Exam Flashcards
Spinal cord Injury in Canada
-Over 86,000 people living with SCI in Canada
-Over 4500 new SCI cases in Canada each year (estimated).
–>51% cases traumatic, 49% non-traumatic
The top causes for traumatic spinal cord injury include:
–>motor vechile accidents (38%)
–>Falls (37%)
–>Sports (15%)
Spinal Cord Injury in Canada - Cost
Direct costs of healthcare utilization = $123, 674 (2205/06)
- Inpatient rehab care cost = large cost driver to the health care system ($3.6 billion in Canada)
- ->3x more expensive than inpatient acute care
- Manual wheel = ~ $4-5,000
- Power wheelchair = $10-15,00
Tetraplegia
- loss of impairment in motor and/or sensory functions in the cervical segments of the spinal cord
- Results in functional impairments in the arms, trunk, legs and pelvic organs
- Has replaced the term “quadriplegia”
Paraplegia
- Loss of impairment in motor and/or sensory functions in the thoracic, lumbar or sacral segments of the spinal cord
- Results in impairments in the trunk, legs, and pelvic organs
- Arm function remains intact
Complete SCI ~ Incomplete SCI
Definitions based on the ASIA definition
Complete: Absence of sensory and motor functions in the lowest sacral segments
Incomplete: Preservation of sensory or motor functioning below the level of injury, including the lowest sacral segments
SCI Categories Based on Type/Level of impairment
The extent of injury is defined by the American Spinal Injury Association (ASIA) Impairment Scale, using the following categories:
A= Complete: No sensory or motor function is preserved in sacral segments S4-S5
B= Incomplete: Sensory, but not motor function is preserved below the neurologic level and extends through sacral segments S4-S5
C = Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have a muscle grade of less than 3
D= Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have a muscle grade that is greater than or equal to 3
E=Normal: sensory and motor functions are normal
Types of Spinal Cord Injury
Upper motor Neuron Lesion (T12 or higher)
-Spasticity of limbs below lesion
Types of Spinal Cord Injury
Lower motor neuron Lesion (T12 or lower)
- Flaccid paralysis of legs
- Loss of reflexes
- Atonicity of bladder and bowel
- Reduced muscle tone
Myotomes (what neurons innervate what muscle
C3-5 Diaphragm
C5: Biceps (bends elbows), shoulder abduction
C5-C6: Elbow flexion
C6: Deltoids, Extensor Carpi (bends wrist back)
C7: Triceps (straightens elbows) Elbow extension, wrist flexion, finger extension
C8: Palmar Interossei (bends fingers), wrist extension, finger flexion
T1: Dorsal Interossei (spreads fingers) (finger abduction)
T1-T2 Muscles of the chest and abdomen
L2: Iliopsoas (bends hips) (L1,2 Hip Flexion)
L3: Quadriceps Femoris (straightens knees)
L4: Anterior Tibialis (pulls feet up) (knee Extension L3, 4) (Ankle Dorsi Flexion)
L5: Extensor digiti (wiggles toes) (L5, S1 Hip extension and Knee flexion) (1st metatarsal extension)
S1: Posterior Tibialis (pulls feet down) (S1,2 Ankle Plantar flexion)
S3-5: Bladder, Bowel and Sex Organs
Common Types of Incomplete Spinal Cord Injuries
Brown-Sequard Syndrome
Below injury level, motor weakness r paralysis on the side of body (hemiparaplegia). Loss of sensation on the opposite side (hemianesthesia)
Common Types of Incomplete Spinal Cord Injuries: Anterior Cord Syndrome
-Below injury level, motor paralysis and loss of pain and temperature sensation. Proprioception (position sense) , touch and vibraroty sensation is preserved.
Common Types of Incomplete Spinal Cord Injuries
Posterior Cord Syndrome
Below injury level, motor function preserved. Loss of sensory function: pressure, stretch, and proprioception (position sense)
Common Types of Incomplete Spinal Cord
Central Cord Syndrome
Results from cervical spinal injuries. Great motor impairments in upper body compared to lower body. Variable sensory loss below the level of injury.
Impairments Post -SCI
Paralysis -Sensory Problems -Respiratory Problems -Autonomic dysreflexia -Orthostatic hypotension -Pressure ulcer -Bowel and bladder dysfunction -Sexual Dysfunction -Problem in regulating temperature -Pain fatigue -Spasticity and Spasms -Deep Vein thrombosis -Heterotrophic ossification
Referrals for SCI
physicians dentists dentalhygienists pharmacists pharmacy technicians physician assistants nurses advanced practice registered nurses surgeons midwives dietitians psychologists chiropractors social workers phlebotomists occupational therapists optometrists physical therapists radiographers radiotherapists respiratory therapists audiologists speech pathologists paramedics medical laboratory scientists medical prosthetic technicians
OT Assessments
Assessments for ADL/IADL
- Functional Independence Measure (FIM)
- Quadriplegia Index of function
- Modified Barthel Index
- The Catz -Itzkovich Spinal COrd Independence Measure (SCIM)
- Wheel chair Outcome Measure (whOM)
OT Assessments
Leisure
- COPM
- Interest Inventory Checklist
OT assessments
Vocation
- Define client’s abilities and interests
- Observations of clients’ abilities and function
OT assessments
Home and community
-Home visits to assess accessibility and safety is crucial (performed early)
What to consider When Starting your OT Assessment
- Get to know the person
- Read the file -Special attention to other trauma or injuries
- Be flexible with your time
- Functional evaluation
- Talk with significant others
Spinal Cord Independence Measure (SCIM)
SCIM assess the following areas
SCIM III (done by instructor) or SCIM Self Report
Self-care (4 items) Feeding, bathing, dressing and grooming
(transfer is not considered here)
-Respiration and Sphincter Management (4 times)
–>Breathing, secretion clearance, bladder management, bowel management, use of toilet(
-Mobility (room and toilet) and (indoors, outdoors on even surfaces) (9 items)
–> variety of surfaces, move to relieve pressure and wound risk, walk or wheel indoors and outdoors, navigate stairs
-30 to 40 minutes -19 questions
15 minutes for self report
-Typically or most frequently if they can not complete it due to medical issues
scored out of 100, 3 sub scales (the ones above)
OT treatment by Stage
Acute Stage
- 1-2 session(s) per day (each about 15 minutes)
- Positioning
- Splinting
- Tenodesis Grasp
- Family Education
OT treatment by Stage
Rehabilitation Stage
- Support
- Education
- Meaningful Activity
Phases of Spinal Shock
Areflexia (0-1 day)
Initial Relex Return (1-3 days)
-Hyperreflexia (1-4 weeks)
-Hyperreflexia + spasticity (1-12 months)
Areflexia (0-1 day)
- Flaccid paralysis of the muscles
- Absence of reflexes below the level of injury
- Bladder flaccidity
- No control of bowels
- May require ventilator to breathe
What are the OT roles, what do you need to know about the client before approaching the client
Spasticity
- Increased muscle tone below the level of injury after spinal shock
- Triggered by sensory stimuli (touch, infection, or other irritation)
- Might hinder function
Autonomic Dysreflexia
- Uncontrolled sympathetic activity (most common in T6 level or above - rarely in T6 to T10)
- Life Threatening
Clinical Presentation
- Increase in blood pressure
- Pounding heachache
Causes: UTIs, overfull bladder/bowels, bladder or kidney stones, ingrown toenails, decubitus ulcers, pain and invasive procedures such as urinary catheterization
OT intervention for Autonomic Dysreflexia
1) Stop doing activity
2) if BP is high
–>seek medical assistance - do not leave the patient alone
–>Upright posture with head elevated
Loosen all restrictive clothing or devices
-Check for kinks or folds in the urinary catheter
-Continue to monitor BP
Preventative Strategies:
- ->education on the causes and management of symptoms
- ->Creating a regular bowel and bladder schedule
- ->encouraging regular checkups for ulcers and wounds
Orthostatic Hypotension
- A sudden decrease in blood pressure following a transfer into upright position (e.g., supine to sit)
- ->decrease supply returned to the heart plus increase blood pools in LE
Clinical presentation:
- Light headedness/dizziness
- ->sudden weakness
- ->unresponsiveness
- ->loss of consciousness
Common in T6 or above injuries
OT intervention for Orthostatic Hypotension (do not leave the person unattended until a nurse or a physician is present)
- Check blood pressure
- Positioning
- ->If the person is in bed, lower the head of the bed.
- ->if the person is in a wheelchair, lift the person’s legs and observe for signs of relief
- ->If symptoms persist, recline the wheelchair to place the head at or below the level of the heart - If symptoms persist put the person to bed
Monitor BP and seek medical assistance if the above steps did not work
Deep Vein Thrombosis
Blood clot in LE, abdomen or pelvic area, caused by:
- ->reduced blood flow
- ->increased tendency for blood to clot
- ->changes in the blood vessels
Clinical Presentation:
Swelling, localized redness in LE + low-grade fever
OT Interventions to prevent Deep Vein Thrombosis
- Monitor for asymmetries in color, size, and temperature
- Compression stockings
- Physical activity
- education of symptoms and preventative strategies
Pressure Ulcers and stages
-Continuous pressure on bony prominence reduces flow to the area which causes skin breakdown
Stage 1:
- Skin is not broken, but it is red and discoloured
- Superficial dermis and epidermis intact
- “non-blanching” provide pressure on spot, if it remains
- There is a permanent state of inflammation
Stage 2:
- The epidermis or top layer of the skin is broken
- Shallow open sore/blister
Stage 3:
- Break the skin extends through the dermis into the subcutaneous and fat tissue
- Wound drainage and texture around the sides
- Muscle may be visible
Stage 4:
Breakdown extends into the muscle and as far as the bone
-Infection and bone decay can occur
-Dead tissue and drainage are present
-Surgery likely to remove dead tissue (debridement)
Pressure Ulcers are Expensive
- Pressure ulcers cost $9.1-$11.6 billion per year in the US.
