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OCCUPATIONAL THERAPY
Practice Skis forPhysical Dystunetion
Visit our website at www.mosby.com
UCCUPATIONAL
THERAPY
Practice Skil forPhysical Uystunetion
Edited by
LORRAINE WILLIAMS PEDRETTI, MS, OTR
Professor Emeritus, Department of Occupational Therapy
San José State University
San José, California

MARY BETH EARLY, MS, OTR/L

Professor, Occupational Therapy Assistant Program
LaGuardia Community College
The City University of New York
Long Island City, New York

FIFTH EDITION
With 53 contributors and 764 illustrations

N'A Mosby
An Affiliate of Elsevier Science
NA Mosby
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Editor: Kellie White
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FIFTH EDITION

Copyright © 2001 by Mosby, Inc.

Previous editions copyrighted 1981, 1985, 1990, 1996

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O39.04 05) CL/KPTS OS Sie Ome See

Carole Adler, BS, OTR Ann Burkhardt, MA, OTR/L, FAOTA, BCN
Occupational Therapy Supervisor Director of Occupational Therapy
Spinal Cord Injury Unit New York Presbyterian Hospital
Therapy Services Division Columbia Presbyterian Center
Santa Clara Valley Medical Center Associate Professor of Clinical Occupational Therapy
San José, California Programs in Occupational Therapy
Columbia University
Denis Anson, MS Professional Associate
Assistant Professor Mercy College
Occupational Therapy Department Dobbs Ferry, New York
College Misericordia
Dallas, Pennsylvania Cindy Maultsby Burt, MS, OTR
Assistant Director of Rehabilitation Services
Diane J. Atkins, OTR, FISPO Sport/Hand/Work Programs
Assistant Professor/Coordinator Department of Rehabilitation Services
Amputee Program 5 University of California-Los Angeles
The Institute for Rehabilitation and Research (TIRR) Los Angeles, California
Department of Physical Medicine and Rehabilitation
Baylor College of Medicine Gordon Umphred Burton, PhD, OTR
Houston, Texas Chair and Professor
Department of Occupational Therapy
Julie Belkin, OTR, CO, MBA San José State University
President San José, California
3-Point Products, Inc.
Annapolis, Maryland Sonia Coleman, MEd, OTR/L
Assistant Professor
Estelle B. Breines, PhD, OTR, FAOTA Department of Occupational Therapy and Occupational
Program Director, Occupational Therapy Science
School of Graduate Medical Education Towson University
Seton Hall University Towson, Maryland
South Orange, New Jersey
Teru A. Creel, MS, OTR/L
Wendy Storm Buckner, MHE, OTR/L Assistant Professor and Academic Fieldwork Coordinator
Assistant Professor Department of Occupational Therapy
Department of Occupational Therapy Medical College of Georgia
Medical College of Georgia Augusta, Georgia
Augusta, Georgia
 CONTRIBUTORS
Jan Zaret Davis, BS, OTR Lynn Gitlow, PhD, OTR/L
NDT Occupational Therapy Instructor in Adult Hemiplegia Department of Occupational Therapy
President, International Clinical Educators, Inc. Husson College
Port Townsend, Washington Bangor, Maine

Elizabeth DePoy, PhD, MSW, OTR Coralie H. Glantz, BS, OTR/L, FAOTA
Professor Glantz/Richman Rehabilitation Associates
Department of Social Work Riverwoods, Illinois
University of Maine
Orono, Maine Carolyn Glogoski, PhD, OTR
Associate Professor
Maureen Duncan, BA, BSOT, OTD Department of Occupational Therapy
Assistant Professor Program in Gerontology
Department of Occupational Therapy San José State University
Creighton University San José, California
Omaha, Nebraska
Sharon A. Gutman, PhD, OTR
Laura E. Dunlop, OTR/L Assistant Professor
Adjunct Instructor Department of Occupational Therapy
New York University Long Island University
Department of Occupational Therapy Brooklyn, New York
Clinical Specialist in Pain Management
Private Practice Including Consultation and Supervision Linda Gutterman, BS, OT
New York, New York Director
Rehabilitation and Holistic Health Service
Mary Beth Early, MS, OTR/L Village Center for Care AIDS Day Treatment Program
Professor New York, New York
Occupational Therapy Assistant Program
FE. H. LaGuardia Community College Diane Harlowe, MS, OTR, FAOTA
The City University of New York Associate Lecturer and Administrative Program Specialist
Long Island City, New York Occupational Therapy Program
University of Wisconsin-Madison
Joyce M. Engel, PhD, OTR/L, FAOTA Madison, Wisconsin
Associate Professor
Department of Rehabilitation Medicine Meenakshi B. Iyer, PhD, OTR
Division of Occupational Therapy Assistant Professor
University of Washington Department of Physical Therapy
Seattle, Washington Georgia State University
Atlanta, Georgia
Diane Foti, MS, OTR Adjunct Assistant Professor
Senior Occupational Therapist Department of Physical Therapy
Kaiser Permanente Medical Center University of Texas Health Science Center at San Antonio
Hayward, California San Antonio, Texas
Lecturer
San José State University Janet L. Jabri, MBA, OTR, FAOTA
San José, California National Director of Rehabilitation
GCI Rehabilitation Division
Patricia Ann Gentile, MS, OTR/L Pan Care, Inc.
Chief Occupational Therapist San José, California
The Jamaica Hospital Medical Center and The Brady Institute
of Traumatic Brain Injury Karen Nelson Jenks, MS, OTR
Jamaica, New York Occupational Therapist
Community Home Health
Glen Gillen, MPA, OTR, BCN Los Gatos, California
Instructor in Clinical Occupational Therapy
College of Physicians and Surgeons Mary C. Kasch, OTR, CHT, FAOTA
Columbia University Executive Director
New York, New York Hand Therapy Certification Commission
Kansas City, Missouri
 CONTRIBUTORS Vii

Denise D. Keenan, OTR, CHT Linda Anderson Preston, BS, OTR, BCN
Program Coordinator Clinical Specialist
IHC Hand Care Patricia Neal Outpatient Therapy Center
Sandy, Utah Roane Medical Center
Harriman, Tennessee
Amy Phillips Killingsworth, MA, OTR
Professor Sandra Utley Reeves, BS, OTR/L
Department of Occupational Therapy Staff Occupational Therapist
San José State University Department of Rehabilitation Services
San José, California Shands Hospital at the University of Florida
Gainesville, Florida
Regina M. Lehman, MS, OTR/L
Director Nancy Richman, BS, OTR/L, FAOTA
Department of Occupational Therapy Glantz/Richman Rehabilitation Associates
Coler-Goldwater Memorial Hospital Riverwoods, Illinois
Roosevelt Island, New York
Lynda M. Rock, MOT, OTR
Susan M. Lillie, BS, OTR, CDRS Formerly Unit Coordinator
Senior Occupational Therapist OT/PT Outpatient Services
Adaptive Driving Evaluation Program The Institute for Rehabilitation and Research
Department of Therapy Services Houston, Texas
Santa Clara Valley Medical Center
San José, California Charlotte Brasic Royeen, PhD, OTR, FAOTA
Associate Dean for Research
Maureen Michele Matthews, BS, OTR Professor in Occupational Therapy
Therapy Services Outpatient Program Manager School of Pharmacy and Allied Health Professions
Santa Clara Valley Medical Center Creighton University
San José, California Omaha, Nebraska

Guy L. McCormack, PhD, OTR, FAOTA Joyce Shapero Sabari, PhD, OTR, BCN
Chairperson and Associate Professor Associate Professor and Chair
Department of Occupational Therapy Occupational Therapy Program
Samuel Merritt College State University of New York
Oakland, California Downstate Medical Center
Brooklyn, New York
Patricia Ann Morris, OTR, BS ~

Senior Occupational Therapist Winifred Schultz-Krohn, MA, OTR, BCP, FAOTA

Department of Occupational Therapy/Supportive Services Assistant Professor
Wayne State University Department of Occupational Therapy
Detroit, Michigan San José State University
San José, California
Ed Nickerson, PT, OCS
Senior Physical Therapist Kathleen Barker Schwartz, EdD, OTR, FAOTA
Campus Commons Physical Therapy Professor
Sacramento, California Department of Occupational Therapy
San José State University
Lorraine Williams Pedretti, MS, OTR San José, California
Professor Emeritus
Department of Occupational Therapy Patricia Smith, MS, OTR, FAOTA
San José State University Director
San José, California Occupational Therapy Assessment and Modification
San José, California
Sara A. Pope-Davis, MOT, OTR/L
Occupational Therapist
Memorial Home Care
South Bend, Indiana
Joan Smithline, BS, PT Carol J. Wheatley, MS, OTR/L, CPCRT
Clinical Specialist Occupational Therapist
Stanford Health Services, Department of Rehabilitation Rehabilitation Technology Services
Services Maryland Rehabilitation Center
Stanford, California Division of Rehabilitation Services
Founder, Back On-Line Maryland State Department of Education
Work Place Design Baltimore, Maryland
Menlo Park, California
Lynn Yasuda, MSEd, OTR, FAOTA
Michelle Tipton-Burton, BS, OTR Interim Director
Occupational Therapy Supervisor Education and Staff Development
Day Treatment Program Rancho Los Amigos Medical Center
Therapy Services Division Downey, California
Santa Clara Valley Medical Center
Instructor Elizabeth June Yerxa, EdD, LHD, ScD, OTR, FAOTA
San José State University Distinguished Professor Emerita
San José, California Department of Occupational Science and Occupational
Therapy
Mary Warren, MS, OTR/L University of Southern California
Director Los Angeles, California
Visual Independence Program
Eye Foundation of Kansas City
Department of Ophthalmology, School of Medicine
University of Missouri-Kansas City
Kansas City, Missouri
Dye hcertareyel

To my mother (in memoriam), who taught me compassion.

To my father (in memoriam), who taught me to strive and honored my
achievements.
To my sister Mary, who nurtured my spirit and my intellect.
To my brother Lawrence, who was my hero and my advocate.
To my brother Julius (in memoriam), who was a role model for holiness,
goodness, and love.
To my sister Jean, who inspired me to take the risks that made this possible.

Lorraine Williams Pedretti

December 2000

To my mother, who showed me joy in doing.and pleasure in creating

To my father, who taught me to question and persevere.

Mary Beth Early

December 2000
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 uccessful rehabilitation of the adult with physical ment, oncology, special needs of the older adult, and
dysfunction requires the skillful collaboration of many HIV infection and AIDS.
participants: the patient, the family or significant others, This book is intended as a text for occupational
and a variety of health care professionals from a range of therapy students in baccalaureate and entry-level
disciplines. Occupational therapists contribute signifi- master’s degree programs and as a reference for occupa-
cantly to the achievement of successful rehabilitation tional therapy practitioners. The text has these aims:
outcomes. 1. To introduce the reader to occupational therapy prac-
Health care and rehabilitation today look very differ- tice in physical dysfunction
ent than in 1981, when the first edition of this text was 2. To prepare the student for occupational therapy prac-
published, and they continue to change. Increased pres- tice with adults who have acquired physical disabili-
sures for accountability and cost containment have ties
drastically altered the manner in which therapy services 3. To teach skills necessary for beginning practice in oc-
are provided and have shifted services away from the cupational therapy for physical dysfunction
hospital and into less expensive settings in the home 4. To provide a foundation for the development of clin-
and community. Funding limitations and health care ical reasoning skills
regulations now force therapists on a regular basis to The editors have assumed that the reader has mas-
make difficult choices about the extent, frequency, and tered foundation concepts in general psychology,
duration of treatment. Thus today’s occupational thera- anatomy and physiology, neuroanatomy and neuro-
pist must be prepared with a high degree of profession- physiology, kinesiology, human growth and develop-
alism, ethical judgment, clinical reasoning skills, cre- ment, medical terminology, conditions of orthopedic
ativity, adaptability, and _ resourcefulness. An and neurological dysfunction, and theories of occupa-
appreciation of the greater context in which health care tional therapy.
occurs is invaluable. The text is divided into six parts. Part One ad-
Since first published in 1981, this text has enjoyed a dresses models for practice, and history and practice
reputation for being practical, practice oriented, and trends. Part Two describes occupational therapy
tich in the technical details that clinicians seek. The process and practice (OT process, treatment contexts,
editors have sought to preserve this emphasis while also evaluation, treatment planning, evidence-based prac-
including information about the contemporary context tice, OT for prevention of injury and physical dysfunc-
of health care. In the fifth edition of this text the reader tion, teaching activities, documentation, and infection
is introduced to important changes in practice that have control and safety in the treatment environment). Part
occurred in recent years. Chapters new to this edition Three explores occupational performance and covers
include the occupational therapy process, treatment evaluation and intervention for the performance areas:
contexts, evidence-based practice, occupational therapy ADL, mobility, sexuality, work evaluation and work
in prevention programs, teaching activities, infection hardening, leisure activities, and assistive technology.
control and safety, occupational performance, leisure Part Four gives a detailed exploration of evaluation
activities, functional motion assessment, pain manage- and intervention for the performance components.

41
xil PREFACE

Topics covered include functional motion assessment, The reader might also survey the headings within the
range of motion, muscle strength, motor control, chapter before starting to read. Review questions at the
visual deficits, sensory dysfunction, perceptual motor end of chapters are intended to assist the student in
deficits, cognitive dysfunction, social and psychologi- mastering content, beginning to develop clinical rea-
cal factors, and pain management. Part Five introduces soning skills, achieving learning objectives, and prepar-
occupational therapy interventions for the perform- ing for evaluation of learning. Instructors may wish to
ance components and performance’ areas. These use the questions to construct examinations.
include therapeutic occupations and modalities, or- Sample case studies are included in each chapter in
thotics, and the sensorimotor approaches to treat- Part Six. These case studies serve as models of OT inter-
ment. Finally, Part Six provides treatment applications vention for the novice and are not meant to present a
for selected physical disabilities. These include cere- comprehensive treatment picture. An appendix at the
brovascular accident, traumatic brain injury, degenera- end of the book includes 12 case studies and a repro-
tive neurological diseases, dysphagia, spinal cord ducible treatment plan outline that can be used for
injury, neurogenic and myopathic dysfunction, arthri- classroom discussion, homework assignments, and in-
tis, hand and upper extremity injuries, hip fractures dividual and group treatment planning practice. Some
and lower extremity joint replacement, low back pain, of the case studies are based on patients seen in actual
burns, amputations, cardiac and pulmonary diseases, practice; however, all identifying information has been
oncology, special needs of older adults, and HIV infec- changed or deleted.
tion and AIDS. It is not possible to cover all of the The terms patient and client are used in this book to
physical disabilities that may be acquired in adult life. designate the consumer or recipient of occupational
Those chosen are often encountered in practice and therapy services. The use of one term or the other in an
employ principles of treatment that are applicable to individual chapter may reflect the practice context, as
similar disabilities. well as the preference of the particular contributing
Each chapter begins with key terms and learning author.
objectives and concludes with review questions. We
suggest that the reader preview the key terms and learn- Lorraine Williams Pedretti
ing objectives before turning to the text of the chapter. Mary Beth Early
W., this edition several new chapter contribu- and to Maureen Matthews, who graciously took on re-
tors are introduced. Many are nationally and interna- sponsibility for several chapters and who was instrumen-
tionally known experts in their disciplines. Administra- tal in identifying and helping with other contributors.
tors, educators, researchers, and master clinicians are To those publishers and vendors who permitted us to
represented. Our expert contributors, past and present, use material from their publications, we extend our
are gratefully acknowledged for their excellent work. sincere gratitude. Photographers and artists, and the pa-
Sincere appreciation is extended to Martha Sasser, tients and models who posed for photographs, are also
former Executive Editor, and Amy Christopher, former gratefully acknowledged.
Developmental Editor, for their guidance and support Finally, special appreciation is extended to our profes-
through the conception and development of the pro- sional colleagues, and to our families, Robert Pedretti,
posal and the manuscript. Kellie White, Executive Mark Pedretti, Robert Dehler, and Jeffrey Felipe Dehler,
Editor; Christie Hart, Developmental Editor; Leslie for their ongoing support, patience, and assistance.
Mosby, Associate Developmental Editor;, Christine
Lorraine Williams Pedretti
O’Brien and Rebecca Swisher, Assistant Editors; and
Mary Beth Early
Larry State and the production staff are gratefully ac-
knowledged for their continued assistance.
Gratitude is extended to Dr. A. Lee Dellon for review-
ing the chapter on sensation and sensory dysfunction

xiii
 PART ONE
HISTORY AND THEORY FOR THE TREATMENT OF PHYSICAL
DYSFUNCTION, 1
1 1. Occupational Performance and Models of Practice for Physical
Dysfunction, 3
LORRAINE WILLIAMS PEDRETTI and MARY BETH EARLY
2. History and Practice Trends in the Treatment of Physical Dysfunction, 13
KATHLEEN BARKER SCHWARTZ

