Vous êtes sur la page 1sur 64

Last minute review for NBCOT Pediatrics y Clawing: fanning , ability to spread toes to maintain balance in standing.

Cruising: occurs at 12 months of age, precedes walking. Creeping: 4 point mobility in prone with only hands and knees on the floor. Occurs from 7-12 months. A premature infant is any infant born before 37 weeks. Children diagnosed with spina bifida often have flaccid bladders and can typically not control urination. Vestibular stimulation when used to treat a child with autism is most effective for improving communication, hyporesponsiveness, and muscle tone. Toilet training should begin when the child indicates discomfort with being wet or soiled. If an 8-month-old child is observed sitting by propping forward on his arms, a sensorimotor evaluation should be conducted. Sitting with arms propped forward is typical of a 5-6 month-old. The therapist cannot set accurate treatment goals without a full evaluation. Children with ADHD may also have learning disabilities, which cause decreased memory. A memory evaluation should be included when evaluating a child with ADHD. A 3 year old can typically string large beads, snip paper with a scissors, and copy a circle. Copying a square occurs at age 4.5 Putting bracelets or rattles on a babies ankle, having parents make faces and sounds to attract the baby s interest, and holding toys at different positions are all ways to facilitate gravity-resisted play in supine to develop midline control. Using a mirror to encourage baby to lift head would be more effectively done in prone. At 3-4 months a child is able to ban toys on a tabletop but they do not have voluntary release. Voluntary release takes place at 1 year Greenstick fractures are seen in immature bones of children Good skin techniques are essential for children with spina bifida. These techniques include checking the skin for pressure sores, change positions frequently, and avoid tight-fitting clothing. Thick and deep padding often adds more pressure to the skin and should be avoided. At 40 weeks, a child is approximately capable of sitting alone, creeping, and ability to say 1 word. At 3 4 years a child is able to feel shame Infancy stage is considered from 0-18 months and ends when the child is able to speak Slow rocking will result in dampening the vestibuloproprioceptors, and decreasing tone (reduce hypertonicity) throughout the body. Slow rolling and a quiet environment will also decrease tone.

y y y

y y

y y

y y y

y y y

y y y y y y y

y y

y y y

y y

The spinal cord of the child with spina bifida is sometimes attached to the spinal column and becomes taut as the child grows. This condition is called a tethered cord and is noted by loss of bladder control, decrease in strength of bilateral LE and UE, and an increase in the equinovarous position of the feet. Hand preference is usually determined by the age of 5 Newborns and children have the highest frequency of epilepsy. Social smiling elicited by a mother can occur at 4-8 weeks. Visual fixation occurs between 2-4 weeks Spontaneous smiling occurs at 16 weeks By 8-9 months an infant sits erect and unsupported for several minutes. At 4 months old, developmentally, an infant uses a bilateral approach at this age. A child who strongly favors an L hand should be evaluated for possible right-sided dysfunction. Infants born at 30 weeks gestation tend to show flaccid muscle tone. Smooth motor movements are more likely at 32 weeks gestation. The ability to fixate on a visual stimulus for 15 seconds and trunk flexion occur at 34-36 weeks gestation. Effective finger feeding occurs at 9-12 months At 21 months, a child is cognitively able to operate and control mechanical toys. A chin-controlled switch will enable self-directed play and is age appropriate. A child can maintain head control while supported at 2 months. At 1 month the child can move his or her head slightly while in prone. At 4-5 months the child can hold his or her chest off of the floor while in prone. An infant should sleep and play in supine or side-lying to prevent SIDS In screening a child who has been referred for OT, the primary goal is to determine the need for future evaluation/treatment. A mature dynamic tripod grasp is typical of a 5-6 year old. A less mature static tripod is used by a 3-4 year old and the hand moves instead of the fingers while writing. A power grasp is used by a 1 year old and is fisted with wrist flexed. Children aged 7-12 are developmentally able to participate in games with rules, competition, and social interaction. Such games include playing cards. Creative play is appropriate I children age 4-7. A child with spina bifida with LE paralysis would benefit the most from using a prone scooter for exploratory play because children with this condition has enough UE coordination and strength to propel themselves on a scooter where the LE are supported. Children with Downs Syndrome use the W sitting position to increase stability in sitting. This is common for children with this disorder. When testing a child for tactile defensiveness, have them roll in a carpet barallel before brushing, lotion, or swinging. This gives the child the opportunity to control the activity and warm up .

y y y

y y

y y y

Treatment planning for a child with an underreactive vestibular system would most likely include specific activities to address poor postural responses. Major signs of shunt malfunction in children are irritability, nausea, vomiting, changes in behavior, visual perceptual difficulties, and headaches. It is most important for an OT to look for unexplained sensory loss that would indicate an emergency. Developmentally, some typical children do not know 3 of 4 colors until age 4.5-5. Color recognition comes at about 4-5. When a child is born premature, the number of months premature is subtracted from the child s chronological age to adjust for prematurity. Maternal Toxemia (preeclampsia): is a possible complication of gestational diabetes, and is characterized by edema and high BP in the LE, and possible protein in the urine. This can lead to eclampsia, which includes headaches, seizures, and even coma. Other complications include baby being large for gestational age and hypoglycemia in the newborn. The first toileting skill that must be developed is the child s recognition of being wet or soiled. This typically occurs at 12 months. Developmentally, rolling from supine to side-lying starts at about 2 months. Rolling from prone to side-lying is the next stage that begins at about 4 months. Rolling from supine to prone and from prone to supine begin at about 7 months. Easiest to roll supine to side-lying. Children with hearing loss often omit initial consonants, use mostly unintelligible words, and use one word combinations for communication. Flushing, sweating, and increased HR are autonomic NS signs of sensory overload. Spastic diplegia is defined as abnormal tone affecting all four extremities but with primary involvement of the LE; therefore, a child may use his UE to propel himself through space while having his LE positioned on the scooter. The best choice of a mobility device for this child is a body length prone scooter with hand breaks. To promote isolated head control in a child who has poor head and trunk control, the optimal position is prone over a wedge because head control is isolated with trunk supported. This position is also gravity eliminated, which makes it easier for the child to isolate head control When treating a child with visual memory deficits, incorporate activities that have increased sensory input because additional sensory input, when combined with a visual memory task, facilitate memory. It is most effective to use chaining when teaching a child with moderate MR to dress and groom. Chaining with a child who demonstrates a cognitive disability shows them the entire process of a task with all sequences. Initially, the child performs only the beginning or end of the task and gradually increases participation in all sequences in the correct order. Chaining is particularly successful in individuals with MR.

y y

y y y y y

Children with Downs Syndrome who are demonstrating hyperextensibility of all joints most likely have decreased muscle tone. Decreased muscle tone is characterized by joints that are lax and hyperextensible. Low muscle tone and hyperextensibility are also frequent characteristics of Down Syndrome. The child with Down Syndrome is susceptible to atlanto-axial dislocation from rough activity such as tumbling or bouncing on the therapy ball. These types of activities should be avoided. The movements can be stressful on the first and second cervical vertebrae. An individual education plan (IEP) is a form that must be completed for children receiving services, including OT, in the school system. When providing OT for a child with a terminal illness, the underlying principle is to add quality to their remaining days. OT should address play activities and ADLs. When working on tying shoes with a child who has learning disabilities, low frustration tolerance, and poor self-esteem, it is best for the therapist to use backward chaining. In backward chaining, the OT completes all of the steps except the last one. As a child becomes more competent, the practitioner completes all but the last two steps and so on, until the child is able to perform the entire activity. This method provides immediate gratification and is particularly useful for children with low frustration tolerance and poor self-esteem. Forward chaining is better for children/individuals with difficulty sequencing and generalizing skills because the pt does the first step and sequentially more of the steps. Motor problem or praxis problems are often seen in young children when they are dealing with novel equipment. Motor planning requires an adequate body concept and the ability to cognitively plan movements. Exploratory play provides children with experiences that develop body scheme, sensory integrative and motor skills, and concepts of sensory characteristics and actions on objects. Ex: obstacle course. Symbolic play is associated with the development of language and concepts. Ex: dress up Creative play and interests are characterized by refinement of skills in activities that allow construction, social relationships, and dramatic play. Recreational play is leisure experiences that allow the exploration of interests and roles such as arts and crafts or sports. Control develops cephalocaudally; neck and shoulder control should be addressed first. At 6 months of age, a child should initiate head flexion when pulled into a sitting position. The child assists with pulling of the arms and some trunk flexion or use of the abdominals by this age. Usually by 2 months of age, an infant is beginning to assist with being pulled to sit. Working on trunk balance is within normal limits for the eight month-old. The development of gross motor skills in the child with myelomeningocele

y y

parallels those of the typical child. The difference is that upright mobility at the 12-18 month level concentrates on the use of assistance devices. Transferring objects from one hand to another is found at the 6-8 month level. Righting reactions develop after the integration of primitive reflexes and allow children to right their heads against gravity and to realign their bodies around the movement of the head in that process. Moving from a completely prone position to a prone-on-elbows position is an example ADHD: one of the keys to the diagnosis of ADHD is that the non-purposeful, hyperactive behavior must interfere with functioning in age-appropriate skills in school, play, and social settings. In the adolescent and adult, behaviors must interfere with work tasks. Symptoms of shunt malformation include headaches, vomiting, irritability, sunken appearance of eyes, and seizures.

Anatomy of the Hand y Intrinsic muscles innervated by the median nerve - Abductor pollicis brevis: palmar abduction - Opponens pollicis: opposition - Flexor pollicis brevis: thumb MCP flexion - Lumbricals (radial side): MCP flexion & extension of IP joints Intrinsic muscles innervated by the ulnar nerve - Abductor digiti minimi: abduction of 5th digit - Opponens digiti minimi: opposition of 5th digit - Flexor digiti minimi: flexion of MCP joints &opposition of 5th digit - Lumbricals (ulnar side) MCP flexion & extension of IP joints of digits 4 and 5. - Palmar and Dorsal Interossei: abduction & assist of MCP flexion/extension of all IP digits Extrinsic flexors innervated by the ulnar nerve - Flexor digitorum profundus: flexion of DIP joints to digits 4 and 5 Extrinsic extensor muscles innervated by the radial nerve - Extensor digitorum communis (EDC): extension of MCP joints & contributes to extension of the IP joints - Extensor digiti minimi (EDM): extension of MCP joints of the 5th digit & contributes to extension of the IP joints - Extensor indicis proprius (EIP): extension of MCP joint of the 2nd digit & contributes to extension of the IP joints - Extensor pollicis longus (EPL): extension of thumb IP joint - Extensor pollicis brevis (EPB): extension of MCP & CMC thumb jt - Abductor pollicis longus (APL): abduction & extension of CMC jt

y y

Anatomy of the Wrist y Wrist flexors innervated by the median nerve - Flexor carpi radialis (FCR): flexion & radial deviation of wrist - Palmaris longus (PL): wrist flexion Wrist flexors innervated by the ulnar nerve - Flexor carpi ulnaris (FCU): wrist flexion & ulnar deviation Wrist extensors innervated by radial nerve - Extensor carpi radialis brevis (ECRB): extension & radial deviation of wrist - Extensor carpi radialis longus (ECRL): extension & radial deviation of wrist - Extensor carpi ulnaris (ECU): extension & ulnar deviation at wrist

y y

Grasp and disorders of the Hand y y The intrinsic muscles of the hand include flexor digiti minimi, flexor pollicis brevis, and abductor pollicis brevis. The flexor pollicis longus originates on the body of the radius and inserts on the base of the distal phalanx of digit 1. Therefore, the muscle belly is located within the forearm and not the hand. Fingertip pinch strength: thumb is positioned against tip of index finger Ulnar palmar grasp is seen before palmar grasp. Ulnar palmar grasp (using ulnar side of hand) is the first stage to functional grasp. Lateral Pinch: placing the pad of the thumb against the radial side of the index finger near the DIP joint. Used to stabilize a pen between thumb and index fingers. Lateral prehension: formed by positioning the pad of the thumb against the radial side of the finger. Used to hold a pen, utensil, or key. Palmar prehension/three-jaw chuck/palmar pinch: positioning the thumb in opposition to the tips of the index and middle fingers, forming a pad-to-pad opposition. This form of prehension is commonly used to lift objects from a flat surface and tie a shoelace. Palmar grasp: power grasp, which individual flexes fingers around an object while stabilizing it against the palm. Pincer grasp: tip pinch, characterized by opposition of the thumb and index fingertips to allow the individual to make a circle with the fingers. Static Tripod Posture Grasp: characterized by the ability to grasp a pencil proximally with crude approximation of the thumb, index, and idle fingers, and the ring and little fingers slightly flexed. The next grasp pattern to be mastered would be the dynamic tripod grasp. A shift involves linear movement on the fingers surface. An example of a shift is turning the pages of a book.

y y y

y y

y y y

y y y

y y y

Translation involves linear movemet of an object from the palm to the fingers. Rotation involves turning or rolling. This is seen in a child who can open a combination lock, open a lock with a key, and turn a pencil over to erase. Reflex Sympathetic Dystrophy: A disabling reaction to pain that is generated by an abnormal sympathetic reflex. Signs include pain, edema, coolness of hand, and blotchy skin. Colles Fracture: A fracture to the distal radius with dorsal displacement. One of the most frequent injuries to the wrist. These fractures may result in limitations in wrist flexion and extension, as well as pronation and supination resulting from the involvement of the radioulnar joint. Smith s Fracture: Fracture of the distal radius with volar displacemen Carpal Fractures: most common in scaphoid fx (60%) Swan-Neck Deformity: Pattern of hyperextension of the PIP joint and flexion of the DIP joint. Caused by a rupture of the lateral slips of the extensor digitorum communis or flexor digitorum superficialis tendon. Commonly caused by RA Boutonniere s Deformity: Flexion of the PIP joint and hyperextension of the DIP joint. Caused by a lengthening or rupture of the extensor digitorum communis tendons. Commonly caused by RA Dupuytren s Disease: Disease of the fascia of the palm and digits. The fascia becomes thick and contracted, resulting in flexion deformities of the involved digits - Surgical release is required - Night extension splints, A/PROM and progressive strengthening, scar/wound management. Ulnar Nerve Palsy: the hand assumes a claw position, or intrinsic-minus position, with the ring and small finger hyperextension of the MCPs and flexion of the IPs. This is a result of weakness or loss of lumbricals and interossei muscles, which are responsible for MCP flexion and IP extension. Splinting objective is to assist in grasp and release of objects by preventing claw position. Skier s Thumb (Gamekeeper s Thumb): Rupture of the ulnar collateral ligaments of the MCP joint of the thumb. Commonly caused from skiing injuries/falling on an outstretched thumb. - Focus on ADLs that require opposition and pinch strength. Complex Regional Pain Syndrome (CRPS): Type 1 formerly known as RSD: Vasomotor dysfunction as a result of an abnormal reflex. - Symptoms include severe pain, edema, discoloration, osteoporosis, sudomotor changes, temp changes, trophic changes, and vasomotor instability. - Contrast baths are a primary/preferred intervention because they facilitate the opening and closing of the vascular and lymphatic vessels. - Stress loading is a recommended intervention for CRPS.

y y y

OT intervention include modalities to decrease pain, AROM, ADLs to encourage pain free use, stress loading, splinting to prevent contractures. A pinch meter is used to measure the strength of a three-jaw-grasp pattern (palmar pinch), as well as key (lateral) pinch and tip pinch. Prehension is a hand position that permits finger and thumb contact, while facilitating the manipulation of objects. Tenodesis grasp is developed by allowing the finger flexors to shorten. Functional grasp is then achieved by extending the wrist. This improves the ability of C6 and C7 SCI pts to grasp and hold objects. Degenerative Joint Disease: results from changes in the cartilage, the proteoglycans in the joints and leads to development of changes in the subchondral bone and marginal osteophytes. Secondary DJD develops as a result of trauma or infection. Symptoms include pain, edema, weakness, and difficulty grasping. Scleroderma: Systemic disease, symptoms include calinosis, Raynaud s phenomenon, esophageal dysfunction, sclerodactyly of fingers and toes, and telangiectasis or red spots covering the hands, feet, forearms, face, and hips. Poor circulation is a common sign, especially hands and feet. Dressing in layers can compensate for this problem. -

