Exam 2 Flashcards
What is a skilled service?
Term used by insurance
Government uses it to determine fraud
Includes PT/PTA, OT/COTA, SLP, nursing, and doctors only
- home health aide is the only non-skilled service that is allowed; they are paid as a non-skilled service
To charge for a service that is not skilled is insurance fraud
8 areas of occupations
ADLs
IADLs
Rest and sleep
Education
Work
Play
Leisure
Social participation
What are ADLs?
Bathing and showering
Toileting and toilerting hygeine
Dressing
Swallowing and eating
- dysphagia: swallowing difficulties
Feeding (includes the emotional, social, and sensory)
Functional mobility
Personal device care
Personal hygiene and grooming
Sexual activity
What are IADLs?
They have a strong tie to the OT profile.
Executive function - self awareness
Social skills
Complex interaction with environment
- getting on the bus
- driving
Examples: driving, pets, childcare, financial management, community mobility, religious participation
The assessment of ADLs
Starts with the OT profile
- look at previous level of function
Influenced by the time of intervention
- acute vs. chronic
Influenced by setting
- inpatient vs. outpatient
Identify the barriers
- client factors
- environment
Current
- occupations
- roles
- routines
- environment
Learning and teaching of ADLs
You and your patient
- remediation
- adaptation
Then decide the frame of reference you want to use
Stages of learning in the adult
- Cognitive of acquisition stage
- New learning, lots of errors, inconsistent, needs repetition and feedback - Retention
- Recognition of the new skill, that they are doing it better nor not improving - Associative stage or transfer
- Skill refinement, decreased errors, learning based on past performance
- Same skill in different places - Autonomous stage or generalization
- Retains the skill, uses it functionally, transferred to other setting
What FORs can be used with remediation?
Motor learning - muscle memory
NDT - abnormal input –> abnormal output
What FORs can be used with adaptive?
Brunstrom - all movement is good movement
Rehabilitative - adaptive equipment
What MOPs can be used with modifications?
MOHO
PEO
Development (opportunity is based on)
Cognition
Perception
Action
Environment
CO-OP
Cognitive orientation to daily occupational performance
Specification of the goal
Developing a plan
Actual implementation
Evaluation
The primary objective of CO-OP is skill acquisition through cognitive strategy use.
Strategies used in CO–OP is domain-specific strategies (DSS). DSS are specific to a task or part of a task and support the acquisition of the particular skills in the particular context.
Goal Plan Do Check
Supports problem solving and is intended to be used over long periods of time in a variety of different contexts.
The client strives to solve occupational performance problems:
- GOAL: What do I want to do?
- PLAN: How am I going to do it?
- DO: Do it!
- CHECK: How well did my plan work? Do I need to revise my plan?
Examples of strategies used within CO-OP
Based on the individual occupations and goals include
1. Self-coaching: I can do this! Only a few more times and I will have it!
2. Self-guidance/verbal script/mnemonic techniques: Make
bunny ears when tying shoes; Use helper hand when printing or cutting.
3. Attention to doing/verbal script: Where do I start my letters? At the top, at the top! when forming letters or printing.
4. Body position: Pinch the pull the tab between your inbox finger and thumb when buttoning (pinching the button to improve manipulation).
5. Feeling the movement: Feel the edge of the button and grip that as you pull it through the hole when buttoning
How to improve learning?
Transfer or learning is more likely to occur if practice is in the “real world” and if the task is functional and the child’s real occupation.
