Competency Exam 1 Flashcards
What structures are needed for swallowing?
Tongue, soft palate, esophagus, hyoid bone, epiglottis, trachea, thyroid cartilage, vocal folds, pharyngoesophageal sphincter, cricoid cartilage
What are the phases of swallowing?
Preoral phase,oral preparatory phase, oral phase, pharyngeal phase, & esophageal phase
Describe the pre-oral phase of swallowing.
Cognitive and physical orientation to the eating activity occurs. Feeding takes place during the preoral phase, during which the client moves food or liquid to the mouth. This phase is primarily voluntary.
Describe the oral preparatory phase of swallowing.
A solid or liquid bolus is prepared by the structures of the oral cavity to be swallowed, which involves tasting, chewing, manipulation, and containment of the bolus in the mouth. This phase is also primarily voluntary.
Describe the oral phase of swallowing.
The bolus is propelled toward the pharynx by motion of the tongue against the hard and soft palates. Both voluntary and involuntary controls occur during the oral phases.
Describe the pharyngeal phase of swallowing.
The soft palate elevates to close off the nasopharynx. The larynx lifts and protracts, and the epiglottis moves posteriorly to cover the opening to the larynx, protecting it from the entry of the food or liquid bolus. The swallow response is initiated as the bolus is propelled through the pharynx during closure of the larynx and the opening of the upper esophageal sphincter (UES). This phase is primarily involuntary, although voluntary controls may alter its motions.
Describe the esophageal phase of swallowing.
The UES returns to its closed position to keep food from reentering the pharynx. The bolus travels through the esophagus, and the lower esophageal sphincter opens, allowing the bolus to pass into the stomach. This phase is involuntary, although body position changes may alter the movement of the bolus through the esophagus.
What are the screening tools for dysphagia?
Screening - process of determining whether a patient requires a full formal dysphagia evaluation. Can be done through a combo of oral report from caregivers and observation of the patient.
SCREENING TOOL
- Nutrition and Swallowing Screen (observational checklist)
- Burke Dysphagia Screening Test (Checklist)
- Northern Dysphagia Patient Check (Checklist)
- Gugging Swallowing Screen (Checklist)
- Massey Bedside Swallowing Screen (Checklist)
Describe the Burke Dysphagia Screening Test.
Format: Checklist
Standardization and Comments: Uses 3 oz.of water to screen; stroke patients; standardization protocol
Describe the Northern Dysphagia Patient Check.
Format: checklist
Standardization and Comments: Uses thin liquid of pudding texture and cookie; Standardized protocol
Describe the Gugging Swallowing Screen.
Format: checklist
Standardization and Comments: Standardized protocol; reliability and predictive and concurrent validity tested
Describe Massey Bedside Swallowing Screen.
Format: Checklist
Standardization and Comments: Content validity; predictive validity, and interrater reliability tested
Describe Dysphagia Assessment Components.
They commonly include information on cognitive status, including alertness and orientation; motor control, including posture and positioning and the ability to self-feed; oral and pharyngeal control without test foods; and oral and pharyngeal control during swallowing.
List the standardized dysphagia assessments.
- Dysphagia evaluation protocol
- MASA: Mann Assessment of Swallowing Ability
- Clinical Swallowing Examination
- Occupational Therapy Clinical Dysphagia Assessment
Describe the Dysphagia Evaluation Protocol
- standardized
- developed by occupational therapists in an acute care settings
- applicable to all dysphagia diagnoses
- has reliability and validity testing
- Is comprehensive
Describe the MASA: Mann Assessment of Swallowing Ability
- 24 pt scale
- quickly administered
- applicable for neurogenic dysphagia
- has reliability and validity testing
- is comprehensive
Describe Clinical Swallowing Examination
- uses a scoresheet form
- developed by a speech-language pathologist
- applicable for all dysphagia diagnosis
- does not have reliability and validity testing
- is comprehensive although does not include dysphagia history and demographic information collection
Describe the Occupational Therapy clinical Dysphagia Assessment.
- scoresheet form
- developed by occupational therapists
- applicable to all dysphagia diagnoses
- Does not have reliability or validity
- is Comprehensive
What are the instrumental evaluations for dysphagia?
MBS (modified barium swallow) - sometimes called the videofluoroscopy - the patient eats therapist-selected textures of food and fluid that have been combined with barium. Swallowing images are caputres on videotape or DVD. The study can then be viewed later, including frame-by-frame analysis if necessary, to not elements of swallow.
FEES - an endoscopic swallowing evaluation. A small flexible fiberoptic endoscope is passes through one of the patient’s nares through the nasopharynx to the level of the valleculae. Easily done at the patient’s bedside and may be particularly useful in the intensive care unit setting
Blue Dye Testing - used to assess for aspiration in clients with tracheostomy or during FEES. Dye is given to the patient either mixed with food or by itself. IF the patient has a tracheostomy, tracheal secretions are observed for blue food color; during FEES a blue tinge is observed below the level of the vocal cords
What interventions are used with dysphagia?
Typical interventions include positioning and mobility, oral care, and self-feeding, and they may have great impact on the patient’s ability to manage safe oral intake over the course of an initial intervention session.
Describe the positioning and mobility intervention for dysphagia.
- stable trunk position with core and extremity symmetry can optimize the client’s swallowing
- eating in a chair is best, and it encourages arousal when the patient is drowsy
- seated in an upright chair or wheelchair with legs supported on the floor and arms on the table
Describe oral care for dysphagia intervention.
(good oral care has been shown to reduce pneumonia rates because the same organisms that colonize the oral cavity can enter the airway and cause pneumonia in the lungs)
- provides important sensory and motor stimulation for the client in preparation for a meal or the feeding-trial portion of the dysphagia assessment
- remove and clean dentures and partial plates -use of mouthwash and toothpaste
Describe the self-feeding in dysphagia intervention.
likely improves the quality of the swallow and of course, reinforces independent self-care goals
- there are several strategies to encourage self-feeding for different challengesm A
What strategies are used to encourage self-feeding for someone who is disoriented or distracted to activity?
- remove distractions (visual and auditory) from environment; turn off TV
- Present one food container at a time
- Provide verbal cues to orient the client as needed during eating
What strategies are used to encourage self-feeding for someone who has unilateral neglect or visual field cut?
- present one food container at a time, and cue the client to observe it as needed
- provide an anchor (a colorful piece of paper at the side of the plate)
What strategies are used to encourage self-feeding for someone who has low vision?
- use clock method to describe location of food on the plate
- present a limited number of food containers at one time
- Use a dark tray or placemat and a light-colored plate
What strategies are used to encourage self-feeding for someone who has a lack of appetite?
- present favorite or preferred foods
- discontinue pump feedings 1 - 2 hours before meals or snacks
- limit portion size so as not to overwhelm patients with large amounts of food on the tray
What strategies are used to encourage self-feeding for someone who has difficulty bringing food to mouth?
