Pedretti Ch. 3 - Application of OT Practice Framework to Physical Rehabilitation

Question 1

Occupational therapy process

Answer 1

• Should be conceptualized as a circular process
• Initiated with a referral
• Then Evaluation to determine the client’s needs
  Intervention is developed based on the evaluation
  –The targeted outcome of the intervention is supported through the client’s health and participation in life through engagement in occupation
• All parts are mutually influential

Question 2

Referral

Answer 2

• Physician or other legally qualified professional requests OT services for the client
• May be oral, but written is usually a necessity
• Guidelines vary

Question 3

Screening

Answer 3

• OT determines if further evaluation is warranted and if OT services would be helpful for this client
• Generally brief
• Consider prior evaluations, diagnosis, physical condition, reason for referral and information from other professionals

Question 4

Evaluation

Answer 4

• Refers to the “process of obtaining and interpreting data necessary for intervention”
• Assessment: specific tools or instruments that are used during the evaluation process
• Two parts of the evaluation process:
  1. Generation of an occupational profile
  Assessments are chosen to help generate
  2. Analysis of occupational performance
  Synthesis of data collection through a variety of means

Question 5

Occupational Profile

Answer 5

• Reviews the client’s occupational history and describes the client’s current needs and priorities
• Includes client’s previous roles and contexts for occupational performance
• Initiated through an interview with the client and/or family and record review

Question 6

Purpose of the Occupational Profile is to answer the following questions:

Answer 6

1. Who is the client? – include significant others/ dependents
2. Why is the client seeking service?
   Needs of individual and significant others
3. What occupations and activities are successful or are problematic for the client?
4. How do contexts and environments influence engagement in occupations and desired outcomes?
5. What is the client’s occupational history?
   Level of engagement in various occupations and activities along with the value attributed to those
6. What are the client’s priorities and targeted outcomes?

Question 7

After completing the Occupational Profile, the OT must decide what additional information is needed

Answer 7

1. What additional data are needed to understand the client’s occupational needs including contextual supports and challenges?
2. What is the best way to collect this data?
3. How will this information support the intervention plan?
4. How will this information influence potential outcomes?

Question 8

Final steps of eval process

Answer 8

Then the OT will evaluate the client’s ability to plan, initiate and complete various occupations

The OT will then analyze the data to determine the specific strengths and weaknesses that impact their occupational performance → impact of contextual factors will be included

The OT will also consider if the client would benefit from a referral to other professionals

Question 9

Intervention Planning

Answer 9

When selecting an intervention plan the strategies should be linked to the intended outcomes of service.

They should answer the question: “What type (approach/strategy) of intervention will be provided to meet the client’s goals?”

Question 10

Examples of types of interventions:

1. Prevention of disability

Answer 10

Focused on developing the performance skills and patterns that support continued occupational performance and provides intervention that anticipates potential hazards or challenges to occupational performance

• Contextual issues (environmental barriers) are also addressed
• Ex: patient with balance issues → fall prevention tips

Question 11

Examples of types of interventions: 2. Health Promotion

Answer 11

Provided to enhance and enrich occupational pursuits

• May be used to help clients who are transitioning in roles or foster occupational performance across contexts
• Ex: promoting a transition of role from worker to retirement → anticipating changes and making choices

Question 12

Examples of types of interventions: 3. Establish or Restore a Skill or Ability

Answer 12

Aimed at improving child’s skills or abilities, thus allowing greater participation in occupations
- Ex: CVA → restore ADLs and iADLs

Question 13

Examples of types of interventions: 4. Adapt or Compensate

Answer 13

Modifying the environment, activity demands, client’s performance patterns to support participation in occupations
- Ex: Dyspnea → energy conservation techniques

Question 14

Examples of types of interventions: 5. Maintain Current Functional Abilities

Answer 14

Approach focuses on clients diagnosed with degenerative disorders and OT services should actively address the need to maintain occupational engagement
- Intervention may focus on activity demands, performance patterns or context for occupational engagement

Question 15

Through collaborating with the client and significant others, the intervention plan identifies specific focus of the goal but also explicit content of the goal

The plan includes:

Answer 15

Client-centered goals and methods for reaching them – values and goals of the client are primary and those of the therapist are secondary

