OP2 (Early and Middle Adulthood) quiz 1

Types of Ambulation Equipment (DME)

(All support body weight through arms) A. Walkers: standard, wheeled (2 in front or 4 wheels with brakes), platform, hemi, seat attached B. Crutches: axillary (short-term), forearm, platform C. Canes: single-point, quad (four-footed), J-top, offset, adjustable

stand to sit with crutches

* Approach chair and pivot on stronger LE so that client's back is toward chair. Client steps back until the posterior thigh of the strongest LE touches the front of the seat. Client removes crutches from axilla and holds them with the hand on the same side of the body as the weaker LE to widen the BOS and increase stability. * Holds the crutches with the hand on the same side of body as the strongest LE as described above. The client uses the free hand to grasp the armrest of the chair and lowers hips into the chair using the UEs and the stronger LE. If the knee of the affected LE cannot be flexed, the client should allow it to slide forward as he/she sits. Once sitting, the client places crutches on the floor. Avoid placing crutches against wall, table, or chair as they could fall.

stand to sit with cane

* Approach the chair the chair and turn sideward, leading with the strongest LE. With the strongest LE nearest the chair, the cane is placed to the side or in front of the armrest the client faces. The client then grasps the near and then the far armrest and continues to pivot until client's back is toward the chair. The client lowers the hips into the chair seat using the strongest LE/UEs and then positions self in the chair by moving hips back into the chair.

transfer with walker

* Can be a standard walker or a wheeled walker. Walker may or may not have brakes Technique: A. Transfer to sit: 1. Have backside directly in front of surface transferring to. 2. Reach one hand behind to "feel" for surface and one hand on walker. 3. Reach behind with other hand transferring weight to back of feet. 4. Slowly lower self down to surface. B. Transfer to stand: 1. Always have clients use armrests to push up from chair or firm surface if on bed to rise. 2. Grasp walker with dominant hand and continue to push up from surface. 3. Once standing place both hands firmly on walker. 4. Allow client to stand briefly to establish balance and to determine whether he/she experiences lightheadedness or a dizzy sensation. · NOTE: A walker is frequently used for THR clients to improve stability. PRECAUTIONS: each surgeon will have instructions or preferences re: wt bearing and permitted activities. These are designed to reduce the risk of dislocation. Generally used precautions are: Maintain hip in slight abduction and neutral rotation- avoid adduction beyond midline. Maintain hip in neutral extension. Avoid external rotation when an anterior or anterolateral surgical approach is used and internal rotation and hip flexion beyond 60-90 degrees when a posterior or posterolateral surgical approach is used.

Sit to Stand with Cane

* Client. places hands on armrest of chair as described above. Standard cane is hooked over the front portion of the armrest on the side of the stronger LE. With quad cane, cane is placed next to the front of the armrest of stronger LE. Position of the cane widens the BOS and allows some weight shift from the LE onto the cane when both items are used during the weight bearing phase of the gait pattern. * If the chair does not have arms, the client can be taught to hold the cane in the hand on the side of the stronger LE and use the other UE to push against the chair seat to assist in standing.

dependent transfers

* Designed for use with the client who has minimal to no functional ability. With heavy clients, it is best to have at least a second person available to spot. * Types: · One person dependent, transfer board · Two person dependent transfer with or without sliding board, sitting/bent pivot technique. · Mechanical Lift

Sit to Stand with Crutches

* Holds both crutches with the hand on the same side as the most affected LE or opposite to the foot of the stronger LE (widens BOS so when client stands, the vertical gravity line will be located between the crutches and the strong lower extremity). Once standing, the free hand reaches for the crutch and positions the crutch in the axilla. * Holds both crutches with the hand on the same side as the stronger LE. This narrows the BOS but increases the force the client is able to use to stand. The client pushes from the armrest, seat or back of chair with the opposite hand to assist with the stand.

Sit to Stand with Walker

* Position the walker directly in front of the chair and client with the open side toward the client. The client grasps the chair armrest in front of the hips-provides the greatest stability and allows the client to use the UEs and LEs most effectively to stand. To stand, the client.pushes down simultaneously with the UEs and the strongest LE, leans forward, and stands. One arm is then moved onto the handgrip of the walker when client is partially standing, the opposite hand moves to the other handgrip. *If no armrests, use alternate method: place one hand on one handgrip of walker and the other hand on the chair bottom-CAUTION: WALKER IS NOT SECURE AND THIS POSITION CAN BE UNSAFE IF CLIENT ATTEMPTS TO PULL SELF TO A STANDING POSITION USING WALKER. DO NOT USE THIS METHOD WITH CLIENT WHO IS WEAK, MENTALLY CONFUSED, OR HAS POOR BALANCE OR DECREASED STRENGTH IN UE/LEs.

Mobility

1. Bed/chair transfer 2. Toilet transfer 3. Tub/shower transfer

What an occupational therapist MUST know to safely address transfers with clients:

1. Client status- physical, behavioral, cognitive and perceptual. 2. Proper transfer techniques to use for specific clients. 3. Be aware of your own restrictions/limitations. 4. Any caregivers involved. 5. How to effectively communicate to client and caregivers.

Backwards Turning

1. Four-point: move one aid back, then step back with the opposite LE; move other aid back, the other opposite LE. 2. Two-point: Simultaneously move one aid and the opposite LE back and then move the opposite two extremities back simultaneously. 3. Three-point: crutch tips positioned lateral and even to toes, step back approx. 6 inches, and reposition crutches. 4. Modified three-point: step back with strongest LE with crutches maintained in front or even with weaker LE, then step back with crutches and weaker LE to place in line with stronger LE.

sitting transfer: lateral/swinging

Designed for the client who has good sitting balance and upper body strength to transfer from a WC to bed/toilet, who no longer needs a sliding board to facilitate the transfer. · Client may advance to this type of transfer if the client has mastered the sliding board transfer. Technique: A. Client moves forward in chair with feet on the floor and buttock past drivewheel. B. Removes armrest nearest surface. C. Moves buttock to partially pivot body so back is toward bed. If moving to the right, the right hand is placed on edge of bed and left hand is placed on armrest or seat of chair, or on back of chair. D. Client pushes with UEs to elevate the body and to swing buttocks onto the edge of bed by moving head quickly in opposite direction. Uses PNF patterns to gain momentum. E. Repositions hands and moves farther on bed. F. Stabilizes self on edge of bed, places LEs on bed (long sitting), and lies down.

Modify/Compensate/Adapt

Developing a new way of doing an occupation Use -When remediation is NOT an option -With remediation -When some, but not all remediation is achieved Examples -SCI -do not know if function will return, so -AE may be used until strength returns -Limb loss Appropriate when -Remediation is not an option (SCI) -In combination with remediation - compensation necessary due to time limitations, client motivation, self esteem -When some but not all remediation is achieved. Methods of Compensation: (may combine these methods) -Alter the task method: same task objects are used in the same environment, but the method of performing the task is altered. Ex - one-handed techniques, energy conservation and work simplification, joint protection. -Adapt the task objects or prescribe assistive devices; alter the objects used to perform task. Built up handles, long handled sponge. -Adapt the environment: a fixed adaptation: installing ramps, handlebars in bathroom, Durable Medical Equipment. Compensation Strategies -What tasks are valued by the client, which ones take too long or require too much energy expenditure. -List all the steps of the task and analyze it - why is it necessary? What is the purpose? When and where is it performed? What is the best way for the client to perform the task. -Develop a new method of performing the task. Eliminate unnecessary steps, combine motions, rearrange the sequence of the steps, simplify the details of the task -modify ex: cutting your food with the side of your fork instead of a knife -compensation ex: using a built up knife to cut your food, so you are using bigger joints -adaptation ex: using a rocker knife to cut your food

What can we evaluate as OTs?

