PR Summer Exam 3

Contrast is so important Acuity readings don't often determine one's functioning

"Of course I can see the eye chart b/c it is perfect B&W but I can't read my local newspaper b/c it is much grayer)

Video fluroscopic swallow study

***The video is the gold standard b/c you are able to assess more accurately however the Fiberoptic endoscopic evaluation of swallowing (FEES)-can be helpful b/c it can be done at bedside for patients not able to leave their room

Causes of SCI u Trauma is the most common cause u 37 % of reported injuries were due to Motor vehicle crashes, followed by falls and acts of violence. u Other causes: Diving and non traumatic causes such as stenosis, tumors, ALS, syringomyelia, MS, Guillaine Barre, and cancer

***Trauma= most common cause of SCI MVA, falls, acts of violence Stenosis - causes squeezing and pinching on the spinal cord which can lead to a fall causing a traumatic injury A lot more cancer patients have SCI - usually not primary to the spinal cord but has metastasized

What do we do about these deficits? Intervention Approaches for Cognitive Deficits • Approaches • Neuroanatomical-based: treatment protocols that target specific dysfunction -- unilateral spatial neglect (OT, others) • Restorative/remedial approaches: improve cognitive deficits such as attention and memory, assume transfer of learning (neuropsychology) • Cognitive Compensatory: focus on acquisition of processing strategies and retraining, use assets to achieve successful occupational performance (OT, others) • Functional and Environmental: modify the task and/or environment to reduce impact of cognitive deficits and enable optimal participation in meaningful occupation (OT, others) Which ones do OTs use more???

***Where OT comes in more= cognitive compensatory - use assets to achieve successful occupational performance AND functional and environments- modify task/environment Will focus on cognitive compensatory and functional and environmental strategies

SCI Cathing hooks

Cathing hooks Hangs on the handle on one part of the cushion Holds pants open to keep hands free Women need to bring pants down to access

u Conus Medullaris: Injury to sacral cord and lumbar nerve roots. Results in areflexic bowel, bladder and Legs

Conus medullaris= Above Cauda equina

Interventions for Oral Phase - Alertness - Independence in oral cares - Posture Where is eating optimal for patient? - Tolerance for sitting up - Set-up for safe eating - Self-feeding

- Alertness Make sure the patient is awake and able to safely participate in swallowing Just staying awake can be difficult for critically ill patients or neuro patients where alertness waxes and wanes- so need to instruct caregivers and family that they need to eat only when they are awake and alert—if they doze off, they won't initiate that swallow and are at greater risk for aspirating and choking - Independence in oral cares Oral care is very important for patients at risk for aspirating If they are aspirating, an unclean mouth that is full of bacteria, they are more likely to develop an infection - Posture Where is eating optimal for patient? - Tolerance for sitting up Sitting upright is crucial for safe eating Patients are so tired and in pain and sitting up can be really challenging and effortful for them But its important not only for eating but also helps with whole body recovery gaining that strength - Set-up for safe eating Providing them with the tools and set-up they need to be as independent as they can - Self-feeding Encourage patient to do as much as they can by themselves so they can gain that strength and independence

Maslow's Hierarchy of Basic Needs At the very least, we have to work with people on eating so they can get their nutrition back on track

- Make sure you address hydration and nutrition - Eating is part of these different levels, social, belonging, self-esteem- really important to people

Oral Phase Interventions: Exercises Basic tongue range of motion: Basic lip and jaw exercises Use of popsicle for tongue protrusion, use of bubbles to blow to pucker Breathing exercises as provided by Respiratory Therapist

- Basic tongue range of motion: in/out, side to side, use to sweep out cheek - Basic lip exercises: pucker, smile say "mmm", say papapa", say "he-who" - Basic jaw exercises: open/close, move side to side (I will apply resistance and you can test strength too-- have them open and say to hold and see if they can stay open) - Use of popsicle for tongue protrusion, use of bubbles to blow to pucker - Breathing exercises as provided by Respiratory Therapist to work on control and strength and improve the respiratory and pulmonary function

do you know anything about how Medicare determines reimbursement?- Bill this driving simulation under general eval for home safety b/c an IADL task

- But difficult to get it covered if doing it outside the clinic - In the clinic if family comes we ask their viewpoint in front of the patient - Driving assessments are difficult- takes a lot of communication skills, documentation, and collaboration with family and other professionals

Cranial Nerves of Swallowing

- CN V: Trigeminal nerve Muscles of biting and chewing Sensation to the face and oral cavity Upward/anterior movement of the larynx - CN VII: Facial Nerve Sensation and taste of anterior 2/3 of tongue Sensation to the face and lips; lip closure (if this is impaired, you may see patients biting on their tongue or inside their cheek) - CN IX: Glossopharyngeal Nerve Sensation to the tongue, pharynx, soft palate Taste to posterior 1/3 of tongue Salivation

Cranial Nerves of Swallowing

- CN X: Vagus Nerve Sensation of larynx, pharynx, palate, base of tongue Motor control of larynx, pharynx, and palate Vocal cord adduction Motor function of the esophagus (***Vagus= may be one of the most important in swallowing) - CN XI: Spinal Accessory Nerve Head control and movement Elevation of the soft palate Elevation of the larynx and pharynx - CN XII: Hypoglossal Nerve Lingual position and control Elevation of the larynx

Complications of SCI u Decreased vital capacity: Reduced due to paralysis of the diaphragm and accessory muscles. This can lead to increased fatigue and greater risk for respiratory tract infections. Strengthening, manually assisted coughs, and deep breathing exercises may help increase vital capacity.

- Decreased vital capacity - Use abdominal muscles and diaphragm to breathe

Some Clinical Presentations for Dysphagia

- Drooling - Coughing or clearing throat frequently - Gagging on foods or liquids - Change in voice quality- as things start to enter the airway, it might rest on the vocal cords and give you that gurgly sounding voice - Being unable to swallow- when asked voluntarily cannot swallow but may be able to reflexively swallow - Pain with swallowing - Frequent heartburn See these especially in the oral phase

Structures of the Pharyngeal Phase of Swallowing Pharynx= broadly described as your throat - Pharynx is a cavity behind the nose and the base of the tongue where food and/or liquid passes to enter the esophagus

- Epiglottis (works in conjunction with the larynx) is the cartilage structure that works with the vocal cords to protect the airway for a safe swallow - Valleculae is a paired pocket where the root of the tongue attaches to the epiglottis - Pyriform sinuses are pockets formed by attachments of the constrictor muscles to the sides of the thyroid cartilage - Hyoid bone (looks like a floating muscle in the throat) anchors the muscles of the tongue, epiglottis, and larynx during swallowing

Structures of the Esophageal Phase of Swallowing- the last of the swallowing phases

- Esophagus is a 18-22 cm muscular tube connecting the pharynx to the stomach - Upper esophageal sphincter (UES) -at the top of esophagus- a musculoskeletal valve made up of the cricopharyngeus muscle and the cricoid cartilage (relaxes and allows food to pass through) - Lower esophageal sphincter (LES) is a muscular sphincter that relaxes to open and contracts to close (right before entry to the stomach) Passage of food takes b/w 8-20 seconds to travel from the esophagus to the stomach

Penetration/Aspiration Scale - Level 1 not in airway - Level 2 enters above vc, w/o residue - Level 3 above vc with residue - Level 4 contacts vc w/o residue - So level one is no material enter the airway. >>

- Level 5 contacts vc with residue - Level 6 passes glottis w/o residue - Level 7 passes glottis, residue with response - Level 8 passes glottis, residue w/o response - And then level eight, the material passes below the level of the vocal chords and there's no response. >> So no coughing or throat clearing. >> - So this would be level eight, would be silent aspiration

Different Types of Dysphagia Mechanical Dysphagia

- Mechanical dysphagia: loss of motor and sensory innervation occurs however CNS and peripheral neuron relays usually remain intact Trauma, surgery , or illness (car accident, surgery or illness)

Interventions for Pharyngeal Problems - Modifying diet for safety and recognizing when its not safe - Chin tuck, head turn, or tilt - Effortful swallow, tongue holding, Mendelshon Maneuver - Cuing to swallow "hard and quicker" - Awareness of swallowing

- Modifying diet for safety and recognizing when its not safe May involve thickening liquids or having softer foods to reduce the amount of chewing required Patients can get really discouraged with diet recommendations - Chin tuck, head turn, or tilt May have them perform these compensatory strategies Practice chin tuck on video to see if this is helpful for them Head turn can help people with unilateral weakness who has pooling in sinuses - Effortful swallow, tongue holding, Mendelshon Maneuver These are swallowing exercises covered more later - Singing/talking more Singing and talking can encourage vocal chord movement and strength - Cuing to swallow "hard and quicker" Especially for those dementia patients who are holding that food or liquid in their mouth - Awareness of swallowing Eliminating distractions, having the patient focus on the task If prescribed, performing the necessary compensatory strategies

Bladder and bowel function u Many injuries involve bladder problems including retention, inability to urinate, and tripping (leaking) --intervention includes medicine, intermittent straight cathing, Foley placement, suprapubic catheter placement Placement of a Foley or cathing put a patient at greater risk for UTIs

- Mostly every one gets a Foley placed and then see if they can pee on their own Others do intermittent cathing and drain every 4 hours- less risk for UTI with this If you have something in there all of the time, more at risk of UTI May need a Foley if they can't cath on their own - People with big bellies can't really reach and access their holes - This requires a lot more education for signs and symptoms of UTI

Structures of the Pharyngeal Phase of Swallowing --nasopharynx, larynx, and trachea

- Nasopharynx extends from the skull base to the soft palate and should be closed off during swallowing (will do a classic doctor exam using a tongue depressor, say "ah"- we want to see that soft palate rising so it can close off the nasopharynx and nothing comes out of your nose) - Larynx (voice box) is a muscular organ that forms an air passage to the lungs and houses the vocal cords for speech production Trachea is a large membranous tube that extends from the larynx to the bronchial tubes to pass air to and from the lungs (we want to prevent food and liquid from passing into here)

Multidisciplinary Dysphagia Team

- OT or SLP- deal with dysphagia evaluation specifically - Primary physicians and team (RN, CNP, PA) - discuss tx plan and recommendations and consult on precautions to ensure carry over - Consulting physicians (radiologist, GI, ENT, pharmacists) - Dieticians- communicate about diet recommendations - Respiratory therapists- help pts with breathing and gain strength - Palliative care team/hospice team- getting more involved with this team - Kitchen/dietary staff- sometimes our role is patrolling and making sure the textures we recommend is being sent out correctly (often times liquids are too thin or too thick)

If you feel somebody should not be driving- tell them our recommendation but have doctor make conversation with them to remove drivers license

- OTs cannot take away license - we just give the recommendation Police can also recommend a driving test if pulled over for inappropriate driving Why would the doctor get mad at Jopp for her recommending they don't drive- B/C they don't want to be the bearers of bad news - this is why we always talk about this with pt so they don't only hear about it from their OTs but also their doctors too Sometimes doctors develop rapport with people and want people to keep driving - but you want to keep them safe

Different Types of Dysphagia Paralytic

- Paralytic: disruption of lower motor neurons (ALS- since it is both upper and lower motor neuron, Guillain Barre, Myasthenia Gravis) causing weakness and sensory deficits in oral, pharyngeal, or laryngeal structures Swallow may be weak, poorly coordinated, or absent

Dysphagia in the oral phase - pocketing, drooling, coughing, dysarthria, aphonia, pills in mouth, poor dentition and mastication

- Pocketing - especially apparent in the brain population (ex. Food may stick on the side of the cheek of the stroke person's weak side) - Drooling- if poor lip closure - Coughing - Dysarthria- if they have slurred speech or unclear speech - Aphonia- person may not be speaking at all - Pills remaining in mouth- could be due to a number of reasons like impaired sensation or due to weak oral motor function and their tongue is not able to manipulate the pill so they aren't able to move it to the back of the throat to start the swallow - Poor dentition- do they have adequate dentition- missing teeth, do they wear dentures? Sometimes the patient won't have dentures at hospital or they don't fit well - Poor mastication- Sometimes we have to downgrade their food just because they are not able to chew their food - Tongue thrust- more common in populations like Parkinson's - Tongue fasciculations- looks like the tongue is almost quivering and having a difficult time pushing the bolus back and starting the swallow - Poor soft palate elevation - Repeated swallow- it may take multiple swallows to be able to clear out the oral cavity - Slow eating- more commonly seen in dementia patients so they will just chew for a prolonged time- They may need a cue to swallow - Inability to propel bolus to back of mouth- could be due to weakness or neuro deficit in pairing initiation - Biting down on utensils- can happen if they have impaired sensation - Biting inside of cheek- can happen if they have impaired sensation What does this look like and what we see at bed side

Phases of the Normal Swallow 3 main phases of swallowing: oral, pharyngeal, and esophageal But we like to look at pre-oral and oral preparatory as OTs- b/c these can play a large role in pt's ability to participate in eating and drinking

- Pre-oral: how food and drink are brought to your mouth (we are looking at, are they able to feed themselves or do they need someone to feed them, are they able to sit up in a chair or are they able to be all the way upright in bed, do they need any Ae) - Oral preparatory: how food is chewed and manipulated (will assess their ability to masticate or chew and do they have adequate dentation, are their teeth missing, do they wear dentures) - Oral: how bolus is propelled (once the food is chewed up, the tongue pushes the food to the back of the throat, then the swallow response is initiated) - Pharyngeal: how the swallow response is initiated (this happens very quickly in less than one second, many parts and muscles are coordinating in this phase) - Esophageal: how food travels through esophagus and into stomach (once bolus passes through UES)

Different Types of Dysphagia Pseudobulbar

- Pseudobulbar: disruption of upper motor neurons (Like ALS, SCI, Stroke, MS, HD) affecting sensation, muscle tone, and coordination in oral, pharyngeal, and laryngeal structures Swallow may be weak, poorly coordinated, or absent

Aspiration in Cerebral Vascular Accident: Cortical, Subcortical, and Brain Stem Infarcts - Aspiration in stroke is determined to be between 29% and 81%

- Silent aspiration is present in half of clients with acute stroke (all stroke patients at Mayo are screened for dysphagia) - There is a wide range in reported aspiration rate due to different diagnostic parameters, lesion site, and length of time following stroke

OT Scope of Practice - Specialty trained OT to treat patients w/dysphagia (40-50 specialty trained dysphagia OTs at Mayo clinic) - Reimbursement for specialty trained dysphagia therapists - Support from AOTA for continuing education, self-paced course

- Support from AOTA with regards to Specialty certification in Feeding, Eating, and Swallowing - Fellowship Dysphagia Program = get fast track to certification - gives you a leg up when applying for jobs

Special Considerations - Tracheostomy - History of throat cancer - Special medications? - Dietary needs - Consider quality of life consider preferences

- Tracheostomy (new, chronic, weaning from vent? Speaking valve) Pts with tracheostomy have a high prevalence of swallowing difficulties Before treating patients w/trachs we ask lots of questions Is it capped or uncapped? Is the cuff up or down? Have they been doing speaking valve trials? ( a valve that can be placed over the trache that allow the patient to verbalize)- often work with SLP to coordinate breathing and talking - History of throat cancer At Mayo, throat cancer patients go to speech so we don't typically work with this population Need to consider if there was a surgery to this area or if there was radiation- both could impact mobility and patient's ability to swallow - Special medications? Pts with Parkinson's Disease may be having swallowing difficulties b/c they missed a dose or two of their meds Once they are back on the meds, their dysphagia may resolve but they could like a totally different person off of it Patients with reflux or GERD may be taking meds at home but haven't in the hospital - they may be in danger of aspirating on a reflux So need to interview pt and family that regular meds are being taken - Dietary needs A lot of patients have diabetes so checking in with the nurse to find if their blood sugars need to be tested before eating or drinking - Consider quality of life consider preferences As OTs we are always asking patients what their goal is and what is important and meaningful to them instead of trying to impose what we think they need We need to realize that some functions won't be able to be restored and that is just part of the natural aging process In dysphagia we need to have a lot of end of life conversations and help them navigate and get them back to their wishes - Some people just want to eat what they want and not be on a modified diet - We need to respect their wishes

What do we do about these deficits? Intervention Approaches for Cognitive Deficits • Who "does" cognition?