Sequencing and adapting tasks
- Discrete (definite start and end, buttons), dynamic or continuous, ongoing and variable, (walking, jumping on trampoline)
- Unilateral then bilateral (one handed or two handed activities)
- Stationary then moving
- Closed task (the environment is stationary) vs open (environment is dynamic) tasks
- Cognitive level of the task: the number of steps
- Role of the environment
The therapist’s role: modes of teaching
Instructional
- visual, written, auditory, hand over hand
Reinforcement
- praise, tactile, stars
Facilitative prompts
- “check your grip”
- suggestions or hints, not direct instruction
Self monitoring aids
- smart phones
- check lists
Guidance or modeling
- like facilitative prompts but fewer
Motivational cues
- cheerleader
- encourage but no direct instruction
Therapist support
- support and facilitate
- direct and instruct
- basically all of the modes combined
Massed practice
Practice with a rest period
Practice time is greater than the rest time
Rest time is shorter than activity time
Think training - doing the same thing repeatedly
Early in the learning stages
Fine tuning something they are struggling with
Distributed practice
Practice with rest, but rest time is much longer than practice
Practice once a day or once in the morning and once in the afternoon
Constant vs variable practice
Training conditions
Counting: either speed or reps
Constant
- same every time
- in line with massed practice
- write same letter 10x a day
Variable
- changes
- in line with distributed
- what the same letter 10x today and 3x tomorrow
Random vs blocked practice
Random: irregular patterns, requires more thought and planning like distributed and variable practice
Blocked: same thing, same way, same order
Whole vs part practice
Whole: show client how to put a shirt on, them tell them to try
- practicing the whole activity
Part: button board to practice buttoning, putting on one sleeve of the shirt
- focusing on one part of the activity
Mental practice
Can be effective for adults, re-learners, cognitively intact learners, and gross motor activities
Mental rehearsal
Not effective with peds or people with sensory issues
Mental practice is a training method during which a person cognitively rehearses a physical skill using motor imagery of physical movements for the purpose of enhancing motor skill performance.
Intrinsic vs extrinsic feedback
Intrinsic: recognizing whether someone is motivated by praise or scowling; what is felt by the performer during a performance.
- For example, a skier may feel that they don’t have very good control of the skis when making a turn and can feel off-balance
Extrinsic: provided by external sources, during or after a performance
- It includes things that the performer can hear or see: pat on the back, cheering
Knowledge of performance
Focuses on how well the athlete performed, not the end result.
For example, a golfer may receive feedback that they have putted very well even if their drives were less effective.
Knowledge of results
Focuses on the end of the performance.
For example, the performer’s score, time or position. It is sometimes called terminal feedback.
Sensory feedback
Visual: see they completed something
Auditory: told how well they did
Haptic: simulating the sense of touch
- “back up until you feel your thighs touch the wheelchair”
Multimodal: more than one
- “Back up until you feel your thighs touch the wheelchair (haptic), then look back (visual).”
Levels of independence
Independent (I): patient doesn’t require physical supervision or any type of assistance
Modified independence (MI): Patient uses adaptive or assistive equipment
Supervision (S): patient requires only supervision with therapist in room
Standby assist (SBA): patient requires verbal or tactile cues (not instruction), no touching
Contact guard assist (CGA): patient requires support from another person touching them or their gait belt
Minimal assist (MinA): patient is able to perform 75%+ of the activity
Moderate assist (ModA): patient performs 50%+ of the activity
Maximal assist (MaxA): patient performs 25% of the activity
Total assist: patient performs 0% of the activity
FIM Scores
Gait belt
Adjust balance
Prevent a fall
“Handle” for transfers
- less stress on you or the caregiver
Less likely to injure client
Bed Mobility: Bridging
Independent
With positioning
With stabilization
Helps to get dressed in bed, clean patient, change diaper or linens
Bed Mobility: Rolling
Right or left
- Left side paralyze – roll left
Using just legs
Grabbing bed rail
Log rolling – everything rolls at once, not segmentally
Therapist assist
- May be able to get the roll started, but OT needs to help push
Bed Mobility: Scooting
Bridging with a push
Bed Mobility: Bed Walking
Once a pt has learned to sit at bedside and can scoot side to side
Bed Mobility: Sidelying to Sitting
Roll to the WEAK SIDE
- Cradle don’t trap or roll over on it
Allow legs to fall off
Reach across and push to sit
Bed Mobility: Supine to Sit
Scoot to head of bed
Drop legs off side of bed
If they have a weaker leg, they can take the stronger one and trap it
Sit up
Draw sheet
Two people to move patient
Can also be used to roll
Fold sheet hamburger
Can be used to bathe, change diaper or linens
Bed ladder, trapeze bar, leg lifters
LE weakness
Hoyer lift
May need two to roll patient into the sling
- Electric and manual
- Often Bed to wheelchair
What are the multiple parts of toileting and toileting hygiene?