- provide adapted eating tools: utensil, plate guards lidded cups, universal cuffs
- provide finger foods to start
What strategies are used to encourage self-feeding for someone who has difficulty using dominant arm to eat?
- use hand-over hand guiding techniques
- provide splints, overhead slings, or mobile arm supports as needed
- If motion is absent, retrain self-feeding with non-dominant arm
List the modified swallowing techniques used for direct intervention in dysphagia.
- Chin Tuck
- Supragottic swallow
- Mendelsohn maneuver
- Effortful swallow
- Neck rotation
Describe the chin tuck technique for dysphagia.
Movement Required: Capital flexion
Effect: Chin tuck narrows the entrance to the larynx, reducing the chance of food or fluid falling into the airway; chin tuck has been shown to reduce aspiration of thin liquids.
Describe the Supraglottic swallow technique used in dysphagia intervention.
Movement required: Breath hold, swallow, maintaining swallow, cough,then reswallow
Effect: Supraglottic swallow causes a prompt upper esophageal sphincter opening, prolongs the pharyngeal swallow, and helps to close off the larynx. Any bolus that drips into the airway is coughed up above the vocal cords and can be reswallowed.
Describe the Mendelsohn maneuver used in dysphagia intervention.
Movement Required: Push the tongue up into the hard palate and maintain laryngeal elevation during the swallow
Effect: Increases extent and duration of laryngeal elevation, which increases duration and width of cicopharyngeus opening, allowing easier bolus passage
Describe the Effortful Swallow technique used in dysphagia intervention.
Movement Required: Contract the throat muscles hard while swallowing
Effect: Moves the base of the tongue posteriorly, thus helping to clear food material from the valleculae during swallow. Also, it further elevates the hyoid bone and reduces oral residue during the swallow and increases pressure in the pharynx during the swallow.
Describe the Neck Rotation technique used in dysphagia intervention.
Movement Required: Turning the head to the weaker or hemiparetic side during the swallow as far as range of motion and comfort will allow.
Effect: Rotation closes off the side of the pharynx to which the head is turned.
What is the OT role in dysphagia intervention?
screening, evaluating, assessing, indirect and direct intervention
What are the typical swallowing problems found in dysphagia?
coughing while eating, wet vocal quality complaints of pain with swallowing, throat clearing, effortful swallowing, drooling, residual food in the oral cavity, and weight loss
What are the different health systems?
Acute Medical Care system (hospitals) Post-Acute Care System (Long Term Care & Ambulatory Care)
What is the progression from one health system to another?
Acute care occurs at the beginning of the continuum; which is to the say, at the beginning of the course of illness. A pattern of heath care in which a patient is treated for a brief but severe episode of illness, for the sequelae of an accident or other trauma, or during recovery from surgery. Acute care is usually given in a hospital by specialized personal using complex and sophisticated technical equipment and materials and it may involve intensive or emergency care. This pattern of care is often necessary for only a short time, unlike chronic care.
Ambulatory Care (subcategory of acute care)- outpatient and no overnight stay required
Long-term care - the provision of medical, social, and personal care services on a recurring or continuing basis to persons with chronic physical or mental disorders. The care may be provided in environments ranging from institutions to private homes.
What areas does an OT evaluate and what assessments he/she may choose?
Evaluation is usually on cognitive (KELS) and physiological performance factors such as strength (MMT), ROM (goniometer), balance (Berg balance, functional reach, single leg stance, Romberg, & Timed up and Go), mobility (Barthel index & FIM), cardiopulmonary functions, and ability to participate in BADLs (Barthel Index & FIM).
Define evaluation.
An evaluation is focused on finding out what the client wants and needs to do, determining what the client can do and has done and identifying those factors that act as supports or barriers to health and participation. The evaluation consists of the occupational profile and analysis of occupational performance. The occupational profile includes information about the client and the client’s needs, problems and concerns about performance in areas of occupation. The analysis of occupational performance focuses on collecting and interpreting information using assessment tools designed to observe, measure, and inquire about factors that support or hinder occupational performance
Describe the FIM.
Functional Independence Measure - uses a 7 point ordinal scale to evaluate occupational performance for 18 items (13 motor and 5 cognitive) in the areas of self-care, sphincter control, transfers, locomotion, communication, and social cognition. Basic measure of severity of disability, not impairment
Describe the Barthel Index.
Evaluates 10 activities: feeding, bathing, grooming, dressing, bowel and bladder control, toilet use,transfers between chair and bed, mobility, and stair climbing. A score of 60 seems to be the transitioning point from dependency to assisted independence.
Describe the Functional Reach Test
A visual assessment determining how far the client can reach safely without losing balance. Level yardstick at height of acromion. Position client next to,but not touching, the yardstck. Instruct client to lift arm forward to 90 degrees of shoulder flexion and make a fist. Have client reach as far forward as possible without taking a step. measure distance of movement from 3rd metacarpal. (<15.2 cm = increased fall risk)
Describe Single Leg Stance Time.
Test to determine fall risk of the client. Instruct client to attempt to stand on one foot while standing upright. Knees must be maintained apart during test. Time standing balance for a maximum of 30 seconds. (<10 sec = increased fall risk)
Describe the Vestibular and Visual Aspects of Balance (Romberg Test).
Test to determine impaired balance. Test client under 4 conditions of standing balance. Instruct client to stand with feet together and hands resting on hips. Time trial for a maximum of 30 second. (<30 seconds = impaired balance)
Describe the Timed Up and Go Test.
Determines the level of mobility of the client. Position client sitting in a chair. Instruct client to rise, momentarily stand stil, walk toward a destination point 10’away, turn around, return to chair, and sit down. Time the entire sequence for a score.
< 10 sec = high mobility
10-19 sec = typical mobility
20-29 sec = slower mobility
30+ sec = diminished mobility
Describe the Berg Balance Test.
14 item detailed test to determine the mobility of the client
0-20= w/c bound
21-40 = walking with assistance
41-56 = independent
Describe the OTPF process from screening to outcomes.
Evaluation: 1) Occupational profile - The intial step in the evaluation process that provides an understanding of the client’s occupational history and experiences, patterns of daily living, interest, values, and needs. The client’s problems and concerns about performing occupations and daily life activities are identified, and the client’s priorities are determined. 2) Analysis of occupational performance - The step in the evaluation process during which the client’s assets, problems r potential problems are more specifically patterns, context or contexts, activity demands, and client factors are all considered, but only selected aspects may be specifically assessed. Targeted outcomes are identified.
Intervention: 1) Intervention plan - A plan that will guide actions taken and that is developed in collaboration with the client. It is based on selected theories, frames of reference and evidence. Outcomes to be targeted are confirmed. 2) Intervention implementation - ongoing actions taken to influence and support improved client performance. Interventions are directed at identified outcomes. Client’s response is monitored and documented. 3) Intervention review - A review of the implementation plan and process as well as its progress toward targeted outcomes
Outcomes: outcomes - determination of success in reaching desired targeted outcomes. Outcome assessment information is used to plan future actions with the client and to evaluate the service program (i.e., program evaluation)
What does a rating of 7 mean on the FIM?