- Who "Does" cognition - Speech therapy gets seen by the rehab team as the kings and queens of cognition - Do you think only one profession can take care of cognition alone? - NO it's a big job- cognition is part of EVERYTHING we do!!! - It is the duty for everyone to address it - There is this perception in the rehab world that the patient should go to speech - but you should fight this and work with the whole rehab team - Make sure you aren't overlapping for insurance purposes with other disciplines

What do you mean do they only go to the grocery store? does that mean you'd be concerned if this client doesn't use their car often on unknown routes?

- YES - They can get from point A to point B - But if there is a road closure or traffic this might not be the safest - A red flag to us that it is hard for them to drive

What is Dysphagia? Dysphagia= Basically any difficulty swallowing

- a swallowing disorder that can involve any of the stages of swallowing including oral, pharyngeal, and esophageal Etiology may vary and may be due to - Narrowing of pharynx or esophagus- as we age, esophagus gets smaller and tighter - General weakness/debility - Paralysis or spasms - Degenerative processes- ALS, MS - Neurovascular events - Trauma to the pharynx, pressure exerted- MVA or trauma to the throa Intubation and extubating can be traumatic to the pharynx too affecting swallowing

OT Intervention Approaches for Cognitive Deficits: Cognitive Compensatory Models • Multicontext Treatment Approach One thing the OT could have done in this model?

---the pt was talking about breaking all of these plates what could have the OT did there?? The OT could have asked the patient how to prevent breaking plates "Can you show me how you get plates out of the cupboard" he could observe that and then say, "So what do you think about how you are doing that" "You are telling me you are breaking a lot of plates, why do you think that?" Trying to pull out changes they need to make from the patient themselves In therapy we have this compulsion to solve people's problems for this Have the patient pull from their own understanding- you get better at problem solving by PRACTICING

Types of Occupational Therapy Intervention - Occupations and activities- purchase groceries for a meal - Preparatory methods- hand to mouth motion - Education and training instruction in aspiration precautions - Advocacy- oral care in long term care - Group interventions- feeding group with adaptive equipment

>> Alright, so types of occupational therapy intervention. >> So these are things related to eating for occupations and activities. >> Purchasing groceries, preparing the food Working on hand to mouth activities and upper extremity coordination. - Really encouraging the patient to feed themselves Providing education on aspiration precautions - And making sure that they have their appropriate supports during meals. Advocating for oral care, especially in long-term care Forming group activities like feeding group with different adaptive equipment and tools.

Incidence of Dysphagia Dysphagia affects as many as 15 million Americans Affects 1 in 25 adults in the US annually ***50-75% of nursing home residents experience dysphagia

40-78% of stroke survivors experience dysphagia 50-60% of head and neck cancer survivors More than 80% of patients with Parkinson's disease have dysphagia 60,000 Americans die annually from complications associated with dysphagia

Dysphagia Fellowship Program - 2 fellows/year - Length of program- 12 months - Salary and benefits - Fellows participate in clinical practice, education and research - 1:1 mentorship - Didactic days

>> And then just to give you a little information about the fellowship it's a 12-month program with two fellows per year, and they do receive a salary and benefits. >> The fellows participate in clinical practice, education, and research. >> They're involved in patient care, and they receive one-on-one mentoring, teach, and they have teaching responsibilities. >> So they'll do different presentations and projects for students, residents, fellow therapists. >> And each week they have planned didactic days where they dive into topics and different diagnosis is and just dig a little bit deeper to better understand the various populations they treat

Compensatory Interventions Double Swallow - Technique- swallow bolus then swallow 1-2 additional times (dry swallows) before adding more food/liquid - Use when either oral or pharyngeal clearance during initial swallow is incomplete - Rationale- a second swallow results in additional clearance of bolus from mouth and pharynx when no additional bolus is added

>> Double swallow is used for patients who have weak swallows and residue building up in their pharynx. >> So having them do one to two additional swallows before adding another bite helps them clear out their pharynx instead of continually building material up in the throat.

Some General Aspiration Precautions - Sit upright for all oral intake - Take small bites and small sips - Chew well - Avoid oral intake when overly fatigued - Avoid talking during meal time - Empty mouth before adding more

>> Here's some general aspiration precautions. This is just a sampling of some, but we'll, we'll select specific recommendations based on the patient and, and what they're presenting. >> So sitting upright, taking small bites and sips, chewing their foods really well, avoiding eating or drinking if overly fatigued or drowsy, avoiding talking while eating and emptying mouth before adding more food. So all these are really important for safe eating, but we generally select the most important based on their impairments.

Intervention Planning - Restorative intervention: exercises and eating techniques - Modified intervention: compensatory techniques - Direct intervention: address client factors and swallowing performance within the context of eating - Indirect intervention: address strengthening client factors and swallowing performance outside the context of eating

>> So for intervention planning, it's dependent on their rehab potential, their cognition, their functional abilities. So we determined if they're going to be doing more restorative or modified intervention. So restorative is working towards, we're storing the function. >> - So treatment may include exercises and eating activities. >> And then a modified intervention is where we use the compensatory strategies. Direct intervention addresses client factors and swallowing performance within the context of eating. >> Whereas indirect is outside of the context of eating, which would be those swallowing exercises. >> We like to provide as much direct intervention, intervention as we can because it's easier for the skill to transfer if we're doing it within that context. >> So we swallow as much as a 150 to 200 times per meal. >> So that that would be a lot of repetitions of a swallowing exercise. >> So sometimes it's just easier to get them if they're safe to get them started on eating.

Possible Interventions Following the Clinical Dysphagia Evaluation - Safe diet recommendations - Proper positioning - Exercises - Instruction in aspiration precautions and symptoms of aspiration - Consequences of aspiration - Instruction in good oral care routine - Compensatory techniques/exercise - Further assessment needed

>> So once a bedside evaluation is completed, here are some of the follow-up interventions we provide. We determine safest diet recommendations. - Do we need diet modifications or do we need to prescribe compensatory strategies? - Of course, as I've said multiple times, proper positioning, so reiterating the importance of sitting upright and encouraging patients to try to eat meals in the chair. - Exercises which could be while eating or separate from the task of eating if they're not ready to start on an oral diet. - Providing education on aspiration precautions, symptoms of aspiration - As well as consequences of aspiration, especially for those patients who are having difficulty with compliance instructing on good oral cares

Compensatory Interventions Effortful Swallow - Technique- swallow hard while pushing the back of your tongue against the roof of your mouth - Used for reduced posterior movement of the tongue base - Rationale- effort increases the posterior tongue base movement

>> So the effortful swallow, your most basic swallowing exercise, you just swallow as hard as you can. >> That focuses on pushing the back of your tongue against the roof of your mouth. So just trying to engage as many of the swallowing muscles to increase posterior tongue base movement and improve clearing or pooling and residue in the pharynx. >> For this one, you can do it with just a dry swallows or you can do it with therapeutic feeds and instruct the patient to just swallow hard. >> If the patient has a weak swallow, they may be instructed to do this during mealtime to help with that pharyngeal clearance

Intervention Planning - Restorative intervention: exercises and eating techniques - Modified intervention: compensatory techniques - Direct intervention: address client factors and swallowing performance within the context of eating - Indirect intervention: address strengthening client factors and swallowing performance outside the context of eating We like to provide as much direct intervention, intervention as we can because it's easier for the skill to transfer if we're doing it within that context.

>> So we swallow as much as a 150 to 200 times per meal. >> So that that would be a lot of repetitions of a swallowing exercise. >> So sometimes it's just easier to get them if they're safe to get them started on eating.

Some Compensatory Interventions - Effortful swallow - Tongue holding- Masako Maneuver - Mendelsohn Maneuver - Supraglottic Swallow - Double Swallow - Throat Clear

>> Some more details on the compensatory strategies and exercises. And we'll go through each of these in detail. >> But depending on the cognitive abilities of the patient, we determine and select the most appropriate exercises or if they have any medical reasons that they shouldn't be doing some of these. Because some of these require you to hold your breath or bear down, so we're very careful to select appropriate ones.

Free Water Protocol - Frazier Free Water Protocol - Option used to allow patients who are on thickened liquids to also have thin water as part of their diet - Patients follow special protocol to decrease risk of developing aspiration pneumonia while continuing oral intake of water

>> The Frazier free water protocol is an option for patients who are on thickened liquids to have water. The principle behind it is if you have a clean mouth free of bacteria in food and liquid particles, if water is aspirated, it's relatively benign and can be reabsorbed by the body. So during meal times, they would still have their recommended thickened liquids. - But between meals, after they brush their teeth, they're able to drink water, but no juices, pops or additives. And this is something we carefully consider to determine if a patient is appropriate for this protocol because it is strict. - >> So cognition is considered as well as family support to enforce the guidelines. - >> And then we also review it with nursing and PCA

Compensatory Interventions Mendelsohn Maneuver - Technique- swallow a couple of times and concentrate on feeling your "Adam's apple" going up and down. When you feel your "Adam's apple" go up to the top of your throat, use the muscles in your throat to hold that position for a couple of seconds. Then relax. - Use when there is reduced Rationale- laryngeal movement opens the cricopharyngeal region. By prolonging the laryngeal elevation you hold this open longer

>> The Mendelssohn maneuver works on holding the Adam's apple or the larynx up. >> So it's kinda like a pause swallow. >> When you swallow, the larynx rises up and so you hold it there for a second before releasing it. This works on the muscles that raised the larynx, which ultimately can improve laryngeal closure as well as allowing the upper esophageal sphincter to relax and allow the bolus to pass into the esophagus.

Compensatory Interventions Supraglottic Swallow - Technique- swallow while holding your breath, cough hard immediately after swallowing and before taking a breath - Use for reduced for late vocal fold closure - Rationale- voluntary breath hold usually closes the vocal folds before and during a swallow

>> The Supraglottic swallow has a couple steps. >> It's a little bit more involved, but this is one that we would make sure that they can follow multi-step directions before prescribing. It's patients who have reduced or late vocal cord closure. >> For this, patients hold their breath and then swallow, cough and then swallow again. For these patients, they may have material entering the airway, but they have a strong cough so they're able to eject it out and then you have them reswallow again.

Compensatory Interventions Chin Tuck - Technique- tip head forward to touch chin to neck - Use when there is a delay triggering a pharyngeal swallow, if tongue base retraction is reduced or airway closure is reduced - Rationale- pushes tongue base and epiglottis posteriorly, narrows airway entrance and widens valleculae space

>> The chin tuck is a common compensatory strategy that is used with dysphagia patients. >> So when you're eating or drinking, it'll take a normal bite or sip, and then you'll bring your chin down to your chest and then swallow. The rationale is that it narrows the airway entrance and then widens the pharyngeal space. So this can be helpful for patients with a delayed swallow or inadequate laryngeal closure.

Silent aspiration is the most concerning, because as the word silent indicates, you can't hear it. - Some material may enter the airway and they may not have an awareness or be able to sense it and cough it out.

>This can be difficult because patients sometimes don't believe they have a swallowing impairment. >> So they may have poor compliance of the modified diet or swallowing strategies, ultimately magnifying the risk of aspiration.

SCI Equipment Dig stick & suppository

A dig stick ((Bottom)) (acts like a gloved finger) and a suppository inserter (top) for people that don't have the finger movement These with UMN injury allow more independent in bowel program

Increase in use of telehealth due to COVID-19 • At this time occupational therapy services are being delivered more than ever in a telehealth format to limit spread of COVID-19 and conserve PPE • This includes a lot of settings: pediatric settings, outpatient therapy, school settings, others • Some settings are using telehealth technology due to COVID-19 but are being told to charge for in-person treatment if in the same building as the patient (ask your Department regarding billing procedures)

A huge increase in telehealth services We are doing more telehealth than ever Trying to limit COVID spread and preserve PPE Some settings like acute- there is even some telehealth being done inside the hospital with people who have COVID so not too many people go in there But there is some distant therapy being done IN the hospital- the OT is in the hospital but not directly in the room w/ the patient So they are told to charge for in-person treatment if they are in the same building You have to rely on your employer or your FW supervisor b/c there are so many rules and loopholes

Complications of SCI u Circulatory: Can develop a DVT or PE due to lack of muscle movement and decreased time up. Prevention includes blood thinner, TED hose and daily ROM.

A lot of circulatory complications - TED hose, daily ROM - Biggest thing to prevent DVT or PE is to get them up and moving as quick as possible

Structures of the Oral Phase of Swallowing - Tongue - Lips - Cheeks - Jaw - Palate- hard and soft - Faucial arches- uvula - Oral sulci - Dentation - Salivary glands

A lot of these are structures of the MOUTH All of these structures play a role in swallowing Just like we do MMT in UE, we can actually do testing of the strength of your oral mechanism of your lips, your tongue, and jaw

Outpatient u Usually seen 2-3 times a week u Not all injuries need outpatient OT u Can focus more on home making tasks, hobbies and return to work issues. u update HEP as needed u May need services for changes in strength or life events such as pregnancy or changes in care giver availability u Facilitate case management assistance for in home and transportation issues

A low paraplegic may not need OT in outpatient but a lot more people need this b/c length of stay in hospital is shorter

Orcam

A text to speech tool Orcam- a small camera that attaches to the side of a pair of glasses Even with the best magnifier - people can strain for lengthy text This takes a picture of text and reads it out loud Very pricey around $4,000 Non-visual way to access information using sensory substitution

ASIA cont.... u A: Lack of sensation and movement at S4-5 (complete injury) u B: Sensory, but no motor function at S4- 5 u C: Motor function at S4-5 with more than half of the key muscles below grade 3 u D: Motor function at S4-5 with more than ½ of the key muscles at grade 3 or higher u E: Normal function

A- complete B- sensory but no motor at S4-S5 C- motor function at S4-S5 with more than half of key muscles below grade 3 D- motor function at S4-S5 with more than ½ of key muscles at grade 3 or higher E- normal function

ASIA Classifications u A complete injury presents with no sensation or movement at the last level of the spinal cord S4-5 (may have sensory or motor sparing below the level of injury) u An incomplete injury presents with some degree of sensory or motor preservation at S4-5. u Injuries are given an A through D classification as well as a level More information can be found at the ASIA learning center---www.ASIAlearning

ASIA levels A-E A= complete injury Check rectum - May be able to wiggle a toe but considered a complete if no sensory motor at S4-S5

Clinical syndromes u Spinal shock: Can last from 24 hours to 6 weeks and is characterized by areflexia below the level of injury, with deep tendon reflexes decreased and sympathetic functions disturbed. After spinal shock there may be hyperactive deep tendon reflexes and spasticity (often see more spasticity with incomplete injuries.) Bowel and bladder function may also change after spinal shock, Persons with UMN injuries (T12 and above) may have spastic bowel and bladder and LMN (L1 and below) may have flaccid bowel and bladder. This will dictate the type of bowel program which is performed.