EVERYTHING

Exercise and EBP with RA

Exercise and Evidence-Based Practice: The weight of the evidence supports the use of an aerobic exercise program combined with a dynamic strengthening program for individuals with RA. The evidence supports the use of dynamic strengthening exercises 2-3 times per week, in addition to physical activities such as walking, swimming, and biking 3 or 4 times a week for 50-60 minutes (Hakkinen, Hakkinen & Hannonen,P., 1994). After the 12-week program, the aerobic groups significantly improved aerobic capacity, endurance, depression, anxiety and physical activity compared to the non-aerobic group, group three. At the nine-month follow up, the aerobic groups had significant decreases in blood pressure, physical activity dysfunction, and total number of clinically active joints while they showed significant increases in aerobic capacity, exercise endurance, heart rate recovery, flexibility, and grip strength. Overall, exercise is beneficial for those with osteo- and rheumatoid arthritis. Participants were randomly divided into three exercise groups: 1) aerobic walking, 2) aerobic aquatics and 3) range of motion exercise. Group three was the control group The aerobic sessions, involving groups one and two, included a warm-up with general flexibility and isometric strengthening of postural muscles, an aerobic stimulus period progressing to 30 minutes of aerobic activity, and a 10-muinute cool-down of active range of motion and stretching. Group three walked on a level course progressing from 10-30 minutes and experienced range of motion exercises (Minor, Hewett, Webel, Anderson & Kay (1989). Persons who participated in intensive dynamic group exercises experienced significantly more benefits in terms of their increase in aerobic capacity, muscle strength and joint mobility when compared to the other three groups directly after their twelve-week course. There was no significant increase in daily functioning or any difference in disease activity in any of the participants. Patients with rheumatoid arthritis participated in a twelve-week exercise course to improve their physical condition, muscle strength, joint mobility, daily functioning, and disease activity. Each participant was assigned to one of four groups which included 1) intensive dynamic group exercises 2) range of motion and isometric exercises in a group 3) individually supervised range of motion and isometric exercises and 4) home written instruction for range of motion and isometric exercises. Measurements were taken before the courses started, after the courses, and twelve weeks after the courses ended. There were 100 participants in this study (Ende, et al, 1996). Massage therapy was found to decrease anxiety, stress hormone levels, morning stiffness and pain compared to relaxation therapy in children with JRA. (Field, et al.1997). Exercise and wax baths resulted in significant improvements in range of motion and total grip function. Exercise only resulted in a significant reduction of stiffness, pain and an increase in range of motion. Wax bath alone showed no significant effects. A decrease in stiffness was observed in all groups receiving treatments. Persons with rheumatoid arthritis were divided into four subgroups to evaluate various treatment methods. The treatments included 1) both exercise and wax bath, 2) exercise only, 3) wax bath only, and 4) controls. Participants attended treatment sessions three times a week for four weeks. Observations at the start of the study and at the end focused on deficits in flexion and extension in digits II-V bilaterally, grip function, grip strength, pain, and stiffness (Dellhag, Wollersjo,& Bjelle, 1992). Participants in the experimental group statistically improved their knee extension and trunk extension over the control group. The experimental group improved their knee extension strength, grip strength, trunk extension and flexion as well as decreased their pain and morning stiffness greater than the control group. From baseline both group significantly improved in walking speeds and stair climbing times. Participants were randomly divided into a control group, who performed range of motion exercises, and an experimental group who performed strength training. The experimental group participants were personally instructed in arms, legs, and trunk strength exercises, which were recommended twice a week, as well as instructed on range-of-motion and stretching, also recommended twice a week, and recreational physical activities recommended 2-3 times a week for 24 months. Overall benefits from strength training were the focus of this study (Hakkinen, Sokka, & Hannonen, 2004).

Functional Independence Measure Review

FIM

Intervention Approaches

I.Establish/Restore/Remediate II.Modify/Compensate/Adapt III.Education IV.Grading V.Prevent

Clinical Suggestions for Enhancing Compliance:

Learning principles Clients best remember instructions presented first. Emphasized instructions are recalled better The fewer instructions, the greater the proportion remembered Pace the amount of information to avoid overload Use simple, understandable language without medical jargon Individualize teaching methods to the client Reinforce essential points by review, discussion, or summary Ask the client to repeat essential elements of the message Provide written instructions for home reference Devise mechanisms for helping clients remember advice. Client expectations and experiences · Beliefs and misconceptions about the cause, severity, and symptoms of illness and susceptibility to complications and exacerbations. · Goals of treatment · Perceptions about cost and risks vs benefits · Existing health related knowledge, skills, and practices · Degree of adaptation to the disease · Sense of self efficacy or lack of control and hopelessness · Learning limitations · Extent of family involvement and influence Encourage client to assume responsibility for disease management · Behavioral contracts if needed · Motivational techniques · Encourage success with management techniques 4. Use a facilitating affective tone · Listen · Be approachable · Appear knowledgeable · Inspire trust and confidence · Be enthusiastic and expect positive results

Home Management adaptive equipment for RA

Long-handled dustpan, bucket on rollers, reachers to pull items out of areas and from floor.

Work and School adaptive equipment for RA

Luggage cart, rolling cart, back pack, fanny pack, computer forearm-wrist rest, adapted key holder, built up handle for writing, telephone headset, adapted hand tools, electric stapler and pencil sharpener, car door opener.

medicinal treatment of RA

MD (rheumatologist, hand surgeon) Drugs - antisteroidal, antiinflammatories

Limited ROM and/or Strength

Major problem: compensate for lack of reach due to joint limitations or muscle weakness. Possible Conditions: Rheumatoid Arthritis, Osteoarthritis, Neuromuscular Diseases (e.g., Polymiositis, ALS) generalized weakness due to chronic conditions. Solution: Explore environmental adaptations or assistive equipment. Dressing: front-opening garments, one size larger. Dressing sticks, larger buttons or zippers, velcro fasteners, elastic shoelaces or sock aide. Buttonhook, reachers. Eating: Built up handles on utensils, elongated or curved handles, swivel spoon or spork. Long straw or straw clips on glasses or cups, universal cuffs or utensil holders, plate guards or scoop dishes Hygiene and Grooming: handheld shower, long handled bath brush or sponge, bath mitt, soap on a rope. Position adjustable hair dryer, long handles on combs, brushes, toothbrush, razors. Spray deodorant, spray powder or perfume, electric toothbrush, short reacher for toilet paper, dressing sticks to use after toileting safety rails near tub/toilet, tub chair or transfer bench, grab bars. Communication and environmental hardware adaptations: Extended or built up handles on faucets, telephone speaker phone, head set, extended receiver holder, dialing stick. Built up pens and pencils, computers, book holders, doorknob extensions. Mobility and transfer skills: Platform crutches, enlarged grip on crutches, canes, walkers, raised toilet seat and rails, walker with forearm troughs, walker bag, crutch bag. Home Management Activities: Store frequently used items on the first shelves of a cabinet or on counter, use high stool to work at counter top, utility cart, reachers, lightweight utensils, electric can openers and mixers, adapted loop scissors, extended handles on dust pans, brooms, adapted knives for cutting, top loading washer and dryer (unless WC bound then front loading), elevate playpen and diaper table, looser garments on children with velcro, reachers to pick up clothing and toys.

Incoordination

Major problems: Incoordination resulting from tremors or ataxia can result from a variety of CNS disorders. The major problems with ADLs are safety and adequate stability of gait, body parts, and objects to complete the task. Fatigue, emotional factors and fear can all affect incoordination. Possible Conditions: Multiple Sclerosis, cerebellar disorders. Solutions: Energy conservation and work simplification techniques, work pacing and safety methods to avoid fatigue. When muscle weakness is not a factor, weighted devices can help stabilize objects (ataxia, MS) while stabilizing the elbow and forearm. Dressing: front opening garments that fit loosely, large buttons, velcro, or zippers with loops, buttonhook with weighted handle. Elastic shoelaces, velcro, slip on shoes. Elastic tops for pants or with velcro closures, front opening bras, or velcro, clip-on ties, dress while sitting (in bed, side of bed, in chair with arms) Eating: plate stabilizers (nonskid mats), plate guard or scoop dish, weighted utensils, long straws, arm brace (MAS). Hygiene and Grooming: attach razor, lipstick, toothbrush to cord if drop, weighted cuffs when applying makeup or shaving, electric razor, suction brush to clean nails or dentures, soap on a rope, nail clipper or emery board glued to board, large roll-on deodorant, bath mitt, nonskid mat in tub, safety bars, tub chair. Sponge bath at sink Communication and environmental hardware adaptations: lever type doorknob, holder for phone receiver, large button phones, speaker phone, weighted enlarged pencil or pen, computer with keyboard guard, adapted key holder, lever type faucets, wall switch for lamp. Mobility and transfers: ambulation aide, slide items, utility cart, remover doorsills, throw rugs, and thick carpet, install banisters, ramps. Home management: major problems are stabilization of foods and equipment to prevent spilling and accidents and safe handling of appliances, pots, pans, and household tools to prevent cuts, burns, electric shock, falls: wheelchair and lapboard, use convenience and prepared foods, easy-open containers, jar opener, use heavy utensils, mixing bowls, pots and pans for stability, nonskid mats, electrical appliances, minimize bending and stooping at work areas, oven mitts, pots and pans with bilateral handles, cutting board with nails, heavy dinnerware, use tongs to turn food, dust mitt to dust, eliminate fragile knickknacks, unstable lamps, eliminate ironing, front loading washers, sit while working with infant, disposable diapers, infant clothing larger and loose.