Complete Independence (timely, safe)
What does a rating of 6 mean on the FIM?
Modified Independence (device)
What does a rating of 5 mean on the FIM?
Modified dependence - supervision (cuing) or set-up (open containers, apply device) then client performs
What does a rating of 4 mean on the FIM?
Modified dependence - minimal assistance (client performs 75 %)
What does a rating of 3 mean on the FIM?
Modified dependence - moderate assistance (client performs 50% or more)
What does a rating of 2 mean on the FIM?
Complete Dependence - Maximal assistance (client performs 25% or more)
What does a rating of 1 mean on the FIM?
Complete Dependence - Total assistance (client performs less than 25%)
What does a rating of 0 mean on the FIM?
Complete Dependence - activity does not occur
What safety concerns are there in balance and mobility?
- Gait belt
- Endurance Weight bearing status
- Footwear
- Guarding from therapist
- Environment: spills, throw rugs, floor surface
- Use caution standing for the first time
Describe how you guard a patient.
- Stand behind and slightly to one side (toward weak or affected side)
- Keep one hand on gait belt
- Grasp belt with palm up Keep other hand on client shoulder
Do not:
- Hold their arm or hand
- Hold onto their clothing
Describe the difference between dynamic and static balance. how is it graded?
Sitting Balance : Static - writing notes in class; dynamic: reaching around the post to pass handouts
Standing Balance: Static: washing hands at the sink; dynamic: unloading the dishwasher supported vs unsupported
Grading:
- good - able to assume and maintain balance in different situations; able to weightshift independently;
- fair - can assume and maintain balance but impaired when challenged;
- poor: unable to assume or maintain balance
Specify sitting, standing, dynamic, static, supported, unsupported
Name the balance assessments mentioned in class.
- Resistance Test
- Functional Reach Test
- Single Leg Stance
- Romberg
- Timed Up and Go
Describe the Resistance Test for Balance assessment.
Equipment: none
Procedure:
- Give client a slight push at the shoulder level
- Perform in sitting and standing
- Observe reactions, ability to maintain balance
- May need a spotter
Scoring: good, fair, poor
What needs to be considered before doing a transfer?
- Strength & ROM
- sitting & standing balance
- Motor control
- Cognitive status
How do you prepare for a transfer?
- Decide on type of transfer
- Explain procedure to the client and instruct them on their role
- Apply safety belt
- Organize environment -lock brakes, lower bed, drop handrails, etc
- Get help if needed
What are the proper body mechanics for a therapist doing a transfer?
- Stay close to client
- Face them directly
- bend knees and widen stance
- keep a neutral spine
- ask for help if needed
- use leverage!
What types of transfers are there? Please describe each.
Stand pivot - used for those able to come to standing and pivot on one or both feet
Squat pivot - used for those unable to initiate or maintain standing
Transfer Board
Dependent transfers
- two person lift
- mechanical lift
What are the levels of weightbearing?
NWB - non-weightbearing
TTWB- toe-touch weightbearing - 10-15% body weight; “walking on eggshells”
PWB - partial weightbearing - 30-50% body weight; “favoring” limb
WBAT - weightbearing as tolerated - between partial and full
FWB: Full weightbearing - 75% to 100%; distributing weight evenly
What is the rationale behind testing ROM?
- Determine how movement limitations impact occupational performance
- determine need for adaptive equipment
- Identify limitations in joint movement
- Establish baseline
- Prevent deformities
What are the precautions and contraindications for testing ROM?
- Sensory loss
- pain
- pain medications or muscle relaxants
- inflammation
- infection
- severe osteoporosis
- prolonged immobilization
- hemophilia
Describe ROM Assessment: Palpation.
Purpose
- find bony landmarks for goniometric measurement
diagnosis
- detect variations from normal anatomy, discover unusual masses or bumps, assess muscle tone, locate tenderness, compare bilaterally
Refer as appropriate
What preparations should be made before assessing ROM?
Know the anatomy of the area before you begin
Position the person comfortably
May need to expose skin
- privacy
- warmth
- security
Education
Describe the ROM Assessment: End Feel.
End feel: normal resistance to further movment
- Hard: abrupt, hard stop to movement when bone contacts bone (elbow extension)
- Soft: when two body surface come together a soft compression of tissue is felt (passive knee flexion)
- Firm: firm or springy sensation that has some give when muscle is stretched (ankle dorsiflexion)
Describe the general procedure for measuring ROM.
- Position client comfortably
- Explain procedure
- Uncover joint (or at least remove layers)
- Palpate bony landmarks
- Move part through PROM
- joint mobility
- end feel pain
- Stabilize proximal joints
- Measure and record starting position
- Move joint
- Reposition goniometer, measure and record end position
- Rest joint
What is the rationale behind muscle strength testing?
- Determine how muscle weakness impacts occupational performance
- determine need for adaptive equipment
- Understand patterns of weakness or identify specific muscle involvement
- Establish baseline
- Prevent deformities from imbalance
What methods are there for testing muscle strength?
MMT - evaluation of strength and function of individual muscles and/or muscle groups;
break test of maximum voluntary contraction
Dynamometer
Pinch Gauge
Observation of functional tasks
What are the precautions/contraindications for MMT?
- Sensory loss
- Pain
- Pain medications or muscle relaxants
- Inflammation or infection
- Dislocation or unhealed fracture
- Osteoporosis
- Abdominal surgery or hernia
- Cardiovascular disease
What are the muscle grades for MMT and their meaning?
- 0 0 : no muscle contraction seen or felt
- 1 T : contraction seen or felt, but no movement
- 2- P-: Part moves through less than full ROM with gravity eliminated
- 2 P : Part moves through complete ROM with gravity eliminated, no resistance
- 2+ P+: Part moves through full ROM with gravity eliminated and minimal resistance
- 3- F- : Part moves through less than full ROM against gravity
- 3 F : Part moves through full ROM against gravity, no resistance
- 3+ F+ : Part moves through full ROM against gravity with minimal resistance
- 4 G : Part moves though full ROM against gravity with moderate resistance
- 5 N : Part moves through full ROM against gravity with maximum resistance
What is the procedure for grip and pinch assessment?
Grasp
seated shoulder adducted
elbow at 90 degrees
forearm/wrist neutral
set dynamometer at 2nd position
demonstrate
2-3 min rest between trials
average 3 trials
3 types of pinch
- tip
- lateral
- palmar/3 jaw chuck
seated
average of 3 trials
What are the dysfunctions in muscle tone caused by UMN?
abnormal reflexes, abnormal timing of muscle activation, muscle paresis, hypertonicity, clonus
What are the dysfunctions in muscle tone associated with LMNs?
loss of reflexes ‘
muscle atrophy
flaccidity
What is flaccidity?
absence of tone, DTRs, & active movement
What is hypotonicity?