All different SCI syndromes besides complete/incomplete Spinal shock - Sympathetic functions disturbed - Often see more spasticity with incomplete SCI - With a C6 injury a person should have a rectal reflex, if it is flaccid this is abnormal, so likely in spinal shock---so then a suppository would not work - May need to shift bowel program then

Complications cont... u Heterotopic Ossification: Bone that develops in an abnormal place. Usually occurs in the muscles around the hip and knee and can severely limit ROM. The signs include swelling, warmth, and decreased ROM. Treatment includes, medication in early stage and surgical intervention later if needed

Also called HO We are usually the ones to notice this first b/c it limits ER of the hip the most so limits bathing and dressing Cannot reverse the formation of the bone If gets bad enough they may not be able to sit in chair Rare but if it happens it needs to be treated right away

Before the Telehealth visit • There are some things we should consider prior to offering OT services via telehealth which consider whether it will be effective (WOTA 2020): • Experience of the therapist: within scope of practice? • Appropriateness of this mode of treatment for client (e.g., avoid showing clients in state of undress; consider cognition of client & can they follow 2-3 step commands) • Privacy of client • E-helper for safety • Environmental factors and liability • Best to call re: telehealth OT being covered by insurance

Always consider whether or not telehealth is within the OT's scope of practice- Washburn does not do OT in the school setting - so not qualified to work in a school setting - do you have enough skill to be working in this area? Not right to have clients in a state of undress via telehealth So need to rely on caregivers to tell us how much help they have to give May be important to have a helper there to ensure safety of client throughout the treatment Environmental factors and liability Need to make sure telehealth is covered by insurance

AOTA - self-paced dysphagia course - Specialty certification in Feeding, Eating, and Swallowing - AOTA Sponsored Dysphagia Fellowship Program at Mayo Clinic

And just to wrap it up just as a review, AOTA really supports the dysphasia practice. - There's a self-paced course. - There's a specialty certification in feeding, eating and swallowing - At Mayo Clinic we have an AOTA sponsored dysphagia fellowship here in Rochester. ***And right now it's the only one in the nation.

Quality of Life and Ethics - Remember changes occur in our swallow mechanism as we age - End of life wishes - Diet modifications - Discussion with patients and caregivers - Consequences of choice - Promote positive feeding interactions

And one of the more challenging parts of dysphagia is dealing with quality of life and ethics Many times we are working with an older population. >> And as we age, the swallowing mechanism gets weaker and it narrows. So patients may have difficulty swallowing at the end of their life. >> And while we wanted to provide them the best recommendations, we also want to take into account their wishes. So we'll discuss, safest recommendations with patients and caregivers and educate them on the risk of aspiration pneumonia. - And if they would like to go against the recommendations, then we respect their choice and their decision. >> Palliative care is typically involved in these cases, and they're the experts at navigating these tough end-of-life decisions and, and help determining what the goals are for the patient and the family.

Syndromes cont... u Anterior Spinal cord syndrome: Damage to the anterior portion of the cord resulting in loss of movement, pain, temperature, and touch sensation with preservation of proprioception.

Anterior SC syndrome- rare - Damage to anterior SC - Preserved proprioception - But can't move or feel

Perceptions of telehealth • Many therapists perceive interpersonal barriers with telehealth services, and they don't like the lack of physical contact • Some patients really like it, however, and may even prefer this mode of treatment - many seniors have experience with Zoom to talk to grandkids • AOTA 2020

Apparently telehealth is going on okay with a lot of people

Intervention C6 u Can begin to work on full body washing and dressing in the hospital bed with head of bed up initially, then may be able to work towards flat bed u Educate patient on use of bathroom equipment (tub bench-padded, raised toilet seat, drop arm commode) and work on transfers - teach compensation technique of external rotation at the shoulder to lock elbows for transfers. u Work on strengthening of shoulders and wrist extension (for increased tenodesis pinch) u May be able to complete self catheterization with or without use on catheter clamp. u Games and peg activities to facilitate use of tenodesis u May need short opponens splint. Will no longer need wrist support u Possible goal: The patient will dress LB with minimal assistance, and use of dycem gloves.

At C6 have no elbow extension but shoulder ER can help to lock the elbows A tub buddy is a commode on wheels that can also act as a tub bench but only Title 19 and VA can cover this When we are working on C4 we want to make sure that when they curl the fingers the wrist is back Dycem gloves help give people grip b/c they don't have a true pinch

Things to keep in mind with OT treatment... • Attendance of OT visits is sometimes poor • Understand that clients with psych histories have widely varied responses to treatment; interventions that are usually therapeutic for most patients with their diagnosis may not be helpful for them • If progress cannot be made it may be necessary to defer OT treatment & recommend psych treatment

Attendance is poor- so give them more leniency than other patients Give them six strikes instead of three maybe People with psych histories have wide responses to treatment Have to be creative May be necessary to defer OT tx and recommend psych tx before they get physical OT tx

Complications cont... u Autonomic dysreflexia: Occurs in persons with T6 injury or above. It is the autonomic nervous system's response to noxious stimuli (most commonly involving the bladder or bowel). Symptoms: pounding headache, anxiety, sweating, blotchy skin, chills, nasal congestion, and increased blood pressure. Action: Bring client upright to lower blood pressure, and remove restrictive clothing. The caregiver should search for reason and take care of it (example: cathing to empty full bladder). The increased blood pressure is the most life threatening symptom and AD should be taken seriously. Clients shouldknow signs and symptoms and carry a card describing AD with them

Autonomic dysreflexia- if something happens to a person's body below T6 level Ex. Ingrown toe nail - body can't sense this but body knows something is wrong so autonomic system gets out of whack Increased BP is the worst symptom b/c if it goes too high they are at a high risk of stroke Post injury SCI pt are likely hypotensive so be sure to know what is "normal" bp for them with their SCI You as a caregiver want to search for a reason (ex. Haven't cathed in a while, their foley bag is kinked, a wrinkle in their clothing, their bowel program is not working) If they are at home alone need to call 911 Give people a little card describing this b/c people who don't work in SCI don't know this exists so they have to advocate for themselves

Types of Cognitive Deficits: Review • Awareness (self-awareness, orientation) • Memory (short term, long term, etc.) • Attention (decreased, neglect) • Executive function: skills like sequencing, organizing, problem-solving, ability to change behavior, judgment put together and used to achieve a goal

Awareness issues maybe they aren't very oriented to their environment, the day of the week or even their situation ST memory or LTM Maybe decreased attention or neglect When you have deficits with basic cognition (memory, attention, and awareness) Will have EF deficits - in problem solving, judgment, and putting things together

Why would the doctor get mad at Jopp for her recommending they don't drive

B/C they don't want to be the bearers of bad news - this is why we always talk about this with pt so they don't only hear about it from their OTs but also their doctors too Sometimes doctors develop rapport with people and want people to keep driving - but you want to keep them safe

What can any OT do to help? Basic Interventions - Positioning and facilitating postural control - External pacing - Limiting distractions; environmental adaptations - Small bites/small sips - Improve self-feeding, self-cares - Overall functional abilities - Strengthening - Understanding when to collaborate with others You don't have to be specially trained in dysphagia to be able to observe for signs of aspiration and enforce dysphagia recommendations

Basic Interventions Positioning and facilitating postural control - Ideally you want the patient in a chair for every meal - Sometimes they don't have the strength or the tolerance - We can work on trunk and core control and strength to progress toward this External pacing - Cueing them to eat slowly especially for impulsive patients - You could have them put their fork or spoon down between bites so they can clear out their mouth before adding more food and liquid Limiting distractions; environmental adaptations - Especially for brain patients that might be easily distractible - A lot of times patients will be watching the TV or talking to friends and family and they really need to focus on swallowing - Especially if they were recommended compensatory strategies often in patient's rooms the TV is up higher, so their neck is in cervical extension when it should be in neutral or in flexion Small bites/small sips - You can see this really well in a swallowing video - If a patient is taking really large sips, it is difficult to coordinate holding your breath and closing off the airway for an extended period of time - If a patient has a weak pharyngeal contraction it may take multiple swallows to clear the material out so smaller bites are safer and easier to manage Improve self-feeding, self-cares - If you have ever been feed by someone before it can be kind of awkward - You don't know how fast they are going to feed you or how much - Naturally you just retract which puts you in an awkward and weird position for swallowing - Being able to present yourself with food is better for the whole swallowing mechanism - They may need adaptive equipment so finding out what tools could be helpful for independence in self-feeding Overall functional abilities - We've seen the relationship between when a patient is functionally improving and the swallowing mechanism sometimes just follows suit - Working on checking in on adherence to swallowing exercises Strengthening Understanding when to collaborate with others - There may be a vocal cord impairment that SLP is working with - Or consulting GI if there are esophageal symptoms You don't have to be specially trained in dysphagia to be able to observe for signs of aspiration and enforce dysphagia recommendations

Syndromes cont... u Central Cord syndrome: Presents like and "upside down Quadriplegic" with more deficits in the arms than the legs. This happens when there is more damage to the center of the cord than the outside. Frequently occurs with falls resulting in hyperextension of the neck with no fracture. Also can result from narrowing of the cord. Greatest weakness will be in the shoulders.

Basically presents like an upside down quad If someone is injured at C5- have more movement in their arms often recover from the top down But in central cord syndrome have more deficits in arms than legs and more deficits in shoulders than their fingers - ex. May not be able to get their arms where they need to be but be able to use their fingers perfectly

Video demos: telehealth in ot • https://www.youtube.com/watch?v=AfjFptKOq5Y • https://www.youtube.com/watch?v=D6k0U3R7c18 • Video on Canvas

Before Wednesday, watch some of these links in the PPT to get a feel for telehealth and how it would be conducted Certain activities not able to be done via telehealth - you need to decide what is safe and what is not safe - Usually have a family member or caregiver there - They need to make sure that the caregiver is able to keep the patient safe

Billing can be complex with OT via telehealth • It is recommended to work with your fieldwork sites if you do use telehealth regarding proper billing for OT services in a telehealth format • Usually you must have a license in the state the patient is located to bill telehealth services, but some restrictions have been relaxed during the COVID-19 pandemic (AOTA, 2020; WOTA, 2020) • Sometimes there are limitations on codes accepted or modifiers that have to be added to codes - need to check with insurance • Caps on number of visits are not in place for Medicare at this time (AOTA 2020) but it is important to check this for all insurance

Billing can be super complex with OT via telehealth Modifiers are 2 digits added onto the end of CPT codes for billing For Medicare there is no cap on visits as of now- but its important to check on this

SCI tech adaptive equipment

Bottom right is splinting material hook for back of phone even if have no finger movement Can also do speaker Top left is commercial phone holders Also phone holders for wheelchairs and set them up with voice control TEPP- State will give up to 1600 for hands free equipment

Levels of SCI

Bowel and bladder function come in pretty low

Syndromes cont... u Brown Sequard: Primary damage to 1 side of the cord (mainly from GSW and stabbing). Below the level of injury will have some degree of motor paralysis loss of proprioception on the ipsilateral side and loss of pain, temperature and touch sensation on the contralateral side

Brown Sequard- Gun shot wound / stabbing - The side they can feel well they can't move - And the part they can move they can't feel

Dysphagia in the Esophageal Phase - Reflux of the bolus - Sensation of the food sticking in chest - Heart burn - Persistent halitosis - bad breath

Once the bolus passes through the UES, they enter the esophageal phase

Key muscles tetraplegia u C6 Wrist extensors u C7 Triceps u C8 Finger Flexors u T1 Intrinsics

C6- With wrist extensors you will get tenodesis- you can get rudimentary grip to use C7- triceps C8- finger flexors T1- intrinsics So paraplegia is really T2 and below

What does the evidence say? CO-OP intervention with patients post-stroke

CO-OP intervention with patients post-stroke, allowing guided discovery and meta-cognitive strategy training, shows promise over directed training for reducing disability

What types of patients have cognitive deficits? • Diagnoses?

CVA, TBI, MS, elderly following surgery, depression, HD, concussions, sepsis, cancer patients, Alzheimer's, Dementia, ID, UTI, diabetes, mental health conditions (BP, ED, schizophrenia, substance abuse), pain, organ failure, heart conditions, kidney failure Need to assess for cognitive issues in EVERYONE!!!!

Cognitive Functional Evaluation (CFE) as a Strategy • Stages: • Interview and background information, including an occupational history (social, family, falls history); • Cognitive screening and baseline status tests; • General measures of cognition in occupations (look at ADL/IADL); • Cognitive tests for specific domains; • Specific measures of cognitive domains in occupations; and • Environmental assessment

Can do standardized and informal assessments

Driving an adapted vehicle • Equipment must be installed by reputable installer • Must retest on the road at DMV • New equipment must be listed on DL • Other drivers can not drive with equipment

Cannot buy something off Amazon and install it themselves Need to retest with DMV with equipment to make sure they are safe in driving New equipment must be listed on their drivers license Nobody else can drive with equipment besides the patient themselves

Syndromes cont... u Cauda Equina: Involves peripheral nerves rather than the spinal cord and usually occur with fractures below L2. Will have flaccid paralysis below level of injury but may have a better chance of recovery since peripheral nerves may regenerate.

Cauda equina - involve peripheral nerves not SC The part that looks like the horse tail So better chance of regenerating Likely difficulty with plantar/dorsiflexion And bowel/bladder

Distance Magnification

Clients may have distance viewing goals Street signs, watching TV, reading fast food sign Working with telescopes Try to match device with client goals Top left- handheld monocular- good for seeing signs in community, not as good for extended distance viewing like a lecture Device below- max TV glasses designed for TV watching about 10 feet away, realtively inexpensive usually does the trick - or just getting closer to TV helps Right tool-Bioptic Telescope glasses- you can walk with them on up to your eye= handy and hands-free- students and teachers like these -but cost is a factos Two left devices - The other two blocks your field of view so can't walk around with them Vocational State assigned counselor can help with coverage too In some states, you can use telescope glasses during adapted driving - not illegal to wear telescope glasses while driving but cannot pass the road training in WI with bioptic telescope glasses

Compact 10 - magnification tool

Compact 10 Allows more paragraph reading AND portability Much smaller foldable and compact Can listen to text that is read aloud Instantly powers up And has touch screen function Swing out camera arm Can take photos, write your signature, read medication labels Around $2,000 with the speech $1,500 without the speech option INSURANCE DOES NOT COVER ANY OF IT!!!!! If someone is a veteran, the VA will cover it Or if someone has family care community care- a supplemental Medicaid - may get some funding Or a grant request

Mind-Body Connection: Pain Example • Patient is under stress due to physical pain • Chronic pain is a significant stressor that causes cortisol levels to rise • This leads to high levels of glucose in response • Cortisol will break down protein in muscle and inhibits the ongoing replacement of calcium in bone in order to maintain high levels; immunosuppression also occurs • These biological effects damage patient's physical health and cause depression

Cortisol is a hormone that leads to high levels of glucose You have a fx and your healing is worse, have suppressed immune system and now you are also subject to other illnesses Then people are in pain so much that they start to get depressed

Case Study #1: Ms. Shoulder • Status post (S/P) rotator cuff repair of dominant arm which was repaired 1 year after complete supraspinatus tear; had generalized anxiety disorder (GAD) • Came to therapy 2 weeks late which negatively affected her rehab potential • Had a "baby arm" • During evaluation stated, "Why do you need all this information?"

Cycling: over a period of months you may observe a significant fluctuation in a patients behavior usually from an unstable state to a manageable one back to an unstable state and beginning again toward a manageable one. She had a massive tear of the supraspinatus- it was complete- completely tore off the bone Waited a year to get this surgery Had generalized anxiety disorder (GAD) symptoms but was not diagnosed with it at the time Has the RC repair then came two weeks for therapy Was supposed to come to therapy 2 weeks BEFORE therapy You really need to be on time with therapy Already had two strikes Was already putting off going into surgery And had a "baby arm" - holding onto her arm like cradling it "I want you to move your arm" - you want me to move my arm? She was not happy with that b/c she was in a lot of pain She did not like being asked so many questions

Discharge planning u ISNCSCI will be completed again u Reassess ADL function u Develop home exercise program u Help patient get the right equipment u Confirm family teaching u Facilitate outpatient if needed

Discharge planning works from day 1 On discharge day do ASIA exam again Length of stays have gotten so short Its hard to determine bathroom equipment right away

Case Study cont. } First 2 sessions in the clinic followed by 2 home visits. } Near Mag Recommendations: 4x Illuminated Handheld, 4x Stand, +12.00 reading glasses, video magnification } Distance Mag Recommendations: 4x Handheld Telescope, Max TV } Non-Optical Recommendations: Eccentric Viewing, Kitchen Appliances Safety / Organization, Task Lighting, Contrast Enhancement } Resources/Referrals: Talking books, transportation, meals on wheels (MOW), Support group at VF

Decided to just sit closer to the TV Used regular binoculars for objects 20 feet or closer Did bump dots on her microwave Got a big button phone Addressed transportation even since she had family members willing to drive her Got signed up with free talking books - through library of congress VF support group Do you have issues with elderly people not being comfortable learning the technology or not using them? - Yes usually start with low vision and then introduce tech options Vision loss is usually so hidden!!