- Cost of individual patient care ranges from 20,900, to 151,700 per pressure ulcer
OT interventions for Pressure Sores
Goal: prevention
- cushions
- Tilt and recline wheelchairs
- Repositioning (every two hours while laying in bed; every 15 minutes in the wheelchair)
- Skin inspection on a daily basis
- Skin moisture and shearing
- Offloading pressure
- ->keep pressure off affected area once ulcer has formed
Encourage your client to:
- Have good nutrition - high protein foods
- Drink water
- Do not smoke
- Do physical activity
Physical Activity Guidelines for SCI
-Starting level
The starting level is the minimum level of activity needed to achieve fitness benefits
Aerobic Activity
-20 minutes, 2 times a week of moderate to vigorous intensity AND
Strength-based-training activity
3 sets of 10 reps 2 times a week for each MAJOR muscle group
Start meet exceed
Physical Activity Guidelines for SCI advance level
The advanced level will give you additional fitness and health benefits, such as lowering your risk of developing Type 2 diabetes and heart disease
Aerobic Activity
-30 minutes, 3 times a week of moderate to vigorous intensity AND
Strength-based-training activity
3 sets of 10 reps 2 times a week for each MAJOR muscle group
Start meet exceed
Thermal Irregulation
- Problem with maintaining a proper body temperature (T6 and above)
- Increased risk of developing sunburns, frostbite, hypothermia and heat stroke
OT intervention
- Protect skin from sun and serve temperatures
- Avoid extremes in temperature
- Wear the correct clothing for the weather
Incontinence - Bladder Dysfunction
1) Lower Motor Neuron - Below T12 (flaccid bladder)
- ->non reflexive/flaccid bladder
- Moust catheterize or use external pressure abdomen with fists to remove urine
2) Upper Motor Neuron - Above T12 (spastic Bladder)
- Reflexive/spastic bladder
- Bladder can contract and void reflexively
- Use catheters and specific voiding schedules
OT Role for Bladder management
- Intermittent Catheterization (IC) every 4-6 hours
- Education to use adaptive tool for catheterization
- Managing clothing for individuals with tetraplegia
Bowel Dysfunction
1) Spastic (reflex) Bowel T12 or above
- Stool can be eliminated reflexively if nerves located in the rectum are manually stimulated
2) Flaccid Bowel (Below T12)
- Cannot be stimulated reflexively to empty
- Manual removal is required
OT role in Bowel Management
OT will help with client with:
- Managing oral medication
- Creating daily routines
- Learning how to manage clothing
- Learning how to insert a suppository
- Learning digital stimulation
Sexual Function
Males:
T11 and above injuries
-Complete injuries-reflex erections but no voluntary erections and ejaculations
Reflexogenic Erections from touch are possible in most men at this level of injury; However, psychogenic erections from arousing thoughts, sights, or sound are not usually possible.
The ability to ejaculate si rare
T12 and lower injuries
-Psychogenic erections from arousing thoughts sights,
or sound may possible but reflexogenic erections from touch are usually not
-Not ability to ejaculate especially if the sacral nerves are involved
-Complete injuries at S2-5 = loss of bowel, bladder, genital reflexes and complete loss of erection
Sexual Function
Females
- Dysreflexia (T6 or above) and bladder incontinence during intercourse
- Complications related to pregnancy and delivery
- Less desire, body image problems, menstructual cycle might be delayed, less satisfaction, delayed arousal, delayed oganism
Sexual Function - OT Intervention
Spasticity Management
Grooming
Comfortable environment
Adaptive Equipment
Pain
-65% of people with SCI report having chronic pain
Musculoskeletal Pain
- Dull or aching pain in the bones, joints or muscles
- Secondary overuse; muscles spasm pain; mechanical instability of the spine
Visceral Pain
–>Burning, cramping or constant pain in the abdominal above or below the level of injury
Neuropathic Pain
-Sharp, shooting or burning pain
–>central Pain and segmental Pain
Consequences??????
Fatigue `
very common
Causes:
- Chronic pain, medications and prolonged bed rest may cause fatigue
- Nightly check-ups, overnight medication administration, and frequent repositioning
OT: keep these factors in mind when planning sessions with clients - remain flexible
-Observe and listen to clients for signs and symptoms of fatigue
Psychological Consequences of SCI
- ~30% of people with SCI are at risk of having a depressive disorder although in rehabilitation
- ~approx 27% are at risk of having raised depressive symptoms when living in the community
Higher comparative risks of:
- Anxiety disorder
- Elevated levels of anxiety
- Feelings of helplessness
- Poor quality of life (QOL)
Factors Related to Rehab Prognosis
Attitude
- Type of injury
- Comorbidity
- Age
- Support
Age-Specific Considerations
Children: Natural development
Adolescence and young adults: Student role, sexual role, driver role
Adult: parent role, employment
Older Adults: Complications, falls, physical limitations weakness, = skin integrity
Aging with SCI: chronic Shoulder, elbow and wrist pain, energy conservation, joint protection
How to Talk with Your client?
- Give hope
- Do not give too much information
- Use plain language
- Plan for discharge
- Remain client-centred
Wheelchair Prescription
Proper seating postural alignment
- Pelvic
- ->Neutral alignment
- ->90 degree
- Symmetrical alignment of trunk head
- ->over pelvic
- ->horizontal gaze
- Knee and ankle: 90 degree and thighs in neutral abduction
- Shoulder neutral (avoid elevation, protraction or retraction)
Consider: type of activity bed sores incontinence person's strength -Type of wheelchair
Wheelchair Outcome measure (WhOM)
- Client-centred measure
- Interview based
- Available in English, French and some other languages
- 10-15 minutes to complete
- Participation and satisfaction
- Problems with seating
client centered measure Ask what activities do they want to use the wheelchair for inside and outside the home Part 1 - rate on a likert scale 1-10 Part 2 Satisfaction for: Body positioning Comfort -Skin Break down
re-administer just do the satisfaction again
any satisfaction under 7 there are areas of improvement
whOM per wheelchair
OT Role - To Facilitate Community Integration
Goal: restoring at home and in the community
- Adaption
- Advocacy
- Service Provision
- Assisting with funding to buy assistive devices or amkin modifications in the house/workplace
- ->March of Dimes
- ->tetra Society
Return to Work (RTW) following spinal cord Injury: A systematic Review
- Individuals who sustained SCI during childhood or adolescence had higher adult employment rates
- Most common reported barriers to employment:
- ->problems with transportation
- ->health and physical limitations or lack or work experience
- ->education or training
- ->physical or architectural barriers
- ->Discrimination by employers
- ->loss of benefits
SCI Recovery Within Auto-Insurance Funding System
-Within auto-insurance funding system, SCI considered “catastrophic” injury
-Eligible for $1,00,000 in medical/rehabilitation benefits, which is covered:
–>therapies/medical treatments
-Assistive Devices
-Home accessibility renovations, vehicle mods.
Attendant Care support (i.e Personal Support Worker) - up to $6000 per month (~200 hours per month)
-Eligible for weekly housekeeping services
-Eligible for caregiving benefit if previously provided caregiving support
-Income replacement benefit (up to $400 per week)
Occupational Therapy and Return to Work for Clients After a Brain Injury
- Occupational Therapist’s (in return to work and ABI) use their skills in occupational analysis to bridge the gap between the person’s abilities, limitations, the environment, and the cognitive demands of a job (PEO model)
- Identify, resolve or compensate for issues that contribute to disability
- Facilitate the transition from worker readiness; to re-integration into work tasks; to establishing sustainability at work
- OTs often work in a multi-disciplinary program
Cognition and return to work after mild/moderate traumatic brain injury: A systematic review.
Cognition plays a significant role in predicting and facilitating RTW in patients with TBI
Opportunities and barriers for successful return to work after acquired brain injury: a Patient perspective.
-Three themes that influenced RTW were identified: individually adapted rehabilitation; motivation
Opportunities and barriers for successful return to work after acquired brain injury: a Patient perspective.
- Three themes that influenced RTW were identified: individually adapted rehabilitation; motivation for RTW; and cognitive and social abilities
- An individual adapted rehabilitation was judged important because the patient were involved i their own rehabilitation and required individually adapted support from rehab specialists, employers and colleagues
- A moderate level of motivation for RTW was needed
- Awareness of person’s cognitive and social abilities is essential in finding compensatory strategies and adaptations
Evidence-Based Cognitive Rehabilitation: Updated Review of the Literatur From 2003 Through 2008
- Highlights metacognitive approach to rehab (self-awareness, self-monitoring) anda holistic approach to gain better outcomes
- The study found that participants, despite being more severely disabled and further post-injury, receiving comprehensive-holistic rehabilitation were twice as likely to make clinically significant gains in community functioning
- Examining this evidence base, there is clear indication, that cognitive rehabilitation is the best available form of treatment for people who exhibit neurocognitive impairment and functional limitations after TBI or stroke.
Referral Process
In a private practice setting, referrals typically come through Insurance Companies (LTD, MVA, WSIB) or Employers
- Referral for an assessment, treatment and development of GRTW plan, Discharge
- Expectations for regular reporting and communication
- Consideration of client, third party payer, and employer
Barriers to the Process
- Funding for comprehensive multidisciplinary treatment
- Mismatch between job demands and client ability
- Employer inability to accommodate; lack of education/understanding of brain injuries
- Workplace negativity; previous workplace performance issues
- Client compliance
- Poor communication
- Stigma and “invisible Illness”
- Coping and communicating with “comparisons to BEFORE”
- Client confidence
Assessment Process
The assessment follows a biopsychosocial approach. An interview is conducted including the following sections: client history, exploration of symptoms, subjective report of engagement in meaningful occupations, information about social supports, detailed work information, client goals. Pysocial and COgnitive Assessments. You may assess:
- Ability to follow instructions
- Ability to carry on conversation
- Ability to concentrate, focus on handle distractions
- Ability to make decisions
- Ability to remember
- Ability to finish task
- Insight/self-awareness
Standardized and nonstandardized assessments and activities would be completed
Assessments tool (a few options for brain injury and return to work)
- Repeatable battery for the assessment of Neuropsychological Status (RBANS)
- Comprehensive Trail-Making Test
- Recent Memory Screen
- Attention Vigilance Test
- Plan Your Day
- Divided Attention - UNO
- Edgar’s Garage (memory test)
- Multiple Errands Test.