Abnormally low resistance to passive stretch usually no decrease in PROM
Where does hypotonicity/flaccidity occur?
cerebellar & LMN disorders
Termorarily following an acute UMN lesion (CVA and SCI) flacid initially (shock phase) then switches to hypertonicity
What is hypertonicity?
Increased muscle tone abnormally strong resistance to passive stretch
Two types: spastic rigid
Where does hypertonicity usually occur?
UMN lesions
Some basal ganglia disorders
What is hypertonicity associated with?
synergistic patterns: fixed movement patterns
primitive reflexes
associated reactins
abnormal increase in tone when there is an activity that requires excessive effort of the unaffected limbs
What is spasticity?
Increased muscle tone that is velocity dependent
elicited by quick stretch
clasp knife phenomenon
quick passive stretch to sudden catch of release of resistance
Where does spasticity usually occur?
UMN lesions
What is rigidity?
Increased muscle tone that is constant, regardless of velocity
constant resistance throughout PROM in any direction
lead pipe (rigid the whole time) and cogwheel (acts like a tightening mechanism)
Where does rigidity usually occur?
Basal ganglia, diencephalon, brainstem
Some degenerative diseases such as Parkinson’s
What is clonus?
Repetitive stretch reflexes in response to rapid stretch foot placed on footrest and bounces
Associated with spasticity
Evoke with a quick stretch, then count beats
How do you evaluate UE Tone?
Position client’s feet on the floor in a supported seat (record testing position)
Move UE slowly through ROM
hold proximal and distal to joint, on lateral aspects avoiding tactile input to muscle belly note if limb feels light or heavy
Perform quick stretch at elbow or wrist note clasp knife or resistance
Record findings ultimate purpose is to determine how function is affected by tone
What is the scoring for the Modified Ashworth Scale?
- 0 = no increase in muscle tone
- 1 = slight increase in muscle tone manifested by a catch & release or by minimal resistance at the end of the ROM
- 1+= slight increase in muscle tone manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM
- 2 = Marked increase in muscle tone through most of the ROM, but affected parts are easily moved
- 3 = considerable increase in muscle tone; passive movement difficult
- 4 = affected part or parts rigid in flexion or extension
What additional scoring is involved in muscle tone other than the modified ashworth scale?
May also record with goniometer the degree that tone is first felt
Record what muscle group or movement
Record presence of associated reactions
Record presence of a flexor pattern or extensor pattern (synergy) may qualify with severe, moderate, mild
Note: no MMT with moderate to severe spasticity because it is not voluntary or selective movement
What factors influence tone?
emotion (anxiety, fear)
temperature extremes
pain
infection
sensory overload
position
Why do we assess endurance?
determine how limitations in endurance impact occupational
performance establish baseline
What are the cardiovascular precautions in testing endurance?
Valsalva’s maneuver:
- expiratory effort against closed glottis (hold breath during effort)
- usually occurs during isometric or heavy resistance exercises avoid with clients with history of cardiovascular disease (HTN, MI, CVA), abdominal surgery, hernia
To prevent: don’t hold breath, count aloud, exhale while performing motion
What do you analyze during an endurance test?
- HR
- BP
- Respiratory Rate
- Number of reps/ length of time
- Rate of perceived exertion (RPE)
- MET levels
What is the rate of perceived exertion?
It is a visual scale that the client points to a number that they feel is closely related to how they feel in response to their level or exertion
What are the observable signs of intolerance?
SOB
Pale color
Increased RR
Perspiration (diaphoresis)
Muscle fatigue
tremor
incoordination
What are the areas of sensation?
pain, touch localization, vibration, stereognosis, 2 pt discrimination, proprioception, kinesthesia, general touch (light touch)
What method and/or instrument is used to test touch threshold?
Semmes-Weinstein monofilaments
Method: begin testing wtih filament marked 2.83; hold filamnt perpendicular to skin, apply to skin until filament bends. Apply in 1.5 seconds, hold 1.5 seconds, and remove in 1.5 seconds. Repeat three times at each testing site, using thicker filaments if the patient does not perceive thin ones (except for filaments marked >4.08, which are applied one time t each site). Patient says yes upon feeling the stimulus
What method and/or instrument is used to two-point discrimination?
disk-criminator or aesthesiometer
method: begin with a 5-mm separation of points. Lightly (just to the point of blanching) apply one or two points (randomly sequenced) in a transverse or longitudinal orientation on the hand; hold for at least 3 seconds or until patient responds. Gradually adjust distance of separation to find least distance that patient can correctly perceive. Patient responds by saying 1, 2, or I can’t tell.
What method and/or instrument is used to test Touch Localization?
end or a pencil
Method: apply touch to patient’s skin. Patient remembers location of stimulus. With vision no longer occluded, patient uses index finger or marking pen to point to spot just touched.
What method and/or instrument is used to vibration threshold?
Instrument: tuning fork
Method: generally, vibrating head is applied to area to be tested. Stimulus intensity is gradually increased or decreased. Patient indicates when vibration is first felt or no longer felt.
What method and/or instrument is used to test light touch?
Instrument: cotton ball or swab
Method: Light touch to a small area of the patient’s kins. Patient says yes or makes agreed-upon nonverbal signal each time stimulus is felt.
What method and/or instrument is used to test pain?
(Pinprick or Pain Awareness test)
Instrument: New or sterilized safety pin
Method: Randomly apply sharp and blunt ends of safety pin, perpendicular to skin, at pressure necessary to elicit correct response on uninvolved side of body. Patient says “sharp” or “dull” after each stimulus
What method and/or instrument is used to test temperature awareness?
Instrument: Hot and Cold Discrimination kit
method: Apply cold (40 degrees F) or warm (115-120 degrees F) stimulus to patient’s skin. Patient indicates hot or cold after each stimulus.
What method and/or instrument is used to test Sterognosis?
Instrument: number of small objects known to patient
Method: Place a small object in the hand to be tested. Patient may manipulate object within the hand; patient names object.
What method and/or instrument is used to test Proprioception?
Instrument: none
Method: Hold body segment bing tested on the lateral surfaces; move the part into different positions and hold. Patient duplicates position with opposite extremity.
What method and/or instrument is used to test kinesthesia
Instrument: none
Method: Hold body segment being tested on the lateral surfaces; move the part through angles of varying degrees. Patient mirrors the movement of the manipulated limb.
What is the definition for occulomotor control?
ability of the eyes to move smoothly and in a coordinated manner through full ROM
What is the OT’s role in screening occulomotor function?
The role of the OT is not to diagnose the deficit, but to describe its functional effect and formulate the critical questions for the ophthalmologist or optometrist.
The therapist screens binocular vision, including eye alignment and convergence, accommodation, smooth pursuits, and saccades.