Intervention (Rehab) u The intervention will depend on the level of injury and neurological function u Many of the sessions will be ADL focused, however strengthening and balance are important to facilitate increased function

Depends on level of injury when they are in rehab A lot of times have 1.5 hours of OT with pt if speech is not involved Do 1 hour of ADLs in morning Then 0.5 hour of strengthening

Case Study #2: Mr. TENS • He was S/P rotator cuff repair and distal clavectomy (years ago) and many rounds of therapy • He had depression with psychotic features • Came in wanting TENS unit; insurance requires 6 visits and proof TENS relieves pain prior to issuing it • We would have to negotiate for 5 minutes each time he came to therapy about interventions we would use that day and would never perform his home exercise program

Didn't see the psychosis during therapy - seemed well managed- somewhat paranoid about OT tx He wanted a TENS unit Would no-show for a lot of visits b/c he was not invested - he didn't think OT would help Would give the pt 3 to 4 intervention choices - all of them would help him- would have these negotiations with the patient

SCI writing aids

Different types of writing aids Pen or pencil can fit in there But need to write with their whole arm Otherwise can put foam on there for people with wrist movement

What do we do about these deficits? Intervention Approaches for Cognitive Deficits • Issues to think about as we discuss intervention: • How is it best to attempt to improve function? Consider: • Insight • Cognitive deficits • Ability to learn • Disease/condition prognosis • As rehab professionals, should we direct or guide our patients? • Opinions from the class?

Do they have insight to their deficits? - affects their attitude, important for safety concerns ****If they have insight it adds to their motivation--- Should we direct or guide our patients? - GUIDE - But currently most therapists direct patients- tell them what to do - There are times when we need to direct people but we direct them a lot more than we need to

Overall takeaways of SCI OT

Dorsal wrist support for people who are C5 - like the U-cuff but with wrist support- use it for eating and grooming Dycem gloves slips on and helps grip - use this for dressing a lot AND pushing the wheelchair for people with no grip Basically just doing a lot of problem solving and adaptation Adapt only what you need to b/c don't want to have them rely on Adaptive equipment Biggest takeaway SCI is a specialty A lot lower incidence than stroke Know what you don't know- ask questions ***Biggest thing is PADDED EQUIPMENT- this is a huge risk for skin breakdown

OT Intervention Approaches for Cognitive Deficits: Cognitive Compensatory Models Dynamic Cognitive Intervention (DCI) • Structured cognitive modifiability: the human being is an open system that can be modified regardless of age and disability status • The principles are to (1) improve independent learning ability; (2) develop awareness, insight, and feelings of competence; (3) expand a person's ability to participate in desired occupations; (4) focus on the positive (the client's strengths); (5) allow client to choose task; (6) match tool to client; (7) focus on ability as that produces motivation; (8) position client and therapist as equal partners • Ben: LE Dressing: https://videos.icelearningcenter.com/universityofwisconsinmilwaukee/detail/video/4998546223001/self-care:-dressing-in-acute-care-part-2?autoStart=false&q=cognition • Discussion: Do you see elements of this approach, and/or what could be changed to better fit/enhance the approach?

Dynamic cognitive intervention (DCI) An assumption from the model is humans are open systems that can be modified regardless of age and disability status Using a strength—based approach Client-centered - allow client to choose task Ben: LE dressing Are there aspects that are consistent with the model? - She did not position herself and the client as equal partners - Allowed him time to try things out for himself - Let him make the error to learn from it- allowed him to develop awareness of difficulty of putting weak arm in last - Could have given him more time- she was too quick to jump in and help him - She is not letting the pt come to his own conclusions - Starts out with good intentions but becomes impatient - She didn't give him the choice to want help - She didn't allow the "just right" challenge - She did not focus on the positives overall- did give him some positive feedback but not a lot - She did not produce motivation in her patient - We are often worried about people getting frustrated, but learning can come from frustration - If we prevent anyone from getting frustrated at all we prevent people from learning at all

Dysphagia Screening Eating Assessment Tool: EAT-10

EAT-10 goes through subjective questions on a scale you answer "To what extent are the following scenarios problematic"- 0 being no problems at all, and 10 being very severe very problematic

Mind-Body Connection: Bipolar example • Bipolar disorder causes periodic hospitalizations every 2-3 years due to poor medication management • As patient ages physical ailments occur: severe arthritis leading to hip replacement, hypertension begins • Early dementia begins due to bipolar disorder; patient forgets to take necessary medications to control hypertension • Stroke occurs resulting in hospitalization; patient gets DVT...this leads to a worsening of bipolar disorder

Early dementia can happen with bipolar disorder Worsening of BP b/c stress and increased physical disabilities- a cycle- one feeds on another Our role is to break this cycle Work with physical rehab AND psychosocial rehab

Ms. Shoulder • Was encouraged to try anxiety meds (thru doctor) but could not find one that made her "feel right" • Eventually got functional shoulder AROM in dominant arm but still had high levels of pain; insurance capped her visits and would not allow more • Patient stated she knew she needed to "push through the pain" to do functional activities

Encouraged pt to go see doctor b/c her pain was interfering with therapy Not able to focus on therapy Took anxiety medication for ONLY ONE DAY (takes 4-6 weeks to have a full effect) Stopped taking it after taking it one day She got about 90—95 degrees In shoulder abduction and flexion- right when Medicaid capped her visits Understood at the end that she needed to push through the pain in her activities - new she needed to keep moving to stay moving

Environmental Modifications } Home visits are ideal for addressing independent and safe use of appliances, lighting needs, glare control, organization, labeling, and functional mobility.

Environmental modifications really apply to OTs the most Maximize safety and vision in the home Normal aging changes to the eye in older adults Need proper lighting for reading and walking In LV often with a home visit you will help mark people's appliances and keep it simple Only mark the most important settings to make it simple (ex. Mark power button on TV remote) Can draw lines using puffy paint that becomes 3D

What is Dysphagia? Dysphagia= Basically any difficulty swallowing etiology

Etiology may vary and may be due to - Narrowing of pharynx or esophagus- as we age, esophagus gets smaller and tighter - General weakness/debility - Paralysis or spasms - Degenerative processes- ALS, MS - Neurovascular events - Trauma to the pharynx, pressure exerted- MVA or trauma to the throat Intubation and extubating can be traumatic to the pharynx too affecting swallowing

Intervention-- Paraplegia u Work on self cares, from flat bed if possible u Shower on tub bench u Complete bowel program on raised toilet seat or drop arm commode u general UE strengthening u Need to work trunk strengthening and balance at edge of mat, in circle sit and in chair u Homemaking at wheelchair level u Possible Goal- patient will complete wheelchair to tub bench transfer independently

Every one is different so someone who is T3 will move a lot different than T10 b/c lack of trunk muscles

Possible equipment u C4-5-hospital bed, Hoyer lift, tilting roll in shower commode (if shower available) power wheelchair, slide board u C6- T1 Tub bench, raised toilet seat or drop arm commode, slide board, manual or power chair, dig stick, suppository inserter

Everything has to be padded b/c they are at risk for skin breakdown

OT Intervention Approaches for Cognitive Deficits: Functional and Environmental Models • Adaptation of task/environment and caregiver education approach • Modifies activities and/or environmental factors to make them compatible with a client's cognitive level (reduce attention demands, structure the activity, modify caregiver expectations) • Designed for clients with (1) poor ability to transfer learning from one task to another, (2) poor insight, (3) severe cognitive disabilities, (4) reduced participation, (5) safety concerns • Discussion: Do you see elements of this approach, and/or what could be changed to better fit/enhance the approach? • Frank - Toilet Transfer:

Examples: If client will not stop cooking, unhooking the stove; providing more assist and hand over hand technique for deodorant application (educate caregiver to hide deodorant until ready to assist client) Frank is having trouble with the throw rug- so the answer would be- get rid of the throw rug - wasn't aware that it was a problem Ex. Home health pt who would cook and leave stove on - so they unhooked the stove Changed the environment to make it safe for the person

Tools for treating cognitive deficits (for a variety of models/abilities; use with approaches) External strategy- using devices or cueing for working with the patient

External strategy examples= - Verbal cueing to time, place, situation (directing stuff) - Mnemonics- coming up with acronyms for different things - Notebook, journal, log Best if we can use internal strategies -bc more likely perpetuated over time

Complications cont... u Skin breakdown: Includes pressure sores and decubitus ulcers. Can be caused by staying in one position as well as bumps and shearing. Areas of greatest risk: sacrum, heels, ischium, trochanter, and elbows. Other areas at risk are spine, ankles, knees, toes, and scapula. Signs of breakdown include redness or darkened area, swelling, and open areas. Prevention: pressure reliefs, changing in position in bed, checking cushion, Staying dry and clean, inspecting skin, good nutrition, proper seating and feeling good about yourself

Feeling good about yourself is important b/c if get depressed and stay in bed all day they are more likely to get skin breakdown Make sure they check cushion - Check air levels in cushions - Squish gel around cushion so they stay in the right places - Make sure they check skin- with flexible mirrors or take your phone and take a picture - you can also send these pictures to doctors through iChart

Driving Screen • History: (how often, to wear, when, habits, rituals routines, accidents) • Occulomotor skills (Convergence, saccades, acuity) • Visual fields (Confrontation Testing)- 70 degrees peripheral vision in BETTER eye OR 105 total • Visual acuity- 20/40 (can drive with one good eye) (Snellen Chart 20 feet away) • Functional visual skills • Depth Perception (Finger to nose Test)

First we get their history Do they only drive during the day, how often do they drive b/c this changes their risk We do confrontation testing Oculomotor skills- If they have 70 degrees of peripheral vision in their better eye, or 105 degrees total - ROM in their acuity to see if they have their appropriate completion visual acuity - typical eye doctor chart- Snellen chart- need 20/40 vision in their good eye in order to drive If they are blind in the other eye that is fine Functional visual skills- will have them go on a walk in the hospital and use signs to get around

OT Intervention Approaches for Cognitive Deficits: ***Functional and Environmental Models • Modify the task and/or environment to reduce the impact of cognitive deficits and enable optimal participation in meaningful occupation • Designed for clients with (1) poor ability to transfer learning from one task to another, (2) poor insight, (3) severe cognitive disabilities • Use primarily external strategies to achieve functional goals

For people with late-stage dementia and poor ability to transfer learning These are EXTERNAL strategies So transitioning now from internal to external strategies

Assessment during a telehealth visit • Assessment forms for completion (medical history & individual assessments) can be sent before visit • Edema can be checked with patient/caregiver using tape measure at bony prominences • Functional activity assist level done by observation • ROM can be measured right off the screen • Patient photos could be sent to the therapist ahead of the visit

Forms can be sent and filled out ahead of time Caregiver/pt can measure edema Report or observation can help with functional activity assist levels ROM can be measured right off the screen

Evaluation u orders are received u formal evaluation is coordinated with PT. (A co- evaluation with PT may or may not be necessary depending on severity of the injury and any secondary diagnosis, like head injury. u Complete a thorough chart review to acknowledge the order, obtain, prior medical history, current medical history, any surgeries that were performed, social history and precautions. Common precautions: spine precautions, bed rest, weight bearing, dietary restrictions, isolation (like C-diff or MRSA) and bracing u Check with the nurse and meet the patient

Get orders from the doctors Do a formal evaluation Often do eval with PT Do full ASIA exam Go in as a team and this helps avoid doing things twice Also getting them up for the first time is important to have a second member there to help If a person is a TBI and SCI often want a second person there too

Dysphagia Screening Massey Bedside Screen

Goes through some yes/no questions If you select yes on certain questions, it will prompt the person filling it out to get a dysphagia evaluation

Case Study: Mary } Client is an 84 y/o who lives alone; single family home. } Diagnosis of macular degeneration with distance acuities of 20/200 in the right eye and 20/100 in the left. } No recent falls; uses support cane. } Family (2 adult daughters) assist with transportation, shopping, finances. } Co-morbidities: hypertension, arthritis, mild hand tremor, hearing loss (wears hearing aids). A "typical" client Most clients are referred by ophthalmologist

Has macular degeneration- central vision loss 20/200- she can see at 20 ft what you can see at 200 ft Not legally blind Doesn't have as much trouble with safety as those with peripheral vision loss, so she's doing okay with walking Arthritis and hand tremor can make it hard to handle handheld devices Hearing loss can make it difficult to use audio devices

Compensatory Interventions Head Turn - Technique- turn head toward weaker or damaged side so patient is looking over their shoulder - Use for unilateral pharyngeal wall impairment or unilateral vocal cord weakness - Rationale- head rotation to damaged side twists pharynx and closes damaged side of pharynx so food flows down the more normal side

Head turns are more commonly used with neuro patients who may have unilateral weakness. >> So one side of their pharyngeal muscles may also be weak, causing material to build up on that side. >> But by turning your head towards the weaker side, the stronger side can take over and then clear that material from the pharynx.

Case Study cont. } OT Evaluation (SRAFVP) reveals difficulties in the areas of: reading (medication and food labels, menus, magazines), watching TV, seeing faces at church, setting the microwave. } Mars Contrast: mild-moderate loss of contrast sensitivity } MNread: 2.0M with current glasses: magazine headlines ok, but not the articles

Her top two goals were reading her tabloids and watching what her neighbors were up to

What types of patients have cognitive deficits? • Approach: Restorative vs. Compensatory?

How do we decide the approach? Depends on age and diagnosis Try restorative first, then do compensatory if necessary Potential for Neuroplasticity- we can affect cognition in a positive way So consider restorative!!

Some Cognitive Assessments Used by OT • Arnadottir OT-ADL Neurobehavioral Evaluation (A-ONE) • Assessment of Motor and Process Skills (AMPS) • Mini-mental state exam • Functional Independence Measure (FIM) • Saint Louis University Mental Status (SLUMS) • Montreal Cognitive Assessment (MoCA) • Behavioral Inattention Test (BIT) • Trail Making Test Parts A and B • Executive Function Performance Test (EFPT) • Kettle Test • Weekly Calendar Planning Task

How is this person doing with their cognition- we can do standardized and informal assessments

SCI Intervention (acute phase) u In ICU- Complete P/AA/AROM, work on grooming, begin strengthening, begin patient and family education, and monitor splinting needs. u Possible goal: the patient will participate in AA/PROM with bilateral UE daily to increase strength and ROM for future dressing tasks

If possible get them up to a chair Even if the person is really weak we can encourage AA/PROM and connect it to ADLs

Instant fails • Visual field cuts • Reduced attention to R/L side of body or space • Seizures in past 3 months

If somebody has any of these scenarios these are instant fails- we don't even screen them then Neurologically if any visual field cuts R or L cannot compensate for this - so an instant fail If they have reduced attention to R/L side - a lot of people can compensate pretty good for this but need to compensate very well in order to drive- most people don't feel comfortable with inattention and neglect Seizures in past 3 months are pretty much gold standard for not driving

Things to keep in mind with OT treatment... • We need to be client centered; negotiation of plan of care and therapy activities is necessary so patients have to have a sense of control over therapy activities • Physical pain seems to be worse when psych symptoms are not well controlled, and pain may be perceived as very severe as compared to similar patients without psych deficits. Poor management of symptoms may lead to discharge until psych symptoms are better controlled. • Patients with psych diagnoses sometimes have a heightened sense of touch so manual therapy can be difficult at times for them to tolerate.

If their psych symptoms are not well controlled, need to ask them about their medications People with psych diagnoses sometimes have a heightened sense of touch so manual therapy can be difficult So maybe it's a heightened sense of touch or it could be trauma- so keep this in mind Light MFR techniques may be more appropriate

Evaluation cont... u The evaluation is a wonderful way to develop rapport with the patient, the patient will buy into therapy more if he/she trusts you. u Introduce yourself u Explain the role of OT and any evaluations you may be completing as well as how long it will take. u Establish neurological deficits first with sensory and motor testing exam (ISNCSCI) u Assess ADLs and cognition as able u Involve the patient in establishing goals u Explain to the patient what future sessions will involve and what is expected of them. u Thank your patient . Whenever possible you should involve the family.

