OT662 FINAL :)

Pain Facts: -Gradual increase in activity also lessens the likelihood of flare up of pain -ENERGY CONSERVATION, PACING, AND JOINT PROTECTION

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LIMB WRAPPING: -Trans-tibial leg wrap: go distal to proximal, cover bottom og wound figure 8 style, and wrap up leg -Trans-femoral leg wrap: same technique, just wrap around hip because these fall more often than the others

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Edema affects? (3)

ROM Sensation Dexterity & function

Things to think about with burns: ♣ Latent muscle weakness and neurological changes ♣ Check vitals frequently: Interference with electrical conductivity of organs . ♣ Trauma associated with electrical injury victim thrown from electrical source etc. ♣ Early mobilization: Positioning and splinting

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Work hardening no longer exists, it's work conditioning!

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PD: OT Interventions? (~9)

-Adaptive equipment & compensatory strategies to minimize tremors & to maintain independence in ADLs -Education on timing of important activities -Exercise program for mobility, coordination, ROM & postural awareness: *Big movement (LSVT big) most evidenced based*, yoga, Tai Chi, Dancing -Group activities -Fall prevention -Facial exercises -Home modification -Maintaining QOL -*Look at mobility with functional activities*

Edema Intervention? (7)

-Elevation of the hand -Retrograde massage -Pressure glove (edema glove) -In the earlier stages post stroke edema, elevation and light retrograde massage followed by edema glove on the hand can be effective for reducing hand edema -Should avoid allowing hands and arms to hang down for long periods of time -Prolonged hand edema can limit PROM, pain and soft tissue contractor -Development of CRPS

Coordination Tx?

-Fine motor coordination activities: Buttons, tying shoe laces Managing coins Writing, typing Cutting with scissors

GBS: Interventions: *OVERALL LTG?*

-Full recovery, so the client performs at the same level as before onset of GBS with or w/o modifications

Front On Back Off transfer for Amputees?

-Position wheelchair facing bed or mat; pt should push down with both arms; lean to one side to un-weight the opposite side and move forward; caregiver can assist under the thigh; gradually move forward/backward until pt is on desired surface (w/c or bed); when pt is positioned in w/c please elevate both leg rests so that both limbs are supported

MS: CLINICAL MANIFESTATIONS? (12)

-Sensory deficits are the common initial complains. -Paresthesias in one or more extremities (trunk, or in the face) -Weakness or clumsiness in the leg or hand is common -Visual disturbances: blurred vision, diplopia, nystagmus, eye pain, partial blindness -Balance loss -Vertigo -Loss of autonomic control: bowel and bladder dysfunction -Pain -Fatigue -Spasticity -Ataxia, dysarthria, tremor -Depression, higher level cognitive dysfunction

Rancho Los Amigos Levels of Cognitive Functions

-Uses behavioral observation to assess person's level of cognitive function -First 3 levels of assessment describe response to stimulation and the E as the pt. is emerging from coma *P.1049 Table 34-2*

If pt receives epidural shot you cannot treat them for ___1___!

1. 24 hours

no IR to small of back until ___1___ weeks after TSR

1. 6

-Pain is the most common symptom; also joint stiffness, muscle tightness, redness and swelling of the affected area. Some workers may also experience sensations of "pins and needles," numbness, skin color changes, and decreased sweating of the hands. -CTD/WMSDs may progress in stages from mild to severe. -Early stage: ___1___ -Intermediate stage: ___2___ -Late stage: ___3___

1. Aching and tiredness of the affected limb occur during the work shift but disappear at night and during days off work. No reduction of work performance. 2. Aching and tiredness occur early in the work shift and persist at night. Reduced capacity for repetitive work. 3. Aching, fatigue, and weakness persist at rest. Inability to sleep and to perform light duties.

Orthopedic Management for Upper Limb: -___1___: acromioplasty, small & medium & large tears ♣ Acromioplasty: decompresses the subacromial space ♣ Open repair: medium, large & massive Incision/Scar: Glue is now the way to hold the scars together

1. Arthroscopic

___1___: o Ipsilateral loss of: Proprioception Vibration two-point discrimination fine touch Stereognosis motor function o Contralateral loss of: pain temperature

1. Brown Sequard

___1___: injury to sacral and lumbar nerve roots oSee: LE motor and sensory loss Areflexic bowel and bladder

1. Conus Medullaris

Work conditioning/hardening goals? (5)

1. Decrease secondary impairment effects, by improving strength, flexibility and endurance 2. Decrease functional limitations by learning effective adaptive behaviors 3. Decrease work related disability, by re-establishing worker role 4. Improve vocational feasibility by identifying and remediating potential problems with productivity, increasing safety and strengthening interpersonal relations.

Impairments that can hold you back from being successful w/ bed mobility? (4)

1. Decreased arm strength (C7 or below) 2. Intra and inter limb coordination 3. Cognition 4. Muscle & joint tightness

3 Types of Pressure Relief?

1. Dependent Pressure Relief 2. Forward Weight Shift 3. Lateral Weight Shift

Skin Anatomy: -___1___ ♣ Melanocytes and Langerhans cells -___2___ ♣ Interface between Epidermis & -___3___ ♣ Blood and lymph vessels, nerves, sensory receptors, hair follicles, sweat and sebaceous glands

1. EPIDERMIS 2. BASEMENT MEMBRANE ZONE 3. DERMIS

ORTHOPEDIC MANAGEMENT -Intact RTC and OA: ___1___ -Cuff Tear Arthropathy: ___2___ -Fracture: ___3___

1. Hemi-arthroplasty or Total Shoulder Replacement (TSR) 2. Total Shoulder or Reverse Total Shoulder Replacement 3. ORIF, Hemi-arthroplasy or Total Shoulder Replacement (TSR)

PREVENTION OF PRESSURE ULCERS? (3)

1. Importance of general skin hygiene o Fully washing & drying area o Moisturizing o Length of nails 2. Avoidance of shearing & friction forces 3. Daily skin checks o Which areas are more prone for skin breakdown?

3 Healing Phases?

1. Inflammatory-> where all swelling occurs 2. Fibroblastic-> collagens starts laying down new tissue, including scar tissue 3. Maturation Phase

BLADDER CARE: (PRIMARY GOAL) -Bladder Emptying Techniques: ___1-4___ -*If bowel care is not performed right, it can lead to issues with bladder care*

1. Intermittent catheterization (more common) 2. Indwelling catheter (more common) 3. Stimulated voiding 4. Spontaneous voiding

DIFF TYPES OF SURGERY: -___1___ One level vs. multiple levels -___2___ Anterior Lumbar Interbody Fusion (ALIF) Posterior Lumbar Interbody Fusion (PLIF) With this surgery: -single level vs. multiple levels -use of instrumentation vs. no instrumentation -bone graft

1. Laminectomy 2. Spinal Fusion

___1___ ARE LEADING CAUSE OF LOST WORKDAYS IN USA

1. MUSCULOSKELETAL DISORDERS

Intervention for Motor Recovery? (4)

1. Management of spasticity: ROM, splinting, meds i.e. botox 2. Task Oriented Approach 3. Constraint Induced Therapy 4. Fine motor skills skill building w/ buttoning, feeding, handwriting *Same interventions as CVA

___1___: head trauma in which the skull is punctured ___2___: Skull is NOT broken

1. Open head injury 2. Closed head injury

___1___: -The causes: a combo of genetic, E factors and loss of dopamine -Progressive degeneration -Loss of dopamine -Possible risk factors: genetics, age, gender, head injury, chemical exposure -Mean age of onset: 55-60 years

1. Parkinson's Disease (PD)

Purposes of Work Rehab? (3)

1. Return injured workers to work 2. Prevent work related injuries 3. Incorporate "ergonomics" principles in everyday practice

___1___: -Normal or abnormal structural imaging -Loss of consciousness (LOC): >24 hours -Altered State of Consciousness (AOC): >24 hours -Severity is based on other criteria -Post Traumatic Amnesia (PTA): >7 days -Glasgow Coma Scale (GCS): Score 3-8

1. Severe TBI

Dopamine is made in ___1___

1. Substantia Nigra

___1___: -Key movements o better trunk control o core strength and sitting balance o Able to perform unsupported seated activities -Abilities: Walking can be viable function with help of specialized leg and ankle braces and assistive devices

1. T10-L1

AD: Applies to ___1___ o Sign: red flush o Symptom: headache

1. T6 pt and above

Scar Management-> ___1___ o 24 hour wear o Helps break adhesions in underlying scar tissue o Apply 50% stretch over scar tissue directly

1. Use of Elastic Tape

Edema Evaluation? (3)

1. Volmetric measurement 2. Circumferential measurement 3. Sensibility Test -Monofilament -Sensory deficit can range from decreased light touch to loss of protective sensation and to loss of deep touch

EXERCISES for PAIN: -headache due to poor posture.___1___ -pain pain due to: sitting for long time, forward posture standing desk. take 20/30 min walk -WANT TO OPEN UP CHEST -Weak core muscles: on your belly and forearm. weak core can cause back pain!! • Herniated disc

1. chin tucks

Subacromial Space: -Space below acromion & above the humerus -Average height between the acromion & humeral head is 1.1. cm w/ humerus at side -RTC job: ___1___ -Structures located in space: ___2-5___

1. hold head of humerus in glenoid fossa 2. Bursa (most superior) 3. Supraspinatus 4. Joint capsule 5. Long head of biceps (superior to inferior)

POSTURE/BODY POSITION: -There are two aspects of body position (posture) that contribute to injuries in jobs involving repetitive tasks. 1.The first relates to the position of the part of the body that performs the actual task, usually the upper limb. E.g. tasks that require ___1___ to the extreme ranges of the joint in the wrist, elbow or shoulder contribute to the occurrence of a painful condition in those areas. 2.The other is a ___2___ of the neck and the shoulders. To perform any controlled movement of an upper limb, the worker must stabilize the shoulder-neck region. Muscles in the shoulder and the neck contract and stay contracted to hold the position stable for as long as the task requires. This results in pain and fatigue in the neck-shoulder region.

1. repetitive movements 2. fixed position

3 components of job analysis?

1. worker 2. work 3. worksite (workstation, objects, E)

-Traumatic Causes of SCI: Majority are MVA (39.2%) and falls (28.3%)

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ASIA form: http://sci.rutgers.edu/forum/attachment.php?attachmentid=19916&stc=1&d=1200 243671

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Burn Classification: o *TBSA = Total Burn Surface Area* o Rule of Nines o Lund & Browder Chart o Palm Method Types of Burn Injury: o Thermal 80 % o Electrical 7% o Chemical 3% o Radiation <2%

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Extra Lecture Notes from PT on SCI: (IMP :) ) • OT: get pt back to driving to get to work; PT: ambulate down stairs, transfer into car, w/c propulsion into work • Falls & MVA most common cause of SCI • Syringomelia: CSF too great in central canal can walk okay but can't do ADLs • 100% of people who use w/c as primary means of mobility after SCI have UE pain/dysfunction within 20 years • 78% have HS diploma or less problem for employment bc many of jobs for this education is manual labor and cant get employed • Life expectancy: normal as there peers except x2 causes of death that are common o Pneumonia: can't produce strong enough cough to cough up everything; lack of diaphragm muscles but don't have strength to use it o Septicemia: infection of blood from pressure ulcers and decreased immune system • More incomplete injuries because decreases swelling around spinal cord to preserve some sensory/motor; better technology/orthotics & procedures • 20 years post SCI, only 35% employed; they get $$ from SSDI but don't let them work part time... they want opportunity to collect SSDI and work part time • SCI often accompanied by TBI TBI often goes undiagnosed • Slide 14: red part will never get back; want to try and get back surrounding tissue • Want to administer methylpredmisolone to pt w/ SCI within 3 hours of the injury, can be administered by EMS, want to administer it within 3 hours this is standard of care • With halo vital to make sure pt doesn't fall on pins bc if they do will go into brain tissue major precaution • Jewett brace make sure pt doesn't flex • COMI: for T1 injury so holds their chin up • Knight taylor brace: PREVENTS HYPEREXTENSION OF SCI • CENTRAL CORD SYNDROME: BLOWS OUT CENTRAL CORD BUT LEAVES SIDES, FRONT & BACK you take away UE function and LE are least involved; little UE movement with arms but usually CAN ambulate, trunk usually gets some return • Brown-Sequard: mostly stabbing/gun shot; often looks very much like person with a stroke; so have decrease balance, hemiparesis; AMBULATORY! ; one side is more impaired than the other • Anterior Cord: damage to ant cord • Incomplete SCI more spasticity (spasticity not always bad bc muscles moving; NEVER MMT a person who cant isolate movements bc that's tone; actually helps create muscle bulk bc muscle contractions constantly) • UMN: spasticity, Babinski • LMN: flaccidity, no reflexes • ASIA determine neurological & motor level • MOTOR LEVEL: i.e. C5 ASIA A then C5 in biceps 3/5 but C4 muscle strength of 5/5 • Trunk: no motor assessment; just assess through sensory • Sensory on right of chart you want 2!!!!!; motor is on left; look at sensory first (last one that is 2/2); then look at motor: L1 ASIA C • SCIM better than FIM bc they don't change much so FIM misses their progress want you use outcome measures that work with actual SCI population • AD above level of lesion gets red, symptoms: HEADACHE, anxiety; this is medical emergency bc BP elevated enough to give the pt stroke; SIT PT up (gravity pulls blood from brain so wnt stroke out) ; take abdominal binder off; then check for causes kinked CATHETER, clothing is too tight, UTI & ingrown toe nails; SO common with C6 and above

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KT ON SKIN FUNCTION: -Skin -Skin is the body's largest organ - Filled with sensory receptors • Pain and Motor Control -KT tape provides low threshold input to somatosensory receptors -Increases sensory to mechanoreceptors -Possibly activates inhibitory system

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SCI Stats: -Nearly ½ of all injuries occur between ages 16 and 30 -80.7% of SCI reported to national SCI database are males -50 % of all cases have associated injuries in addition to -Overall 85 % of SCI who survive initial 24 hours are still alive 10 years later -*Most common cause of death: Pneumonia, pulmonary emboli, septicemia*

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See other quilt for OA/RA, Cancer & Quizzes! :)

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-duration/endurance/fatigue, positional tolerance, physical demands

Biomechanical approach to job analysis

-Compression applied at the time of surgery allows for counterforce to outflow -Must be monitored by therapist -If too tight: ♣ Increase temperature ♣ Increased edema ♣ Painful ♣ Can lead to tissue breakdown

Bulky Dressing

develop exercise program, foster social relationships, social activities

Create/Promote: TBI

Main goal of work rehab?

Getting people back to work

Note if they are developing bone in the soft tissue where bone does not normally exist i.e. common in hip/elbow; often seen w/ SCI, central cord injury; look for inflammation/ limited ROM/pain during ROM

Heterotropic Ossifications

-"A process by which an individual evaluates a job & its specific components in order to make a definitive statement about that job, its risk, requirements, productivity, the methodology/techniques required of the worker"

Job Analysis

perform ROM, serial casting, tone inhibiting techniques, skin breakdown, postural deformities

Prevent: ABI *Prevent & establish/restore for early TBI rehab*

Causes of non-traumatic SCI?