Cumulative Trauma Disorders y Cumulative trauma disorders are viewed as a mechanism of injury for tendonitis, nerve compression syndromes, and myofascial pain because of the repetitive strain and motion disorders. - Risk factors include repetition, static position, awkward posture, forceful exertions, and vibration. Non-work risk factors include acute trauma, pregnancy, diabetes, arthritis, and wrist size/shape. Cold, massage, elevation, and isotoner gloves are all effective ways to reduce edema post surgery. Wet packs are contraindicated post surgery DeQuervians: Stenosing tenosynovitis of the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB). - Symptoms include pain and swelling over the radial styloid, positive Finkelstein s test. - OT tx include thumb spica splint, activity/work modification, ice massage over radial wrist, AROM of wrist and thumb to prevent stiffness, operative tx. Lateral and Medial Epicondylitis: Degeneration of the tendon origin as a result of repetitive microtrauma. - Lateral epicondylitis: overuse of the wrist extensors, especially the extensor carpi radialis brevis. Commonly called tennis elbow. - Medial epicondylitis: overuse of wrist flexors. Also called golfer s elbow.

y y

y y

y y

Treatments include elbow strap/wrist splint, ice, deep friction massage, stretching, activity modification, strengthening with decreased pain. During the acute stage of epicondylitis (tennis elbow), ice, immobilization, and splinting are all interventions that are considered to be appropriate. Trigger Finger: Tenosynovities of the finer flexors, most commonly at the A1 pulley. Results from a thickening of the flexor digitorum superficialis tendon at the flexor tunnel/tendon sheath. - Caused by repetition and the use of tools that are placed too far apart. - OT tx includes scar management, edema control, tendon gliding, activity/work modification. Tendon Repairs: Early mobilization prevents adhesion formation and facilitates wound/tendon healing. - OT goals include increased tendon excursion, improved strength at repair site, increased joint ROM, prevent adhesion, facilitate resumption of meaningful roles. In observing a pt for signs of overexertion, a therapist should look for decreased speed of performance. The Kleinert protocol for up to 4 weeks post-surgery has the person performing active extension and passive flexion within the limits of a dorsal block splint. Active flexion is contraindicated. Carpal Tunnel: The most common UE nerve entrapment. Caused by compression of the median n. at the wrist. The carpal bones form the floor of the carpal tunnel. The transverse carpal ligaments (flexor retinaculum) form the roof of the tunnel, and act as a pulley for the flexor tendons during gripping. - Inside the carpal canal there are 9 flexor tendons (4 FDP, 4 flexor digitorum superficialis (FDS), the flexor pollicis longus, and the median n.) - Swelling or thickening of the tendons can lead to pressure on the nerve, resulting in sensory symptoms in the distribution of the median n. - Occurs most commonly among women 40-60 and is commonly bilateral. - Symptoms include hand numbness, particularly at night or when driving a car, pain and paresthesias in the distribution of the median n. (thumb through radial ring finger pads), and clumsiness or weakness. - May be associated with repetitive use. - Heat packs are contraindicated for CTS - Associated diagnoses include RA, Colles fx, diabetes, deconditioning, obesity, and thyroid disease. - Evaluations include ROM, grip and pinch, Tinel s (tapping on volar wrist elicits Tinel s sign, which is a sensation of tingling or electric

shock if the median n. is compromised. , Phalen s (provokes sensory symptoms in the median n. distribution if positive, created by maintaining the wrist in flexion for 60 seconds), Semmes-Weinstein Monofilament, and two-point discrimination test. Treatment for carpal tunnel include night splinting with the wrist in neutral to minimize pressure in the carpal tunnel, exercises for median n. gliding at the wrist, aerobic exercise, proximal conditioning, ergonomic modification, and postural training. Pts should avoid extremes of forearm rotation or of wrist motions, sustained pinch, and forceful grip. Surgical intervention consists of decompression of the carpal tunnel by division of the transverse carpal ligaments. Common.

Splinting y y A resting hand/pan splint is the most appropriate splint to fabricate for the maintenance of functional hand position. A wrist cock-up splint is the best splint to use for carpal tunnel because it positions the wrist in 10-20 degrees of extension to alleviate symptoms and prevent further damage. To reduce splint pressure, increasing the area of force application is recommended. The recommended splint length is 2/3 the forearm. Spreading and flattening the edges also decreases pressure but is not the primary method. A Kleinert or Duran dorsal splint are indicated for flexor tendon injuries Ulnar nerve palsy splints assist in grasp and release of objects by preventing the claw position. This is accomplished by a bar splint, which blocks the MCPs in slight flexion, allowing the force of the unaffected long finger extensors to extend the IPs A wrist-driven flexor splint is indicated for individuals who lack prehension power (C6-C8 SCI patients). An elbow lock splint should be used for the individual with Erbs palsy. Erbs palsy results from injury to the 5th and 6th brachial plexus roots. This results in the arm hanging limp with the shoulder internally rotated. Bell s Palsy is the result of a problem affecting the seventh cranial nerve that produces unilateral facial weakness or paralysis. A facial splint is provided to prevent long asymmetry of facial muscles. A mold of the inside and outer lip of the mouth on the involved side is attached with elastic to an ear piece. The primary purposes of an ulnar n. splint is to block hyperextension of the MCP joints and allow MCP flexion. The buddy strap helps to provide passive ROM to the injured finger. The buddy strap can also help improve a deformity that has been caused by immobilization due to injury, weakness, or casting

y y

y y

y y

y y y y

y y y SCI y y y y y y y y y y

Tennis shoes are the best option for use with ankle-foot-orthoses (AFO) because they provide the most support. A forearm trough splint should be two thirds the length of the forearm When a pt has fluctuating edema and a dual diagnosis of hemiplegia, an OT should use wide, soft, foam-like straps on the splint. Trim lines of a splint that extend proximal to the MCP crease allow for adequate MCP digit extension and flexion. This should be implemented when making a carpal tunnel splint to allow for adequate digit motion A dynamic extension splint for a low level radial nerve injury should provide wrist extension, MCP extension, and thumb extension The dynamic extension splint provides the best tx for wrist drop The most appropriate splint for DeQuervian s syndrome is a forearm-based thumb spica. It is stenosing tenosynovitis of the abductor pollicis longus.

y y y y

Tetraplegic: impairment or loss of motor and/or sensory function in the cervical segments of the spinal chord, involvement of 4 limbs. Paraplegia: Impairment or loss of motor and/or sensory function in thoracic, lumbar, or sacral segments of the spinal chord (T1 and down) Quadriparesis and Paraparesis: describe incomplete lesions imprecisely. Use of these terms is discouraged Neurological Level: Level where they are both sensory and motor complete. Sensory testing in SCI patients should be proximal to distal and consider dermatomal distribution. Zone of Partial Preservation: some sensory and motor but no function An individual with a C7-8 quadriplegia has the hand strength to hold a toothbrush with a built up handle. Quick icing, especially applied in the midline area to someone with a SCI at or above the C5 level can produce autonomic dysreflexia. Touch pressure, firm touch, and light vibration are all appropriate techniques to stimulate the abdominal area in the midline axis. Anterior Spinal Chord Syndrome: Caused by damage to the anterior spinal artery or anterior spinal cord. Proprioception is maintained with the condition of anterior spinal cord syndrome. Light touch, pain sensation, and temperature sensation are absent/impaired in anterior spinal cord syndrome. Dorsal (Posterior) columns of the spinal cord transmit proprioceptive information. A person with a C8 SCI would likely be able to button a shirt and tie shoes. Using momentum and substitution movements to don pants is a good goal for a pt with a C6 SCI A wrist splint in the functional position will provide support needed due to the absence of wrist extensors and wrist flexors. A person with a C-5 SCI can perform keyboarding tasks with a typing stick inserted into a splint.

Autonomic Dysreflexia: One of the most serious life-threatening complications of SCI. It is a massive uncompensated cardiovascular reaction of the sympathetic division of the autonomic NS to visceral stimulation. - Found in pts with SC lesions at T6 or above - Reflex pathways have lost their ability to respond to a stimulus due to blockage in the communication system. - Can be caused by distended bladder (most common), fecal impaction, pressure sore, ingrown toenail, any infection process, catheterization or urologic instrumentation. - Causes HYPERTENSION (High BP) seen as diaphoresis, goose bumps, flushing above the level of injury, pallor below the level of injury. - TREATMENT: Remove the cause (if unknown start with bladder), elevate HOB - Results in an outburst of sympathetic overactivity or massive reflex response to any noxious stimuli. Orthostatic Hypotension: Sudden drop in blood pressure occurring when a person assumes an upright position. - Most common with pts with lesions at the T6 level and above. - Caused by impaired autonomic regulation when there is a decrease in the returning blood supply to the heart, commonly because of blood pooling in the LE. - Increased by a prolonged stay in bed - Occurs most often when the pt tries to sit up. - Symptoms include light-headedness, dizziness, and fainting - TX: lower head of bed or lift legs and observe for signs of relief, recline wc or place the head at or below the level of the heart. - When pt is in bed, elevate HOB to get pt used to being upright. SCI Performance Levels

C1-C3: (vent dependent)  Require supervision for power reclining weight shifts and wc propulsion  Verbally understand equipment needs, ROM, and other tx issues  Require minimal assist with use of speaker phone, computer, electric page turner, and environmental control unit.  Pt has limited to no head control  Hoyer transfers are required  24-hour supervision required. C4: Pt has head control  Requires minimal assistance for drinking  Independent with wc propulsion  Supervision required for architectural barriers and uneven terrain  Modified independent with computer, turning pages with mouthstick.  Can use variety of switches. Pt has fair to good head control C5: Has biceps but not triceps  Has elbow flexors and limited distal function

 A lot of shoulder pain  No wrist or hand movement  Universal cuff is essential for assisted feeding.  Elbow flexion contractures are very common, splint.  Very little proximal stability  May benefit from wrist orthosis, over head slings  Very little scapular intervation so pts are prone to shoulder pain.  Mobile arm supports or overhead slings are very useful for this level  Independent with power reclining weight shifts  Minimal assistance washing face, brushing teeth, and feeding  Moderate assistance with UE dressing C6: Have tenodesis  Has supinators and radial wrist extension  No triceps but have tenodesis! Very critical  Modified independent with feeding and dressing UE  Requires min-moderate assistance with LE dressing  Modified independent with transfers using sliding board  Modified independent with weight shifting C7: Should be independent with all ADLs, have triceps  Have triceps  Can perform depression transfers and weight shifts  Paralysis of trunk and LE, limited grasp release  Have hand function  Should be independent to some assist in ADLs, driving, and transfers  Pts at this level have enough fine motor coordination to be independent with bowl and bladder program. T1-T9: Lower trunk paralysis  Total paralysis of LE  UE fully intact  Limited upper trunk stability  Endurance increased secondary to innervation of intercostals  Should be independent in all areas except homemaking y y y Dermatome: The area of skin innervated by the sensory axons within each segmental nerve root. Tenodesis grasp: Passive opening of the fingers when the wrist is flexed and closing of the fingers when the wrist is extended. Central Cord Syndrome: Incomplete injury most common to the cervical region in which the center part of the cord is damaged. This lesion results in greater weakness in the upper limbs than in the lower limbs, with sacral sparing. Prognosis is good. (Joy) Stages of Skin Breakdown (more common in paraplegics) 1. Red area that does not become lighter when pressed with finger 2. Red area that becomes hard and/or scabby. Blister may form 3. Open blister/wound, hole or ulcer forms. Takes months to heal

y y

4. Ulcer is all the way to the bone. Amputations common. A C6 SCI pt may have tenodesis grasp or no grasp at all. A buttonhook that fits on to the palm or a buttonhook with a built up handle are the only choices for this type of dressing aid. A mobile arm support would be the most appropriate piece of feeding equipment for a C5 SCI pt. When working on sitting balance with a C6 quad, the best position for the pts hands to be in when using them for support is flexed (fisted) at all joints. This preserves tenodesis function and protects the finger flexors from overstretching.

Neurological System/Disorders y Lobes of the Brain/Functions 1. Frontal Lobe: primary motor cortex for voluntary muscle activation. Prefrontal cortex controls emotions and judgment. - Broca s area: controls motor aspects of speech 2. Parietal Lobe: primary sensory cortex for integration of sensation, receives fibers conveying touch, proprioception, pain, and temperature sensations from opposite sides of the body. 3. Temporal Lobe: primary auditory cortex, receives processes auditory stimuli. - Wernicke s area: language comprehension 4. Occipital Lobe: primary visual cortex, processes visual stimuli Spinal nerves are formed by joining dorsal and ventral roots. They are composed of a mixture of motor, sensory, and autonomic fibers. The ventral root carries motor information from the motor cortex out to the muscles. Efferent projections are motor in nature and carry output from a neural structure. Afferent projections are sensory in nature and carry input to a neutral structure. The function of the cerebellum is the execution of smooth, coordinated, and properly timed movement. Ataxic gait, hypotonia, dysmetria, and dyskiakochokinesia are all clinical signs of injury to the cerebellum The tx goals for persons with cerebellar dysfunction (intention tremor, dysmetria, decreased equilibrium and nystagmus) are focused on strengthening the proximal muscles, improving postural responses, and increasing stability. Weight bearing of the UE can increase shoulder girdle stability. Clinical signs of premotor cortex damage include motor apraxia and difficulty with tasks that require sensory guidance Clinical signs of basal ganglia damage include akinesia, bradykinesia, dystonia, and preservation Clinical signs of parietal lobe damage include sensory disorders, apraxia, and perceptual problems.

y y y

y y

y y

y y

y y

The cerebellum receives input from the proprioceptive pathways and modulates the smooth coordination of voluntary movement Limbic System: Controls instincts and emotions contributing to preservation of the individual. Basic functions include feeding, aggression, emotions, endocrine aspects of sexual response. Autonomic Nervous System (ANS) Concerned with innervation of involuntary structures: smooth muscles, heart, glands, helps maintain homeostasis. Divided into 2 divisions 1. Sympathetic Division: prepares body for fight or flight, emergency responses, raises HR and BP, constricts peripheral blood vessels. 2. Parasympathetic Division: conserves and restores homeostasis; slows HR and reduces BP. - Lower Motor Neurons: Cell bodies in the anterior horn of spinal chord, spinal nerves, the cranial nerve fibers that travel to target muscles. Symptoms of a lesion include flaccidity, decreased or absent deep tendon reflexes, atrophy. - Upper Motor Neurons: Any nerve cell body or nerve fiber in the spinal chord (except in anterior horn), all superior structures, cranial nerve nuclei. Symptoms of a lesion include increased deep tendon reflexes, spasticity, clonus, emergences of primitive reflexes. The anterior motor roots within the spinal cord are considered to be lower motor neurons. The CNS includes the brainstem, cranial nerves, and the cerebral cortex. An upper motor neuron lesion may occur in the brainstem, cranial nerves, and/or cerebral cortex. The reticular formation is responsible for controlling consciousness and regulating the sleep-wake cycle The prefrontal association circuit within the basal ganglia has been implicated to be involved in obsessive-compulsive disorders. The prefrontal association circuit is involved in cognitive processing. It is believed to be affected in patients who are unable to control ritualistic and repetitive behaviors. Motor circuit aids in making movements automatic and coordinated and is believed to be involved in Parkinson s disorder and Huntington s disease. The inferior and superior colliculi are the areas that integrate stimuli from the visual, auditory, vestibular, and somatosensory systems. They also respond to stimuli of a protopathic nature and play an important role in spatiotemporal orientation. Reticular formation is responsible for regulation of reflex centers for eye movements, sleep-wake cycles, heart rate, respiration, perspiration, salivation, and vomiting. The limbic circuit plays a role in emotions and motivation and is believed to be involved in behavior associated with Tourette s syndrome. Executive functioning (frontal lobe) includes initiation of action in new situations, ability to recognize and correct one s behavior, and evaluation of one s ability with an expected performance standard.

y CVA y y y y

Injury to the brainstem presents with strabismus, diplopia, and ptosis.