PART TWO
OCCUPATIONAL THERAPY PROCESS AND PRACTICE, 19
3. The Occupational Therapy Process—An Overview, 21
MARY BETH EARLY ‘
4. Treatment Contexts, 29
MAUREEN MICHELE MATTHEWS and MICHELLE TIPTON-BURTON
5. Occupational Therapy Evaluation and Assessment of Physical
Dysfunction, 39
LORRAINE WILLIAMS PEDRETTI and MARY BETH EARLY
6. Treatment Planning, 46
LORRAINE WILLIAMS PEDRETTI and MARY BETH EARLY
7. A Model of Evidence-Based Practice for Occupational Therapy, 58
ELIZABETH DePOY and LYNN GITLOW
8. Occupational Therapy for Prevention of Injury and Physical
Dysfunction, 69
DIANE HARLOWE
9. Teaching Activities in Occupational Therapy, 83
JOYCE SHAPERO SABARI
10. Documentation of Occupational Therapy Services, 91
MAUREEN MICHELE MATTHEWS and JANET L. JABRI
11. Infection Control and Safety Issues in the Clinic, 101
WENDY STORM BUCKNER
 CONTENTS
PART THREE
OCCUPATIONAL PERFORMANCE AND THE PERFORMANCE AREAS:
EVALUATION AND INTERVENTION, 115
12. Occupational Performance, 117
MARY BETH EARLY
13. Activities of Daily Living, 124
DIANE FOTI
14. Mobility, 172
Section One Functional Ambulation
TERU A. CREEL
Section Two Wheelchair Assessment and Transfers
CAROLE ADLER and MICHELLE TIPTON-BURTON
Section Three Transportation, Community Mobility, and Driving Assessment
SUSAN M. LILLIE
15. Sexuality and Physical Dysfunction, 212
GORDON UMPHRED BURTON
16. Work Evaluation and Work Hardening, 226
CINDY MAULTSBY BURT
17. Americans With Disabilities Act: Accommodating Persons
With Disabilities, 237
PATRICIA SMITH

18. Leisure Activities, 249

CORALIE H. GLANTZ and NANCY RICHMAN

19. Assistive Technology, 257

DENIS ANSON

PART FOUR
EVALUATION AND INTERVENTION: THE PERFORMANCE
COMPONENTS, 277
20. Functional Motion Assessment, 279
AMY PHILLIPS KILLINGSWORTH and LORRAINE WILLIAMS PEDRETTI

21. Joint Range of Motion, 285

LORRAINE WILLIAMS PEDRETTI
22. Muscle Strength, 316
LORRAINE WILLIAMS PEDRETTI
23. Motor Control, 360
LINDA ANDERSON PRESTON

24. Evaluation and Treatment of Visual Deficits, 386

MARY WARREN

25. Evaluation of Sensation and Treatment of Sensory Dysfunction, 422

MEENAKSHI B. IYER and LORRAINE WILLIAMS PEDRETTI
26. Evaluation and Treatment of Perceptual and Perceptual Motor
Deficits, 444
CAROL J. WHEATLEY
27. Evaluation and Treatment of Cognitive Dysfunction, 456
CAROL J. WHEATLEY
28. The Social and Psychological Experience of Having a Disability:
Implications for Occupational Therapists, 470
ELIZABETH JUNE YERXA
29. Pain Management, 493
JOYCE M. ENGEL
 CONTENTS Xvil

PART FIVE
OCCUPATIONAL THERAPY INTERVENTIONS, 501
SECTION I The Biomechanical Approach
30. Therapeutic Occupations and Modalities, 503
ESTELLE B. BREINES
ag Orthotics, 529
Section 1 Hand Splinting: Principles, Practice, and
Decision Making
JULIE BELKIN
Section 2 Suspension Arm Devices and Mobile Arm Supports
LYNN YASUDA
SECTION II Sensorimotor Approaches
32. Traditional Sensorimotor Approaches to Treatment:
An Overview, 567
PATRICIA ANN GENTILE and MEENAKSHI B. IYER
33. The Rood Approach: A Reconstruction, 576
CHARLOTTE BRASIC ROYEEN, MAUREEN DUNCAN, and GUY L. MCCORMACK
34. Movement Therapy: The Brunnstrom Approach to Treatment
of Hemiplegia, 588
LORRAINE WILLIAMS PEDRETTI
35. Proprioceptive Neuromuscular Facilitation Approach, 606
SARA A. POPE-DAVIS
36. Neurodevelopmental Treatment of Adult Hemiplegia:
The Bobath Approach, 624
JAN ZARET DAVIS

PART SIX
TREATMENT APPLICATIONS, 641

37. Cerebrovascular Accident, 643

GLEN GILLEN
38. Traumatic Brain Injury, eval
SHARON A. GUTMAN
39. Degenerative Diseases of the Central Nervous System, 702
WINIFRED SCHULTZ-KROHN, DIANE FOTI, and CAROLYN GLOGOSKI
40. Dysphagia, 730
KAREN NELSON JENKS
41. Spinal Cord Injury, 767
CAROLE ADLER
42. Neurogenic and Myopathic Dysfunction, 792
REGINA M. LEHMAN and GUY L. MCCORMACK
43. Arthritis, 806
WENDY STORM BUCKNER
44. Hand and Upper Extremity Injuries, 833
MARY C. KASCH and ED NICKERSON
45. Hip Fractures and Lower Extremity Joint Replacement, 867
SONIA COLEMAN
46. Low Back Pain, 881
JOAN SMITHLINE and LAURA E. DUNLOP
47. Burns and Burn Rehabilitation, 898
SANDRA UTLEY REEVES
 CONTENTS
48. Amputations and Prosthetics, 924
Section One General Considerations of Upper and Lower Extremity Amputations
DENISE D. KEENAN and PATRICIA ANN MORRIS
Section Two Upper Extremity Amputations
Part1 Body-Powered Prostheses
DENISE D. KEENAN and LYNDA M. ROCK
Part 11 Electric-Powered Prosthesis
DENISE D. KEENAN and DIANE J.ATKINS
Section Three Lower Extremity Amputations
PATRICIA ANN MORRIS
49. Cardiac and Pulmonary Diseases, 966
MAUREEN MICHELE MATTHEWS
50. Oncology, 981
ANN BURKHARDT
SL. Special Needs of the Older Adult, 991
CAROLYN GLOGOSKI and DIANE FOTI
eee HIV Infection and AIDS, 1013
LINDA GUTTERMAN

APPENDIXES
One Sample Case Studies
Two Sample Treatment Plan Form
 TORYAND
:0'010):0s |
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TMENT OF

-cupational Performance and Modelsof

ctice for Physic | Dysfunction oo
 | Wumeleestetelearvevemylelerats
or Physical Dysfunction

LEARNING OBJECTIVES
Occupational performance After studying this chapter the student or practitioner
Domain of concern will be able to do the following:
Frame of reference 1. Define occupational performance.
Performance areas 2. Name the performance areas and performance
Performance components components.
Performance contexts 3. Compare the American occupational performance
Occupation model with the Canadian Model of Occupational
Occupational role Performance.
Occupations 4. List the intervention levels in the treatment
Purposeful activity continuum and give examples of the kinds of
Adjunctive methods intervention strategies that are used at each level.
Enabling activities 5. Define and compare frame of reference, theory, and
Intervention level conceptual model of practice.
Theory 6. Name and describe four models of practice that are
Model of practice used often to guide treatment intervention for
Model of human occupation physical dysfunction.
Biomechanical model 7. List four treatment approaches that are considered
Motor control model within the motor control model.
Rehabilitation model 8. List intervention strategies that are considered part
of the rehabilitation model.
9. Describe the kinds of physical dysfunction most
likely to be treated using the biomechanical model
and the motor control model.

ccupational performance is the domain of Also in this chapter, the scope of practice in physical dys-
concern of occupational therapy (OT). The elements of function is outlined on a continuum within the context of
the occupational performance domain of concern are the occupational performance. Additionally, a summary is
performance areas, performance components, and per- presented of models of practice most often used to guide
formance contexts, '* which are described in this chapter. clinical reasoning in physical disabilities practice.
 HISTORY AND THEORY FOR THE TREATMENT OF PHYSICAL DYSFUNCTION
OCCUPATIONAL PERFORMANCE
The elements of occupational performance are the
Occupational performance describes the content of performance areas, performance components, and
the OT process and the domain of concern in OT prac- performance contexts. The performance areas are (1) ac-
tice across specialty areas.”!* Work, play, and self-care tivities of daily living, (2) work and productive activities,
have always been the core of OT, but the performance and (3) play or leisure activities. Supporting these per-
components and scope of occupational performance formance areas are the performance components: (1) the
were further developed by a series of task forces and sensorimotor component, (2) the cognitive integration
committees of the American Occupational Therapy As- and cognitive components, and (3) the psychosocial
sociation (AOTA) in the 1970s.””* The current con- skills and psychological components. Performance of oc-
ception of occupational performance was generated cupation occurs within the temporal and environmental
from conceptualizations of professional practice and contexts’? in which tasks are performed (Fig. 1-1).
was originally described as a frame of reference for The Canadian Model of Occupational Performance
practice and for curriculum design in education.***" (CMOP) is similar to the American model. It includes
Subsequently, occupational performance terminology performance areas of self-care, productivity, and leisure,
was defined and standardized in official documents of and classifies occupation under these categories. The en-
the AQUA vironment consists of physical, social, cultural, and

OCCUPATIONAL PERFORMANCE

PERFORMANCE
CONTEXTS
Temporal/
Environmental

ADL WORK/ PLAY/

PRODUCTIVE LEISURE
(Self- ACTIVITIES
maintenance
tasks)

PERFORMANCE COMPONENTS

SENSORIMOTOR COGNITIVE/ PSYCHOSOCIAL/

COGNITIVE INTEGRATION PSYCHOLOGICAL

FIG. I-1I
Occupational performance: domain of concern. Based on uniform terminology for occupational
therapy, ed 3,Am J Occup Ther 48:1047-1054, 1994. (Diagram adapted from the American Occupa-
tional Therapy Association: A curriculum guide for occupational therapy educators, 1974.)
 Occupational Performance and Models of Practice for Physical Dysfunction

Performance Areas
institutional elements. Occupational performance is
described as “the result of interactions between the Activities of daily living (ADL), work and productive ac-
person, the environment and the occupation. The tivities, and play or leisure activities are the performance
person is seen as possessing physical, affective, and cog- areas. ADL include the self-maintenance tasks of groom-
nitive performance components, central to which is the ing, hygiene, dressing, feeding and eating, mobility, so-
essential core of being, the spiritual element.””” Spiritu- cialization, communication, and sexual expression.
ality as the central core of being is a unique feature of Work and productive activities include home manage-
the CMOP (Fig. 1-2).'”° ment, care of others, educational activities, and
Occupational performance refers to the ability to vocational activities. Play and leisure include play
perform those tasks that make it possible to carry out exploration and play or leisure performance in age-ap-
occupational roles in a satisfying manner appropriate propriate activities.*1**°
for the individual’s developmental stage, culture, and
environment.”*’°?* Occupational roles develop in
conjunction with the occupations that the individual
Performance Components
performs in the society. These include such roles as pre- Performance components are “the learned developmen-
schooler, student, parent, homemaker, employee, vol- tal patterns of behavior which are the substructure and
unteer, or retired worker.”** foundation of the individual’s occupational perform-
Occupational performance requires learning and ance.”*”’® Performance components include (1) the
practice opportunities specific to life roles and develop- sensorimotor component, (2) the cognitive integration
mental tasks and the use of all performance compo- and cognitive components, and (3) the psychosocial
nents. Deficits in task learning experiences, performance skills and psychological components.*””!* Adequate
components, or impoverished performance contexts neurophysiological development and integrated func-
may lead to limitations in occupational performance.” tioning of the performance components are basic to an

Environment

x
& Affective Occupation
inl
o
a)

Spirituality

Cognitive

Leisure

Person

FIG. |-2
The Canadian Model of Occupational Performance. From Enabling occupation: an occupational therapy
perspective, 1997. Reproduced with permission, CAOT Publications.
 HISTORY AND THEORY FOR THE TREATMENT OF PHYSICAL DYSFUNCTION

individual's ability to perform occupational tasks or ac- tional performance the OT program may include treat-
tivities in the performance areas.** ment methods designed for the remediation of deficits
The sensorimotor component includes three function or for the compensation for deficits in performance
types: sensory, neuromusculoskeletal, and motor. areas, performance components, and performance con-
Sensory functions include sensory awareness and pro- texts; in many cases both remediation and compensa-
cessing and perceptual processing. Neuromusculoskele- tion are used.” In a remediation approach, treatment is
tal functions include reflex responses, range of motion, focused on improving performance components. It is
muscle tone, strength, endurance, postural control, pos- assumed that improvement in performance compo-
tural alignment, and soft-tissue integrity. Motor func- nents (e.g., strength, visual perception, or cognitive
tions include gross coordination, crossing the midline, skills) can be expected and, in turn, will lead to im-
laterality, bilateral integration, motor control, praxis, fine proved functioning in performance areas. Examples of
coordination and dexterity, and oral motor control.'* remediation strategies are muscle _ strengthening,
The cognitive integration and cognitive components sensory reeducation, and cognitive retraining. When
refer to the ability to use higher brain functions. These improvement is not expected or a remediation ap-
components include level of arousal, orientation, recog- proach is not feasible, the compensation approach may
nition, attention span, initiation of activity, termination be used. The compensation approach focuses on re-
of activity, memory, sequencing, categorization, concept maining abilities and aims to improve function by
formation, spatial operations, problem solving, learn- adapting or compensating for performance component
ing, and generalization.'* deficits. Compensatory interventions might include
The psychosocial skills and psychological compo- strategies such as adapting methods of task performance
nents comprise the abilities for social interaction and to accommodate muscle weakness, providing assistive
emotional processing. In this category are values, inter- devices to compensate for limited joint motion, and
ests, self-concept, role performance, social conduct, in- changing the environment to accommodate limited
terpersonal skills, self-expression, coping skills, time mobility. '”77
management, and self-control.'* Because the achievement of functional independence
in performance areas is a core concept of OT theory and
the ultimate goal of the OT process, intervention strate-
Performance Contexts
gies must ultimately be directed to the patient's achieve-
Successful occupational performance occurs in the ment in performance areas'***® when a performance
context of the individual's cultural requirements and is component (e.g., motor skill development) is being
consistent with age and developmental stage.*” When addressed.
assessing function in performance areas, the occupa-
tional therapist must consider the performance contexts
Assumptions About Occupational
in which the patient must operate. The selection of ap-
Performance
propriate interventions is determined, in part, by the
performance context.'* The following are assumptions about occupational
Performance contexts have both temporal and envi- performance:
ronmental dimensions. Temporal dimensions include ® Occupational performance is essential to satisfactory
the individual’s age, developmental stage or phase of occupational role fulfillment.
maturation, and stage in important life processes such @ The development, performance, and maintenance of
~ as parenting, education, or career. Disability status (e.g., occupational performance are influenced by intraper-
acute, chronic, terminal, improving, or declining) must sonal and extrapersonal elements. Intrapersonal ele-
also be considered.'? ments include the temporal aspects of performance
Environmental dimensions are manifested in three contexts, as well as genetic, neurophysiological, and
frameworks: physical, social, and cultural. The physical pathological factors. Extrapersonal elements include
environment includes home, buildings, outdoors, furni- the physical environment, objects and tools, and
ture, tools, and other objects. The social environment social, cultural, and familial elements.
includes significant others and social groups. The cul- @ An appropriate balance in occupational performance
tural environment includes customs, beliefs, standards is essential for the maintenance of health.
of behavior, political factors, and opportunities for edu- @ Appropriate balance changes with chronological and
cation, employment, and economic support.'* developmental age, life cycle, and life events and
circumstances.
m™ Appropriate balance is personally chosen and may
Concerns of Occupational Therapy
vary widely from individual to individual.
The concerns of OT are the performance areas, perform- @ Failure in development of occupational performance
ance components, performance contexts, and occupa- or loss, disruption, or change of occupational roles
tional performance itself.”’*°°** To facilitate occupa- can arise from intrapersonal or extrapersonal factors.
 Occupational Performance and Models of Practice for Physical Dysfunction

@ Adequate occupational performance is dependent on pational roles. The treatment continuum identifies the
intact neurophysiological development®? and the in- concerns of OT practice within the context of occupa-
tegrated functioning of the sensorimotor, cognitive tional performance. Four intervention levels in the
integration and cognitive, and psychosocial and psy- treatment continuum are described as follows:
chological subsystems of the individual.
™ Defect, disease, or injury affecting any performance
component may lead to a failure of integration of the
performance component subsystems and results in a
failure or disruption in the performance areas and Procedures that prepare the patient for occupational
thus a failure or disruption in satisfying fulfillment of performance but are preliminary to the use > of a
occupational roles. ful activity are concerns of ae ne
@ The role of the occupational therapist is to facilitate
both an appropriate balance and optimum occupa-
tional performance toward the resumption of occu-
pational roles. ang sense
m@ The occupational therapist is concerned with com- s and de vices are often used in (but arenot
pensation for deficits in the performance areas and d to lransbetessiaccesof illness or injury. When
remediation of performance components. using these methods Be occupational Speistitslisis
@ The primary treatment tool of the occupational thera- aoe) toabe most con
pist is purposeful activity.
@ Other treatment tools of the occupational therapist cueanional Rages toaE ie progression of treat-
include adjunctive methods and enabling activities, ment so that adjunctive modalities are used as
described below, that are used to prepare the patient aration for purposeful activity and are directed
for function in the performance areas.*' rd maximum independence
in the performance
@ Exclusive use of such preparatory methods out of
context of the patient's occupational performance is
not considered OT.
Intervention Level Two:
Enabling Activities.
TREATMENT CONTINUUM IN THE
Many methods used in OT may not be considered pur-
CONTEXT OF OCCUPATIONAL
poseful activity but may be steps toward ability to
PERFORMANCE
perform purposeful activities. Such methods are re-
As OT has become less dependent on medical direc- ferred to as enabling activities. Purposeful activity has
tion, its role has expanded considerably. Occupational an autonomous or inherent goal beyond the motor
therapists have developed and demonstrated compe- function required to perform the task’* and requires the.
tence in many specialized practice areas associated with active participation of the patient.”’'* Many patients are
physical dysfunction. The occupational therapist's not ready for activity at this NeHORNANCE level
concern, from the onset of the illness or injury, is for Occupational therapists have created many enabling
the patient to become as independent as possible in devices and methods that simulate purposeful activi-
the performance areas and to resume previous occupa- ties, such as sanding boards, skate boards, stacking ©
tional roles or to assume new and satisfying occupa- cones or blocks, practice boards for mastery of clothing v.

tional roles. In the treatment of many physical disabil- fasteners and hardware, driving simulators, work simu-
ities OT intervention may begin at the time of surgery lators, and tabletop activities such as form boards for
or in the early stages of acute care and continue training in perceptual-motor skills. Such devices and
through the final stages of rehabilitation. Thus OT can activities are not likely to be as meaningful to the
make an important contribution at every level in the patient or to stimulate as much interest and motivation
treatment continuum.*” as purposeful activities. They may be needed, however,
Fig. 1-3 shows a conceptualization of the treatment asa" preparatory or ancillary part of the treatment
continuum in physical disability practice. The contin- program to train patients in specific sensorimotor, per-
uum consists of four levels of intervention or interven- ceptual, or cognitive functions necessary for activities in
tion categories.’” The levels in the continuum overlap, the performance areas.
or can occur simultaneously. The treatment continuum “Such equipment as wheelchairs, ambulatory aids,
is not a strict step-by-step progression. It addresses the special clothing, communication devices, environmen-
performance components and performance areas of oc- tal control systems, and other assistive devices may also
cupational performance and takes the patient through a be enabling» These devices can be important for increas-
logical progression from dependence to occupational ing independence in the performance areas and as-
performance to resumption of valued social and occu- sumption of occupational roles.
a Cisvory AND THEORY FOR THE TREATMENT OF PHYSICAL DYSFUNCTION

ADL
t%

Se =a
Occupational Work/
performance/ productive a <= Sensorimotor
Occupational activities
roles <== Cognitive/cognitive
Play/leisure integration

<= Psychosocial/
psychological

INTERVENTION
LEVEL 4

OCCUPATIONS

INTERVENTION
LEVELS

PURPOSEFUL
ACTIVITIES

INTERVENTION
LEVEL 2

ENABLING
ACTIVITIES

INTERVENTION
LEVEL 1

ADJUNCTIVE
METHODS

FIG. 1-3
Treatment continuum in occupational performance.