• Spina Bifida • Spinal stenosis • Scoliosis • Bacterial or viral infections • Tumors, metastases • Genetic disorders • Embolism • Spinal stroke • Transverse myelitis • Spinal abscess • Guillain-Barre Syndrome

Diagnosis of GBS? (3)

-Based on clinical symptoms: gather detailed history of symptoms and complete physical neurological examination -Spinal tap: CSF contains more protein than usual -Nerve conduction studies may support the diagnosis

SPINAL PRECAUTIONS- THORACIS & LUMBAR?

-avoid BEND, LIFT, TWIST

Physiological Effects of Heat: ___1___: ♣ Alters nerve conduction ♣ Decreases pain ♣ Decreases muscle spasm ___2___: ♣ Increases extensibility nature of tissue-> Heat with stretch results in elongation go after tissue! Do NOT just put HP on pts shoulder ♣ Increases tissue healing

1. Analgesia 2. CT effects

___1___: -Key Movements: o elbow extension o Wrist flexion o Finger flexion/extension -Abilities: Requires fewer adaptive equipment/ techniques to UE/LE ADL's and daily tasks o Able to perform w/c pushups and lateral transfers without transfer board

1. C7-C8

___1___: o Full loss of sensory and motor function below the level of injury o Includes loss of sacral segment Anal motor function and sensation are lost

1. Complete SCI

___1___ happens during any injury, esp hand injuries: o Accumulation of excessive fluid in the intercellular spaces o Leads to other problems i.e. lack of ROM o Usually one of the first priorities because decreasing this almost naturally increases ROM

1. Edema

Heat w/ stretch-> ___1___

1. elongates tissue

-Tuck in shirt: shoulder extension, adduction & IR -Wash opposite axilla: shoulder flexion, abduction & ??

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Body Mechanics to Avoid Pain: -Maintaining a straight back BUT WANT TO MAINTAIN SPINAL CURVATURE -Avoiding twisting during activities -Turn as a unit while maintaining a neutral spine -Carrying objects close to body -Lifting w/ legs -Using wide BOS -Reducing back stress while standing (i.e. opening a cabinet door & resting the foot inside the cabinet space)

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Concepts of MEM: -Light massage (not deep, crushes structures) -Exercise before/after MEM -Massage in segments ♣ Proximal -> distal ♣ Distal -> proximal -Massage follows flow of lymphatic pathways -Reroutes around scar tissue -Must include client home self massage program

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MS: OT INTERVENTIONS?

*(spasticity management: PROM, splinting; energy conservation: decreasing number of times for a transfer, ambulation, sit in shower)* -Activity strategies and energy Conservation Techniques -Work Simplification -Environmental modification -Exercise programs (strengthen but be aware of weakness, watch weight; watch reps) -Strategies and adaptations to compensate for cognitive deficits -Pain intervention -Tremor and ataxia intervention (LOOK UP) -Mobility training during ADLs and community -Patient and caregiver education: avoid extreme heat, stress, and fatigue

Diagnosis of MS?

-Largely based on symptoms -Characterized by patches of demyelination in the brain and spinal cord -Neurological examination -MRI is a good indicator -The more lesions on initial MRI, the worse the prognosis. -Lumbar puncture shows elevated immunoglobulin indicating an inflammatory response -Prognosis: - Life expectancy is slightly reduced - Death is highly correlated with severity of symptoms

Fine & Gross Motor Coordination: Evaluation?

-Std. Assessments: Fugl-Meyer, Jabsen Taylor hand function test, nine-hole peg test -Observation during functional tasks -Incoordination is noted as decreased ability to target, unable to perform coordinated movements and decrease speed

ALS: CLINICAL MASIFESTATIONS? (5)

-Varies depending on whether upper motor neuron or lower motor neurons are predominantly involved -Muscle weakness and atrophy begins distally and asymmetrically -Signs usually begins in the hands -UMN involvement -LMN involvement -Bulbar Signs

Players of work rehab?

-Worker, OT, OT, Psychologist, Vocational Counselor (if can't go back to job they used to do, then helps pt go thru process to get them ready for new job), Rehab Nurse (worksite), Case manager, Work hardening/conditioning techs, Physician, Employer

Grading Scale for Edema

1+: Mild, barely perceptible indentation; <1/4 inch of pitting 2+: Moderate, easily IDed depression; returns to normal w/I 15 seconds; ¼ inch pitting 3+: Severe, depression takes 15-30 seconds to rebound; ½-1 inch of pitting 4+: Very Severe, depression lasts >30 seconds; >1 inch pitting

WHAT IS SCI? -Traumatic or non- traumatic event causing damage to spinal cord. -Resulting in motor and or sensory impairments at and below the level of injury. -Causes of SCI since 2010: ___1___ ___2___ 14.3%: violence 11.4%: other/unknown 9.2%: sports

1. *36.5%: vehicular* 2. *28.5%: falls*

AMYOPROPHIC LATERAL SCLEROSIS (ALS): -Known as ___1___ -Unknown cause -No special test is available to establish the diagnosis -Progressive disease of ___2___ -Disease is more common in ___3___ -Late onset, average age 58 y.o -Death usually occurs in 2-5 years

1. *Lou Gehrig's Disease* 2. UMN and LMN (upper and lower motor neurons) 3. MEN

WORK RELATED RISK FACTORS FOR CTD'S (NIOSH GUIDELINES)? (7) *(MEMORIZE)*

1. *Repetition:* performing repeated motions in the same way with same part of the body 2. *Pace:* The faster the pace, the less time is available for rest and recovery in between cycles 3. *Force:* performing an activity with excessive muscular exertion/force 4. Contact stress: direct pressure on nerves or tendons due to resting the body part against a hard and possibly angled surface 5. Posture/Body Position: placing a joint towards its extreme end of movement in any direction away from its neutral, centered position 6. Low Temperature 7. Vibration

ADL's Post RTC Surgery: -Low Range (Below 90 degrees of shoulder elevation) ♣ Tuck shirt in, put belt on, toileting care, feeding, don/doff shirt, dusting ♣ Some of the above activities require IR to small of back; make certain that movement is approved by MD -Mid Range (90 degrees): ___1___weeks ♣ Wash opposite axilla, wash face, brush teeth, apply make up, shave, fold laundry, hook bra -High Range (Above 90 degrees): ___2___ weeks ♣ Can do these as long as NO HIKING ♣ Hair care, reach into above shoulder level cabinets

1. 6-8 2. 8-12 weeks

Musculoskeletal D/o's related to MMH fall into several categories: -___1___: worker loses balance or control of load & gets injured, often in form of a muscle strain -___2___: worker attempts to lift heavy load or conditions of a lift have high physical demands i.e. task requires awkward handling/extreme postures -___3___: induced high frequency, handling of a load that is within a worker's capability begins to wear down the body & yields an injury (the cumulative trauma model)

1. Accident 2. Overexertion 3. Fatigue

GBS: Clinical Manifestations: 3 Phases?

1. Acute Inflammatory Phase 2. Plateau Phase 3. Progressive Recovery Phase

Bulbar Signs (damage in the medulla, or "bulb") for ALS? (3)

1. Affects speech: (articulation, slurring of speech, tongue weakness, and facial muscle weakness), swallowing and breathing 2. Sensory systems, eye movements, bowel and bladder control are not affected 3. Cognition is rarely affected (so, intact)

___1___: o Damage to anterior sp crd o See with: Tear drop or burst fracture o Results in: bilateral loss of motor function, pain & temperature (depends on extent) intact proprioception

1. Anterior Cord Syndrome

Somatosensory: -CVA can cause sensory deficits -Mild CVA and those who have intact primary sensory awareness may need to be tested further -Most tests of sensation require ___1-3___

1. Attention 2. Recognition 3. Response to multiple stimuli

___1___: sensory loss, motor paralysis, loss of bowel and bladder control -*Medical Emergency* related to Autonomic Dysfunction Autonomic Dysreflexia: (___2___) See: BP Bradycardia Nasal congestion Pounding headache Anxiety Flushing Profuse sweating

1. Autonomic *Dysfunction* 2. T6 and above

BLADDDER MGMT AND PROB SOLVING: -Avoiding infections o Urinary tract infections o Possible sepsis -Kidney damage & failure -Urinary stones -Incontinence can lead to SKIN BREAKDOWN -A poor bladder regimen can lead to ___1___

1. Autonomic Dysreflexia

PROBLEM SOLVING W BOWEL CARE: • Diarrhea • Constipation • Impaction • Rectal Bleeding • Lack of Bowel Movement o What can cause this ? o What are the solutions? • A poor bowel regimen can lead to ___1___

1. Autonomic Dysreflexia

___1___: -Causes: Anything that can be perceived as a *noxious stimulation* -Treatment: Immediately sit person upright Fix problem

1. Autonomic Dysreflexia

PD Assessments? (5)

1. Berg Balance 2. FIM 3. ROM test 4. 9-hole Peg Test 5. Jebson Hand Test

___1___: -Pic first looks at nociceptive response, then persons unique pain experience, then feels then pain behaviors -The principle of the model is that all issues related to health are products of a complex interplay of biological, psychological and social factors -Commonly used to address *chronic pain* -FOCUS ON FUNCTION NOT PAIN -Model encourages use of activity and functions to manage pain -Discourages focus on pain & dysfunction -Approaches used in the model include: CB psychotherapy, mind body treatment & integration of physical modalities

1. Biopsychosocial model of pain

___1___: -Key Movements: o Head/neck control o Scapular elevation ( shoulder shrug) o Inspiration ( diaphragm) -Abilities: Potential to be weaned from Ventilator o I with pressure relief with power w/c, I'ly direct all aspects of care -Mobility: electric w/c with head control, mouth stick, chin control, sip and puff. Independent with power tilt for pressure relief

1. C4

___1___: -Key Movements: o Shoulder flexion/abduction o Elbow flexion o Supination o Scapular abd/add -Abilities: Independence with eating, drinking, face washing, brushing teeth with U cuff, adaptive equipment. Mobility: May be able to push manual w/c short distances Power w/c with hand controls

1. C5

___1___: damage at L1 or below which results in flaccid paralysis

1. Cauda Equina

___1___: o damage to central part of cord o seen with cervical hyperextension injuries o see damage to tracts of UE, Trunk, LE respectively o sacral sparing usually present

1. Central Cord Syndrome

PRACTICAL SOLUTIONS TO REDUCE THE RISK OF CTD? (2)

1. Changes To The Way Work Is Organized -Reorganize the work so it be a combination of repetitive and non-repetitive activities -Frequent, short breaks should be introduced if the job cannot be varies or rotated -Work rates can be reviewed to ensure they are realistic and within physical and psychological capabilities 2. Changes to the workplace Environment -Ergonomically designed furniture which can be adjusted to suit the person -Work area should be rearranged to avoid stretching or twisting of limbs/body -Hand tools for repetitive tasks should be comfortable and well designed and should not require excessive force to operate -If the job requires precise movements adjust work surface to slightly above elbow level. Arrange work so as to promote relaxed elbow position and relaxed shoulders -If job requires a lot of muscle strength, the work surface should be slightly below the elbow level

Concepts of MEM: -"U" hand movements -___1___ ♣ Tractioning segments ♣ Starts proximally -> Distal ♣ Minimum of five "U" ♣ Creates interstitial pressure that causes initial lymphatics to take lymph -___2___ (Exact opposite of clearing, go distal to proximal) ♣ Starts Distally -> next set of lymph nodes (proximal) ♣ Minimum of five "U" ♣ Performed all the way to contralateral segment ♣ Purpose is to direct flow -___3___ ♣ Involves simultaneous, synchronized movement of two hands in U pattern over lymphatic bundles ♣ 20-30 "U's" -Disclaimer: should not perform MEM without additional coursework or mentorship

1. Clearing 2. Flowing 3. Pump Point Stimulation

Intracranial Pressure (ICP) Precautions? (3)

1. Closely monitor patient 2. Pupil changes, decreased neurological responses, abnormal brainstem reflexes, flaccidity, behavioral changes, vomiting, changes in pulse rate, BP & RR 3. Head may be positioned in neutral at 30 degrees of elevation

___1___: -cause Vasoconstriction ♣ Reduction of outflow of fluid in acute phase -Research shows if temperature is lower than ___2___ degrees F can cause leak of proteins into Interstitium ♣ Can lead to increase in edema ♣ How do we address this?

1. Cold pack 2. 59

Thermal Agent Principles? (3)

1. Conduction 2. Convection 3. Conversion

ULTRASOUND -___1___. BENEFITS: ♣ Increase tissue extensibility (increases ROM, decreases joint stiffness) ♣ Reduces pain ♣ Increases blood flow and tissue permeability ♣ Reduces muscle spasms ♣ Reaches deeper tissues (up to 5 cms) -___2___. BENEFITS: ♣ Decreases inflammation ♣ Heals tissue

1. Continuous (thermal) 2. Pulsed (non-thermal effects)

Contributions to Activating Lymphatic System: Involved Structures: ___1___ -Target structures that are involved with the edema; help lymph flow into pathways they should be; don't want to crush skin bc would crush lymph nodes and could cause more edema -Molecules are absorbed from interstitium because pressure causes lymphatics to open -External stimulation to facilitate uptake of lymph -Treatment includes: • Manual edema massage at site • Elastic taping • Gentle myofascial release • Compression • Heat • Exercise

1. DISTAL TO PROXIMAL

___1___: pt does no work; for C1-C5 or any one who is having a hard day -You tilt the manual w/c back so handles on the sofa, this is for manual w/c; for tilt in space the bottom of w/c stays at 90 but back reclines; recliner w/c -Manual w/c-> pro: easy to transport in car, con: can't push themselves back up need someone to do it -Most people do 10 min every hour; esp important in beginning stages

1. Dependent pressure relief

___1___: -Key Movements: Neck flexion, extension, rotation -Abilities: Limited movement of head Dependent on ventilator for breathing Talking is limited if possible. Can be achieved via mouth stick, eye gaze system, Dynavox. Environmental control units improves control over environment. -Mobility: electric w/c with head control, mouth stick, chin control, sip and puff. Independent with power tilt for pressure relief

1. FUNCTION: KEY MUSCULATURE AT C1-C3

___1___: ♣ Used with children, adults w/ cog deficits and adults in ICU unable to speak ♣ Based on OT observation ♣ Scaled is scored in range of 0-10 ♣ 0= no pain, 10= worst pain ♣ Scale has 5 criteria, which are assigned a score of 0, 1 or 2

1. Face, Legs, Activity, Cry, Consolability Scale (FLACC Scale)

___1___: -Dry convection -Hand placed in container of air heated, circulating cornhusk particies -Higher temps possible 43-48C (110-118F) -Remove all jewelry and wash hand -Inspect hand -Place if sleeve of machine -Set dial to desired temp -Set slower to desire flow (low for someone hypersensitive) -20-30 mins tx -Can be rented by facilities so they don't have to purchase it -Advantages: self sanitizing, temp control, hand/wrist/forearm are moving while being heated, adjustable blower controls particle stimulation (good for desensitization) -Disadvantages: semi-dependent position, can be messy