y y

Third leading cause of death Symptoms of CVA include abrupt onset of unilateral neurological signs (weakness, vision loss, sensory changes, etc.) Right sided weakness indicates CVA Individuals with receptive aphasia cannot comprehend spoken or written words and symbols; therefore, they cannot understand verbal directions or consistently respond to stimuli. The sensory portion of the evaluation would be invalid for this patient. Expressive aphasia interferes with the person s ability to verbally express him/herself. Therefore, the most effective method for assessing the individual /s understanding of teaching is via demonstration. Have the client demonstrate the techniques/precautions that have been taught. Pointing to pictures of precautions provides limited information. Difficulties with spatial perception are related to R CVA Souque s phenomenon: fan shaped finger extension on the involved side when extremity is raised to a position above 90 degrees of shoulder flexion or abduction. Demonstrating each step of an activity will provide visual clues that the person can follow. A person with R hemiplegia has had a L CVA. Typically, left hemisphere damage results in language deficits that can make it difficult for the person to understand verbal directions and/or interpret pictures. Hemianopsia: decreased awareness of environment; decreased ability to adapt to environment. Impaired ability to read, write, navigate during mobility, recognize people and places, drive. Can affect all ADLs A basic principle of intervention for body neglect, according to a deficitspecific approach, is to provide bilateral activities. During activities, the OT can guide the affected extremity through the activity if needed. Providing unilateral activities does not work on the identified deficits. Right CVA: Left hemiplegia or hemiparesis, hemianopsia, visual spatial deficits, left inattention, position in space problems, difficulties with spatial perception are common for R CVA s Left CVA: Right hemiplegia or hemiparesis, apraxia, hemianopsia, receptive/expressive/global aphasia, difficulty with temporal sequencing, receptive language, and motor planning are common for L CVA s (Bea) Left Hemisphere Specialization: Movement of the right side of body, processing of sensory information from the right side of body, visual reception from right field, visual verbal processing, bilateral motor praxis, verbal memory, bilateral auditory reception, speech, and processing of verbal auditory information. Right Hemisphere Specialization: Movement of left side of the body, processing of sensory information from left side of body, visual reception

y y

y y y y

from left field, visual spatial processing, left motor praxis, nonverbal memory, attention to incoming stimuli, emotion, processing of nonverbal auditory information, interpretation of abstract information, and interpretation of tonal infections. Sensation testing for hemiplegia: OT should first apply stimuli to the uninvolved area proximally to distally in random patterns. Motor apraxia would be a sequencing problem, ideation apraxia would be if a patient was handed a shirt and did not know what to do with it. Astereoognosis is the inability to identify objects through touch alone. Hypertonia (increased muscle tone): More than normal resistance of a muscle to passive elongation. Both neural (spasticity) and mechanical (soft tissue stiffness) factors cause it. Hypotonia (decreased muscle tone or flaccidity): Less than normal resistance to passive elongation; the affected limb feels limp and heavy. Most often caused by neural factors. - A lesion in the cerebellum may cause hypotonia. The proper steps for removing a t-shirt with an individual with left hemiplegia is 1) Gather the shirt up at the back of the neck , 2) Pull gathered back fabric off over head, 3) Remove shirt from unaffected arm, 4) Remove shirt from affected arm When working with an individual that has had an injury to the nondominant right cerebral hemisphere, use simple concrete verbal instructions to enhance the persons understanding of directions. Abstract information may be very difficult to understand. This person will have difficulty understanding facial expressions and body gestures as a result of difficulty processing visuospatial information. The individual will often have neglect to the left side of the visual field. Agnosia: inability to identify body parts. Right/Left discrimination is the differentiation of one side of the body from the other Unilateral Inattention: when the individual neglects the side of the body contralateral to the CVA site and the environment to that side. TYPICAL FLEXOR SYNERGY: scapular adduction and elevation, shoulder abduction and external rotation, elbow flexion, and forearm supination.

Common Diagnoses y Dysphasia: Difficulty with any stage of swallowing. Inability to swallow. Coughing and choking are common motor problems associated with dysphasia. Dysarthria: slurred speech secondary to cerebral lesion, difficulty in articulation

Dysmetria: inability to estimate how much motion is required to reach a desired target, overshooting Dysdiadochokinesia: impaired ability for rapid, repeating alternating movement Raynaud s Phenomenon: abnormal vasoconstriction reflex exacerbated by exposure to cold or emotional stress; affects largely females. Thromboangilitiis Obliterans (Buerger s disease): chronic inflammatory vascular occlusive disease. Mostly seen in young men who smoke. Begins distally and progresses proximally in both UE & LE. Symptoms include pain, parenthesis, cold extremities, diminished temperature sensation, fatigue, and risk of ulceration and gangrene. Poor or absent temperature sense can placed a person at serious risk for scalding burns. Checking the water temperature should be a primary concern! Post Polio Syndrome: Occurs years after initial polio incident. Symptoms include weakness, fatigue, and chronic overuse resulting in limb pain. Onset of symptoms is slow/progressive. Athetosis: slow, twisting movements Rett Syndrome: marked by loss of hand skills already acquired in motor development. Ataxia, uncoordinated and stiff gait. Language and social skills may plateau at 6 months to 1 year. Loss of purposeful movement and development of hand wringing and licking, biting, and slapping of fingers. Regression in cognition and praxis, progressive encephalopathy. Fatal. More common in girls. Muscle wasting and increased seizures Autism: More boys. Characterized by impaired social interaction, difficulty relating to others and forming relationships, difficulty with communication, repetitive and stereotyped behaviors such as flicking and wiggling of fingers, head banging, rocking of the head/body, ritualistic nonfunctional routines, restriction in the appropriate use of objects, difficulty with sensory processing and perception of various sensory stimuli, difficulty with modulation of stimuli. 70% of children need supervised living, occurs birth3. Aspberger s Disorder: Difficulty with social interaction, restricted interests in behaviors, characterized by clumsiness, delayed developmental motor milestones. Differentiated from autism by adequate language and the level of social interaction and engagement in activity.

y y

Mental Retardation: Mild MR is characterized by ability to carry out consistent ADL routine, live in a group home, trainable. People with mild MR are able to learn academic information from a 3rd-7th grade level. Extrapytamidal Syndrome: may cause muscular rigidity, tremor, and/or sudden muscle spasms. These individuals should avoid using power tools or sharp instruments. Korsakoff s Syndrome: amnestic disorder caused by thiamine deficiency not uncommon in persons with chronic alcohol abuse or poor nutritional habits. Dyspraxia: Seen in children. Difficulty planning new motor tasks. Difficulty with thinking out, planning and carrying out sensory/motor tasks. Children with dyspraxia often have poor balance; poor fine and gross motor coordination, poor posture, difficulty throwing a ball, and poor awareness of body position in space. Developmental Dyspraxia: Characterized by gross motor tasks, particularly those which require relating the body to objects in space. An example is being able to skip rope in the forward pattern but not backward. Children with developmental dyspraxia often have trouble with altered tasks Apraxia: Disorders of practice. The inability to perform goal-directed motor activity in the absence of paresis, ataxia, sensory loss, or abnormal muscle tone. Apraxia is characterized by omissions, disturbed order of submovements within a sequence, clumsiness, preservation, and inability to gesture or use common tools or utensils. Caused from cortical lesions resulting in trauma, stroke, and/or tumor. Constructional apraxia, ideomotor apraxia - visualizing a task and its movement sequences helps the individual with motor apraxia by giving visual model to refer to during the activity. Using general comments such as Lets get ready is more effective because individuals with motor apraxia have difficulty imitating or initiating motor tasks on command, though they understand the concept of the task. - Individuals with ideational apraxia would benefit from physical prompts to initiate steps of tasks because they may not understand the concept of the task but may be able to perform individual steps of the task on command. Agnosia: Loss of ability to recognize objects, people, sounds, shapes, or smells. Inability to attach appropriate meaning to object sense-data despite having knowledge of the characteristics of those persons and objects. Unaware of any deficits

y y

Aphasia: loss of language ability Cerebral Palsy: Caused by injury and/or disease prior to, during, or shortly after birth resulting in brain damage and secondary neurological and muscular deficits. Nonprogressive, may be accompanied by seizures, intellectual and/or behavioral disorders. Persistence of primitive reflexes contribute to diagnosis. - A lesion in the motor cortex results in spasticity with flexor and extensor imbanace. - A lesion in the basal ganglia results in fluctuating muscle tone causing dyskinesia, dystonia, - A lesion in the cerebellum results in ataxic movements and is characterized by a lack of stability so coactivation is difficult resulting in more primitive total patterns of movement - Athetoid CP: Choreoathetosis with jerky involuntary movements more proximal than distal and lack of cocontractions. Children with athetoid CP have fluctuating muscle tone, which usually fluctuates from low to normal. Children with athetoid CP usually responds respond more positively to activities that help modulate sensory input, work in midranges, and focus on function rather than accurate execution and full ROM. Weighted cuffs can help to decrease athetoid movements and increase accuracy of movements to improve functional UE use. - Spastic CP: spastic muscle tone is a characteristic - Spastic Diplegia: characterized by less UE involvement and greater LE functional impairment - Flaccid muscle tone or low muscle tone is usually seen in young children with CP. - Language and intellectual deficits occur in 50-75% of children w/ CP - Seizures occur in 50% and visual impairments occur in 40-50% Ataxia: Unsteadiness, incoordination, or clumsiness of movement. Ataxic gait is a wide-based, unsteady, staggering gait with a tendency to veer from side to side. Caused from cerebellar lesions. Dystonia: Characterized by a powerful, sustained contraction of muscles that cause twisting and writhing of a limb or of the whole body, often resulting in distorted postures of the trunk and proximal extremities. Basal Ganglia Lesion

Disorders of the Peripheral Nervous System

Amyotrophic Lateral Sclerosis (ALS): late-onset fatal neurodegenerateive disease of upper motor neurons and lower motor neurons. Most common disorder of the motor neurons. - No specific test to diagnose, terminal, no cure - Average age of onset is 58 but that is variable - Voluntary muscle control is affected and early manifestations indicating UMN or LMN disease vary. - UMN damage results in general weakness, spasticity, and hyperrelexia. LMN involvement results in weakness or muscle atrophy of the extremities, cervical extensor weakness, muscle cramps, and a loss of reflexes. - Speech, swallowing, and breathing may be affected by damage to the bulbar nerves. - Focal weakness of the arm, leg, or bulbar area is a common initial symptom. Atrophy may begin in the hands, with wasting of the thenar and hypothenar eminences. Atrophy of the shoulder musculature is also common early in the disease. - OT works to optimize strength and ROM, improve level of independence in ADL and IADLs, Improve function and decrease pain and fatigue, joint protection, energy conservation, work simplification, pain management, manage dysphagia, teach safe transfers, manage assistive devices. : Guillian-Barre Syndrome: Inflammatory disease resulting in axonal demyelination of peripheral nerves. Characteristics of GBS include a quickly progressing, symmetrical ascending paralysis starting with the feet; pain, particularly in the legs; absence of deep tendon reflexes, mild sensory loss on hands and feet. - LMN disease - Autonomic NS response of postural hypertension and tachycardia; and respiratory muscle paralysis occur. - Often presents as acute weakness in at least 2 limbs that progresses. - Men slightly more affected, occurs most in young adults and elderly. - Rapid onset - Prognosis is good. - Cause unknown, no evidence of heredity. Previous viral infections are thought to be associated. - OT intervention includes ROM, mobility, self-care, communication, leisure, reintegration into workplace, adapting environment, adaptive equipment for temporary use. - Because the prognosis of Guillian-Barre Syndrome is usually good, adaptive equipment should be ordered before DC to give the rehab stay the appropriate time to determine individual needs. - Evaluation should be done over numerous sessions in acute phase because fatigue needs to be avoided with this disease.

Myasthenia gravis: a progressive condition marked by facial muscle drooping. Caused by an autoimmune attack on the acetylcoline receptors of the postsynaptic neuromuscular junction. Common symptoms include drooping of facial muscles, ptosis, diplopia, muscle fatigue after exercise, dysarthria, and proximal limb weakness, increased difficulty swallowing finely cut foods, increased difficulty buttoning shirt. Life threatening respiratory muscle involvement may occur. Sensation and deep tendon reflexes are in tact. A facial tic is not a typical symptom and should be reported to a physician. Brachial Plexus Disorder: secondary to traction during birth, cancer, trauma, or traction injury. Symptoms include mixed motor and sensory disorders of the corresponding limb; rostural injuries produce dysfunction in the hand. EMG/nerve conduction velocities are used to localize the plexus lesion. Peripheral Neuropathies: Multiple nerves or a single nerve may be involved from trauma, pressure, forcible overextension of a joint, hemorrhage, and exposure to cold or radiation. Symptoms include sensory, motor, reflex, and vasomotor symptoms including pain, weakness, and parasethesis in the distribution of affected nerve.

Disorders of Movement/Neuromuscular y y y A muscle fiber can shorten up to one-half its total length. Fusiform or strap muscles are longer than other types of muscles and allow the greatest ROM. A fracture in a diseased or weakened bone that has been subjected to a normal strain is called a pathological fracture. Classification of Symptoms: - Tremor: rhythmic, alternating, oscillatory movement produced by repetitive patterns of muscle contraction and relaxation. - Dyskinesias: involuntary, nonrepetitive, but occasionally stereotyped movements affecting distal, proximal, and axial musculature in varying combinations. - Myoclonus: brief and rapid contraction of muscle or groups of muscles - Tics: brief, rapid, involuntary movements, often resembling fragments of normal motor behavior, repetitive, not rhythmic. - Chorea: brief, purposeless, involuntary movements of the distal extremities and face. - Dystonia: sustained abnormal postures and disruptions of ongoing movement resulting from alterations of muscle tone.

Parkinson s Disease: Chronic, progressive disease that is common in older adults with a mean onset of 55-60 years old. Typically defined by 4 cardinal signs: 1. tremor 2. rigidity 3. bradykinesia 4. postural instability - Tremor is commonly the first complaint and increases with stress. - Tremor may present as a pill-rolling, which is unique to PD - Bradykinesia is slowness or poverty of movement causing lack of facial expression. It affects walking, participation in activities, and eye blink. - Postural instability begins to decrease arm swing and causes shorter strides, progressing to a shuffling gait. - Lack of postural reflexes often result in increasing falls and akinesia, or freezing episodes that reduce or eliminate spontaneous initiation of gait. - OT treatment include areas of mobility issues, quality of movement, postural instability, rigidity that limits home, community, leisure, and work activities, fall prevention, ADLs, swallowing or other dysphasia problems prolonging eating and decreasing intake, cognitive problems, fatigue, sexual activity limitations, and sleep disturbances.  Stages of Parkinsons: 1. Unilateral tremor: rigidity, minimal-no functional involvement 2. Bilateral tremor: rigidity or akinsia, independent ADLs, no balance impairments 3. Worsening of symptoms, impaired righting reflexes, some impairment in ADLs 4. Requires help with some or all of ADLs, unable to live alone. 5. Confined to wheelchair or bed, dependent Spina Bifida: Genetic, intrauterine, environmental factors can contribute to neural tube defect. Lack of folic acid. Lesions usually occur in the thoracic or lumbar spinal column. Neural tube not closing in uterus. - May result in spinal cord being split or being tied down or tethered, which may lead to neurological damage and developmentally abnormality as the child grows. - Spina bifida cystica: exposed pouch - Spina bifida meningocele: protrusion of the sac through the spine. usually does not present with symptoms impacting on function as the spinal cord itself is not trapped. - Spina bifida with a myelomeningocele results in sensory and motor deficits occurring below the level of lesion, and may result in LE paralysis, deformities, and bowel/bladder incontinence. - Lesions of S2-S4 result in bowel/bladder problems. - Shunts are placed and it is critical to know signs of shunt malformation, which include headaches, vomiting, irritability, and seizures.

Tethered Cord Syndrome: occurs in the tail end of the spinal cord when it is stretched as a result of compression, being trapped with a fatty mass, or developmental abnormality. Visual signs of tethered cord include hairy patch of skin, dimple of the lower spine. Difficulties with bowel/bladder, gait disturbances, and/or deformities of the feet may result from tethered cord.