- Card sort/Card tapping/Foam Sort
- Web-based cognitive assessments
Assessments categorized for Functional Task Performance
Time Management-Multiple Errands Test
-Use of time sheet, complete tasks at certain times throughout the assessment, manage interruptions, monitor time, initiation of tasks
Planning
-Plan your day (time and accuracy)
Organization
-Category organization, mental flexibility (change the categories), category naming (foam sort, coin sort, card sort)
Problem Solving
-Logic puzzles, medication management exercise
Attention
-Vigilance test (finding all the F’s), divided attention card/uno game, with and without distractions, auditory divided attention
Word Finding
-Worksheets - add word with similar meaning, opposite meaning, naming
A job Site Assessment may include
- tour of the workplace
- observation of environment
- Ergonomic assessment of the workstation
- observing employees and/or client completing work tasks
- interview with management or HR to assist in identifying availability of modified duties and/or hours, as the client returns to work.
- Identification of any cognitive factors that may influence safety and productivity at work (e.g. noise level, concentration and attention span, order of work tasks)
Cognitive Abilities Analysis
–>More detailed analysis of the cognitive abilities of the client
Cognitive Demands Analysis
–>more detailed analysis of the cognitive demands of the job
Intervention
Based on Assessment Results
(different options)
-Cognitive Rehabilitation Program
–>Improve cognitive function to better match with physical/cognitive demands of the job
Some examples:
-On-line cognitive games
-Knitting (increase complexity of patterns)
-Paragraph memorization,
-Concentration exercise,
-Mental arithmetic exercise involving grocery tasks,
-Auditory memory exercises
-Reading program
–>throughout the return to work so that reading can be done in a quiet environment with appropriate proactive cognitive rest breaks
–>Prioritize reading requirements and break the requirements into manageable parts
–>Use strategies to improve reading comprehension and retention (highlighting, not taking, etc. )
- Psychsocial Intervention
- Return to Work Planning
- Task or Jo Modification, Compensatory Strategies, Assistive Devices and Job Coaching need would be identified
What is MS
- Degenerative neurological condition
- Disease of white matter
- Attacks Central Nervous System (CNS)
- Affects both men and women - children and adults
- Unpredictable symptoms
Cause of MS
- Exact cause is currently unknown
- Theories: Autoimmune, CCSVI (almost rejected)
- A combination of environmental and genetic risk factors
MS in Canada
10,000 people in Canada (>50 per 100,000 of population
- Commonly diagnosed between 15 to 50
- Estimation of 500 to 1000 children and teens with MS
Types of MS
PRMS- Progressive Relapsing MS
SPMS - Secondary Progressive MS
PPMS - Primary Progressive MS
RRMS - Relapsing Remitting MS
Relapsing-Remitting MS (RRMS)
-Episodes:
Unpredictable onset
- Clearly defined by worsening symptoms or new symptoms appearing
- May also be called attacks, exacerbations, or flare-ups
- Episode length ranges from 48hrs to several months
Hallmark: recovery or “remission” period
Relapsing-Remitting Subgroups
Benign MS
- Following diagnosis, it may be 15-20 years before a flare-up
- physical disability is minimal
- Symptoms mainly affect sight and/or touch
- Clinically Isolated Syndrome (CIS)
- Single episode of neurological symptoms
Progressive-Relapsing MS (PRMS)
- Symptoms steadily worsen from onset of disease
- Clear attacks or flare-ups also occur with or without remission following
- Very rare, in only 5% of those diagnosed
Secondary Progressive MS (SPMS)
- Progresses from RRMS
- Progressed stage where remission is less common
- Continuous worsening of symptoms and accumulating disability
Primary Progressive MS (PPMS)
- Slow progression of disability
- Symptoms may stabilize for periods of time
- Sometimes minor improvement may be seen
- Only seen in 10% of people diagnosed
How does the type of MS impact a person’s life
fill in later
Diagnosing MS
diagnosis generally happens over a period of time
- Physicians look for evidence of lesion on the nerves
- Lesions may or may not cause symptoms
- Diagnostic tests: MRI, Lumbar puncture, Evoked potential (EP)
Common Symptoms of MS
Central
- Fatigue
- Cognitive impairment
- Depression
- Anxiety
- Unstable mood
Visual
- Nystagmus
- Optic neuritis
- Diplopia
Speech
-Dysarthria
Throat
-Dysphagia
Musculoskeletal
- Weakness
- Spasms
- Ataxia
Sensation
- Pain
- Hypoesthesias
- Paraesthesias
Bowel:
- Incontinence
- Diarrhea or Constipation
Urinary
- Incontinence
- Frequency or retention
Less Common Symptoms of MS
- Speech problems
- Swallowing Problems
- Tremor
- Seizures
- Breathing problems
- Itching
- Headaches
- Headaches
- Hearing Loss
MS impact on life
-Employment:
50-70% of people with MS lose their job during the first 5 years after diagnosis
Family
-Having a baby
Marriage
Caregivers
Expanded Disability Status Scale
0-4 Fully ambulatory
5-9 impaired ambulation (Disability precludes full daily activities) 9-confined to bed
10 death
Disease-Modifying Therapies (DMTs)
How they Work:
-Target some aspect of the inflammatory process to reduce relapses and slow disease
What Type of MS:
-Relapsing-Remitting MS and Secondary progressive MS, with relapses
Most common DMTs in MS
copy later
Steroid Medications
Goal: Help to decrease the severity and duration of MS relapses
How they work: Actively suppress the inflammation to improve relapse symptoms and speed healing
General Side Effects:
Short-term
-Difficulty sleeping
Stomach upset
Long-term
Liver and kidney dysfunction
-Decreased bone density
Rehabilitation
main Goal: Maintain general health and prevent loss of function as much as possible
This is achieved through
- Improving impairments
- Educating to compensate for problems
e. g. decline in cognitive function and constipation - Providing adaptive equipment and devices
- Enhancing vocational capabilities
- Counseling to help adapt and cope with the changes
- Educating patients and caregivers on MS and its consequences
- Supporting medical therapies to increase compliance with treatment and manage side effects
Examples of Assessment Tools for MS
- Canadian Occupational Performance Measure (COPM)
- Modified Fatigue Impact Scale or Fatigue Severity Scale to assess fatigue
- 6-Minute Walk Test to assess endurance
- Activities-specific Balance Confidence (ABC) Scale
- Multiple Sclerosis Walking Scale or mobility section of the Functional Independence Measure (FIM) to mobility concerns
- Pittsburgh Sleep Quality Index (PSQI)
- Home Assessment
- Beck Depression Inventory-Fact Screen to assess depression
- ADL, IADL, and dysphagia assessments
- Nine-Hole Peg Test to assess dexterity
- Semmes-Weinstien Monofilaments to test sensation
- Manual Muscle test, ROM evaluation, and grip strength (dynamometry)
Occupational Therapy interventions for M
-Equipment, Behavioural and environmental modifications
-Exercise
-Spasticity management
-Cognitive management
-Pain intervention
-Tremor and ataxia
Employment modification
-Fatigue management
MS Self Management model -Person and Contextual Requirments
I feel like this is important but don’t have a lot of time
Heat Intolerance (uhthoff’s Phenomena)
Marked sensitivity to increased body temperature
Cause: Demyelinated fibers in the NS are very sensitive to even small evaluation of core body temperature resulting in conduction delays or even conduction blocks
Result: In Any MS symptom can present this way; most common presentation is the blurring of vision after physical activity
Common Triggers: Sunbathing, exercise, bot baths, emotion, fatigue, fever
Management: cooling, management of fever if present
Bowel Incontinence
Problems:
- Delayed gastric emptying
- Constipation
- Fecal incontinence
Cause
- Neurologic
- Poor diet
- Medication such as antidepressants, narcotics, muscle relaxants
Physical Activity Guidelines for Adult with MS
To achieve fitness benefits, adults aged 18-64 years with multiple sclerosis who have mild to moderate disability need at LEAST:
30 minutes of moderate intensity aerobic activity, 2 times per week, AND
strength training exercises for major muscle groups, 2 times per week
-Meeting these guidelines may also reduce fatigue, improve mobility and enhance elements of health-related quality of life
Constipation - Intervention ( MS)
-Fluid and fiber intake
-Regular Exercise
-Bowl Program
-20-30 minutes after meal (which is when there is strongest bowel movement)
-Medication
-Sit on toilet for at least 10 minutes
-Rocking back and forth on toilet
-Massaging abdomen
Note: it might take several weeks until treatment si effective
Bladder Dysfunction
Type: usually Spastic
Sometimes flaccid during MS attacks
Urgency
Incontinence
which causes other problems
Interventions: add later
Sexual Dysfunction
Type: Usually spastic
-Sometime flaccid during M attacks
Assessments:
Multiple Sclerosis Intimacy Questionnaire (MSISQ-19)
Likert scale from 1-5 5 ebing always 1 being never (bad symptoms) higher the score the harder the intimacy
Common Problems:
- Erectile Dysfunction
- Impaired genital sensation
- Decrease viginal lubrication
Access to Health Services
- Lack of information provided by the healthcare providers
- Lack of communication and interaction of persons with MS with their HCPS
- Lack of finances
- Inconvenient Location/proximity to services
- People with MS Feel uninformed and involved in decision making surrounding their healthcare
Parkinson’s Disease (PD)
- Progressive neurological condition
- Degeneration of substantia nigra –> Decreased Dopamine –>slowness of movements
- Average age of diagnosis is 60
- 20% are under the age of 50 when diagnosed
- Can start even before age of 40 (early onset).