1. Fluidotherapy

___1___: occurs in a specific area; i.e. due to tumor or stroke & sx associated w/ damaged area ___2___: occurs over a wider area; i.e. common w/ MVA from the jolt of the brain; harder to detect bc more widespread

1. Focal 2. Diffuse

ALS: OT INTERVENTION: Goal setting for later stages? (7)

1. Focus on educating the caregiver to assist the client safely and effectively. 2. Assess positioning, perform safe transfers, and maintain skin integrity. 3. Employ augmentative communication equipment. 4. Assess and manage dysphagia. 5. Optimize social participation 6. Identify and obtain equipment to allow continued mobility 7. Environmental modification

___1___: you lean forward on thighs -Do 5 min every 30 or 10 min every hour -Hard to get back up

1. Forward weight shift

5 Types of FCE Processes? (5)

1. Functional Goal Setting 2. Disability Rating 3. Job Matching 4. Occupation Matching 5. Work Capacity Evaluation

Diagnostic Testing for TBI? (3)

1. Glasgow Coma Scale 2. Racho Los Amigos 3. CT Scan & MRI

___1___: common in hands, knees (shoulders & elbows for tetraplegia only) -Bone gets laid down where it shouldn't -Decreased ROM, swelling and warm -Biggest thing-> decreased ROM -Treatment: meds but don't always work, gentle ROM (gently move them through their ROM so you don't cause noxious stim again) or aggressive ROM (ROM aggressively bc noxious stim will happen anyway)

1. Heterotropic ossification

*___1___: thick scar tissue, remains in area of injury, contracts, produces scar bands* Characteristics of scar tissue: o Immature = 3 R's - Raised, Red, Rigid o Mature = 3P's - Pale, Pliable, Planer Burn Scar Treatment: -Pressure garments -Conformers & inserts -Scar massage & lotion -Sun protection

1. Hypertrophic Scarring

Why Job Analysis? (3)

1. ID critical physical demands of the job to formulate a job description 2. ID unsafe job demands- basis for ergonomic adjustment of the job 3. Compare worker abilities to demands of job- Functional Capacity Evaluation (FCE)

Vascular Structures: -___1___: Space between cells -___2___: The smallest arterial vessel -___3___: Smallest venous structure -Each of these structures terminate in the capillaries -Red pumps from heart, blue to heart; green is lymphatic system

1. Interstitial 2. Arteriole 3. Venule

___1___: -Key muscles: fully intact abdominals, and all other trunk muscles -Key movements: good trunk stability, and partial to full LE control -Depending on level: hip flex/ext/abd/add, knee flex/ext, ankle dorsi/plantar

1. L2-S5

___1___: REMOVE arm rest you are leaning to, have pt cross leg prior to lateral lean, rest wrist -OT needs to put hand on bony prominence and feel to see if pressure is on bony prominences

1. Lateral weight shift

HOW SCI IS CLASSIFIED? (4)

1. Lesion site: cervical, thoracic, lumbar, sacral 2. Segment number: C6, L4 etc. 3. Complete: no motor/sensory function below level of injury 4. Incomplete: partial preservation of motor/sensory function below level of injury

-With AD and a modified technique, C6-C7-8 can be mod I with BADLs; to teach dressing ___1___ on the bed is best

1. Long sitting

CTD? (5)

1. MSD - Musculoskeletal Disorders 2. OOS - Occupational Overuse Syndrome 3. RMI - Repetitive Motion Injury 4. UEMSD - Upper Extremity Musculoskeletal Disorder 5. WRULD - Work Related Upper Limb Disorders

___1___: -"Any process in which the human operator is asked or required to lift, lower, push, pull, carry or perform any other similar task in which an object is moved through space solely under the power of the human operator" -MMH involves any handling of a product, whether a pencil or 70 lb piece of electronics equipment, not just objects that are perceived as "heavy: -MMH is NOT regulated solely to heavy manufacturing E's; it includes jobs in an office where a person has to lift a ___2___ component & jobs in a heavy industry where a person must lift ___3___ object

1. Manual Materials Handling (MMH) 2. 1 lb 3. 55 lb

CHARACTERISTICS OF CTD'S? (6)

1. Mechanical and physiological processes 2. Related to work intensity and duration 3. Development requires weeks, months and years 4. Recovery requires weeks, months and years 5. Symptoms often poorly localized, nonspecific and episodic often unreported 6. Multifactorial (more than one causal factor)

Medical Management of Acute SCI -Pharmacological Sharma (2012) -2 Corticosteroids: -___1___: prevents lipid perioxidation, posttramatic ischemia, destruction of neuronal & microvascular membranes -Tirilazad mesylate -GM-1 ganglioside -In animal studies: (Geisler et al, 1991) Promotes growth of nerve cells Regeneration of damaged nervous tissues -Available medical evidence does not support a significant clinical benefit from the administration of GM-1ganglioside in the treatment of patients after acute spinal cord injury

1. Methylprednisolone (naloxone)

___1___: -The exact cause is unknown -The myelin damage is resulting from autoimmune attacks on the central nervous system and that affects the brain and spinal cord -Gray areas develop (plaques) in the white matter of the CNS (visible in MRI) -Occurs most often between the ages of 15 and 50 Years (average age of onset is at 30s) -More prevalent in women than in men

1. Multiple Sclerosis (MS)

___1___: -Motor and or sensory function fully or partially spared below level of injury -Some motor/ sensory function below level of injury -Sensory or motor function S4-S5 -Damage does not cause complete transection of cord

1. NEUROLOGICAL OUTCOMES INCOMPLETE INJURY

Pain: An unpleasant sensory & emotional experience that significantly affects an individual's QOL -Types of pain: ♣ ___1___: BODY SIGNALS ♣ ___2___: PAIN RELATED TO CNS & PERIPHERAL NS I.E. PEOPLE W/ DIABETES HAVE NEUROPATHY ON THEIR LEG ♣ ___3___: TELLS BODY THAT SOMETHING HAPPENED AND PERSON SHOULD BE AWARE OF THAT i.e. pain is short lived bc once we address the pain then it goes away ♣ ___4___: lasts >3 months, don't always know what is causing it

1. Nociceptive pain 2. Neuropathic pain 3. Acute pain 4. Chronic pain

ALS: OT INTERVENTION: Goal setting for early stages? (4)

1. Optimize strength and range of motion using home exercise programs. 2. Maintain function in ADL and IADL through use of assistive or adaptive devices. 3. Decrease pain and fatigue through use of splints and orthotics. 4. Implement joint protection, pain management, energy conservation, and work simplification techniques.

OUTCOME MESAURE FOR LOW BACK PAIN: -Based upon original ___1___ -Designed for LBP patients, but used for other conditions as well -Measures patient's perceptions of their levels of disability -Scoring system allows for determination of percentage of perceived disability -Several versions have been constructed over the past 25 years and found to be reliable and valid XXX

1. Oswestry Low Back Pain Questionnaire

___1___: you have to work muscle to a certain extent to exert soreness (NOT bad :) ) -Can only do isometrics with pts with MMT grade of 1+

1. Overload principle

___1___: -Cancer -Pacemaker -Pregnancy -Cog/sensory/vascular impairment -Deep Vein Thrombophlebitis

1. PAMS: General Contraindications

Treatment of Spasticity?

1. Passive stretch 2. Wt. bearing positions 3. Active movement in opposing direction 4. Splint: dynamic & resting 5. Oral medications: Baclofen 6. Botox injection 7. Surgical Interventions: tendon lengthening, tendon release, tendon transfer 8. Reducing spasticity does not result in automatic improvement in function 9. OT must manage spasticity to prevent soft tissue contracture, prevent deformity & maintain a flexible arm

___1___: [ONLY a PREP activity; do NOT use in isolation] -Physical Agent Modalities: o Preperatory Intervention o Enhance treatment i.e. ROM o Prepare soft tissue for therapeutic procedures o Should never be used in isolation: must be linked to function

1. Physical Agent Modalities (PAMS)

Edema Evaluation: -Volumetric measurement -Circumferential measurement -Sensibility Test Monofilament Sensory deficit can range from decreased light touch to loss of protective sensation to loss of deep touch -___1___: apply pressure to swollen area depressing skin w/ a finger. The pressure causes indentation that persists for some time after release of the finger. -___2___: pressure that is applied to the skin that does NOT result in a persistent indentation

1. Pitting edema 2. Non-pitting edema

GBS: OT Evaluation: -Referral to OT services is common when course of GBS is moderate to severe -During ___1___, screening may involve areas of communication, control of the E as appropriate, comfort & level of anxiety -During ___2___, evaluation surrounds areas of mobility, self-care, communication, leisure and reintegration into school/work as appropriate

1. Plateau phase 2. Recovery phase

GBS: Interventions: *Acute Phase* (often on vent, with respiratory problem, fatigued)? (3)

1. Prevent contractures: ROM activities & splinting (functional hand splints) 2. Preventing secondary complications/ skin breakdown 3. Want to *MAINTAIN*

GBS: Interventions: Recovery Phase? (10)

1. Provide activities & splints to maintain ROM 2. Transfer training & functional mobility 3. Train in modified self-care techniques 4. Adapt modes of communication according to client's priorities 5. Encourage community access 6. Encourage participation in routine activities as appropriate 7. *Adapt* equipment to increase participation in leisure & work activities Train in energy conservation & fatigue management strategies 8. *Modify* tasks and E as appropriate 9. Provide home program for strength, coordination & sensation 10. Focus on *restoring* & improving strength to return to prior roles

GBS: Interventions: *Plateau Phase* (watch TV, adapt so can do things, start educating the pt.)? (7)

1. Provide temporary modifications 2. Develop communication tools 3. Ensure access to nurse call button TV and lights as appropriate 4. Adapt telephone for hands free access 5. Modify lying and sitting positions for optimal function & comfort 6. Position for trunk, head & UE stability 7. Educate about GBS & strategies to reduce anxiety

COURSE OF MS: Categorized into 4 types? (4)

1. Relapsing remitting 2. Secondary progressive 3. Primary progressive 4. Progressive relapsing

Bilateral Training: -___1___: Metronome -___2___: Stroke survivor copes movement of the unaffected arm with the affected arm while looking at the unaffected side through mirror

1. Rhythm Rehab 2. Mirror Therapy

___1___: -Biggest thing is elevate body -Pt is going to left with hips and lean head forward and to the right (if para go above knee cap), pt can have knees on footrest or on ground -Common mistake-> pt doenst move hand far enough out (need room for butt on transfer), in addition to not enough elbow flexion to start & keep shoulders down -*SCOOT FORWARD IN W/C TO START ANY TRASNFER, THEN CAN INSERT BOARD* -Want 1/3 under pt, 1/3 in air, 1/3 on mat -If board moves you have to lift butt higher to unweight board

1. SCI Transfers

Scar Management-> ___1___ o Only initiate after scar can withstand friction o Apply deep pressure in circular or perpendicular pattern on the scar o Use lotion to reduce friction o Should be performed three times daily o Aids in desensitization

1. Scar Massage

Scar Management-> ___1___ o Works 24 hours a day o Increases hydration to the region o Protects from infection o Modulates growth o Decrease itch and pain

1. Silicone + Light Compression

___1___: increase in the involuntary reflex activity in response to stretch Evaluating spasticity: 1. Motor assessment: min, mod, severe 2. Std. assessments: i.e. Modified Ashworth Scale

1. Spasticity of the UE

___1___ (how lymph is moved) imbalance with this can lead to edema: o The balance of the fluid moving in and out of vessels on a cellular level o Arteriole hydrostatic pressure ♣ Pressure in arterial vessel wall o Osmotic Pressure ♣ Pressure in the interstitium

1. Starling's Equilibrium

___1___: when head of humerus moves up & hits head of the fossa

1. Superior Migration

___1___: -Key Movements o UE's are fully intact o limited trunk stability o improved endurance -Abilities: ADL's should be I w/c level or bed level with use of manual w/c. -Mobility: Few individuals are capable of limited walking with extensive bracing ( requires extremely high energy demand and puts a lot of stress on upper body

1. T1-T9

MULTIPLE SCLEROSIS (MS): TRUE OR FALSE: -Demyelinating disorder of CNS? ___1___ -More in women? ___2___ -Cognitive and sensory deficits aren't present? ___3___

1. TRUE 2. TRUE 3. FALSE

Seizure Precautions? (4)

1. Tactile simulation, and slow ROM 2. Monitor: HR, BP & facial color 3. Autonomic changes: sudden perspiration or increase in restlessness 4. Avoid rapid, repetitive stimuli (i.e. vibrations, flickering lights, etc.)

OUTCOME MESAURE FOR NECK PAIN: -___1___ was developed in 1989 by Howard Vernon. The Index was developed as a modification of the Oswestry Low Back Pain Disability Index with the permission of the original author -The NDI has become a standard instrument for measuring self-rated disability due to neck pain and is used by clinicians and researchers alike. -Each of the 10 items is scored from 0 - 5. The maximum score is therefore 50. The obtained score can be multiplied by 2 to produce a percentage score. Occasionally, a respondent will not complete one question or another. The average of all other items is then added to the completed items.

1. The Neck Disability Index (NDI)

___1___: Use of mild electronic impulses to block pain messages & endorphins -Noninvasive pain relief -*Contraindications:* pts w/ cog deficits, pregnant women, pts w/ pacemaker or any other implanted electronic device, pts who have an allergic response to electrodes/gel/tape, electrode placement over dermatological lesions i.e. dermatitis, eczema, application over the anterior aspect of the neck or carotid sinus & pts who have epilepsy

1. Transcutaneous Electrical Stimulation (TENS)

PD: 3 Cardinal Signs? (3) *These clinical signs are used for diagnosis*

1. Tremor: Usually resting tremor, increases w/ stress, may represent as "pill-rolling" 2. Bradykinesia: ♣ Lack of facial expression ♣ Slowness of movement ♣ Akinesia: w/o movement "freezing" ♣ Loss of eye blinking movement 3. Muscle Rigidity: ♣ Stiffness in musculature ♣ Cogwheel- jerky movements when the muscle is passively stretched

___1___: -Active malignant tumor -Sensory issues -Inflected areas -Growth plates -Pregnancy -Area near pacemaker -Some joint replacement (cemebted or plastic) -Thrombophlebitis -There are additional contraindications, but not common w OT see text. -Precautions: fractures, plastic and metal implants, primary tendon repair and breast implants

1. Ultrasound Contraindications

Upper Motor Neuron Involvement of ALS results in following? (3) [wsh]

1. Weakness 2. Spasticity 3. Hyperreflexia (overresponsive reflexes)

Pressure relief: -C7 need to do pressure relief ___1___

1. for 60 seconds every 15 min

Life Expectancy of SCI: live as long as peers but common causes of death are: ___1-2___

1. pneumonia 2. septicemia

____1___: are the nation's most common and costly occupational health problem, affecting hundreds of thousands of American workers, and costing more than $20 billion a year in workers compensation.

1. repetitive strain injuries

SPLINTING for PAIN: -Splint of the upper extremity may be necessary if contractures occur -Splint use is alternated with tasks -Total immobilization could lead to increased pain and dysfunction -Rheumatoid arthritis: ___1___ maintain joint alignment, reduce inflammation and pain during flare ups -CRPS: ___2___ may provide pain relief • Gentle ROM

1. static splint 2. static resting splints

Respiratory complications for any pt above ___1___: -Intervention: change positions, get pt on the stomach to aerate different lobes of lungs & drain lobes, precussion/vibration to remove secretions -High spinal cord injuries often breathe with accessory muscles to breath bc that's all they have available to them, so, strengthen these muscles -Use a spirometer for breathing have pt suck in as far as they can

1.T12 (don't have all respiratory muscles until T12...)