• Cultural, social and environmental factors are incorporated
• Must identify scope and frequency of intervention and anticipated date of completion → outcomes must be written at the time the plan is developed
• Discharge planning is initiated during the intervention planning process

Question 16

Clear and measurable goals

Answer 16

Long-term goals or terminal behaviors must reflect a change in occupational performance

Outcomes may be achieved through several means: improved occupational performance, role competence, adaption, prevention and quality of life

Short-term goals or behavioral objectives reflect the incremental stages that must occur to reach this target

Question 17

Intervention Implementation

Answer 17

OT retains the responsibility to direct, monitor, and supervise the intervention and must ensure the necessary and relevant interventions are provided in an appropriate and safe manner and that documentation is accurate and complete

Methods used to provide interventions include:
- Therapeutic use of self, therapeutic use of occupations and activities, consultation, advocacy and education

The intervention would identify which approach or strategy will be used in combination with the methods
- During the intervention the clinician may shift between methods depending on the needs of the client

Question 18

Anticipatory Problem Solving – Schultz Krohn

Answer 18

Helping the client anticipate needs and solutions

Developed from model of human occupation and person-environment occupation

Empower client to anticipate potential challenges and develop solutions prior to encountering those challenges

Key elements:

1. Identify the occupation or activity to be performed
2. Features of the environment – contextual and environmental factors; necessary equipment
3. Potential safety risks or challenges to engagement
4. Develop a plan for these risks and challenges

Foundation of this process is to engage the client in developing solutions for everyday challenges encountered as they engage in occupations/activities

Question 19

Intervention Review

Answer 19

OTs evaluate the intervention plan on a regular basis → determine if the client’s goals are being met

Review includes a re-evaluation of the client’s status

Critical for showing the effectiveness of the intervention

The intervention may be changed, continued or discontinued based on the results of the re-evaluation

Question 20

Outcomes

Answer 20

Working with the client, client’s family and the intervention team, the OT/OTA identify the intended outcome of the intervention

Outcomes may be written to reflect a client’s improved occupational performance, a change in the client’s response to an occupational challenge, effective role performance, habits and routines that foster health or prevention of further disability, and client satisfaction in services provided

Question 21

Overarching outcome of OT intervention

Answer 21

supporting health and participation in life through engagement in occupation

Question 22

A client is formally discharged when:

Answer 22

A client is formally discharged when they have reached their established goals or achieved maximum benefit from OT services

OT will formally discontinue services and create a discontinuation plan that documents follow-up recommendations and arrangements

Necessary revision of the client’s outcomes and goals occur if it becomes apparent that the desired outcome is not realistic

Question 23

Clinical Reasoning in the Intervention Process is

Defined as:

Answer 23

Defined as: the process used by OT practitioners to understand the client’s occupational needs, make decisions about intervention services, and as a means to think about what we do

Question 24

Five forms of clinical reasoning

Answer 24

1. Procedural
2. Interactive
3. Conditional
4. Narrative
5. Pragmatic

Question 25

1. Procedural Reasoning

Answer 25

• Getting things done, “what has to happen next”
• Medical form of problem solving
• Emphasis is placed on client factors and bodily functions and structures
• Critical pathway: form of decision making tree based on a series of yes/no questions that can direct client interventions
• -Developed to support best practice when there is substantial information about a client’s course of recovery
• Used to develop critical pathways and is driven by the client’s diagnosis and potential outcomes anticipated for individuals with this outcome

Question 26

2. Interactive Reasoning

Answer 26

• Concerned with the interchanges between the client and therapist
• Therapist uses this kind of reasoning to engage with, understand and motivate the client
• Understanding the disability from the client’s POV is fundamental
• Used during the evaluation to further explore the client’s occupational needs
• During the intervention it is used to access the effectiveness of the intervention

Question 27

3. Conditional Reasoning

Answer 27

• Concerned with the contexts in which interventions occur, the contexts in which the client performs occupations and the ways the various factors might affect the outcomes and direction of therapy
• Using “what if?” – imagining possible scenarios for the client
• Integrate the client’s current status with the hoped for future
• Recognizes that the process of intervention often necessitates a reappraisal of outcomes
• Reappraisal should be encouraged to help the client refine goals and outcomes