- Can start even before age of 40 (early onset).
- About 100,000 Canadians are affected
- Estimated about 1 in 100 people over 75 years have PD
Main Symptoms (BRT)
Bradykinesia
Rigidity
Tremor (Resting)
Clinical features of a client with PD
- Head bent forward
- Stooped posture
- Rigidity
- Tremors of the hand/head
- Akinesia (absense or poverty of normal movement)
- Shuffling gait, and/or propulsive gait (festinating gait)
- Mask-like facial expression
- Drooling
- Weight loss
- Loss of Postural reflexes
- Bone demineralization
Other Physical symptoms of PD
- Reduced arm swing
- Postural instability
- Microphonia
- Micrographia
- Sequencing
other Sensory Functions and Pain of PD
- Reduced sense of smell
- Blurred vision, double vision
- Parestesia
- Pain
- Cold Sensation
Other symptoms (more categories)
-Sleep disorders
- Voice and Speech Functions
- ->Dysarthria
- ->Perseveration, language disorders
Functions of Digestive system
- ->swallowing disorders
- ->Constipation, weight loss
Genitourinary and Reproductive Functions
- Urinary disorders
- Disorders in sexual functions
Cardiovascular Functions
-Orthostatic hypotension
Functions of the skin
–>increased sweating
Mental Function (other symptoms for PD)
- Depression
- Anxiety disorder
- Apathy
- Cognitive impairments which can lead to: dementia, visuospatial impairments, obsessive compulsive behaviour
PD over Time
- Usually symptom start unilaterally
- Slow progression
- Decline in motor ability
- Other symptoms develop over time e.g. depression, postural and cognitive problems
- Drug Therapy loses effect over time
- Normal life expectancy
Stages of Parkinson’s disease
- Only unilateral involvement, usually with minimal or no functional disability
- Bilateral or midline involvement without impairment of balance
- Bilateral disease: mild to moderate disability with impaired postural reflexes: physically independent
- Severely disabling disease: still able to work or stand unassisted
- Confinement to bed or wheelchair unless aided
Medication
Levodopa (L-Dopa) –>Dopamine precursor
- Tolerance develops
- Short half life (on/off periods)
- There is medicine with longer half life
Dopamine agonists
- Anticholinergic agents
- Catecholo-omethyl transferase inhibitors
Deep brain Stimulation
- Improves motor symptoms
- Designed to modulate signals
Medications side effects
- Dyskinesia
- Daytime sleepiness
- Hallucinations, confusion
- Impulse control -Uncontrolled or compulsive behaviours
- ->eating, shopping, gambling sexual urges
- Other symptoms associated with PD
OT Assessment -Identification of OPI’s; DPA
-Safety in the home/workplace
-Medication management
-ADL/IADL task completion
-Eating
-Communication -Handwriting
-Mobility
-Transfers
-Seating
-Awareness of fluxuations in symptoms (day-to-day and during the day)
-Balance
-Tremors
-Grip strength
-Coordination
-Consider emotional well-being: depression and anxiety
Contextual factors
Recommendations for OT involvement
- Limitations in domains of living/caring, work (paid and unpaid work), leisure
- The caregiver experiences problems in supervising or supporting the PwP in daily activities
- Safety and self-reliance concerns
Other considerations: Early involvement to promote continued engagement
Areas of OT interventions for PD
- Intervention to maintain independence
- Interventions related to decreasing isolation and improving community access
- Interventions related to safety
really looking at that person-environment-occupation
Ways to improve satisfaction with activities
- Optimizing timing and choice of activities
- Avoid stress and time. pressure
- Strategies to improve attention
- Training of motor skills of the arm/hand
- Thinking BIG
Some other strategies to improve occupational performance
- Cognitive movement strategies (step-by-step occupational performance)
- Minimizing dual task
- Use of cues
- Change of environmental factors
Examples for environmental changes
- Unobstructed walking and turning route for freezing
- ->remove obstacles that create risk of falling
- Visual reminders, structure and overview i the arrangement of the space
- Rearrange space and objects based on ergonomic principles for people with fatigue
- Create support points or possibilities for sitting during activities
- Increase the transfer height and pay attention to ergonomics
- Install good lighting and sufficient visual contrasts
Where, when and how to conduct OT sessions
Home or clinic
On phase or off phase
Group or individual
-Role of community supports/resources
Specific OT interventions for
Tremor
- Dressing and eating
- Bed mobility
- Freezing
Tremor intervention
- Medication
- Weight bearing
- Support with other forearm
- Resting -relaxing
- Control of triggers e.g. anxiety and fatigue
- Hand in pocket
- Fiddle with coins in pocket
Optimising dressing and eating
- Sitting with good balance/support
- Not dual tasking
- Allow time
- Set-up and plan
- Sequencing
- Assistive devices
- Loose, easy fastening clothing
- Always dress most affected side first
- Consider types and location of clothing closures (e.g. zipper, buttons/back, front)
Optimising bed mobility
- Bed rails
- Have mediation about 30 minutes before
- Visual curs
- Sateen sheet inserts
- Sateen pyjamas
- Exercise before getting up
Freezing
- Do not walk any distance alone.
- A visual or sensory “cue”
- Have a companion turn sideways and put one foot in front of person. On a count of three, step over it and continue counting and walking until stride is normal
- Try carrying a cane. If freeze while walking, turn it upside down and use the handle on the ground as a cue to step over and to get going again
- Laser light cane
Client and family education
- Warm baths and massage to relax muscles
- Device to meet daily needs
- ->eg. raise toilet seat, long-handle comb
- ->range of motion exercises to maintain flexibility and prevent deformities
- Self-management support
- Exercise
- Dance therapy
Caregiver Support
- Support self-management
- Provide information to increase understanding of the effect of PD on occupational performance
- “advise” and train the caregiver in skills required to supervise and support the PwP in occupational performance
- “advice” the caregiver about relevant aids, adaptations and other modifications to the environment that can ease physical care giving burden
- Coach the caregiver re.opportunities to maintain or re-acquire own activities
Communication Strategies
- Choose times when the person’s meds are “on” to have important conversations
- Speak and be sensitive to tone, e.g, avoid sounding impatient or frustrated
- Speak clearly with short sentences, Give the person time to respond
- Remain an engaged listener
- Encourage the person to speak loudly when giving their response
- Ask the person how they are feeling or what they are thinking when their facial expressions masks their responses
- Use actions as well as words
Amyotrophic Lateral Sclerosis (ALS)
- UMNL +LMNL +brain stem and spinal cord
- Weakness of muscles + atrophy (LE, UE, Cervical extensors), spasticity
- Fasciculation
- Muscle cramp
- Loss of reflexes
- Speech + swallowing problems, dysphagia
- Cognitive and/or behavioural difficulties (about 50%)
- Very rarely bladder and bowel an sensation problems
The target of ALS
The course of ALS varies greatly from patient to patient, but usually affects both upper and lower motor neurons are in the brain’s motor cortex 1, and their axons extend to either the brain stem (2) or the spinal cord (3). Nerve impulses then travel to lower motor neurons (4), whose axons relay the signals to the body’s muscles (5)
Etiology of ALS
unknown- genetic and environmental factors
- Course: two main types:
- Start with UMN +LMN signs
- Starts with bulbar onset with speech and swallowing difficulties (30% of cases)
- Starts with focal and asymmetrical symptoms
- ->finger extensors affected before flexors
Incidence and Prevalence of ALS
- Average age of onset 40 to 70
- Higher prevalence in men
- Incidence rate: 2.7 per 100,000 people
- Between 2500 to 3000 Canadians live with ALS
- 80% die between 2-5 years after diagnosis
- Some die in few months
- 10% live from 10 years or longer
Diagnosis of ALS
- Difficult because the initial symptoms can be very similar to other diseases
- ->process of reviewing symptoms and eliminating other possible diseases
- Any or all of these tests may be used to help diagnose ALS
- Blood and urine sample
- Electrodiagnostic tests including electromyography (EMG) and nerve conduction (NCV)
- Magnetic resonance Imaging (MRI)
- Muscle and nerve function tests
Medication
- Riluzole (rilutek) pills to slow the course of the disease
- ->side effects: dizziness, fatigue , and gastrointestinal and liver problems
Edaravone (Radicava): to reduce the difficulty in daily activities associated with ALS
- Taken by intravenous infusion
- Side effects: swelling, shortness of breath, walking difficulties, hives, allergic reactions for those with sulfite sensitivity
ALS Stages
- Ambulatory, no problem with ADL
- Mild Muscle weakness
- Normal activities, exercises, AROM
- Exercise Moderate AROM - Ambulatory
- Moderate Muscle weakness
- Modifications to activities
- Exercise modest; active assistance - Ambulatory
- Severe Muscle weakness
- Active life; joint pain management (activities to maintain)
- Exercise: Active Assisted, PROM - wheelchair, almost independent
- Severe in LE
- Exercise: Modest in unilvelend msucles; PROM - Wheelchair, dependent
- Severe muscle weakness in LE and UE
- Pain management, ulcer prevention (activities to maintain)
- Exercise: PROM - Bedridden, No ADL, max assistance
- Severe muscle weakness in LE and UE
- Pain management, ulcer prevention + venous thrombosis (activities to maintain)
- Exercise: PROM
Other Complications after ALS
- Injuries to limbs
- Pain
- Pressure ulcers
- Depression
- Quitting job, financial problems
Types of Mechanical Ventilation
- Invasive: through tracheostomy
2. Non-invasive: using removable face mask or through nasal tube
OT Assessment tools
-ALS Functional Rating Scale
-Revised (ALSFS-R)
-Purdue Pegboard, 9-hole peg test
-Function tests
-Standard ROM, MMT
Multidimensional Fatigue Inventory
ALS Functional Rating Scale - Revised (ALSFS-R)
(1) Speech
(2) Salivation
(3) Swallowing
(4) handwriti
(5) cutting food and handling utensils (with or without gastrostomy)
(6) dressing and hygiene
(7) turning in bed and adjusting bed clothes
(8) walking
(9) climbing stairs
(10) Dyspnea (new)
(11) Orthopnea (new)
(12) Respiratory insufficiency
Occupational therapy goals and interventions
Goal Setting:
mobility, ADL, IADL, Safety, social participation
Interventions
- Environmental modifications/assistive devices
- Exercise
- Joint protection/Work Simplification
- Dysphagia, skin integrity, pain
- Social life
- headmaster collar
- Splits, othosises
- adaptive kitchen utensils
- wheelchair
- home modifications
- Driving modifications if possible
- Clothing adaptations
- exercise depending on severity
Guillain-Barre Syndrom (GBS)
- Inflammatory, autoimmune disorder where immune system attacks PNS
- Damage to myelin sheath
- Often seen after recovery from an infectious disease
- In serious cases can cause paralysis in the entire body
- Can be life threatening
- About 30% live with complications even after full recover
GBS symptoms
Axonal demyelination of peripheral nerves Symptoms: -symmetrical paralysis starting with feet -no deep tendon reflex -Mild sensory loss glove and stocking distribution -Cranial nerve dysfunction -Possible facial palsy -respiration problems -Fatigue -Pain -Urinary dysfunction -Cognitive problems
Gullain-Barre Syndrome Subtypes
Acute inflammatory demyelinating polyneuropathy (demyelinating)
Antibody injures myelin membrane
Acute motor axonal neuropathy or acute motor and sensory axonal neuropathy (axonal)
-Antibodies injures axonal membranes
Normal motor nerve
Mian symptoms of GBS
- Numbness and tingling
- Uncoordinated movements
- Trouble breathing
Phases of GBS
- Acute phase (2-4 weeks)
- ->increase symptoms
- Plateau phase
- ->greatest disability, no significant change
- Recovery Phase
- ->progressive few days to week up to 2 years (starting at head and neck)
Recovery Percentages
50% complete recovery
35% some residual weakness
15%permanent disability
OT assessment for GBS
- Patient/caregiver interview
- Sensory function
- Skin inspection
- ROM
- Muscle testing
- Functional testing
- Respiration
- Deep vein thrombosis
- Endurance
OT intervention in Acute and Plateau phases of GBS
- Communication
- Equipment
- Positioning to increase function
e. g. (support upper limbs, avoid prolonged hip and knee flexion) - Reduce anxiety
- Energy conservation
OT interventions in Recovery Phase of GBS
- Safe mobility
- fatigue management
- Fine motor program
- Splinting
- Modifying roles
- Home Modifications
- Community integration
Assistive Technology
“any item, piece of equipment or product system whether acquired commercially off the shelf, modified. or customized that is used to increase, maintain, or improve functional capabilities of individuals with disabilities
HAAT
Assistive Tech
-Device, service
Activity
- Self-care
- Productivity
- Leisure
Person
- Physical
- Cognitive
- Emotional
- Novice vs. Expert
Context
- Social
- Cultural
- Institutional
Communication
- Is the essence of human life
- Purposes of communication:
- communicate needs and wants
- Information transfer
- Social closeness
- Social etiquette
- Internal dialogue (voice identity)
- Sender and receiver
AAC (augmentative and alternative communication) is
anything that can supplement or replace communication for a person whose own communication is insufficient or ineffective. It can be strategies, techniques, or devices. It can be no-tech, low-tech, or high tech. It can be used independently or aided by a communication Partner
Who can benefit from AAC
- Anyone who is not able to communicate effectively with speech (and writing)
- Anyone who is partially able to communicate with speech (has speech but is not understood by most listeners)
- Anyone who is having difficulty understanding and/or using oral language
AAC systems
- Picture based (graphic)
- ->Traditional grid display
- ->-Visual Scene display
- Word based (orthographic)
-Variety of “voice” and “no voice” solutions
Fitzgerald Key
Core-Fringe (core vocabulary and fringe) Language functions -Social -Request -Describe -Question -Direct -Give information
Vocabulary selection for AAC Users: Pragmatic Organisation Dynamic Display (PODD)
Minspeak and semantic compaction
using two buttons to make a word
bed + person = sleep
bed + paint = tired
picture of apple but a bunch of words show up hungry, eat, bite
characteristic of device
capabilities and preferences
- variabilities across disability groups (ALS, TBI, aphasia, brainstem, stroke, MS etc.)
- Ongoing desire to use residual speech
- Acceptance and use of AAC and AT
- Changing living situations, activities, and supports
- Gradual or sudden loss of function, including speech or language capabilities
- Restricted participation in all life areas
- Loss of physical independence and shrinking social networks
Goals fo technology
-To connect people to their world
-To maintain such connection as long as possible
-To support independence and autonomy
To support decision-making and control
Communication and Acute care facts
15% of people admitted to a University Hospital will have a communication disability
- there may be as much as 70% discordance between patient wishes and their chart
- Patients who cannot speak are more than twice as likely to have multiple adverse events in hospital than patients who can
- Problems communicating with nurses can affect health and well-being
- People are intubated for longer than we think
Communication Vulnerable
-Patients in acute care experience
- Loss of control
- Fear
- Panic
- Worry
- Stress
- Withdrawal
Communication vulnerable because of
- a tracheotomy
- A medical condition which has caused them to have difficulty talking or understanding (ABI, CVA, MVA)
- A pre-existing communication impairment
- English is a second language
AAC Interventions in acute care
- Communication boards/displays
- Low-tech
- High-tech options including alternate access and mounting
- Used to assist with patient comprehension and expression with staff and family members
Communication after stroke
- Medical model
- Psycholinguistic Model
- Supported Conversation
- Talking Mats
- Visual Scenes
Global Aphasia
-Most severe form of aphasia
-Few recognizable words
-Understand little or no spoken language
unable to read or write
injuries to multiple language processing areas (Broca’s and Wernicke’s)
Expressive Aphasia
- Language disorder resulting in the loss of ability to create expression by speech, writing or signs.
- Broca’s aphasia-non-fluent aphasia (halting and effortful;telegraphic speech); damage typically in the anterior portion of the left hemisphere
- Comprehension is typically mild to moderately impaired
Receptive Aphasia
- Receptive aphasia, -loss of comprehension of spoken or written language
- Wernicke’s Aphasia-fluent aphasia; damage is typically in the posterior portion of the left hemisphere
- Comprehension is poor and person often produces jargon (nonsensical words and lack meaning)
- may not be aware of their deficits
Aphasia
not like losing your voice - the words are not going to pour out in the correct order if you can only find the right app
- Aphasia affects symbolic communication of all types; both grammar and syntax are impaired, as well as understanding of icons that symbolize concepts
- Many people with severe aphasia struggle to match a drawing of a cup
- How can we then expect them to use a tool that requires matching a picture of a cup with their feeling of thirst
Augmented input
-Aided language input is an evidence-based intervention that is motivating an can help people learn to use AAC faster
Aphasia:
Use qualitative rating scales
Specific Principles underlying SCA (supported conversation for adults with aphasia)
- Emphasis on the social unit or dyad incorporating the conversation partner - not only the person with aphasia
- Interactions/social connection is as important as transaction/information exchange
- The person with aphasia is treated asa. competent person capable of making decisions if appropriate support is provided
- A commitment to decrease the barriers to conversation
Is your message clear
- Use short, simple sentences and expressive voice
- As you are talking:
- ->Use gestures that the patient/client can easily understand
- Write key/words/main idea “pain” in large bold print
- ->use pictures-focus on one at a time
Talking mats
- place the topic on the bottom of the mat
- At the top have the decisions: no, maybe, yes
- Client then places the symbol card under the appropriate decision
ALS and AAC
- Voice banking
- Eye-tracking technology
- Maintaining social networks via technology
Physiotherapy
Promoting optimal mobility, physical activity and overall health and wellness
Preventing disease, injury, and disability
Managing acute and chronic conditions, activity limitations, and participation restrictions Improving and maintaining optimal functional independence and physical performance
Rehabilitating injury and the effects of disease or disability with therapeutic exercise programs and other interventions
Educating and planning maintenance and support programs to prevent re-occurrence, re-injury or functional decline
Focus of Physiotherapy Interventions
- Pain
- ->pain management
- ->manual techniques -massage, manual therapy
- ->Physical agents
- ->hydrotherapy
- ->Positioning and support
- ->electrotherapeutic agents
- Skin
- positioning and handling to prevent skin breakdown, contractures, and (pain)
- Cardio-respiratory
- ->Cardiorespiratory function: aerobic fitness training
- ->pulmonary function
- MSK
- ->Body function and structure/impairments
- Gait and mobility
- ->gait analysis and training
- ->Functional mobility assessment and training
- ->mobility aid and assistive devices
- Postural control
- ->Balance/postural control
- Muscle Tone (kind of)
- Motor Control
Promoting Participation
- Patient-centred goal setting
- Practice of functional activities with real objects/tools in real-environments
- Home-based therapy
- Community mobility activities practice
- ->Promoting self-management of aspects of their own rehabilitation
- Promoting increased physical as a health and wellness strategy
RESNA Wheelchair Service Provision Guide
- Introduction
- Referral
- Assessment
- Equipment
- Recommendation/Selection
- Funding/Procurement
- Product preparation
- Fitting/Training/Delivery
- Follow-Up Maintenance, and Repair
- Outcome Measure
Why is wheelchair fitting and delivery so important
People who use wheelchairs are more likely to abandon products when they are not active participants in the process. This includes evaluation and delivery
Clinician/Therapist (client in the centre) supplier
Importance of a good match
-A good match between the user and the device is essential
-The wheelchair is reported as the most common limiting factor, followed by physical impairment and physical environment.