At intervention level two the therapist is still con- giene, dressing, mobility, communication, arts, crafts,
cerned with assessment and remediation of perform- games, sports, work, and educational activities.
ance components and begins to assess and teach activi- The individual performing the activity determines its
ties in the performance areas. purposefulness. Purposefulness is also affected by the
context in which the activity is performed. OT practi-
Intervention Level Three: ° tioners use purposeful activities to evaluate, facilitate,
restore, or maintain a person’s ability to function in life
Purposeful Activity»
roles.'* Purposeful activity is used to enhance function-
Purposeful activity has been the core of OT since its Hi ing in the performance areas. The OT practitioner carries
ception. Purposeful activity includes activities that have out treatment with purposeful activity in a health care
an inherent or autonomous goal and are relevant and facility, a community agency, or the patient's home. At
meaningful to the patient:’* Purposeful activity is part this level the OT practitioner is concerned primarily
of the daily life routine and occurs in the context of with assessing and remediating deficits in the perform-
occupational performance.'* Examples are feeding, hy- ance areas.
 Occupational Performance and Models of Practice for Physical Dysfunction

Intervention Level Four: Occupations — Model

The highest stage of the treatment continuum engages Mosey defined model’as “the typical way in which a pro-
the patient in natural occupations in his or her living fession perceives itself, its relationship to other profes-)
environment and in the community.'° The patient per- sions.and its association with the society to which itis
forms appropriate tasks of ADL, work and productive resp °* The model is characterized by “a de-
activities, and play and leisure to his or her maximum eanptin % the profession’s philosophical assumptions,
level of independence. Involvement in scheduled OT ethical code, theoretical foundation, domain of
decreases and ultimately ends as the individual resumes concern, legitimate tools, and the nature of and princi-
and effectively performs valued occupational roles. ples for sequencing the various aspects of practice.”**
Christiansen’® defined a model as a way of “structur-
ing or organizing knowledge for the purpose of guiding
CONCEPTUAL SYSTEMS
thinking.” The purpose of a model is to help the practi-
The practice of OT in physical dysfunction should be tioner analyze situations, determine methodologies,
guided by a unifying conceptual system. Frames of refer- and conceive alternatives—in other words, to provide
ence, theories, and models can be used as conceptual guidelines for practice. The use of a model in practice
systems. These three terms are sometimes used inter- can be the basis for theory development.'®
changeably, and there is no universal agreement on their Kielhofner referred to “conceptual models of prac-
definitions.'*Theories, models, and frames of reference tice.”** He stated that the purpose of conceptual models
have been described for OT by Fidler,** Mosey,**** is to provide specific prescriptions for practice. He stated
Reilly,** Kielhofner,***’** Ayres,*? Llorens,** Gilfoyle that “a conceptual practice model presents and organ-
and Grady,” King,*® Allen,’ and Schkade and Schultz,”? izes a number of theoretical concepts used by therapists
among others. in their work.”*4
Several models of practice are used in OT. Some of
these have also been referred to as treatment ap-
Frame of Reference
“proaches.**°° Each conceptual practice model ad-
According to Mosey,** a frame of reference is derived dresses a specific area of human function and is based
from a profession’s model and guides interaction with on a theory that explains the organization and order
clients. She defined frame of reference as “a
setof interre- © of some aspect of human function on which the
in LeTT) ally consistent concepts, definitions, and- model focuses. More than one practice model is
that provides a systematic description of or» needed to address the broad range of OT’s domain of
presctrif Or a practitioner's interaction within a par- concern.~* The practice models summarized below are
Waaibisaspet of a profession’s domain of concern.”** those considered to be used most often (though not
tames of reference link theory to practice and must exclusively) and most applicable in physical disabili-
meet certain criteria to be considered frames of refer- ties practice.
ence. Mosey saw a frame of reference as a guide rather
than a formula for action.** MODELS OF PRACTICE
Model of Human Occupation
Theory
The Model of Human Occupation (MOHO)*?~*’ applies
ee principles and relationships 3s to all aspects of occupational performance, not just the
edict or explain phenomena under specified physical. Itis a systems model, in which the human being
onditions. 18 Mosey?4 stated that theory development engaged in occupation expresses a complex interaction of -
occurs through direct observation or through ee aspects that cannot be fully comprehended when viewed
ulation about the relationships between events.** Ac- separately. Engagement in occupation requires three sub-
cording to Reed*’ “theory attempts to (1) define and systems intricately linked to produce performance: the vo-
explain relationships between concepts or ideas re- lition subsystem (personal causation, values, interests), the
lated to the phenomenon of interest [occupational en- habituation subsystem (habits and roles), and the perform-
deavor in occupational therapy], (2) explain how ance subsystem (the skills of the mind, brain, and body
these relationships can predict behavior or events, and working together). Engagement in occupation occurs
(3) suggest ways that the phenomenon can be within the environment, which constantly provides ©
changed or controlled.”*’ OT theory is concerned with feedback and information that intimately and dynami- ©
concepts
the of person, environment, health, and oc- cally influence the three subsystems and their product—
c . OT and other practice professions must have occupational performance. —
— base that can be translated into specific Assessment and intervention within MOHO may
guidelines for practice and continuously examined for address any of the subsystems, or their constituent parts,
their effectiveness.*”
 HISTORY AND THEORY FOR THE TREATMENT OF PHYSICAL DYSFUNCTION

or the environment, or any combination of these. The

concepts defined within the volition subsystem allow
the therapist to consider motivational factors. The
patient with a weak sense of personal causation?°—
feelings of competence and belief in one’s own ability
to be effective—may respond better to a therapeutic ap- 7 —n vill
proach that is highly directive and authoritarian than to tcenaomsboshaneinaloetunit or orthopedic disorders but
one that is more collaborative and puts the burden of
responsibility on the patient. ; tients can canto isolated movement and specific
The habituation subsystem is relevant to any inter- movement patterns, but have weakness, low endurance,
vention plan that requires a patient to develop or or joint limitation. Examples of such disabilities are or-
relearn habits or roles. For example, a consideration of thopedic dysfunctions, including rheumatoid arthritis,
habit maps*°—how habits are constructed and cued by osteoarthritis, fractures, amputations, hand trauma,
features of the temporal environment—may assist the burns, and motor unit disorders, such as peripheral
therapist in creating and refining a compensatory strat- nerve injuries, Guillain-Barré syndrome, spinal cord in-
egy to maximize functional independence in a patient juries, and muscular dystrophy.
who is relearning grooming routines after a head nanical met adsofevalmtiamandte atment
injury. The concept of role scripts*°—an internalized are directed primarily at restoring sensorimotor compo-
sense of how a role is understood and how it should nents. Many of the adjunctive or enabling techniques and
be translated into action—may help the therapist modalities are also biomechanical, and biomechanical
analyze how an individual approaches a particular oc- principles can also be applied to purposeful activity in the
cupational role. performance areas. For example, the activities of sawing
Altering features of the environment to elicit a wood, rolling out dough, and vacuuming carpets rely on
change in occupational performance is a key principle biomechanical principles for their actions and therapeu-
of MOHO. The following types of change are tic effects when used to improve physical performance.
employed?°: Before the motor control model of treatment
1. Purposeful alteration of the physical setting (e.g., evolved, therapists tried to apply biomechanical princi-
adding aramp) ples to patients with damaged central nervous systems
2. Providing a new object (e.g., equipping the patient and met with many problems as a result. Because bid-
with a reacher to grasp objects out-of arm’s reach) ~ mechanical treatment requires controlled voluntary,
3. Providing or facilitating a change in social groups movement, it is inappropriate for patients who |
(e.g., training the caregiver to break down and cue a such control.
sequence such as brushing teeth)
4. Arranging for the patient to experience new occupa-
Motor Control Model
tions (e.g., using a computer to access the internet)
A further principle of intervention in the model of The motor control model is used with persons who have
human occupation is that “change is often disor- CNS dysfunction. Four approaches to treatment, vari-
derly.”*° Therapeutic progress is therefore not linear and ously referred to as the sensorimotor or neurodevelop-
predictable but may meander and fluctuate as the mental approaches, are included in this model.** These
patient seeks to establish a new balance in occupational four approaches are based on theories of CNS develop-
performance. The model of human occupation may be ment and motor recovery.*° The normal CNS produces
useful in combination with any of the models ad- controlled, well-modulated movement. In the damaged
dressed below. CNS, coordination and well-modulated, controlled
movement are not possible. Methods of treatment in
sensorimotor approaches use neurophysiological mech-
Biomechanical Model
anisms to normalize muscle tone and elicit more normal
The biomechanical model for the treatment of physical ” motor responses.*”*? Some approaches use reflex mech-
dysfunction applies the mechanical principles of kinet- anisms, and the sequence of treatment may be based on
ics and kinematics to the movement of the human the recapitulation of ontogenetic development.*°
body.**°° These mechanical principles deal with the Chapters 32 through 36 describe the sensorimotor ap-
way that forces acting on the body affect movement and proaches of Rood, Brunnstrom (movement therapy),
equilibrium.'° Methods of treatment in this model use Knott and Voss (proprioceptive neuromuscular facilita-
principles of physics related to forces, levers, and torque. tion), and Bobath (neurodevelopmental treatment).
Examples of biomechanical techniques are joint ~ All of the sensorimotor approaches are directed to
measurement, muscle strength testing, kinetic activity, — motor recovery and improvement of motor perform-
 Occupational Performance and Models of Practice for Physical Dysfunction

ance. They do not consider motivation, arousal, atten- @ Wheelchair management

tion, role dysfunction, or temporal adaptation and the @ Work simplification and energy conservation
influence of these factors on motor behavior.”° @ Work-related activities
Sensorimotor treatment principles can also be Frequently the methods of the rehabilitation model
applied to purposeful activity, as described in Chapters are used in combination with methods of the biome-
33 through 36. Sensorimotor treatment methods may chanical or motor control model. Biomechanical or
be used “to prepare the client or patient for better per- sensorimotor principles can be applied during rehabili-
formance and prevention of disability through self- tation activities to enhance and reinforce the restoration
participation in occupation.”* When used to precede of the sensorimotor and cognitive components. Further,
and enable purposeful activity, and as part of purpose- the treatment program often focuses on performance
ful activity, sensorimotor methods can be a valuable aid areas and performance components simultaneously.
in restoring occupational performance. Thus the combined restoration of sensorimotor, cogni-
tive, and psychosocial functions improves functioning
Model in the performance areas.

The term rehabilitation means a return to ability, that is,

the return to the fullest physical, mental, social, voca-
SUMMARY
tional, and economic usefulness that is possible for the Occupational performance describes the domain of
individual. It means the ability to live and work with re- concern for OT practice. The treatment continuum, con-
maining capabilities.** Therefore the focus in the treat- ceptualized within an occupational performance frame-
ment program is on abilities rather than on disabilities. work, accommodates a broad spectrum of OT from
Rehabilitation is concerned with the intrinsic worth acute care to long-term rehabilitation. It also encom-
and dignity of the individual and with the restoration passes the wide range of modalities used in OT practice
of a satisfying and purposeful life. The rehabilitation for physical disabilities.
model uses measures that enable the patient to live as The OT practitioner uses a suitable practice model or
independently as possible with some residual disabil- models to guide clinical reasoning in evaluation and
ity. Its goal is to help the patient learn to work around treatment planning. The OT practitioner assesses per-
or compensate for physical, cognitive, or perceptual formance areas, performance components, and per-
limitations.*° formance contexts and then identifies assets, skills, and
The rehabilitation model is a dynamic process and deficits in the individual’s occupational roles and role
requires that the patient be a member of the rehabilita- dysfunction. Guided by the selected practice model or
tion team. It requires ongoing assessment and follow- models, OT practitioners select goals, objectives, and in-
up to maintain maximum function and therefore must tervention strategies designed to restore the patient to
keep pace with advances in methods and equipment his or her maximum level of performance in valued oc-
(rehabilitation technology), social change, and commu- cupational roles.
nity resources to provide the best services and opportu-
nities for each patient.”*
Using this model, OT focuses on performance areas
REVIEW QUESTIONS
more than on performance components. The aim of the 1. Briefly outline the elements of the occupational
OT program is to minimize disability barriers to role performance domain of concern.
performance. The occupational therapist. must assess 2. Define model, theory, and frame of reference.
the patient's capabilities and determine how to over- 3. What is the purpose of a model?
come the effects of the disability. The treatment 4. What is the difference between a performance area
methods of the rehabilitation model include modalities and a performance component? How are they related?
such as the following: 5. Define occupational role. Give some examples.
® Acquisition of and training in the use of assistive 6. Select one of your occupational roles and list all of
technology the tasks in each of the performance areas that are
= Adaptive clothing necessary to fulfill that role.
@ Architectural adaptations 7. List the levels in the treatment continuum and give
# Community transportation examples of treatment modalities that might be
Home evaluation and adaptation used in each.
Homemaking and child care 8. Define enabling activities as used in this chapter.
Leisure activities 9. Relate the MOHO concepts of personal causation,
Prosthetic training habit map, and role script to one of your occupa-
Self-care evaluation and training tional roles.
 HISTORY AND THEORY FOR THE TREATMENT OF PHYSICAL DYSFUNCTION

10. Which treatment modalities can be thought of as 17. Canadian Association of Occupational Therapists: Occupational
primarily biomechanical in nature? therapy guidelines for client-centered practice, Toronto, Canada, 1991,
The Association.
Ai With which diagnoses is a biomechanical model 18. Christiansen C: Occupational therapy, intervention for life per-
most likely to be used? Why? formance. In Christiansen C, Baum C: Occupational therapy: over-
12: For which diagnoses is the motor control model coming human performance deficits, Thorofare, NJ, 1991, Slack.
most likely to be effective? 19. Culler KH: Home and family management. In Hopkins HL, Smith
13. How can the sensorimotor approaches be inte- HD: Willard & Spackman’s occupational therapy, ed 8, Philadelphia,
1993, JB Lippincott.
grated in an occupational performance framework? 20. Di Joseph LM: Independence through activity: mind, body, and
14. Describe the rehabilitation model. environment interaction in therapy, Am J Occup Ther 36:740,
15: List six treatment modalities that are within the re- 1982.
habilitation model 218 Gilfoyle E, Grady A: Children adapt, ed 2, Thorofare, NJ, 1989,
16. How is the rehabilitation model integrated with the Slack.
Ap) Holm MB, Rogers JC, James AB: Treatment of activities of daily
other models of practice discussed in this chapter? living. In Neistadt M, Crepeau EB: Willard & Spackman’s Occupa-
tional Therapy, ed 9, Philadelphia, 1998, JB Lippincott.
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 ractice Trends in the Treatment
Jiensteureye

LEARNING OBJECTIVES
Moral treatment After studying this chapter the student or practitioner
Rehabilitation model will be able to do the following:
Medical model 1. Trace the ideas, values, and beliefs that have
Reductionism influenced the development of occupational therapy
Arts and crafts movement (OT) as a profession.
Scientific management 2. Understand how the history of the profession has
contributed to the opportunities and challenges that
physical disabilities practitioners face today.