Getting to the bathroom
Transfer to and from toilet
Clothing management
Hygiene
Alternate ways to toilet
Modifications for toileting and toilet hygiene
Routines or alarms for bowel and bladder management
Bed pan, adult diapers, urinal
Equipment for toileting and toilet hygiene
Raised toilet vs BSC (3 in 1)
Arms on toilet or grab bars
Drop arm commodes
Toilet seat lift
Bidet
Comfort wipe extended handle-bottom buddy
Personal hygiene and grooming equipment
Sit vs stand
Build ups
Electric
Safety razor
Dispensers
Suction brushes
Wall mounted items
Structures related to orthopedics
Ligaments
Tendons
Cartilage
Muscle
Sometimes nerves
Role of OT with acute injuries
Position
Skin integrity
Maintain healthy joints
- AROM, functional activities, PROM
Edema control
- retrograde massage, modalities, positioning, compression
Pain relief
- visual imagery, prayer, ice
Restore function/prevent loss of function
- surrounding joints
- restore function: rehabilitation, motor learning, adaptation
- Loss of function: education, orthotics, positioning
Adaptation as needed
- if too early, you can stunt progress
Role of OT with chronic injuries
Adaptation
Positioning
Deal with pain
Joint protection/energy conservation
- body mechanics
- new roles
Bone healing process
Healing begins in the first couple of days.
The callus begins to form. 21-35 day hopefully have healing of the bone.
Start with AROM to prevent pain and added stress.
ARTHRITIS VOCAB
Gelling – gooiness of synovial fluid, can limit motion
Crepitus - popping
Energy conservation
Hyperalgesia – excessive. pain
Joint protection
Morning stiffness
Nodules
Synovitis
Tenosynovitis
Flare
Joint Laxity
Subluxation
Compare normal, osteoarthritic, and rheumatoid arthritic joints
Stages of rheumatoid arthritis
Stages of osteoarthritis
Acute care of arthritis
Move it, calm it, support it
- education
- ROM with no pain
- modalities
- gentle stretching
- functional tasks
- orthotics
- assistive devices
Rules of joint protection
Respect Pain
Use larger joints,
Use joints in their most staple positions
Avoid odd positions
Maintain ROM and strength
Avoid staying in one position for a long time
Don’t start something you can’t stop
Listen to your body
Balance rest and sleep
Use two hands when you can
Goals of therapeutic exercises
Improve ROM
Reduce pain
Restore joint flexibility
Improve muscle mass, strength, and endurance
Reduction of limb edema
Increase body function
Improves balance control
Increase cardiovascular strength and endurance
Helps preventing further injury
Gain self confidence
Types of therapeutic exercise intervention
Aerobic conditioning
Muscle performance exercises
Joint mobilization techniques
Neuromuscular control, inhibition, and facilitation
Posture awareness training
Postural control, body mechanics, and stabilization
Balance exercises
Relaxation exercises
Breathing exercises
Task-specific functional training
Ergonomics
Reduce pain
Reduce force on joints
Reduce secondary inflammation
Reduce loading joints
Prevent overuse
Reduce fatigue
Common arthritic deformities
Due to biomechanical changes, tendons can stretch or rupture
Swan neck
Boutonniere
Ulnar drift
Bouchard’s nodes
Herbeden’s nodes
Swan neck
Lateral bands of the extensor mechanism slip above the PIP, thereby hyperextending the PIP joint and flexing of the DIP
Boutonniere deformity
flexion of the PIP joint and hyperextexion of the DIP
occurs when synovitis weakens, lengthens, or disrupts the dorsal capsule and central slip of the extensor mechanism; the lateral bands displace volarly below PIP
Bouchard’s nodes
PIP joint
Herbeden’s nodes
DIP
Hip fx
Elective or nonelective
Frequently seen in women over 60
Can be due to osteoporosis or osteoarthritis
Fell and broke or broke and fell?
Surgery
- pin, plates, screws, complete or partial replacement
Anterior vs posterior hip replacement
Anterior
- low dislocation risk
- minimal muscle damage
- less postop pain
- quick rehab
- sx in supine position
- long learning curve
- femur fx
- more blood loss
- longer sx
- different approach for revision
Posterior
- short learning curve
- proven excellent long term outocome
- little blood loss
- more muscle damage
- higher dislocation risk
Things to consider with hip fx
Bed mobility and rolling over
Get into tub
- Lifted shower bench, bend the knee to get in so you don’t bend at hip
Sitting for ADLs
- Raise chair of seat
Adaptive equipment
- Bedside commode (reimbursed unlike raised toiler seat, can be placed over toilet), reacher so they don’t have to bend to pick stuff up, sock aide, dressing stick for pants and to take off socks, adduction pillow, shoehorn
Usually walking with cane by 6 weeks
Hip restrictions for 6-8 weeks
Abduction wedge
SCD - sequential compression devices
- Ted hose (compression socks)
Incentive spirometer
- For breathing, helps patient clear lungs after surgery
How are knee replacements different from hip replacements?