Duchenne Muscular Dystrophy: degenerative disorder that is the most common form of muscular dystrophy. Missing dystrophin muscle protein. - Detected between age 2-6 - Symptoms include enlargement of calf muscles and at times enlargement of forearm and thigh muscles giving an appearance of a healthy child. - Enlargement due to fibrosis and formation of adipose tissues, which causes weakness in voluntary muscles, including heart and diaphragm. - Weakness of the proximal jts progresses to the point that the child has to crawl up his thighs with his hands to stand from a kneeling position known as Gower s sign. Most individuals rarely survive past 20 due to respiratory problems, infection, and cardiovascular problems. - The biomechanical FOR is applied when a person cannot maintain posture through appropriate automatic muscle activity because of neuromuscular or musculoskelatal dysfunction. Low muscle tone that affects trunk control is often seen in Duchenne muscular dystrophy. Myasthenia Gravis (congenital): disorder involving transmission of impulses in the neuromuscular junction. Onset starting near birth and occurring more frequently in males. Charcot-Marie-Tooth disease: A disease involving the peripheral nerves marked by progressive weakness, primarily in peroneal and distal leg muscles. Occurs in teenage years or earlier. Supranuclear Palsy: Manifested by a loss of voluntary, but preservation of reflexive eye movements, bradykinesia, rigidity, axial dystonia, pseudobulbar palsy, and dementia. Occurs in later middle life. Huntington s Chorea: Autosomal dominant disorder, characterized by choreiform movements and progressive intellectual deterioration. Psychiatric disturbances (personality changes, manic-depressive symptoms, schitzophreniform illness) may precede the onset of the movement disorder.

Cardiac Rehab y y y y Isometric exercises are contraindicated for all stages of cardiac rehab. Alka Seltzer brand stomach and cold remedies are contraindicated for cardiac rehab patients because of high sodium. Anxiety and stress are issues of first priority for most patients, relaxation techniques are most valuable in the education phase People with hypertension or heart disease should perform isotonic exercises. Isometris, contract-relax exercises, and holding muscle contractions are all contraindicated. Grooming while sitting is a MET level of 1-2. Grooming while standing is a MET level of 2-3, and light housework is a MET level of 3-4. Normal HR for adults = 60-80 BPM, BP = 120/80, Resp = 12-18 br/min Normal HR for infant = 120 BPM, BP = 75/50, Resp = 40 br/min Diaphoresis: excessive sweating associated with decreased cardiac output. Cyanosis: bluish color from decreased cardiac output Stages of cardiac rehab 1. Focus on pt education regarding disease process and recovery. Increase knowledge of energy conservation. Decrease anxiety and focus on slow self cares. ROM in supine. Keep activities 0-1.4 METS. Activities such as listening to the radio 2. (1.4-2 METS) Tx should focus on ADLs in sitting and exercise to all extremities progressively increasing the number of repetitions. Unlimited sitting. Activities such as a light tabletop craft 3. (2-3 METS) Tx focused on tasks with brief standing periods, exercise in standing with light ROM to all extremities and trunk. May include balance activities. Begin progressive ambulation at 0% grade and short distance. Activities such as sitting to play cards or the piano. 4. (3-3.5 METS) ADLs in standing including total washing, dressing, shaving, grooming, and showering. Practice energy conservation. Balance and mat activities with mild resistance. Activities such as light gardening, canoeing, or driving. May begin stair climbing 5. (3.5-4 METS) Standing to wash dishes, washing cloths, ironing, and making bed. Increase speed of ambulation to 2.5 mph at 0 grade. Cycling up to 8 mph without resistance. Activities such as slow swimming, light home repair, and light carpentry. 6. (4 + METS) Mopping, raking, and homemaking tasks that require resistance. Increase time and speed of ambulation. May use 10-15 lb weights for resistive exercise in sitting. Activities include slow dancing, roller skating, volleyball, badminton, light calisthenics. A patient is generally discharged from inpatient when they are able to carry out activities at MET level 3.5-4. Sexual activity is usually at 5-6 MET level, about the same as walking a flight of stairs. A patient with hypotension is a candidate for a modified exercise program.

y y y y y

y y y

y y

Exercise programs are contraindicated for patients with unstable angina, venous thrombosis, and uncontrolled atrial arrhythmia. MET Levels: - 1-2: activities in supine/sitting - 3-4: self cares=3, - 4-5: stair climbing=5 - 5-6: sexual activity=5-6 - 6-7: water ski on two skis for 10-15 min, play badminton, fast walking =7,bicycle at 11 MPH - 7-8: play touch football at a senior league

Nerves and Nerve Injuries of the UE y y y y Three Major Nerves: Median, Ulnar, and Radial Two types of nerve injuries: Compression and Laceration. Injury to the radial nerve in the wrist area causes sensory damage only. This damage occurs to the radial two thirds of the dorsum of the hand. Damage to the median nerve at the wrist causes decreased thumb and prehensile strength and complete or partial loss of sensation in the distal portion of the second and third digit. Damage to the ulnar nerve at the wrist causes decreased grip strength and complete or partial loss of sensation to half of the fourth digit and all of the fifth digit as well as proximal hypothenar region. Pronator Teres Syndrome (proximal volar forearm): A medial n. compression between two heads of the pronator teres. - Caused from repetitive pronation and supination and excessive pressure on volar forearm. - Symptoms are the same as CTS and also aching pain in proximal forearm, positive Tinel s sign at forearm - OT tx includes elbow splint at 90 degrees with forearm in neutral, AROM, nerve gliding, strengtheining (2 wks post op) sensory reeducation, work/activity modification. Guyon s Canal: An ulnar nerve compression at the wrist. - Caused from repetition, ganglion, pressure, and fascia thickening. - Symptoms include numbness and tingling in the ulnar nerve distribution of the hand, motor weakness of ulnar nerve intervated musculature, positive Tinel s sign at guyon s canal. - Tx includes surgical decompression, wrist splint in neutral, work/activity modification, edema control, AROM, nerve gliding, strengthening (2-4 wks post op) to focus on power grip. Cubital Tunnel Syndrome: An ulnar nerve compression at the elbow. - The second most common compression at the elbow. Caused from leaning on elbow and extreme elbow flexion.

Symptoms include numbness and tingling along ulnar aspect of forearm and hand, pain at the elbow with extreme position of elbow flexion, weak power grip, and positive Tinel s sign at elbow. Radial Nerve Palsy: A radial nerve compression. (Saturday Night Palsy) Paitents present with weakness of the wrist, MCP, and thumb extensors. - Saturday night palsy is a term used to describe sleeping in a position that places stress on the radial nerve. Also, compression as a result of a humeral shaft fracture. - Symptoms include weakness or paralysis of extensors to the wrist, MCPs, and thumb, pt may demonstrate wrist drop. - Tx includes dynamic extension splint, work/activity modification, strengthening of wrist and finger extensors when motor function returns, surgical decompression, ROM, nerve gliding, strengthening Median Nerve Laceration: Pt will experience sensory loss in the central palm, palmar surface of thumb, index, middle, and radial half of ring fingers, and the dorsal surface of index, middle, and radial half of ring fingers. Ape Hand or flattening of the thenar eminence is caused by medial nerve lacerations Clawing of index and middle fingers for a low lesion laceration of the median nerve. Benediction Sign is caused by a high injury of the median nerve. Benediction Sign is flexing of the 4th and 5th digits at the PIP jts. - Median nerve injuries cause loss of thumb opposition and weak pinch. - OT tx include dorsal protection splint with wrist positioned in 30 degrees of flexion for low lesion and 90 degrees of flexion if high lesion, scar management, AROM, sensory reeducation. Ulnar Nerve Laceration: Pt will experience sensory loss in the ulnar aspects of palmar and dorsal surfaces, ulnar half of ring and little fingers on palmar and dorsal surfaces. Motor loss at palmar and dorsal interossei (adduction and abduction of MCP joints), lumbricals III & VI (MCP flexion of digits 4 &5), FPB and adductor pollicis (flexion and adduction of thumb), ADM, ODM, FDM (abduction, opposition, and flexion of 5th digit). If lesion is at wrist or above, pt will also have motor loss of the FCU (flexion towards ulnar wrist) and FDP IV & V (flexion of DIPs of ring and little finger). Pt will also have loss of power grip and decreased pinch strength. - Deformities from ulnar nerve lacerations include Claw Hand and Flattened metacarpal arch. - OT tx include MCP flexion blocking splint - Fromment s sign assesses the motor function of the adductor pollicis which is innervated by t he ulnar nerve. It involves an attempt to pinch an object firmly with the thumb. With an ulnar nerve injury, this attempt results in flexion of the distal joint of the thumb. Radial Nerve Laceration: Pt will experience sensory loss at the medial aspect of the dorsal forearm. Radial aspect of dorsal palm, thumb, index, middle, and radial half of the ring phalanges. Motor loss of wrist extension -

y y

due to absent or impaired innervation to ECU. EDC, IE, EDM (MCP extension), EPB, EPL, APL (thumb extension. With high lesions at the level of the humerus, all of above including ECRB, ECRL, and brachioradialis. - Functional loss includes inability to extend digits to release objects and difficulty manipulating objects. - A deformity from radial nerve laceration is Wrist Drop . Pain, progressive weakness of thumb, atrophy of thenar muscles, no proximal UE limitations, numbness, and tingling in thumb, index, long, and half of the ring fingers are common signs/symptoms of median n. injury. Tendon gliding exercises help to prevent adhesions of the tendons in the healing process Peripheral Neuropathy: Neurological disorder that affects the sensory, motor, and/or autonomic nerves caused by abnormal function of these nerves. - Symptoms include weakness or paralysis, decreased or absent muscles reflexes, decreased or absent muscle tone, loss of muscle mass, or a loss of pain sensation.

Shoulder and Common Disorders of: y Anatomy of the Rotator Cuff: The Rotator Cuff functions together to control the head of the humerus in the glenoid fossa. - Supraspinatus: functions to abduct and flex - Infraspinatus and Teres Minor: functions to externally rotate - Subscapularis: functions to internally rotate The anterior longitudinal ligament limits extension to protect the vertebral column from excess extension. The posterior longitudinal ligament protects the spine in flexion. The rotator cuff muscles include the SIT muscles: supraspinatus, infraspinatus, teres minor, and subscapularis. A rotator cuff injury would result in clinical features of painful arch 50-100 degrees and restricted AROM in shoulder abduction and flexion Sleeping with the shoulder extended and adducted is an acceptable position for rotator cuff tendinititis. Above shoulder activities and positions are contraindicated for persons with rotator cuff injuries, even with extended handles to assist in reach. Shoulder flexion muscles: anterior deltoid, coracobrachialis, supraspinatus Shoulder abduction muscles: middle deltoid, supraspinatus Shoulder horizontal abductor muscle: posterior deltoid Horizontal adduction muscle: pectoralis major Shoulder extension muscles: latissimus dorsi, teres major, posterior deltoid The upper trapezius and levator scapula controls scapular elevation. Pectoralis minor acts as a downward rotator of the scapula

y y y

y y y y y y y

y y y

The acromion process is found on the posterior lateral aspect of the scapula. The ratio of scapulohumeral rhythm is 1:2 scapula:humeral. Optimal scapula: humeral rhythm is required in order to provide optimal ROM. Rotator Cuff Tendonitis: Site of impingement is at the coracoacromial arch (acromion, coracoacromial ligament, and coracoid process) - Caused from repetitive overuse, curved/hooked acromion, weakness of the rotator cuff or scapula musculature, trauma, or ligament/capsule tightness. - OT intervention includes activity modification (avoid above shoulder level activities until pain subsides), education in sleep posture (do not sleep with arm overhead), positioning to decrease pain, ROM, strengthening Adhesive Capsulitis (Frozen Shoulder): Restricted passive shoulder ROM, greatest limitation in external rotation, then abduction, internal rotation, and flexion. - Inflammation in the glenohumeral ligaments and joint capsule. - Linked to diabetes and Parkinson s disease - Encourage use of extremity for all ADLs and role activities!!

Standardized Testing and Formalized Assessment y MMT: - Gravity eliminated planes make pt do less work. Stabilize proximal to the joint the muscle crosses over. Do not hold over the muscle belly of the muscle being tested. - Muscles with poor minus strength would only be able to move a body part through partial ROM in a gravity eliminated position. 0: no muscle contraction 1. Trace: contraction but no movement 2-. Part moves through incomplete ROM in gravity eliminated. 2. Part moves through complete ROM in gravity eliminated. 2+ Part moves through incomplete ROM (less than 50%) against gravity or through complete ROM in gravity-eliminated plane with slight resistance. 3-. Part moves through incomplete ROM (more than 50%) against gravity. 3. Part moves through complete ROM against gravity. 3+. Part moves through complete ROM against gravity with slight resistance. 4. Part moves through complete ROM against gravity and moderate resistance. 5. Part moves through complete ROM against full resistance. If PROM and AROM are same, use available ROM for assigning a muscle grade. For example: If a person has 100 degrees of A/PROM but is a 5/5 in strength, still give person a 5/5 in available range.

Goniometer positioning for ROM: - Shoulder Flexion (0-180): Axis located at a point which motion occurs through the lateral aspect of the glenohumeral joint, at the start of motion it lies approximately 1 inch below the acromion process. At the end position, the axis has moved and the goniometer must be repositioned. Stationary arm parallel to the lateral midline of the trunk. - Shoulder Extension (0-60): Axis of goniometer at a point around which motion occurs; it lies approximately 1 inch elbow the acromion process through he lateral aspect of the glenohumeral joint. Stationary arm is parallel to the lateral midline of the trunk. - Shoulder abduction (0-180): Axis pointing through the posterior aspect of the glenohumeral joint, stationary arm laterally along the trunk, parallel to the spine. - Horizontal abduction (0-90): Movement of the humerus on a horizontal plane from 90 degrees of shoulder flexion to 90 degrees of shoulder abduction. Axis on top of the acromion process, stationary arm is parallel to the longitudinal axis of the humerus on the superior aspect and remains in that position even as the arm moves. - Horizontal adduction (0-45): Movement of the humerus on a horizontal pane from 90 degrees of shoulder abduction through 90degrees of shoulder flexion, across the trunk to the limit of motion. Axis on top of acromion process, stationary arm parallel to the longitudinal axis on the superior aspect of the humerus in the starting position, remaining perpendicular to the body. - Internal Rotation (0-70): Movement of the humerus medially around the longitudinal axis of the humerus. Axis on olecranon process of the ulna. Stationary arm perpendicular to the floor and parallel to the lateral trunk. - External Rotation (0-90): Movement of the humerus laterally around the longitudinal axis of the humerus. Axis on the olecranon process of the ulna. Stationary arm perpendicular to the floor. - Forearm Pronation (0-80): Rotation of the forearm medially around its longitudinal axis from midposition so the palm of the hand faces down. Longitudinal axis of the forearm displaced toward the ulnar side. Stationary arm perpendicular to the floor. - Forearm Supination (0-80): Rotation of the forearm laterally around its longitudinal is from midposition so that the palm of the hand faces up. Longitudinal axis of the forearm displaces toward the ulnar side. Stationary arm perpendicular to the floor with the moveable arm across the distal radius and ulna on the volar surface. - Elbow Flexion-Extension (0-150): Axis on the lateral epicondyle of the humerus while the stationary arm is parallel to the longitudinal axis of the humerus on the lateral aspect.

Wrist Flexion (0-80): Movement of the hand volarly in the sagital plane. Axis on the dorsal aspect of the wrist joint in line with the base of the third metacarpal. Stationary arm along the midline of the dorsal surface of the forearm. Wrist Extension (0-70): Movement of the hand dorsally in the sagittal plane. Axis on the volar surface of the wrist in line with the insertion of the tendon of the palmaris longus. Stationary arm along the midline of the volar surface of the forearm. (Must do this measurement off of the side of a table because the volar surface is what is being measured.