If you come in as a united front makes patient feel more comfortable 99% of people don't know what OT is - For someone with a traumatic injury you explain yourself differently - Often you are the first person to tell you what their injury means - Going in and saying this is what you see and right now you aren't moving these muscles we are going to work with you to make sure you take care of yourself as best you can using your working muscles and try to see if they will get further function - Prepare you to live this way but always looking for new movement in other muscles - You need to be honest and realistic - You don't know what is going to happen but this is what is happening right now and what you have to work with - Try to involve the family as much as possible

A picture of what we typically think of how people eat - Sitting upright in chair - At the table - In good position

In reality this is often what happens Shows you the importance of positioning b/c a lot of times swallowing safety is affected by how you are positioned So eating in this position puts this person at risk for aspirating and choking

Interventions for esophageal phase - Positioning - Referral to right providers, GI specialists Endoscopy Dilatation, Botox injections - Precautions with GERD Avoid laying down after meals Avoid eating 2 hours before bed

In this stage, peristalsis takes over which is an involuntary function - a wave like motion that pushes the food into the stomach - Actually, once it hits the esophageal phase, it is more of a GI issue - If symptoms are really disruptive, we may recommend a GI consult and they can complete further imaging or tests such as an esophogram an EGD - They can do dilations or Botox During our interview we will ask if they have been experiencing symptoms prior to hospitalization and finding out if they were on medications for acid reflux or GERD - And if they continued with those medications if they were taking them at home Since the esophageal phase is involuntary, we are not able to provide interventions to improve function - However, we do provide esophageal precautions like avoid laying down 30 minutes after meals, sitting upright, not eating 2 hours before bed, and trying to avoid spicy food and caffeine

How can you establish therapeutic relationships with these clients? • Don't downplay the client's perception of the seriousness of the complaints; be empathetic • Ask what clients would like to be done or how they believe the problem should be solved; encourage their participation in treatment planning • Explain changes in treatment ahead of time • Understand adherence is low, so try to make home exercises functional

Instead of giving shoulder flexion exercises- tell them I want you to put dishes away in a high cupboard and reach as high as you can

OT Intervention Approaches for Cognitive Deficits: Cognitive Compensatory Models • Goal Planning & Self-Awareness Approach (Doig et al., 2014 & Kehm 2014)(Continued) • Damon: bathroom modifications: https://videos.simucase.com/video/6121546186001 • Discussion: Do you see elements of this approach, and/or what could be changed to better fit/enhance the approach?

Internal strategy Damon: bathroom modifications Pt identified need for Grab bars higher Transfer seats Use bathroom you can get walker in No observation or trial The OT seems to be lecturing the patient There is a goal of making the shower more accessible for him In order to further this tx based on this approach- what could the OT do? What's the problem with this situation? It sounds like the pt has it all figured out But needs a boost of confidence and self acceptance of his condition the patient does not see the need for the adjustment Pt does not see how the falls are dangerous The OT could use a motivational interviewing technique The OT did acknowledge the pt's concerns but still emphasized importance of safety but did not go far enough- needed to involve the rest of the family Motivation is LACKING!! Doing MI could help get that goal solidified and help the pt with the process of remodeling the bathroom

OT Intervention Approaches for Cognitive Deficits: Cognitive Compensatory Models Goal Planning & Self-Awareness Approach • Method for increasing self-awareness of deficits • Patient is asked to: • Work with a significant other to determine occupational performance goals & predict their ability to reach the goals; • Do the work toward completing the goals; and • Compare the prediction to the actual goal attainment. • Goal is related to occupational performance • Therapist works with patient on the process of goal attainment, then helps them reflect on their ability to achieve it

Internal strategy In this approach, we are wanting to increase self-awareness and reflection

OT Intervention Approaches for Cognitive Deficits: Cognitive Compensatory Models • CO-OP • Guided Discovery: • "Remember also that each time one prematurely teaches a (child) something he could have discovered for himself, that (child) is kept from inventing it and consequently from understanding it completely." Jean Piaget • Four key phrases: (1) One thing at a time, (2) Ask, don't tell, (3) Coach, don't adjust, (4) Make it obvious • Requires clinical judgement regarding how much frustration the patient can tolerate for that "just right challenge" • Patient may engage in self-talk: move from talking out loud to inner talk

Internal strategy Originally devised by John Piaget- in relationship to children and motor learning - theory said children need to explore things for himself

OT Intervention Approaches for Cognitive Deficits: Cognitive Compensatory Models • Cognitive Orientation to Daily Occupational Performance (CO-OP) • "A client-centered, performance-based, problem-solving approach that enables skill acquisition through a process of strategy use and guided discovery" • Overall goal is skill acquisition (any type), (1) cognitive strategy use (GOAL-PLAN-DO-CHECK then domain-specific strategies), (2) generalization of learning (the degree that a specific skill, learned in a specific context, can be performed in another context), and (3) transfer of learning (the degree to which learning one skill influences the learning of another skill) • Ray - Hot Meal Prep Task: https://videos.simucase.com/video/6090083136001 • Discussion: Do you see elements of this approach, and/or what could be changed to better fit/enhance the approach?

Internal strategy Starts out with a cognitive strategy - (goal- plan- do-check) - Generalization and transfer of learning- is what we hope for doing this - Ray Hot Meal Prep Task - The OT did involve him and let him think - She did give him solutions - She did not deny his beliefs - she took more of an experiential approach (ex. He didn't agree about putting a lid on- instead said "let's try it out and see how it goes" letting him learn from the experience) - Supporting more of an experiential learning model - She did not correct him- she let him put twice as much water in the oatmeal but he added another packet of oatmeal - A lot of people insist they cook in a certain way - you have a choice- let them learn from that experience or are you going to let the cooking experiment fail and let them learn - In the video the OT said - How did you know that was the right burner? - Is there another way you could have figured that out? - Is there any other way? - The OT used this strategy pretty well in the video - When you push people to do novel tasks they never have done before, it can improve learning

Before the telehealth visit (AOTA 2020) • Know your patient and think of their abilities related to working with the platform -- can they have meaningful participation? • Send appointment reminders once when appointment is set, then on visit day • When reminding patient tell them what supplies to have ready for the visit • Encourage patient to set up for optimal viewing with lighting in front; avoid busy walls; pick a quiet location (both for patient and therapist); allow six feet around patient and therapist • Tell patient to put Ipad in a box

Is this going to work for your patient? Sending appointment reminders once appt is set AND on the visit day Remind patient to have supplies ready for the visit The patient can put their Ipad in a shoe box so they can carry it room to room if they need to

Food for Thought: Rehab Delivery Today • Some of these cognitive intervention approaches can be very effective but may take long periods of time to improve level of function • Rehab delivery in our current system tends to be directive rather than guided • Currently in the US we focus primarily on inpatient delivery of cognitive rehab which does not thoroughly address "mild" cognitive impairment ("walkie-talkies"); other countries do long term • "Mild" cognitive impairment, if not effectively treated (when possible), will result in clients not being able to return to desired occupations causing poor community re-integration and inability to return to PLOF

It can take a long time to improve one's cognitive function We don't have a lot of time so advocating for continued treatment is important We tend to direct and not guide which is not good Need to be advocates for tx of pts with Mild cognitive impairment

Silent Aspiration Silent aspiration can occur due to the client's lack of awareness of laryngeal entry and lack of ability to cough and clear residuals

Lack of awareness may lead to poor compliance by clients for use of altered textures or swallowing strategies magnifying risk of aspiration Silent aspiration is the most concerning, because as the word silent indicates, you can't hear it. - Some material may enter the airway and they may not have an awareness or be able to sense it and cough it out. >>This can be difficult because patients sometimes don't believe they have a swallowing impairment. >> So they may have poor compliance of the modified diet or swallowing strategies, ultimately magnifying the risk of aspiration.

ASIA scale

Look at the dermatome man and check every dot on the area Do light touch with cotton swab with flared tip Sharp/dull use a pin to have them determine b/w the two On the left side is the muscles Do this when they are first injured, first come to rehab, and when they are injured too

Scanning can be challenging during reading Low tech solutions= line guide

Low tech solutions- line guide- can be helpful for reading and using one's finger Basically a thick black bookmark helps keep eyes on the guide and pull attention to the line she is on If there is a lot of lines on the page, visual clutter can make it hard to focus So instead may use sensory substitution and use audio as an alternative option

Eccentric Viewing Training

Macular degeneration is the eye disase she sees most often Peripheral vision is preserved A loss of central vision Eccentric viewing - Teaches them how to use their peripheral vision The preferred retinal locus (PRL) is the site of best vision when the fovea is damaged. Eccentric viewing is the fixation of the fovea in one location in order to see using another part of the retina.

Equipment u manual chair, raised toilet seat or drop arm commode, slide board, tub bench, dig stick, suppository inserter *note all bathroom equipment should be padded to protect skin integrity.

Many paraplegics have manual chairs, but some use power chairs Power chairs make it a lot harder to get out of the home

Eccentric Viewing Training--Simulated view of a couple of blind spots- scotomas - damaged- right in central vision

Might be easier for a smaller scotoma Intervention is to help practice turning their eyes to the side or up Reinforcing and doing practicing and training Can help with reading seeing faces and objects

Intervention C5 u Continue previously mentioned activities. u Begin working on feeding and grooming with or without a mobile arm support (will need to use wrist support with utensil holder). u May be able to start working on UB bathing and dressing. u Can begin to work on typing and writing with adaptive equipment. u Work on strengthening shoulders and biceps. u May need long opponens splint. u Possible goal: The patient will feed self with use of wrist support, u-cuff, MAS (mobile arm support) and minimal assistance.

Mobile arm support (MAS) attaches to chair and acts as deltoid - helps them hold their arm up and bend elbow Opponens splint as preparation for recovered movement in the wrist - want to put thenar eminence in a good opposition position to encourage tenodesis

SCI feeding equipment

Mobile arm support is top left - rubber bands keeps arm up on a pivot point Plate guard keeps food from falling off Bottom left- a long straw for person to drink from the table Splinting material cup holders and handles Utensil holders with spoon

u At hospital: X Rays, MRIs, and CT scans are done to evaluated damage. If necessary surgical intervention is performed . Bracing may be needed to stabilize, including cervical collars, halos, TLSO(thoracic lumbo sacral orthosis) and LSO (lumbo sacral orthosis). Not all not all traumatic injuries require surgery or bracing (most commonly GSW) u Patients are usually allowed to get up with nursing or therapy soon after surgery.

Most common Sci that don't require surgery is Gun shot wounds - May have just broke one side of the spinal column - The swelling may be the thing that damaged the SC not the bullet directly - Important to know which kind of bracing and limitations they have - Make sure we know other precautions - A lot of time below surgery, we often will be in there doing ASIA before they go into surgery if involved in drug study

Neurological-Related Vision Loss } Same eval and intervention components } Organized scanning (visual skills) and environmental modifications are often the focus of treatment sessions } Prism glasses for diplopia (double vision) } Peli prism glasses for peripheral field expansion (hemianopsia)

Most of clients have eye disease Others have vision-related illnesses from stroke, brain tumor, etc. Any damage along the visual pathways can cause vision loss, visual perceptual problems Compensatory techniques at LV to help maximize safety and vision Eval is self-report Do the same self-assessment components More often with neuro-related vision loss it is usually peripheral vision loss- so scanning training is needed NOT magnification and environmental modifications are needed Double vision - prism glasses help correct these Peli-prism glasses- hemianopsia- lose half of visual field in each eye

Key Muscles u C1-3 Facial musculature and some neck muscles --will be vent dependent u C4 Upper trapezius, diaphragm -- can be weaned off of vent u C5 Partial innervation of shoulder, biceps

Mostly test key muscles to determine levels of injury C1-C3- will be vent dependent - typically don't survive at this level of injury C4- be able to move head and shrug shoulders- will be weaned off vent as diaphragm gets stronger C5- can shrug shoulder- biceps

Muscles of the Anterior Neck When you swallow, your larynx or voice box moves ANTERIORLY and SUPERIORLY- when that happens, the epiglottis inverts to protect your airway Muscles that are helpful in that anterior superior movement:??

Muscles that are helpful in that anterior superior movement: - Digastric muscles - Myohyoid muscle

National Dysphagia Diet Level 1- all foods must be pureed and thickened (if necessary) to a pudding-like consistency. It must be lump free and little or no chewing is required Level 2- all foods are moist, soft textured and easily chewed. Meats are ground and served with gravy or sauce. Cooked breakfast cereals and soft pancakes moistened with syrup are included in this diet. Tuna salad and egg salad are allowed. Some chewing is required. Level 3- includes most regular consistency foods but excludes hard, dry, sticky or crunchy foods. Food should be moist and in bite-size pieces. Dry breakfast cereals must be well moistened and meats must be tender. Lettuce can be served if shredded. Level 4- no restrictions FOUR levels of liquids: thin, nectar-like, honey-like, and spoon thick

National Dysphagia Diet Level 1- all foods must be pureed and thickened (if necessary) to a pudding-like consistency. It must be lump free and little or no chewing is required Level 2- all foods are moist, soft textured and easily chewed. Meats are ground and served with gravy or sauce. Cooked breakfast cereals and soft pancakes moistened with syrup are included in this diet. Tuna salad and egg salad are allowed. Some chewing is required. Level 3- includes most regular consistency foods but excludes hard, dry, sticky or crunchy foods. Food should be moist and in bite-size pieces. Dry breakfast cereals must be well moistened and meats must be tender. Lettuce can be served if shredded. Level 4- no restrictions FOUR levels of liquids: thin, nectar-like, honey-like, and spoon thick >> So these are the diet dysphasia diet levels that we recommend for patients. >> Level one is going to be those pureed foods. - So foods that require no chewing, like apple sauce, yogurts, puddings, mashed potatoes. Level two is mechanically altered, which requires minimal chewing. - So meats are going to be ground, foods are going to be covered in sauces, gravy, and butters to help with pharyngeal transit. - So foods are going to be really moist and have a soft texture. >> Level three is advanced. - More chewing is required. - The meats are cut up into small pieces, but they're still moist. >> And then it goes to level four, which is just regular. - And, and they are any, they have the mixed textures, a hard, dry, sticky, crunchy foods. >> And then the liquid levels are going to be: - thin or normal - nectar, which is going to be like a pancake syrup for like an egg nog. - Honey-like- Thick is going to be like honey consistency - And then pudding thick.

OT Intervention Approaches for Cognitive Deficits: Functional and Environmental Models • Neurofunctional Approach: Errorless learning • Functional task-training approach that focuses on learning specific functional activities through the use of behavioral techniques which reinforce procedural memory • Goal is to improve quality of life for the client and the caregiver, as well as increase participation in the community • Errorless learning (lots of repetition of correct performance, no trial and error) and external supports such as calendar use and time reminders (alarms) • Bethany - letter selection: • https://www.youtube.com/watch?v=udzayBtqc44 • Discussion: Do you see elements of this approach, and/or what could be changed to better fit/enhance the approach?

No trial and error Have poor learning, poor insight, severe cognition problems and safety concerns Included a delay between verbal reminder, and physical option and then verbal praise Doesn't let her take the wrong letter Errorless learning does not allow the person to make a mistake -that is the idea - stop them before they make a mistake

} Peripheral prism glasses for a client with left hemianopsia, providing about 30 degrees of visual field expansion into the blind left visual field.

Not a tool for reading, a tool for safe walking and safe navigation The client doesn't look through the prism, they are looking through the middle part of the lens This shifts things over a bit so the client catches things sooner It doesn't REPLACE scanning, but gets them in the habit of scanning sooner

Intervention C7 u Work on bathing and dressing (initially in hospital bed then in regular bed and shower) u strengthening of triceps, shoulders, wrists u Adapt self care items with hooks, built up handles and straps u Can begin working on homemaking tasks like cooking and making a bed with both C6 and C7 injuries u Can achieve independence with writing and typing with use of adaptations u Possible goal: the patient will complete w/c to tub bench transfer with minimal assistance.