Question 28

4. Narrative Reasoning

Answer 28

• Uses story making as a way to understand the client’s experience
• The client’s experience reveals themes that permeate the client’s understanding and that will affect the enactment and outcomes of therapeutic reasoning
• Also used by therapist to plan the intervention session; and what will happen for the client as a result of therapy
• Therapeutic use of self is critical
• Where context and occupational performance intersect
• -Cultural and social contexts

Question 29

5. Pragmatic Reasoning

Answer 29

• Extends beyond the interaction between the client and therapist
• Integrates several variables: demands of the intervention setting, therapist’s competence, client’s social and financial resources, and the client’s potential discharge environment

Question 30

Clinical Reasoning in Context

Answer 30

• Therapist must balance the needs of the client with the practical realities of healthcare reimbursement and documentation
• -Needs to know: anticipated or requirement date of discharge; scope of services that will be reimbursed

OT must document service accurately and effectively

Therapist is guided by client’s goals and preferences – Client Centered

• Requires client or family involvement and collaboration at all stages
• Must be able to communicate with people of all backgrounds
• Cultural and social factors

Question 31

Client-Centered Practice

Answer 31

• Involving clients in identifying their own goals and in decision making about their own care and intervention
• Begins when the therapist first meets the client
• Occupation based assessment tool: COPM (Canadian Occupational Performance Measure)

Question 32

Client-Centered Practice is Guided by the Following Principles:

Answer 32

• Language reflects client as a person first and condition second
• Client is offered choices and supported in directing the OT process
• Intervention is provided in an accessible, flexible manner to meet the client’s needs
• Contextually appropriate and relevant
• Clear respect for differences and diversity

Question 33

Theory

Answer 33

According to Reed, theories attempt to do the following:

• Define and explain relationships between concepts or ideas related to the phenomenon of interest
• Explain how these relationships predict behavior or events
• Suggest ways that the phenomenon can be changed or controlled

Question 34

Theory is tested across settings for ____.

Answer 34

Theory is tested across settings for confirmation of concepts and relationships

Question 35

From an OT perspective: theories provide the profession with ___.

Answer 35

From an OT perspective: theories provide the profession with a means to examine occupation and occupational performance and understand the relationship between engagement in occupations and participation in context

Question 36

Mary Reilly’s theory of occupational behavior was designed to explain what?

Answer 36

Mary Reilly’s theory of occupational behavior was designed to explain the importance of occupation and the relationship between occupation and health

Question 37

Model of Human Occupation (MOHO)

Answer 37

Engagement of occupational performance is understood as a product of three interrelated subsystems

• Volitional subsystem: refers to the client’s values, interests and personal causation – thoughts and feelings, including occupational forces
• Habituation subsystem: habits and roles that are critical to a sense of self
• Performance Capacity subsystem: reflects the client’s lived experience of the body
• -Refers to the client’s previous experience, changes, and expectations of performance capacity

Question 38

Ecology of Human Performance (EHP)

Answer 38

Intended to serve as a mechanism for understanding human performance across professions

Important is the interaction of the person, the task (activity demands), and the context

• These three factors influence each other and the person and task are linked to the context
• Occupational performance is intertwined and the product of these three variables
• Equal importance is placed on each variable

Question 39

Ecology of Human Performance (EHP) – client centered model

Answer 39

Client centered model – each person is viewed as unique and complex; includes past experiences, skills, needs and attributes

Question 40

Ecology of Human Performance (EHP) – five intervention strategies

Answer 40

1. Establish/restore: focused on improving person’s abilities; includes context for performance
2. Alter: intervention alters contextual factors to foster occupational performance
3. Adapt/modify: task or context is adapted to support performance
4. Prevent: intervention may address the person, the context, or task to prevent potential problems from occurring
5. Create: intervention addresses all three variables of the person, task, and context and is designed to develop or create opportunities for occupational performance

Question 41

Person-Environmental Occupation Model (PEO)

Answer 41

Shares characteristics with EHP; occupational performance is seen as the intersection between person, environment and occupation

Client centered; but equal emphasis is placed on environment and occupation when designing intervention

Defines the person as a dynamic and changing being with skills and abilities to meet roles over the course of time