*Refer to AMP Patient Education Packet as well :) (SKIM!)

:)

Prognosis SCI: -It depends! -Surgical intervention Continued numbness/tingling -Traumatic -May have return quicker than expected at times Pending period of spinal shock -Focus on current level of function & goals

:)

Selecting Intervention Approaches: -Consider the following questions: -How much is expected from the person? -How much learning & generalization are expected? -How much do the activity demands or context need to be changed/altered to meet the pt.'s capabilities? i.e. this is where we do activity analysis of pt in natural/LRE and see what is inhibiting pt from successfully participating in the activity -Is the pt. responsive to cues? (can inhibit learning process think adaptation if needed) -Is the pt. aware of their difficulties? (less self-awareness causes more impulsivities/decreased safety bc they are unaware of precautions)

:)

ASIA Scale?

A: Complete B: Incomplete sensory only C: More than 50% of the key muscles below the neurological level have a muscle grade less than 3/5 D: More than 50% of the key muscles below the neurological level have a muscle grade ≥ 3/5 E: Normal

-Symmetric muscle weakness at least two limbs and mild *distal sensory loss (starts distal!)* -Progresses and reaches its maximum in 2-4 weeks (Phase of GBS)

Acute Inflammatory Phase

♣ Measures pain interference with daily functions ♣ Pts rate on an ordinal scale how much their pain interferes with

Brief Pain Inventory (BPI)

___1___: -There is no function below the level of injury if the spinal cord injury is complete: o No movement o No sharp/dull sensation o No hot/cold sensation o No vibration sensation o No light or deep touch sensation o No Proprioception sensation

COMPLETE SCI

-Not Evidence based treatment, based on anecdotes -Heat ♣ 71.6 - 98 degrees F ♣ Will increase flow and decongestion -Cold ♣ No lower than 59 degrees F -Hot for 3 minutes, Cold for 1 minute (end on cold)

Contrast Baths

o Pale o Painful o Less moist o Cap refill absent or prolonged o Edema o Diminished sensation o Reticular dermis involved o May heal in 3-4 weeks or may require grafting; definite hypertrophic scarring occurs and potentially significant wound contraction

Deep Partial Thickness Burn (Second Degree Burn)

Common term used: ♣ Kinesio Tape -Tape puts movement on skin in opposite direction and put pressure on lymphatic structures to increase absorption -Increases flow by increasing space in structures

Elastic Tape

-Inconsistency in evidence -Transcutaneous Electrical Nerve Stimulation (TENS) -Low Intensity Laser Therapy (LILT) -Non Thermal Ultrasound

Electrical Modalities

o Elevate hand above the heart (if not contraindicated) o Ski Hill Position o Airplane Hanger Position o Elevation during Sleep o Pic on left is more common but pic on right is more realistic

Elevation

#1 cause of TBI in adults over 65?

Falls

o Black to mottled red/brown to pale, waxy white o Leather appearance o May be insensate o No capillary refill o Edema o Epidermis and dermis destroyed o May heal in 4-6 weeks: significant hypertrophic scarring and wound contraction occurs

Full Thickness Burn (Third Degree Burn)

-functional components/factors of work, coordination, kinesiological evaluation of work motions, organizational ability, comparison of functional abilities of workers with the physical demands of the job

Functional Approach to job analysis

-"A systematic method of measuring an individual's ability to perform meaningful tasks on a safe & dependable basis" -Purpose is to collect info about the functional limitations of a person with medical impairment

Functional Capacity Evaluation (FCE)

♣ Rating scale of 0-5 ♣ Pts are asked to rate the pain as either "tolerable" or "intolerable" ♣ The pain interferes with function

Functional Pain Scale

-Short stay to stabilize symptoms with medications -OT evaluates and determine next step in care

Inpatient Acute Care

-May last one, to several weeks, with daily therapy -Patients need to tolerate 3 hours of therapy -Focus is to get the patient back to *previous functional level* as much as possible *(want to get them back to functionally level just prior to injury, not rehabbing old impairments)*

Inpatient Rehab

-Intervention focuses on *establishing or restoring* the client factors or impairments that results from the injury -Also focuses on preventing the development of a secondary impairment

Intervention during coma recovery phase

-Maintenance care -Unable to stay home due to amount of assistance needed, caregiver is unable to provide necessary care, and not safe at home

LTC

-Resuscitation -Management of respiratory dysfunction -Cardiovascular monitoring -Surgical, pharmacological, or decrease intracranial pressure -Neurosurgery to manage lacerated vessels & depressed skull fractures -Pharmacological Interventions: Antibiotics Anticonvulsants Sedatives Antidepressants

Medical Management of TBI

-risk & stress factors; safe & healthy work practices, analysis of injury prevalence, human function parameters (usually monitored by a OH&S nurse)

Medical approach to job analysis

NECK DISABILITY INDEX: 0 - 4 = no disability 5 - 14 = mild 15 - 24 = moderate 25 - 34 = severe above 34 = complete. -Please note: This means 15-24 out of 50 (the RAW SCORE) equates with moderate disability. -It is recommended that the NDI be used at baseline and for every 2 weeks thereafter within the treatment program to measure progress. As noted above, at least a 5-point change is required to be clinically meaningful. Patients often do not score the items as zero, once they are in treatment. In other words, it is common to find that patients will continue to score between 5 - 15 despite having made excellent recovery (i.e., they may be back to work).

NDI Interpretation :)

♣ Stroke ♣ Tumor ♣ Infection ♣ Toxin

Non traumatic brain injury

-O2 consumption, energy expenditure, environmental impact (noise, cold)

Physiological Approach approach to job analysis

-No significant changes -Lasts for a few days/weeks- greatest disability is present (Phase of GBS)

Plateau Phase

-Remyleination and axonal regeneration occur -May las up to 2 years; average length is 12 weeks -Recovery starts @ head & neck -50% of clients have complete return of function, 35% experience some residual weakness that may not resolve -15% experiences more permanent & significant disability -Fatigue is most common residual problem (Phase of GBS)

Progressive Recovery Phase

-Steady decline in neurological function from onset with superimpose relapses with or without full recovery -Between relapses, the disease progressively worsen -Least common type of MS

Progressive Relapsing

-RPE, comparison of physical to mental stress, job satisfaction, work culture, emotional & behavioral components

Psychological/psychosocial approach to job analysis

-Also known as Reverse Total Shoulder Arthroplasty (RSA) -Surgical procedure to address Cuff Tear Arthroplasty (CTA) or 3-4 part fractures of proximal humerus w deficient RTC -POC? (see pic :) )

REVERSE SHOULDER REPLACEMENT

o Bulky Dressing o Elevation: *Contraindicated for pacemaker & right CVA* o Cold Packs o Retrograde Massage o Compression o Exercise o Elastic Tape

Reduction Techniques for Acute Edema

-Most common type of MS -Acute worsening of neurological function - -Lasts days to months, followed by full or partial recovery -Stable periods of remission between attacks

Relapsing Remitting

-Starts with a relapsing remitting course that changes into a steady pattern of progressive decline -There is a continued neurological deterioration (Type of MS)

Secondary Progressive

o Can be used for fingers with edema o Placed around finger circumferentially, creates squeezing effect o Wrap distal to proximal

Self Adherent Wrap

-Controlled application of sensory stimuli in an organized way -Based on belief that through systematic stimulation, a change can be brought about that results in a response, thus increasing arousal

Sensory stimulation programs *Used in earlier states of TBI/coma, sensory stimuli can be auditory, tactile, visual, reading a book to the pt, anything that is meaningful to the pt. *

After Reverse TSR, *Pts were held in an abduction pillow for 6 weeks before starting therapy. As the home care therapist, you would focus on one handed techniques, pain management and ROM of the uninvolved -NO IR until after 6 weeks FRACTURES: A STUDY BY GARRIGUES ET AL 2012: -Hemi-arthroplasty o Mean elevation: 90d o ER: 31d o Functional outcomes: ASES 47, Penn Score 53 -Reverse TSR o Mean elevation: 122d o ER: 33d o Functional outcomes: ASES 81, Penn Score 82

Studies :)

Space below acromion & above the humerus

Subacromial Space

o Dry o Charred appearance o Muscle/ bone exposed or visible o Definitely requires grafting; possible muscle flap for coverage; definite hypertrophic scarring

Subdermal Burn (Fourth Degree Burn)

o Practice Pattern 7C - Impaired Integumentary Integrity Associated with Partial Thickness Skin Involvement and Scar Formation o Pink-red o Painful o Blisters o Moist o Blanching o Edema o Papillary dermis o Heals in 7-10 days with minimal scarring and minimal wound contraction

Superficial Partial Thickness (Second Degree Burn)

TEACHABLE MOVEMENT: • Importance of wrist extensors • Tenodesis action • Tenodesis splint • PROM precautions http://wn.com/quadriplegic_woman_holding_a_cup

Tenodesis Grasp (C6) -NEVER EXTEND THIS GRASP BC WILL LOSE IT

-Often therapist also must address joint and tissue stiffness -Heat between 71.6 - 105.8 degrees F increases lymph flow -However, above this temperature can cause additional swelling -Can include ♣ Hot Packs ♣ Fluidotherapy

Thermal Modalities

When we d/c a pt they may come back to receive more OT services as life changes

duh :)

o Stockinette bags filled with various densities and sizes o Can be worn under bandages, with loose compression gloves or orthoses

Chip Bags

♣ Red ♣ Dry ♣ Painful ♣ Usually heals within 3-4 days without scar

Classic Sunburn

-Light compression (can go in either direction, prox distal or distal prox) ♣ Elastic glove ♣ Coban ♣ Low stretch finger bandage wraps -Helps with absorption of molecules -Precaution: ♣ Make sure not too tight ♣ Does not "roll down" and create additional swelling

Compression

-An exchange of heat when 2 surfaces come in contact with one another -Heat is transferred from the warm object to the cooler one -Hot packs, paraffin

Conduction

• Adapt the workplace to the worker • Support work in the way it is done • Provide appropriate user control • Emphasize ease of use • Provide for Personalization of Space • Train people in the proper use of equipment.

Ergonomics Strategies

hand coordination, balance, strength, ROM, functional mobility, etc. To engage in functional activities

Establish/restore: TBI *Prevent & establish/restore for early TBI rehab*

-pt. unable to get out of the house/ unconditioned to travel -Patients are home bound. Not able to attend outpatient therapy -Focus is to maximize independence in home environment

Home Therapy

What causes edema post stroke? (3)

Loss of muscle activity, hyposensibility & flaccid extremity

routing stretching to maintain ROM, postural alignment w/ proper w/c support

Maintain: TBI *Tough w/ ABI to maintain social relationships for later rehab*

"Any process in which the human operator is asked or required to lift, lower, push, pull, carry or perform any other similar task in which an object is moved through space solely under the power of the human operator"

Manual Materials Handling (MMH)

Continuum of care: Neurodegenerative Diseases?

inpatient acute care -> inpatient rehab -> outpt therapy -> home therapy -> LTC

♣ Measures subjective pain experience ♣ Used to study effects of pain management on quality & interest ♣ Results: 3 qualitative measures to assess quality of pain: -Pain rating index (numerical value assigned to each word descriptor) -Number of chosen words -Present pain intensity (scale 1 to 5)

McGill Pain Questionnaire (MPQ) general activities

Approaches to job analysis? (5)

Medical, biomechnaical, psychological/psychosocial, physiological, functional

adapt E/activity demands ex. adjust lighting, noise level, visual stimulation, AD to perform an activity

Modify: TBI *Modify approach later in the rehab process *

-Sustained pressure on soft tissue -Results in elongation of the fascia and ground substance -Additional education needs to be completed to use this technique

Myofascial Release

Reduction Techniques for Chronic Edema? -Chronic Edema is persistent edema that lasts more than 3 months; Is hard or difficult to pit

o Low stretch bandaging o Chip Bags o Self-adherent wrap

2-6 weeks post op RTC surgery?

o Passive ER @2-4 wks post op; NOT beyond 30 degrees

-Patients are not home bound -Therapy sessions can be from 45 minutes to 60 minutes -Focus is to maximize independence in home and community

Outpatient Therapy

♣ Rating scale 0-10 ♣ Designed to measure impact of chronic pain on functional activities, such as family/home responsibility, recreation, etc.

Pain Disability Index

Medical Complications of SCI? (7)

o Respiratory Complications: Impairment depends on muscles that are damaged o Pulmonary o Skin Compromise: need proper seating & positioning o DVT o UTI o Osteoporosis o GI complications

Non-traumatic causes of SCI?

o Vascular malformations o Vertebral subluxations due to RA or DJD o Infections o Spinal neoplasms o Syringomelia o spinal cord abscess o neurological diseases: MS, ALS o hysterical paralysis/ conversion reaction o congenital: spina bifida, severe scoliosis: cerebral palsy o iatrogenic: Radiation, Injections, surgical procedures

Neurological Level Stats?

o ≈ 41%: Incomplete tetraplegia o ≈ 22% complete paraplegia o ≈ 21% incomplete paraplegia o ≈ 16% complete tetraplegia

Total Shoulder Replacement POC?

Postop: Day 0-3: -Positioning: Sling-this may be discontinued early or be used for up to 6 weeks but varies by MD. When sleeping, position pillow under elbow to place shoulder in slight elevation -Pain management: some patients will have cryotherapy cuff from hospital stay. Consider a frozen bag of corn or peas (place towel between bag and skin: perform skin checks) -*AROM* of uninvolved joints (elbow, forearm, wrist and digits -*Pendulum Exercises: passive only.* Instruct the patient to use their body to perform the pendulum exercises (clockwise and counterclockwise: 3-5 x daily 10 reps each direction) -ADLs: teach 1 handed techniques. Client may use involved externity for waist-level tasks w shoulder adducted to side *See rest of plan in pic!

-Steady decline in neurological function from onset (Type of MS)

Primary Progressive

o Contrast Baths o Electrical Modalities o Thermal Modalities o Elastic Taping o Manual Edema Mobilization (MEM) o Massage o Myofascial Release o Pneumatic Pump o Exercise o Low stretch bandages o Compression Gloves o Chip Bags

Reduction Techniques for *Subacute* and Chronic Edema

Superficial Thermal Modalities? (5) (According to ACOTE 2011)

o Hydrotherapy/whirlpool o Cold pack/ice packs o Paraffin o Water (contrast bath) o Infrared

6-12 weeks Post Op RTC Surgery?

-A/AAROM ♣ Ideal is to begin supine: prevents hiking • Gravity lessened position (cane exercise) ♣ Progress to A/AAROM against gravity • Wall walking should NOT begin until client is okayed for AROM (if hiking or pain occurs, continue w/ AROM supine); consider towel glides on client's kitchen table -In patient's home, A/AAROM can be achieved via ADLs: ex. reaching into cabinets (thumb up); at this time, no lifting any more than the weight of a spice containers ♣ Watch for scapular hiking o AROM can be achieved via ADLs: ex. dressing involves both IR and ER; Make sure IR to small of back is OK by MD

Precautions & Contraindications for KT Tape?