Allen Cognitive Levels (6 levels): - Utilized for populations with psychiatric disorders, acquired brain injury, and or dementia. - Used as a screening tool to estimate cognitive level by having person perform 3 leather lacing stitches. 1. Automatic Action: automatic motor responses and changes in autonomic NS. Conscious response to external environment is minimal 2. Postural Actions: movement that is associated with comfort. Some awareness of large objects in environment. Pt may assist caregiver with simple tasks. Poor imitation of posture. 3. Manual Actions: use of hands to manipulate objects. Manual actions with tactile cues. The pt may perform a limited number of tasks with long-term repetitive training. Pt is able to imitate the running stitch 4. Goal Directed Actions: ability to carry simple tasks through completion. Pt relies heavily on visual cues. May be able to perform established routines but cannot cope with unexpected events. Pt uses a model or demonstration to complete the task. Matching colors of clothing. 5. Exploratory Actions: overt trial and error problem solving. New learning occurs. This may be the usual level of functioning for 20% of population. Pt can carry out a task with three familiar steps and one new one 6. Planned actions: absence of disability. Person can think of hypothetical situations and do mental trial-and-error problem solving. Pt can plan ahead to avoid mistakes. - When a client cannot perform the lowest level (running stitch) of the Allen Cognitive Level Test, the therapist then administers the Lower Cognitive Test. This test evaluates the client s ability to imitate clapping. - People at ACL level 4 are able to copy demonstrated directions presented 1 step at a time. People at level 5 are able to use hands for simple and repetitive task but are unlikely to produce a consistent end product. Level 5 pts can generally perform a task involving 3 familiar

steps and 1 new one. Pts functioning at ACL level 6 can anticipate errors and ways to avoid them. y Ffinkelstein s Test: Used to test for Quevarian s disease. This test exquisites pain with passive wrist ulnar deviation while flexing the thumb. This test has the person grab thumb and ulnar deviate. If test is positive, the person will feel sharp pain. Modified Ashworth Scale for Muscle Tone 0. No increase in muscle tone 1. Slight increase in tone, manifested by a catch and release or by minimal resistance at the end of ROM. +1. Slight increase in muscle tone, manifested by a catch followed by minimal resistance throughout remainder (less than half) of ROM 2. More marked increase in muscle tone through most of ROM, but affected part is easily moved 3. Considerable increase in muscle tone; passive movement difficult 4. Affected part rigid in flexion or extension. Sensory Integration and Praxis Test (SIPT): Requires additional training and experience in pediatrics. Standardized for children 4-8, developed by J. Ayers. Seventeen tests primarily address the relationship among tactile processing, vestibular-proprioceptive processing, visual perception, and practice ability. Sensory Rating Scale: For ages 0-3 years, takes 20 minutes to give Sensory Assessment: Standardized, for ages 5-18 Knickerbocker Sensorimotor History Questionnaire (KSHQ): Questionnaire given to parents about their child s behavior Barthel Index: Used in a geriatric setting, provides information on a patient s independent activities of daily living and effective outcome measures as well. TEMPA: upper extremity test for the elderly. Consists of 9 tasks, five bilateral and four unilateral, reflecting daily activities. Jebsen Test of Hand Function: assesses hand function in terms of simulated ADL, quick. Consists of 7 subtests consisting of writing a sentence, simulated page turning, picking up small common objects, stacking checkers, simulating eating, moving empty cans, etc. Box and Blocks: measures gross manual dexterity. Developed to test people with severe problems affecting coordination. Purdue Pegboard: tests finger dexterity by picking up, manipulating, and placing little pegs into holes with speed and accuracy. Tests finger or fine motor dexterity. Standardized norms for adults in different job categories and for children age 5-15 years of age by age and sex. Canadian Occupational Performance Measure (COPM): Measures a client s perception of his or her occupational performance over time.

y y y y

y y

y y

y y

y y y

Semistructured interview is used. Clients identify problem areas in self-care, productivity, and leisure. The client then rates the importance of the problem area. Used with children and adults Assessment of Motor and Process Skills (AMPS): measures occupational performance, specifically personal and instrumental ADL. Determines whether or not a person has the necessary motor and process skills to effortlessly, efficiently, and safely perform ADL tasks. Used for children and adults with impairment. Predicts IADL performance Functional Independence Measure (FIM): Measures severity of disability related to physical impairments. Used with adults with physical impairments. 18 activities, 13 with motor emphasis related to self care WeeFIM: Measures disability severity related to physical impairments, across health development, educational, and community setting. Children from 6 months 7 years. Same scale as the FIM Sensory Profile: Used for ages 10 +. Determines how well a subject processes sensory information in everyday situations. Sensory processing, modulation, and behavioral/emotional responses. Brunininks-Oseretsky Test of Motor Proficiency: Used for children ages 4.5-14.5. Used to assess the motor functioning of children Cognitive Performance Test (CPT): Assesses how cognitive processing deficits affect performance of common activities. Cognitive processing in adults. Klein-Bell Activities of Daily Living Scale: Measures ADL independence to determine current status; change in status, and subactivities to focus on in rehab. Used with children and adults. Uses 3 pt ordinal scale with 170 subactivities in the domains of dressing, mobility, elimination, bathing and hygiene, eating, and emergency communication. Motor Assessment Scale (MAS): Developed by Carr and Shepard. Assessment relevant to everyday motor activity Fatigue Impact Scale: evaluates the perceived effect of fatigue on the everyday lives of those with MS. Mini Mental Status Exam: Excellent screening tool to track a patient s cognitive state over time. Includes areas of orientation, registration, calculation, recall, language, and construction. Inclusion evaluation appropriate for suspected delirium/dementia. Kohlman Evaluation of Living (KELS): Measure of performance areas. Evaluates readiness for discharge and community integration in the ADL area. Assesses daily activities in self-care, safety, health, money management, transportation, telephone, work, and leisure. Milwaukee Eval of Daily Living Skills (MEDLS): Used to establish baseline behaviors to develop treatment objectives related to daily living skills. Used for low-functioning adults with chronic mental health problems. Communication, personal care, clothing care, home and community safety, and money are subtests evaluated.

y y y y y

y y

y y y

Minimum Data Set (MDS): Describes baseline ADL and tracks changes in ADLs. Used with residents in long-term care facilities and clients in home care. Miller Assessment for Preschoolers (MAP): Designed to identify developmental delays of pre-academic skills in children, preschool screen Peabody Developmental Motor Scales: Assesses fine and gross motor skills in children up to age 7 years Movement Assessment of Infants Screening Test (MAIST): identifies movement patterns in infants 2-18 months Erhardy Developmental Prehension Assessment: Measures changes in hand functioning Motor-Free Visual Perception Test (MVPT): Provides a quick assessment of visual perceptual abilities without requiring the child/patient to have motor skills. Designed for individuals with motor impairments. Fugl-Meyer Scale (FM): Measures motor recovery after stroke Assessment of Motor and Process Skills (AMPS): Examines a person s functional competence in 2 or 3 familiar and chosen BADL or IADL tasks. Individual chooses activities from a list of over 60 standardized tasks. Used in persons 3+ regardless of diagnosis Arnadottir OT Neurobehavioral Eval (A-ONE): Used for adults presenting with cognitive/perceptual (neurobehavioral) deficits. Rivermead Perceptual Assessment Battery: individuals 16+ with visualperceptual deficits after head injury or stroke. Quick Neurological Screening Test (QNST): screens neurological integration (attention, balance, spatial organization, rate and rhythm of movement, motor planning, and coordination). 5 years adult.

Major Frame of References y Behavioral FOR - The potential to measure an activity s results is central to this FOR - Evaluation is of adaptive or maladaptive behaviors - Tx based on classical and operant conditioning such as shaping, chaining, token economy, and biofeedback to reinforce desired behavior Developmental - According the this theory, the focus of adolescence is characterized as developing competence in a variety of skills, the focus of childhood is imagination, the focus of adulthood is work skill competence, and the focus of the aging person is reflecting on productivity. - Evaluation of specific stages that are progressive and hierarchical - Tx addresses developmental themes, drive toward mastery, skills must be learned in sequence of normal development Occupational Performance

Evaluation of performance components including sensorimotor, neuromuscular, motor, cognitive, and psychosocial. - Treatment areas include ADLs, work, and play/leisure - Stage 1: remediate performance components, Stage 2: enabling activities, Stage 3: purposeful activity, Stage 4: community reintegration. Eclecticism - The selection and organized blending of compatible features from a variety of sources. Object relations is a blending of humanisticexistential, Freudian, and Jungian theories. Movement-Centered - Activities that include bilateral use of tonic muscles against resistance, such as digging a garden, playing volleyball, or tug or war, can help normalize tone in this population. Motor Learning - Motor learning is the process of acquiring the capability for skilled action, results from experience or practice, practice in all different contexts. - Provides verbal and visual feedback to give a person the input needed to make postural and limb adjustments. - Summary feedback should be given at the end of patient s attempts after several trials to aid retention and learning by encouraging the person to rely on inner or intrinsic feedback to self-correct errors in performance, rather than the extrinsic feedback given by the therapist. - Learning is distinguished from temporary improvements in performance and is highlighted by relatively permanent changes in behavior - Goal is long-term retention that is resistant to altered context - Requires a multisensory approach, auditory, visual, and tactile systems are all used to achieve the desired response. 1. Auditory: short brief commands at normal pitch 2. Visual: watch that the pt is tracking in the direction of movement 3. Tactile: have the pt feel the movement Biomechanical - Focuses on the ROM, strength, and endurance required to perform an occupation. - Treatment to restore function. - Most commonly used to treat patients with lower motor neuron deficits and orthopedic problems. - Most effective when used in combination with other treatment approaches. Cognitive Disabilities - Developed by Claudia Allen - Evaluation is on assessing cognitive functioning level -

Tx based on brain pathology, match activities to cognitive level by changing activity, not person, function exists when person is capable of meeting routine task demands. - Goal of tx is to improve thinking and performance in various activities with a just right challenge - When people are unable to learn to use psychological compensations effectively, environmental compensations can improve the quality of life for them and their long-term caregivers - Learning to compensate for decreased abilities is critical Rehabilitation/Neurodevelopmental - Evaluation of abilities - Treatment is restorative, acquisition of role performance - Treatment focus in sensory input, which leads to motor output - Evaluation of CNS dysfunction (NDT, Rood, Brunstrom, PNF) Sensory Integration - An approach to viewing the neural organization of sensory information for an adaptive response. Developed by Jean Ayers. - Plasticity (structural changes) of the CNS allows for modification of the CNS. - SI occurs in a developmental sequential manner with higher cortical processing functions being dependent on adequate processing and organization of sensory stimuli by lower brain centers - Adequate modulation of sensory stimuli must occur for an adaptive response to occur - Individuals seek sensorimotor experiences that have organized stimuli. Model of Human Occupation - Man is an open system that interacts with his environment through a system of output, feedback. - Evaluation looks at volition, habituation, and performance - Tx based on human as an open system that can change through interaction with the environment, competency is based on ability to perform daily tasks, directive groups. - Environment is divided into physical and social components - Feedback is processed by the individual from three perspectives or subsets: 1. Habituation 2. Mind-Brain-Body 3. Interplay Psychodynamic/Psychoanalytic - Resolution of unconscious conflict, aspects of personality - Personality, character, and pathology were related to six stages of psychosocial development - Developed by Freud and not widely used today. - Tx integrates wants, needs, drives in conscious awareness, object relations, transference, and counter transference, defenses, and therapeutic sense of self. Behavior Modification -

Provides positive reinforcement for desired behaviors.

Vision and Visual Deficits y y y Figure ground perception: ability to distinguish objects from the background. Seen by difficulty finding white socks on white sheets Deficits in positioning in space refers to difficulty in perceiving the relationship of an object to the self. Visual foundation skills include visual acuity (clarity of vision in both near and far), visual fields (available vision to the R, L, superior, and inferior), ocularmotor function (control of eye movements), and scanning (ability to systematically observe and locate items in environment). In evaluating a senior citizen s ability to keep a drives license, the primary concern is cognitive function, which can inhibit safe judgment. Visual accommodation is the ability to focus efficiently from near to far distance, and vise versa. Ocular motility: ability to pursue an object visually in an efficient and smooth manner. Binocular vision: ability to focus the eyes on an object at varying distances and on seeing a single object clearly. Convergence: ability to move the eye inward or outward with continued focus on the object. Glaucoma: increased intraocular pressure, loss of peripheral vision (tunnel vision) Cataracts: clouding of lens resulting in gradual vision loss, central first An individual with cataracts loses central vision first; therefore, presenting evaluation materials directly in front of the person will be ineffective. Peripheral vision gradually decreases with cataracts, so presenting materials to the side will enable the person to use his/her residual vision. Individuals with cataracts have increased difficulty with glare, so indirect lighting is indicated. Presbyopia: inability to focus properly and blurred images, common in MS Macular degeneration: loss of central vision associated with age-related degeneration of macula. Increased sensitivity to glare Hemianopsia (CVA): loss of half visual field in each eye; inability to receive information from right to left side, corresponds to side of sensorimotor deficits. Form constancy perception: the ability to match similar shapes regardless of change in their orientation in space. Visual sequencing: activity that requires the ability to copy the same sequence. Visual Scanning difficulties are seen when a pt reports frequently losing her place when reading. Upon evaluation an OT may see letter cancellation difficulty.

y y y y y y y y

y y y

y y y

y y y y

Visual Imagery: process of making a mental picture of information so that it can be remembered Visual Cognition: ability to mentally manipulate visual information and integrate it with other sensory information. Visual Memory: the retrieval and recall of information that has been stored and encoded. To begin focusing and working on visual fixation, it is best to start with a constant light that moves steadily in a horizontal line. Vertical focusing developmentally follows horizontal focusing. Irregular intervals and increased number of lights are more advanced techniques. The first step in planning a program for a child with visual perceptual problems would be to focus on visual attention skills because the development of visual attention skills prepare and provide foundation skills for other aspects of visual perception Homonymous hemianopsia is a loss of visual field secondary to a CVA. The visual loss for a right CVA would be left nasal side of the right eye and left temporal side of the left eye.

Miscellaneous y y y Anterograde amnesia: Decreased memory of events occurring post trauma. Ex: Pt not remembering acute rehab stay. Retrograde amnesia: Loss of ability to recall events that occurred before the trauma An individual can be considered homebound for cognitive and psychosocial deficits. A person should continue to receive home OT even if PT discontinues and the person is confused and anxious about community activities Individuals with cognitive and sensory deficits can be effectively managed by the family removing clutter to decrease extraneous stimuli. This will help an individual with cognitive and sensory impairments maintain concentration and attention. Having many different activities can be confusing and overstimulating for a person with cognitive deficits. While evaluating a patient with a CVA who has regained sensorimotor functions in the affected extremity, the most important aspect of driving for the OT to evaluate is the tactile aspects of driving. The tactile aspects of driving include ability to respond to changes in road conditions and driving risks. Biofeedback using guided imagery to concentrate on distal circulation is used to treat Raynaud s phenomenon and scleroderma. When applying hot packs during therapy, use 6-8 layers of toweling between the skin and the hot pack to prevent burns. Identification involves benefiting from the behaviors of others by deciding to imitate these positive behaviors.

y y y

y y y y

y y y y

y y

Direct expenses include costs related to OT service provision such as salaries and benefits. Vacations and sick time are benefits that must be budgeted. Capital expenses are items above a fixed amount (500) such as ADL kitchen and driver rehab computer program. The most appropriate and inclusive evaluation to use with a patient suspected to have delirium would be the Mini-Mental Status Exam. According to the sensorimotor approach, activities should not require the individuals to think about the steps needed to complete the activity. Activities should be spontaneous, non-cortical , and fun. A developmental group s focus is to teach the social interaction skills needed for group participation in a sequential manner. Because Asperger s syndrome is a pervasive developmental disorder, this type of group is effective Interpersonal learning occurs when one receives feedback from group members about one s behaviors and by practicing successful ways to relate to a group s members. Altruism is giving one s self to help others. Guidance is when one accepts specific advice from other group members. Systemic desensitization is a cognitive-behavioral technique that introduces graded levels of the anxiety producing stimuli. Using the movement centered FOR, the best activity for normalizing tone and movements would be activities that include bilateral use of tonic muscles against resistance, such as digging a garden, volleyball, or tug of war. Clubhouse programs utilize a consumer empowerment model that emphasizes the active involvement of all participants in the decision-making process. Activities should be selected by members and lead by members. Wernicke s area is the section of the temporal lobe of the brain that controls the comprehension of language. The removal of a brain tumor from this area will result in damage to this ability; therefore, all information must be presented in a manner that does not rely on the comprehension of language. Using demonstration and kinesthetic cues meets this criterion. Osteogenesis imperfecta results in brittle bones that fracture easily. Fracture prevention through activity restriction is a primary focus. Children should avoid leisure options that put them at increase risk of fractures. During supination, the proximal end of the radius spins within the radial notch. The distal end slides over the ulnar head. The ulna does not move Eccentric contractions is muscle lengthening. Concentric contractions are muscle shortening, isometric is no change in muscle length, and isotonic is muscle shortening. Instrumental groups help individual s function at their highest possible level for as long as possible. They provide supportive structured environments and appropriate activities that prevent regression, maintain function, and meet mental health needs. This type of group is effective for people with dementia. Collateral ligaments are designed to be taut in flexion

y y

y y y y

y y y y y y y y y

y y y y

Research indicates that as high as 50% of female clients with chronic pain are in abusive relationship. The progression of dementia of the Alzheimer s type progresses in impairments linked to memory impairments occurring in the early stages, with social and motor impairments occurring later in the disease. Myopathy is a common side effect of corticosteroids secondary to the inhibition of protein synthesis. Corticosteroids place a client at risk for infection and a host of other disorders affecting multiple systems When a patient is observed fainting with movement and has been medically cleared, a vestibular disorder should be considered. All OT & OTA educational programs must maintain accreditation with AOTA Performance areas in occupation of The Practice Framework include ADLs, IADLs, education, social participation, work, and play/leisure Spasticity may aid in the prevention of osteoporosis, prevent muscle atrophy, and prevent deep vein thrombosis. Although serious complications are associated, these are some of the benefits. Superficial heat agents are contraindicated for deep vein thrombophlebitis and tumors. Prebyscusis is an age related sensorineural loss that results in decreased hearing. Goals need to be functional measurable, and objective. Needs assessments are part of program development Marketing occupational therapy services include environmental assessment, organizational assessment, and market analysis. Effective consultation involves ongoing communication that helps team members problem solve more effectively. 80% of people with epilepsy are successfully treated with antiepileptic medications During supination, only the radius is moving. The ulna is not moving General cognitive changes considered to be a part of aging include loss of brain cells, temporary decrease in mental function following an acute illness, and ability to solve practical problems in daily life. Impaired thought process is not a normal part of aging and should be reported to patient s physician. Process (in groups) is described as understanding the nature of interpersonal relationships. Volition is based on the model of human occupation FROM and includes the subsystems of values and interests. PAMs can be used by OT personnel when used in conjunction with or in preparation of purposeful activity. Simply using PAMs to reduce pain without OT treatment would not be a part of OT. Once short and long-term goals have been agreed upon, an implementation plan must be made regarding how to provide services to meet these goals most effectively.