ROOTS OF OCCUPATIONAL THERAPY’

The founders of occupational therapy (OT) shared a the unity of mind and body, and belief that a humane
belief in the value of occupation. However, they each approach using daily routine and occupation could lead
had somewhat different views of practice, depending on to recovery.’ Moral treatment represented a shift in
their particular disciplines. William Rush Dunton was a thinking from a pessimistic viewpoint that labeled the
psychiatrist, Herbert J. Hall was a physician, Eleanor mentally ill as subhuman and incurable to an opti-
Clarke Slagle came from a background in social welfare, mistic one that viewed the mentally ill as capable of
Susan Johnson was a former arts and crafts teacher, reason and able to respond to humane treatment.
Thomas Kidner and George Barton were former archi- Dr. Benjamin Rush, an American advocate of moral
tects, and Susan Tracey was a nurse. These people were treatment, believed that occupations should “engage
also influenced by ideas and beliefs prevalent during the the mind, and exercise the body: as swinging, riding,
latter part of the 19th century and the early years of the walking, sewing, embroidery, bowling, gardening, me-
20th. The three ideologies that seemed to have most chanic arts; to which may be added reading, writing,
shaped the profession’s development were moral treat- conversation, etc., the whole to be performed with
ment, arts and crafts, and scientific management. order and regularity.”*° Dr. Thomas Kirkbride of the
Pennsylvania Hospital for the Insane described moral
treatment as daily routine to provide “active movements
Moral Treatment
and diversity of occupations” such as agricultural pur-
Moral treatment originated in 19th-century Europe and suits, carpentry, painting, and manual crafts.*” Moral
was promoted by physicians such as Philippe Pinel and treatment as provided in small asylums was initially
Samuel Tuke. The main features of this philosophy in- successful. However, overcrowding and financial diffi-
cluded respect for human individuality, acceptance of culties eventually reduced treatment to custodial care.
 HISTORY AND THEORY FOR THE TREATMENT OF PHYSICAL DYSFUNCTION

Building on these ideas half a century later, the

Scientific Management
famous neuropathologist Adolf Meyer proposed that Frederick Taylor, a prominent engineer, introduced his
many illnesses were “problems of adaptation” that theory of scientific management in 1911.°* He pro-
could be remediated through involvement in curative posed that rationality, efficiency, and systematic obser-
occupations.”" Dunton and Slagle enthusiastically vation could be applied to industrial management and
supported this view, and Meyer’s philosophy of OT to all other areas of life, including teaching, preaching,
was published in the first issue of the profession’s and medicine. Progressive reformers of the period advo-
journal. Slagle, who worked with Meyer at Phipps cated that the ideology of scientific management
Clinics, developed habit training programs in mental address societal problems such as poverty and illness.
hospitals to reestablish healthy habits of self-care and These reformers criticized the noisy, dirty asylum of the
social behavior.*® 19th century and urged that the image of medical care
be transformed into the clean, efficient hospital.’ The
idea that knowledge could be developed through re-
Arts and Crafts
search and observation and applied to patient care
The rise of the arts and crafts movement in the 1890s became an underlying tenet of the science of medicine
was in reaction to the perceived social ills created by the and ultimately resulted in the development of reliable
Industrial Revolution.’ The economy was changing protocols for surgical and medical interventions.**
from an agrarian to a manufacturing society, so that The founders of OT were attracted to the idea of a sci-
what had previously been made by hand was now pro- entific approach to treatment. Barton was particularly
duced in factories. Proponents of the arts and crafts taken with Taylor's time and motion studies and
movement asserted that this resulted in a society of dis- thought they might provide a model for OT research.*
satisfied workers who were bored by monotonous and Dunton advocated that those who entered the profes-
repetitive working conditions. sion be capable of engaging in systematic inquiry in
The use of arts and crafts as a therapeutic medium in order to further the profession’s goals.'° Similarly, Slagle
OT arose from this trend. The arts and crafts approach urged research in OT to validate OT’s efficacy.*° By 1920
was based on the belief that craft work improved physi- the profession was promoting the notion of the
cal and mental health through exercise and the satisfac- “science” of occupation by calling for “the advancement
tion gained from creating a useful or decorative article of occupation as a therapeutic measure, the study of the
with one’s own hands. According to Johnson, the thera- effects of occupation upon the human being, and the
peutic value of handicrafts lay in:their ability to provide dissemination of scientific knowledge on this subject.”®
occupation that stimulated “mental activity and muscu- There is little in the OT literature of the early 20th
lar exercise at the same time.”’° Different handicrafts century to suggest that OT practice was informed by sys-
could also be graded for the desired physical and tematic observation. One exception was the Depart-
mental effects. Crafts were successfully used by OT re- ment of Occupational Therapy at Walter Reed Hospital
construction aides during World War I for the physical in Washington, D.C., under the direction of psycholo-
and mental restoration of disabled servicemen.*’ For gist Bird T. Baldwin.* OT reconstruction aides were as-
treating tuberculosis, Kidner advocated a graduated ap- signed to the orthopedic ward, where methods of sys-
proach that began with bedside crafts and habit training tematically recording range of motion and muscle
and proceeded to occupations related to shop work and strength were established. Activities were selected based
ultimately actual work within the institution.'® on an analysis of the motions involved, including joint
Thus the ideas from the moral treatment and arts and position, muscle action, and muscle strengthening.
crafts movements became intertwined as a definition of Methods of adapting tools were suggested, and splints
OT evolved to include treatment of individuals with were fabricated to provide support during the recovery
physical and mental disabilities. In its early years OT process. Treatment with this systematic approach was
worked with patients throughout three stages of recov- more narrowly focused at times but was applied within
ery.'* During convalescence, patients would engage in the context of what Baldwin called “functional restora-
bedside occupations that primarily consisted of handi- tion,” in which OT’s purpose was to “help each patient
crafts such as embroidery and basket weaving. Once pa- find himself and function again as a complete man [sic]
tients were able to get out of bed, they would engage in physically, socially, educationally, and economically.”
occupations designed to strengthen both body and Besides advocating a scientific approach to practice,
mind, such as weaving or gardening, and occupations the scientific management ideology emphasized eff-
designed to reestablish basic habits of self-care and ciency and a mechanistic approach to medical care.
communication. When they were almost ready to return Using the factory analogy, patients were the product,
to the community, patients would engage in occupa- and nurses and therapists were the factory workers. It
tions that would prepare them for vocational success, was assumed that doctors had the most scientific knowl-
such as carpentry, painting, or manual crafts. edge and therefore should be positioned at the top of
 History and Practice Trends in the Treatment of Physical Dysfunction

the medical hierarchy. Dunton, a physician himself, cluding occupational and physical therapy, psychologi-
seemed to support this arrangement: “The occupational cal, social and vocational.”*° The passage of legislation
therapist, therefore, has the same relation to the physi- establishing Medicare and Medicaid in 1965 put further
cian as the nurse, that is, she is a technical assistant.” As demands on rehabilitation services to serve the chroni-
the profession evolved, an emphasis on efficiency and cally ill and elderly within health care institutions, as
deference to medical authority became problematic for well as the community.
the profession. The focus on science and the resulting
growth of the medical model were both beneficial and
detrimental to OT practice. Physical Dysfunction as a Specialty
The creation of a specialty in physical dysfunction came
EXPANSION AND SPECIALIZATION about as a response to the changing demands of the
marketplace and its requirement that specialists possess
The Rehabilitation Model
particular kinds of medical knowledge and technologi-
The growth of the rehabilitation model began after cal skills.'* This new specialty began with an increasing
World War II and peaked with the health care industry focus on occupations that would promote physical
boom in the early 1970s, following the passage of bills strength and endurance: “The Army is death on the old-
establishing Medicare and Medicaid. Although this time invalid occupations of basket weaving, chair
growth was initially driven by the need to treat the caning, pottery and weaving. These are ‘not believed to
country’s wounded soldiers, care of injured and chroni- be interesting occupation for the present condition of
cally ill civilians also became a concern. men in military service, says an officer from the Surgeon
World War II revived the need for the United States General's office. The stress now is on carpentry, repair
to provide medical care for its wounded soldiers. Many work at the hospital, war-related jobs like knitting cam-
more soldiers survived than in World War I because of ouflage nets, and printing.””
recent scientific discoveries such as sulfa and penicillin. The scientific approach of joint measurement and
The Second World War also served to highlight the muscle strengthening that Baldwin pioneered at the
value of OT services: “Although occupational therapy end of World War I was adopted and improved upon.
started during the last World War, it developed slowly As Claire Spackman wrote, “Communication of new
[until] now when doctors are finding this aid to the sick or improved techniques. . . [was] of vital importance.
and wounded invaluable.”**A major effort was The work of the past had been empirical, now the ther-
launched to reorganize and revitalize the Veterans Ad- apists had the task of. . . becom[ing] highly skilled in
ministration (VA) hospital system. Departments of the treatment of specific types of cases.”*’ According to
physical medicine and rehabilitation were created to Spackman, the occupational therapists serving people
bring together all the services needed to care for the with physical disability needed to be skilled in teach-
large number of war injured. “The theory that handi- ing activities of daily living (ADL), work simplifica-
capped persons can be aided by persons who under- tion and rehabilitation techniques for the handi-
stand their special needs originated during World War capped homemaker, and training in the use of upper
II. The armed services established such hospitals for extremity prostheses. But first and foremost, she as-
disabled veterans as the one for paraplegics in Birmin- serted, “Occupational therapy treats the patient by
ham, California. They helped the morale and physical the use of constructive activity in a simulated,
condition of the patients so much that others were normal living and/or working situation. . . . Con-
built for civilians.””° structive activity is the keynote of occupational
The interdisciplinary approach to care was emulated therapy.”
in the private sector. Demand for medical services in- As the rehabilitation movement helped to establish
creased in the civilian population as the treatment of the importance of OT, it further positioned the pro-
chronic disability became a priority. Howard Rusk, a fession within the medical model. OT was urged to
prominent voice in the development of rehabilitation specialize and separate into two distinct fields, physi-
medicine, asserted that the critical shortage of trained cal dysfunction and mental illness. The head orthope-
personnel would impede the country’s ability to deliver dist at Rancho Los Amigos Hospital in Downey, Cali-
services to the “5,300,000 persons in the nation who fornia argued that the separation would result in
suffer from chronic disability.”'’ He cited OT as one of “strengthened treatment techniques” and thus more
the essential rehabilitation services. In response to the credibility among medical doctors. He asserted that
growing demand for rehabilitation services, Congress “the medical profession in general does not recognize
passed the Hill-Burton Act in 1946 to provide federal your field as an established necessary specialty.”'* The
aid for the construction of rehabilitation centers. A American Occupational Therapy Association sought
proviso of the legislation was that rehabilitation centers closer ties with the American Medical Association to
must “offer integrated services in four areas: medical, in- gain more credibility. The following quote indicates
 HISTORY AND THEORY FOR THE TREATMENT OF PHYSICAL DYSFUNCTION

the difficulties the profession faced in defining and to tell only part of the story. As this chapter describes,
promoting itself: the founders were influenced by at least two other ide-
ologies, scientific management and arts and crafts, both
Both occupational and physical therapy have taken some selling— of which could be placed in the reductionistic para-
to the medical profession as well as to the public. Many hospitals digm. Scientific management's focus was definitely re-
have still to discover occupational therapy. Some die-hard MDs, ductionistic, with its ideas about efficiency and system-
reluctant to see its medical implication, still think a lot of it is atic observation. Handicrafts were frequently used in a
boondoggling, and there’s been a lot of confusion about its func-
manner consistent with the medical model when they
tion. Occupational therapy is not giving someone something to
were prescribed for a particular disability. Indeed, the
do just to keep him happy. It is not vocational training. It is not
making pretty things to sell. All of these have therapeutic value as
Committee on Installations and Advice, directed by
morale builders but they're not occupational therapy. As defined Dunton, was formed to analyze the most commonly
by the American Medical Association, occupational therapy is used crafts and to match the therapeutic value of each
treatment for illness or disability through remedial work activity craft to a particular symptom or disability.7°
prescribed by a doctor and directed by trained technicians." The question arises as to how the founders could
have supported competing visions of practice. The
The closer relationship with medicine probably answer may be that the models were not considered at
helped the profession gain credibility, at least within the that time to be incompatible because the scientific and
medical model. This alignment had the negative conse- medical model had not fully taken hold. It appears that
quences of less autonomy forthe profession anda special- in the founding years OT primarily practiced moral treat-
ized and narrower treatment approach to OT practice. ment and talked about how practice should also be
medical and scientific. When early practitioners were
A CHALLENGE TO OCCUPATIONAL asked to treat patients in order to “restore the functions
THERAPY PRACTICE of nerves and muscles” or to make use of “the affected
arm or leg,”*’ they based their treatment on their belief
Moral Treatment Versus Medical Model in the importance of occupation, habit training, and
A cry arose in the late 1960s and in the 1970s from their knowledge of crafts. Once knowledge and techno-
some of the leaders in OT for practice to return to its logic advances were sufficient and occupational thera-
roots in moral treatment and to forego what Shannon pists could actually practice using a scientific, medical
referred to as the “technique philosophy.””’ In his perspective, it became apparent that the ideas underly-
article on what he called “the derailment of occupa- ing these two paradigms were in conflict.
tional therapy,” Shannon described two philosophies at The physical dysfunction therapist was faced with
odds with each other. One, he asserted, viewed the indi- the problem of how to give treatment that was, on the
vidual “as a mechanistic creature susceptible to manipu- one hand, holistic and humanistic and, on the other,
lation and control via the application of techniques”; reductionistic and scientific. Baldwin’s answer in 1919
the other, based on the profession's early philosophy of was to see activities such as muscle strengthening and
moral treatment, emphasized a holistic and humanistic splint fabrication as techniques that contributed to the
view of the individual. larger goal of “functional restoration” of the individ-
Kielhofner and Burke described the situation as a con- ual’s social, physical, and economic well-being.’ Spack-
flict between two paradigms.”” Early OT practice, they as- man’s answer in 1968 was that the occupational thera-
serted, was based on the paradigm of occupation that pist should use “constructive activity in a simulated,
had moral treatment as its foundation. This paradigm normal living and/or working situation. This is and
provided a “holistic orientation to Man [sic] and health always has been our function.”*’ She emphasized the
in the context of the culture of daily living and its activi- teaching of ADL and work simplification and was criti-
ties.” Post-World War II practice, they asserted, was based cal of treatment that consisted of having patients sand
on the paradigm of reductionism, a mode of thinking or use a bicycle saw when “constructive activity” was
characteristic of the medical model. This view empha- involved.
sized the individual's “internal states” and represented a Another answer to the question of differing para-
shift in focus to “internal muscular, intrapsychic balance digms was to move outside the medical model. Bock-
and sensorimotor problems.” The authors acknowledged oven urged OT practitioners in mental health to stop
that practice based on the reductionist paradigm “would “running dinky little sideshows in large medical institu-
pave the way for the development of more exact tech- tions” and instead to set up services in the community
nologies for the treatment of internal deficits”; however, based on moral treatment. He said, “It is the occupa-
they were concerned it “necessitate[d] a narrowing of the tional therapist's inborn respect for the realities of life,
conceptual scope of occupational therapy.”*° for the real tasks of living, and for the time it takes the
To say that early OT practice was based on the hu- individual to develop his modes of coping with his
manistic and holistic philosophy of moral treatment is tasks, that leads me to urge haste on the profession. . .
 History and Practice Trends in the Treatment of Physical Dysfunction