How is eye alignment generally measured?
By observations of the reflection of light on the cornea. Seated in front of the client, the therapist asks him to gaze at a penlight held in different quadrants of the visual field. The therapist observes the light reflection in each eye; the reflection should be in the same position in both eyes.
How is convergence tested by an OT?
By having the client follow a target moving slowly toward and away from the face. Double vision normally occurs when the target is w/i 2-4 inches of the face, and recovery of a single image takes place at 4-6 inches
What is another name for visual tracking?
Smooth pursuits
What happens if smooth pursuits are impaired?
Visual acuity is impaired when motion is involved.
How are smooth pursuits evaluated?
by asking the client to track a moving object. With a small, interesting target, sit in front of the patient holding the target approx 16 inches from the patient’s face. Do not give any instructions regarding head movement, but ask client to watch the target and don’t take your eyes off it. Move the target clockwise for two rotations and counterclockwise for two rotations. Observe the number of rotations that patient is able to complete, their ability to maintain fixation, this is, the number of times the patient has to refixate, and whether there is movement of the head or body.
What are saccades?
quick eye movements that change fixation from one point to another and allow us to redirect our line of sight. (Most closely related to reading)
How do you test saccades?
by holding two targets and asking the client to keep looking from one target to the next. Performance is based on 1) ability to complete 5 round trips 2) accuracy (amount of over- and underestimating) 3) head and body movement during the test.
When do potential deficits in occulomotor control occur? Where?
Potential deficits occur with brain damage
- Parietal, occipital, and prefrontal lobes, cerebellum, and brainstem
- Cranial nerves 3, 4, and 6 which innervate the extraocular muscles
What is strabismus?
imbalance of eye muscles leading to the eyes being unable to focus together
It causes diplopia, deviant head position and decreased eye movement
What is the definition for visual fields?
the scope of vision in each eye; central visual field: central 20 degrees of vision, peripheral area: seen other than central vision.
How are visual fields tested?
Confrontation testing is typically used to screen for VFD. Visual fields are measured one eye at a time and the client’s visual fields are compared to the examiner’s supposedly normal visual fields. However confrontational testing has been found to be relatively unpredictable and therefore should be used in conjunction with functional observations.
What are the normal limits for visual field?
60 degrees superior,75 degrees inferior, 60 degrees nasal, and 100 degrees temporal
When/where do deficits in visual fields occur?
Lesions to pathway transmitting visual field info from the retina to the cortical areas of the brain Damage to occipital lobe Occlusion of middle or posterior cerebral arteries
What is homonymous heminaopsia?
Loss of visual field in the corresponding right or left half of each eye
It Causes:
- Narrow scope of scanning
- Decreased turning of head
- Focused on midline and turned toward sound side
- Perceptual completion: brain fills in missing portion of visual field. 8=3; radish = dish
- Person is unaware they are missing information
What is visual acuity?
the ability of the eyes to make what is seen sharp and clear.
How is visual acuity screened?
Most often visual acuity is screened using conventional letter charts. However, conventional letter charts measure acuity by determining the smallest high-contrast detail a person can perceive at a given distance and most settings do not provide such high contrast, contrast sensitivity should be evaluated as well. The tester presents a series of sine wave gratings that vary in orientation, contrast, and frequency. The client must indicate the orientation of the grating; the poorer the acuity the more contrast required to detect the orientation of the grating.
When/where do deficits in visual acuity occur?
Deficits occur when ability to focus light on the retina is disrupted: conrneal scarring, cataracts, decreased accomodation, inability of the retina to accurately process the image (damage to the brainstem or retina), and inability of optic nerve to transmit information to CNS (due to direct damage to optic nerve, stretching, tearing, or swelling)
Describe in detail Confrontation Testing.
Equipment: eye patch or patches, interesting target mounted on a wand. Set-up: patient seated directly opposite examiner, approximately 20 inches eye to eye; background behind examiner should be dark and distraction free
Procedure: Patch the patient’s left eye, and close or patch your own right eye; instruct patient to look at your left eye, and tell him or her you will be moving a target in from the side and the atient is to indicate when the target is first seen; move target in from all angles (begin at 12 o’clock, then 2, 4, 6, 8, 10); compare the patient’s response with yours; position hands at 3 and 9 o’clock so that you can just see your fingers. Ask the patient how many fingers you are holding up; patch the patient’s right eye, and close or patch your own left eye. Repeat the previous 4 steps; a problem is indicated if the patient cannot see the target when you do or if the patient does not see both fingers simultaneously.
Describe the convergence test in detail.
Equipment: penlight or target; ruler Set-up: Patient seated directly opposite the therapist; patient’s head should be vertically erect
Procedures: slowly move the penlight or target toward patient at eye level (do not shine light directly into the patient’s eyes; direct it at the brow slightly above eye level); ask patient to keep eyes on the light and to report when two lights are seen. Note the distance at which diplopia occurs; once two lights are seen, move the target in another inch or s and begin to move it away from the patient; ask patient to let you know when he or she can see one light again. Note the distance at which the patient reports single vision.
Describe the smooth pursuits test is detail.
Equipment: small, interesting target Set-up: patient seated directly in front of the examiner; hold target approximately 16 inches from the patient’s face
Procedure: give no instructions regarding head movement; tell patient, “watch the target and don’t take your eyes off it.”; Move target clockwise for two rotations and counter-clockwise for two rotations; observe: number of rotations the patient is able to complete, ability to maintain fixation, that is, the number of times the patient has to refixate, and movement of the head or body
Describe the saccades test in detail.
Equipment: two interesting targets (e.g., two tongue depressions, one with a green circle on the end and the other with a red circle n the end) Set-up:Patient seated directly in front of the examiner
Procedure: HOld wands approximately 16 inches from the face, separated by approximately 8 inches; give no instructions regarding head movement; tell patient, “look at the red dot when I say red. Look at the green dot when I say green, and remember to wait until I say to look.”; tell patient to look from one target to the other for a total of 10 fixations, 5 round trips; Observer: ability to complete 5 round trips, accuracy of eye movements (overshooting or undershooting target) and movement of the head or body
What is the definition of coordination?
Activity of many muscles combined into smooth movements.
What factors does coordination require?
Rhythm
Appropriate muscle tension and speed
Minimum number of muscle groups used for movement
What is the definition for incoordination?
inaccurate, uneven movements
What does incoordination consist of?
decreased speed awkwardness holding tool poor accuracy increased muscle tension
Use of whole arm instead of just hand
What are the potential causes for a decrease in coordination?
Peripheral nerve injuries
edema pain
joint stiffness
decreased strength and ROM
decreased endurance
decreased sensation
decreased proximal stability
neurological deficit (cerebellum)
What factors affect coordination?
emotion
stress
challenge new activity
age
environment
complexity of task: in hand manipulation; bilateral activities; fine motor
Describe the pre-grasp component of reaching.