Use of one hand

Major problems: May need to tackle ADLs with one hand if have hemiplegia, UE amputation, or temporary disorder (fracture, burn, peripheral neuropathy). These techniques may be harder for the person with hemiplegia to learn because may have additional cognitive and perceptual dysfunction, as well as loss of postural control. Possible conditions: Rotator Cuff Repair, Total Shoulder Replacement, Burns, Peripheral Neuropathy, UE fracture, amputation. Solutions: The one-handed person may have problems with work speed and dexterity, stabilization. The person with hemiplegia may have problems with balance and precautions re to sensory, perceptual and cognitive losses. Dressing: If balance is a problem, dressing should be done while seated in chair with arms, clothes easy to reach, reachers. One handed NDT dressing techniques. Dress affected UE/LE first, undress these last. See Pedretti, p. 483-488 for NDT approaches to dressing. Eating: managing knife and fork simultaneously is major problem. Rocker knife. Hygiene and grooming: electric razor, bathmitt, long handled sponge, safety rails, tub chair, sponge bathe while sitting on toilet, place wash cloth on thigh to wash uninvolved side. Spray deodorants, suction brush for dentures or fingernails. Communication and environmental hardware: clipboard or paperweight or tape paper to surface, retraining nondominant hand, book holder. Mobility and transfers: principles of transfer techniques for person with hemiplegia. Home management activities: need to determine if only UE dysfunction, UE/LE dysfunction, visual/perceptual/cognitive issues. Stabilize objects for cutting using board with nails, raised corner to stabilize bread, nonskid mats, use knees to stabilize jars or partially opened drawer, box opener, pan holder, utility cart, clothes carrier on wheels, electrical appliances.

TRANSFERS LAB

OBJECTIVES: You will be able to demonstrate the following functional transfers at a supervision (S), contact guard assist, minimal assist, moderate assist, max assist level:

Evaluation

PUPOSE: ID 1) What is difficult 2) Cause? 3) Client able to modify performance? 4) What type of intervention will be appropriate? Appropriate discharge? Demonstrates OT's distinct value

Intervention

PURPOSE 1.Create/Promote 2.Establish/Restore/Remediate 3.Modify/Compensate/Adapt 4.Prevent -never done it before = create the skill -lost it = establish/restore the skill -need a new way of doing things = modify

Re-evaluation

PURPOSE Determine progress Collect outcome data Determine next step -Discharge from OT -Transfer to next level of therapy -Establish new goals -are they doing well? Do we need to change something? Do they require a more familiar environment?

Meal Preparation adaptive equipment for RA

Rolling cart, knob turner for stove; built up handles on cooking utensils; knives with right angled handles; electric can opener; jar opener, spring lever scissors, cutting board with spikes to stabilize food, electric chopper, high kitchen stool or high stool on roller such as EZ Stand Mobile Stool.

Splinting EBP

Splinting helps reduce joint pain; custom-made splints are most effective (Haskett, Beckman, Porter, Goyert, & Palejko, G., 2004).

ADL Specifics

The purpose of this overview is to give the student some general ideas about how to solve ADL problems for specific problems. Many times the OT will need to rely on problem solving and creativity to solve a client's ADL problem. Review these suggestions and under which circumstances they would be appropriate - review Pedretti reading. 1.) Limited ROM and/or Strength 2.) Incoordination 3.) Use of One Hand

transfer lab notes

o Intro -Introduce yourself, ensure you know a little about the patient and their name prior to your session (from their charts) o Environment -Ensure safety (preparatory measures) and comfort o TEACH -Ensure they know what they are doing and how they will do it -Use teach back method o Sit to stand -Solid BOS -Nose over toes -Sit at edge of seat, feet slightly behind you o Stand to sit -Feel the surface on the back of your legs -Reach back to catch self o Ambulation o Natural environment o Steps

Standing Pivot Transfer

* Requires the client to be able to come to a standing position and pivot on one or both feet. It is most commonly used with clients who have hemiplegia, hemiparesis, or a general loss of strength or balance. Can be one or two person. * Usually used with a client who has greater strength in one UE and LE than the other. * Client needs to learn to transfer by leading with both the weaker and stronger extremities to increase independence and to encourage use of the weaker extremities. Technique: A. Stabilize the involved LE and heels angled toward surface transferring toward. B. If using W/C position W/C at 45 degree angle to mat/bed. C. Control the client's trunk by grasping gait belt and other hand on the client's shoulder. Must be careful reaching under hemiplegic shoulder. You should not use client clothing, belt or UE as a point of control. "Nose over toes". D. Client places hands on armrest and simultaneously pushes down with UEs/LEs while inclining trunk forward. Do not allow client to grasp your neck. If having difficulty with hand placement, have client hold your elbows. E. Client may position the stronger foot posterior to the weaker foot (exception-hemiplegia). F. Initiate trunk flexion by rocking the trunk forward and back to develop momentum before attempting to stand. "Count to three". G. Allow client to stand briefly to establish balance and to determine whether he/she experiences lightheadedness or a dizzy sensation. H. W/C should be positioned prior to lying down or it will have to be positioned after he/she is sitting on the edge of the bed or by another person prior to the transfer.

stand to sit with walker

* The client is instructed to approach the chair and pivot on the strongest LE so that back is toward the chair and the walker remains in front of client. The client steps back until the back of the strongest LE touches the front of the chair seat. Client reaches one hand at a time for each arm rest of the chair and uses UEs and LEs to control the lowering of the body. The chair is more stable than the walker. *If no armrests, can use alternate method: use handgrips of walker to assist to lower the body. CAUTION AS ABOVE.

practice!

**While doing transfers discuss recommendations such as non-slip mats, grab bars, placement of W/C or walker, etc.

Stand to sit

*Back up until feel the chair behind knees. *Position stronger LE nearest to the chair *Reach for armrests of chair *Incline trunk forward.