to assert its leadership in fashioning the design of humanistic values and yet encourage development of the
human service programs. . . . Don’t drop dead, take scientific techniques and procedures that best ensure
over instead!”° Yerxa urged therapists not to rely solely patient success. Efforts today are directed at evidence-
on doctor's orders: “The written prescription is no based practice and identifying treatment models that
longer seen by many of us as necessary, holy or explain and accommodate physical dysfunction OT.'?
healthy. . . . The pseudo-security of the prescription OT's history has shown that although treatment tech-
required that we pay a high price. That price was the re- niques have changed throughout the 20th century, the
duction of our potential to help clients because we often values and beliefs established in the formative years
stagnated at the level of applying technical skills.”*° continue to influence practice. The most enduring belief
is this: that occupation as prescribed by OT practitioners
promotes health, prevents and remedies dysfunction,
Physical Dysfunction Therapists’ Response
and elicits adaptation to the environment. As new treat-
As practice moved into the 1980s, there was much ment techniques and technologies are developed in the
concern that if therapists did as their critics suggested, future, OT intervention that promotes occupational
they would jeopardize reimbursement as well as refer- function will remain consistent with the philosophical
rals. Therapists argued that they were being asked to base of the profession.
exclude skills and knowledge they believed were valu-
able in patient treatment, such as exercise, splinting,
REVIEW QUESTIONS
and facilitation techniques. They further argued that
many patients receiving OT services were initially not at 1. Name the seven founders of occupational therapy,
the level of motor capability that would enable them to and list the professional background of each.
engage in satisfying occupations. It was proposed that 2. What ideologies shaped the development of occu-
adjunctive techniques such as exercise and biofeedback pational therapy in the late 19th and early 20th
should be considered legitimate when used to prepare centuries?
the patient for further engagement in occupation.** A 3. What were the main features of the philosophy of
study conducted in 1984 by Pasquinelli7* showed that moral treatment?
although therapists valued occupation, they used a wide 4. Describe the ideas that were the foundations of oc-
variety of treatment techniques and approaches, includ- cupation as a remedy for mental and physical
ing facilitation and non-activity-oriented techniques. illness.
Both Trombly and Ayres argued that instead of attempt- 5. What provoked the rise of the arts and crafts move-
ing to redirect the focus of OT, the profession should ment?
include current clinical practices that had proved effec- 6. How did the arts and crafts movement influence oc-
tive on an empirical and practical basis.'°* — cupational therapy?
7. Describe scientific management. How did it influ-
ence the development of occupational therapy?
PRESENT PRACTICE: INFORMED
8. When did the rehabilitation model evolve? How
BY HISTORY
did the world wars influence the development of
Health care practice at the end of the 20th century is the rehabilitation model?
heavily influenced by the efficiency ideology initially in- 9. How did physical dysfunction become a specialty?
troduced by scientific management in the first part of 10. What factors influenced occupational therapy to
the century. This only emphasizes the importance of in- adopt the medical model?
tegrating the humanistic and scientific in the practice of 11. What was the apparent conflict between moral treat-
OT for physical dysfunction. ment and the medical model?
Early treatment was based on therapists’ belief in 12. What is reductionism?
the importance of occupation, habit training, and their 13. How is the apparent conflict between reductionism
knowledge of crafts. As scientific knowledge and technol- and holistic or humanistic treatment being resolved
ogy advanced, OT defined a role for itself within the re- in physical dysfunction practice?
habilitation model. This resulted in the emergence of
physical dysfunction as a specialty within OT. The closer REFERENCES
relationship with medicine helped the profession gain 1. Ayres AJ: Basic concepts of clinical practice in physical disabilities,
credibility; however, it became apparent by the late 1960s Am J Occup Ther 12:300, 1958.
that the scientific reductionism of the medical model was 2. Baldwin BT: Occupational therapy, Am J Care Cripples 8:447, 1919.
3. Baldwin BT: Occupational therapy applied to restoration of function
at odds with the holistic humanism of moral treatment.
of disabled joints, Washington, DC, 1919, Walter Reed General
Since the late 1960s, physical dysfunction occupa- Hospital.
tional therapists have been trying to integrate the two 4. Barton GE: The movies and the microscope. Manuscript in Ameri-
views of practice. They have worked to incorporate the can Occupational Therapy Archives: Bethesda, Md, c1920.
 HISTORY AND THEORY FOR THE TREATMENT OF PHYSICAL DYSFUNCTION
5: Bing R: Occupational therapy revisited: a paraphrastic journey: 1943-54, Archives of the Department of Occupational Therapy,
1981 Eleanor Clark Slagle lecture, Am J Occup Ther 35:499, 1981. San José State University, San José, Calif.
6. Bockoven JS: Legacy of moral treatment: 1800s to 1910, Am J 23: OT instructor says San José needs rehabilitation center, Spartan
Occup Ther 25:224, 1971. Daily, San José, Calif, Feb 9, 1953, San José State College, San José,
. Boris E: Art and labor: Ruskin, Morris and the craftsman ideal in Calif.
America, Philadelphia, 1986, Temple University. 24. Pasquinelli S: The relationship of physical disabilities treatment
. Constitution of the National Society for the Promotion of Occu- methodologies to the philosophical base of occupational therapy, unpub-
pational Therapy, Baltimore, 1917, Sheppard Pratt Hospital Press. lished thesis, San José State University, 1984.
. Dunton WR: Prescribing occupational therapy, Springfield Ill, 1928, 2D; Peloquin SM: Looking back-moral treatment: contexts consid-
Charles C Thomas. ered, Am J Occup Ther 43:537, 1989.
10. Dunton WR: The three “t's” of occupational therapy, Occup Ther 26. Putnam ML: Report of the committee on installations and advice,
Rehab 7:345-348. Occup Ther Rehab 4:57-60
. The gift of healing, Mademoiselle, pp 114-15, 177-178, 1943. 27e Quiroga V: Occupational therapy: the first 30 years, 1900-1930,
12" Gritzer G, Arluke A: The making of rehabilitation, Berkeley, 1985, Bethesda, Md, 1995, American Occupational Therapy Association.
University of California Press. 28: Reed KL: The beginnings of occupational therapy. In Hopkins HL,
13. Hanson C, Walker K: The history of work in physical dysfunction, Smith HD, editors: Willard & Spackman’s occupational therapy, ed 8,
Am J Occup Ther 46:56, 1992. Philadelphia, 1993, JB Lippincott.
14. Higher status near, doctor tells therapists: department scrapbooks, 23); Shannon PD: The derailment of occupational therapy, Am J Occup
1955-63, Archives of the Department of Occupational Therapy, Ther si-229 974s
San José State University, San José, Calif. 30. Slagle EC: A year’s development of occupational therapy in New
15% Hofstadter R: The age of reform, New York, 1969, Knopf. York State hospitals, Modern Hosp 22:98-104, 1924.
16. Johnson SC: Instruction in handcrafts and design for hospital pa- Silk Spackman CS: A history of the practice of occupational therapy
tients, Modern Hosp 15:1, 69-72, 1920. for restoration of physical function: 1917-1967, Am J Occup Ther
17. Lack of trained personnel felt in rehabilitation field, The New York 22:67-71, 1968.
Times, Jan 25, 1954. S25 Taylor F: The principles of scientific management, New York, 1911,
18. Kidner TB: Planning for occupational therapy, Modern Hosp Harper.
21:414-428, 1923. SBE Trombly CA: Include exercise in purposeful activity, Am J Occup
189) Kielhofner G: Conceptual foundations of occupational therapy, ed 2, Ther 36:467, 1982 (letter).
Philadelphia, 1997, FA Davis. 34. Weibe R: The search for order, 1877-1920, New York, 1967, Farrar,
20. Kielhofner G, Burke JP: Occupational therapy after 60 years, Am J Straus & Giroux.
Occup Ther 31(1):675-689, 1977. 3}3y Workshop on rehabilitation facilities, 1955: department scrap-
All Meyer A: The philosophy of occupational therapy, Arch Occup Ther books 1955-63, Archives of the Department of Occupational
1:1-10, 1922. Therapy, San José State University, San José, Calif.
22, Occupational therapy classes have outstanding guest speakers 306. Yerxa EJ: 1966 Eleanor Clarke Slagle Lecture: Authentic occupa-
from various army and civilian hospitals: department scrapbook, tional therapy, Am J Occup Ther 21:1-9, 1967.
a,)
 The Occupational Therapy Process—

LEARNING OBJECTIVES
2
Occupational therapy practitioner After studying this chapter the student or practitioner
Referral will be able to do the following:
Screening 1. Identify and describe the major stages in the
Registered occupational therapist occupational therapy (OT) process.
Evaluation 2. Explain why clinical practice may appear less
Certified occupational therapy assistant sequential and orderly than these stages suggest.
Intervention planning 3. Describe how clinical reasoning adjusts to consider
Intervention various factors that may be present in the
Reevaluation intervention context.
Transition services 4. Identify appropriate delegation of responsibility
Discontinuation among the various levels of OT practitioners.
Clinical reasoning 5. Discuss ways in which OT practitioners may
Occupational therapy aide effectively collaborate with members of other
Ethics 2 professions involved in patient care.
Ethical dilemmas 6. Recognize ethical dilemmas that may occur
Clinical context frequently in OT practice, and identify ways in
which these may be addressed and managed.

is chapter introduces the occupational therapy OT practitioners, as well as relationships between OT

(OT) process, briefly summarizing the stages from refer- and the other professional disciplines involved in the
ral through discontinuation of service. The chapter aims care of the patient or client with physical dysfunction.
to acquaint the reader with the complexity and creativ- Common ethical dilemmas are introduced, and ways to
ity of clinical reasoning as it evolves in the transactions analyze these are presented.
between patient and therapist within the context of the
contemporary clinical environment. In so doing, it sets
Steps or Stages of the Occupational
the stage for the chapters that follow. Treatment con-
Therapy Process
texts are covered in more detail in Chapter 4. Chapters 5
and 6 expand on the stages of evaluation and inter- The OT process is often presented as a series of discrete
vention. Chapter 7 presents evidence-based practice. stages or steps. These are”’’®:
Chapter 8 addresses prevention of disability and health 1. Referral: The physician or other legally qualified pro-
promotion, an aspect of intervention. Chapter 9 pro- fessional requests OT services for the patient. Referral
vides an overview and detail of teaching activities. may be oral, but a written record is also necessary.
Chapter 10 addresses documentation. The present Guidelines for referral may vary by state, with some
chapter considers the complementary roles of different states restricting OT to physician referral.
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

2. Screening: The registered occupational therapist change in the patient's status from first evaluation
(OTR) performs a quick assessment to determine through the end of OT services.
whether OT services would be helpful to this patient. Fig. 3-1 shows the relationship between the various
The OTR may perform screening independently or as stages of the intervention process. When the stages of
a member of the health care team. the intervention process are presented and studied in a
3. Evaluation: The OTR identifies the information to be linear and sequential manner, the reader may be led to
collected and the areas to be evaluated and selects as- believe that the stages always occur in this sequence. In
sessment instruments. The OTR may delegate some fact, this is rarely the case. Rather, while the general
parts of the evaluation, such as the administration of trend of the stages follows that presented above and in
selected assessments, to the certified occupational Fig. 3-1 (i.e., referral leading to evaluation leading to in-
therapy assistant (COTA). The data are then ana- tervention planning and then intervention itself), in
lyzed to determine the patient's specific strengths many clinical settings the stages may be compressed. A
and deficits. single visit may encompass receipt of referral and a brief
4. Intervention planning: Working with the patient,
the OT practitioners (OTR and COTA) develop a plan
for restoring, improving, or maintaining the patient's
Referral
ability to function in daily life roles and activities.
The OTR is responsible for the plan and for any parts
delegated to the COTA. The plan includes client-
centered goals and methods for reaching them. The
values and goals of the patient are primary; those of
the therapist secondary.® Cultural, social, and envi-
ronmental factors are incorporated into the plan.
The plan must detail the scope and frequency of the
treatment and the anticipated date of completion.
5. Intervention: The OT team carries out the treatment
plan. The OTR may assign to the COTA significant re-
sponsibilities in providing purposeful activities and
therapeutic modalities. Nonetheless, the OTR retains
the responsibility to direct, monitor, and supervise
the intervention and must ascertain that relevant and
necessary interventions are provided in an appropri-
ate and safe manner and that documentation is accu-
rate and complete.
6. Reevaluation: With the same instruments used in
the initial evaluation, OT practitioners again evaluate
the patient to determine what changes have occurred
since the previous evaluation. This measurement of
the outcomes of treatment is critical in showing the
effectiveness of the intervention. The intervention
plan may be changed, continued, or discontinued,
based on the results of the reevaluation.
7. Transition services: Working in tandem with the
patient, the patient's family, and the treatment team,
the OTR and COTA develop a plan for the patient to
carry over after leaving the current treatment setting.
Transition services
The discharge may be to the patient’s home or to an
intermediate care or long-term care facility.
8. Discontinuation: The OTR determines whether the
patient has reached the established goals or achieved
the maximum benefit from OT; alternately, the
Discontinuation of
patient may choose to discontinue service before service
reaching these limits. The OTR formally discontinues
service and creates a discontinuation plan that docu-
ments follow-up recommendations and arrange- FIG 3-1 ig
ments. Final documentation includes a record of any -
Stages or steps in the occupational therapy intervention preeaame
 The Occupational Therapy Process—An Overview

evaluation and administration of some intervention

procedures. Intervention planning may occur within the
therapist's mind and may not be documented until after uestions for the Three-Track Mind
the first intervention has occurred during this initial
visit. Further, the therapist may consider transition serv- .

ices on first meeting the patient. This rapid and appar- Procedural questions
ently seamless integration of information and action by _ What is the diagnosis?
What prognosis, complications, and other factors are
the therapist requires knowledge of various theoretical
associated with this diagnosis?
models (see Chapter 1) and practical techniques, along
What is the general protocol for assessment and intervention
with clinical experience. with this diagnosis?
What interventions (adjunctive methods, enabling activities,
Clinical Reasoning in the Intervention purposeful activities) might be employed?
Process
Interactive questions
Since 1986 the American Occupational Therapy Associa- Who is the patient?
tion (AOTA) has funded a series of studies to examine What are the patient's goals, concerns, interests, and values?
how occupational therapists think and reason in their How does the patient see his or her life story?
work with patients.'*Clinical reasoning can be defined How does the illness or disability fit into this life story?
How might | engage this patient?
informally as how we think about what we do. Gillette
How can we communicate?
and Mattingly’ identified two aspects of occupational
therapists’ clinical reasoning: the mechanistic and the phe- Conditional questions
nomenological. Mechanistic aspects are closely allied with What are the many contexts of the patient's life? (temporal
the practice of medicine and address factors such as how and environmental contexts, social aspects, cultural aspects,
the body works biomechanically. Phenomenological context of therapy and reimbursement issues)
factors address the experience of “being in the world,” or What future(s) can be imagined for the patient? What events
the life of the individual as perceived by that person. could or would shape the future?
Fleming” further identified three “tracks” used by the How can | engage the patient to imagine, believe in, and work
expert clinician to organize and process data: the proce- toward a future?
dural, the interactive, and the conditional.
=
@ Procedural reasoning is concerned with getting things
done, with what “has to happen next.” This track is peutic intervention. In this sense, narrative reasoning is
closely allied with the mechanistic aspect of reasoning. phenomenological. Narrative reasoning is also used by
™ Interactive reasoning is concerned with person-to- therapists to plan or “emplot” therapy, to create a story
person interchanges with patients. The therapist uses line of what will happen for the patient as a result of
this track to engage with, to understand, and to moti- therapy. Here the therapist draws on both interactive
vate the patient. Understanding the patient's point of and conditional tracks, using the patient's words and
view is fundamental to this kind of reasoning. metaphors to project possible futures for the patient.
= Conditional reasoning is concerned with the contexts in
which interventions occur, the contexts in which the
Clinical Reasoning in Context
patient performs occupations, and the ways in which
various factors might affect the outcomes and direc- Pressures for cost containment and reduction of unnec-
tion of therapy. Using a “what if?” or conditional ap- essary services have forced therapists to divide their at-
proach, the therapist imagines possible scenarios for tention between the needs of the client-patient and the
the patient. practical realities of health care reimbursement and
Experienced master clinicians engage simultaneously in documentation. Thus, on first meeting the patient, the
all three tracks to develop and modify their plans and therapist will want to know the anticipated or planned
actions during all phases of the intervention process. or required date of discharge, as well as the scope of
Some of the questions a therapist might consider on services that will be reimbursed and those that are likely
each of the three tracks are listed in Box 3-1. to be denied. Simultaneously, the therapist is assessing
Yet another dimension of expert clinical reasoning and considering the patient, attempting to engage the
was identified by Mattingly.'’ Narrative reasoning uses patient in identifying and planning goals, and weighing
story making or story telling as a way to understand the the patient’s motivation against the interventions that
patient's experience. The patient's explanation or de- might be possible or useful in the particular situation.
scription of life and the disability experience reveals Further, the therapist is alert to requirements for docu-
themes that permeate the patient's understanding and mentation and the particular current procedural termi-
that will affect the enactment and outcomes of thera- nology (CPT) codes that may apply and is thinking
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

about how to document service accurately and effec- patient's point of view, and find other ways to ensure that
tively so that reimbursement will not be challenged and the intervention plan is acceptable to the patient and family.
so the patient's needs may be adequately addressed. Some of the many questions addressed by the multi-
From first meeting the patient or client, the therapist is level thinking process of the occupational therapist are
guided by the patient's or client's goals and preferences. depicted in Fig. 3-2.
Client-centered service delivery requires client (or family)
involvement and collaboration at all stages of the interven-
Client-Centered Practice: Not Yet a Reality
tion process.® Effectively engaging the client and the family
demands cultural sensitivity and an ability to communicate Involving patients and clients in identifying their own
with people of diverse backgrounds. In some cultures, the goals and in making decisions about their own care and
idea of participating equally in decision making with a treatment is highly valued by leaders in the OT profes-
health professional may be unknown. Being asked by a sion'**?* and is endorsed by the AOTA in its policy
therapist to make decisions may feel quite unfamiliar and and practice guidelines.’” Despite this expectation,
uncomfortable to the patient. Thus the therapist must most clinicians involve clients only part of the time, and
assess the person's readiness to collaborate, adjust to the some therapists do not involve patients or clients at all

Referral restrictions?
Who provides services?
Which services are requested?
aac Documentation questions:

Which services are appropriate? Applicable CPT codes?

Frequency of documentation?
Outcomes to be demonstrated?

Who is the patient?

Patient’s history. . . What does the patient want?
Cultural background. . . Patient’s motivation. . .
Psychosocial adjustment. . . Patient’s view of the future. . .

Clinical conditions?
Diagnosis? Discharge destination?
Prognosis? What is future environment?
Assessment protocol? Evaluation of home or workplace?
Intervention protocol? Transition to another level of care?
——= needed for transition?

Theoretical framework: Discharge date?