Not much different than C6 but they have their triceps Goals like this need to consider who the patient is - a 70 y/o versus a 20 y/o may change this

Classification Normal function: The spinal cord carries messages from the brain to different body parts (including the skin) to carry out basic functions like movement or sensation. It also controls the autonomic nervous system which controls things like blood pressure, temperature control and sweating. Any damage to the spinal cord with disrupt this message.

Not really a muscle issue, it's that the muscles aren't getting messages from the BRAIN Say that normally the brain sends messages through SC to nerves and muscle So brain is outlet and muscles are the radio If cords are frayed or damage radio won't work= so radio itself works but the electricity is not there

OT Intervention } Education } Visual Skills Training (Eccentric Viewing, Scanning) } Magnification Devices (lenticular magnifiers, video magnifiers) } Relative Size Magnification (large print materials). Relative Distance Magnification (get closer). } Sensory Substitution (incorporating other senses to perform the task) } Environmental Modifications (Lighting, Contrast, Glare, Ergonomics) } Resources and Referrals

OT LV intervention encompasses all of these areas Where we start is education!!! Often client sees doctor for very short time and don't understand their disease Large button phone (relative size magnification) Relative distance magnification (getting closer to the TV) Sensory substitution- using hearing or speech (like a talking watch) Environmental modifications - help maximize vision and safety Telehealth is a new intervention due to COVID - Used it once Vision Forward closed in March - Was most helpful with the children - For older seniors- telehealth and remote services was really not accessible

Occupational Therapy Outcomes - Occupational performance- act of eating - Prevention/health and wellness- education - Health and wellness resources available - Quality of life- Satisfaction - Participation- engaged in feeding - Role competence- meet demand of role - Well-being- contentment - Occupational justice- meaningful occupation

Occupational therapy outcomes. So occupational performance, the act of eating itself Prevention, and health and wellness--So that would be where the oral cares education comes in. Health and wellness, providing them with resources on dysphagia and what they can do to decrease their risk of aspiration. >> Thinking about their quality of life, goals of care Participation, are they engaged in feeding? - >> Do they need support or adaptations? Role competence? >> Are they able to meet the demand of someone who is an eater? - someone who eats Well-being- are they content? >> And then occupational justice - Identifying if this is a meaningful occupation, which it is for most people. >> And so they're motivated to work towards the goals established.

Bladder and bowel function cont.. u Often have bowel problems - interventions include medicine, bowel program, timed voiding u types of bowel program: UMN- tone in rectum (may use suppository and/or dig stick and inserter) LMN- Flaccid (below T12)

Often have bowel problems About T10 and above, they will be considered an Upper Middle N injury- meaning involuntary tone and reactions is still there, so they will have the anus squeeze around an inserted finger So a suppository will be inserted to encourage peristalsis and use finger to stimulate rectum Versus LMN where rectum is flaccid - Need to have gravity help pull poop out - Need to have them lean and have someone help - Usually more accidents with LMN

Adaptive Devices

Often low-tech solutions are sufficient Adaptive tools for writing Stencil to keep writing straight Tactile leisure tools a lot of adaptive equipment Currency identifier - free through treasury department, small pocket sized- slip paper currency into slot and it reads it for you

Dysphagia Assessment and Evaluation Bedside clinical assessment Video fluroscopic swallow study Fiberoptic endoscopic evaluation of swallowing (FEES)

Once we get an order, we will always start with a bedside clinical examination During this evaluation first go through a chart review get an idea of what symptoms and issues they may be having, interview patient, family, caregivers, palpate a swallow, observe structures, and then go through some oral trials and make recommendations If further testing is warranted, we will proceed to a video swallow study - allow a more accurate and thorough picture of their swallow Typically estimate around 40% of our bedsides get videos but it depends ***The video is the gold standard b/c you are able to assess more accurately however the FEES can be helpful b/c it can be done at bedside for patients not able to leave their room

Dysphagia Assessment and Evaluation Bedside clinical assessment- patient interview and physical exam of the swallow and involved structures Video fluroscopic swallow study- identify aspiration/penetration, examine abnormal anatomy/physiology, and identify/evaluate strategies and compensations that may allow safe oral intake - May assess if a chin tuck if this would be able to help them eat more safe Fiberoptic endoscopic evaluation of swallowing (FEES)- endoscopic evaluation of the pharynx and larynx. Great tool to assess secretion management. - Another type of instrumental testing - A scope is placed in the back of their throat to visualize pharynx and larynx - A green liquid is swallowed to assess for aspiration

Once we get an order, we will always start with a bedside clinical examination During this evaluation first go through a chart review get an idea of what symptoms and issues they may be having, interview patient, family, caregivers, palpate a swallow, observe structures, and then go through some oral trials and make recommendations If further testing is warranted, we will proceed to a video swallow study - allow a more accurate and thorough picture of their swallow Typically estimate around 40% of our bedsides get videos but it depends ***The video is the gold standard b/c you are able to assess more accurately however the FEES can be helpful b/c it can be done at bedside for patients not able to leave their room

Why Screen for driving?? • Normal aging can impact vision, processing speed, inhibition, reaction time, task switching • Odds of crash involvement were 50% higher for older drivers reporting history of falls in past year

Only have 45 min to an hour to screen for everything Have to get through so much in a short period of time Important to screen driving b/c vision, processing, reaction time gets harder with age Increased risk of falling and crashing in older drivers

Importance of Oral Care - Decreases risk of developing aspiration pneumonia if aspiration does occur - Oral care= brushing all areas of the mouth - Important in nursing home patients - Poor oral health is correlated with an increased risk of aspiration pneumonia

Oral care is such a simple activity, but it's often forgotten or poorly completed. - But it's super important for preventing aspiration pneumonia. As I was saying before, we recommend our patients who are at risk of aspiration to complete oral cares as much as three to five times a day >> Many times patients will say that they brush their teeth or that nurses brush their teeth just before I came in. Then I'll look in their mouth and they have dried secretions or dried blood on the roof of their mouth. >> And it's really gross, but sometimes they'll just brush the front teeth and the bottom teeth and they'll call it good, but they didn't really accomplish anything. >> So education on the importance and reason behind frequent and thorough oral cares to the patient, family, nursing and PCA can help with adherence and compliance. >> It's especially important for nursing homes when they're weaker and they have a higher risk of aspiration. And there's less monitoring to check up on the frequency and the adequacy of oral cares. - And understandably poor health is strongly correlated with an increased risk of aspiration pneumonia. So patients with debility or weakness or who are, who are medically complex are going to be at higher risk.

Sexual Function u Men may have difficulty achieving and maintaining an erection as well as difficulty with ejaculation u Decreased ability to ejaculate contributes to fertility issues u Women can have decreased vaginal lubrication u In women, the reproductive health is not affected u Injuries above the T6 level are at risk for autonomic dysreflexia which can lead to a dangerous spike in blood pressure u Bowel and bladder issues need to be addressed before and during sex (may have to cath prior or manage foley tubing during) u Positioning can be a challenge, however there are many commercially available positioning devices

Part of it is that they are sitting in a chair all the time it gets really warm and decreases the sperm count Women with new SCI can get pregnant right away And men with new SCI can get a woman pregnant right away At a greater risk of autonomic dysreflexia during sex Bowel and bladder need to be addressed before and during sex Positioning devices are commercially available

Structures of the Esophageal Phase of Swallowing- the last of the swallowing phases How long does food take to travel from the esophagus to the stomach

Passage of food takes b/w 8-20 seconds to travel from the esophagus to the stomach

Clinical Bedside Assessment Past medical history and current status Respiratory status Laryngeal examination Oral examination Oral Intake Trials Recommendations

Past medical history and current status Respiratory status Laryngeal examination - Volitional swallow: laryngeal excursion; vocalizations; strength of throat clear - Palpate this by putting finger over the Adam's apple and feeling the range of the laryngeal rise - If it feels delayed or if it is quivering it gives us an idea that maybe there is some weakness - Encourage vocalization and note the strength of their voice and their throat clearing - Sometimes after being intubated for an extended period of time, patients are hesitant to use their voice- nurses, family, are answering questions for them - want the patient themselves to respond and use their voice Oral examination - Tongue; lips; cheeks; jaw; sensation; velar function - Looks at ROM and strength of the tongue, lips, cheeks, and jaw - Also testing sensation and velar function- which is soft palate and the arches in the back of the throat - To test this have patients say "ah" - Assess how high it rises- does it reach full range or is it reduced Oral Intake Trials - Liquids; puree; solids - Depending on info gathered and how it is going, will determine which texture they start with - If it seems like they are going to have more difficulties you start with more conservative, thicker textures and work towards thinner - But this is very patient dependent - If it doesn't seem they are safe on any textures, then we will recommend NPO - We will proceed to a video swallow study as appropriate Recommendations - Need for instrumental assessment? This breaks down the bedside assessment a little bit further - You go through a thorough history - Then you go through different vital signs like respiratory rate (b/c you have to hold your breath momentarily when swallowing it can be difficult to coordinate if you are breathing really quickly)

Complications cont... u Pain: Persons with SCI can present with a wide variety of pain, including nerve pain, shoulder pain and pain at surgical site. Intervention for pain can include medicine, heat, cold, massage, deep breathing, pain patches u It is important for the therapist (along with the rest of the rehab team) to help educate the patient about complications as well as alert the doctors when signs are noted. u Remember every patient experiences complications and neurological function differently- classification is important, but we must look as each case as a person not a level

People always have pain from injury and surgery There are different types of pain - Burning constant pain= nerve- tx with medicine - Shoulder pain- b/c overuse of shoulders with transfers - so need to balance this out by using their back too - Pain at surgical site - Big push to wean people off narcotics ASAP - Need to have patient's the experts in their condition - so they can educate their non-SCI healthcare team and family/caregivers

Dysphagia in the Pharyngeal Phase - Coughing/choking during or after swallowing - Noisy swallow, frequent swallows - Inability to swallow when ready and wanting to (so bolus is prepared in the mouth but they can't get it to go) - Swallow delay > 10 seconds (will see this in dementia patients where it just takes a while to initiate it) - Food "catching in throat" - Food "doesn't want to go down" (may be more of an esophageal issue but can sometimes be in the pharyngeal area if there is significant weakness or structural abnormalities) - Wet, gurgly, or hoarse voice or breath sounds (can indicate material sitting on the vocal chords making that audible noisy swallow) - Frequent or excessive throat clearing (may happen when food is just sitting on vocal chords) - Poor secretion management (patients may sound really junky b/c they are not able to clear their secretions) - Regurgitation of food, nasal regurgitation (this can happen if there is inadequate soft palate elevation and nasopharynx closure)

Pharyngeal phase starts once swallowing is initiated and happens in less than one second The most common or well known symptom of dysphagia is coughing or choking after swallowing

Feeding Adaptations

Plate guards Built up handles The idea is to help them become as independent in feeding as they can

Phases of the Normal Swallow

Pre-oral, Oral preparatory, Oral, Pharyngeal, Esophageal 3 main phases of swallowing: oral, pharyngeal, and esophageal But we like to look at pre-oral and oral preparatory as OTs- b/c these can play a large role in pt's ability to participate in eating and drinking

Driving Screen • Rapid Pace walk- Norm >9.0 seconds= intervention • Begins in standing, walk 10 feet, turns and comes back as fast as can • ROM and Strength- Adequate and pain control for operating car • Neck- look over shoulder to count fingers 10 feet behind pt • AROM- finger flex, shoulder flex, elbow flex, Ankle plantar/dorsi • Strength- Shoulder add/abd, flexion, wrist flex, grip, hip flex/ext, ankle • Trails B- • Criterion- 100% accurate or 1-2 errors <90 seconds • Clock Draw- Norm: All numbers correct and hands to correct position • MoCA- Norm 26 and higher • MVPT: 58/65 Criterion • Brake Reaction Test • Average of 20 trials must be equal to or less than .70 seconds • Clinical Observations ( Presentation, overall behavior, awareness of challenges, compensations used) • Dynavision (balance, reach, scanning, attention, strategy, memory • 193 targets in 4 minutes is WNL

Rapid pace walk - Have them walk 10 feet, stop turn around, and come back as fast as they can If they can't walk fast and can't move their neck as fast, everything kind of plays together to determine driving safety Need adequate ROM and pain control in order to operate car - If patient has a neck brace on it doesn't prevent them from driving but may limit this - Ankle plantarflexion needed for gas pedal - Trails B test - will do Trails A first to understand directions but only grade Trails B - goes number to letter, number to letter - Clock draw- need to be able to draw a clock and place hands in place correctly (ex. "Put clock to ten past eleven") - MoCA - MVPT - Brake reaction test - If we have 20 obstacles need to be able to stop within 0.7 seconds or below - this is very functional - Clinical observations noted in chart- denial of driving challenges is a red flag - note this to make awareness of driver safety - Sometimes people use their cane to drive with their foot- this is not safe - we need to document this - Dynavision - have to on a lightboard have 4 minutes and have to hit 193 targets - Remember it is a COMBINATION of things that disbars them from driving

What do we do about these deficits? Intervention Approaches for Cognitive Deficits • Approaches • Neuroanatomical-based: treatment protocols that target specific dysfunction -- unilateral spatial neglect (OT, others) • Restorative/remedial approaches: improve cognitive deficits such as attention and memory, assume transfer of learning (neuropsychology) • Cognitive Compensatory: focus on acquisition of processing strategies and retraining, use assets to achieve successful occupational performance (OT, others) • Functional and Environmental: modify the task and/or environment to reduce impact of cognitive deficits and enable optimal participation in meaningful occupation (OT, others)

Restorative/remedial approaches -Like basic deficits like attention and memory and assuming transferring of learning- memory drills for attention and improving base skills ***Where OT comes in more= cognitive compensatory - use assets to achieve successful occupational performance AND functional and environments- modify task/environment Will focus on cognitive compensatory and functional and environmental strategies

SCI Statistics As reported by the Spinal Cord injury information network u Incidence: Approximately 40 cases per million in the US or 11, 000 new cases a year. 52% are defined as paraplegia and 47% tetraplegia. u Prevalence: 253,000 people living with spinal cord injury in the US (reported cases) u Age of injury: average age at time of injury is 31 years u Causes of Death: years ago the leading cause of death was renal failure. With recent advancements in urologic management, this has shifted to pneumonia, pulmonary embolism, and septicemia

SCI isn't super prevalent in the US compared to stroke Stroke is about 70,000 per year compared to 11,000 of SCI Used to be younger age of injury Causes of death used to be renal failure but now a lot of bowel and bladder management -***People are living a lot longer with SCI

AOTA Practice Framework - Inability to swallow negatively affects nutrition, overall health and quality of life Swallowing/eating- keeping and manipulating food or fluid in the mouth and swallowing it; swallowing is moving food from the mouth to the stomach Feeding- setting up, arranging, and bringing food (or fluid) from the plate or cup to the mouth; sometimes called self-feeding

SLPs are majority of people who work in speech and swallowing - OTs used to be a lot more involved in this, working to bring this back - Need to gather evidence to solidify our stance in this area b/c we have a big role in this and it is in our OT practice framework Often OTs only address self-feeding but it would be beneficial for OTs to go through the whole process with patients and not just leave it to SLP

Types of Cognitive Deficits: Review • Remember that safety and functional independence can be impaired as a result of cognitive deficits; supervision may be needed • Maladaptive behaviors can be associated with cognitive deficits; consider impulse control (initiation, motivation, aggression)

Safety and functional independence can be impaired b/c cognitive deficits Cognitive pts tend to fall through the cracks- look physically fine but not cognitively Maladaptive behavior is often associated with cognitive deficits- emotional response comes out of frustration with poor cognition Lewy bodies can get very agitated b/c they aren't understanding what is going on, may try to hurt people

Dysphagia Screening Identify risks by assessing the signs and symptoms of swallowing difficulties/aspiration - Used to determine if further evaluation is indicated Dysphagia screening and early intervention have been shown to reduce patient and hospital costs

Screens - Gugging swallowing screen - Self-report symptom inventory - Massey Bedside Screen - what is used at Mayo - EAT-10 - Functional Oral Intake Scale

Case Study for discussion: Mary Jane • Diagnosis of frozen shoulder of uncertain etiology and CRPS; presents as if she has an anxiety disorder but does not have a diagnosis of this • Has difficulty being touched; sometimes yells or screams during therapist PROM (refuses AAROM); must be treated in a private treatment room due to this • Hot packs are the only modality she can tolerate (TENS not possible due to seizure history) • Nurse practitioner has given her very limited pain meds

She would yell and scream during PROM but wouldn't help with AAROM Had to treat her in a private room Washburn contacted her Nurse Practitioner about not giving her pain medicine - NP explained she didn't give her meds b/c her drug screen was positive Can only disclose test results if patient is already aware of the results Our medical system does not take a holistic view of patients Does not acknowledge her anxiety Washburn made psychosocial progress not so much physical

esophageal phase is involuntary

Since the esophageal phase is involuntary, we are not able to provide interventions to improve function - However, we do provide esophageal precautions like avoid laying down 30 minutes after meals, sitting upright, not eating 2 hours before bed, and trying to avoid spicy food and caffeine

Assistive Computer Technology

Smart speakers Text to speech tools Help work with smartphones, tablets, and computers Most computers have these features built in so clients don't have to buy additional software

Re-evaluation and Plan Modification or Discharge - Needed to make sure diet recommendations are most appropriate - Assess if there is a plateau in progress - Assess for any further symptoms of aspiration - Compare level of performance

So re-evaluation, a lot of times after we establish the diet modifications, we will continue to check in and monitor their meal to make sure there's no signs of aspiration. >> If need be, we'll repeat a video swallow and upgrade their diet as appropriate. We reassess if there's any plateaus in progress and observe for further symptoms of aspiration to determine if there needs to be an adjustment in the recommendations or compensatory strategies. And then we compare the level of performance from the initial evaluation to their current performance to assess for progress.

