoulder abduction 0-150 degrees firm end feel shoulder adduction 0-30 degrees firm end feel elbow flexion 0-150 degrees soft end feel elbow extension 0 degrees hard end feel forearm supination 0-80 degrees firm end feel forearm pronation 0-80 degrees hard/firm end feel wrist flexion 0-60 degrees firm end feel wrist extension 0-60 degrees firm end feel wrist radial deviation 0-20 degrees hard/firm end feel wrist ulnar deviation 0-30 degrees firm end feel

Define the ROM parameters of the hand

The following are the normal ROM parameters for each joint in the hand: Metacarpophalangeal (MCP) abduction: 0-25 degrees MCP adduction: 20-0 degrees MCP flexion: 0-90 degrees MCP extension: 0-30 degrees Proximal Interphalangeal (PIP) flexion: 0-120 degrees PIP extension: 120-0 degrees Distal interphalangeal (DIP) flexion: 0-80 degrees DIP extension: 80-0 degrees MCP joint of the thumb abduction: 0-50 degrees MCP joint of the thumb adduction: 40-0 degrees MCP joint of the thumb flexion: 0-70 degrees MCP joint of the thumb extension: 60-0 degrees Interphalangeal (IP) joint of the thumb flexion: 0-90 degrees IP joint of the thumb extension: 90-0 degrees

Discuss how a therapist will determine the frequency and duration of intervention

The frequency and duration of services are based on the setting of practice and clinical judgment. Frequency is the amount of times each week/month that the patient will be seen, and the education is for how long in total. Clinical judgement determines by the evaluating therapist is always the number-one factor, and it is based on patient activity tolerance, progression of illness or disability, new skill acquisition ability, or the ability to recover lost or impaired skills. Outside factors that influence duration can include hospital or facility length of stay, insurance authorization for number of sessions, RUG levels, and the patient's ability to meet the copay. According to the AOTA code of ethics, it is a violation to continue to treat a patient who is no longer benefiting from therapy. The therapist must discharge the patient when the therapy provided does not meet the goals and services of the patient or when progress can't be shown in a measurable outcome. Services should be terminated when the patient is no longer making progress and has met the highest level of functional potential and is unwilling or unable to continue working and meeting their goals.

Describe the movement in the frontal plane of motion used when testing ROM in a patient.

The frontal plane passes through the body from left to right, dividing the body into anterior and posterior adduction: movement toward the midline/ to the body (bringing your arm to your body) Abduction: moving away from the midline. Think of someone being abducted or taken away (moving your arm away from the body). Elevation: scapula movement, superior movement (shoulder shrug). Depression: scapula movement, inferior movement (shoulder shrug). inversion: lifting the medial border of your foot. You bring the sole of the foot to face inward. Eversion: lifting the lateral border of your foot. You bring the sole of the foot to face outward.

Explain the functional reach test

The functional reach test is a criterion-references standardized test. The purpose is to assess forward functional reach in a fixed position. The test is completed five times with two practices and three actual tests. A yardstick is affixed to a wall, and the patient's arm is extended to 9o degrees shoulder level. the patient is asked to "reach as far as you can forward without taking a step," and the location of the third metacarpal is recorded. Typical functional reach is 10 inches or greater. Scores of less than 7 inches of reach indicate limited functional balance, and scores of less than 6 inches of reach indicate a high fall risk.

Discuss monitoring the effectiveness in a group intervention

The key to the success of any group intervention is monitoring the success and failures of the group throughout the activity. Monitoring allows the program to determine what is and is not working so that adjustments can be made to keep the group successful and on task as well as continue to establish the need and importance of the group. Frequent monitoring can encompass standardized testing, surveys, the ability of the members to participate and finish tasks, and member exit interviews. This allows the group leaders to see what is actually happening in the group versus what the group had planned to accomplish. The ability to show the success of a group through frequent monitoring can also impact funding including the ability to apply for and maintain grants.