Single model? What is the planned date?
Multiple models? Is this reasonable?
Assessment/interventions? Is this negotiable?
How best can | use the available time?
Management of resources:
Aspects to delegate to COTA...
Appropriate use of aides. . .
Teamwork with PT and
|others.me

FIG. 3-2
Multilevel thinking of the occupational therapist (arrows show that flow of reasoning process circu-
lates in a multidimensional and open manner, engaging many factors simultaneously).
 The Occupational Therapy Process—An Overview

in making decisions.’? Some factors proposed as gether with several COTAs, the OTR will be able to
reasons for this are time constraints, beliefs about the manage a larger caseload and will have the option of in-
client's cognitive level (and ability to comprehend or troducing more advanced and specialized services
make decisions), and the person's age (older persons (since COTAs provide routine services). Many variations
being less likely to be involved by therapists).'” exist. Some services that may be delegated to service-
As is described further in Chapter 5, effective and competent COTAs include the following:
comprehensive client involvement begins when the ther- 1. Administration of selected screening instruments or
apist first meets the patient or client. Therapists using a of assessments such as range of motion (ROM) tests,
“top-down” assessment model, such as the Canadian interviews and questionnaires, activities of daily
Occupational Performance Measure (COPM),'® initiate living (ADL) evaluations, and other assessments that
assessment by asking clients to identify and choose goals follow a defined protocol.”
early in the intervention process. Regardless of disability 2. Development of some elements of the intervention
status or perceived limitations in cognitive functioning, plan (e.g., planning for dressing training and plan-
every client should be invited to participate in assess- ning for kitchen safety training).”
ment and treatment decisions. 3. Provision of intervention services.” The COTA, by ed-
ucation and training, is prepared to provide interven-
Teamwork Within the Occupational tions in the areas of ADL, work and productive activ-
ities, and play or leisure. With appropriate training
Therapy Profession
and supervision, the COTA can undertake interven-
The OT profession recognizes and certifies two levels of tions related to performance components.
practitioners, the OTR and the COTA. The AOTA has 4. Facilitation of the transition to the next service
provided many documents to guide practice and to setting by, for example, making arrangements with or
clarify the relationship between the two levels of practi- educating family members or contacting community
tioner.*’*’””” The OTR who is managing a case or provid- providers.
ing services to patients should use the following as a 5. Assistance with the development of a plan for dis-
guide: continuation of service.
™@ Services are to be provided by personnel who have 6. Contributions to documentation, record keeping, re-
demonstrated service competency. source management, quality assurance, selection and
@ In the interests of rendering the best care at the least procurement of supplies and equipment, and other
cost, the OTR may delegate tasks to COTAs and, in aspects of service management.
some specific instances, to aides or other personnel, 7. Education of the patient, family, or community
provided these providers have the competencies to about OT services.
render such services. lS
@ The OTR retains final responsibility for all aspects of
Occupational Therapy Aides
care, including documentation.
The OTR may also extend the reach of services by em-
ploying aides. AOTA guidelines stipulate that the OT
OTR-COTA Relationships
aide works only under direction and close supervision
To work effectively with COTAs, the OTR must under- of an OT practitioner (OTR or COTA).® Aides may
stand the role of the technical-level practitioner. It is perform only specific, selected, delegated tasks. While
common for OTRs to alternately overestimate and un- the COTA may direct and supervise the aide, the OTR is
derestimate the capabilities of COTAs. In overestimating ultimately responsible for the actions of the aide.® Tasks
the training and abilities of COTAs, OTRs might assume that might be delegated to an aide include transporting
that a COTA is a “mini-OTR,” believing that the COTA is patients, setting up equipment, preparing supplies, and
trained to provide services identical to those of the OTR performing simple and routine patient services for
but perhaps at a lesser pace and level and with a smaller which the aide has been trained. Individual jurisdic-
caseload. In underestimating the COTA, the OTR might tions and health care regulatory bodies may restrict
assume that the COTA is a “glorified aide,” capable of aides from providing patient care services; reimburse-
performing only concrete and repetitive tasks under the ment may also be denied for some services provided by
strictest supervision. aides. Where permitted, the OTR may delegate routine
The appropriate role of the COTA is complementary tasks to aides to increase productivity.
to that of the OTR. Employed effectively, the COTA can
extend the reach of the OTR by providing therapy serv-
Teamwork with Other Professionals
ices under supervision that ranges from close to general
(depending on the practice setting and the experience Many health care workers collaborate in the care of
and service competencies of the COTA).* Working to- persons with physical disabilities. Depending on the
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

setting, the OTR may work together with physical thera- made for and against cross-training and multi-
pists, speech and language pathologists, activity thera- skilling.'”!*°7? The consumer may benefit by having
pists, nurses, vocational counselors, psychologists, fewer health care providers and better integration of
social workers, pastoral care specialists, orthotists, pros- services. Involving fewer providers may reduce costs.
thetists, rehabilitation engineers, vendors of durable Therapists may benefit by having other practitioners
medical equipment, and physicians from many differ- available to cover services on evenings and weekends,
ent specialties. and in rural areas where specialized services are not
Treatment contexts are discussed in Chapter 4; rela- widely available.
tionships among and expectations of various health The disadvantages cited include the prospect of
care providers are often determined by the context of erosion of professional identity, possible risk to con-
care. For example, in home care in certain jurisdictions sumers of harm at the hands of less skilled providers,
the nurse may be the leader of the team. In settings and ceding the control of individual professions to
under the medical model, the physician is most often outside parties such as insurers and advocates of com-
the leader. Some rehabilitation facilities employ a team peting professions.
approach to assessment and intervention, which
reduces duplication of services and increases communi-
Ethics
cation and collaboration. Several individuals from dif-
ferent professions may together perform a single assess- When studied as part of an OT professional education,
ment. For example, the OTR may be the lead member of ethics may seem an idealized and compartmentalized
the team in some settings, or may be the director of re- course or topic. Yet clinicians encounter ethical dilem-
habilitation services. In a team, members adjust sched- mas with surprising frequency. In an ethics survey con-
uling and expectations to accommodate one another's ducted by Penny Kyler for AOTA in 1997 and 1998,”
goals and plans. clinician respondents ranked the following as the five
Many factors affect relationships among profession- most frequently occurring ethics issues confronting
als across disciplines: the treatment context, reimburse- them in practice:
ment restrictions, licensure laws and other jurisdictional 1. Cost-containment policies that jeopardize patient
elements, and the training and experience of the indi- care
viduals involved. Relationships develop over time, . Inaccurate or inappropriate documentation
based on experience and interaction and sometimes on . Improper or inadequate supervision
personality. Even where formal jurisdictional bound- . Provision of treatment to those not needing it
aries may appear to limit roles for OT, informal patterns W . Colleagues violating patient confidentiality’”
—&
Mm
NH

often develop at variance with the prescribed rules. For Additional concerns were related to conflict with col-
example, while in some states physician referral may be leagues, lack of access to OT for some consumers, and
required to initiate OT service, physicians may expect discriminatory practice. Further, 21% of clinicians re-
the OTR to initiate the referral and actually perform a ported they faced ethical dilemmas daily, 31% weekly,
cursory screening before the physician becomes in- and 32% at least monthly.’”
volved. Some physicians rely on OT staff to identify The AOTA has provided several documents to assist OT
those patients who are most likely to benefit, and issue practitioners in analyzing and resolving ethical ques-
referrals at their suggestion. tions: the Occupational Therapy Code of Ethics,° the Guide-
Another example in which interdisciplinary bound- lines to the Occupational Therapy Code of Ethics, and Core
aries may be at variance with actual practice is in the re- Values and Attitudes of Occupational Therapy Practice.*
lationships among the rehabilitation specialists of OT, While these documents provide a basis for resolving
PT, and speech therapy. By formal definition, each disci- ethical issues, practitioners may find additional resources
pline has a designated scope of practice, with some and support if they also approach institutional ethics
areas of overlap and occasional dispute. Nonetheless, it committees and review boards for guidance. Kyler’? also
is common for practitioners to share skills and case- suggests that OT practitioners act to formalize resolu-
loads across disciplines and to train each other to tions for recurring questions by engaging with peers and
provide less complex aspects of each discipline’s care. others to analyze and consider courses of action.
Two terms used to describe this are cross-training and To reiterate, OT practitioners should anticipate that
multiskilling. they will encounter ethical distress (defined as the sub-
Cross-training is the training of a single rehabilitation jective experience of discomfort originating in a conflict
worker to provide services that would ordinarily be ren- between ethical principles) frequently in clinical prac-
dered by several different professions. Multiskilling is tice. Many approaches may be useful. A plan of action
sometimes used synonymously with cross-training, but for addressing ethical distress and resolving ethical
may also mean the acquisition by a single health care dilemmas may involve the following:
worker of many different skills. Arguments have been 1. Reviewing AOTA guidelines”
 The Occupational Therapy Process—An Overview

2. Seeking guidance from institutional ethics and 3. Define the terms mechanistic and phenomenological
review boards and give examples to illustrate these contrasting
3. Approaching and engaging with colleagues, peers, terms.
and the community to identify and debate ethical 4. Name the three tracks of clinical reasoning identi-
questions and formalize resolutions fied by Fleming and give examples of each.
5. What is narrative reasoning and how is it used in
SUMMARY oe occupational therapy?
6. Discuss some of the obstacles to making client-
The occupational therapy process begins with referral centered practice the norm.
and ends with discontinuation of service. While discrete 7. Contrast the roles of the OTR and the COTA. List at
stages can be named and described, the process is more least six tasks that may be delegated to the COTA.
fluid than stepwise, with the stages at times intermin- 8. What services may the OT aide be assigned? What
gled. This may look confusing to the novice, but it is ac- are the limits, and why?
tually a hallmark of clinical reasoning. 9. Visit and observe two different settings in which OT
Clinical reasoning simultaneously employs three services are offered. Analyze the differences in the
“tracks”: procedural, interactive, and conditional. While two settings in the way members of the different
logically analyzing how to proceed through the steps of professions work together. Suggest possible reasons
therapy, the therapist also considers how best to interact for the differences you find.
with the patient. Further, the therapist creates scenarios 10. Are you comfortable with the practices of cross-
of possible future situations. The expert clinician seeks training and multiskilling? Why or why not?
to uncover how the patient understands the disability 11. Describe an ethical dilemma you have experienced
and uses a narrative or story making approach to or encountered in the workplace or fieldwork. How
capture the patient's imagination of how therapy will did or would you go about resolving the dilemma?
benefit him or her.
The OT profession endorses client-centered practice,
engaging the patient in all stages of decision making, REFERENCES
beginning with assessment. To make this ideal a clinical 1. American Occupational Therapy Association: Concept paper:
reality requires that the OTR approach every patient as a service delivery in occupational therapy, Am J Occup Ther 49:1029-

co-participant and assist the patient in identifying and hee

sok cm P 8 2. American Occupational Therapy Association: Core values and at-
prioritizing goals and considering and selecting inter- titudes of occupational therapy practice, Am J Occup Ther 47:1083-
vention approaches. 1084, 1993.
The registered occupational therapist and certified 3. American Occupational Therapy Association: Career exploration
and development: a companion guide to the occupational
OT assistant have specific responsibilities and areas of
therapy roles document, Am J Occup Ther 48:844-851, 1994.
emphasis within the OT process. The OTR is: the 4, American Occupational Therapy Association: Guide for supervi-
manager and director of the Process and delegates spe- sion of occupational therapy personnel, Am J Occup Ther 49:1027-
cific tasks and steps to the qualified COTA. Aides may 1028, 1995.
also be employed to extend the reach of OT services. 5. American Occupational Therapy Association: Guidelines to the
occupational therapy code of ethics, Am J Occup Ther 52:881-884,
Effective practice typically involves interactions with
1998.
members of other professions. This requires that the OT 6. American Occupational Therapy Association: Occupational
practitioner consider the treatment context, the scope of therapy code of ethics, Am J Occup Ther 48:1037-1038, 1994.
practice of other professions, the applicable jurisdic- 7. American Occupational Therapy Association: Occupational
tions and health care regulations, and other factors (e.g., therapy roles, Am J Occup Ther 47:1087-1099, 1993.
8. American Occupational Therapy Association: Position paper: use
ity, and history) that affect the individ-
eee ality, a “ 1) of occupational therapy aides in occupational therapy practice,
ual situation. — adhe inahal Am J Occup Ther 49:1023-1025, 1995.
Ethical questions arise with increasing frequency in 9. American Occupational Therapy Association: Standards of prac-
modern health care. The AOTA provides guidelines tice for occupational therapy, Am J Occup Ther 52:866-869,
and other resources; practitioners are urged to con- 1998.
10. Collins AL: Multiskilling: a survey of occupational therapy practi-
sider institutional and local resources as well, and to
tioners’ attitudes, Am J Occup Ther 51:749-753, 1997.
take an active role in identifying and resolving ethical 11. Fleming MH: The therapist with the three-track mind, Am J Occup
concems. Ther 45:1007-1014, 1991.
12. Foto M: Multiskilling: who, how, when, and why? Am J Occup Ther
50:7-9, 1996.
REVIEW QUESTIONS 13. Fisher AG: Uniting practice and theory in an occupational frame-
5 : work: 1998 Eleanor Clarke Slagle Lecture, Am J Occup Ther 52:509-
1. Name the eight stages in the OT process. 522, 1998.
2. Explain why these stages are not always distinct or 14. Gillette NP, Mattingly C: Clinical reasoning in occupational
sequential. therapy, Am J Occup Ther 41:399-400, 1987.
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE
IDS}. Kyler P: Issues in ethics for occupational therapy, OT Practice 20. Pew Health Professions Commission: Health professions education
3(8):37-40, 1998. for the future: schools in service to the nation, San Francisco, 1993,
16. Law M, Baptiste S, Carswell A, et al: Canadian occupational perform- The Commission.
ance measure, ed 2, Toronto, 1994, Canadian Association of Occu- 21. Pollock N: Client-centered assessment, Am J Occup Ther 47:298-
pational Therapists. 3017 1993:
Mie Mattingly C: The narrative nature of clinical reasoning, Am J Occup 22; Schlaff C: From dependency to self-advocacy: redefining disabil-
Ther 45:998-1005, 1991. ity, Am J Occup Ther 47:943-952, 1993.
18. Moyers PA: The guide to occupational therapy practice, Am J 23% Yerxa EJ: Who is the keeper of occupational therapy’s practice and
Occup Ther 53:247-322, 1999. knowledge? Am J Occup Ther 49:295-299, 1995.
19), Northen JG, Rust DM, Nelson CE, et al: Involvement of adult re-
habilitation patients in setting occupational therapy goals, Am J
Occup Ther 49:214-220, 1995.
 LEARNING OBJECTIVES
Treatment context After studying this chapter the student or practitioner
Performance context will be able to do the following:
Temporal 1. Define, compare, and contrast treatment context
Environmental and performance context.
Continuum of care 2. Identify ways in which different treatment contexts
Acute care affect the occupational performance of persons
Caregiver receiving occupational therapy (OT) services.
Hospice 3. Identify the treatment contexts that afford the most
Inpatient rehabilitation realistic projections of how the patient will perform
Acute rehabilitation in the absence of the therapist.
Subacute rehabilitation 4. Identify environmental and temporal aspects of at
Residential care least three treatment contexts.
Home health care 5. Describe ways in which the therapist can alter
Respite environmental and temporal features of contexts to
Home- and community-based therapy obtain more accurate measures of performance.
a
Day treatment
Industrial rehabilitation
Work site

ndividuals with physical disability receive occupa- ment rules, the workplace pressures of critical pathways
tional therapy (OT) services in a variety of settings. These and other clinical protocols, the range of services that
may include acute hospitals, acute rehabilitation centers, are considered customary and reasonable, and the tra-
subacute rehabilitation facilities, skilled nursing facili- ditions and culture that the staff have developed over
ties, home health, day treatment, community care pro- time. In addition, there are physical aspects such as the
grams, and work sites. Even within these categories, each building itself, the temperature and humidity of the
facility is different, and each setting represents a different air, the colors and materials that are used, the layout of
treatment context. the space, and the furnishings and lighting. Practition-
Treatment context refers to the environment in ers must always be aware that context influences
which treatment occurs, an environment that includes patient performance in evaluation and in treatment;
the physical setting and the social, economic, cultural, treatment context also determines the kinds of thera-
and political situation that surrounds it. Treatment peutic treatments available.'* Length of stay (LOS) and
context has many aspects. Some are abstract: govern- limitations on numbers of visits constrain therapists in
ment regulations, the economic realities of reimburse- selecting frames of reference, limiting choices to those
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