What can we do with telehealth ot? • Using telehealth, there are five types of service which occupational therapy can provide (AOTA 2020): • Evaluation • Consultation • Supervision • Intervention • Monitoring

So what can we do with telehealth OT? Doing all the same stuff we do in-person but it is a little more complicated b/c you are not physically there with the patient

This is what a normal swallow looks like on a video SWOT study. >> So the black portion is the barium that contrast that they swallow. >> And you could see the different arrows pointing at the structures rising and closing off appropriately. >> But on the video, it happens really quickly. So these images just help slow it down and take a closer look at what's happening. >>

So, in slide three, you can see the epiglottis inverting and the material coming and passing through. >> So this is what it typically should look like. >>

Acute phase cont... u On floor: Patient may start getting up. Will need to work with PT to assess for appropriate temporary chair. Sitting tolerance will be poor and increasing this is one of the most important goals on acute. u Continue to work on grooming, eating (if diet allows), strengthening and ROM. u May start working on bathing and dressing in hospital bed with HOB up. u Possible goal: patient to tolerate sitting in wheelchair for 2 hours to increase activity tolerance for self cares

Some hospitals OTs do seating A lot of time vendors loan out temporary chairs to patients Sitting tolerance will be poor need to increase this Bathing and dressing with head of bed up Really need to work on tolerance b/c once they come to therapy they need to do 3 hours of therapy

Complications cont... u Spasticity: An involuntary muscle contraction below the level of injury resulting from lack of inhibition from the brain. Spasticity can be good by helping to maintain muscle mass increase blood flow, as well as assisting with bed mobility. However it can also be a bad thing if the spasticity inhibits movement, interferes with function or decreases ROM. u Management includes medication, Botox injections, nerve blocks and baclofen pumps.

Spasticity can be a good thing to maintain muscle mass and blood flow but could be bad if it impairs movement and function and decrease ROM - making muscles really tight or making transfers dangerous

Contrast and Safety

Stairs Railings - don't always line up with stairs Contrast can impact safety Bringing in some non-skid tape or paint Contrast is so important Acuity readings don't often determine one's functioning "Of course I can see the eye chart b/c it is perfect B&W but I can't read my local newspaper b/c it is much grayer)

Performance of driving Three levels of driving • Operative • Tactile • Strategic Strategic Skills • Planning and making decisions before the trip

Strategic Skills • Planning and making decisions before the trip • Route • Trip sequence • Stops • Traffic risks • Climate • Associated costs • Seeking help if lost • Involves judgement planning and insight Strategic= Can they find their way, do they only go to the grocery store, how do they plan their trip, can they account for a change in trip sequence Do they realize how much gas costs, can they afford to drive their car

Key musclesparaplegia u T2-9 External intercostals, erector spinea u T10-L1 Fully intact intercostals, external obliques, and rectus abdominus u L2-5 Fully intact abdominals, all other trunk muscles, and leg muscles -Depending on level L2 - hip flexors L3- Knee extensors L5- long toe extensors L4- ankle dorsi flexion, S1- Ankle plantar flexors

T2-9 - external intercostals and erector spinae T10-L1- can't really test this muscle wise so will test via sensation on ASIA exam L2-L5- leg muscles come in here Test the WHOLE body-leg muscles as well - b/c want to know how they function

Performance of driving Three levels of driving • Operative • Tactile • Strategic Tactical Level • Making Decisions in traffic

Tactical Level • Making Decisions in traffic • Adapt speed • Obstacle avoidance • Gap acceptance • Obeying traffic signals • Changing lanes, turning, passing • Reaction to detours, construction • Adjust to conditions (weather) • Involves impulse control, judgement, flexibility Tactical - Can they make decisions in traffic -can they maneuver obstacles, adjust speed How close do they get to the car in front of them Are they impulsive, are they sound in judgment, and flexible in their thinking

OT Intervention Approaches for Cognitive Deficits: Cognitive Compensatory Models • Transfer of acquired strategies to daily function must explicitly and gradually be part of the training • Primary emphasis on a person's current cognitive abilities, which are used to improve broader aspects of function • Strategic learning to overcome deficits and allow goal achievement and improvement in executive function • May require some insight, motivation and ability to learn for these models to be successful; patients tend to underestimate the level of cognitive impairment and overestimate their level of function • Can use a mix of internal and external strategies

Taking real situations and real things that the pt does in their daily life as part of the training Primary emphasis on pt. current abilities Try to broaden that to wider skills for function Do a strategic learning May require insight- definitively require motivation and ability to learn

OT role with spinal cord injury Part of a team u It is extremely important to have a team approach when dealing spinal cord injury. There are many needs post injury, and it takes many disciples to meet them. The team may include (but is not limited to) the following: Occupational therapist, Physical therapist, Speech therapy, Recreational therapy, therapy techs, MDs, nursing, psychologist, Psychiatrist, Social work, Case manager, Vocational counselor, DME coordinator, wheelchair vendor, chaplain, peer counselor, Family and patient.

Talking to psychologist b/c may be more prone to risk taking behaviors from coinciding brain injuries Often brain injuries go unnoticed- so do screening to get them to diagnosed Upwards of 80% of SCI have undiagnosed mild to severe brain injury

Task Lighting

Task lighting is a big factor when maximizing one's remaining vision Intervention is often home visit and adjusting lighting Lighting - ambient (general room) and task lighting Want to educate pt on the difference- want them to know general ambient lights are not sufficient for reading Need higher levels of illumination for reading LED lamps are dimable and you can adjust light brightness Lighting can affect magnification recommendations- proper task lighting can often help them need less magnification

What is Telehealth? • AOTA defines telehealth as the application of evaluative, consultative, preventative, and therapeutic services delivered through information and communication technology. • Occupational therapy practitioners can use telehealth as a mechanism to provide services at a location that is physically distant from the client, thereby allowing for services to occur where the client lives, works, learns, and plays, if that is needed or desired. • Most insurance companies require you to be working in a real time, synchronous video format with clients in order to charge for OT using telehealth (WOTA, 2020) Terminology: "distant site" is where provider is

Telehealth can't be in emails back and forth- it is required to be in a synchronous format to be covered "distant site" - the OT provider's location- You are distant relative to the patient so your site is the distant site

Neurological levels Neurological damage: Depends on the location and severity of injury tetraplegia (quadraplegia) vs. paraplegia

Tetraplegia: results from injury to the cervical area of the spinal cord Paraplegia: Results from injury to the thoracic region and below

Pharyngeal phase starts once swallowing is initiated and happens in less than one second The most common or well known symptom of dysphagia is???

The most common or well known symptom of dysphagia is coughing or choking after swallowing

Physical Dysfunction with Psychiatric Co-Morbidities • "It is more important to know the person who has the disease than to know the disease the person has." ...Hippocrates

That might be kind of opposite of how we usually operate We always talk about different diagnoses and what they can mean for people's physical functioning True for every patient but especially for people with psychiatric comorbidities Have to know the person and tailor your tx more than ever to their disabilities they are presenting to you

Driving simulation video:

What a driving simulator looks like We note if they use their cellphone for directions b/c we don't want them to be looking at their phone while driving

Medical management(for traumatic injuries) u At site of injury: Person is stabilized on a firm board with head and neck supported, taking special care to cause as little movement as possible. An anti-inflammatory drug as well as steroids is administered to minimize swelling and prevent further cord damage.

This would not be us, more the EMT people A lot of time the swelling and movement after the injury hurt the SC more than the injury itself

Compensatory Interventions Throat Clearing - Technique- do an effortful throat clear followed by a purposeful swallow - Use to clear small amounts of airway penetration above vocal chords and to clear vocal cords - Rationale- the vocal cords are designed such that a throat clearing contraction helps to clear secretions in an upward manner thereby protecting the airway from aspiration

Throat clearing- If they have a strong cough, or throat clear, we can have them perform this after every swallow or maybe after every couple swallows. >> And it can help clear secretions and then helps protect the airway as well.

Legal restrictions for OT use of telehealth lifted due to COVID-19 • Occupational therapists in the US are now allowed to deliver telehealth services to Medicare patients because of the COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers: https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf • Occupational therapists in Wisconsin are now allowed to deliver telehealth services to Medicaid patients per a Forward Health temporary COVID-19 waiver: https://www.forwardhealth.wi.gov/kw/pdf/2020-15.pdf • Private insurance makes their own decisions re: telehealth • Most waivers allowing telehealth currently are temporary; AOTA and WOTA are lobbying to make these allowances permanent to better serve rural communities

There has been a temporary lifting of restrictions When we get through COVID these waivers will probably be lifted and may not be able to do much telehealth at all These waivers are in place Medicaid put a waiver in for telehealth Certain private insurances do not allow telehealth AOTA is lobbying to make telehealth a permanent treatment option

Comorbidity of mental and physical health problems • Physical and psychological symptoms increase together; as an example people who have depression and anxiety tend to have more physical symptoms, e.g. mind-body connection • In a recent study it was found that of the top 10% high utilizers of medical care one half carried a psychiatric diagnosis • Psychiatric and medical pathologies interact prominently in the case of pain disorders

There is a bad interaction b/w physical and psych issues Psych and physical symptoms INCREASE together- "depression hurts" - mind body connection - when people have psychological issues that are out of control and affect their daily life, their physical symptoms are worse too - their pain is worse too These symptoms go up and down together The brain is the boss of everything - the boss of physical and mental health symptoms

Videofluoroscopic swallow study - Most common used instrumental tool used - Use of fluoroscopic images are seen with use of barium added to a variety of food consistencies when swallowing - Performed in a radiology suite with a radiologist present along with occupational therapy

There will be a camera that is pulled right alongside the patient and the radiologist is in charge of controlling the camera and capturing the images - We as OTs are the ones instructing the exam so we are picking which consistencies, how much, and which compensatory strategies to trial - Then we chat with the radiologist about what we are seeing if there is any penetration or aspiration - And then from there we formulate our treatment plan and make recommendations

Medullary Swallowing Center Stroke Impairment of sensation and movements in areas of: - Posterior oral and pharyngeal muscles - Laryngeal elevation and adduction - Pharyngeal constrictors - Upper esophageal sphincter opening

These can be very significant b/c it controls sensation and movement in the posterior oral and pharyngeal muscles If you see impairments in this you may see retention in the pharynx b/c the swallow is weak and ineffective in clearing it out UES sphincter may not fully relax so there may be a pooling above in the pyriform sinuses and spill into the airway causing the person to aspirate

How can you establish therapeutic relationships with these clients? • Build mutual respect and trust • Provide simple instructions, tailored to patient • Let client talk without interruption • Be client centered and do not blame them • Develop and convey positive regard for the client • Give undivided attention to complaining clients • Be flexible with the client

Tips to think about with patients These could be used with any patient- but are particularly important with pts who have psych issues A lot of times with patients are treated badly by society These people are more likely to complain to you They need to be heard You want to be flexible

Skin breakdown

Tissue in middle is super unhealthy there Want pink clean healthy issue Wound is tunneling and going under the skin to the bone

Compensatory Interventions Tongue holding/Masako Maneuver - Technique- hold your tongue between your teeth and swallow - May help strengthen muscles at the back of your tongue and throat - Better soft palate movement

Tongue holding or Masako maneuver is intended to improve tongue based retraction. >> So when the tongue base contacts the pharyngeal wall, it adds force to the swallow. >> For this exercise, you would hold your tongue between your teeth and then swallow hard. >> This one shouldn't be used while eating or drinking. >> It incorporates a couple steps, so it can be hard and at first it feels a little, a little funny, but once patients do it a couple times, they're more comfortable with it and are able to adhere to it better.

Pharyngeal and Esophageal Structures of Swallowing --This is what view we would have on a video swallow

Tongue is a big muscle - Soft palate is above this which closes off nasopharynx - Epiglottis flaps over and closes off airway - Larynx is starting into that airway - Trachea - UES and then that's where esophagus starts

SCI bathing equipment

Top left is quite expensive Top right - Raised toilet seat is very good for people to do their own bowel program b/c this has no bars on the side so it makes it easier to reach Bottom left Bottom right- standard rolling shower commode

SCI cuff equipment

Top right is a utensil holder to hold if they have no grip for spoons, forks, toothbrush for people WITH wrist movement Handles on toothbrushes, phones - people with WRIST movement Cuff on shoe to prevent heel from collapsing while putting shoe on

How to Perform a Video Fluoroscopic Swallow Study OT assisting with swallow study Radiologist helps run machine Patient is getting a swallow study after coughing following taking sips of water They tried some thicker liquids b/c the consistencies are easier to control in their mouth- nectar was still troublesome but honey went a lot better - Explained that she will be drinking liquids of different consistencies (thicker to thinner) with barium and watch it go down her throat - And food soft to harder Use shoe horns with metal labels to show consistency as a reference when going back and reviewing the videos

Typically we can gather the information we need from the lateral view but sometimes we like to see the AP (anterior posterior) view, this view can be helpful to assess pooling in the pyriform sinuses and trialing of compensatory strategies such as the head turn and tilt Testing varies by setting and can even be set up like a meal Video swallow studies are not only used to confirm penetration or aspiration, they can also be used for practicing compensation techniques and assessing areas of dysfunction in order to prescribe the most appropriate exercises - When determining if compensatory strategies are appropriate it is important to determine patient's cognition to ensure follow through with recommendations

Intervention C3-4 u Instruct patient in direction of PROM, as well as daily cares. u Instruct caregiver in PROM and how to use proper body mechanics during daily cares (including transfers, bathing and dressing), u educate the patient on available technology as appropriate. -- mouth stick, computer programs (dragon dictate, eye gaze, head control) u Facilitate in teaching with chosen power chair (head control or sip and puff) u Educate patient on his or her injury especially how to recognize complications u Facilitate any new muscle movement through use of modalities (e-stim, vibration, tapping, use of skateboard or slings) u Monitor for splinting/casting needs. u Possible goal: The patient will independently direct 8/8 PROM exercises for BUE to increase range for ease of cares.