Sit to Stand

*Client moves body forward in chair/seat; *Place unaffected/stronger LE slightly posterior to the foot of the opposite LE; *Place hands on chair armrest slightly anterior to hips and PUSH UP.

evaluation examples

-Barthel Index - Determine IND with 10 ADLs -Katz Index - Determine IND with 6 basic ADLs -IADL- Lawton - Determine IND with 8 IADLs -Self care & Mobility GG items - 8 ADLs assessed by Medicare -FIM - Functional Independence Measure A slice of what we can assess. Offer consistency in terminology and reporting across time. -GG items is newer

Strategies for restoration

-Decrease physical assist or verbal cueing (VC) -Increase task demands (cog/physical) -Microwave mealà simple sandwich à hot dinner -Increase number of steps in task -Bathing UB àBathing entire body -Vary type of task/environment(familiar à unfamiliar) -Bathroom transfer at home vs. at a baseball game -Physical assistance: as the client displays increased skill in completing a task, the practitioner should intervene less frequently. -Supervision and cueing: can include the number of cues given and the types of cues used (written, tactile, verbal). Written materials can be used to reinforce the teaching that has occurred during OT intervention. Tactile and verbal cues can be used to guide client performance. Intervention can progress from tactile to verbal to no cues. -Task demands: the amount of cognitive and physical skill required to perform the task. Usually choose a task with either low cognitive skill and higher physical skills (or high cognitive/low physical) and progress to increasing levels of both. -Amount of the task: increasing the number of steps or tasks that a client needs to complete can indicate improved function. -Type of task: grade cognitive tasks from routine and familiar to unfamiliar to new. -Environment: Familiar environments are less demanding than a new environment. -Type of stimulation can vary: quiet to distracting and busy. -not always the demands of the task, could be the endurance that is difficult -be able to generalize

targeted outcomes

-Determine outcome measures Center for Medicare is now reimbursing for VALUE -Value is improvement in outcomes -Must collect data at start and end of OT services -Self-Care GG Items https://www.aota.org/~/media/Corporate/Files/Practice/Manage/Documentation/Self-Care-Mobility-Section-GG-Items-Assessment-Template.pdf

Strategies for Grading

-Follow logical sequence of self-care tasks -Progress positioning -Increase complexity of tasks -Decrease amount of verbal instruction/physical cueing Backward chaining -Assist with all LB dressing except for donning shoes. At next session allow client to don socks and shoes. 3rd session they don 1 pant leg, socks, shoes. The following sequence of training for self-care activities is suggested (easiest to more difficult): feeding, grooming, continence, transfer skills, toileting, undressing, dressing, and bathing, simple IADLs, complex IADLs Progression of positioning during training: Self-feeding: in the bed using tray table, sitting at the edge of the bed using a a tray table (feet flat on the floor), sitting in a chair next to the bed using a tray table, sitting at a table. Can also encourage socialization by having client eat in a dining room with others. Hygiene/sponge bath: in the bed with set up, sitting at the edge of the bed with set up, sitting in a chair next to the bed with set up, sitting in front of the sink, standing in front of the sink. Dressing: UE first, then LEs; positions can be altered too (in bed with back supported, edge of the bed with set-up, in chair next to bed with set up, able to stand to dress, retrieve clothing from drawer, retrieve clothing from closet. Bath/shower: sitting in shower or tub using shower chair. Standing to shower using grab bars. Standing without use of aids. Any IADL may be graded: sitting to standing to retrieving items. The program may be graded by beginning with a few simple tasks and gradually increasing the number and complexity of tasks. Training should progress from dependent to assisted to supervised to independent, with or without assistive devices. Progress is affected by the client's potential for recovery, endurance, skills, and motivation. Verbal instruction: may or may not be helpful depending on the client's language skills and ability to process and integrate sensory information. Tactile cueing: by touching body parts to be moved, dressed, bathed, or positioned, passively moving the part through the desired pattern to achieve a step or a task, and gentle guidance through the task are helpful tactile and kinesthetic modes of instruction. Can accompany or replace demonstration and verbal instruction, depending on the client's needs. Backward chaining: assist the client until the client reaches the last step of process- the client then completes the task, help less after client masters each step. Therapist should be familiar with the task and any modifications before instructing the client and be able to perform the task. Family training to reinforce learned tasks. -logical and motivating, something they can practice/do frequently that is rewarding -easier to sit in a relaxed position while doing a task then working to independently sitting upright -backwards chaining = work backwards, increasing amount of work each time

Occupations; Profile

-Gathers occupational history -Gathers occupational context -Client goals May use chart review, interview of patient and/or caregiver

notes

-Measures the impact of the rehabilitation service -Assesses OPI identification, cognition and emotional status -Can be administered relatively quickly -Will effectively measure change in client functioning Functional Independence Measure Purpose Functional Independence Measure Administration Functional Independence Measure Scoring Functional Independence Measure Occupational Performance Issue Identification Functional Independence Measure Theoretical Considerations Functional Independence Measure Psychometric Properties Functional Independence Measure Limitations SMAF Purpose Administration Scoring Occupational Performance Issue Identification Theoretical Considerations SMAF Psychometric Properties Rationale Limitations Summary Functional Independence Measure Functional Autonomy Measurement System Setting Clients Assessment Requirements An evaluative instrument to measure disability and handicap before and after intervention -Designed for clinical use with older adults -Considers the use of resources in the environment to overcome disability and handicap -First designed to help to assign community resources or chronic care beds to elderly people -Guides therapy Evaluative tool -Measures change in the degree of disability of physical and cognitive functioning in relation to the ability to perform ADLs -Used to determine effectiveness of rehabilitation 18 items: 13 motor, 5 cognitive7 point rating scale 7-6 : independence 5-3: modified dependence2-1: complete dependence client is scored at admission and at dischargechange in total score represents the effectiveness of rehabilitation and an individuals change in functioning Self-care -Sphincter Control -Mobility -Locomotion -Communication -Social Cognition WHO Disablement Model (1980) -Disability occurs at the "person" level and refers to restriction or lack of ability to perform an activity -Burden of Care -Type and amount of assistance required for an individual with a disability to perform ADLs FIM assesses disability based on level of assistance required ReliabilityInter-rater: 0.95 Intra-rater: 0.98 Test-retest: 0.95 -Generally, motor component items had higher reliability than cognitive component items. Validity -Content validity: established using statistical method and rehabilitation expert opinion (114 clinicians from 8 different disciplines and evaluated 110 patients) -Construct validity: demonstrated in many studies -FIM self-care and total scores were significantly correlated with PT and OT visits and length of stay with orthopedic inpatients Client-centered? -Ceiling effects -Issues with using a summed score -Cost Functional Independence Measure Rationale Functional Independence Measure -Clinical Utility -Designed to be used with many populations, ages, disabilities and settings -FIM can be given to a proxy in order to determine clients level of disability -FIM considered to be the most reliable, valid and responsive functional ADL assessment compared to the PECS, LORS, Katz scale and Barthel Index -Considered the "gold standard" for ADL assessment Availability: widely available through UDSMR (Uniform Data System for Medical Rehabilitation) website -Special Qualifications: training required -Time: approximately 30 minutes (varies depending on method of gathering information) -Cost: Annual subscription for facility is $2575 Can be administered by any clinical professional who has been trained in its use -Completed based on observations, interviews (with client or proxy) or medical recordBased on clients usual performance not best performance Can be administered by any health professional -Rater uses all information available to complete the evaluation including: questions to the subject, family and close friends, observe the subject in the environment and test the subject -Ratings must be based on actual performance, not what the client could or should do Comprised of 5 sections: ADLs, mobility, communication, mental function and IADLs26 items total5 level rating scale0 = independent-0.5 = independent but has difficulty carrying out the activity-1 = needs supervision or stimulation to carry out the activity-2 = needs some assistance to carry out the activity-3 = needs complete assistance to carry out the activity WHO Disablement Model (1980) -Disability defined as impairment that limits functioning or activities -Handicap defined as social disadvantages and requirements imposed on the individual Reliability -Inter-rater: 0.96 -Test-retest: 0.95 Validity -Content validity: based on established theoretical framework -Construct validity: discriminant construct validity proven by ability to differentiate between clients with different needs -Responsiveness -more responsive than the FIM -MCID Effective evaluation that measures change over time -Recommended for use in older adult populations

joint protection

-avoid positions that cause fingers to lean sideways towards the little finger (ulnarly). Solution = use devices like jar openers to assist in activities (slide 7) -avoid: wringing towels by twisting. Solution = loop the towel around the sink faucet as if braiding and pull gently, or let drip dry (slide 8) -try pouring with 2 hands (slide 9) -coffee cups with a longer, straighter handle -using both hands to carry a stack of papers -avoid: grasping thin utensils for prolonged periods. Solution = hold thick-handled tools in dagger fashion whenever possible. relaxing fingers every 10 minutes during activity (slide 10) -avoid: tight pinch when holding a pen. Solution = use a thick pen with a felt tip to reduce pressure on the fingers (slide 11) -avoid: carrying items with the weight on the fingers. Solution = use a shoulder bag or backpack (slide 12) -using both arms/shoulders to carry your backpack (slide 13) -avoid: picking up heavy items with one hand. Solution = use both hands and slide the item when possible (slide 14) -hug large objects close to your body, so the weight is supported by larger, stronger joints (slide 15) -adaptive equipment with longer handles = less movement (slide 16) -adapted kitchen supplies (slide 17) -contour grip device (slide 18)

TOTAL ASSITANCE

1 The patient completes less than 25% of the tasks OR requires the assistance of 2 or more helpers OR does not perform the activity

General Rules

1. Gait belt needed? 2. If in W/C ALWAYS lock W/C, caster wheels positioned forward 3. Never leave client unattended until safely completed transfer. If W/C make sure arms on and chair locked - if lying in bed make sure handrails UP. 4. Be able to explain process to client in step-by-step fashion and talk client through process. 5. Have assistance when needed 6. According to the FIM, independence includes the client locking the wheelchair and moving foot rests, as well as placing/removing the sliding board appropriately 7. ALWAYS use proper body mechanics!