that can produce outcomes within the allotted time. in which OT services are provided to persons with phys-
Patient performance in one treatment setting may not ical disabilities.
be a fair indicator of performance in a different treat-
ment context.
CONTINUUM OF HEALTH CARE
This chapter introduces the range in context typically
associated with treatment settings and explores the in- The variety of settings from acute hospital to rehabilita-
fluence of treatment context on patient performance. tion center to day treatment, home health, outpatient,
Suggestions for modifications of the therapeutic envi- skilled nursing facility, and work sites forms a contin-
ronment and clinical approach are given. uum of care, albeit not always in a sequential fashion,
for the physically disabled patient. Persons with physi-
cal disabilities are referred to OT services for a variety of
RELATIONSHIP OF TREATMENT CONTEXT
reasons and may enter the health care system at any
TO PERFORMANCE CONTEXT
point on the continuum. A patient in an acute hospital
To the patient, especially the patient with an acute con- might be referred for bed mobility, transfers, and self-
dition, the treatment context represents a novel per- care retraining. Depending on the severity of the con-
formance context. The third edition of the Uniform dition and the treatment potential, the patient may
Terminology of the American Occupational Therapy later be treated in a rehabilitation or a day treatment
Association (AOTA) defines performance context as program. A home health or outpatient therapist may see
those factors or situations that influence a person’s the same individual to address unresolved problems.
ability to engage in specific performance areas. Per- Should the patient return to the workforce, he or she
formance context has temporal and environmental might later benefit from OT at the workplace, specifi-
aspects. The temporal aspects of performance context cally an assessment of the workplace and recommenda-
are identified as chronological age, stage of develop- tions about modifications to the work environment or
ment, life cycle, and disability status. The identified job tasks.
environmental aspects of performance are physical, Although many OT patients follow the continuum of
social, and cultural.’ health care through several treatment settings, a large
The temporal aspects of performance context derive number receive services in only one of these settings.
from the patient. In other words, the patient is a certain Depending on the setting, the person who receives OT
age and is at a certain life stage. The disability status of may be referred to by a unique consumer name or label
the patient (acute, chronic, or terminal) will affect per- that implies role and behavioral expectations of the
formance and will perhaps change over time. Even consumer (Box 4-1). These role and behavioral expecta-
though most temporal aspects derive from the patient, tions will affect therapist conduct, patient performance,
the treatment context introduces other temporal factors. and treatment options.
For example, perceived control over scheduling of ap-
pointments and over the individual's daily life may vary
Inpatient Settings
with treatment setting.
The environmental aspects of performance context Settings in which the patient receives nursing and other
change as a person moves from location to location health care while staying overnight are classified as in-
(e.g, work to home to gym). A treatment setting is patient settings.
unlike any of these “normal” performance contexts.
Each treatment setting has unique physical, social, and Acute Care Inpatient
cultural circumstances that influence the individual's Patients in an acute care inpatient setting typically have
ability to engage in required performance areas. These an acute disability. The condition that led to hospital-
environmental features make it difficult to project how ization is generally new and either is of recent onset or
the patient will perform in another setting. For example, is a new exacerbation of a chronic condition. Acute hos-
individuals who are in control in their home environ- pitalization, especially when unplanned, results in a
ment may abdicate control for even simple decisions in sudden change in the performance contexts of the
an acute care hospital.* The therapist observing a patient. All previous social roles are left hanging as a
patient passively allowing health care providers to make person who may have been a parent or caregiver
even routine decisions may come to the (erroneous) becomes a patient. Career and education are inter-
conclusion that the patient is generally indecisive and rupted. An individual who had felt in control of his or
Passive. her destiny becomes controlled by the circumstances of
Each treatment setting provides a different context disability and hospitalization.
for treatment decisions by the therapist, as well as a dif- Financial and family concerns that may have been
ferent context for performance by the patient. The fol- manageable before the hospitalization must be
lowing section discusses the main categories of settings managed differently. An acute decline in a chronic con-
 Treatment Contexts

treatment goals more effectively than one who ignores or

coddles patients in pain (see also Chapter 29).
oe Names and Implied Because of the urgent nature of an acute admission,
Roles/Expectations many patients arrive without a change of clothes. Cloth-
ing available to the hospitalized patient is usually
limited to hospital pajamas and gowns. Hospital pants,
_ Patient which are ill fitting with no stretch, can be difficult to
An individual under medical care and treatment. The patient's don and to keep fastened. Dissimilarities between a
role is typically dependent. Patients receive medical care,
hospital gown and a shirt can increase performance
and the control for the patient's care frequently lies
errors in dressing.
implicitly with the therapist or physician.
Patient rooms in an acute care hospital are different
Client from those in homes. Flooring, furniture, lighting, and
An individual who engages the professional services of another. bathroom facilities are designed for providing medical
The client's role is more active than the patient's role. care and comfort to the bed bound or ill. The absence of
Clients typically have identified their goals or objectives carpeting in most hospital rooms presents a smooth
before seeking professional services. and slippery surface for transfer training. Obviously, pa-
tients will perform this task differently on a carpeted
Resident surface. The incidence of falls in the geriatric population
An individual who resides in a long-term care facility.
The resident is higher in acute hospitals than in the community or
may live in a board and care home, skilled nursing facility, or
skilled nursing facilities.°
residential care home. Residents’ roles vary from facility to
Although many hospitals have single rooms, being
facility and are dependent upon medical status and
prognosis.
assigned a roommate is a common situation.’ Screening
performed upon assignment typically follows medical
Employee concerns (e.g., limiting the spread of infection and lo-
An individual worker under the direction of the employer.
The cating surgical patients in the same area) and gender.
employee may have goals that are similar to or different While having a roommate may provide patients with
from the employer's goals. someone to talk to if they feel up to it, the situation may
also expose patients to unfamiliar social and cultural
Employer circumstances.
An individual who is responsible for the work assigned to the Acute hospitalizations are frequently stressful and
employee. The employer may be an individual or a group of frustrating for patients. Away from home while ill, sub-
individuals (supervisor, manager, and executive).
jected to multiple tests and examinations with sleep in-
terrupted by the sounds of the nursing unit or the need
for medical intervention, patients are in a socially com-
dition abruptly confronts the patient with a long-term promised environment. Concerns as to whether they
prognosis, an impending future that may have been might be able to return home after the hospitalization,
ignored for years. who will help with care, or who is helping care for de-
Terminally ill patients may also be found in the acute pendent loved ones may add to the patient's feelings of
care hospital. For some, adjustment to dying may be stress.
just beginning. Other patients may have been ill, may Patients are subjected to frequent intrusions and a
have known the prognosis longer, and may be close to lack of privacy during acute hospitalization. Physicians,
acceptance. Individuals who have been managed in nurses, therapists, technicians, and housekeeping staff
their own home by a hospice program may be hospital- arrive unscheduled. Patients may be exposed for the first
ized for pain management, placement, or imminent time to cultures other than their own. Language and cul-
death; in such cases a patient's hospice goals may be tural barriers may arouse fear and adversely affect
compromised by admission to the hospital. patient performance.
Pain is another factor for many acute care patients. Acute care is a troublesome treatment context for
Movement frequently increases pain but is necessary for therapists, since patient performance is difficult to
healing. Pain decreases the patients’ ability to attend to assess. Performance may be enhanced or reduced by
tasks, and may increase fear and shorten temper. A thera- factors in the hospital environment. Because of time con-
pist unfamiliar with pain levels of patients with acute or- straints, it is often necessary to perform assessments in
thopedic conditions may have difficulty determining patient rooms, rather than in areas elsewhere in the
when it is appropriate to push the patients to do more medical center that have been designed for the prac-
and when it is more appropriate to report the pain to the tice of activities of daily living (ADL). Patient perform-
nursing department. The therapist who develops skill in ance in self-care may be artificially enhanced by a lack
working with patients in pain will be able to facilitate of the extraneous stimuli found in the home and by
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

the physical attributes of hospital equipment. To com- when performing self-care tasks. In this instance, the
pensate, the therapist might position the patient's bed therapist may express these concerns to the discharge
flat, eliminate the bed rails, and lower the bed fully to coordinator or the physician. The social worker might
better simulate the patient’s home environment. be consulted about family support available, or dis-
Bathing ability is difficult to assess if the patient is ac- charge may be delayed to determine the cause of the
customed to taking baths and a tub is not available to patient's cognitive deficits.
assess transfers or bathing status. Using clinical experi-
ence and judgment, the therapist must be able to Inpatient Rehabilitation Context
project from the patient's performance in the hospital Patients may reside in inpatient rehabilitation units
what the patient’s performance might be at home. when they are able to tolerate several (usually 3) hours
Asking the patient how the environment and the per- of therapy per day and are deemed capable of benefiting
formance might vary between home and the acute care from rehabilitation. Rehabilitation settings may be clas-
hospital can be helpful. However, it is difficult to obtain sified as acute or subacute (see below) and are less clin-
accurate information about the relative size and place- ically sterile than acute care hospital environments. The
ment of features in the home environment while the disability status of patients in such settings is slightly
person is away from home; therefore referral to a home less acute than in the acute care hospital. Pain, while
health therapist is often advisable. still present and affecting patient performance, is less
The treatment context of the acute care hospital pres- intense and more familiar to the patient. Fear of move-
ents unique financial, social, and physical constraints to ment while in pain is generally less than in the acute
the acute care therapist. Treatment goals are generally setting. Performance in ADL will reflect the patient's ©
directed toward promoting medical stability or provid- adaptation to pain.
ing for safe, expedient discharge. It is not unusual for Patients are expected to dress in their typical clothing
the acute care patient to receive OT for the first time on rather than hospital issue or pajamas. Expectations that
the day of discharge. In this one visit the therapist must the patient eat meals at a table in a dining area (rather
communicate the role of OT and assist the patient in than in bed or at bedside) lend a social element that is
identifying problems and assets in the discharge envi- not present in the acute care hospital and may not have
ronment. The patient and the family frequently look to been present in the patient's home.
the therapist to identify what the patient will need at
home. The therapist cannot possibly make this determi- ACUTE REHABILITATION. When patients are med-
nation without identifying issues and concerns in the ically stable and able to tolerate 3 hours of combined
discharge environment. The acute care treatment plan therapy services, they may be moved along the contin-
for a patient facing imminent discharge may identify uum from acute inpatient to the acute rehabilitation
durable medical equipment, inpatient rehabilitation, setting. Patients still may need acute medical care in the
skilled nursing, outpatient, or home health therapy acute rehabilitation environment. Stays in acute reha-
needs. Identification of needs by the therapist does not bilitation generally range from 2 to 3 weeks, with some
automatically ensure that the patient will receive the patients discharged in a few days and others in a matter
recommended services. By contacting other members of of months. The usual goal of an acute rehabilitation stay
the health care team and communicating concerns, the is discharge to a lesser level of care (e.g., a board and
therapist can help make sure that evaluation recom- care residence or home).
mendations will be implemented. The process of adjustment to disability has begun by
The occupational therapist must work with the the time the patient has entered acute rehabilitation. As
health care team to rapidly identify issues affecting the patient begins to participate in physical activities,
patient progress or discharge. An experienced therapist deficits and strengths have become more defined. An
equipped with knowledge of the resources available improvement in function from the level at onset of dis-
among the health care team and in the community pro- ability may have occurred. This indicates to the patient
motes swifter recovery and discharges by working with that the disability is not static.
the patient and team to quickly and accurately identify Rehabilitation centers attempt to room patients of
areas of concern and promote solutions for resolution similar diagnosis and age together. In particular, adoles-
of problems. For example, a therapist who determines cents benefit from this approach, because their psycho-
that a patient living alone at discharge would be unable logical development is in an important phase. Issues of
to prepare meals might contact the social worker, who being able to make choices for oneself, control one’s en-
would help set up delivery of hot meals to the home. vironment, and separate from childhood into inde-
Another example is a therapist who evaluates a patient pendent adulthood are forming.’ A rehabilitation team
scheduled for imminent discharge, finding that the sensitive to these issues can promote independent deci-
patient moves impulsively and lacks insight into the sion making within an environment and situation that
consequences of his or her actions and is confused otherwise gives a strong message of loss of control.
 Treatment Contexts

In rehabilitation, there is movement away from the in any phase of rehabilitation, goal attainment and
role of patient to former and new life roles. Interven- patient performance are dependent upon clear commu-
tions focused on resumption of those roles will facili- nication and identification of goals that are relevant and
tate the transition. For parents, introduction of children meaningful to the patient.
into the treatment environment can promote a shift There are more similarities than differences in acute
away from the patient role and toward the role of and subacute rehabilitation settings. The primary differ-
parent. ences found in subacute centers are as follows:
Although bedrooms in acute rehabilitation facilities
are similar to those found in acute hospitals, personaliz- SUBACUTE REHABILITATION. Subacute rehabili-
ing one’s room by bringing in pictures, comforters, and tation facilities are found in skilled nursing facilities
other items from home is encouraged. Rehabilitation and other venues that do not provide acute medical
patients are expected to dress in street clothes rather care. The equipment available to the therapist for treat-
than pajamas, which characterize infirmity. Most cloth- ment and evaluation in the subacute setting may be
ing is easy-to-don leisure wear. A hidden danger is that comparable to that found in the acute rehabilitation fa-
dressing training in the rehabilitation center may miss cility, but in most cases is more limited. Lengths of stay
critical elements associated with donning less comfort- are frequently longer in the subacute setting and may
able but necessary clothes such as neckties and panty last from a few days to several months. The goal in a
hose. subacute setting is usually discharge to a lesser level of
Simulated living environments, family rooms, care.
kitchens, bathrooms, and laundry facilities can be Treatment can be paced more slowly in a subacute
found at most rehabilitation centers. These environ- setting because the urgency for quick discharge is not
ments may be inaccurate replicas of the performance always present. Engaging in 3 hours of therapy per day
contexts in which the person will ultimately have to is not mandatory. Patient endurance will influence the
function. For example, laundry machines may be side frequency and duration of therapies.
by side and top loading rather than coin operated and Because many subacute rehabilitation centers are
front loading. Kitchens may be wheelchair accessible in housed in skilled nursing facilities, the patient may have
the facility but inaccessible in the home. Clutter, noise, roommates who are convalescing rather than actively
and types of appliances will vary from the patient's participating in a rehabilitation program. Under those
natural environment. circumstances, the social and emotional bonds formed
Access to the community is not generally evaluated with roommates can be less motivating than in an acute
in the acute rehabilitation setting because of the inpa- rehabilitation facility.
tient nature of the setting, coordination of multidisci- SKILLED NursINnG Facitities. A skilled nursing facility
plinary schedules, and locations of applicable commu- (SNF) is an institution that meets Medicare or Medicaid
nity environments relative to the facility. Some urban criteria for skilled nursing care, including rehabilitation
facilities are able to integrate community training more services. Subacute rehabilitation centers may be housed
smoothly because stores, restaurants, and theaters are in SNFs, but occupational therapy services may also be
closer. These amenities are not identical to those that provided to individuals who are not in a subacute
patients use within their own community, and perform- program. Many residents (the preferred consumer label
ance will reflect this variance. for persons who live in long-term care settings) will
Within a rehabilitation center, many patients form remain in SNFs for the remainder of their lives; others
new social relationships with individuals who have will be discharged home.* Goals may be directed
similar disabilities. The advantages of these relation- toward independence or toward safe medical manage-
ships are emotional support and encouragement from ment of the resident.
the progress of others. The chief disadvantage is that pa- Extreme variations in disability status are present in
tients may form false expectations (both negative and SNFs. Observing residents who are severely and perma-
positive) of their own potential. nently disabled may lead newly disabled individuals to
The culture of rehabilitation facilities is focused on form negative expectations of their own prognosis and
patient performance and goal attainment. The patient's performance. Younger adults placed in SNFs (where
own culture may be compromised in the process of re- most residents are older adults) may feel isolated, which
habilitation unless the team is sensitive to and adapt- can adversely affect performance.
able to the patient's perspective. For example, some cul- The physical environment in skilled nursing facilities
tures view hospital settings as a place for respite and impedes the natural performance of ADL. Most equip-
Passive patient involvement. Engaging patients in ADL ment is medical or utilitarian, except that found in the
performance can be in direct conflict with patient and common areas. ADL practice in a common area is im-
family expectations. When cultural perspectives clash, practical because the area is frequently crowded and
unrealistic goals are frequently the result. As is the case compromises privacy and confidentiality. The therapist
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