Discuss the scope of practice versus areas of practice

The occupational therapy scope of practice is the domain and process of what a therapist is allowed to do. Domain can be defined as the occupation that the patient finds meaning in during their everyday life. The process of occupational therapy is specifically the delivery of service within occupational therapy. These activities include evaluation, testing, goals, interventions, and final outcomes. The OT is responsible for all of the treatment as well as the safety and effectiveness of the treatment and the modalities. A certified occupational therapy assistant (COTA) can provide occupational therapy services under the supervision and licensed of the OT based on the treatment goals and interventions designated by the OT during the evaluation process. According to AOTA, there are six main areas of practice for an OT. Within each setting, there is unlimited potential to find areas that interest you and create your own niche or job. These six areas include children and youth, mental health, health and wellness, work and industry, productive aging and rehabilitation and disability.

Describe the movement in the sagittal plane of motion used when testing ROM in a patient.

The sagittal plane passes through the body from front to back, dividing the body into left and right sides. Flexion: decrease the angle between two body parts (bending the elbow) Extension: increasing the angle between two body parts (straightening the elbow) Dorsiflexion: ankle flexion (moving toes toward the shin) Plantarflexion: ankle extension (moving the toes toward the ground/pointing the toes).

Explain the sensory profile and how it is used.

The sensory profile is a norm-referenced, standardized questionnaire assessment designed by OT Winnie Dunn to address sensory processing patterns of children and adults. there are six versions of this test based on the age of the patient. They are the infant sensory profile with a caregiver questionnaire for babies from birth-6 months, toddler sensory profile 2 with a caregiver questionnaire for toddlers ages 7-35 months, child sensory profile with a caregiver questionnaire for students ages 3-14 years old, and the adolescent/adult sensory profile with a questionnaire to address ages 11 and older. Eight areas of sensory input are examined on all the tests, including auditory, visual, activity level, taste/smell, body position, movement, touch, and emotional/social. Items are given a score based on the caregiver's indication of how often the behavior is seen: almost always, frequently, occasionally, seldom, or almost never. These scores get added up and the number indicates if the patient falls into a typical performance pattern, probable difference, or definite difference in correlation to his peer group. Often, the results of this exam will lead to the creation of a sensory diet for the patient to address attention, arousal and adaptive responses for integration in daily life.

Discuss the term standards of practice in the context of occupational therapy

The term standards of practice in occupational therapy is the baseline and minimum standard needed to be a practicing therapist as defined by the American Occupational Therapy (AOTA). It is a combination of skills, knowledge, understanding, ethics and responsibilities. The first and most important rule is that all OTs and occupational therapy assistants must practice under the rules and guidelines of federal and state laws. This means that the therapist has graduated from an occupational therapy program accredited by the Accreditation Council for Occupational Therapy Education (ACOTE), has completed fieldwork requirements, has passed the national testing through the National Board for Certification in Occupational Therapy (NBCOT), and has a state license in the state they are working in. Additionally, there are four standard areas that must be met: (1) professional standing and responsibility, (2) screening, evaluation, and reevaluation, (3) intervention, and (4) outcomes. The AOTA "Standards of Practice for Occupational Therapy" was last updated in 2010 and is available at AOTA.org

Explain the timed "up and go" (TUG) test and how it is used.

The timed "up and go" (TUG) test assesses fall risk in adults by looking at how long it takes to complete standing from a seated position, walking, turning, and sitting down. Standardized cutoff scores to predict risk of falling have not been established in research, and there are no formal normal values. However, older adults who take longer than 13.5 seconds to complete the TUG test have a high risk for falling, with 19 seconds or more associated with increased risk of having multiple falls. The therapist times the patient when they stand up from a chair, walk 10 feet, turn around, walk back, and sit down with or without the use of device. The test is used in multiple settings, and it requires only a chair and a stopwatch to complete.

Describe the movement in the transverse plane of motion used when testing ROM in a patient

The transverse plane passes through the body in a line parallel to the floor, dividing the body into top and bottom. Pronation: rotating the hand and wrist medially from the bone. If laying on your back the hand would have the palm to the floor. Supination: Rotating the hand and wrist laterally from the bone. If laying on your back, the palm and wrist would be facing toward the ceiling. Horizontal adduction: the angle between two joints decreases on the horizontal plane. Horizontal abduction: the angle between two joints increases on the horizontal plane. Rotation: pivoting or twisting on the axis ( turning the head left or right).

Explain the two-point discrimination test and the nine-hole peg test and how and why they are used.