BASIC STEPS TO TRANSFER TEACHING/TRAINING:

1. Introducing the transfer and process 2. Scooting to edge of surface 3. Reaching behind to push up 4. Getting balance and checking for dizziness 5. Small steps to new surface 6. Touch back of legs to surface 7. Reach behind and lower self 8. Review transfer and discuss process/recommendations

PRINCIPLES OF JOINT PROTECTION

1. Maintain muscle strength and joint ROM: 2. Avoid positions of deformity and deforming stresses: Avoid positions that place internal forces (tight grasp, key pinch) and external forces (propping chin on side of fingers, pushing off of chair using sides of fingers to achieve standing). · Always turn fingers toward the thumb side (jars, door knobs) - this can be achieved by using right hand to open a door, open jars with right hand, close with the left. · Squeeze clothes with palms by rolling them and pressing down · Avoid leaning chin on fingers or palm of hand · Pick up coffee cup with 2 hands instead of index, middle, and thumb · Use electric can opener instead of hand-operated type · Avoid tight grasps (carrying pails, using pliers, scissors, and screwdrivers, holding spoons to stir or mix foods) · When standing, take body weight through the wrist with fingers straight rather than on the fingers. · Use palm of hand rather than fingers, to take down or hang clothes in closet · Avoid excessive and constant pressure against the pad of the thumb - open car door, screw through thick fabric. 3. Use each joint in its most stable anatomical and functional plains. -Use good body mechanics for transitional movements. Stand directly in front of or under a shelf when reaching for objects on shelf. Use wrist and fingers in good alignment. 4. Use the strongest joints available for the activity. -Use the hips and knees, not the back when lifting and using the entire body to move heavy things. Push carts and chairs from behind, use straps for opening and closing heavy doors and drawers, roll objects on counters and floors rather than lifting them. Lift objects with both hands using palms upward. 5. Avoid using muscles or holding joints in one position for any undue length of time. Sustained muscle contraction is fatiguing. · Use a bookstand instead of holding the book while reading. · When mixing, stabilize bowl with the palm of the hand and fingers against the body or wall or in an open drawer to avoid handling the bowl with the fingers and thumb. · Hold the mixing spoon with the thumb side pointing upward, not with the thumb pointing down and use a built-up handle to decrease the force of grasp · Use a brush to scour pans, not the fingertips. · Use the palm of the hand or the bend in the elbow instead of fingers in carrying handbags and coats. · Hold objects such as vegetable peeler parallel to MP joints and not across the palms. 6. Never begin an activity that cannot be stopped immediately if it proves to be too taxing. -Allow time for resting. Use assistive equipment to help with transfers if necessary, e.g., sliding board, tub chair. Employ principles of energy conservation and work simplification. 7. Respect pain -Some discomfort may be tolerable. Pain lasting one or more hours after activity is a sign that the activity needs to be stopped or modified. Pain can evoke muscle spasm and inhibit muscle contraction.

types of transfers practiced in lab

1. Standing Pivot Transfer (one and two person) 2. Sitting Pivot transfer (one and two person) 3. Sliding board transfer 4. Sitting lateral/swinging 5. Standing transfer with walker

Criteria for competency:

1. You will be able to properly position client for transfer 2. Competent knowledge with wheelchair features to facilitate the transfer 3. Use proper body mechanics 4. Assure the safety of yourself and the client 5. Effectively communicate with the client.

Self-Care

1.Eating 2.Grooming 3.Bathing 4.UE Dressing 5.LE Dressing 6.Toileting

Intervention implementation

1.Preparatory 2.Purposeful 3.Occupation 4.Education 5.Advocacy

Intervention Implementation

1.Preparatory 2.Purposeful 3.Occupation 4.Education 5.Advocacy -preparatory = modalities (ex: ultrasound, e-stim, heat, etc.) -purposeful = leading you closer to goal (ex: having them cut playdough to help them in cutting their food) -occupation = actual occupation (ex: actually cutting food)

6 areas of the FIM assessment

1.Self Care 2.Sphincter control 3.Mobility 4.Locomotion 5.Communication 6.Social cognition

MAXIMAL ASSITANCE

2 The patient completes 25% to 49% of the tasks

MODERATE ASSITANCE

3 The patient completes 50% to 74% of the tasks

MINIMUM ASSITANCE

4 The patient completes 75% or more of the tasks OR touch assistance

FACT: Studies have shown that...

40-80% of the medial information patients are told during office visits is forgotten immediately. and nearly half of the information is incorrect

SUPERVISION/SET-UP

5 The patient completes 100% of the tasks but requires a helper to provide cueing or coaxing without physical contact. OR The helper sets up items/applies orthoses or assistive/adaptive devices

MODIFIED INDEPENDENCE

6 The patient completes 100% of the tasks but uses an assistive device or aid, takes more than a reasonable amount of time, or does so with a concern for safety

COMPLETE INDEPENDENCE

7 The patient completes 100% tasks without a helper and without an assistive device

Preparation

A. Determine the appropriate equipment and pattern based on the medical record, the PT assessment/notes and goals. B. Verify the initial measurement of the equipment to ensure a proper fit and determine that the equipment is safe. C. Always apply a gait belt to the client. D. Explain and demonstrate the gait pattern for the client. Have the client explain the procedure or activity in his/her own words to verify that he/she truly understands and comprehends your instructions. E. Use the gait belt and the client's shoulder as points of control when guarding the client. F. Maintain proper body mechanics for yourself and the client.

Basic Gait Patterns

A. Four Point Gait B. Two Point Gait C. Modified Two Point Gait D. Three Point Gait E. Modified Three Point

Guarding Techniques

A. Gait Belt: necessary during all initial functional mobility activities. Grasp the gait belt from the bottom with one hand with your arm supinated. Your other hand should rest lightly on the client's upper shoulder. B. Position: Stand behind and slightly to one side of the client. You may stand more toward the client's weakest LE or strongest LE-practice both and find out which method you prefer. Your outermost LE moves with the aid, and your inside foot moves with the client's LEs. Be aware of unexpected movements by the client, e.g., misplacement of the ambulation aid, a misstep, slipping of the aid. C. If client loses balance or falls: Your primary objective is to provide a safe environment and treatment and to protect the client from injury. *If the client loses balance forward in a trunk-flexed position, restrain him by firmly holding the gait belt, push forward against the pelvis and pull back on the shoulder or anterior chest. *If the client. falls forward, beyond the point where you can maintain his balance, instruct him to quickly release or remove the AD and reach for the floor. Retard the forward motion by pulling back gently but firmly on the gait belt and the client's shoulder, but do not prevent the client from reaching the floor. Step forward with your outside foot as the client is moving toward the floor and gently retard his descent. Instruct the client to cushion the fall by bending the elbows as the hands contact the floor and to lower himself to the floor. *If the client falls backward, beyond the point where you can maintain him standing, rotate your body so that it is turned toward the client's back and widen your ant-post stance. Instruct the client to release AD, and allow him to briefly lean against your body or to sit on your thigh. It may be necessary to lower the client.onto the floor to a sitting position using the gait belt and proper body mechanics. *Rising from the floor: weaker LE is extended and externally rotated, AD within easy reach, client pushes to stand using the strongest LE and UEs, grasps AD while in semistanding position. Client may also prefer to use a firm object (table, chair, sofa) for support and stability. NOTE: Know the definition of a fall in your treating environment. A client does not need to completely fall to floor from standing to be a fall. Understand an incident report will most likely be required.