y y y

y y y y

y y y y y

y y

An ideal group size is 7-10 members for the most interaction among members. Groups with fewer than 5 members tend to increase the focus on the leader in their interactions. Secondary prevention involves the early detection of problems in a population that have diagnoses that place them at risk for the development of complicating or secondary conditions. Residents of a nursing home have pre-existing medical conditions and constraint reduction is supposed to help them decrease a risk of developing a secondary condition such as deconditioning. A person recovering from a hip fracture and ORIF surgery should only weight bear on the affected LE with TTWB. OT licensure is a state responsibility; registration and certification are granted by NBCOT. A partial tendon tear results in weakened muscles and pain for it is only partially torn. A complete tendon rupture is painless and the muscle can contract but no movement is generated. The most important role of the AOTF is facilitating a foundation and developing research in OT. It also provides scholarships, fundraising, and houses the OT libraries Emotional flight is dominated by the sympathetic nervous system. Symptoms of spasticity include stretch reflex, clonus, and hyperactive tendon tap. It is advisable to provide small meals at frequent intervals rather than 3 large meals a day when a person has significant cognitive impairments. Symptoms of tethered cord syndrome include loss of bladder control, minimal decrease in strength of bilateral lower and upper extremities, and an increase in the equinovarus position of the feet. Individuals with MS often experience visual difficulties (diplopia) and should be assessed. Work skills and productive activities are examples of performance areas. Skill: term that defines the level of proficiency in a specific activity or task A Baltimore Therapeutic Equipment (BTE) simulator is used in work hardening programs and simulates activities common in the job Carpeting with low pile would be the best choice for an elderly person who may be prone to falls because it provides the fewest tripping hazards and provides a sense of security during walking. A wood floor or hard surface can be slippery and hazardous for someone who may fall easily. The senses included in the somatosensory system are touch, movement, pain, and temperature. The somatosensory system has receptors located throughout the body (muscles, tendons, ligaments, joints, skin). Modifying how directions are provided is one way to adapt activities. A key principle intervention for effective transition includes using natural environments and cues and increasing community-based instruction as the student gets older.

Acute pain is experienced before resistance is felt during PROM. Pain experienced at the same time as resistance indicates subacute pain. Pain experienced after resistance is a sign of a chronic condition. Myofascial pain is specific to hyperirritability of fascia, tendons, and muscles. y Difficulty in meal preparation is sequenced and progressed from access a prepared meal, prepare a cold meal, prepare a hot beverage/soup/prepared dish, prepare a one-dish meal, and prepare a multidish meal. y Under the OT code of ethics: If an OT were to find out that a coworker was intimate with a pt she was treating, it would be the OT s responsibility to report this incident to the NBCOT. The NBCOT is the appropriate authority because the issue is practice related. y Numbers tables are used to select members of a population at random. Ex: OT departments choosing to study the charts of patients who had rehab services to identify the typical OT charges that these pts are most likely to incur. y The best way for a pt who is unable to reach past 90 degrees of shoulder abduction or flexion to put on a t-shirt is to: support elbows on a table at chest height to don the t-shirt over the arms, then don over head. y Sensorimotor approach utilizes active, gross motor movements. y The theory of Botox injections is for the Botox to lessen the spasticity for three to six months in order to strengthen the opposing muscles. If a pt has botox injections in the biceps, the OT plan should include bilateral UE weightbearing in sitting and prone to strengthen triceps. y Title III of the Americans with Disability Act addresses accessibility of facilities used by the public and focuses on removal of structural barriers to allow access to the premises and use of facilities including parking areas, walks, ramps, entrances, etc. y Proprioceptive memory is tested by holding the limb in the desired position for 2-4 seconds, then returning it to starting position. The patient then attempts to replicate the position. This is a specific area of proprioception. y Outcome measures are taken at the completion of service intervention and are used to evaluate the effectiveness of the intervention. y Utilization reviews assess the care that is provided to ensure that services were appropriate and not overutilized or underutilized. y Program evaluations are used to determine how well the program s goals have been achieved. y Project groups utilize short-term activities that require the participation of two or more people. Tasks are shared and the focus is on interaction rather than task completion. y Parallel groups do not require any interaction for task completion. This group is for low-level clients because it does not provide the opportunity to build social skills. TBI y y Cerebral edema is a typical secondary effect of a TBI

y y y y y

y y y y

Intracranial hypotension, not hypertension, is a typical result of a TBI Cerebral contusion/laceration/edema accompanied by surface wounds and skull fractures. The brainstem is a common head injury location and the cranial nerve involvement and may be observed as strabismus, diplopia, and ptosis. Symptoms include fixed pupils, coma, rigidity, changes in vital signs, hemiplegia, monoplegia, and/or abnormal reflexes. Rancho Level of Cognitive Functioning: 1. No response, unresponsive to stimuli 2. Generalized response: nonspecific, inconsistent, and nonpurposeful reaction to stimuli. 3. Localized response: response directly related to type of stimulus but still inconsistent and delayed. Sensory stimuli activities such as moving to music are indicated. 4. Confused-agitated: response heightened, severely confused and could be aggressive. 5. Confused-inappropriate: some response to simple commands, but confusion with more complex commands, high level of distractibility. OT should focus on repetitive self-care tasks 6. Confused-appropriate: response more goal directed, but cues are necessary. Individual is appropriate and goal directed but becomes confused. Simple meal prep such as making a sandwich. Cues are required. 7. Automatic-appropriate: response robot-like, judgment and problem solving lacking. 8. Purposeful-appropriate: response adequate, subtle impairments persist. Sensory stimulation is an appropriate intervention for pts at a ranchos level 1 and 2. Sensory stimulation would be inappropriate at a level 4, because the pt is agitated. Clients would benefit from repetition and practice in a safe environment at level 6, because they are appropriately confused. Cognitive rehab is most heavy in ranchos level 5 and 6, with complex tasks managed at level 7 and 8.

Mental Illness y Partial hospitalization is appropriate for individuals who are experiencing acute psychiatric symptoms and who have a place or family to stay with at night. Except for overnight care, partial hospitalization offers most of the structure, staffing, and services available on an inpatient unit.

y y y y

y y y

y y

y y y y

Long-term use of antipsychotic medication can lead to tardive dyskinesia in approximately 15% of individuals. Symptoms of tardive dyskinesia include impaired swallowing and involuntary, jerky movements of the arms and legs. A frequent side effect of neuroleptic drugs is a decrease in BP in response to sudden movements, specifically up and down movements, resulting in faintness or loss of consciousness. Parachute activities involve up and down movement and require therapist alertness to signs of postural hypotension. MAOI medications such as Parnate, commonly prescribed for depression, have serious side effects. The most important precaution to tell patients about are dietary restrictions. Individuals on MAOI meds cannot eat foods with the amino acid tyramine, which increases BP and may lead to stroke. Foods with tyramine include cheese, yogurt, beer, smoked foods, etc. People with depression often interpret events and the behaviors of themselves and others with unfounded or exaggerated negativity. It is important to facilitate reality by testing/challenging negative thinking. Dantrium (dantrolene) is often given to SCI patients to decrease spasticity. A side of this medication is liver toxicity hepatitis. Valium may cause seizures, baclofen may cause hallucinations, and clonidine may cause a decrease in BP. The highest rate of suicide is in people over 65, men are 4 times more likely to commit suicide, and suicide by firearms is the most common method. An increase in dopamine based medicines often cause an increase in psychotic features (Parkinson s (too little dopamine) and schizophrenia (too much dopamine) pts are often given dopamine based medications) The primary problem area for individuals with a personality disorder is the interactions with others. Levodopa often dramatically improves symptoms of Parkinson s disease, especially rigidity and bradykinesia. Most common. Typical signs of conversion disorders are the presence of one or more neurological symptom such as paralysis, blindness, and/or paresis; has no known neurological or medical base; and psychological factors are associated with the initiation or exacerbation of symptoms. Dissociative identity disorder (multiple personality disorder) is caused by a severe trauma. Neurosis is a chronic and recurrent experience characterized by anxiety and often expressed through defense mechanisms that impairs one s life. Examples of neurosis are anxiety, somatoform, dissociative sexual, and dysthymic disorders. ADLs are often problem areas for those with mood and thought disorders Sensorimotor problems are common in those with schizophrenia Antianxiety medications often cause confusion Adverse side effects of antipsychotic medications are akathisia, extrapyramidal syndrome, and tardive dyskinesia.

y y y

Gross hand tremors are a sign of possible overdose of Lithium and should be reported to the physician. Fine hand tremors are a common side effect of lithium and can be controlled by taking propranolol. It is best to provide written direction with a structured, expected outcomes for schizophrenic individuals who are experiencing hallucinations. Side effects of psychotropic medications: photosensitivity, orthostatic hypotension, akathisia, and tremors. An OT using the psychoanalytic FOR suggests kneeding dough to make bread as an activity for a nonverbal and angry pt. This OT choice is based on sublimination, which is rechanneling of the libidinal and aggressive drives into constructive activity. Freud. King believes that persons with schitzophrenia have ineffective proprioceptive feedback mechanisms with an underactive vestibular regulating system. Activities should be non-cortical and pleasurable, since thinking about movements tends to slow a person down. Spontaneous movement to music is a good activity. Individuals taking neuroleptic medications are prone to photosensitivity and need protection from the sun. A PABA-free sunblock is recommended because it reduces the chances of an allergic reaction to the sunblock.

Theories and Foundations of Practice y Brunnstrom s Levels of Recovery: within this concept the early reflexive movement that may be present is seen as a normal process of this evolution. Spastic or flaccid mm tone and reflexive movements are seen as a normal process of recovery. Focuses on synergy status and the stages of recovery. - Components of the flexor synergy of the shoulder include scapular adduction, elevation, shoulder abduction, and external rotation. - Components of the flexor synergy of the elbow include elbow flexion and forearm supination. - Stage 1: flaccidity, has no movement or spasticity on the affected side of the body. - Stage 2: Pt demonstrates weak, associated movements, usually in a flexor synergy. Little or no finger flexion. - Stage 3: All movement occurs in synergy, spasticity is present and mass grasp is present in the affected hand. - Stage 4: Spasticity begins to decrease, there is some deviation from synergistic patterns, lateral prehension and partial finger extension may be present in the hand. Rood Approach: 6 key principles: uses a developmental sequence as a prerequisite for recovery. Icing and brushing are Rood techniques 1. Muscle control and motor control coeffect each other 2. Flexion and extension patterns coeffect each other 3. Repetition of muscular response creates movement patterns

4. Intention or goal direction coeffects movement-the intent of the movement effects the quality of motor action. 5. Activities which provide approximation of real life context increase treatment effectiveness and generalize ability. 6. Therapist use somatic markers to select interaction methods with clients-refers to a working hypothesis that master clinicians intuitively and automatically fit their demeanor and emotional state to those of the client being. Rood identified the importance of components of motor control in the therapeutic context. i. Reciprocal Inhibition (innervation) an early mobility pattern that serves a protective function with movement antagonist relaxes. ii. Cocontraciton: provides stability and provides the ability to hold a posture. iii. Heavy Work: mobility superimposed on stability. iv. Skill: highest level of motor control and combines the effort of mobility and stability-the proximal segment is stabilized while the distal segment moves freely. Vestibular stimulation, neutral warmth, slow stroking, light compression, etc. According to Rood, slow stroking produces an inhibitory effect y PNF techniques: Uses the theory of diagonal or spiral movement as essential for motor control and the basis for normal movement. Grounded in reflex and hierarchical models of motor control. Using movement patterns to promote movement. D1 makes an A (up and away), D2 makes a V (down and in). - Rhythmic rotation is used when a restriction is felt during ROM. When the restriction is felt, the OT repeats rotation of all the components of the PNF pattern at the point of restriction slowly and gently. - Rhythmic initiation is used to improve movement initiation and quick stretch is used to elicit a contraction. - In PNF diagonals, adduction of the shoulder is always combined with wrist flexion and adduction of the fingers. - In both D1 flexion pattern and D2 extension pattern the shoulder is adducted and the wrists are flexed with fingers adducted. D1 Flexion also has components of external rotation and supination, but D2 extension has the components of internal rotation and pronation. Wrist extension and finger abduction are components of D1 extension and D2 flexion which also include shoulder abduction. NDT (Neurodevelopmental Treatment) Bobath: emphasis on reflex inhibiting postures and key points of control

Based on normal development and movement. Began in children w/ CP - Program developed to help pts avoid abnormal patterns of movement. - Position pts so there abnormal movements and motor tone are reduced or eliminated and by facilitating individuals in new, more typical movements patterns. If pts experienced more typical movement patterns, their brains would accommodate new motor memories that could support normal purposeful movements. - Central principle focusing on alignment and symmetry of the trunk and pelvis, as well as using both sides of the body. - Key points of control for handling/controlling movements are neck, shoulders, hips, and pelvis area. - Handling and positioning to promote more typical movement patterns. - Weight bearing through the affected side is the most effective way of normalizing tone. - Handling and positioning are used with inhibiting techniques - The CNS is damaged, resulting in abnormal movements - Change in motor patterns result from the individual feeling more normal movements. - Adaptive equipment only used for last resort - Weight bearing can help regulate both high and low tone. - Trunk rotation, scapular protraction, and positioning the pelvis forward are all ways to help develop better tone. Mosey s 5 nonfamilial groups simulating normal development: - Parallel: individuals work side by side - Project: emphasize a task accomplishment with some interaction - Egocentric-cooperative: members select and implement a long-term task. - Cooperative: therapist is an advisor - Mature -

SOAP Notes & Documentation y The Objective section of the DC summary should summarize the pts condition upon DC and summarize the pts hospital/rehab stay. - Subjective: Patient reports or comments about tx. - Objective: Well defined. Measurable and/or observable data obtained by the OT through specific evaluations, observations, or the use of therapeutic activities. - Assessment: Contains the analysis of plans and goals of the pt and involves the professional judgment of the therapist. Refers to the effectiveness of tx and any changes needed, the status of the goals, and the justification for continuing tx. The therapist draws conclusions that justify his/her decisions in this section.

Plan: Includes statements related to continuing treatment, frequency and duration of tx, suggestions for additional activities or treatment techniques, the need for further evaluations, and recommendations.

y y

OT evaluation begins with the initial interview and chart review, which guides the OT in deciding on a FOR and the identification of specific evaluation procedures or assessments. Assessments are then performed to gather information to identify problem areas and plan treatment. After the assessments are complete, the OT uses clinical reasoning skills to analyze data and to identify the person s strengths and weaknesses. The treatment plan is developed after the individual s problems have been identified and evaluation data has been analyzed. Finally, specific interventions are selected. Documentation must first comply with regulation and laws. Management, OT staff, and the faculty can provide suggestions within the regulations. Principle 6 in the AOTA code of ethics (veracity) covers documentation under communication that contains false, fraudulent, deceptive, or unfair statements.