Use voice controls on phones In-motion robot is an adaptive program that helps them like a skateboard Can also hook them up to functional E-Stim

Ms. Shoulder • Would rather talk about politics than do therapy (anxious) • Had low tolerance for AAROM, AROM was much better tolerated; pain levels were very high • Suggested techniques: deep breathing, pain meds prior to exercise worked to a certain extent • Would wake up at 4 AM on therapy days worrying about the impending pain from the OT session

Using politics as a procrastination technique b/c she had so much pain Her anxiety really centered around the pain in her shoulder Had very low tolerance with AAROM- she would not let Washburn do PROM She would physically stop her b/c she was worried about how much it would hurt AROM was much better tolerated but pain was still high Instructed pt to take meds before which she did but still had high pain Washburn instructed in non-pharm pain management- Imagine yourself on a beach, encourage deep breathing Would wake up at 4 am on day of therapy worrying about pain

SCI Statistics u Gender: 82 % of reported cases are males u Ethnic groups: 63 % of injuries are Caucasian, 22% African American, 11.8% Hispanic, and 2.4% are of other origins u Discharge: 89 % of all persons with SCI are discharged to home, 4.3% are discharged to nursing homes and the other to group homes or other types of institutions

Usually a lot more males with SCI- this is especially b/c of risk taking behaviors- motorcycles, gunshot wounds, tree stand falls 63% white A lot of black gun shot wounds in summer 89% are discharged home- this is Froedtert's goal -but may send them to subacute b/c of making homes accessible

SCI equipment for women toileting hygiene

Usually for ladies too Asta cath- has three holds- urethra and vagina - 2 holes So may accidentally get into vagina which is not good Lines this right up to urethra to cath a lot easier This is a cath spreader and mirror- it holds legs open b/c of increased tone and a mirror to see

Near Magnification Where they spend the bulk of their time at Vision forward- near magnification is the most requested vision service

Very client centered goals Usually reading is the top goal!!! - Usually medication label reading - And leisure reading - Do training with recommended devices - Top left hand corner is handheld magnifier- good for brief reading or spot reading- good for price tag or meds bottle- NOT paragraph reading - Going over pros/cons - Being realistic that one device won't do everything for them - Others are designed for paragraph reading- the bulky one that can rest on the page- good for people with tremor - Picture of man - is strong powered glasses - The stronger the reading lens, the closer you have to put the glasses to the page - Usually too close and uncomfortable - Top right is handheld portable electrical magnifier- better for spot reading - A much bolder image, higher contrast b/c it is electronic- adjustable not locked into one power - Very adjustable and can change as vision changes - Desktop magnifier- attached reading tray, 24 inch display - Better for paragraph reading - Funding is very important!!!! - $400-3,000 At vision forward, they can lend out devices

OT Intervention Approaches for Cognitive Deficits: Cognitive Compensatory Models • Multicontext Treatment Approach (Toglia et al., 2011): • Four main components: (1) consideration of personal context and use of everyday activities; (2) an emphasis on self-monitoring and self-awareness, (3) strategy self-generation and training, and (4) practice across multiple activities and contexts, emphasizing similar elements • In practice, look at similarity of one task to another and gradually decrease similarity as patient progresses (but draw attention to any similarity) • Damon: Meal Prep: https://videos.simucase.com/video/6121545401001 • Discussion: Do you see elements of this approach, and/or what could be changed to better fit/enhance the approach?

Want them to self-monitor and develop self-awareness Develop own strategies and training Practice across contexts to help learning Damon meal prep In the multicontext approach Occurring right in his home environment which is really important and true to the approach therapist compared taking cereal out of high reaching places like he reaches for dishware Pt could have done better with self-awareness --- said everybody breaks plates, but may not be aware that breaking 18 plates is excessive Therapist gave him some ideas- is that consistent with this model? Tx wasn't super consistent with the model- the OT was making decisions for the client ---OT could have encouraged problem solving Encourage self-awareness and how he could adjust things for himself

OT Telehealth legal issues (wota 2020) • HIPAA compliant telehealth platform is normally required (e.g., Zoom has a HIPAA compliant version available) - due to COVID-19 public health emergency this has been waived for many plans • Informed consent is required (must sign a legal document; good for 1 year); includes permission to record, confidentiality agreement, patient right to withdraw at any time; and risks, consequences and benefits of telehealth visits • Therapist and client usually must be in the same state, and/or therapist must have a license to practice in the state where they are located AND where the client is located • Certified OT Assistants still must be supervised, but this can be done within the telehealth platform (AOTA 2020)

We are supposed to have a HIPAA compliant platform Right now we could do telehealth on our phones IN THEORY - but typically need a HIPAA compliant platform - this has protections in place to make sure people can't hack into your information So the therapist could dial in to supervise the COTA

Dysphagia after Cerebrovascular Events - Treatment will vary depending on location of stroke - Right parieto-temporal infarcts: sensory and attention deficits - Left middle cerebral artery infarts: buccal - Right or left precentral gyrus: motor function of lips, cheeks, and tongue

We know a stroke in the frontal lobe will impact executive functioning so someone may have difficulty with problem solving Temporal lobe houses comprehension of speech - so person may not understand prompts or cues provided Brainstem strokes can result in significant swallowing impairments b/c It involves swallowing centers

Recommendations • CDRS (certified behind wheel specialist) for behind the wheel • Driving assessment, recommendations, adaptations, training • For a list of Certified Driving Rehab Specialists (CDRS) go to www.aded.net • Out of pocket • DMV Test • Patient had recent accident or violation that prompted a Medical Examination Card/ Condition & Report Behavior • Patient lacks awareness of deficits and believes that they can pass without difficulty. • Minimal to no charge

We look at everything together - not just one specific deficit SCI patients often need to get adaptations from CDRS to use hand throttle

Possible Interventions Following the Clinical Dysphagia Evaluation - Instruction in good oral care routine - Compensatory techniques/exercise - Further assessment needed

We recommend for patients who are at risk of aspiration to brush their teeth three to five times a day because bacteria grows in their mouth super fast. And so having a clean mouth reduces the bacteria and germs and reduces their risk of developing aspiration pneumonia. And then also educating on denture care. >> A lot of our patients have dentures and we'll have them in their mouth for multiple days without taking them out and cleaning them. And actually the best way to clean them is to treat them like a dish. >> So take them out and scrub them with any antibacterial soap and then keep them in water so they're moist, just like the oral cavity environment. It's also best for the gums to have a rest for at least six hours a day from wearing the dentures. >> So some patients will take them out at night to get that six hours of rest - Compensatory strategies such as the chin tuck can sometimes be helpful for closing off the airway. - And then lastly, determining if a video swallow study if needed for further assessment of the swallow.

Penetration/Aspiration Scale - Level 1 not in airway - Level 2 enters above vc, w/o residue - Level 3 above vc with residue - Level 4 contacts vc w/o residue - Level 5 contacts vc with residue - Level 6 passes glottis w/o residue - Level 7 passes glottis, residue with response - Level 8 passes glottis, residue w/o response

We use a penetration aspiration scale to categorize the level of impairment based on their video swallow results. So you select a level for each consistency you trial. - So level one is no material enter the airway. >> - And then level eight, the material passes below the level of the vocal chords and there's no response. >> So no coughing or throat clearing. >> - So this would be level eight, would be silent aspiration.

IrisVision (wearables)

Wearables- you are wearing an electronic magnifier Pros- you get near, middle, and distance magnification in one device Cons- costs, kind of clunky and bulky, cannot walk with it on Essentially an android phone repurposed as a magnifier- Locks into VR goggles A pt used it with sheet music

Complications cont... u Orthostatic hypotension: Lack of muscle tone in abdomen and legs leads to pooling of blood and decreased blood pressure. Can cause dizziness, nausea and loss of consciousness with change of position. If this occurs the patient should be tipped back with legs elevated till the symptoms subside. May diminish over time but can be managed with TED hose, leg wraps, abdominal binder and medications. u Sexual dysfunction- males may have difficulty with erection as well as fertility however, female fertility remains intact.

When we are moving patients at first take it SLOW!! Raise head of bed up first before moving them to normalize blood pressure Exact opposite of autonomic dysreflexia!! So treat it in the opposite way Often with SCI in men- just brushing the penis can cause an erection Need to also educate men that they can get women pregnant

Cognitive Functional Evaluation (CFE): Must consider frame of reference person-occupation-environment • Person: • What is the severity of cognitive deficits? • What are the person's strengths and weaknesses? • What is the client's learning potential? • What level of awareness of deficits does the client have? • What are the psychological factors? • What are the disease/injury variables: time since onset, severity, progression? • Environment: • What are the barriers to rehabilitation? • Occupation: • What is the occupational history, and what goals must be met to move forward with daily life?

When we are talking about cognition it is important to think of the PEO model Barriers to rehab could be discharge from therapy too soon

Case Study for discussion: Mary Jane • Diagnosis of frozen shoulder of uncertain etiology and CRPS; presents as if she has an anxiety disorder but does not have a diagnosis of this • Has difficulty being touched; sometimes yells or screams during therapist PROM (refuses AAROM); must be treated in a private treatment room due to this • Hot packs are the only modality she can tolerate (TENS not possible due to seizure history) • Nurse practitioner has given her very limited pain meds ***How should we approach this patient for treatment?

Where do we start with this lady? SROM she would have more control over Educate on phases of frozen shoulder Education on relaxation training Make environment as comfortable as possible Center treatment around her interests and values Acknowledge her pain Address anxiety with pain - what was making her nervous Give her choices in treatment - give patient control over what they are doing - at least as much as you can

Intervention C8-T1 u Continue all self care activities u Begin strengthening hand muscles (may need MP Block splint to increase strengthening of intrinsic muscles) u May splint for increased finger extension ( once the patient has a fair amount of finger flexion it is no longer necessary to maintain finger tightness for tenodesis) u Possible goal- patient will demonstrate a grip strength of 15 # to increase independence with manipulation of grooming containers

Will have finger movement Start to get hand-based muscles If you just do grip and squeezes won't get all hand muscles so will also need to use MP block Tenodesis stretch is no longer needed when they can do this Usually C6 and below we are doing strengthening of the arms but also work on core strengthening

Peli-prism glasses- hemianopsia- lose half of visual field in each eye

Will report bumping into things on that side or being startled by people in that field Would benefit from scanning training making it automatic to turn to right to prevent falls, NOT magnification

Glare Control

With eye disease- most people have difficulty with glare Want to maximize safety and prevent falls Help find the correct tint There are indoor tints- also adjusting blinds and glares entering That education piece and recommendations is really important

Case Study cont. } Rehab potential is good: motivated and good cognition. } Treatment Plan: (self-care: 97535) adaptive device training, visual skills training, safety awareness, glare control techniques, contrast enhancement methods, education of functional effects of eye condition, task lighting techniques, sensory substitution } POC: f/u,1-3 x month, for 90 days, 4 sessions tot.

Working with client letting them try the device She decided to use bulkier magnifier b/c of her hand tremor, can set it on print- but not strong enough to read her tabloids Also bought a used desktop video magnifier

Dysphagia is a specialized practice - AOTA offers a specialty certification for feeding, eating, and swallowing

You DON'T need a certification to treat this population You need additional training to be able to perform evaluations and treatments

Traditional telehealth visit structure (AOTA 2020) • Welcome the patient; keep in mind video may lack so speak, then pause • Assess how patient is functioning: Issues? Pain? Improvements noted? • Identify problems and issues: swelling, ROM, pain, etc. -- ask for visuals of affected extremity or other body part, movements; can ask e-helper for physical assist when needed, e.g. AAROM/PROM • Demonstrate treatment: "Move your arm like this" • Educate: "We need to get your wrist to bend backwards to help you hold objects," give handouts via email or telehealth platform • Provide guidance: "Show me - touch your thumb to your finger like this" • Modify, assess patient and caregiver activities • Plan for next visit

You have to show people more, and cannot touch them Just like a regular session Assess how the pt is functioning- ID problems and issues- swelling, ROM, Pain - hold up their arm and show you how they can do certain things Ask helper to help with AAROM - this is tricky if they are post-surgical - a lot of times caregivers are afraid I want you to bend your elbow like I am doing Provide guidance Modify, assess patient and caregiver activities Plan for next visit Some patients are not appropriate for telehealth but there is a lot you can do!

To Consider...Depression and chronic illness co-occur at a high rate AND???

and poor mental health has a strong negative effect on physical outcomes

SCI Evaluation cont... u Other exams that may be performed on day 1 and throughout the rehab stay:

u * 9 hole peg test, grip strength, pinch strength, proprioception, PROM, skin integrity, cognitive function, hot/cold discrimination

OT Intervention Approaches for Cognitive Deficits: Functional and Environmental Models Cognitive Disabilities Model • Includes graded cognitive levels to describe the status the client is presently in, then analyzes tasks to match abilities to task requirements

• Designed for clients with more severe cognitive compromise, poor insight & safety, and limited ability to learn

Contrast Enhancement

} Think in terms of opposites } And avoid patterns • Placemat/tablecloth also reduces glare • Often hard to detect object if similar in color to background • (ex. Pour coffee into white mug) • Don't sort pills over a pattern table cloth • Use a black marker instead of a pencil

Performance of driving Three levels of driving • Operative • Tactile • Strategic Operative Level Controlling a Vehicle through Physical Actions

• Controlling a Vehicle through Physical Actions • ROM (neck, extremities) • Strength • Proprioception • Scanning • Attention • Reaction time Don't do on-road assessments at Froedtert - all clinical driving treatments are reimbursable at Froedtert Why are there so few people doing on the road assessments - b/c it is such a high risk - Apparently it is hard to get reimbursed by insurance and Medicare Operative level- Physical actions required to operate the vehicle Assess strength- UE, grip, pinch Proprioception Scanning visually- so don't hit things Attention to task Reaction time Through driving simulator

OT Intervention Approaches for Cognitive Deficits: Cognitive Compensatory Models Multicontext Treatment Approach

• Emphasis is not on improving underlying cognitive skills but on improving activity management by increasing efficiency and effectiveness of strategy use across activities • Therapists help clients learn to anticipate task challenges and self-generate strategies that are practiced in a wide range of activities to promote transfer, with generalization being the goal What we do with this approach

Performance of driving Three levels of driving • Operative • Tactile • Strategic

• Evaluation of driving should be at the performance level- NOT the component level. If there is areas of deficit in clinic then need to complete on road assessment Operative- can they operate a car, do they have the neck ROM Tactile- Strategic Should look at performance level - NOT at each individual component- so if have deficits in neck ROM can do compensatory strategies to make up for that

Tools for treating cognitive deficits (for a variety of models/abilities; use with approaches) • External vs. Internal Strategies

• External to the patient: devices or cuing Internal to the patient: self-generated procedures to enhance control

Definition of Terms Generalization of learning vs. Transfer of Learning

• Generalization of learning: Refers to the degree that a specific skill, learned in a specific context, can be performed in another context • Transfer of learning: Refers to the degree to which learning one skill influences the learning of another skill • ***Generalization and transfer allow the client to draw on previous experiences to perform the same or similar skills in a new context***

Mr. TENS • He was initially very suspicious of what I might do with him in therapy • He was Spanish speaking and would routinely correct my grammar during our therapy sessions

• He came exactly six sessions (with several no-shows) and was issued a TENS unit, was then satisfied with therapy!

Mind-Body Connection

• Mental health influences physical health • Physical health influences mental health • To treat the whole person we need to address both

Tools for treating cognitive deficits (for a variety of models/abilities; use with approaches) • Examples of external tools/external strategies

• Verbal cuing to place/time/situation, support, direct • Demonstration of correct task performance • Pacing of activity: begin slower • Spaced retrieval of information: tell info, retrieve, increase time demands • Mnemonics for important processes/info • Backward chaining: grade the help/cues given for task and gradually withdraw help/cues • Memory notebook, journal or "key ideas log" • Assistive technology/memory aids: functions for dictation, alarms, alarms, contacts, to do lists, map functions, etc. External strategy examples= - Verbal cueing to time, place, situation (directing stuff) - Mnemonics- coming up with acronyms for different things - Notebook, journal, log Best if we can use internal strategies -bc more likely perpetuated over time