Further differentiates the progression from an activity, a small portion of a task, a task that is a clear step toward an occupation, and the occupation itself evolves over time

Question 42

Frames of Reference (FOR)

Answer 42

Purpose: help the clinician to link theory to intervention strategies and to apply clinical reasoning to the chosen intervention methods

Tends to have a more narrow approach to occupational performance when compared to models of practice

Offers a way to structure intervention and think about intervention progressions

Should be well fitted to meet the client’s goals and hoped-for outcomes

A clinician may blend intervention strategies for multiple FORs to meet the client’s needs

Question 43

Biomechanical

Answer 43

Kinematics and kinesiology are foundations

Analyzing the movement required to engage in the occupation

Principles of physics, the force, leverage, and torque required to perform a task are assessed → basis for intervention

The outcome must reflect engagement in occupation

Question 44

Rehabilitation

Answer 44

Focuses on the client’s ability to return to the fullest physical, mental, social, vocational and economic functioning as possible

Emphasis is placed on client’s abilities and using current abilities coupled with technology or equipment to accomplish occupational performance

Compensatory intervention strategies are employed

Focus of the intervention is often engagement in occupation through alternative means

Clinician must always link intervention to the client’s occupational performance

Question 45

Sensorimotor

Answer 45

Several FORs are included in this grouping

• Proprioceptive Neuromuscular Facilitation (PNF)
• Neurodevelopmental Treatment (NDT)
• These approaches share a common foundation of viewing a client who has suffered from CNS insult to upper motor neurons as having poorly regulated control of lower motor neurons
• Various techniques are employed to promote reorganization of the sensory and motor cortices of the brain
• Basic premise: client receives systematic sensory information, his or her brain will reorganize and return of motor function will be obtained

Question 46

Meeting the Client’s Needs

Answer 46

As a therapist applies theories, models, or FORs to meet the client’s needs, a series of potential questions should be posed:

1. Does the theory, model of practice, or frame of reference help with understanding and interpreting the evaluation data while considering the client’s expressed needs?
2. Does the theory, model of practice, or frame of reference provide a good fit for the type of intervention that will meet the client’s needs?
3. What evidence is available that the theory, model of practice, or frame of reference can efficiently produce the results requested by the client?

Question 47

Teamwork within the Occupational Therapy Profession – Two levels of practitioners: OT and OTA

Answer 47

OT ability to provide occupational therapy services independently
- Should seek supervision and mentoring to foster professional growth

OTA must receive supervision from an OT to deliver occupational therapy services

Question 48

OT – OTA Relationships

Answer 48

Appropriate role of the OTA is complementary to that of the OT

Many variations in the use of OTAs exist across settings

AOTA has identified critical factors to consider in the delegation of delivery of occupational therapy services
- Factors include the severity and complexity of the client’s conditions and needs, the competency of the practitioner, type of intervention selected to meet the identified outcomes and requirements of the practice setting

Question 49

Occupational Therapy Aides

Answer 49

Must work only under direction and close supervision of an OT practitioner (OT or OTA)

Provides supportive services – do not provide skilled occupational therapy services

Question 50

Teamwork with Other Professionals

Answer 50

Many healthcare professional collaborate in the care of persons with physical disabilities

Relationships are determined by the context of care or setting

Advantages: better integration of services, fewer healthcare providers, cost reducing

Disadvantages: erosion of professional identity, risk to consumers of harm at the hands of less skilled providers and ceding control of individual professions to outside parties such as insurers

Question 51

Many factors affect the relationships among professionals across disciplines

Answer 51

Intervention setting, reimbursement restrictions, licensure laws, other jurisdictional elements and the training and experience of others involved

Each discipline has a certain scope of practice, but there might be some overlap

Question 52

Cross Training

Answer 52

training of a single rehabilitation worker to provide services that would ordinarily be rendered by several different professions

Question 53

Multiskilling

Answer 53

used synonymously with cross training; acquisition by a single healthcare worker of many different skills

Question 54

Ethics

Answer 54

OT practitioners should anticipate that they will frequently encounter ethical distress

Plan of action:

1. Reviewing AOTA guidelines
2. Seeking guidance from institutional ethics and review boards
3. Approaching and engaging colleagues, peers, and the community to identify and debate ethical questions and formalize resolutions