-Allergic reaction or intolerance to material -Improper tension -Caution should be used with the geriatric population -Do not use if: o Infection present o Fragile healing tissue o Cellulitis -Disclaimer : Further education or supervision required to perform these techniques

PD: OT Evaluation? -*OT most often required during intermediate and later stages of PD*

-Balance assessment (Berg Balance Test) -Swallowing or other mealtime problems -Fatigue & cognitive problems -Sleep disturbances -ADLs & IADLs (FIM) -Home evaluation -Coordination & manipulation -Postural instabilities & their impact on occupations -Safe mobility -ROM test -Bradykinesia, postural instability & rigidity that affects occupational performance -Psychosocial issues -Work evaluation in early stages to reduce risk of unemployment

Occupations at work for CTD?

-Process work (assembly line, sorting, packing and press operation) -Piece work (clothing machinists at home or in a factory) -Office work (keyboard, typing, clerical work) -Mail sorting -Kitchen work -Cleaning (janitorial) -Hairdressers -Musicians -Construction workers (bricklayers, carpenters, plumbers, tilers) -Manual handling (objects or people)

PD: Progression? (5 Stages; MEMORIZE :) )

-Stage 1: unilateral symptoms, no or minimal functional implications, usually a resting tremor -Stage 2: midline or bilateral symptom involvement, no balance difficulty, mild problems with trunk mobility & postural reflexes -Stage 3: Postural instability, mild to moderate functional disability -Stage 4: Postural instability increased, able to walk; functional disability interferes w/ ADL; decreased manipulation & dexterity -Stage 5: confined to w/c or bed

Craniotomy Precautions? (2)

1. Avoid direct pressure to the area 2. Wear helmet at all time when out of bed

GUIDELINES FOR ACTIVITY AFTER LUMBAR SPINE SURGERY? (10)

1. Avoid twisting low back 2. If u need to turn, do by movng your feet 3. When getting OOB, log roll onto your side then sit up from sidelying position 4. Don't lift > 10 lbs 5. No forceful pushing/pulling heavy objects 6. Don't bend over from waist 7. If u must pick up from floor, squat. 8. Walking is encouraged to your tolerance 9. Limit sitting in chair to 30 mins at time, 4x/day 10. Discontinue other back exercises that u may have been doing prior to surgery

BOWEL CARE: -May not function the way it used to -Steps for safety: ____1-7___

1. Establish a regular time for bowel care - usually 30-45 min after a meal (most commonly breakfast or dinner) 2. Make sure all equipment is present 3. Check for stool 4. Insert Stimulant medication 5. Wait 5-15 min 6. Digital Stimulation 7. End of Bowel Care

Purposes of FCE? (3)

1. Improve likelihood that a person will be safe in subsequent job task performance (match worker's capacity to the job demands) 2. Assist the person to improve role performance by IDing functional decrements. Triage person intro proper treatment programs & measure treatment progress 3. Determine the presence & degree of disability i.e. judicial entity can assign, apportion or deny financial & medical benefits

___1___: o Partial loss of sensory and motor function below the level of injury o Includes sparing of the sacral segment o Anal motor function and/or sensation are intact

1. Incomplete SCI

ASAI Definitions: -___1___ Most caudal level with intact sensation and motor on both sides of the body -___2___ Most caudal level with 3/5 strength AND with all higher levels at 5/5 on both sides of the body -___3___ Most caudal level with intact sensation on both sides of the body -___4___ Used only with complete injuries Most caudal segment with some motor or sensory function -___5___ No motor assessment for the trunk Assume motor and sensory at same level

1. Neurological level 2. Motor Level 3. Sensory level 4. Zone of Partial Preservation 5. Trunk

Upper Limb Conditions:Rotator Cuff Tears (SITS): -Can happen anytime your arm is over your head & IR at risk for problems, especially supraspinatus -Intrinsic: Degenerative changes due to the aging process -Extrinsic: Compression and impingement of rotator cuff ___1-3___

1. Subacromial bursa; side from acromial spurs & coracoacromial ligament (during elevation & IR) 2. Trapping of the tendons on the articular side (during extreme abduction & ER) 3. Shape of acromion

PAM: -___1___: ♣ Thermal agents: hot packs, paraffin, fluidotherapy ♣ Colling agents: ice packs, ice pops (cup with water put stick in there & freeze i.e. do this exactly on lateral epicondyle) -___2___: ♣ Electrical modalities: TENS, HVGS, NMES, Iontophersis, etc. ♣ Mechanical agents: whirlpool, ultrasound, vasopneumatic pump

1. Superficial 2. Deep

OUTCOME MEASURE FOR MUSCULOSKELETAL DISORDERS OF THE UPPER LIMB: -___1___ was jointly developed by the Institute of Work and Health (CA) and the American Academy of Orthopaedic Surgeons (AAOS). • The questionnaire was designed to help describe the disability experienced by people with upper-limb disorders and also to monitor changes in symptoms and function over time. Testing has shown that the DASH performs well in both these roles. • It gives clinicians and researchers the advantage of having a single, reliable instrument that can be used to assess any or all joints in the upper extremity. • The Quick DASH is a shorter version that is more commonly used by therapists.

1. The DASH Outcome Measure

Lower Motor Neuron Involvement of ALS results in the following? (5) [MCWCFR]

1. Weakness or muscle atrophy of the extremities 2. Cervical extensor weakness 3. Fasciculation (flicker of muscle) 4. Muscle cramps 5. Loss of reflexes (so, prone to FALLS)

BICU (Burn ICU) Admission Criterion (need one of these to be admitted): o 20% or greater total body burn o 10% or greater burn of child or elderly o 5% or greater full thickness injury o Burns to hands, feet, face, perineum o Burns to eyes or ears o Any suspected inhalation injury o All electrical and chemical burns o Patients with pre-existing illness o Patients with associated injuries

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PAMS: TIPS: -Competence must be established for any and all PAMs used in OT -Be aware of state licensure laws -Establish competency and supervision of OTA when using physical agent modalities -PAMS should not be used in isolation. Preparatory.

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SCI NOTES: -Front on back off transfer: Position wheelchair facing bed or mat; pt should push down with both arms; lean to one side to un-weight the opposite side and move forward; caregiver can assist under the thigh -C4 SCI -> C4 is intact; it's the last vertebrae intact that it's named off of

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-Maintain a client centered approach to the treatment of UE dysfunction -Eval & plan treatments that focus on improving occupational performance -Focus treatment of task specific training -Incorporate resistance training into treatment plans -Maintain mobility of the scapula and humeral ER to prevent pain syndromes and prepare for retyrn of function -Maintain soft tissue length and joint mobility in the trunk, head and neck, and affected UE -Provide appropriate positioning strategies for times when patients are not involved in activities -Provide opportunities for patients to use the UE outside of structure therapy time -Train all caregivers in the appropriate handling of the more affected UE during ADL and mobility -Eval and treat pain syndrome immediately and consistently until symptoms are alleviated -Grade activities systematically and with control to increase level of control and functional use -Prevent learned nonuse by incorporating the UE into daily life immediately after CVA -Avoid the use of aggressive PROM and overhead pulleys -Encourage patients to take responsibility for the protection, maintenance & improvement of their more affected UE

General Tx Principles for UE Dysfunction

-Begins *as soon as the pt. is medically stable & out of coma* -Must address the pt.'s physical, cognitive, communicative, emotional and spiritual needs while planning for their transition -The pt. can transition to sub-acute, outpt. or home in the community

Intervention: During Acute Rehab Phase

-Developed by Sandra Artzberger in 1995 ♣ Used concepts from MLT (lymphedema treatment) and applied to traditional edema -Used to reduce subacute edema where substance are congested within the interstitium due to damage to lymph structures ♣ Typically contraindicated for acute care setting -A full MEM program takes 30 minutes ♣ Short version take 15 minutes -Can be combined with other techniques ♣ MEM should be performed before other techniques -MEM decongests most proximal edema, creating space for distal edema to move proximally

Manual Edema Mobilization (MEM)

Glasgow Coma Scale (used initially for evaluation & continuously)

-Neurological scale which records the conscious state of a person -Used for initial evaluation & continuously to assess & determine a person's level of consciousness -Eye + Verbal + Motor = GCS [Scale 3-15] -Minor GCS: 13-15 (15 is fully conscious person) -Moderate GCS: 9-12 -Severe GCS: 3-8 (3 is deep comma or death, the lowest total GCS) *P.1045 table 34-1* -Also an outcome measure scale of how the pts. Progress will be -Higher the number the better

Fatigue (often fatigue more quickly than normal population bc they require extra attention to complete a task): -Physical fatigue: from muscle weakness, body has to work harder to do things that were easy before injury -Psychosocial fatigue: associated w/ anxiety and stress, sleep doesn't help with this fatigue and stress increases it -Mental Fatigue: person cannot focus/concentrate

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Motor Recovery: -Clinical presentation mat include hemiparesis, hemiplegia, ataxia, synergies, abnormal tone, postural instability, impaired motor speed, weak grip strength and general weakness

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Symptoms of TBI: -ABI can affect physical, cognitive, emotional, behavioral and family status -Signs & symptoms may occur alone or in varying combinations, which can affect an individual's occupations -Symptoms generally fall into 3 categories: Physical (what we will be focusing on in this class) Cognitive Psychosocial/Behavioral

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The OT is performing an initial bedside consultation on a CVA pt. The pt. presents w/ a flaccid left UE & demonstrates impaired sensation throughout the arm. Based on prioritization of the individual's needs, the initial recommendations would include: A. Positioning, compression glove & edema massage, followed by PROM exercises B. Splinting, elevation of the arm, & AROM exercises C. No action until edema subsides D. Have pt. attempt to squeeze a ball

Answer: A -Positioning, compression glove & edema massage, followed by PROM exercises

A 55-year-old mail carrier w/ a left CVA is being evaluated for functional transfer skills. The most important element of developing an objective of the pt.'s abilities is the: A. Pt.'s description of his transfer abilities B. Performing Berg Balance test C. The pt.'s goal of independence in transfer from shower chair to w/c D. Observation of transfer abilities from walker to the therapy mat

Answer: D -Observation of transfer abilities from walker to the therapy mat

Skin compromise: -Pressure ulcers-> pt has to be off that site so become more deconditioned -Interventions: air mattress so don't have sustained pressure, tell pt to sleep on stomach so bony prominences really are only knees & also can expand lungs -Use long handled mirror to check skin

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TYPES OF CURRENT & WAVE FORMS: -Current: movement of ions from 1 point to another o Direct current (DC) o Alternating current (AC) o Pulsating current -Wave forms o Monophasic wave form o Biphasic wave form o Polyphasic wave form

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Intervention Process for Neurodegenerative Diseases? (~4 but elaborated lol :) )

*Goal setting:* -Goals need to be individualized -Prioritize activities based on clients' goals -The primary goals of intervention are to reduce the effects of disability, maintain or maximize independence in occupations and improve quality of life -Due to the progressive nature of the disease frequent reassessment and reordering of goals may be necessary *Treatment strategies for self-maintenance roles:* -Assisting in setting priorities -Educating on how the disease process affects motor or cognitive changes -Environmental modifications at home to promote safety and independence -ROM and strength exercises to facilitate and maintain occupations -Behavior modification such as use of energy and time management techniques -Using technology to compensate for cognitive deficits, such as create grocery list, calendars, etc. -Balance independence with assistance from others *Work:* -Critically review job expectations -Suggest modifications to the work environment -Recommend equipment -Identify resources -Make recommendations to the individual for the employer *Leisure:* -Maintaining leisure pursuits may be a high priority, but they are often the first roles to be abandoned. -Occupational therapists can help to modify activities, provide transportation solutions, use technology, and provide proper equipment to allow clients to continue with leisure pursuits

PD: Medical Management? (7)

-No cure -Only symptoms are managed using medications -Pharmacology: Sinement (Levodopa/Carbidopa), dopamine agonists, Congentin for rigidity & tremors -Side effects are common when disease is managed pharmacologically ♣ *Dyskinesia (involuntary movements)* (EXAM ? :) ) -Deep Brain Stimulation ♣ Most effective for pt.'s who experience disabling tremors & medication induced dyskinesias -PD related death due to aspiration pneumonia, fall -Often thin because of rigidity & involuntary movement so often burning calories!

MS: MEDICAL MANAGEMENT? (~6) *(WEIGHT GAIN BECOMES A HUGE PROBLEM THAT AFFECTS FUNCTIONAL LEVELS)*

-No cure, and treatment is symptomatic -Acute exacerbation is treated with anti-inflammatory drugs, e.g. prednisone, cortisone, ACTH (adrenocoticotropic hormone) -Immune-modulatory medications (enhance immune response) e.g. Avonex, , Betaseron, Copaxone- these drugs have been shown to reduce number of lesion and the frequency and the severity of relapses -Mitoxantrone (Novantrone) is an immunosuppressant medication (suppresses immune system)- reduce number of acute attacks. it is rarely used because of side effects -Another class of medication Neurofunctional modifiers- treats MS symptoms. E.g. Dalfampridine drug has shown to improve walking ability in any type of MS clients. -Medications are also used to manage depression, spasticity, pain, bowel and bladder dysfunction, and sleep disorder

PROGRESSION OF ALS? (6 stages) *(fatigue is a big part of this disease process)*

-Stage I: Ambulatory, no problems with ADLs, mild weakness -Stage II: Ambulatory, moderate weakness in certain muscles, increase fatigue (energy conservation) -Stage III: Ambulatory, severe weakness in certain muscles, increased difficulty with ADLs -Stage IV: Wheelchair confined, almost independent, severe weakness in legs -Stage V: Wheelchair confined, dependent; pronounced weakness in legs, severe weakness in arms (caregiver education, preventing secondary complications, PROM/positioning) -Stage VI: Bedridden, unable to perform ADLs, maximal assistance required

12 weeks Post Op RTC Surgery?