The two-point discrimination test is a standardized test used to assess if the patient is able to identify two close points on a small area of skin, and it determines how fine the ability to discriminate this is after injury or surgery. It is most commonly used after hand surgery, grafts, nerve repairs, and tissue transfer for desensitization and to determine the level of impairment. The therapist requests that the patient closes his eyes and then states "I will touch you with either one or two points, and tell me if you feel one or two points when you feel the touch." The nine-hole peg test is a standardized test used to measure finger dexterity, and it is also used to assess patients with stroke, brain injury, Parkinson's disease, and multiple sclerosis (MS). The test is given four times: twice with the dominant hand and twice with the nondominant hand. The patient is timed picking up nine pegs, one at a time as quickly as possible, and putting them in the nine holes on the board. Once they are placed in the holes, he removes them again as quickly as possible one at a time, replacing them into the container at the other end of the peg board. The total time to complete the task is recorded.

Discuss the therapeutic use of self and how it is used in therapy

Therapeutic use of self is when a therapist uses his personality and personal experiences and skills to build rapport with his patient. this builds a relationship with the patient in which the patient can feel comfortable sharing and builds trust so that they can focus on their treatment. in some ways, therapists become chameleons by adapting to fit the needs of a client. The therapist needs to be aware of visual and verbal cues and how much personal information he or she is willing to share so as to not cross professional boundaries. During the evaluation, the therapist needs to collect as much insight on a patient as possible. The patient's communication style alone can set the groundwork for successful participation and rapport. Notice if the patient speaks loudly or quietly; what is the tone; how much personal space does the patient requires; and what is the patient's sense of humor, short words complex wording, slang, bluntness, and sarcasm. Can you meet their level of communication in order to make the patient comfortable? Are they comfortable being told how to complete an activity seeing the therapist as the expert, or do they need to feel more give and take by having more of a say in their treatment? Determine how much personal experience you are willing to share without making yourself or the patient uncomfortable. Did you go through cancer treatment and feel that sharing your experience will help build comradery? Are you are parent? Have you traveled to their home state or city? Have you broken your leg before? the goal is to make your patient as comfortable as possible to get the best results from therapy without lying and also not making it all about you.

Discuss how therapists maximize safety in the care delivery or services and explain the term safe patient handling and mobility.

Therapy treatments are fluid in nature. Therapists enter a session with a plan in place with the activity and skills that they plan to address each session. However, when treating a living, breathing person, sessions can change quickly for many reasons. A patient can have a medical emergency or be emotionally unstable on any given day, and this can change throughout the session. Therapists needs to be aware of signs that can indicate a physical problem such as diaphoresis, skin pallor, attention levels and breathing. Additionally, nonverbal signs of aggression and psychosocial issues such as tensions with guests and family members can affect therapy and patient and therapist safety. Being aware of how to get help quickly, the ability to cotreat for patient and therapist safety, and changing tasks quickly to promote safety are important skills as a therapist. Safe patient handling and mobility refers to policies and program interventions that direct how healthcare professionals move patients in a way that does not cause strain or injury to the patient to themselves. Most facilities have their own specific guideline including items such as manual lifting of patients becoming minimized and encouraging the use of a mechanical lifts, ergonomic training for transfers and mobility, and creating strengthening programs for staff to address their own stress, strength and body fatigue.

Discuss the two categories of the functional independence measure (FIM) and the areas of scoring for the ADL items.

There are 18 items on the functional independence measure (FIM) organized into 2 categories: motor and cognitive. The motor category is comprised of eating, grooming, bathing, upper body dressing, lower body dressing, toileting, bladder management, bowel management, transfers (bed/chair/wheelchair), transfers ( toilet), transfers (bath/shower), ambulation ( walking/wheelchair), and stairs. The cognitive category is comprised of comprehension, expression, social interactions, problem,-solving, and memory. There are six ADL areas that cover the following tasks: Feeding: - Picking up a utensil, using suitable utensils, scooping food onto a utensil, bringing food to the mouth, drinking from a cup or glass, chewing and swallowing, managing a variety of food consistencies. Grooming: - Oral care, hair grooming (combing or brushing), washing hands, washing the face, shaving the face or applying make-up. Bathing - leg arm, chest, right arm, abdomen, front perineal area, back perineal area ( buttocks), left upper leg, right upper leg, left lower leg including the foot, right lower leg including the foot. Upper body dressing: - shirt, right arm, left arm, overhead, arranging the back, fasteners; bra, right arm, left arm, overhead, arranging in the back, fasteners; and sweater/jacket, right arm, left arm, overhead, arranging in the back, fasteners. Lower body dressing: Pants, right leg, left leg, arranging over hips, fasteners; socks, right foot left foot; shoes, right foot, left foot, fasteners; underwear/brief, right leg, left leg, arranging over hips; and compression stockings, right foot, left foot. Toileting: Transfer, clothing management, hygiene