Reflexes

Innate Primary Reaction y Rooting Reflex: Turning the head toward tactile stimulation near the mouth. y Sucking Reflex: stimulation to lips, gums, or front of tongue produces sucking/swallowing motion. Birth 2 months y Reflex Stepping: supported in upright position with some weight bearing on feet, lean patient forward with pressure on feet. Response is rhythmic, alternating stepping. Birth 3 months y Grasp Reflex: Pressure in palm of hand or ulnar side of hand produces flexing of fingers; grasping of stimulus object. Birth 4 months y Placing Reaction: In sitting or supine, brush dorsum of one of the patient s hands against under edge of a table or edge of a stiff cardboard. Response is flexion of arm with placement of the hand on the tabletop y A downward parachute reflex (protective extension downward reflex) is normal from 4 months and persists throughout the lifetime. y The onset of the standing tilting reflex is from 12-21 months. y Moving from lying to sitting is initiated by flexion of the neck. The presence of a symmetrical tonic neck reflex will cause this flexion to result in increased hip extension, making it difficult to assume a sitting position. The presence of the asymmetrical tonic neck reflex can decrease the ability to bring both

arms to midline when supine. An individual with a motor pattern indicative of being influenced by the symmetrical tonic neck reflex would exhibit functionally when the individual has difficulty moving from lying supine to sitting. Automatic Movement Reflexes y Moro Reflex: characterized by abduction, extension, and external rotation of the arms. Can be in response to noise. When a child is supported in the supine position and his head is gently dropped, Moro s reflex elicits abduction and extension of the arms followed by the arms coming together in an arc. y Landau Reflex: Positioned in prone, suspended in space with chest supported, provide stimulus of passive or active neck extension. Patient response is back and neck extension. 4-12 to 24 months. y Protective Extension Thrust: From sitting or prone position, provide stimulus of displace body forward, sideways, or backwards. Patient responds by protective extension of limb to protect head. 6 months + Spinal-Level Reflexes y Flexor Withdrawl Reflex: From supine or sitting with head extended, stimulate by touching the sole of the foot. Patient responds by uncontrolled flexion of stimulated leg. Birth 2 months y Extensor Thrust Reflex: From supine or sitting with head in midposition with one leg extended and the other fully extended, stimulate by applying pressure to the ball of the foot of flexed legs. Patient will respond by uncontrolled extension of stimulated leg. Birth 2 month y Crossed Extension Reflex: From supine with head in midposition with one leg is extended and the other fully flexed, stimulate by passively flexing extended leg. Patient will respond by extension of the opposite leg, with hip internal rotation and adduction. Brainstem-Level Reflexes y Asymmetrical Tonic Neck Reflex (ATNR): From supine or sitting with legs extended, provide stimulation by passively or actively turn the head 90 degrees to one side. Patient will respond by increase of extensor tone of limbs on face side and flexor tone of limbs on skull side. Birth 6 months y Symmetrical Tonic Neck Reflex (STNR): From sitting or quadruped, flex patient s head and bring head toward chest. Patient will respond by flexion of the UE and extension of the LE. Extension of neck produces extension of UE and flexion of LE. Birth 6 months y Tonic Labrinthine reflex (TLR): when infant is placed in supine, facilitates extensor tone. When infant is placed in prone, facilitates flexor tone. caused by lower brain stem injury y Associated Reactions: Resist any motion or have client squeeze an object with unaffected hand. Patient will respond by mimicking motion with the other hand. Normal throughout life

Midbrain-Level Reflexes y Neck Righting Reaction: Involves body alignment in rotation after turning the head. y Labyrinthine righting reflex: when infant is suspended vertically and tilted slowly to the side, forward, and backward. This facilitates upright positioning of the head. 2 months death y Body Righting (acting on head) Reflex: with patient blindfolded in prone or supine, stimulate asymmetric stimulation of pressure sense organs on anterior of body surface. Responds by head bringing into a face-vertical position that orients it to surface with which client is in contact. 6 months 5 years. y Body Righting on Body: with supine with arms and legs extended, passively or actively turn head to one side. Patient responds by segmental rotation around body axis toward direction of head. Cortical Reactions y Optic Righting Reflex: with patient in prone or supine on a raised mat sitting with head laterally flexed; eyes open. Stimulate position of head in relation to landmarks in space. Patient responds by raising head upright in space. 2 months death. y Equilibrium Reaction Reflex: Stimulate by rocking patient or supporting surface sufficiently to disturb balance. Responds by automatic movements to maintain balance, right head and body; protective reactions. Throughout life. ------------------------------------------------------------------------------------------------------y Body-on-body reflex: when infant is placed in supine, flex one hip and knee toward the chest and hold briefly. This facilitates segmental rolling of the upper trunk to maintain alignment. caused by upper brain stem injury y Symmetrical tonic neck reflex: when the reflex is present, it provides the child with bilateral arm extension and hip flexion with head raised, which can be used to move forward. y Babinski Reflex: Stroking the sole of the foot facilitates the big toe rising. This reflex is present at birth until the age of 1. After 1, the toe should plantar flex. y The flexion righting reaction is seen when an OT practitioner gently pulls the infant from supine into sitting when the child shows the ability to hold her head and trunk in alignment against gravity. y The Moro reflex, Babinski reflex, and Impassive facial expression reflex are all present at birth. y Symmetrical postures are not present at birth but predominate at 16 weeks y Rooting, flexor withdrawl, and stepping/gallant are all spinal cord level reflexes. y Asymmetrical tonic neck reflex and symmetrical tonic neck reflexes are brainstem level reflexes. y Vertical righting reactions: activate muscles to move the midline of the body into alignment with the center of gravity. Develops with interaction with the environment, not at birth

Spinal reflexes are considered to be more primitive and are noted for their quick action and extinction. They include Flexor withdrawal, extensor thrust, and positive supporting reaction Associated reactions: involuntary and nonfunctional changes in limb position and muscle tone associated with difficult or stressful activities. ex: the hemiplegic arm may assume a flexed position when the patient walks.

Feeding y When working with a patient on feeding to decrease choking and manage swallowing difficulties, head should be positioned in neutral or slightly flexed. Tucking chin slightly can decrease the risk of aspiration. In stabilizing a jaw when assisting with feeding, an OT should know that the opening and closing of the jaw are controlled by your index and middle fingers. Place thumb on cheek and two fingers on jaw. Direct OT treatment for oral motor control/feeding involves techniques that utilize a bolus. These techniques can involve modification of bolus amount, consistency, and temp. The best approach to decrease a gag reflex is to press down firmly on the center of the tongue and to apply pressure from distal to proximal. Lateral and circular movements can facilitate gag reflex. A combination of food (liquid and solid such as minestrone soup) are the most difficult to swallow The best device to use when trying to facilitate upper lip control is the use of a shallow spoon. The use of a shallow spoon encourages the development of upper lip control because it makes it easier for the lip to remove all the food on the spoon. Foods with even consistency, uniform texture, and increased density such as applesauce are the easiest to control and swallow. Foods with multiple textures like chicken noodle soup, sticky foods like peanut butter, and foods that are fibrous or break up in the mouth like carrots should be avoided. A swivel spoon helps primarily when supination is limited. Mobile arm supports are used in feeding to position the arm and help the weak shoulder and elbow muscles to position the hand. The optimal position for a pt with mild difficulties in swallowing is when the pts neck is kept at 10 degrees of flexion past midline. This closes the passage to the lungs but allows food to easily pass down the esophagus. Built up foam handles can accommodate up to 60 degrees ROM of the IPs of the fingers to hold the utensil.

y y

y y y

Sexual Activity

The best positioning during sex for someone with L-sided hemiplegia with spacticity is to have to pt lying on L side while propped up on pillows. Lying on the affected side allows the unaffected side to remain free and provides weight bearing and tone reduction to the affected side. A brisk walk or climbing a flight of stairs is equivalent to the MET level of sexual activity.

Definitions y y y y y Altered Task Method: Teaching a client to perform a familiar activity or skill Disability (defined by the WHOIC): Restriction to perform an activity within a normal range of functioning AC MRDD: Accreditation Council for services for the Mentally Retarded and other Developmentally Disabled persons Individual Family Service Plan: required by federal law and is required for school-aged children. JCAHO: Joint Commission of Accreditation of Hospital Organizations. This organization recommends policies and procedures be retrieved and updated annually. Eccentric Contraction: a contraction that occurs with muscle lengthening Process in groups is defined as understanding the nature of interpersonal relationships. Suppression: a defense mechanism that allows an individual to divert uncomfortable feelings into socially acceptable feelings in order to avoid thinking about a disturbing issue (talking about a dress for a wedding before surgery for amputation) Regression: returning to an earlier stage Displacement: redirection of an emotion or reaction from one object to a similar but less threatening on (child who is angry at parent yells at sibling) CARF: Commission of Accreditation of Rehabilitation Facilities NLN/APHA: National League for Nursing, American Public Health Association. This organization surveys nursing homes. Akathesia: side effect of anti-psychotic medications that is exhibited by restlessness, hand tremors, and shaky legs. Akinesia: lack of movement, also a side effect of anti-psychotic meds Tardive dyskinesia: irreversible condition caused by many years of taking neuroleptic meds. It would not be evident in someone being treated for a first break with neuroleptic meds. Total Quality Management: encourages health care institutions to move away from a focus on compliance to standards and refocus on improving goals in an effort to deliver high quality care.

y y y

y y y y y y y

y y y y y y

y y y y y

Durable Medical Equipment: That which can withstand repeated use, is primarily and customarily used to serve a medical purpose, and is generally not useful to a person in the absence of an injury. Program Evaluation: Systematic collection and reporting of outcomes data to document effectiveness and cost efficiency. Lordosis: concave posterior curvature of the spine, in a result of excessive anterior pelvic tilt. Ergonomics: the science of workplace design Diagnosis related groups: categories that suggest the acceptable length of stay in hospitals for each diagnosis and often influence hospital stay Patient Descriptor: measure of percentage of patients who Medicaid: Joint federal and state program. Because it is a joint program, benefits vary widely from state to state. In each state, the Medicaid program must include Aid to Families with Dependent Children (AFDC) and Supplementary Securing Income (SSI). Medicare: Federal program that funds health coverage for individuals 65 years of age or older, disabled individuals, and people in the end stages of renal disease. Functional Capacity Evaluation (FCE): evaluates an individual s capabilities for the physical demands of a specific job or a group of occupations. Displacement: occurs when an individual redirects an emotion from one object or person to another object or person. MBO: Management By Objective is a common approach to managing OT departments and other health care programs Rehabilitation Act of 1973, Section 504: Prohibits discrimination based solely on an individual s disability in any program receiving federal money. Workers Compensation: State supported program funded by employer contributions. Beneficiaries receive coverage for services identified as covered within their respective states. Education for All Handicapped Children Act: mandates programs funded in part through state and federal grants. It does not fund health care but requires any school receiving federal assistance to provide handicapped children with a free, appropriate education in the least restrictive environment. Functional Capacity Evaluation: comprehensive battery of tests that yields objective measures regarding client s current level of function and their abilities to perform work-related tasks. Commonly standardized FCE s include Bennett Hand Tool Dexterity Test, Minnesota Rate of Manipulation, Purdue Peg Board, Nine Hole Peg Test, O Connor Finger Dexterity Test, and Jebsen Hand Function Test. Paradigm: provides a conceptual structure for understanding the world; within a profession, provides an accepted orienting structure for the profession, its values, beliefs, and knowledge. Supports a field s identity by providing a common focus. Criterion Measure: used with other data to determine rates of success

y y y

y y y y y y

y y

y y

Improvement Measure: technique to measure relative improvement on one level of the program such as percentage of participants who have decreased reaction time in stopping a car. Outcome Measure: final results, the measurements of ability to achieve improvements in quality rather than quantity. Scaled Score: used to measure various changes in behavior. Compensation techniques: used to work around a deficit area by alternative methods to accomplish the same task. Teaching the use of a diary or log is an example of an external memory aid that provides cues to compensate for memory deficits. Remote Memory: The ability to recall events from one s distant past. Is commonly assessed through verbal interviews and informal testing. Retention is determined by giving the pt information and asking the same information a few minutes later Recent memory is determined by asking about meals eaten that day. Service Competency: indicates an interrater reliability between two OT professionals. Veracity: providing accurate information Transdisciplinary Method of Teamwork: One member provides the direct intervention and other team member s function in collaborative consultant roles. This allows the family to interact with one service provider rather than several. Myofascial Pain: specific to muscles, tendons, or fascia. Myofascial pain syndrome (MPS) is characterized by persistent, deep aching pain in muscle, nonarticulate in origin, characterized by well-defined, highly sensitive tender spots (trigger points). Amelia: absence of one arm. A person with Amelia is missing one arm. Utilization review is an internal management review on how resources are utilized and would be used when examining the efficiency of institutional use and the appropriateness of admissions, services, length of stay, and discharge. Utilization reviews involve the analysis of the use of the resources within a facility. It examines the medical necessity and cost efficiency of these resources. An ADL apartment would be considered a facility resource. Praxis or Motor Planning: the ability to attend to and plan a motor act cognitively, based on adequate sensory input. The highest, most complex of children s motor functions. Topical Group: verbal discussion group that focuses on a specific activity engaged in outside of group such as identifying leisure activities Dynamic interaction approach: utilizes awareness questioning to help the individual detect errors, estimate task difficulty, and predict outcomes. Therefore, the therapist must consider the client s level of auditory processing skills. Self-monitoring techniques and awareness are also used in this technique. This is done by asking the patient how he/she knows the items are correct.

Assistive Device Usage y y y An arm trough is less restrictive than a lap tray or splinting and should be used first when a client has a flaccid extremity. In assessing if a person is a candidate for using a mobile arm support, the OT would have to determine if the person demonstrates lateral trunk stability. A three in one commode is the best piece of bathroom adaptive equipment for an individual recovering from a total hip replacement who is receiving Medicare because medicare does not cover any equipment that can be useful to individuals without a disability. The best way for a person to wheel a wheelchair down a steep grade is backwards with all wheelchair wheels maintaining contact with ground surface. A person who is R handed with L hemiplegia can drive one-handed using a spinner knob on the steering wheel Taping or slings can control for subluxation but do not assist in edema control because the hand remains in a lower position A person with only gross motor hand control would want to use a single switch device. Word prediction software anticipates the word desired and increases the speed of input by decreasing the number of keystrokes required. Used with an augmentative communication device. The most appropriate adapted computer device for an individual with fluctuating muscle tone would be a single pressure switch firmly mounted within easy reach. A vacuum feeding cup with a control button, pinching straw, or a cup with a small opening is best to use with patients who drink too quickly or those with impulsive behavior or poor judgment, because they often tend to drink too fast.

y y y y

Sensation and SI y The sensation of pain and temperature are carried along small, unmyelinated n. fibers, which recover more rapidly than senses carried by large, myelinated fibers. Pain and temperature are first to return after an injury causing sensory loss. In peripheral nerve injuries, sensory testing should be done by presenting the stimuli distal to proximal. A stimulus is applied according to dermatome patterns during sensory testing for individuals with neurological disorders. A tight pencil grip, incoordination, and use of visual cues could indicate proprioceptive deficits.