- Shaping of the hand that occurs during the reach (anticipatory)
- Affected by: 1) intrinsic properties: object’s size, shape and texture 2) extrinsic/contextual properties: object’s orientation, distance from body and location with respect to the body
- Based on our previous experiences of grasping objects
What is used to correct errors and ensure accuracy?
feedback
What is used prior to movement to plan movement?
feedforward
What components of sensation are used in feedforward?
vision
touch
proprioception
When assessing coordination, what are you trying to determine?
Trying to determine:
- to what degree can client perform functional tasks
- what strategies they use to perform the task
- what impairments are limiting their performance, and can these impairments be changed
What are the standardized tests for dexterity?
Purdue Pegboard
Nine Hole Peg Test
O’Connor Finger Dexterity
Box and Block test
Jebson
Describe the PurduePegboard.
- Timed test to place pins into holes and assembling pins, washers and collards
- unilateral and bilateral
- assesses picking up, manipulating, and placing little pegs into holes with speed and accuracy
- tests finger or fine motor dexterity
- It has a wooden board with two rows of tiny holes plus reservoirs for holding pins, collars, and washers.
- four subtests are performed with the subject seated.
Describe the Nine-hole peg test.
- measures finger dexterity among patients with physical disabilities.
- Test administration is brief, involving the time it takes to place nine pegs into a 5-in square board and then remove them.
- has high inter-rater reliability, test-retest reliability was moderate
Describe the Box and Block test.
- -place the test box lenghtwise along the edge of a standard-height table
- -the 150 cubes are in the compartment of the test box to the dominant side fo teh patient
- -sit facing the patient to monitor the blocks being transported
- -give these instructions “I want to see how quickly you can pick up one block at a time with your right [left] hand [the therapist points to the dominant hand]. Carry the block to the other side of the box and drop it. Make sure your fingertips cross the partition. Watch me while I show you how”
- -Transport three cubes over the partition in the same direction the patient is to move them. After the demonstration say, “if you pick up two blocks at a time, they will count as one. If you drop one on the floor or table after you have carriered it across, it will still be counted so do not waste time picking it up. If you toss the bocks without your fingertips crossing the partition, they will not be counted. Before you start, you will have a chance to practice for 15 seconds. Do you have any questions? Place your hands ont eh sides of the box. When it is time to start, I will say Ready, and then Go”
- -If patient makes a mistake during the practice period correct them.
- count cubes transferred and subtract mistakes.
- -return cubes to one side and test non-dominant hand with same instructions
What are you determining during observation or a non-standardized assessment of coordination?
Determine what strategy the client is using where the breakdown occurs:
- locating the target visually
- identify strength and ROM deficits: grip and pinch strength
- identify sensory deficits
- measure edema
- identify postural control deficits: do they need to lean on something for support, lose balance
- reaching ability
What are some characteristics of impaired grasp?
- absence of anticipatory hand shaping during reach
- hand that doesn’t close in relation to the object or closes to soon
- inability to alter shape of hand to the object
- irregularity of movement
- compensatory movements (sudden, jerky)
- extraneous movements
Visual acuity
Ability of the eyes to make what is seen sharp and clear.
Functional Description of deficit: Client complains of blurred vision (near or far); print too small, too faint; headaches, squinting.
Effect on Function: holds objects too close to the face; decreased facial recognition; fear of new environments; lack of interest in environment; difficulty localizing objects; decrease interest in reading; vision fluctuates throughout he day; bumps into low-contrast objects
Visual fields
Definition: Area that one seas when looking out into the environment. Central visual field (VF): central 20 degrees where vision is clear and focused; peripheral VF: area seen other than central where vision is not as clear but used for motion detection and orientation in space
Functional Description of Deficit: Client complaints: bumps into objects; can’t find things; difficulty reading.
Effect on function: difficulty moving in crowded or busy environments: anxiety; startle response; difficulty with self-care; unsafe
Binocular vision
Definition: Ability to resolve two images (one from each eye) into one. Motor component: muscles and nerves that align the eyes with the object. Sensory component: activity within the cortex that allows perception of one image.
Functional Description of Deficit: Client complaints: double vision; difficulty sustaining visual work effort; eye fatigue with sustained work, eyes look crossed; blurred vision; headaches.
Effect on function: poor eye contact; inability to concentrate; avoidance of activities at near distance; loss of vision; difficulty with activities requiring depth perception.
Accommodation
Definition: Ability to adjust focus of vision at different distances.
Functional Description of Deficit: Client complaints: headaches; eye strain; difficulty with sustained activity at near distance; print moves while reading.
Effect on function: under- and over-reaching; frustration when maneuvering in visually stimulating environments; road fatigue.
Occular motility
Definition: Ability of the eyes to move smoothly and in a coordinated manner through full ROM
Functional Description of Deficit: Client complaints: headaches; difficulty keeping eyes focused; dizziness; balance problems.
Effect on function: excessive head movements; frequent loss of place and skipping lines when reading.
Anosognosia
Definition: Unawareness or denial of deficits.
Functional Description of Deficits: Functional activities are unsafe: unable to learn compensatory techniques
Unilateral Neglect
Definition: Neglect of one side of the body or extrapersonal space.
Types: motor (output/intentional) and perceptual (input/attentional).
Functional Description of Deficit: Shaves only one side of face, dresses only one side of the body; eats food from ony half of the plate; reads only a half of a page or half of a word; transfers and functional mobility are unsafe; bumps into objects on one side.
Body Scheme
Definition: Awareness of body parts and position of body and its parts in relation to themselves and objects in the environment.
Functional Description of Deficits: May result in dressing apraxia; may not recognize body parts or relationship between them; transfers may be unsafe
Right/left discrimination
Definiton: Ability to understand the concepts of right and left; with right brain damage (RBD), may be caused by a visuospatial deficit; with left brain damage (LBD) and aphasia, may be caused by language deficits or by general mental impairment.
Functional Description of Deficit: May have difficulty dressing and understanding concepts of right and left.
Body part identification
Definition: Ability to identify parts on self and/or others
Functional Description of Deficit: May respond incorrectly when told to move a specific body part.
Position in space
Definition: ability to understand the concepts of over adn under, above and below, etc.
Functional Description of Deficit: Difficulty moving through a crowded area; difficulty with dressing; difficulty following directions using these terms
Spatial relations
Definition: Ability to perceive self in relation to other objects
Functional Description of Deficits: Difficulty moving through a crowded area; difficulty with dressing; difficulty following directions using these terms (over/under/above/below); transfers unsafe
Topographical Orientation
Definition: Ability to find one’s way from one place to another
Functional Description of Deficit: Difficulty finding the way to a room, to therapy, or from one room to another.