Weight bearing to tolerance
No restrictions
Can bend, cross, and roll
No tub until 48 hours after removal of stitches
OT process for hips and knees
Evaluation
- Focus is on adaptations, ADLs, and IADLs
- How does the location impact the eval?
- Performance skills: ROM, strength, balance, weight bearing, endurance, pain management, joint protection
Client Education
ADLS
- Sleeping (which side) with hip, with knee
- Dressing, to aid or not to aid
- Sit to stand
- Bath, toilet, car, dressing lower body
Low back pain
Pain will be located along nerve distribution if nerve Is impinged
Pain at specific site:
- Soft tissue
- Bone to bone or articular surface contact
- Referred pain from internal organs (gallbladder)
Body mechanics
Poor posture
- lumbar curves
- pelvic tilt
High risk for depression because they are treated symptomatically
- often given short limited answers
Can become chronic
Most neck and LBP is related to ergonomics and stress which is related to occupation
Rupture vs bulge/herniation ADD MORE
Body will not repair a rupture on its own.
- nucleus pulpous
Common back injuries
Nerve root - disc
Spinal stenosis - narrowing of intervertebral foramen
Facet joint
Spondylosis - stress fracture of transverse process and dorsal aspect
Spondylolisthesis - vertebra slips on another
Compression fracture - stable
Good body mechanics
Use pelvic tilt
- Unload joint
Objects close to body
Avoid twisting
Hip and knee lift
Avoid prolonged positions
Balance with rest
Wide base of support
Good posture
Test loads
Stay fit
Get help
Surgical options for back stabilization
Laminectomy - remove lamina
Fusion - stabilization
- one or two fusions should still have normal ROM
Nerve ecompression
Disk dissection
Vertebroplast/kyphoplasty
UE injuries
Fractures
Nerve injuries - brachial plexus
Complex regional pain syndrome
Tendon/ ligament/ muscle injury
Cumulative trauma/ repetitive stress injury
- torn rotator cuff
- tommy john (UCL)
- carpal tunnel
- CMC arthritis
Sensory evaluations
Two point discrimination
Moberg
Sensory mapping (monofilament)
Hot/cold
Sharp/dull
Antideformity position
Wrist: 10-20º of extension
MP: 70-90º flexion
PIP and DIP: 0º
What to evaluate in hand and UE
History-function
Pain: using analog pain scale, Ransford
Whole UE
Wounds: Surface area, color, smell
Scars: hypertrophic, keloid, mature or immature
Vascular: pulse ox, assess color, temperature, Allen’s, blanching
Edema
AROM: goniometer, uses negatives, (total ROM of index involved MP, PIP, DIP), composite/flat fist
Grip and pinch
MMT
Sensation
Dexterity and function
General timeline for fracture healing
2-3 weeks callous (spider web between fx) forms
- Can be longer depending on comorbidities, vascular supply, medications
- AROM to adjacent joints
- Stability at fx site
4-6 weeks-clinical union (begin movement)
- Spider web connects
- AROM of adjacent joints
6-8 weeks-consolidation occurs
- Still healing between fx sites
- Light resistance
- PROM
“Healing” can take up to one year-lifetime
- Mild swelling
- Pain
- Residual stiffness
Long term mobilization
Usually fine for kids since their ligaments and tendons are stretchy.
Long term mobilization for adults can cause cast disease.
- Cast disease: causes atrophy of musculature, immobility of companion joints (joints surrounding area)
Methods for immobilization
Splint
Cast
External fixators
- Clean pins - peroxide, alcohol
- Look for infection
K-wires (Kirschner wires) - pericutaneous (sticking out)
Pins, screws, prosthetics, may be included
Rotator cuff
Special tests:
- neer: forced flexion with internal rotation
- drop arm test: 90º slowly try to bring to side
- empty can test: in scaption, thumb down
Therapy used as a diagnosis instrument
Often immobilized
Functional activities ASAP
Isometrics
Codman’s
Tbar
Rule of nines
Cataracts
Decreased acuity
Difficulty seeing at night
Foggy appearance
Glaucoma
Increase pressure
Poor night vision
Loss of peripheral vision
Diabetic retinopathy
Loss of color
Loss of contrast
Poor night vision
#1 cause of blindness in the US
Preventable
Age related macular degeneration
Decreased acuity
Loss of central vision