y y y

y y

y y

Ayers believed that adaptive responses could be achieved when sensation is organized and situations provide a just right challenge with built-in success. Slow rocking or stroking, deep tendon pressure, and joint compression inhibit negative motor responses in a client with excess tone and limited participation in ADLs Ayers believed in plasticity within the CNS: through adaptive responses to environmental demands (purposeful activity), changes occur at the neuronal synaptic level. Brushing with a surgical brush is a treatment for overesponsiveness to sensory stimulation. This technique administers direct deep touch pressure (willabugers protocol) When treating a child with DD and hypersensitivity to touch, the progression for facilitating the child s integration of touch, temperature, and pain would be fast brushing, firm consistent touch, light consistent touch, and then light moving touch as tolerated. Ayers also believed that SI processes occur in a developmental sequence as the CNS organizes adaptive responses to sensory information with increasing levels of complexity. The client with a vestibular disorder has poor balance, vertigo, blurred vision, nausea, and spatial disorientation issues. Prism glasses bend the light by 90 degrees. This angle enables a person who is lying on his/her back to read anything that is resting on his/her lap. Convergence/integration of sensory input from all sensory modalities occurs in the reticular formation (brainstem and thalamus), which has a widespread influence over the rest of the brain. SIPT is the primary instrument for identification of SI dysfunction Developmental dyspraxia: difficulty with the planning and execution of movement patterns of a skilled or nonhabitual nature and originates in childhood. It refers to a disruption in sensory processing and motor planning Bilateral integration and sequencing dysfunction is thought to reflect problems in central vestibular processing. Hypersensitivity training is typically graded by texture and force. Texture begins with soft, progresses to hard, and moves to rough. The force begins with touch, progresses to rub, and moves to tapping. An aesthesiometer measures two-point discrimination with a moveable point attached to a ruler that has a stationary point at one end. People with sensory loss in the hand often drop things because they are not receiving adequate sensory input. Problems with the peripheral NS diminish sensation transmission to the brain, which interferes with perception, interpretation, or ingeneration of sensory information. When a person displays limited movement in a muscle group, the OT provides tx to facilitate the muscle group. The bicep muscle is responsible

y y y y y

y y

for elbow flexion. According to Rood, fast brushing over a muscle belly will facilitate movement. Slow brushing and maintaining firm pressure over a muscle belly are inhibitory. To elicit elbow flexion, fast brush over the biceps muscle belly. Safety is ALWAYS the first concern for any pt with sensory loss. The patient must be taught compensatory techniques for the sensory loss. Firm pressure and resistance are less threatening than light touch Linear movement is less threatening than angular movement Slow movement is less threatening than rapid movement In working with a pt with hypersensitivity to touch to facilitate the integration of touch, temp, and pain, the best choice for the initial technique would be fast brushing. The progression would likely be fast brushing, firm consistent touch, light consistent touch, and then light moving touch as tolerated. Icing is a technique listed with the most unpredictable results. It would be advisable to use the other techniques rather than use icing. Criteria for SI dysfunction assessment include trunk flexion in supine, trunk extension in prone, and ocular pursuits. Signs of sensory integrative dysfunction include oversensitivity to sound, movement, touch, and visual input. Impulsive, lack of self-control, distraction, poor self-concept, and social problems. Vestibular stimulation can be used to increase muscle tone in both adults and children. Spinning should not be done with individuals who are prone to seizures. Sensory integration development continues throughout life but is generally completed by 8-10 years of age. Sensory integration treatment is complex and highly individualized and must be monitored carefully to observe the effects of sensory input of varying types on the individual. Characteristics of facilitatory sensory input are unexpected, arrhythmic, uneven, or rapid input. This type of sensory integration should be used on an individual with underreactive sensory processing. Gravitational insecurity: excessive fear during ordinary movement activities. The child easily experiences a fear of falling and prefers to keep his/her feet on the ground. The sequence method of textured material, rubbing, tapping, and prolonged contact is the most appropriate method to achieve sensory desensitization. Deep touch and firm pressure help to decrease tactile defensiveness Deep touch stimuli is often comfortable for children with tactile defensiveness and can eve provide relief from irritating stimuli when deep pressure is applied over the involved skin areas.

y y y

Ergonomic Design and Workplace Info

y y y y y y y y

y y y

y y y

y y

y y y y

The minimum doorway width that allows a standard wheelchair to pass through easily is 32 inches. Narrow adult wheelchair are 16 wide x 16 deep x 20 high Standard/regular adult wheelchairs are 18 wide x16 deep x20 high Standard toilet seat height is 15 inches, which is 3 inches lower than the standard height of a wheelchair seat. Standard wheelchair seat height is 18 inches. Wheelchair seat belts are to extend across the hips and into the lap at a 45 degree angle The recommended maximal height of a countertop is 31 inches. 36 inches for a doorway width exceeds the minimum accessibility standard of 32 inches and is within reason. This measurement allows for adequate hand clearance and is sufficiently wide enough for non-standard width chairs. Standard kitchen counters are 21 inches deep and an individual in a wheelchair must have 21 inches of available reach to access items on counter When determining if a wheelchair is too narrow, observe for red marks on the greater trochanter at the hips. Wraparound armrests (space saver armrests) reduce the overall width of a wheelchair by 2 inch. Because churches are exempt from ADA, it would be best for a person to get this type of wheelchair to access the doorways of a church. Door Thresholds may have a max height of .5 inches and these must be beveled. Doorknobs should be located 36 inches from the floor to allow for access for a person using a wheelchair Work Hardening Programs focus on returning an individual to work in physically appropriate settings as quickly and feasibly through reconditioning. Pain management techniques and proper body mechanics are often part of work hardening programs. The proper height for grab bars to allow for the UE to lift the body with enough clearance to transfer onto the toilet is 33-36 inches. The recommended wheelchair seat width is 2 inches wider than the widest point across the hips and thighs of the seated individual. Wheelchairs should be as narrow as possible while allowing for comfort, ease of repositioning, and transfers. Accessibility guidelines state that the ramp should be constructed with one foot of ramp length for each inch of rise. 1 inch: 1 foot A seat belt should be placed across the lap inferior to the anterior superior iliac spine to prevent the hips from being extended into a posterior pelvic tilt. An outward opening door needs a space of 5 feet by 5 feet to allow for the wheelchair to be maneuvered around the door. A seat belt correctly placed at a 45-degree angle to the patient s hips would be the best way to inhibit extensor tone.

OSHA has identified three factors as significant contributors to risk in the workplace: force, distance (awkward posture), and frequency.

Role of COTA s y One of a COTA s defined roles is to complete data collection records such as record review, chart review, general observation checklists, or behavioral checklists. COTA s can record factual information at the time of discharge Because of the analytical nature of provision of discharge recommendations, the COTA does not complete this activity independently. A COTA is qualified to perform and ADL evaluation A COTA who works as an activities program director is not providing OT, therefore, does not require OTR supervision. COTA s should not be making discharge recommendations on their own. They will contribute to the process but this section of the discharge evaluation is to be completed by the OTR. General supervision given by the AOTA includes a minimum of monthly direct contact with supervision available as needed by phone or other forms of communication Close Supervision: daily supervision Routine Supervision: weekly supervision, direct contact occurring a minimum or every week. Minimal Supervision: occurs on an as-needed basis. Cosigning notes is not evidence of supervision. The OT should maintain a separate log book whenever the OTA and the OT meet to review a case. A COTA can become a certified alcohol and substance abuse counselor, subject to state requirements. Advanced levels of supervision occurs on an as-needed basis When there is not a referral for OT services, the OTR must assume responsibility for all OT services delivered. Entry-level OTAs are required to have supervision by an OT for the first year. All personnel should have supervision as needed. An advanced-level COTA can accept the position of director of an independent living center without OTR supervision as long as state regulations allow autonomous practice and the COTA recognizes situations that require consultation with or referral to an OTR. AOTA supports the autonomous practice of the advanced COTA practitioner in the independent living setting.

y y y y y

y y y y y y y y y

Medicare and Insurance y Medicare Part B defines medically necessary as necessary and reasonable to treat an injury or illness or to improve functioning of a malformed body

y y y y y

y y

member . Medicare Part B does not typically cover items such as raised toilet seats; grab bars, or adaptive equipment. Under Medicare, an OT working in a home care setting must have a physician s order, which identifies the services that are to be provided. Medicare standards state that OT services are only covered if prescribed by a physician or furnished according to a physician-approved plan of care. According to Medicare guidelines, a case must be opened by a registered nurse, physical therapist, or speech-language pathologist. Occupational therapy services for a Medicare pt at home are covered as long as physical therapy, nursing, or speech is also servicing the patient. A physician s referral for OT services may be required by federal and state governmental agencies and third-party payers. AOTA does not require a physician referral. Any person can make a referral to OT; however, third party insurance providers often require a physician s order for reimbursement. If an OT is employed by a long-term care facility, even though the residents are not eligible for OT reimbursement, the OT can and should provide direct services to the patients.

Arthritis (funny I have this on my study guide) y Rheumatoid Arthritis: Systemic, symmetrical and affects many joints. - Most commonly attacks the small joints of the hands - Characterized by remission and exacerbations. - Begins in the acute phase as an inflammatory process of the synovial lining. - May be infectious or autoimmune in etiology - Common deformities include swan neck, Boutonniere, and ulnar deviation and subluxation of the wrists and MCP joints. Activities that use AROM are indicated for the tx of RA both in its acute and chronic phases. Passive ROM and progressive resistance are contraindicated in tx of RA The maintenance of AROM is a primary anti-defority technique. PROM and resistive exercise to increase strength are contraindicated for persons with arthritis OsteoArthritis: Degenerative joint disease - Not systemic but wear and tear - Commonly affects large weight bearing joints - Attacks hyaline cartilage. - Bone spurs are a symptom OT Interventions: - Focus on AROM, PROM should be avoided, especially in inflammatory stages; all ROM should be pain free.

y y y

Avoid muscle testing unless ordered by physician, document strength in relation to function. - Joint protection and energy conservation should be focused on - Use grip sphygmomanomenter, not dyn. - Resting hand splints in acute stage. - Ulnar drift splint to prevent deformities. Silver ring splints to prevent boutonniere and swan neck. - Dynamic MCP extension splint with radial pull for post operative MCP arthroplasties - Hand base thumb splint for CMC arthritis. DMARD (disease modifying drugs) attempt to halt the progression of the disease and have many side effects such as skin rash, diarrhea, and irritation of the oral mucus. -

Hip Precautions y Hip Precautions after total hip replacement/total hip arthroplasty - Do not flex beyond 90 degrees - Do not adduct or cross legs - Do not pivot or twist on/at hip - Sit only on raised chair and raised toilet seat - Transfer sit to stand by keeping operated/affected hip in slight abduction and extended out in front. Following hip arthroplasty, positions such as flexion of the hip past 60-90 degrees, internal rotation, and adduction can cause dislocation and are contraindicative.

Amputations y To train a person in the operation of the TD, the therapist initially locks the elbow in 90 degrees of flexion and teaches only the TD control. Locking the elbow joint into flexion places the TD in a functional position. The most important goal of teaching ADLs to a patient with LE amputation is energy conservation and work simplification. Myoelectrically controlled prostheses (hands) are common and frequently prescribed for transradial amputations. The positioning of elbow flexed at 90 degrees with 0 degrees of internal rotation is the easiest position in which to begin grasp and release activities, either with a prosthesis or for an individual with UE difficulty. When working on feeding using a terminal device with a pt with a below elbow amputation of the dominant R arm, the safest position for cutting meat is holding a regular fork in the terminal device and the knife in the hand.

y y y

y y y

A cosmetic prosthesis requires more muscle function to operate and it does not enhance functional abilities. The prosthesis can become unnecessary if the patient learns unilateral skills Dynamic balance is essential for a patient to understand the safety concerns with shifting of COG, especially in preparing for community integration Patient s acceptance of new body image is the most important area to address to encourage acceptance of prosthetic device The first step to evaluate trunk and LE ROM to determine if the patient can use the LE to dress, as many persons with Amelia do. Hip ROM is essential to be able to don shirts with the feet. The first step in an evaluation for a person working on dressing with bilateral UE amputation would be to evaluate ROM. Classification of UE Amputations: - Forequarter: loss of clavicle, scapula, and entire UE - Above-elbow (AE): amputation above the elbow at any level on the upper arm, most common. - Elbow disarticulation: amputation of the UE distal to the elbow joint. - Below-elbow (BE): amputation below the elbow at any level of the forearm. - Wrist disarticulation: amputation distal to the wrist joint. Loss of entire hand. - Finger amputation: amputation of digit(s) at any level. Classification of LE Amputations: - Hemipelvectomy: amputation of half of pelvis and entire LE. - Hip disarticulation: amputation at the hip joint. Loss of entire LE - Above-knee (AK): Transfemoral, amputation above knee at any level of the thigh. - Knee disarticulation: amputation at the knee joint - Below-knee (BK): Transtibial, amputation below knee at any level of calf. Most common LE amputation. - Complete Tarsal: amputation at the ankle - Partial Tarsal: amputation of the metatarsals and phalanges - Complete phalanges: amputation of toes. Terminal Devices: Function to grasp and maintain hold on object. The two main terminal devices are hook and hand. - Voluntary opening (VO): hook remains closed until tension is placed on cable and then it opens - Voluntary closing (VC): hook remains opened until tension is placed on cable and then it closes. - Cosmetic device: minimal function. Complications include neoromas (nerve endings adhere to scar tissue that can be very painful and hypersensitive), skin breakdown, phantom limb, phantom pain, infection, knee flexion contractures in transtibial amputations, psychological changes. OT Interventions: ROM, desensitization, wrapping to shape and shrink residual limb (wrap distal to proximal), ADL training, education in skin care,

functional training with prosthesis, donning/doffing prosthesis, increase wearing tolerance. For an amputation pt, a hook terminal device provides better prehensile function and allows greater visibility of objects than a functional hand prosthesis.

Burns y In the acute stage of burn rehab, when burn wounds are partial or full thickness in nature, maintenance of joint ROM and skin mobility is the primary goal of intervention. Heterotropic ossification can occur in or near the joint after burns. Circumferential burns are most susceptible to this condition. Symptoms include decreasing joint excursion, stiff endpoints, and increased pain. Contact a physician immediately. The neck should be splinted in neutral when a person has a burn over the neck. This is antideformity position, which is a major focus of acute care. The position of comfort is often assumed by individuals recovering from burns. This position occurs when the person assumes the protective postures of adduction and flexion of the UE, flexion of the hips and knees, and plantar flexion of the ankles. This position is nonfunctional and can result in contractures and should be avoided. Complications include pulmonary, metabolic, and cardiac problems Total Body Surface Area (TBSA) is calculated by the rule of nines (the body is divided into areas of 9%) in patients over the age of 16 Infections are the single most serious concern during the acute phase of burn management Airplane and burn hand splints are most commonly seen in the treatment of patients with burn injuries, especially when the wounds involve the crossing of a joint. The burn hand splint prevents ligamentous stress at the interphalangeal joints while aiding in the reduction of edema. The airplane splint maintains the shoulder in 90 degrees of abduction in attempts to prevent contracture development at the axillary region. Burn Classification: 1. Superficial (1st degree) involves the epidermis only - Minimal pain and edema, no blisters - Healing time is 3-7 days 2. Superficial Partial Thickness (2nd degree) Involves the epidermis and upper portions of the dermis (e.g., sunburn) - Appearance: red, blistering, and wet - Painful, no grafting necessary, heals on its own - Healing time is 7-21 days 3. Deep Partial Thickness: second degree burn involving the epidermis and deep portions of the dermis, hair follicles, and sweat glands - Appearance: red, white, elastic

y y

y y y y

Sensation may be impaired Potential to convert to full thickness burn due to infection Healing time is 21-35 days Full Thickness (3rd degree) involves the epidermis and dermis, hair follicles, sweat glands, and nerve endings. - Appearance: white, waxy, leathery, and non-elastic. - Pain free, requires skin graft - Hypertrophic scar - Healing time can take months 5. Fourth Degree Burns: Involves fat, muscles, and bone - Electrical burn: destruction of nerve along pathway. OT Evaluation and Treatment: evaluation and treatment will vary depending on the degree of the burn and the area the burn is in. - Wound care and debridement, sterile whirlpool, dressing changes, Gentle AROM and PROM to individuals tolerance, edema control, splinting, ADLs and role activities, strengthening when wounds are healed. Antideformity Positioning: - Neck: neutral to slight extension - Chest/abdomen: trunk extension and scapula retraction - Axilla: shoulder abduction 90 degrees and external rotation (airplane splint) - Elbow: extension - Wrist: 30-45 degrees extension - Hand: MCPs 70 degrees flexion, IP extension, and thumb abducted - Hip: 10-15 degrees abduction - Knee: knee extension, anterior burns: mild flexion - Ankle: 5 degrees dorsiflexion Hand Splints - Burns to dorsum of hand: wrist in 30-45 degrees extension, MCP joints in 70-90 degrees flexion, IP joints in full extension, and thumb abducted and extended. - Burns to volar surface of hand: wrist in 0-30 degrees of extension, MCP joints in neutral and abducted, IP joints in full extension, and thumb abducted and extended. Hypertrophic Scarring: most common with deep second and third degree burns. Appears 6-8 weeks after wound closure; compression garments should be worn 24 hours per day for 1-2 years. 4.

Vous aimerez peut-être aussi