Describe the planes of motion used when testing ROM in a patient

There are three different planes of motion: sagittal, frontal, and transverse. In each of these planes, several different movements occur at the joints. The frontal plane passes through the body from left to right, dividing the body into anterior and posterior. The transverse plane passes through the body in a line parallel to the floor, dividing the body into top and bottom. The sagittal plane passes through the body from front to back, dividing the body into left and right.

Discuss the orthopedic intervention for a total knee replacement (TKR)

There are two types of knee replacement surgeries: total knee replacement (TKR) and partial knee replacement (PKR). TKR, or total knee arthroplasty (TKA), is a surgical procedure in which parts of the knee joint are replaced with artificial parts (prosthetic). In a PKR, the damaged portion of the knee ( bone and/or cartilage) is replaced with metal and plastic components. The need for these surgeries can be because of trauma or arthritic issues. A TKR is more commonly seen than a PKR. Generally, people are up and walking hours after surgery and will be weight-bearing as tolerated barring any complications and patients can put as much weight as they can tolerate on the surgical knee. In the hospital, the OT will evaluate the patient's ability to care for themselves at home including getting in and out of bed, functional transfer, toileting, self-care, dressing and grooming and will review the equipment needed for the return home post-surgery (shower chair, toilet riser or commode, reacher, sock aide, and long handled shoehorn). The home health or facility-based (SNF or rehab) OT will further address using stairs, getting in and out of the car, meal prep, laundry, dressing techniques, energy conservation, as well as UE strengthening because there will likely be more emphasis on arms for transfers and activity while the LE recovers and heals.

Discuss the cognitive neurological determinants and the social, cultural and economic determinants of occupation

When a therapist is looking at patients' needs using the cognitive neurological determinants of occupation, he or she looks at how the central nervous system affects and impacts occupational performance. More specifically, we focus on memory, motor planning, attention to task, balance, coordination, sensory perception, executive functioning, and neuroplasticity. Assessments during evaluation would include a combination of interview, observation, as well as cognitive testing and balance and coordination testing. Sessions would likely include home modifications, adaptive equipment training, ADL training and functional adaptation, balance and fall prevention, memory aids , sensory retraining and pain management. Looking at the social, cultural, and economic determinants of occupation, a therapists needs to be aware of how the roles, habits, and beliefs of the patient impact occupation. The greatest impact on occupation is often not disability but the influence of income levels and poverty, employment and occupation, education, housing, culture and ethnicity. Treatment needs to consider the demands and expectations of occupational performance. Culturally, is it reasonable to expect your male patient to cook his own meals and do laundry to return home, or is it expected that his children will do this for him? Does the patient live in a house and have funds available to make major environmental changes for ease in mobility and ADLs, or does she live in a small apartment where she can't make structural changes to the home? These roles will impact what is reasonable and attainable in goal setting. treatment will always be influenced by these factors, so the expectations of the patient and family need to be addressed at the evaluation.

Discuss the physical determinants and the psychosocial determinants of occupation

When an OT is looking at patient's needs using the physical determinants of occupation, the overall musculoskeletal system is taken into consideration. Strength, ROM, and endurance are addressed in order to best meet the patient's needs. The ability to evaluate stamina and physical demands to complete occupational performance and task is key. As a therapist, your sessions would likely include strengthening, endurance, activity tolerance, balance, pacing, coordination, and overall exercises in order to address functional mobility and ADLs. When a therapist is looking at patient's needs using the psychosocial determinants of occupation, the patient's thought , feelings and emotions that could be impacting functional performance are taken into consideration. The context of people's lives has a large impact on their overall health and well-being. People see things and react through the lens of their own experiences. Personal circumstances and environment make a difference in the outcome of the treatment plan that the therapist creates for the patient. Treatment would likely include cognitive evaluation, stress relievers, coping mechanisms, problem solving, relaxation techniques, projective techniques, and basic skills training in order to address functional mobility, cognition and ADLs.