-Strengthening is initiated: ♣ Begin w/ isometrics ♣ Hold count of 5, perform 8-10, 2x daily ♣ ER, flexion, elevation & abduction ♣ For pic below apply resistance on distal forearm; stabilize on muscle doing movement & start by finding spine of scapula; for ER be out to at LEAST 15 degrees ER o Progress to isotonic exercises o Pts are usually d/c from homecare before this stage & referred to outpatient OT

MS: OT Eval: -Occupational profile -Assess Fatigue and endurance:___1___ -Cognitive Screening: ___2___ -ADL, IADL and functional mobility assessment (FIM) -Assess dexterity: ___3___ -Sensory test: ___4___ -MMT, ROM test, grip strength -Vestibular evaluation -Home assessment -Spasticity Assessment: ___5___ -Visual evaluation -Work

1. *Modified fatigue Impact scale, 6 minutes walk test to assess endurance and fatigue 2. MACFIMS (minimal assessment of cognitive function in MS) or MOCA (Montreal Cognitive Assessment) 3. Nine-Hole Peg Test, Purdue pegboard 4. Weinstein Monofilaments 5. Modified Ashworth Scale

___1___: a broad term that describes a variety of traumatic & non traumatic injuries that can occur to the brain after birth

1. ABI

ALS: OT EVAL -Evaluation should be geared toward clearly defined levels of functional stage of ALS progression -Assessments: ___1-3___ -Reevaluations should be done on a regular basis due to the progressive nature of the disease

1. ALS Functional rating scale (http://www.neurology.org/content/suppl/2006/10/07/6 7.7.1294.DC1/E3.pdf) 2. Purdue pegboard, range of motion and manual muscle testing 3. Multidimensional Fatigue Inventory (http://link.springer.com/chapter/10.1007/978-1-4419- 9893-4_57#page-1)

Bed Mobility for SCI: ___1___: -With addition of triceps = ease of movement -Still difficult ___2___: -Momentum still key -Remains difficult as no abdominal muscles for trunk support ___3___: -Addition of abdominal muscles provides stability

1. C7-C8 2. T1-T6 3. T6 & below

___1___: -NIOSH (National Institute for Occupational Health and Safety) defines work-related musculoskeletal disorders as those diseases and injuries that affect the musculoskeletal, peripheral nervous and neurovascular systems that are caused or aggravated by occupational exposure to ergonomic hazards. -Cumulative Trauma Disorders (CTDs) indicates that these injuries developed gradually over periods of weeks, months even years as a result of repeated stresses on a particular body part. *NOTE: The term CTD is a description of the mechanism of injury and not a diagnosis.*

1. CUMULATIVE TRAUMA DISORDERS (Ergonomics Related Injuries and Illnesses)

RTC Protocol: -Protocols will vary depending on surgeon, size of repair, type of repair/tension & quality of tissue -SR found that no one protocol was superior over the other ♣ Common interventions include PROM, AAROM, AROM, CPM, Strengthening, aquatic therapy & no mention of ADLs/functional activities ♣ Aim is to increase ROM, strength & function American Association of Orthopedic Surgeons 2010 recommendations: Post surgical recommendations: ♣ ___1___to relieve pain: limited evidence but in favor of its use post surgery ♣ Lack of evidence & no recommendation of the following: sling/abduction sling, start of exercise (ROM or active resistance) & home base vs facility base

1. Cold pack :)

Lymph-> accumulation of tissue cells (can be healthy or cancerous, foreign objects, also have white blood cells) -Lymph starts ___1___ and wants to travel ___2___ (top takes 90%, bottom takes 10%)

1. Distally 2. Proximally

___1___: ___2___: -Gather information about client's value, role, previous and current strategies used to manage daily life. -Present concerns or problems -Interview needs to be sensitive to address area that might not arise such as fatigue, depression, sexual function, cognitive deficits that affect occupations. ___3___: -Focus on specific area or broad areas of occupational performance: ADLs, iADLs, work, leisure

1. EVAL (OCCUPATIONAL PROFILE) 2. INTERVIEW 3. OCCUPATIONAL ANALYSIS

Edema Treatment? (3)

1. Elevation & retrograde massage 2. Edema glove 3. In the earlier stages of post stroke edema, evaluation & light retrograde massage followed by edema glove on the hand can be effective for reducing hand edema

ABI Assessments? (4)

1. Fugl-Meyer: motor assessments (also ROM & strength) 2. Modified Ashworth Scale: tone 3. FIM 4. Jabson-hands, 9-hole peg test -> fore fine motor and light touch, for sensory

CTD INCLUDE 3 TYPES OF INJURIES: ___1___: -A muscle contraction that lasts a long time reduces the blood flow. -Consequently, the substances produced by the muscles are not removed fast enough, and they accumulate. -The accumulation of these substances irritates muscles and causes pain. -The severity of the pain depends on the duration of the muscle contractions and the amount of time between activities for the muscles to get rid of those irritating substances. ___2___: -Tendon disorders related to repetitive or frequent work activities and awkward postures occur in two major categories -Tendons with sheaths found mainly in the hand and wrist; -Tendons without sheaths generally found around the shoulder, elbow, and forearm. ___3___: -Nerves carry signals from the brain to control activities of muscles. -They carry information about temperature, pain and touch from the body to the brain, and control bodily functions such as sweating and salivation. -Nerves are surrounded by muscles, tendons, and ligaments. -With repetitive motions and awkward postures, the tissues surrounding nerves become swollen, and squeeze or compress nerves.

1. MUSCLE INJURY 2. TENDON INJURY 3. NERVE INJURY

___1___: -Normal structural imaging (may not see anything on CT scan) -Loss of consciousness (LOC): less than 30 minutes -Altered State of Consciousness (AOC): up to 24 hours -Post Traumatic Amnesia (PTA): 0-1 day -Glasgow Coma Scale (GCS): Score 13-15

1. Mild TBI (mTBI) AKA CONCONUSSIONS (used interchangeably)

___1___: -Normal or abnormal structural imaging -Loss of consciousness (LOC): 30 minutes-24 hours -Altered State of Consciousness (AOC): >24 hours -Post Traumatic Amnesia (PTA): 1-7 days -Glasgow Coma Scale (GCS): Score 9-12

1. Moderate TBI

___1___: -Based on a scale of 0-4; 0=no spasticity & 4= rigidity in flexion or extension -Pt. is placed in supine. If testing elbow flexors, place joint in max flexion and move to max extension over "1 second." -Grade of 4 is given when there is rigidity that is unable to be stretched and is considered a muscle contracture

1. Modified Ashworth Scale

Intervention: During Coma Recovery Phase: -___1___ -Focuses on either impairments that are primary due to injury or secondary impairments resulting from the immobility or excessive muscle tone -PROM, splinting, serial casting, positioning, pain control -Heterotropic Ossifications

1. Neuromusculoskeletal

Contributions to Activating Lymphatic System: Uninvolved Structures: ___1___ Proximal uninvolved structures must be stimulated: -Creates lower negative pressure -Works as a vacuum to draw edema out of involved area -Treatment includes: • Manual edema massage starting in uninvolved axilla • Diaphragmatic breathing stimulates lymph system • Trunk exercise • PNF Patterns

1. PROXIMAL TO DISTAL

Physiological Effects of Cold? (4)

1. Pain reductions Blocks sensory transmission 2. Muscle spasms reduced 3. Vasoconstriction Decreases histamine release resulting in diminished inflammatory response 4. Edema reduction w compression Little evidence supports that ice alone reduces edema

___1___: -High degree of local heat o 125-127d F o Less heat released during cooling bc of specific heat -Application by *dipping method* Remove jewelry Inspect skin Client washes hand and dries it thoroughly Dip hand 6-8x MOST COMMON METHOD USE THIS METHOD -Wrap w plastic or place in plastic bag Wrap w towel or special mitt Can combine w stretch Some OT wrap hand in hot pack over the paraffin (8 layers of towels) Tx 15-20 mins -Other methods: immersion not common but leave hand in there for 20 min and paint you can paint it on, but again not common, great for RA cant bill for this but can bill for educational session ♣ GET ONE WITH OIL IN THE WAX -Advantages; soothing, indication; especially effective w painful joints caused by arthritis; teach pt how to do paraffin at home, can by kit for cheap at Walgreens -Disadvantages: hand is static, not moving. Hypersensitive skin not solerant -Contraindications: open wounds, incisions, skin grafts, rash, recent scar, infections -Most paraffin machines have something built into them that keep them at the right temperature For paraffin you can't see the hand so you absolutely must make sure they have intact sensation! Very specific to hand and wrist area Can wrap limb in i.e. flexed position put isn't strong enough to hold it so may need to wrap w/ co-band?

1. Paraffin

Physical Demand Factors (PDF)? (3)

1. Strength: Lifting (NIOSH lifting equitation: RWL (recommended weight limit); for a given task, the weight that all healthy workers could perform over a substantial period of time without increased risk of LBP), Carrying, Pushing, Pulling, standing, walking sitting, climbing (ascending/descending stairs, ladders, scaffolding), balancing (maintaining body equilibrium to prevent falling during activities such as walking, standing, etc.), stooping (bending the body forward), kneeling, crouching, reaching (extending hands & arms in all directions), handling (Seizing, holding, grasping, turning or otherwise working with hands/fingers, fingering (picking, pinching, i.e. working primarily with fingers), feeling, talking 2. Hearing: ability to perceive the nature of sounds 3. Seeing: near & far vision acuities, depth perception (3D vision), accommodation (adjustment of lens of ete to bring an object into focus), color vision (ability to ID & distinguish colors), field of vision (observation of an area that can be seen up and down or to the right & left while eyes are fixed on a given point)

___1___: -Can be complete or incomplete injury -Loss or limited UE, LE limb function due to damage of cervical vertebrae -Impairments seen in arms, legs, trunk, neck and pelvic organs -Injury to C5 most common than C4, C6 -Eric Legrand - Rutgers University Football Player. Incomplete injury to C3 -C4 playing football

1. TETRA/QUADRIPLEGIA

Guillain-Barre Syndrome (GBS): TRUE OR FALSE: -GBS can occur after an infectious disorder, surgery or an immunization ___1___ -GBS is most prevalent in young males: ___2___ -An inflammatory disease resulting in axonal demyelination of peripheral nerves: ___3___

1. TRUE 2. FALSE 3. TRUE

ALS: OT INTERVENTION: In general for ALL stages? (7) *IMP TO KNOW STAGES & WHAT INTERVENTIONS TO DO IN EACH FOR EXAM :)*

1. Therapists need to consider client's financial resources, social and cultural context. 2. Quality of life 3. Caregiver Education 4. Exercise 5. Adaptive Equipment 6. Assistive technology 7. Dysphagia management

UE Weakness Following CVA: Evaluation? (2)

1. UE assessment of AROM and MMT 2. Determine how the weakness affects functional use, interview, observation and outcome measures

AUTONOMIC DYSREFLEXIA (AD)-> SIT THEM UP IMMEDIATELY -What is it? o Blood Pressure: HIGH o Heart Rate: LOW -Causes: o Overfilled bladder/possible kink in catheter line o Constipation o Infection o Pressure ulcers o Pain o Tight clothing/pressure o Certain Tests -Symptoms: o Severe pounding headache o Visual spots o Blurred vision o Slow heart rate o Nasal stuffiness o Goosebumps, sweating, and flushing of skin above level of SCI -What actions do you take if this occurs with your patient? SIT THEM UP IMMEDIATELY

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Scar tissue requires deep massage in order to decrease its hardness and allow it to move like skin Scar Management: -Scar tissue formation is a natural response to wound healing -Can take up to two years after injury to mature

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Tape Application: -Tissue Preparation o Clean skin (free of oils, hair, ect) o Perform ROM/Massage first, muscle must be pliable -Cutting the Tape o I, Y, X or Fan Shaped -Application o Start of tape is deemed the "anchor" o Percentage of stretch o Activation of tape -Anchor is typically to the origin or insertion of the muscle depending on the goal of intervention

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W/c pushup: -Pt presses on arm rests/tries to elevate themselves up (C7 and down can do this bc triceps; but some males C6 wants to externally rotate and extend elbows can do it) -*MAKE SURE SHOULDER BALDE IS DEPRESSED w/ ARM EXTENSION! IF NOT TRICEPS WONT BE ENOUGH FOR C7 and below; second mistake is elbow isn't bent enough before they start*

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-"Exercise is key to lymphatic activation" -Exercise moves lymph 10-30x faster -Proximal Activity ♣ Decongests lymphatic structures ♣ i.e. PNF patterns -Involved Structures ♣ Limited movement ♣ Check for signs of redness, swelling & pain

Exercise

-Brain injury can impede participation in life roles and activities (work, education, family life, leisure & social participation) -Community based programs focus on: ♣ Social & coping skills ♣ Return to role of student/worker ♣ Community mobility

Intervention: During the Community Phase *This phase is where pts make the least gains/progress; these areas require a lot of time for pt to improve*

-*Headache, dizziness, seizure* -Balance & coordination problems -Abnormal Reflexes -Ataxia -Broken bones -Visual & sensory loss (imp. To perform visual screen; may need to refer to ophthalmologist) -Muscle weakness -Abnormal muscle tone -Paralysis (hemiplegia or monoplegia) -Dysphagia -Fatigue *(most common is headache, dizziness, nausea/vomiting) *

Physical Symptoms of TBI

o Light massage type ♣ Very gentle ♣ Not to crush underlying lymph structures

Retrograde massage

Complications with SCI?

• Pain • Bowel/Bladder Issues • Tone • Pressure Ulcers • Respiratory Complications • Physical Deconditioning • Musculoskeletal Changes • Autonomic Dysreflexia • Circulatory Issues: Blood Clots Orthostatic Hypotension • Weight Management • Depression

___1___: -Cause is unknown. May occur after a viral infection, surgery or an immunization -Affects both sexes at any age -An inflammatory disease results in axonal demyelination of PNS starts with DSITAL WEAKNESS -Axonal damage can also occur

1. GBS

Examples of CTD's?

-Carpal Tunnel Syndrome: caused by compression of median nerve in the carpal tunnel of the wrist -Epicondylitis: tendons attaching to the epicondyle become irritated. -Shoulder Tendonitis: Shoulder disorder at the rotator cuff as a result of inflamed rotator cuff tendons. -Thoracic Outlet Syndrome: a disorder resulting from compression of nerves and blood vessels between clavicle and first and second ribs, at the brachial plexus -Tenosynovitis: Occurs to tendons that are inside synovial sheaths, when swollen, restricts movement of the tendon within the sheath. -Gamekeepers thumb: sprain of the ulnar collateral ligament, which holds the proximal phalanx of the thumb to the metacarpal. -De Quervain's disease: inflammation of two thumb tendons; the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB). -Trigger Finger: finger locks in bent position as the tendon gets locked outside the flexor tendon sheath or sleeve. -Guyon's canal syndrome: numbness and tingling in the ring & small fingers caused by the irritation of the ulnar nerve in the canal. -Vibration hand-arm syndrome (HAVS): caused by repeated use of vibrating tools; repeated injury to the small nerves and blood vessels in the fingers.

PD: Diagnosis: 2 Additional Signs to Help Diagnose PD? (2) Neurological Test: https://www.youtube.com/watch?v=sJqKvajUC3k

-Postural instability is often added to this list ♣ Begins with reduced arm swing ♣ Head & trunk leaning forward ♣ Shorter strides (shuffling gait) -Positive response to Sinemet (levodopa): drug that gives brain false info that it is producing dopamine in the form of levodopa

Characterizations of GBS? (9)

-Quickly progressing, symmetrical ascending paralysis starting with the feet -Pain, particularly in the legs -Absence of deep tendon reflexes -Mild distal sensory loss -CN dysfunction with possible facial palsy and swallowing problems -Autonomic NS response of postural HTN and tachycardia -Respiratory muscle paralysis -Fatigue -Urinary dysfunction

Facts & Figures, SCI: -1 in 50 people living with paralysis - approximately 6 million people(www.christopherreeve.org) -Traumatic ≈ ___1___ -Non-Traumatic ≈ ___2___ 11,000 people in the U.S. sustain an SCI each year -25,000 -228,000 patients living in USA with SCI average age of spinal cord injured person is 41 56% of injuries occur between the ages of 16 and 30 81% of patients are male o 56% of people who have a traumatic SCI are between the ages of 16-30 (X=31.7 yr, mst cmn: 19 yo) o 78% of patients have a high school diploma or less o ≈ 52% of patients are single at time of injury o higher incidence of SCI in summer (June-August) & on weekend days SCI Statistics o 1 yr post SCI: ≈ 12 % employed o 20 yrs post SCI: ≈35% employed -60% (n=118): Traumatic SCI w/ concomitant TBI Mild & Mild Complicated:44% Moderate: 6% Severe: 10%

1. 70% 2. 30%

___1___: *Diagnosis:* -Usually made by clinical presentation with generalized motor involvement -Electromyography (EMG): can support diagnosis - Rule out other diagnoses, such as spinal cord tumors and myopathies -Time of actual diagnosis from initial symptoms can be long *Prognosis:* -ALS is a progressive disease with no known cure *Medication:* -Can slow the process: Riluzole (Rilutek), an antiglutamate agent (only FDAapproved drug for ALS) -Slows the course of the disease by 10-15%. -Other medications and treatments are aimed at treating secondary complications such as spasticity, prevention of aspirations, prevention of contracture, and pain management.