Subjects identified their wheelchair as more limiting to participation than their impairment
Rule out Ambulation
- Non-functional ambulator -what does that mean
- Can ambulater to some degree with an assistive device but limitations prevent completion of ADLS safely and in a timely manner:
- Significant gait abnormalities
- Risk of falls or other injuries
- Need for assistance
- Cannot ambulate for distances required
- Cannot complete ADLs in a reasonable time
- Functionally limiting adverse effects with ambulation
- Unable to ambulate consistently through a day
Rule out Ambulation and Manual wheelchair
Take Quantitative measures
- Cardiopulmonary effects
- O2 saturation, HR, BP, RR, SOB
- Baseline (at rest) vs after ambulation
- Time needed to recover
Pain
- Pain scale, describe specific location
- Baseline (at rest) vs after ambulation
- Time needed to recover
Distance traveled
- Does it decrease after several trials?
- Is it functional within individual’s environment?
- Impact on independence with MRADL
- Level of independence, safety, timeliness
What is the cost of mobility
Efficiency of mobility
1.8 mph = predictor of household ambulation
Chronic Fatigue
-Individuals >6 months post CVA energy consumption 1.25-1.5 time times that of age-matched controls when performing MRADLs
Propulsion Patterns
-In skills that have higher rolling resistance or high balance demands, difficulty many be due not to neurologic impairment but inherent in the hemi-propulsion technique
Pain wear and tear
75% of MWC uses report pain
- impacts quality of life
- impacts mobility
- Impacts function
CPGs recommends:
- regular assessment of function, ergonomics, equipment and pain
- Minimize the frequency of repetitive UE tasks
- Minimize the force required to complete tasks
Who may need Power?
- Have a prior injury to the UE
- Are obese
- Are elderly
- Have poor endurance
- Have changing condition
- Have significant postural asymmetries
- Live in a challenging environment
- Return to work/community
Mobility and Quality of life
- with increasing age pos SCI, there are declines in health status and functional independence, and a corresponding increase in medical systems utilization
- ->lifestyle, environmental, employment, income, factors impact participation, aging and longevity
- “People with stroke appear to rank the value and use of…equipment more highly when the equipment is explicitly linked to a social interaction or occupational performance goal
I want my mobility device to be
comfortable to sit in
Help me go where I want to go with confidence
Indoor and/or outdoor mobility help
Able to be used in a variety of places
Able to help me do the things I want to do
Able to fit in my house
Easy to transport
Easy to take care of
Easy to use
Assist with doing new things that they can’t do now
Evaluation what are the goals
Seating system:
-Accomodate or correct postural limitations
-Fluctuating tone?
-Is vision a contributing factor to postural asymmetries?
Mobility base:
–>what does the client need to achieve independendent, safe, and efficient mobility
configuration of mobility base
-Cognitive, perceptuals, and visual considerations
-Training techniques
Postural support directly relates to outcomes
- Improve comfort
- increase safe sitting tolerance
- Improved skin and tissue health
- Efficient use of limited energy and endurance
- Improved ability with MRADLs
- Increase Participation and quality of life
-Decrease pelvic tilt and kyphosis
-Decrease leaning forwards, sideways, or sliding out of chair
-Caregivers restrain or wedge
-continued discomfort; unable to move
decrease difficulty with MRADLs
Seating needs (what to consider)
- skin and tissue protection
- Postural support
- Individual size requirements
- Adaptability to changes in condition
- Help with weight shifting
- Help with MRADLs
functional goals of seating
- Position for independent mobility
- minimize trunk asymmetry
- ->facilitate neutral and stable pelvis
- ->maximize head and upper extremity function
- ->consider modified functional reach test
- Optimize overall function for MRADLs
- Prevent skin and tissue breakdown
- Achieve reasonable wheelchair activity tolerance
Hemi Propulsion
-Momentary Switch control
- In skills that have higher rolling resistance or high balance demands, difficulty may be due not to neurologic impairment but inherent in the hemi-propulsion technique
- In high rolling resistance situations, success rats were 30-50% higher in the backward direction
Solutions for a variety of mobility needs
- switch control
- Jack for alternative switch
Tilt in space Options
Dependent or independent control
Momentary or Latched Switch control
When should we consider power mobility
- Need for power seating function
- Positioning needs
- Need for joystick or drive input device
- Diagnosis/prognosis consideration
- Is the user able to mobilize with their device:
- ->in all environments,
- ->in all situations
- ->Safely
- Efficiently
Scooters
Consider limitations of the device vs client goals/needs
-limited seating options vs Need postural support or pressure relief
-stability issues …. vs planned environment of use
-Transfer needs, …ability to manage platform
-Table access… swivel vs pull up to the table
Turning radius for in home use
-Ability to meet long term meds considering diagnosis/prognosis
Captain’s seating
- limited postural support
- Poor position for function
- decreased sitting tolerance
- Increased risk for pain/skin tissue breakdown
- Decreased functional independence
- Less time up in the chair
- Poor position for function
- Decreased participation
Rehab Seating
- ability to utilize pressure relieving cushions, supportive back options, an other positioning accessories
- Power seat functions available
- More sizes and adjustability
- Improved adjustability of electronics to ensure user safety
- Improved motor power, torque and durability
- requires can or tailgate to transport
Maneuverability
FWD least amount of space for L-Turn
MWD Least amount of space for 360 turn
MWD and FWD Best for maneuvering in confined spaces
Power tilt Benefits
- Seat to Back angle remains consistent
- ->Access to devices doesn’t change
- Pressure relief
- Postural stability
- Improved sitting tolerance
- Position of rest
- Can minimize functional shear
- Good consideration for custom molded seating
Graph of power tilt research
- can’t actually get to the 65 just using tilt benefits so include power recline
Power Recline
Risks
when used without tilt thought to increase the risk of shear
-Potential loss of positioning
-Decreased access to switches/input device/headrests
Benefits
- Greater pressure reduction with recline as opposed to tilt
- reduction of seat load during full recline: 61%
- reduction of seat load in full tilt: 46%
Power Tilt+recline
Health benefits -Superior Pressure Relief -->with shear reductions Respiration -->Respiratory care -Spasticity Management -Pain management -Medical management Bladder management Position of rest
Functional Benefits -Toileting -Clothing Management -Under Table Access Van Access -Improved sitting tolerance
Power Elevating legs
- Reduces LE edema
- Accommodates contractures
- Supports L Casts and splints
- Improves circulation
- Pain management
- Assists in maintaining position in the wheelchair during weight shift (when combined with tilt and recline)
Reducing risk of pressure injury with PSF
45% tilt and 120 degree recline
-resulted in 40% weight shift
> 25 tilt and 120 recline
required for tissue reperfusion; cannot be done with tilt alone
2-4X/hour for 2 min
-weight shifts need to be performed
Power Tilt and Recline Research
-The individual is recommended to initially move to fully titled position to stabilize the pelvis and the n follow with activation of recline system so as to minimize loss of postural stability
weight shifts defined
- Magnitude vs frequency
- During functional activities
- small weight shifts count too
Power standing
improves participation in standing program
- Greater medical benefits of weight bearing
- ->higher frequency
- ->dynamic loading
- Provides multiple physiological benefits :
- ->bowel
- ->bladder
- ->respiratory; GI
- ->ROM;
- ->Spasticity Reduction
- Reducing Cervical Spine pain or strain
- Optimal Pressure Relief
Stand for function
- to improve performance of MRADLS
- to improve reach and protects shoulder
- to improve participation in standing program
- to provide energy conservation
- to provide energy conservation
- to improve productivity and performance at work or school
- to possibly reduce cost of home modifications
Power Seat elevation
-Improved independence with transfers
–>sit to stand, lateral transfers
-Improves vertical reach
-Clients with UE weakness/pain/limited ROM
-Reduces cervical spine pain and strain
improves visual attention psycho-social benefits
Anterior tilt
-combine vertical height with horizontal reach
-Allows for closer reach
-Provides joint protection
-Access and independence
-getting closer to objects to perform fine motor skills or reaching deeper into shelves and cabinets
-without anterior tilt would need to approach countertops from the side and rotate their trunk
Functions
-MRADLs
-Functional reach
-Transfers
–>mitigates risk of skin shearing and other injuries during transfers
–>functional compensation for limited hip flexion
–> si to stand transfers
–>”nose over toes”
Positioning
–>tone management
-Communication
-Participation
-Weight Shifting Assistance
Thinking about powered wheelchair, can they drive
Stability and consistency
- What is the location of their most consistent control
- Are positioning optimized
Location
-What type of movement pattern is used
-do different positions elicit more/less stability and control
Control
-with this control site, is the person using fine motor or gross
ROM
-How much movement is required to effectively operate input
Endurance and Fatigue
-doe the driver have enough endurance
Interface
- a custom goal post, tennis ball
- Cognitive abilities/limitations
- Visual/perceptual abilities/limitations
- Role of wheelchair skills evaluation and training
Non Proportional
Non-proportional Control
- Either On or OFF
- Up to 8 discrete directions (Fwd, Rev, Left, Right and the 45 degrees in between)
- can be programmed for single or multiple speeds
Ability and technology Relationship
ability and technology have an inverse relationship
-as ability decreases, technology need increases
Standard Proportional joystick
- Consider the following prior to moving to an alternative joystick or switch input
- ->positioning of individual
- ->mounting/placement of joystick
- ->alternative joystick knobs
- ->programing adjustments
Adaptive joysticks
- Shape
- Texture
- height added, can joystick mount be adjusted if needed?