Precautions

A. Guard the client by standing behind and slightly to one side of him/her (usually weak side), and maintain a grip on the gait belt until the client is able to ambulate independently and safely. B. Do not leave the client unattended while he/she is standing, because he/she may not be as stable as he/she appears or indicates to you, and he/she could fall. C. Protect client appliances (IVs, drainage tubes, catheters, dressings) during ambulation. D. Be certain the area used for ambulation is free of hazards, such as equipment or furniture, throw rugs, clutter, and the floor or surface is dry. Safe conditions must be maintained to reduce the risk of injury to the client.

general preparation

A. Must be aware of the client's problems and abilities and of the PT goals for ambulation. What gait pattern is the PT using with the client, what is the client's ambulation status? Independent, S, contact guard, minimal/moderate/max assistance. Why is coordination with the PT so important? B. Understand the proper fit of equipment needed for each client. Know orthotics and rationale for use of orthotics. C. Provide safety and protection to each client through the use of proper guarding techniques, precautions, and instructions. D. Need to prepare the client physically and/or emotionally to perform the activities you and he/she decide on. E. Understand how functional ambulation is different than functional mobility. F. Ensure proper footwear and know level of endurance client has. G. Understand falls and body mechanics.

Weight Bearing

A. NWB-involved LE not to be WB or touching floor B. TTWB-Pt can rest toes on the floor for balance, but not WB C. PWB- limited amount of WB permitted on LE (example: 25% PWB = 25% of pt's total body weight is allowed to be transmitted through the involved LE) D. WBAT-pt allowed to place as much or as little weight through the involved LE, depending on pt. tolerance E. FWB-pt. permitted full weight bearing through involved extremity

Some Interventions ideas for 20-25 minutes:

ADLs: -Grooming (washing face at sink, brushing teeth, combing hair) -Shaving face -Putting on makeup -Filing or cutting fingernails -Dressing - clothes laid out by therapist -Getting out of bed and into a chair for breakfast IADLs: -Making tea, instant coffee or instant hot chocolate -Making a bed -Watering plants -Dusting furniture in one room -Mopping a floor -Folding laundry

Some Intervention ideas for 40-45 minutes:

ADLs: -Showering and dressing (clothes laid out by therapist) -Shaving face, flossing and brushing teeth, combing hair -Tweezing eyebrows, putting on makeup -Polishing nails -Dressing, including getting clothes from closet and drawers -Getting out of bed and toileting IADLs: -Making a small meal (sandwich, salad) -Changing the sheets on a bed -Repotting a plant -Cleaning a bathroom sink and toilet -Vacuuming rug in one room -Taking laundry out of a dryer and folding it.

Lleisure adaptive equipment for RA

Adapted gardening tools, rolling stool for gardening, card holder, reading rack, embroidery hoop holder, rolling golf cart, know turner.

Modify/Compensate/Adapt Strategies

Alter the task method (eliminate unnecessary steps, simplify) Sit to complete grooming Adapt objects or prescribe AE Use elastic shoe strings, provide long-handled shoe horn Adapt environment Elevated toilet seat, remove rugs, grab bars,

doors

Approach door at an angle- on door handle side. If door swings out, client will need to back up while opening door.

Education Strategies

Assess ability to learn (language, cognition) and teach on appropriate level Instruct/Demonstrate/Rtn demonstrate/Generalization to other situations Handouts, videos, HEP Quiz them -Teach ECWS, Demo principles, Ask for client to demo, Assess if they utilize the same principles when doing a new task Have a clear plan about the purpose of the teaching session. Need to consider client and family motivation, cognitive status, skill level that needs to be achieved, and time availability for the teaching and learning process. Levels of goals include: knowledge (client will discuss learned information), application (client will demonstrate learned information), and problem-solving (client will apply information to new situations). The presentation of information needs to be appropriate to the client's level of educational and emotional levels. Instructions must be clear. Ask open-ended questions to ensure client understanding Use client response to determine appropriate amount of information presented: may need to provide information in short sessions. Promote the highest level of learning if possible (problem-solving) Illustrate or demonstrate the points being taught. -instruct --> demonstrate --> return demonstration --> generalize

analysis of occupational performance

Assessments https://www.aota.org/Practice/Manage/value/quality-toolkit.aspx May use observation of actual ADL performance and assessment of environment

MOST COMMON TRANSFERS OCCUPATIONAL THERAPISTS ADDRESS (keep in mind they can be a precursor to ambulating or surface to surface):

Bed Transfers Chair Transfers Toilet Transfers Shower/Tub Transfers Car Transfers

steps to using a hand rail

Bilat canes: hold canes in one hand, rail in other; or grasp cane (parallel to rail) and rail with one hand, cane in other. Crutches: both crutches under axilla farthest from handrail, rail with other hand; one crutch under axilla farthest from handrail, other crutch horizontally to the crutch in axilla, other hand grasps handrail; one crutch under axilla farthest from rail, other crutch horizontally along handrail with hand that grasps handrail. Walker: without aid; with special step walker. Kitchen/reaching: use counter for support, approach refrig/lower counters from the side.

Try the teach back method

Keep in mind this is not a test of the patient's knowledge. It is a test of how well you explained the concept. Plan your approach. Think about how you will ask your patients to teach back the information. For example: "We covered a lot today and I want to make sure that I explained things clearly. So let's review what we discussed. Can you please describe the 3 things you agreed to do to help you control your diabetes?" "Chunk and Check." Don't wait until the end of the visit to initiate teach-back. Chunk out information into small segments and have your patient teach it back. Repeat several times during a visit. Clarify and check again. If teach-back uncovers a misunderstanding, explain things again using a different approach. Ask patients to teach-back again until they are able to correctly describe the information in their own words. If they parrot your words back to you, they may not have understood. Start slowly and use consistently. At first, you may want to try teach-back with the last patient of the day. Once you are comfortable with the technique, use teach-back with everyone, every time! Practice. It will take a little time, but once it is part of your routine, teach-back can be done without awkwardness and does not lengthen a visit. Use the show-me method. When prescribing new medicines or changing a dose, research shows that even when patients correctly say when and how much medicine they'll take, many will make mistakes when asked to demonstrate the dose. You could say, for example: "I've noticed that many people have trouble remembering how to take their blood thinner. Can you show me how you are going to take it?" Use handouts along with teach-back. Write down key information to help patients remember instructions at home. Point out important information by reviewing written materials to reinforce your patients' understanding. You can allow patients to refer to handouts when using teach-back, but make sure they use their own words and are not reading the material back verbatim.

Education EBP

Patients were split into a control group and an intervention group, which attended eight 2.5 hours sessions for eight weeks. Discussions and topics covered in the sessions included physical pain, social and emotional challenges, strategies to handle the symptoms of rheumatoid arthritis, diet and nutrition, home exercise, living with rheumatoid arthritis, and efficiency training for maintaining a house hold were all led by various health care providers. Questionnaires were filled out before the program, 3 months after the program and 12 months after the program. There were 96 participants who completed this one year study. There were 12 men and 84 women between 27 and 77 years of age. After 12 months, the intervention group displayed increased knowledge about rheumatoid arthritis in the areas of anatomy, inflammation, pain relief, and available treatments. They also had significantly higher ability to handle their pain as well as a reduction of problems with their disease due to their practicing of joint protection. Education does seem to provide benefit to those with rheumatoid arthritis (Lindroth, et al, 1997).