Figure-ground perception
Definition: Ability to distinguish foreground from background
Functional Description of Deficit: Unable to find object in cluttered drawer, white washcloth on white sheet, brakes on wheelchair, food in refrigerator, etc
Limb apraxia
Definition: inability to carry out purposeful movement in the presence of intact sensation, movement, and coordination
Functional Description of Deficit: May experience difficulty with functional tasks involving objects, as client does not know how to use objects or attempts to use the incorrect object (e.g. uses a knife to eat soup); difficultly with production and understanding gestures; may be clumsy and have trouble with writing, knitting, etc
Constructional apraxia
Definition: deficit in constructional activities: graphic and assembly; RBD; drawings are complex but exhibit disorganized spatial relations and poor orientation in space; LBD: drawings are simplified with few details.
Functional Description of Deficits: May result in dressing apraxia; difficulty setting a table making a dress, wrapping a gift, arranging numerical figures for mathematical processing, making a sandwich, assembling a craft project from a kit, etc
Dressing apraxia
Definition: inability to dress oneself
Functional Description of Deficit: Attempts to put clothes on inside out, backwards, or in the wrong order; dresses only one half of the body.
How does VFD compare to unilateral neglect?
VFD
- Abbreviated scanning pattern
- Scanning pattern is organized
- Re-scanning is observed
- Length of time/effort are appropriate for the task
Unilateral Neglect
- -Disorganized, random scanning pattern
- -Asymmetrical search pattern in hemispace
- -Scanning pattern is carried out with reduced effort and little or no re-scanning
- -Task is completed swiftly, or if patient is aware of deficit, will take an inordinate amount of time in an attempt to compensate
How are drawing and copying tasks used in the assessment of sensory neglect?
The therapist looks for omissions and errors concentrated to one side. Observes how the client approaches the task, variations between copying the free drawing, and missing elements on one side of the picture or on one side of objects within the picture. These tasks alert the OT to a moderate or severe neglect but should be used in conjunction with other tests of neglect and functional activities to provide a clear picture of mild neglect.
What is a cancellation test?
A common evaluation method for sensory neglect. The client is presented with a sheet of paper with several lines of letters or shapes and is asked t mark a specific stimulus letter or shape that is scattered randomly throughout the page.
- organized or random
- density of stimuli in ipsilateral space
- complexity of stimuli in ipsilateral space
- amount of similarity between the target and distracters
What is the line bisection test and how is it used in assessing sensory neglect?
Traditional test that requires the client to divide a line or lines in the center. The therapist notes the direction and amount of deviation from center.
What are the different types of limb apraxia?
Ideomotor
Conceptual
Disassociation
Conduction
Ideational
What is Ideomotor limb apraxia?
Error type: production errors
How Elicited: Most errors are made on pantomiming transitive tasks; improves with imitation and usually does best with the actual object.
Functional Example: Movements will be awkward but will bear a resemblance to the intended movement. Able to use tools to complete tasks but may appear clumsy or awkward
What is Conceptual Limb Apraxia?
Error Type: Content errors: tool-action knowledge; tool-association knowledge; mechanical knowledge; tool fabrication
How Elicited: Use of tools; actions associated with specific tools, association between tool and object
Functional Example: Patient has obvious difficulty with tool use: may use a tube of toothpaste to brush teeth, comb hair with fork, etc
What is Disassociation Limb Apraxia?
Error Type: Thought to be a disconnection between hemispheres; therefore, there is no recognizable movement on command
How Elicited: Pantomime to command is impaired; imitation and use of object will be much better.
Functional Example: Unable to pantomime movements, but since able to imitate and use tools, minimal effect on functional activities.
What is Conduction Limb Apraxia?
Error Type: Difficulty decoding and understanding gestures.
How Elicited: Impaired imitation of gestures; does better when asked to pantomime.
Functional Example: A client with aphasia might have difficulty understanding and using gestures.
What is Ideational Limb Apraxia?
Error Type: Difficulty with a series of tasks.
How Elicited: Tasks requiring a series of activities (e.g., clean pipe, put in tobacco, and light pipe).
Functional Example: Task may be completed more skillfully than with Ideomotor apraxia, but client will have difficulty sequencing steps in the correct order (e.g., client might ry to light the empty pipe, then put the tobacco in, then clean it).
What is Limb Kinetic apraxia?
Characterized by a loss of ability to make finely graded precise finger movements and is thought to be a motor problem rather than a true apraxia
How do you differentiate between apraxia and aphasia?
If the client performs poorly but can answer yes/no questions, he or she may be apraxic. Similarly, if the client is unable to respond to yes/no questions, failure to make the appropriate movement to command may be due to a language problem rather than apraxia. If the client has only a mild language deficit but uses a body part as object or makes a clumsy but recognizable response, it is probably due to apraxia rather than language.
What is the LOTCA?
The Lowenstein Occupational Therapy Cognitive Assessment (LOTCA) battery was standardized on brain-injured adults and consists of 20 subtests in four areas: orientation, perception, visuomotor operations, and thinking operations. It takes 30-45 minutes to administer. Has strong inter-rater reliability. It provides a snapshot of a number of cognitive capacities in a relatively short amount of time. But does not pick up subtle cognitive deficiencies on persons with mild injuries; does not include measure of memory
What is the definition for Cognition?
Ability of brain to process, store, retrieve, and manipulate information. Mental process by which knowledge is acquired, the ability to think and reason
What are the cognitive functions?
Process skills: Energy: pace, attention; knowledge use: choice, inquiry; temporal organization: initiation, sequencing; Organization: searching, navigating; adaptation: respond, adjust
Cognitive skills: Orientation; memory; attention; following directions; sequencing; calculations; abstract reasoning; judgement; problem solving
What are the 3 primary reasons for an OT to assess cognition in clinical practice?
1) establish baseline against which to measure change
2) To inform intervention and discharge planning
3) To identify those who would benefit from more detailed neuropsychological evaluation
What is the difference between a static assessment and a dynamic assessment?
Static assessments are standardized evaluations that provide a snapshot of the client’s functioning at a specific period of time.
Dynamic assessments focus on client performance at two or more points in time and examine learning potential and the client’s ability to transfer or generalize new skills.
What two complementary approaches do OTs use to assess cognition?
1) assessing function to make inferences about cognitive capacities and abilities
2) assessing cognitive capacities and abilities to make inferences about function
What three standardized assessments are mentioned in the book to simultaneously examine function and cognition?
1) Arnadottir OT-ADL Neurobehavioral Evaluation (A-ONE)
2) Rabideau Kitchen Evaluation - Revised (RKE-R)
3) Kitchen Task Assessment (KTA)
What are the standardized and non-standardized tests mentioned in the powerpoint to test cognition?
Standardized
- -mini-mental
- -LOTCA
- -Kitchen Task Assessment
Non-Standardized:
Cognitive Screen
What does the A-ONE evaluate?