1. ALS Medical Management

RTC Evidence: -___1___: decreases subacromial space -___2___: cleared the head of the humerus under the acromion -Studies have shown that empty can exercises increase anterior tipping of the scapula. Anterior tipping decreases the subacromial space. DO NOT DO THIS! Instead, DO ___3___ -Implications for home OT: Focus on full can exercises which increases posterior tipping of the scapula (increases subacromial space). When performing above shoulder level ADLs encourage the client to perform all reaching activities with combined humeral eleva3on and ER (thumb up)

1. Anterior tilting 2. Posterior tilting 3. *FULL CAN EX IN SCAPULAR PLANE!*

REVERSE TOTAL SHOULDER PRECAUTIONS? (3) *Ideal position is abduc3on and external rotation in the scapular plane: common is an abduction sling that holds the shoulder in approximately 30 degrees of ER 15 degrees. When supine, keep a pillow under the extremity to prevent extension.*

1. Avoid IR, 2. Avoid Adduction 3. Avoid Extension (12 weeks)

GUIDELINES FOR ACTIVITY AFTER CERVICAL SPINE SURGERY? (9)

1. Avoid twisting neck 2. Maintain neck color according to doc's instructions 3. When getting out of bed, log roll onto your side then sit up from sidelying position 4. Don't lift < 10 lbs 5. No forceful pushing or pulling w arms (opening door, propelling WC) 6. Avoid reaching for objects w both arms overhead 7. When shirts on/off, do 1 arm at a time 8. Walking is encouraged to your tolerance 9. Discontinue other neck exercises that u may have been doing prior to surgery

SCI Transfers: ___1___: Momentum Head/Hips Relationship Moving body weight Shoulder ER & EXT Tenodesis ___2___: Triceps improve ease of movement = still difficult Momentum Head/Hips Relationship ___3___: Continues to be difficult No trunk stability ___4___: As abdominals come in so increased balance during task

1. C5-C6 2. C7 3. T1-T6 4. T6-T12

Hierarchy of Risk Control in Manual Handling? (5)

1. Elimination: Design out the risk, don't use the equipment. Don't use the process 2. Substitution: find a safer piece of equipment or better way to perform the process 3. Engineering: Modify the process or equipment *(consider if you adapt something what other new risks you may introduce)* 4. Administration: procedures, signage & warnings 5. Personal Protective Equipment (PPE): Last layer of protection for the person

Other Dx in BICU: ___1___: Injury caused by freezing of the skin and underlying body tissues. The most common body parts to get frostbite are toes, feet, fingers, hands, nose, and ears. ___2___: Widespread, irregularly shaped erythematous (red) or purpuric (hemorrhagic) macules (flat lesions) with blistering ___3___: Usually begins as centrally distributed, flat, atypical targets or purpuric macules o Blisters become more confluent and result in detachment of the epidermis ___4___: Soft tissue infection characterized by widespread necrosis of fascia and subcutaneous tissue that may progress to muscle and skin necrosis o Group A streptococcus is the most common cause, also known as "flesh-eating bacteria"

1. Frostbite 2. Stevens-Johnson Syndrome 3. Toxic Epidermal Necrolysis Syndrome (TENS) 4. Necrotizing Fasciitis

___1___: -Absent motor/sensory function below level of injury -Total paralysis -Complete interruption of ascending and descending nerve tracks below level of injury -No sensory or motor function S4-S5 ( lowest sacral level) -No anal sensation or anal sphincter control -Approx 45 % of injuries UMN injury: reflex arcs are intact below level of injury

1. NEUROLOGICAL OUTCOMES *COMPLETE SCI*

___1___: -Damage occurs in thoracic, lumbar or sacral area -Can be complete or incomplete injury -LE's, trunk and pelvic organs affected -Upper Extremity function is preserved

1. PARAPLEGIA

___1___:Used to clean and debride wounds: -Fill tank w water at 100-108 deg; if treating burns, water should be set at body temp -Maintain sterile technique -Adjust turbine and turn it on. Check temp again -Slowly lower the extremity into the whirlpool -Tx: 20 mins -**whirlpool must be cleaned following strict sterile protocol -*note: whiropool is not used as a heat modality, as the temp of the water cant be increased for tissue to reach a therapeutic range*

1. Whirlpool

Superficial heat for Pain: hot packs, paraffin, fluidotherpay, hydrotherapy & whirlpool -HEAT IS FOR CHRONIC OR SUB-ACUTE NOT ___1___ -Heat ___2___ blood supply & results in muscle relaxation -Heats indicated in treatment of subacute & chronic tramautic & inflammatory conditions (i.e. tendonitis, muscle spasms, bursitis, arthritis of the small joints) -Precautions & safety: ___3___ -Heat is *contraindicated for:* acute inflammatory conditions, acute edema, cardiac insufficiency, reduced sensations, DVT, malignancies, open wounds, burns, rashes, metal or peripheral vascular disease, RA (NOT for acute inflammation) or if pt had a hip/knee replacement do NOT put heat on that area

1. acute!!! 2. increases 3. SKIN CHECK, 8 LAYERS

Lymphatic Anatomy: -The lymphatic system originates in the ___1___ ♣ Initial lymphatic (capillary) -These culminate to create ♣ Thoracic duct last place before the heart we want to bring our lymph -No central pump ♣ Must be stimulated by internal or external for pump -As an OT, important to know axillary lymph nodes, cervical lymph nodes and the thoracic duct

1. interstitium

Cryotherapy (cold) for Pain: Can be applied via commercial packs, sprays, ice cups or massage sticks -Cold numbs affected arrow, ___1___ blood vessels, slows down blood flow & reduces fluid buildup in affected areas -Cold is indicated for acute pain, acute inflammation, relieve any inflammation or pain that occurs after exercise -Acute pain (postop)): RICE= rest, ice, compression, & elevation -Always wrap ice packs in towel before applying to affected area -Skin check -Excessive cold can cause tissue damage -*Contraindications:* pts who are extremely sensitive to cold may not be able to tolerate cold, history of frostbite to the area being treated, Raynaud's Disease, circulation problems, very young & very old because of their thermoregulatory responses -Ice for ~15-20 minutes

1. narrows

DASH OUTCOME MEASURE: -The DASH Outcome Measure is scored in two components: the disability/symptom section (30 items, scored 1-5) and the optional high performance Sport/Music or Work section (4 items, scored 1- 5). -At least 27 out of the 30 items must be completed for a score to be calculated. The assigned values for all completed responses are summed and averaged, producing a score out of 5 -Equation? ___1___

1. where n= # of completed responses, 0=no difficulty, 100=unable

Pathophysiology of SCI: 1̊: mechanical damage due to deformation of spine 2̊: cascade of biochemical and cellular processes: o electrolyte abnormalities o marked depletion of the high-energy phosphate reserves o formation of free radicals o vascular ischemia o tissue edema o Lactic acidosis o posttraumatic inflammatory reaction and apoptosis o genetically programmed cell death.

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Patient Demographics: -Men are 5x's more likely than women to get burned. (JK-AS Gene) -Higher incidence associated with PMHx of: ♣ Mental Health / Mental Retardation ♣ Diabetes Mellitus / Neuropathy ♣ O2 dependent population (COPD; CHF; etc.) ♣ Substance use / abuse Hx (TOB / ETOH)

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FORCE: -The force required to do the task also plays an important role in the onset of CTD. -More force equals more muscular effort, thus a longer time is needed to recover between tasks. -In repetitive work, as a rule, there is not sufficient time for recovery. -The more forceful movements develop fatigue much faster. -Exerting force in various hand positions: gross grasp, palm pinch

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Future Hope with Medical Management of SCI o 4-Aminopyridine (chronic spinal cord injury) o Neotrofin o GM-1 o Guanosine derivatives o Activated macrophages o Alternating current stimulation o Fetal neural transplantation o Olfactory ensheathing glial cells o Transplantation of stem cells

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-Person's motivation, family and social support, psychosocial status, PMH, etc. will determine their prognosis; just bc pt has moderate or sever TBI doesn't mean prognosis is poor

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3 Components of Job Analysis: -Worker: gender variable, age variables (musculoskeletal, respiratory, neurological, sensory), *anthropometric (measurement of body parts i.e. length of radius; led to sizing of clothes) data*, skill level, preexisting conditions, conclusions -Work: Forces angles, speed, repetitions, rest breaks, stress level, boredom level -Worksite: -Workstation: work area, seated, standing, kneeling -Objects of work: materials to be handled, objects to be used/manipulated, controls, tools, people -Environment: lightening, temperature, noise, IAQ (indoor air quality), other people

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BURN MANAGEMENT BY OT's (TREATMENT BEGINS ON DAY 1!): -POSITIONING- STARTS DAY 1!: (SPLINT) •Purpose: o Minimize edema o Maintain soft tissues in an elongated state o Protect tissues -Acute Phase (Day 1-14): o Edema Mgt o Maintain ROM o Wound / Graft Care o Pain Management o Patient Education o ADL Skill Adaptation o Mobilization o Skin Care / Scar Mgt -Rehab Phase (Day14-?): o Maintain ROM o Skin Care / Scar Mgt o Graft / Donor Care o Patient Education o Psychosocial Adaptation o Modalities o Cardiovascular o Strengthening TREATMENT GOALS: • Prevention of scar contracture • Preserve normal ROM • Prevent or minimize hypertrophic scar formation and deformity • Maintain or increase muscle strength • Maintain or increase cardiovascular endurance

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Client Evaluations: -Focused on what the client needs and desires to be able to perform -ID factors which support or hinder the desired occupation -Multiple evaluation methods are used to gather info -OT eval done in combo with pt and interdisciplinary team Occupational Profile: -ID the client, their needs/concerns, and analyze how these concerns affect engagement in occupational performance -Occupational profile information is gathered thru informal/formal interviews w/ client, family members, chart reviews and/or check lists Analysis of Occupational Performance: -Information from the occupational profile is used by the OT to focus on the specific areas of the occupation, context and E in which the client lives and functions -Information is gathered thru observing the client perform the occupation in the LRE using standardized/non-standardized assessments

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-An exchange of thermal energy between an object and the fluid moving past it -Heats quicker than conduction; more rapid -Fluidotherapy & whirlpool

Convection

-Transmission of various forms on energy (mechanical, electrical) into body where they appear as heat -Ultrasound

Conversion

0-6 weeks Post Op RTC Surgery?

-Recommend strict immobilization for 2 weeks post op ♣ Type of sling/orthosis will vary depending on repair and tension -Initiation of PROM will vary (common 2 weeks post op) (large & massive tears may be immobilized for 4-6 weeks) -*Pendulum (2-4 weeks post op) emphasize (passive only):* counter in the kitchen is usually a stable and good place for this exercise (3-5 x daily: 10 reps clockwise, 10 reps counter clockwise) ♣ Pendulum position used to wash axilla when no active movement is allowed ♣ Pendulum position is used to don a button down shirt when no active movement is allowed: use one handed dressing technique -*Passive Elevation (initiated 2-4 weeks post op) in the plane of the scapula.* Teach client to perorm this on their own; best to have them perform this supine (couch or bed: home care therapist-watch your body mechanics) o Place a pillow under the arm to prevent extension o Note: PROM (taking extremity to the point you feel resistance, OT would raise it up), NOT passive stretching (this is when it's past resistance and causes a pressure feeling, don't do this until farther out from surgery)

Interventions: -OT focuses on: ♣ Increasing physical activity ♣ Improving performance in life task and roles ♣ Mastery of self and the environment Therapeutic Modalities of Physical Agent Modalities (PAM): -Used as adjuncts to or in prep for purposeful activities -Heat & cold are used in reducing pain & muscle spasms Pharmacological (Oral & non-oral): -Acute pain management ♣ ___1___ often used to treat mild pain ♣ ___2___ often used to treat moderate pain ♣ ___3___ used for severe pain ♣ ___4___ used for postop situations -Chronic pain management: ♣ Involves more invasive approaches & use of non-oral pharmacology: controlled analgesics, implanted delivery systems (SC stimulations), epidural injections (anti-inflammatory steroids), nerve blocks & transdermal pathces ♣ OT: observes for possible drug reactions & checks that pt is adequately medicated in advance

1. Aspirin & acetaminophen 2. Codeine 3. Morphine 4. PCA (pt controlled analgesia)

___1___: -Key movements o wrist extension o scapular protraction o Forearm pronation o Forearm supination -Abilities: Can assist in tasks of feeding, bathing, grooming, personal hygiene and dressing. -Mobility: Some can perform lateral transfers with transfer board Independently Uses manual w/c for daily activities

1. C6

___1___: • Irreparable RTC in combo w severe GH osteoarthritis • Irreparable RTC in combo w humerus fracture • Humeral Head Migration -Results in: pain, decrease ROM and strength, decrease ADLs

1. CUFF TEAR ARTHROPATHY (CTA)

ELECTRICAL STIMULATION -___1___: used to prevent atrophy and encourage active movement / strength / reeducation. Targets peripheral nerve using pulsating and alternating current. o Radial nerve palsy, Subluxation, Tendon repairs -___2___: delivers electrical impulses via the skin to address pain, not muscle contraction -___3___: targets muscles that are denervated. Helps to prevent muscle atrophy. o Nerve repair -___4___: low volt direct current that drives meds to a localized area. Inflammatory injuries: Lateral epicondylitis, DeQuervains -___5___

1. NMES/ Neuromuscular Electrical Stimulation 2. TENS/Transcutaneous Neuromuscular Stimulation 3. EMS/Electrical Muscle Stimulation 4. Iontophoresis 5. HVGS/High Volt Galvanic Stimulation

___1___: -Why would a patient with a Spinal Cord Injury be at risk? -The patient needs to understand early on the importance of repositioning -Turning/repositioning program -External factors for pressure relief o Example: wheelchair cushion o Different type of wheelchair -Determining ways for the patient to allow for pressure relief is extremely important -Complications of ulcers • Worsening - tunneling • Infection • Scarring • May see increased tone