TYPICAL DEFORMITIES ASSOCIATED WITH RA

Piano key sign zig zag deformity ulnar drift swan neck boutonniere mallet Thumb CMC collapse pictured: ulnar drift

Evaluation of specific areas

Piper Fatigue Scale - 27 questions DASH - 30 items to assess Disability of Arm, Shoulder, & Hand -Additional sports and work modules Modified Falls

Education

Providing useful information (written, video, audio) to increase understanding Uses -Group -Individual -Caregivers Examples -Ortho surgery AE, ECWS, Jt. Protection, Body Mechanics Instructional Methods: -Group instruction: joint protection, energy conservation, body mechanics -Individualized instruction: when personal nature and more heterogeneous population -Written materials, videos, audiotapes. Caregiver training: -If new caregiver, need to consider caregiver's capacity to understand and apply information necessary for safe and effective management. If under emotional duress, may need more time and repetition to process information. If physical assistance to client is required, does caregiver have the physical capacity to provide needed assistance? -Learn by doing. -Give opportunity to ask questions. Videos to reinforce. Need to instruct them in home programs and specific cueing skills. -Caregiver training should focus first on safety for clients and caregivers - determining if these skills are safe to perform at home without therapist supervision. -can educate prior to surgery on how to use equipment, etc.

what is RA?

RA is a disease of the synovium. The immune response goes out of control.

Measurement/Fit

RULE OF THUMB: Handgrip level with ulnar styloid, 15-25 degrees (some say 20-30 degrees) of elbow flexion, shoulders relaxed and even.

TEACH BACK METHOD

Regardless of a patient's health literacy level, it is important that staff ensure that patients understand the information they have been given. The teach-back method is a way of checking understanding by asking patients to state in their own words what they need to know or do about their health. It is a way to confirm that you have explained things in a manner your patients understand. The related show-me method allows staff to confirm that patients are able to follow specific instructions (e.g., how to use an inhaler). -The teach-back and show-me methods are valuable tools for everyone to use with each patient and for all clinic staff to use. These methods can help you: -Improve patient understanding and adherence. -Decrease call backs and cancelled appointments. -Improve patient satisfaction and outcomes

Establish/Restore/Remediation

Restore component skills -strength, endurance, ROM, memory, interests Use -when you can expect improvement -To slow progressive disorders -Endurance effects occupation -When you can NOT assume generalization will occur Examples -Infant with CP -After CVA -After heart attack -Includes the biomechanical and sensory integrative frames of reference. -Intervention is used to restore component skills, such as strength, endurance, ROM, memory, interests. Must establish a link between the performance component deficit and the resulting functional task deficit. Appropriate when: -Performance Skill deficit is expected to improve -May be appropriate for some clients with progressive disorders to slow the decline of specific component skills. (Parkinson's) -Endurance is an issue - grade activity -Cannot assume generalization will occur - perceptual skills, motor control/motor learning -restoration only if they have the ability to (ex: would not work bilateral movements on someone with an amputation) -ex: cannot get stronger with ALS, only maintain strength/muscle. Can strengthen with Parkinson's

Grading

Starting at a basic level of a task and continually progressing to maximize potential Uses -Building upon skills/performance components -When endurance is poor Examples -Self care can begin with brushing teeth and progress to bathing BASIC PRINCIPLES: -Grade task progression from easier to harder: Begin with oral hygiene, progress to bathing -Increase complexity within the task: simple meal prep, such as sandwich, to more complex task, such as baking. -Same task in varied performance context: difficult to generalize skills from clinic to home. -grading: just right challenge -based on what they need on that given day

OT Assessment

Subjective: age, hand dominance, onset of symptoms. Percentage of good/bad days; periods of remission and exacerbation. Types of treatment (OT and other). Morning stiffness and duration, location of stiffness, joints, severity, and affect on endurance. Medications. Support systems and their understanding of the disease. Home environment - architectural barriers. Hobbies and interests: prior and current. Occupations. Assess AROM - be careful of shoulder - work within painfree range. Note elbow - can have an inflamed bursa resulting in limitations in extension. Measure AROM of hand. (may need to do lateral measurements). Distal Palmar Crease, ulnar drift (if greater than 20 degrees) Assess sensation - semmes weinstein monofilaments - may have nerve compressions Assess grip/pinch strengths. Defer Jamar dynamometer if inflamed. Measure on 1/2/3 positions. NEVER MEASURE KEY PINCH because exerts lateral forces on MPs. Assess MMT: may defer if too painful. May be able to tolerate slight resistance. NOTE DEFORMITIES -Slide 2 Assess ADL performance

Turning

Teach client to turn in both directions regardless of weakness. Should pivot on the strongest LE regardless of direction and gait type (exception: bilat THR-pivoting of any type is contraindicated). Aid is moved in the direction of the turn. Type of flooring will affect ease in turning (carpet harder than tile).

Edema EBP

The Isotoner and the Futuro compression gloves equally and significantly reduced pain, stiffness and swelling while they increased range of motion, rate of finger motion, and grip strength (McKnights & Kwol, 1992).

Curb/Steps/Incline

Three rules: 1. "Up with the good, down with the bad" -lead with uninvolved for ascending -lead with involved for descending 2. The assistive device remains with the involved extremity 3. The clinician always guards the patient from below -So behind an ascending patient & in front of a descending patient UP: place strongest LE on step/curb and then simultaneously raise the crutches/canes and weaker LE onto the curb/step. IF incline, may need to zig-zag DOWN: Simultaneously place weakest LE and both canes/crutches onto the step/surface below while flexing the strongest LE hip/knee slightly.

Sideward turning

To move to the right- client positions left aid next to outside of left foot and right aid six inches from right foot- Step to the right and reposition aids.

bent pivot transfer

Used when the client cannot initiate or maintain a standing position. A therapist often prefers to keep a client in the bent knee position to maintain equal weight bearing, provide optimal trunk and LE support, and perform a safer and easier therapist-assisted transfer. Same as standing pivot, except client does not stand, stays in trunk/hip flexion position; OR, therapist can perform sitting and use a stool to elevate client's feet for increased hip flexion.

Four Point Gait

Used when there is bilateral LE involvement. Use bilat crutches. Right crutch then left foot; left crutch then right foot. Slower gait and good stability.

Purpose of joint protection

Used with individuals with rheumatoid arthritis. The purpose is to instruct the client in methods of reducing joint stress, decreasing pain, preserving joint structures, and conserving energy. Clients with RA need to employ these methods in all of their daily activities when in active phase of the disease or where joint instability is present to maintain maximal function and prevent joint damage and deformity.

Occupational Therapy Intervention Implementation

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PRINCIPLES OF ENERGY CONSERVATION/WORK SIMPLIFICATION

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Rheumatoid Arthritis Intervention

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4. LEISURE TIME

a. Devote a portion of your day to an activity that you enjoy and find relaxing b. Check out what's available in the community.

5. WORK METHODS

a. Keep items within easy reach b. Use good light and proper ventilation and room temperature c. Use joint protection techniques d. Work surfaces should be a correct height (elbow height)

7. HOW TO BEGIN

a. Plan ahead by charting your daily routine b. Make a list of tasks and spread them out in your schedule c. Include daily periods and rest breaks during energy consuming times.

6. ORGANIZATION

a. Plan ahead; do not rush or push yourself b. Decide which jobs are absolutely necessary c. Share the workload with family and friends

3. WORK PACE

a. Plan on getting 10-12 hours of rest daily (naps/night) b. Work at your own pace c. Spread tedious tasks throughout the week d. Do the tasks that require the most energy at the times you have the most energy e. Alternate easy and difficult activities and take a 10-15 minute rest break each hour.

1. ATTITUDES AND EMOTIONS

a. Remove yourself from stressful situations b. Avoid concentrating on things that make you tense. c. Close your eyes and visualize pleasant places and thoughts.

2. BODY MECHANICS

a. When lifting something that is low, bend your knees and lift by straightening your legs. Keep your back straight b. Avoid reaching. Avoid stretching, bending, carrying, and climbing. If you have to bend, keep your back straight. c. Incorporate good posture into activities. d. To rise from a chair, slide forward to the edge of the chair. With feet flat on the floor, lean forward and push with your palms on the arms or seat of the chair. Stand by straightening your legs. e. Before you get tired, stop and rest.

Three Point Gait

bilateral aids or a walker, NO canes. Client is able to fully bear weight on one LE but cannot bear weight on the opposite LE. The walker or crutches and the non-weight bearing LE are advanced, and the client steps up to the walker or through the crutches. Most rapid gait but least stability.

self-care adaptive devices for RA

buttonhook, dressing stick, sock aid, reacher, long handled sponge, extended handle for managing toilet paper, long handled comb or brush, electric tooth brush, pump toothpaste dispensers.