It evaluates performance of ADL and examine the effect of neurobiological dysfunction on task performance. There are 2 parts to the assessment. Part 2 is optional. During Part 1, the OT observes the patient performing dressing, hygiene, transfer and mobility, feeding, and communication tasks and completes the Functional Independence Scale by assigning a numerical score (0-4) for each aspect of the various tasks.
What is the RKE-R?
Requires that persons with brain injury synthesize an array of cognitive capacities and abilities in the context of preparing simple meal, a cold sandwich with two fillings and a hot beverage. The OT should use the scores to determine where to begin with a treatment protocol designed to improve meal preparation skills but suggested that this test may not be sensitive enough to use with persons who have subtle cognitive or perceptual deficits.
What is the Kitchen Task Assessment?
A standardized scripted assessment that measures the cognitive support necessary of the patient to prepare cooked pudding or oatmeal. Specific neurobiological components, such as initiation, organization, and safety, are scored on a 0-3 scale, reflecting the degree of cueing or physical assistance required for that aspect of the task. This test was standardized on patients with Alzheimer’s disease
What questions do you ask pertaining to orientation do you ask a client?
Person: name, age, birthday, family names
Place: Hospital, town, directions
Temporal: Date, Day of the week, time of day, season
Situation: “what would you do?”
Document: Oriented x 3 or 4
Hint: If you ask open ended questions, you must know the answer!
What is attention span?
Ability to focus without being distracted - may affect other cognitive and perceptual tasks
What is attention span related to?
Alertness: state of arousal, ability to respond to stimuli; can be alert and not attentive but not vice versa
Perseveration: difficulty to disengage attention
Distractible: failure to engage attention
Divided attention: attend to more than one task
Vigilance: sustained attention
What is memory?
Process of registration and encoding, consolidation and storage, recall and retrieval
What is the memory process?
Immediate : conscious awareness (usually 1 minute) Working: Limited capacity (1 minute to 1 hr)
Short term: temporary (longer than 1 minute; usually can remember 7 items/clusters of items plus or minus 2)
Long term: Permanent knowledge and skills (weeks, months, years)
- declarative: memory holds factual information which is subdivided into episodic and semantic;
- procedural: holds information related to knowing how to do something
What are the different types of memory and their definitions?
Declarative: ability to recite, recall, or reproduce information
- subdivided into episodic and semantic
Episodic: memory of one’s personal history (e.g. what you had for breakfast this morning)
Semantic: Personal knowledge of the world (e.g. that horses are big and ants are small)
Procedural memory: Recall skills, habits, and skill movements
Visual memory: recall of what you see
Prospective memory: ability to recall events set for future
How do you evaluate working and short term memory?
- ask client to recall 3-4 words
- use both abstract (truth) and concrete (shirt)
- after you state them, have them repeat them back
- ask again in 5, 10, 30 minutes
- normal to recall all words after 10 minutes, and at least 3/4 after 30 minutes
- may need verbal cues to remind them of words (i.e. its something you sit on)
How do you evaluate visual memory?
- point to items on a tray or in a picture
- look at items for 45 seconds
- write down as many as you can
- recall again after 15 minutes
How do you evaluate long term memory?
- birthday
- history questions
- question regarding their past
What is logical sequencing?
sequencing cards: put in order what do you do first: shoes or socks; dial phone or put in money trail making
What are the post-op hip precautions?
Weight bearing as tolerated
Must avoid flexing the hip past 90 degrees
adducting the leg past midline
externally rotating the leg
If a client has limitations in an AROM Scan but no limitations in PROM what does that imply?
The client has issues with muscle weakness.
If a client has limitations in an AROM scan and limitations in a PROM scan what does this imply?
There could be something obstructing the joint like a bony structure or tight muscle ligaments.
What is the principle of screening?
- Screening is quick, cost-efficient method of detecting the presence of a deficit. If through screening a deficit is detected, then assessments are administered to better discern a) degree of severity and b) how the deficit has impaired the patient’s daily life functions
- Screening is not used for planning intervention as only the results of an in-depth evaluation can be used to design an intervention plan. A screen is a quick way to know if/which assessment tool to administer (pragmatic reasoning)
What are the three steps in the screening process?
- Identify possilbe dysfunction.
- Document possible dysfunction
- Determine if further in-depth evaluation is warranted
What are the screening procedures?
- Facility policy
- type 1 - general screen/ significant change is noted
- Receipt of a referral
- type 2
SCREEN –> 4 Options
- refer to anoher discipline
- request to evaluate (request referral)
- re-screen later date
- document ‘No need to follow-up’
What are the principles of an evaluation?
- Prepare by reviewing medical information and client history
- complete and reflect on occupational profile
- Document an evalutaion plan which includes assessment instruments relevant to client at the levels of performance areas, performance skills, client factors, performance patterns and contexts
- Adhere to administration guidllines
- Carefully document findings/interpret results
- protect the privacy of the information gathered
- Utilize frames of reference to guide steps and choices in the evaluation sequence: for example, Biomechanical, or Allen Cognitive Disability
What are the Goals of evaluation?
To identify what obstacles interfere with participation in daily life
Establish a baseline for comparison
Measure progress
Measure Outcomes
What is the role of an OTA in screening and evaluation?
OT is responsible for all screening, evalutaion and referral procedures
OTA, under the supervision of an OT, may contribute objective data to the process but may not perform evaluations or reevaluations, or make clinical judgements or decisions
How would you interpret a client’s score on the Barthel Self-Care Rating Scale?
Persons with scores >60 are likely discharged home, between 21-60 have equal probability of home, rehab or LTC
What is the OT process for a dysphagia assessment?
- Observation of the client during a meal to determine whether clincial indicators warrent an evaluation
- Complete a screen upon recommendation of a team member, or upon request of a family member
- Perform clinical evaluation to identify the impact of cognition, perception, sensation, oral and pharngeal control during swallow, motor skills and postural control on client’s intake
- Perform feeding trial using safest food textures to observe client ability at each phase
- Evaluate use of assistive technology
- Document evaluation results
What strategies are used to encourage self-feeding?
Challenge - Strategy
- Disorientation - make sure they are comfortable, temporal cueing, orientation, remove distractions
- Unilateral neglect - cueing, put a generally large anchor within visual field that would cause them to acknowledge that side
- low vision - clock orientation; high contrast utensils (pink mat, yellow plate, green napkin)
- lack of appetite - use smaller positions - use favorite foods - five a visual appeal - hot foods hot, cold foods cold, using spices to season rather than salt. better resposne if they help prepare food
- Difficulty bringing food to mouth - see AE
- Difficulty using dominant arm - hand over hand - timing of feeding is unique to person. help person aim food into mouth
What is the general progression of dysphagia diets?
Solids:
Thick purees; pudding and applesauce
Soft, moist chewables; cooked vegetables or fruit
Drier chewables; cookies and bread
Food requiring biting; meats, and mixed textures such as soup or milk/cereal; pills with sip of water
Liquids
No fluids
Honey-thick
Nectar-thick
Thin, flavored
Water