1. PRESSURE ULCERS

AMYOPROPHIC LATERAL SCLEROSIS (ALS) TRUE OR FALSE: -Neurodegenerative disease of UMN and LMN ___1___ -Found more in women than men ___2___ -Vision, bowel and bladder control, and sensation are affected ___3___

1. True 2. False 3. False (Bladder usually intact)

Parkinson's Disease (PD): TRUE OR FALSE: -PD is progressive: ___1___ -One of the causes of PD is loss of dopamine: ___2___ -Dementia occurs in 15-20% of people with PD: ___3___

1. True 2. True 3. True

PD: Mobility Device: -___1___: has built in red laser beam that can be turned on with a switch to control "freezing" episodes https://www.youtube.com/watch?v=J6g-OjBJ5c0

1. U-step rolling walker (part 2)

Manual Materials Handling System? (4)

1. Worker Characteristics i.e. age, pre-existing injury -Physical, Sensory, Motor, Psychomotor, personality, training & experience, health status, leisure time activities 2. Material Container Characteristics i.e. weight, texture 3. Task-Workplace Characteristics i.e. extreme temperatures, heights -Load, dimensions, distribution of load, couplings, stability of load 4. Work Practice Characteristics i.e. repetition, length of time

Evaluation: -Use of a ___1___ is the most accepted method o How to select a tool for evaluation? -Acute pain: tools that assess physiological changes (swelling, temperature changes) pain, hot (could be infection), amount of swelling, etc. -Chronic pain: tools that assess dimension of pain -Develop an occupational profile will give pts past history and what things pt can't do because pain and what they would like to get back to -Determine location of pain: localized vs. diffuse Evaluate intensity of pain: -Pain intensity scale of 0-10 is most common (esp. in acute care) -ID the time of day pain is most intense -Should be done on a regular basis -Determine the onset & duration of pain ♣ Gradual or sudden onset ♣ The length of time pain has been experienced -Description of pain (use facial expression scale for pediatrics)

1. client self-reporting tool

KT ON MUSCLE FUNCTION -Support Muscle Function o Assist a weakened muscle and provide facilitation o Tape anchored at origin, and ends at insertion o Enhance contraction, increase sensory input and decreases muscle fatigue -Inhibit Muscle Function o Decrease tone by compression o Pressure at the tendinous insertion o Apply to muscle with increased resting tone to reduce cramping and over activation KT ON JOINT FUNCTION -Improves joint function by balancing tone of muscles that affect the joint -Provides a support for ligament structures • Assists in adjusting structural alignment • Improve ROM by relieving pain cause by joint misalignment

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Analysis of Occupational Performance: -OT may not be able to focus on pts. Occupational performance in beginning due to pts confusion/coma state; OT may address underlying impairments during this time period i.e. ROM, strength or cognitive skills -When OT can analyze occupational performance: observe client in natural/LRE, note pts skills, physical & social bx, patters, select sp. Assessment & interpret scores, collaborate w/ pt and & family for goals & interventions

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Cooling Agents: -Indications: o Pain control o Inflammatory conditions Tendinitis, post exercise inflammation, edema control post-op combined w compression -Contraindications: o Diminished sensation: very old or young o Vascular compromise: replant, PVD o Raynaud's disease -Ice packs, ice pops, frozen veggie (home use) -Towel layer for hygiene and skin protection -Wet towel for maximum effect -Advantages: easily applied -Disadvantages: cant observe skin during applications

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Coping & Support for SCI: -Peer interactions -Support groups -Adapted Sports & activities in order to interact with members of the community -Understanding more about the current condition o - Accredited websites o - Experience from medical team

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ELASTIC TAPE: -Commonly referred to as Kinesio Tape or KT Tape -Was developed by Dr. Kenso Kase in the 1970's -Gained a lot of recognition in the 2008 Olympics -Claims: o Provide support to injured muscles and joints o Relieve pain ♣ Lifts skin for improved blood and lymph flow Kinesis Tex Tape: -Unique woven pattern that allows the skin to breathe to allow perspiration and sweat without changing the integrity of the product -Very light weight -Can be used up to 3-5 days -Control of tape stretch during application is the key to avoid adverse effects and over stimulation -Patient can shower -Up to 3 - 5 days of clinical wear

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HOT PACKS: -Advantages: inexpensive, easily set up, can do easy skin checks, can apply stretch w heat -Disadvantages: observation of body parts not possible if lying on splint. Body part is usually static and not moving while being heated

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HOW CAN OTS SPECIALIZE IN WORK REHAB? -If you are interested, get a job where you are exposed to the practice of 'Ergonomics'; e.g. emphasis is on getting people back to work after work rehab to the most suitable job with the goal of not exposing that person to re injury or preventing work related injuries. -Get involved in research (biomechanics) -Continuing education in the field of Ergonomics (e.g. FCE's, work conditioning programs) -Get certification e.g. HFES (Human Factors and Ergonomics Society) offers certification for CPE (Certified Practicing Ergonomist) www.hfes.org -Degree in Human Factors and Engineering or Ergonomics

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Head opposite direction of w/c for transfer C6 can do transfers with transfer board because have lats; C7 can do transfer with depression transfer (depression is the same as pop over transfer) with no transfer board bc you have triceps!) ; C7 new freedom because don't have to carry around transfer board (when transfer board transfer mastered, Tenodesis grasp & release (C6), NEVER stretch out fingers on transfer board, this they have ECR but look if longus or brevis; may have to use universal cuff for feeding in beginning bc weak tenodesis grasp; work on strengthening!

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Heat Agents: -Indications ♣ Decrease pain/spasm ♣ Increase sift tissue flexibility hypermobile joins & soft tissue ♣ Increase blood flow enhance healing -Precautions ♣ Fragile skin ♣ Decreased cognitive status may not be able to tell you it's too hot ♣ Child -General Contraindications ♣ Diminished or absent sensation EXAM QUESTION (NO PAM w/ diminished/lost sensation) • Very young/very old • Nerve injured or insensate hand ♣ Impaired circulation • Vascular instability o Replant o Recent skin graft ♣ Tumors/Active cancer ♣ Infection ♣ Skin grafts

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KT TAPE & SHOULDER IMPINGEMENT: -Experimental study completed in 2015 focused on reducing pain and normalizing scapular movement for patients with shoulder impingement using KT tape -Used two Subgroups o Rigid tape applied to the thoracic spine o Elastic tape applied to supraspinatus and deltoid -Study found KT helped with scapular kinematics but not with pain KT TAPE AND SHOULDER SUBLUXATION: -Quasi experimental design completed in 2012 looked at effectiveness of KT tape on shoulder subluxation -Article focused on "California Tri-Pull" method of tape -Found tape decreased inferior subluxation, increased AROM and increased function during ADLs during intervention -However, study found no cross over post intervention

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MMH Injury Data (NOISH) (according to CDC): -Overexertion injuries among most costly & disabling work-related injuries in U.S. -2007 Liberty Mutual Workplace Safety index overexertion injuries were responsible for $12.7 bil in direct costs to employers in 2005 -Overexertion injuries account for more than ¼ total direct costs of top 10 most disabling injuries (employee misses 6+ days of work) -In 2006, US BLS reported total of 47, 350 overexertion related injuries resulting in days off work

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MODIFIED OSWESTRY Interpretation: -0% to 20%: minimal disability: The patient can cope with most living activities. Usually no treatment is indicated apart from advice on lifting sitting and exercise. -21%-40%: moderate disability: The patient experiences more pain and difficulty with sitting lifting and standing. Travel and social life are more difficult and they may be disabled from work. Personal care sexual activity and sleeping are not grossly affected and the patient can usually be managed by conservative means. -41%-60%: severe disability: Pain remains the main problem in this group but activities of daily living are affected. These patients require a detailed investigation. -61%-80%: crippled: Back pain impinges on all aspects of the patient's life. Positive intervention is required. -81%-100%: These patients are either bed-bound or exaggerating their symptoms.

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Magnitude of Health & Safety Problems: -The Bureau of Labor Statistics has reported annually on the umber of days away from work injuries & illnesses since 1970s -Nearly 3 mil nonfatal workplace injuries & illnesses were reported among private industry employers in 2014, resulting in an incidence rate of 3.2 cases per 100 equivalent full-time workers -More than 2 mil workers are injured severely enough on the job that they miss work & need ongoing medical care -Workplace deaths, illnesses & injuries cost society $155.5 bil annually -Healthcare workers accounted for 6.5% of workplace injuries & illnesses -> nurses most! *So huge opportunity for OT's

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Mobilization Guidelines After Skin Graft: Upper Extremity graft over joint(s): -POD (Post op day) # 1 Splinted & no motion -POD # 2 Active ROM OK with bandages off to visualize graft, May hold ROM if graft looks moist & leave splint in place -POD # 3 AAROM OK after graft visualized, Graft should be carefully observed for : Hematoma formation, bleeding, graft slippage & loss during and post TX -POD # 4 AROM / AAROM / PROM OK w/ all areas grafted, Splints still used but may change schedule or application -Upper Extremity graft NOT over joint(s) ♣ UE can move if no graft over joint

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Movement strategies for SCI: -Muscle sub: use fixation of distal extremity to achieve movement Leg lifter and leg ladder (has hand holds) -NEVER OVER STRETCH WRIST FLEXORS BC WILL STRETCH TENODESIS for C6 and THE LOW BACK (i.e. lats, paparspinals, hamdstrings, etc.) bc they lose the ability to do head hips relationship -> head to the right then head has to go DOWN first then to the LEFT ; they have to THROW arm back (angular velocity, hand to plant hands; EXTERNAL ROTATION, ARM EXTENSION & PLANTING IS MOST FUNCTIONAL) but watch grasp so not extended; they have to use HEAD to roll -> say "throw your head up and into armpit" -> this leads charge for all prime movements -Be aware of overuse injuries -> watch back, need to strengthen this! -When rolling from supine to sidelying, fling head and punch (like PT ex.)

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OT ROLE IN SCI REHAB: • Seating and positioning? • AT needs? • Look at Remedial perspective vs. compensatory strategies to perform: • Grooming, dress, bathe, toilet • Functional transfers: what kinds? What type? • Bowel/ bladder management • Personal device care • Sexuality and intimacy • Parenting • Coping strategies • Social Support • Leisure interests/ Community integration

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PROCESS FOR PATIENT W AD: -If lying down, have them sit up o Why would we want the patient sitting? So Blood moves -Loosen clothing -TEDS o Abdominal binder o Additional Bracing o Find & Remove the cause -Medication may be needed if cause is not found & pressure remains high -If pressure does not decrease, this is a medical emergency

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SCAR TREATMENT DONE BY OT's: -Treatment Staples: o Positioning o Splinting o ROM o Stretching o Exercise o Wound Care o Patient Education -Burn Specific TX: o Pressure Garments o Conformers and Inserts o Silicon Gel Sheets o Scar Massage

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SCI Complications & Interventions: DVT: -Interventions: keep pt up and moving & use blood thinners UTI: -SUPER COMMON; should be lemonade color, not OJ; often don't drink enough though Osteoporosis: -Not weight bearing for LE; but if trying to cross legs, for shoes/pressure relief etc. could cause a fracture AD: -Could be bc kidney stones GI complications: -bc they don't have normal nerve input -Interventions: standing program: lets everything line up and assist things, also helps with osteoporosis Pain: -20 years after injury 100% of people have wrist and shoulder pain Spasticity: -Baclofen pump to reduce-> use this if med doesn't work

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SCI Functional Outcome Measures: (better to use SCI assessment, FIM is poor indicator) -FIM: Reliable and valid for SCI Alexander (2009) -FIM+5 (5 added items for w/c users with SCI, Better able to distinguish paraplegia vs. tetraplegia Items are valid and responsive Items represent different aspects of mobility & locomotor function -Spinal Cord Independence Measure(SCIM) Ackerman (2009) o 17 items o Good reliability and validity o Average change pre/post rehab for 114 pts was 5 points (statistically significant) o Scale has some ceiling and floor effects -Quadriplegia Index of Function (QIF) Specific to cervical SCI Reliable Validity needs more research -10m walk test Valid and most clinically useful -Walking Index for SCI (WISCI) 19 point scale that rates walking ability based on devices used, braces used, assistance required, and distance Good reliability and construct validity Most clinically useful with incomplete SCI -Wheelchair Skills Test 50 skills, good reliability & construct validity -FEW: Functioning Everyday in a Wheelchair 10 items Assesses ability to function in specific w/c

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SCI Model Systems: -Sponsored by National Institute on Disability & Rehabilitation Research -The 14 designated Model System Centers across the US work together to: demonstrate improved care maintain a national database participate in independent and collaborative research Provide continuing education relating to spinal -Regional Spinal Cord Injury Center of the Delaware Valley -Thomas Jefferson University Hospital (acute) -Magee Rehabilitation: (rehab, outpatient, lifetime follow-up)

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SPLINTING FOR COMMON POST-BURN DEFORMITIES: -Purpose: o Control edema o Maintain soft tissues in an elongated state o Prevent deformity!! o Preserve skin graft integrity o Support / restore function and independence o Maintain/Increase available ROM -Splint for burn to hand: ___1___ -Splint for burn to forearm: ___2___

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Why OT & Work Rehab?: -AOTA has IDed "work & industry" as one of the 6 centennial vision focus areas where OT practitioners have great potential to provide expert services -OTPF identifies "work" as one area of occupational performance

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Hot Packs: -Hydrocollator pack -Heated in water to 50-70 deg C (165-170 deg F) -Heats to 1 cm in depth (1/2 inch) in 6-8 minutes; 2 cm in 15-30 min -Cannot heat to 3 cm because intensity would be too great -*8 towel layers or Hot pack to cover and 1 towel folded into 4 layers (TEST ?)* This will vary: if a pt has fragile skin or must be placed on the pack add additional towels -Moist heat: *peaks at 5 minutes, so check pts skin prior to reaching peak. Hot pack stays on for 15-20 minutes* ♣ 20 min is ideal ♣ Dr. Maher likes moist heat better than classic hot pack -*Skin check BEFORE you put ANY modality on pt!!!!; check after 5 minutes too! & after they're finish and ask how they are feeling! it's all about SAFETY!!!!*

:) Notice Test Question :)

♣ Falls ♣ MVA's ♣ Sports injuries ♣ Physical Violence ♣ Explosive blasts and other combat injuries *from blow or jolt to head

TBI

Strength exercises: -Scapular -Shoulder: flexion/extension/abduction & ER -Elbow: flexion/extension, pronation/supination -Gravity: eliminated, assisted, against -Weight of objects used during tasks -Amount of external support (i.e. slide hand across table vs. reach intro space) -External resistance (i.e. weights, elastic bands, resistance from OT's hands -Prone on elbows, sidelying on forearm -Sitting at table- wt. bearing on forearm during reading, eating -Standing- participate in activity with unaffected extremity; grooming, cooking Task Specific Interventions for UE Weakness: (IMP. :) ) -Wiping table -Sliding objects across table -Cleaning sink/counter -Rolling dough -Bilateral UE training: folding laundry, sweeping, opening containers, lifting & placing light boxes

UE Weakness Interventions

Contraindications of MEM? (6)

o Patient has an infection o If hematoma or blood clot is present in the area o If active cancer is present o CHF or other severe cardiac/pulmonary problems o During acute wound healing o Renal failure or severe kidney disease