Alternative drive control: joystick
-requires display module
-Considerations:
Throw
-Force
-Size
-Mounting location/hardware
compact joystick (head mounting for chin)
Additional Proportional Input Devices
ASL extremity control joystick (decreased range of motion)
ASL MEC
ASL Micro Mini (for very small movements)
Switch-it-Micro Guide (gives feedback) (
Switch-it Micro Pilot (has no movement, finger or thumb, does not need much for)
Throw
-The amount of deflection (from centre) it takes to reach maximum available speed
Joystick force
how much force is required to move the joystick
for reference, standard joystick is approx 250 g of force
some of them need barely anything
Mounting
- Size of joystick
- mounting location
- Support required
- Degrees of movement required
- Built in mode switch or ports?
Additional Proportional Input devices
-Touch drive 2 RIM (back cushion) Foot control Magitek Gyroset Vigo
Proportional Drive control
Benefits may include
- Infinite control of speed based on amount of user input
- 360 degree of directional movement
- Continuous fluid response of wheelchair as the user moves the drive control away from neutral
- Use of drive control access (mouse emulation)
Considerations
- most require some amount of range of motion and strength to activate, this may not be possible for everyone
- for someone with severe cognitive impairment, the freedom of movement of the drive control may be too demanding, and may do better with an “on/off” non-portional drive control
Non-proportional SIDs
- Head array
- Sip and Puff
- Switch array
- Eye Gaze
- Single switch scanning
Head array
- Use head movement to activate proximity switches built into pads
- Requires good neck/head control
- Some models also have a proportional component
Sip and puff
- Pneumatic switch that uses varying air pressure from the person’s mouth via sips or puff to control the wheelchair
- Strength of sip/puff is adjusted based on user’s ability
Switch Array
Proximity
may be placed/mounted in various ways and locations
Fiber optic
select left and right
eye gaze
camera pointed at eyes tracking movement
Single Switch Scanning
- For someone with one switch site, allows for driving control of power seating functions via scanning
- Some manufacturers have built. in single switch scanning capabilities
- Can typically program speed and pattern of scan in order to increase efficiency
Switch options: mechanical
ASL Ultra Light Dome Switch, gooseneck Egg Switch Micolite Switch Push Button Tape switch Touch contact Wobble switch
Switch options Electronic
-Fiber optic
Proximity sensor
Tinkerton EMG
Programming Considerations
Proportional
- Drive parameters -Acceleration, declaration, speeds
- Throw
- Sensitivity/Tremor Dampening
- Deadband
- Changing Axes
Non-proportional
- calibration
- Latch/Latch type (most often pneumatic)
- Sensitivity/Tremor Dampening
- Changes axes
- Tracking technology
Electronic Aids to Daily living (EADLs)
-Provides remote access to electrical such a slights, TV, computer, phone and thermostats
-Use of EADLs has been found to contribute to:
feeling of well-being/competence
-Maintenance of independence
-Participation in communication/entertainment activities
Wheelchair with Infrared or bluetooth
Power wheelchair Training
-Turn w/x on; start/stop
-Gross circle, figure eight
-Spatial orientation: centre alignment
Interior and exterior doorways
-Parallel parking for transfers
-Uneven/even terrain, ramps, curb cuts
-Programming considerations
Dynamic Performance Analysis
Occupation Hierarchy
- Occupation
- Activity
- Tasks
- Actions
- Movements
Example
Occupation
-self-care
Activities
- Toileting
- Bathing
- Dressing
- Grooming
Activity Analysis
- Analyzing an activity to understand how it is “normally” or “typically” completed
- Determine activity demands
- Client is not observed doing the activity
- How is this useful
Activity analysis: cognitive Neurological determinants
- Sensory processing
- Perceptual processing
- neuro-musculoskeletal components
- Cognitive integration and cognitive components
Sensory Processing
- Tactile
-Perceptible to sense of touch, tangible - Proprioceptive
-Interpreting stimuli; originating in muscle and joints and other internal tissues that give information about the position of the body - Vestibular
-The sensory system that respond to the position of the head and body movement and coordination movement - Visual
-Interpreting stimuli through the eyes including peripheral vision and acuity - Auditory
Interpreting and localizing sounds and discriminating backgrounds sounds - Gustatory:
-interpreting taste with tongue - Olfactory:
-Interpreting odors, pertaining to the sense of smell
Perceptual Processing
- Stereognosis
Ability to identify sizes, shapes and weights of familiar object without use of vision - Kinesthesia
-Identify the excursion and direction of joint movement - Pain response
-Interpreting noxious stimuli - Body scheme
Acquiring an internal awareness of the body and the relationship of body parts to each other - Right-left discrimination
-Differentiating one side from the other side - Form Constancy
-Recognizing forms and objects as the same in various environments positions and sizes - Position in Space
Determining the spatial relationship of figures and objects to self or other forms of the place of his or her body in space - Figure Ground
Differentiating between foreground and background forms and objects - Depth Perception
Determining the relative distance between objects, figures and observe and changing place or surface
Neuromusculoskeletal
- Reflex
- Rapid movement response to stimuli - Range of motion
- Active and passive ROM, Measurable with goniometry - Muscle Tone
- Resistance against passive movements - Strength
- Relation to muscle contraction, often referring to the force generated - Endurance
- Sustaining cardiac, pulmonary and musculoskeletal exertion over time - Postural Control
- Using righting and equilibrium adjustments to maintain balance during functional movements
Motor Control
A. Gross Coordination
-Using large muscle groups for control or movement
B. Crossing the middling
-move of limbs at body’s midline
C. Laterality
-High level skill, using a preferred unilateral body part for activities
D. Bilateral Integration
-Ability to perform activity that requires interaction between both side of body
E. Praxis
-Skilled purposeful movement to carry out sequential motor acts
F. Fine motor coordination/Dexterity
-Using small group for controlled movement. object manipulation
G. Visual-Motor Integration
-Coordination the integration of information of eye and body movement
H. Oral-Motor Control
-Coordination oral -pharyngeal musculature for controlled movement
Cognitive Integration and cognitive components
- Level of arousal
-Demonstrating alertness and responsiveness to environmental stimuli - Orientation
Awareness to person, place, time - Recognition
-Identifying familiar faces, objects and other previously presented materials - Attention span
-Focusing on a task over time - Initiation of Activity
- Termination of Activity
- Memory
-Recalling information after brief or long period of tie - Spatial Operation
-Imaging and control of object with subjective ability - Problem Solving
-Recognizing a problem, defining a problem, selecting a plan implementing and evaluating the outcome
Performance Analysis
- Analyzing a client performance a activity
- Ideally done in real environment
- How is it useful
Dynamic Performance Analysis (DPA)
- task oriented, performance based occupational performance analysis.
- ->structured approach to analyze performance
DPA overall assumptions
- Theory of human occupation
- Top-down perspective
- Performance is an interaction of P, E and O
DPA
- Individualized approach
- Assists with analysing performance of client
- Breaks down task performance
- Identify performance problems to guide intervention
Therapist Requirements
- Having a top-down mind set
- A certain knowledge with respect to the occupation or activity (activity analysis)
- Appreciating that there is more than one way to do things
- Actually observe the client doing the activity
Performer Requirements
- Motivation
- ->at least minimal intrinsic or extrinsic motivation is needed
- ->increased purpose, meaning and motivation –>better learning and performance
- Task knowledge
Performance Requisites
Individual ABILITY
Environmental/Occupational DEMAND
-Environmental/Occupational SUPPORT
Question to follow for DPA
- Does the client want to do the occupation
- Does the client generally know what to do
- Is the performance competent
- Where in the performance is/are the breakdowns
(for each breakdown)
Does the client know what to do?
Does the client want to do it?
Can the client do it?
Does the client have the ability?
most commonly used impairment rating instruments in both clinical and research settings.
The Expanded Disability Status Scale (Kurtzke, 1983) and the MS Functional Composite (MSFC) (Fischer et al., 2001)
MS Fatigue
-most common and pervasive MS symptom and a primary reason for referral to occupational therapy.
varies from slight to severe with worsening typically in the afternoon, and may be related to increased ambient and core body temperature
-Primary MS fatigue
-Secondary fatigue
–>untreated MS problem such as walking difficulties
-Physical Fatigue
–>limbs, torso
Cognitive fatigue
–>one’s thinking, planning, memory
Local or focal fatigue
–>nerve conduction to selected area
Generalized fatigue
–>exhausted body
Normal fatigue
–>experienced by humans after excessive energy output
MS weakness
-dorsiflexion weakness (impact mobility)
intervention needs resting, orthosis
Cognitive Problems
Common cognitive problems for people with MS in- clude memory (acquiring and retaining new information) word finding; attention, concentration, and executive function; and slowed information-processing speed (NMSS, 2012).
Perceptual-cognitive problems may also occur such as visual-spatial impairments that might result in a tendency to get lost or a history of motor vehicle accidents
MS Typically Addressed Occupational Therapy
- fatigue
- weakness
- cognition
- pain
- Spasticity
- Tremor and ataxia
- Dysphagia
Adjusting to MS
coping techniques were used more often by those experiencing a MS relapse, whereas problem solving and using one’s social network were used when in remission
-Stress management Program
Several SOURCES OF FATIGUE
For example, therapists must differentiate among various types of fatigue by considering the results of several assessments. A high score on a depression index may indicate that depression is contributing to fatigue, whereas slow times on the 6-Minute Walk Test may also suggest a nerve fiber or motor fatigue component. Information from a sleep questionnaire may indicate that disturbed sleep caused by urinary frequency is a factor in daytime fatigue. It is common for persons with MS to have several sources of fatigue (Forwell et al., 2008), requiring intervention from multiple health care professionals.