Modified Three Point Gait

can use canes. Used when the client is permitted full weight bearing on one LE and partial weight bearing on the other LE. Advance walker, crutches simultaneously with the PWB LE then advance the FWB LE while the client distributes body weight onto the aid.

occupational performance =

context + environment + client factors + performance skills + performance patterns

OT process

evaluation (occupational profile, analysis of occupational performance, and targeted outcomes) --> intervention (intervention plan and implementation) --> re-evaluation (re-analysis of occupational performance, review of targeted outcomes, and identify actions to be taken) --> continue OR discontinue OT all revolves around evidence (theory, research, therapist experience, and client preferences)

splinting

more on slide 5 working vs resting hand splints

joint protection stuff from lab

o Open jars with the right hand, close with the left (fingers moving toward the thumb side to prevent ulnar deviation) o Joint protection is one of the components of energy conservation o Joint protection not always needed (identify what their problem areas are) o Kitchen tools with suction cups (no prolonged holding) o Card holder (no prolonged tight pinch) o Care shuffler o Scissors with a loop (passive opening) o Door grips o Jar openers o Denture cleaning tooth brush (suctions to mirror) o Long handled hair brush o Handle attachments (Velcro to handle, for no gripping needed) o Finger nail clippers with suction cups and base (bigger joints) o Cutting board with prongs to hold food item to be sliced o Dysom

Teach back method notes

o True understanding --> better patient outcomes o Go over all handouts provided to ensure they understand what they should be doing o Ask them questions and allow for them to ask questions o Give easy ways to remember information (ex: pneumonic, chunking, once in the morning and once at night, etc.)

aim of this course

putting it all together -condition -environment -stage of life -body habitus

cars

similar to chairs; passenger side easier. Back seat may be more comfortable. OT's need to be aware of DMEs available as well as "tricks of the trade". Caregiver education very important here.

example of documentation for CC

slide 16

The normal forward step consists of two phases:

the stance phase, during which one leg and foot are bearing most or all of the body weight, and the swing phase, during which the foot is not touching the walking surface and the body weight is borne by the other leg and foot.

Bathrooms

toilet-same as chairs; interview client re: bathroom set-up. We'll talk about tub and toilet transfers during next section.

Two Point Gait

used when there is bilateral LE involvement; use bilat crutches. Right crutch and left foot together; left crutch and right foot together. Faster gait than 4-point but less stability.

Modified Two Point Gait

used with client with only one functional UE or uses only one ambulation aid. Hold the aid in the UE opposite to the lower extremity that requires protection. Widens BOS and assists in shifting the client's COG away from the protected LE. Referred to as hemi gait pattern. Ex: Left crutch and right foot.

Suggested ADL/IADL Interventions for Different Time Limits

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Lateral Transfer with Board

· Are best used with those who cannot bear weight on the LEs and/or who have paralysis, weakness, or poor endurance in their lower extremities. · The client should have good UE strength for this transfer. · In order to be independent and safe a client must have good core strength and balance. If decreased trunk balance assist would be required for safety. · It is most often employed with persons who have LE amputations or individuals with SCIs or with clients with weakness in one side and are unable to stand safely. Often a precursor to lateral swing transfer. Technique: A. Client moves forward in chair with feet on the floor. B. Removes armrest nearest bed. C. Positions transfer board under client's thigh and firmly on surface transferring toward. Therapist may block client's knees. D. Client performs push-up with UEs to elevate the body and begins to move toward the bed until hips are on the bed. Should tranfer upper body weight in opposite direction of transfer. Client may also use forearms and scapula to advance self across the transfer board (SCI). E. Therapist should guard client's knees and use gait belt to assist in elevating the body or moving the buttock across board. Therapist can perform sitting. F. Remove transfer board when client is seated securely on surface. Do not leave client sitting unattended.

about RA

· Onset between 20-55 years · Develops suddenly, within weeks or months · Usually affects same joint on both sides of the body/bilaterally (MPs, PIPs): results in weak intrinsics. Can lose 50% or more of strength. · Causes redness, warmth, and swelling of joints · Affects many joints, including elbows and shoulders · often causes a general feeling of sickness, fatigue, weight loss and fever

OT Intervention

· modalities (heat/cold) · therapeutic exercise (to maintain strength/ROM) · education to patient/family · splinting to prevent worsening of deformity and loss of function · joint protection and energy conservation · exercises · job/home/environment modifications · adaptive equipment -modalities: give them what they want (heat or cold, whatever works for them) -splinting = resting splints at night and soft/dynamic splints during the da, compression glove for swelling -joint protection and energy conservation = what can they do differently to decrease injury to the joints

SCORING

•1. Total Assistance •2. Maximal Assistance •3. Moderate Assist •4. Minimum Assist •5. Supervision/Set-up •6. Modified Independence •7. Complete Independence

FIM layout

•18 items: 13 motor, 5 cognitive7 point rating scale 7-6 : independence 5-3: modified dependence2-1: complete dependence client is scored at admission and at dischargechange in total score represents the effectiveness of rehabilitation and an individuals change in functioning

FIM

•Characterize deficits •Monitor progress •Target interventions •Establish goals & monitor attainment •Determine discharge location & LOS •Increase communication among patient, caregiver, and team •Designed to assess many populations, ages, disabilities, settings •Most reliable, valid, and responsive ADL assessment compared to PECS, LORS, Katz, Barthel •Gold Standard of ADL assessment •Focuses on the burden of care •Includes 18 items scored from 1 to 7 based on level of independence •Scores range from 18 to 126, higher score= > independence •It takes ~30 min to score •Can be administered by a physician, nurse, therapist or layperson who is trained in its use. •Completed based on observation, interview, medical record •Based on usual performance, not best performance -higher score = more independent

limitations of the FIM

•Client-centered? •Ceiling effects •Issues with using a summed score •Cost -Not easily accessible -Client-centered? -Clinical Utility Cost: $1600 for a training session -Specificity: Acute setting, the elderly with disabilities -Availability: User manual available with training course -Special Qualifications: 1 day, 7 hour training course -Time: approximately 40 minutes (varies depending on method of gathering information) -Acceptability: non-invasive, relatively short time required SMAF (Personal communication with Johanne Guilbault, November 13th, 2012)

ADLs-toileting

•Consists of 3 steps: 1. Adjusting clothing before using toilet/commode/bedpan/urinal. 2. Managing perineal hygiene 3. Adjusting clothing after going to the bathroom. *Rate on continent episodes only *Does not include getting on/off toilet.

ADLs-dressing

•Dressing and undressing including applying and removing a prothesis or orthosis when applicable. •Assess the steps performed, not the articles of clothing.

Purpose of the FIM

•Evaluate •Target interventions •Establish goals & monitor attainment •Measure change in functioning and cognition •Determine the effectiveness of rehabilitation •Characterize deficits •Determine discharge location & LOS •Increase communication among patient, caregiver, and team -objective data for certain areas -can do it frequently -created to ID where they should go upon discharge

Positions of deformity (slide 2)

•Normal • •Swan neck • •Boutonniere • •Mallet

ADLs-grooming

•Oral care 20% •Hair combing 20% •Washing face 20% •Washing hands 20% •Shaving/applying make-up 20% •If patient does not shave/apply make-up each =25%

ADLs-eating

•Using suitable utensils to bring food to the mouth, chew food, and swallow it once presented. Rate entire task (picking up utensil, scooping, bringing hand to mouth, chewing/swallowing, and drinking.

ADLs-bathing

•Washing, rinsing, and drying body. Can be rated in tub/shower/or sponge/bed bath. Does NOT include neck or back. 10% left arm 10% right arm 10% chest 10% abdomen 10% front perineal area 10% left upper leg 10% right upper leg 10% left lower leg 10% right lower leg 10% buttocks

Intervention Plan

•What is the rehab potential? •Client prognosis? •Timeline? •Motivation? •Problem areas •Goals •Methods -prioritize, cannot address everything (try and work broadly, like working on balance which can help with multiple ADLs) -methods = specific ways you will conquer the problems