MS (intervention Process)
For example, Finlayson (2004) suggests that, for older adults with MS, the therapist must ensure they feel a sense of control over their future,
work with families affected by the MS,
and advocate for enhanced community support options.
Exercise
recommending appropriate aerobic exercise routines, and educating on the difference between energy expenditure during functional activities and exercise to increase endurance.
- Two MS symptoms, fatigue and spasticity, often decrease with regular exercise. A structured aerobic program has been shown to reduce fatigue and increase endurance
- Good illustrations and written instructions should accompany every home program.
Activities Strategies and Energy Conservation Steps
-providing explanations of each relevant underlying type and factor of fatigue impacting the individual
-detailed activity diary that can be done on well-selected apps and makes a list of goals and priorities
- analyze daily work, home, and leisure activities and understand rest–activity ratios
-activity and environmental modifications, equipment, and technology to address fatigue issues then follows.
Energy conservation strategies and exercise routines will also be incorporated to help the individual perform valued occupations and activities through o
Energy Conservation MS
Use high, low, and smart technology appropriately.
○ Use smart devices and helpful apps to save steps,
such as voice options to replace touch typing.
○ Decrease prolonged standing and walking by modifying tasks to be done sitting.
○ Maintain a cooler body temperature by using, for
example, an air conditioner, cooling wraps fitted comfortably at wrist or on neck or a cooling vest when active (Fig. 35-1).
○ Reduce the energy required to walk by using an ankle–foot orthosis, cane, or walker.
○ Obtain seating systems for trunk support in wheelchairs.
○ For work, use a fitted ergonomic chair with arm-rests, correct height, and back support.
● Plan approaches to occupation and daily schedule.
○ Do important activities in the morning.
○ Break large time-consuming activities into smaller
tasks and do one task at a time.
● Problem solve using a step-by-step approach.
○ Use techniques to maintain cooler body tempera- ture, for example layer clothing, have warm versus hot showers, and avoid electric blankets or down comforters when sleeping.
● Delegate necessary highly energy-consuming occupations.
● Manage environmental controls and modifications.
○ Adjust heights of work surfaces to avoid strain.
○ Avoids stairs in daily activities.
● Simplify or eliminate tasks.
○ Avoid multitasking.
○ Have tools required for the task readily available in
arm’s reach.
● Educate others about your energy limits.
○ Teach others about increased body temperature and effects on reduced function and energy.
○ Work with others to accomplish a task, sharing the energy expenditure.
● Punctuate activities with rest.
○ Alternate activity with intervals of rest, such as
walking, sitting, and then walking.
Cognitive Compensation.
Interventions that include group therapy, stress management, personal digital assistants, electronic memory aids, and cognitive-behavioral therapy have been shown to
Cognition techniques, strategies, and modifications include
scheduling work responsibilities and cognitively demanding tasks to reduce the influence of the cognitive problems; for example, planning to do these in the morning or after breaks
● maintaining a paper, smart phone, or electronic diary as a memory aid and to help identify the timing of cognitive and fatigue problems as well as the environment in which these problems occur
● changing the environment to reduce distractions and interruptions and promote organization
● using problem-solving strategies for decision making rather than emotion-focused strategies
● supporting involvement of social network to assist with problem solving
● using step-by-step written home and/or work directions
● doing one activity at a time and avoiding multitasking
● incorporating assistive technology to improve function
in high-order IADL, such as money management and bill
payment, family schedules, and transportation options
● increasing time allotted for an activity and reducing
the number of activities planned or undertaken
● delegating difficult tasks to others
● using repetition in the learning process
● assessing driving safety and recommending appropriate testing and interventions
Pain Intervention.
posture training, ergonomic seating, stretching, supportive splinting, and focal heat modalities on muscle trigger points may be effective
Employment Modifications.
● changing the times at which tasks are performed
● limiting prolonged walking, standing, and travel by
using conference calls, Internet, and apps
● using appropriate gait equipment and powered mobil-
ity devices
● changing to an office that is convenient to frequent
activities
● modifying work hours
● working completely or partly at home ● arranging a space to rest periodically
PD is defined by the three cardinal signs
tremor
-is a resting tremor that increases with stress and may present as pill-rolling
rigidity,
-more advanced stages of PD
bradykinesia.
- causes a lack of facial expression, or “mask face,” and affects walking, involve- ment in activities, and eye blink
Postural instability is often added to this list
Other symptoms of PD
particularly in the middle to later stages, include swallowing changes, soft speech, festinating gait, autonomic deficits, constipation, fatigue, sleep disturbances, psychiatric complications (particularly depression and anxiety), and dementia
Cognitive function
cognitive functions most affected are motor planning, abstract reasoning, concentration, organizing, and sequencing
rely on external cues, feedback, and repetition when learning new tasks
PD and communication issues
handwriting may be shaky and micrographic, reducing legibility (Gillen, 2000). In intermediate and later stages, the voice softens and becomes monotone. Reduced facial expression and minimal hand gesturing contribute to reduced communication and negative messaging
Interventions Related to Decreasing Isolation and Communication Problems
Educate about timing activities to synchronize with maximum medication effectiveness.
● Modify leisure activities to encourage participation and decrease isolation.
● Provide information on support and advocacy groups.
● Educate caregivers about modifying communication and activities to support engagement
● Participate in programs such the LSVT and LSVT®BIG.
● Implement writing modifications, including using an
enlarged felt-tip pen and writing when rested.
● Use communication aids, including smart devices such as electronic tablets (mobile phone may be too small), large-key telephones, and electronic aids to daily living (EADL)
● Provide home exercise program to maintain facial movement and expression for socializing.
interventions Related to Safety
● Instruct in sit-to-stand and bed mobility using the Rehab Self Cue-Speech program.
● Instruct to manage motoric “freezing” while walking, includes avoiding crowds, narrow spaces, and room corners; reducing distractions and not carrying items while walking; reducing clutter in pathway; focusing when changing directions; using a rhythmic beat or counting to maintain momentum.
● Recommend equipment to increase independence such as a raised toilet seat and grab bars.
● Prescribe walking aids (walker for festinating gait).
Recommend, if required, a wheelchair having a proper seating system, cushion, and adjusted foot/leg rests and armrests that is appropriate for transporting within the community.
● Recommend good, uniform lighting, particularly in narrow spaces and at doorways.
● Provide home exercises to maintain mobility, coordination, posture, and tolerance.
● Perform home assessment and recommend modifications that might include alterations to the bathroom (e.g., nonskid surfaces, bath bench/chair) and flooring (e.g., eliminating throw rugs), horizontal strips on the floor where “freezing” episodes occur, and reducing furniture congestion (Gillen, 2000).
Interventions to Maintain Independence and Participation
● Modify eating routine to include small portions, reduced distractions, schedule frequent meals that allow adequate time, and provide adapted equipment such as non slip surfaces for plates and built-up handles.
● Recommend use of adult absorbent underwear to reduce embarrassment should a bathroom be difficult to access.
● Recommend that sexual activity be engaged in following rest and urination and when medications are most effective.
● Instruct on energy effectiveness strategies in home, leisure, and work activities.
● Reduce or eliminate the need for fine-motor control, such as clothing with minimal or no fasteners.
● Reduce the impact of perceptual problems by using visual cues and rhythmic music in a non distracting environment; speak slowly using simple instruction.
● Perform a home assessment.
Occupational Therapy Intervention Process
Early stage include
optimizing strength and ROM using home exercise programs (Drory et al., 2001)
● maintaining function in ADL and IADL through use of assistive or adaptive devices
● decreasing fatigue in the neck and extremities through use of splints and orthotics
● managing pain and energy using joint protection and work simplification techniques
Later on
optimize safety and positioning, perform safe transfers, and maintain skin integrity
● enable communication using augmentative communication equipment (Ball, Beukelman, & Pattee, 2004)
● assess and manage dysphagia (Higo, Tayama, &
Nito, 2004)
● optimize social participation
● identify and obtain equipment, such as a hospital bed,
to allow continued mobility and comfort
● modify the environmental to enhance participation,
safety and comfort
Throughout the stages of the disease, the occupational therapist must be sensitive to the client, family, and caregiver as physical demands, financial concerns, and transformation of the home into a hospital-like setting produce enormous stress and strain
Interventions
exercise
–>might need caregiver to help
Equipment and Assistive Technology
Dysphasia
Gullian Barre Syndrome
- Fatigue is most common residual problem
- Goals should focus on achieving optimal function at each level of recovery within tolerated pain levels
Acute Phase
the patient may be actively involved in directing care rather than physically involved, providing the opportunity for educating the patient and others about maintaining comfort in bed, protecting against bed sores, and future therapy
Modifications during the acute and plateau phase should be considered temporary and may include:
● communication tools, such as sign or picture board or voice-activated devices, if appropriate
● access to the nurse call button, TV, and lights by remote control, as appropriate
● use of hands-free telephone
● modification of lying and sitting positions for optimal
function and comfort
● positioning trunk, head, and upper extremities for stability and comfort
● introducing strategies to reduce anxiety
he number and complexity of tasks should be increased gradually (GBS-CIDP, 2012). Examples of interventions include
●providing activities and dynamic splints to maintain ROM, particularly of wrists, fingers, and ankle (hinged drop-foot orthosis)
● instructing both caregiver and client in safe mobility and independent transfers
● providing a sensory stimulation or desensitization program, as appropriate
● training in modified self-care techniques and adapting other daily activities
● using smart devices to facilitate communication and conserve energy
● modifying and encouraging re-engagement in routine activities, as appropriate
● adapting equipment for in home, leisure, and work activities
● instructing in energy conservation and fatigue management strategies
● modifying employment roles, tasks, and environment, as indicated
● recommending a fine-motor program to enhance strength, coordination, and sensation
● completing a home assessment and modifications, as appropriate, to facilitate return to home