is challenged to adapt medical equipment to simulate that the health care provider will prevent the patient
real-life surroundings and must be able to project how from returning home is eliminated. The patient can
actual performance will vary from therapeutic trials. begin to view the therapist as an ally for home living.
Friends are less likely to visit in this environment. The therapist and patient meeting in the patient's
Feelings of abandonment are not uncommon. Maintain- home take on new roles. A visiting therapist is a guest in
ing connections with friends from the outside demands the home and is subject to certain social rules associated
active pursuit of these relations. A strong family commit- with guests. For example, following the family customs
ment can support outside relationships by providing of removing street shoes may seem odd to a hospital
transportation to church and social gatherings. therapist but is standard practice in many home set-
A common belief in American society is that people tings. Schedules for meals, waking, and sleeping fall
go to skilled nursing facilities to live out their final days. within patient and family control. The home health
Family and friends may expect less of the individual therapist's schedule is more likely to be dictated by the
than they would in other settings. A therapist who facil- patient than vice versa.
itates identification of realistic and meaningful expecta- The physical environment at home is familiar and
tions and goals for the resident can promote a more affords orientation in its familiarity. The confusion that
positive outlook and outcome. might be experienced in a hospital or clinic setting is
Many skilled nursing facilities are staffed with indi- reduced. However, the moving of furniture to make
viduals from other cultures. Language barriers between things more accessible for the patient may decrease ori-
the residents and staff may further isolate the resident. entation and increase confusion.
Incompatibilities in cultural expectations are not un- Self-care, homemaking, and cooking tasks evaluated
common. The occupational therapist can improve com- in the context of the home define the challenges that the
munication between residents and staff by educating patient meets daily. The clothing, furniture, appliances,
staff members about each resident's goals and culture. and utensils used in everyday life are present. No longer
RESIDENTIAL Care. Generally, residential care facili- must the therapist project how the patient can get into
ties are long-term settings that resemble home situa- or out of the bathtub. Rather, the task of bathing can be
tions; persons may reside there on a permanent or tran- worked on in its natural context, and patient perform-
sitional basis, depending on prognosis.'* Facilities are ance is realistic. Caring for and feeding animals, answer-
staffed 24 hours a day, but therapists and assistants are ing the door safely, and determining a grocery list for
present for only part of the day. Rehabilitation techni- the week suddenly become treatment goals and venues.
cians implement treatment plans. This “real world labo- Social and family support or lack thereof is readily
ratory” creates an environment that is more conducive evident to the home health therapist. Individuals who
to autonomy and independence. appeared alone and unsupported while hospital inpa-
Similarities in the age of residents, their disability tients may have a network of friends and family
status, and even diagnoses are commonly present. The members who lend support at home. Conversely, other
bonds formed typically promote better performance. individuals who had frequent visitors in the hospital
Cooperative living is the expectation; performance can may be abandoned when the realities of disability reach
be enhanced by this standard. the home setting.
Although the environment is not the resident's own The home health patient typically requires the assis-
home, it more closely resembles the resident's natural tance of a caregiver for some aspects of his or her ADL.
living situation than do other inpatient settings. The Nearly 20% of all family caregivers are employed full-
therapist can identify key performance issues in this time outside the home.” These caregivers are available for
context. Difficulties with evening self-care, follow- only part of the patient's day and will be concerned pri-
through with safety guidelines, problem solving, sched- marily with the safety of the patient during their absence.
ules, and rules are reported to the therapist by the tech- Stress is common among caregivers. Respite care,
nician. Modifications in treatment can be more easily which temporarily places the patient under the care and
tailored to promote independence under such close supervision of an alternative caregiver for a few hours or
supervision. several days, can provide necessary relief for a caregiver.~
Home HeattH. Home health care, treatment based Caring for a person with a disability in one’s home is
in the patient's home, affords the most natural context not an easy task. Box 4-2 identifies practical concerns
for treatment. Blue Cross of California defines a mean- surrounding the presence of a patient in the home.
ingful therapeutic outcome as “one in which the activity The unique culture of the patient and family unit are
level achieved by the patient. . . is. . . necessary for evident at home. Religious symbols and practices may
the patient to function most effectively at home or be brought into therapy by the patient. A desire to
work.”'° The patient, returning home from the hospital, kneel, to genuflect, or to light a candle may never have
begins to resume life roles at home. Fear of the health been communicated in other settings, where the context
care provider is frequently decreased at home. The belief did not evoke these behaviors.
 ipeemendeanteis
rectly, the therapist can address most hazards and ac-
complish their removal. In a rental situation, the patient
Coen in Caring for a Person may wish to avoid having safety concerns presented to a
with Disability in One’s Home landlord for fear of eviction. Inclusion of the patient in
problem identification and solution generation may
not yield the desired results. Consultation with other
Amount and type of care needed professionals can prove fruitful in issues of ethics.
_ Long-term versus temporary, intensive supervision or
assistance versus minimal, help available to the caregiver,
presence of alternative solutions, and personal feelings Outpatient
about the patient and the type of care required (intimate
assistance versus household tasks) Outpatient OT is provided in hospitals and freestanding
clinics to patients who reside elsewhere. Outpatients are
Impact on the household medically stable and able to tolerate a few hours of
Effect on spouses, children, and others living in the home; therapy and a trip to an outpatient clinic. Although
possible involvement of family in making decisions many outpatients are adjusting to a new disability, some
persons with long-standing disability may be referred
Environmental concerns for therapeutic tune-ups and equipment-related issues.
Need and possibility of adapting the home, expenses of Individuals may view themselves either as dependent
adaptations (the patient role) or as more in control (the client role),
depending on the type of problem for which they are
Work and finance
referred.
Options for family medical leave; ability and need to quit work;
benefits available
Outpatient therapy schedules are under the control
of the patient more frequently than therapy schedules
Adapted from Visiting Nurses Association of America: Caregiver's handbook: a for inpatients are. Transportation issues and pressing
complete guide to home medical care, New York, |997, DK Publishing. family matters necessitate that clinics offer a variety of
treatment times from which a patient may choose. Oth-
erwise, the patient may turn to a different clinic or
Viewing the patient's environment firsthand, the choose to forego therapy.
therapist can make recommendations for environmen- To evaluate home-based tasks in an outpatient
tal adaptations, see them implemented, and modify setting the therapist must extrapolate how task perform-
those changes as needed to best meet the patient's ance will vary at home.'* Similarity or difference relative
needs.” Physical changes to the home, including to home will affect the patient's ability to perform ADL
moving furniture, dishes, or bathing supplies, should tasks. The physical layout and equipment of outpatient
not be undertaken without the permission of the clinics vary and tend to be designed to meet the treat-
patient. If the patient is in the home of a family member ment needs of specific disabilities. Hand therapy pro-
or friend, the permission of the homeowner must also grams, for example, will have treatment tables for exer-
be sought. cise and activities and areas for splint fabrication. An
Control of the environment in the home falls to the industrial work area with special exercise equipment
patient and family. Clinicians who fail to ask permis- such as Baltimore Therapeutic Equipment (BTE), which
sion before adapting the environment will rapidly mimics work tasks, is not uncommon. Less commonly
alienate their patients. A throw rug, viewed by the thera- found in the outpatient setting are complete kitchens
pist as a tripping hazard, may be a precious memoir with cooking equipment and therapeutic apartments
from the patient's childhood home. In seeking permis- with bathing facilities, living rooms, and bedrooms.
sion of the patient and family and providing options, Hospital-based outpatient programs might have access
the therapist opens communication. An adhesive mat to homemaking and bathing areas used in the inpatient
placed beneath the throw rug will provide a safer surface rehabilitation center.
on which to walk. Another possible solution is to hang The context of self-care tasks is rather awkward for
the rug as a wall tapestry, where it will be more visually outpatients. Patients who have been assisted with
prominent and less prone to damage. bathing and dressing before coming to the clinic may
Health care workers in the home occasionally en- resist working on these same tasks during therapy. The
counter ethical dilemmas, often involving safety.'’ The more unnatural and inappropriate a task seems to pa-
therapist must be able to determine the best mechanism tients, the less likely that they will perform well and
for resolving issues of safety hazards. Fire and health benefit.
hazards must be discussed and corrected when the The social context found in outpatient programs is
safety of the patient or adjacent households is in jeop- quite distinctive. The patient has begun to resume life in
ardy. By broaching the subject diplomatically and di- the home and community and may be newly aware of
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

problems not previously foreseen or acknowledged. If and cultusal order are ill advised, since things are likely
the therapist is viewed as an ally in resolving problems to return to their natural state when the treatment
and promoting a smooth transition to home, the session ends and the therapist leaves.
patient or family members may easily disclose con- When practice is necessary for goal attainment, a re-
cerns. However, if the patient and family fear that the habilitation technician or therapy aide may be charged
patient will be removed from the home because of an with carrying out treatment programs set by the thera-
inability to manage there, they may actively hide con- pist. The technician who spends many hours with the
cerns from the therapist. In the former instance the patient can provide greater insight in cases when treat-
patient and family view themselves as being in control ment is not succeeding because it interferes with the
of the situation. In the latter, control and power are natural context of the client's lifestyle. Adjusting treat-
assumed to belong to the health care professional. An ment strategies to adapt to these lifestyle differences will
outpatient therapist must be skilled in giving control to ensure better clinical outcomes.
the patient. Soliciting patient opinion and listening for
unspoken needs are two methods for increasing the Day treatment
patient's sense of control.'° Providing choices for treat- Day treatment programs are becoming more popular as
ment does much to motivate clients and improve per- a way of decreasing the length of inpatient hospitaliza-
formance in tasks. tions and containing rehabilitation costs. Programs
Each outpatient clinic has its own culture. Some are vary, but the underlying philosophy is to provide an in-
perceived as clinically more professional, while others tensive interdisciplinary treatment for patients who do
have more of an office atmosphere, and still others the not need to be hospitalized.* Patients receiving day
flavor of a community center or gym. The culture of the treatment typically live at home. Most programs offer a
clinic lends a context for performance to the patient. team approach. Professionals from all disciplines are
More clinical and professional settings may help some engaged cooperatively, sharing their expertise to meet
patients feel most comfortable and _ professionally the patient's individual goals.
managed. The same setting might lead other patients to Many day treatment programs are designed without
fear failure; a community center atmosphere may be the traditional time constraints inherent in a more
comfortable to these patients. traditional outpatient program. Lengthy community
outings and home and work site treatment sessions may
Home- and community-based therapy be used as a method of attaining goals. A day treatment
Most clinicians are familiar with home health care. An therapist may have the best opportunity to evaluate and
alternative course for patients with traumatic injuries treat patients in all of their natural environments.
such as head or spinal cord injuries is a home- and
community-based therapy program. Treatment is deliv- Work site therapy programs
ered in the home, but that is where the similarity to Industrial rehabilitation can be conducted in the
home health ends. This type of program provides inten- context of the employee’s place of work. Work site
sive rehabilitation in the patient's own home and com- therapy programs in the workplace are designed to
munity. The client receives comprehensive rehabilita- address an employee's therapy needs related to work
tion services and acquires functional skills in daily injury. The injured worker can remain at or return to
activities in the normal environments of home, school, work for treatment. Work hardening is taken out of the
work site, and community. This enhances the likelihood clinic setting and put back in the workplace. This cost-
of a successful and functional outcome. effective approach places the patient back into the work
For example, a young mother may benefit more from role. Prevention of further injury occurs naturally when
working on realistic meaningful tasks in her home and employees are treated at the work site. .
community than she would in a clinic setting. The Treating individuals at their place of work helps them
patient is performing in her natural physical, social, and make the transition from the patient role to the role of
cultural environment. Scheduling is within control of client or worker. The therapist engaged in the treatment
the patient, and treatment sessions vary in length and context of the worksite must never compromise the
frequency depending on the goals. An all-morning worker's status.” The employer and peers must view the
session to work with the client as she moves through her employee as a worker rather than as a patient. Maintain-
daily routine (e.g., bathing and dressing her child, going ing confidentiality can be challenging because the
grocery shopping, and performing various household coworkers’ curiosity is often aroused by the unfamiliar
chores) would be possible. face of the therapist in the workplace. The therapist
Clinically, the therapist must be able to adapt the must remember never to answer queries that would
treatment to the natural social and cultural aspects compromise client-therapist confidentiality. Unsolicited
present in the home. Attempts to alter the natural social requests from coworkers for medical advice and work
site modifications are best referred to that employee's guide the patient via careful questioning toward mean-
doctor or manager, respectively. ingful and attainable goals. Sensitivity to the unique
In the work setting the therapist is answerable to the needs of each individual in each treatment setting is
employer as well as the employee, and often also to an in- critical.
surance company. By encouraging the injured employee
to communicate his or her needs for work modification
and suggestions for how productivity might be main-
REVIEW QUESTIONS
tained, the therapist will pave the way for a successful 1. Identify the temporal and environmental aspects of
transition to work. The therapist must be able to step performance context.
back from the client, see the needs of the employer, and 2. Name at least five treatment settings in the contin-
promote resolution of work-related issues that would in- uum of care.
terfere with a smooth transition to productive work. 3. Discuss how names applied to various consumer
Scheduling of therapy visits to the workplace must meet groups affect performance.
the needs of both the employee and employer. Work site 4. Identify environmental and temporal aspects of
visits should be scheduled in a manner that minimizes acute hospitalization and identify modifications a
stopping or interfering with the natural flow of work. therapist can make to adjust performance to more
The financial impact of work modifications will closely mimic that at home.
concern the employer. Employers do not have unlim- 5. Discuss how control over the schedule promotes a
ited resources for modifying work environments. Only sense of control in patients and clients.
reasonable and necessary work modifications should be 6. Identify persons with whom home modifications
considered. Suggestions for work modifications that must be discussed before they are implemented, and
have an associated cost should be discussed with the explain why.
employer and not with the employee. This is unique to 7. Identify modifications that should not be discussed
the environment of work and one of the rare times in with the employee without employer approval, and
which the patient will not be privy to all of the thera- explain why.
pist’s recommendations and suggestions. The therapist 8. Discuss situations that have the potential to compro-
can suggest work modifications that do not have any mise patient confidentiality at the work site, and
cost, but must consider the impact of these modifica- identify appropriate responses.
tions on coworkers using the same equipment. As a rule
of thumb, modifications that affect workers other than
the employee must be discussed with management REFERENCES
1. American Occupational Therapy Association: Uniform terminol-
before they are presented to the employee.
ogy for occupational therapy, ed 3, Am J Occup Ther 48:1047-1055,
In a traditional clinic setting, a secretary who sus- 1994.
tained a repetitive motion injury of her wrist may 2. Atchison B: Occupational therapy in home health: rapid changes
receive various modalities to control her symptoms of need proactive planning, Am J Occup Ther 51(6):406-409, 1997.
pain and edema and may be educated on joint and 3. Blau SP, Shimberg EF: How to get out of the hospital alive: a guide to
patient power, New York, 1997, Macmillan.
tendon protection techniques while performing various
4. Bausell RK, Rooney MA, Inlander CB: How to evaluate and select a
movements in a clinic setting. When the secretary is nursing home, Beverly, Mass, 1988, Addison-Wesley.
treated in her work environment additional benefits 5. Boaz RF: Full-time employment and formal caregiving in the
may occur. Joint and tendon protection techniques are 1980's, Medical Care 34(6):524-536, 1996.
applied at work while performing day-to-day work 6. Chu LW et al: Risk factors for falls in hospitalized older medical
patients, J Gerontol A Biol Sci Med Sci 54(1):M38-M43, 1999.
tasks. Since the client's injury occurred at work, it could
7. Dunn W: Pediatric occupational therapy—facilitating effective service
be exacerbated or prevented at work. See also Chapters provision, Thorofare, NJ, 1991, Slack.
16 and 17 with regard to the role of the occupational 8. Gilliand E: The day treatment program: meeting rehabilitation
therapist with workers and in work settings. needs for SCI in the changing climate of health care reform, SCI
Nurs 13(1):6-9, 1996.
9. Haffey WJ, Abrams DL: Employment outcomes for participants in
SUMMARY a brain injury reentry program: preliminary findings, J Head
Trauma Rehabil 6(3):24-34, 1991.
Treatment context, the environment in which treat- 10. Head J, Patterson V: Performance context and its role in treatment
ment occurs, has temporal and environmental dimen- planning, Am J Occup Ther 51(6):453-457, 1997.
sions that affect both the therapist and the person re- 11. Opachich KJ: Moral tensions and obligations of occupational
therapy practitioners providing home care, Am J Occup Ther
ceiving therapy services. Knowing the features of each
51(6):430-435, 1997. :
treatment context and anticipating how the context 12. Park S, Fisher AG, Velozo CA: Using the assessment of motor and
will affect performance prepares the therapist to best process skills to compare occupational performance between
meet patient and client needs. A skilled therapist can clinics and home setting, Am J Occup Ther 48:697-709, 1994.
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

13. Proctor D, Kaplan SH: The occupational therapist's role in a tran- SUGGESTED READING
sitional living program for head injured clients, Occup Ther Health Heron E: Tending lives—nurses on the medical front pulse, New York,
Care 9(1):17-35, 1995. 1998, Ballantine.
14. Rogers JC, Holm MB, Stone RG: Evaluation of daily living tasks: Visiting Nurses Association of America: Caregiver’s handbook: a com-
the home care advantage, Am J Occup Ther 51(6):410-422, 1997. plete guide to home medical care, New York, 1997, DK Publishing.
15. Stewart DL, Albin SH: Documenting function in physical therapy, St
Louis, 1993, Mosby.
 | Therapy Evaluation
nt of Physical Dysfunction

LEARNING OBJECTIVES
Evaluation After studying this chapter the student or practitioner
Assessment will be able to do the following:
Client-centered practice 1. Differentiate and define evaluation and assessment.
Evaluation process 2. List and describe the steps in the evaluation process.
Initial evaluation 3. Know the purposes of occupational therapy (OT)
Screening evaluation.
Occupational therapy diagnosis 4. Describe the desired outcome of the initial
Clinical reasoning evaluation.
Informal observation 5. Describe four methods of assessment that
Formal (structured) observation occupational therapists use.
Standardized test 6. Compare standardized and nonstandardized tests.
Nonstandardized test

valuation refers to “the process of obtaining and In occupational therapy (OT), evaluation of occupa-
interpreting data necessary for intervention. This in- tional performance, performance areas, performance
cludes planning for and documenting the evaluation components, and performance contexts is the basis for
process and results.” Assessment refers “to specific tools developing treatment objectives and intervention strate-
or instruments that are used during the evaluation gies. The OT evaluation should identify occupational
process.”* problems that are of concern to the patient.”'°
Evaluation is the process of gathering data, identify- An initial evaluation takes place before treatment
ing problems, formulating hypotheses, and making de- begins, and reevaluation occurs periodically during the
cisions for treatment interventions.”'’The evaluation is course of OT intervention.’ The results of the initial
carried out using formal and informal screening and evaluation are used to identify deficits in performance
other methods, including a review of the medical areas and performance components. Deficits in per-
record, an interview, observation, standardized tests, formance areas are defined as limitations in the ability
and nonstandardized tests.’ In client-centered practice, to perform desired self-care, work and productive activi-
the patient and patient's family participate in decision ties, or leisure skills. Deficits in performance compo-
making, to the extent possible, throughout the evalua- nents are physical, cognitive, or psychosocial impair-
tion process. Evaluations are usually performed at the ments that limit adequate and satisfying function in the
beginning of treatment, periodically during the term of performance areas. Performance contexts may also be
treatment, and at the end of treatment.'° assessed at this time. The occupational therapist must
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

assess the environments in which tasks are to be per- cumstances, describes the occupational therapy diag-
formed and features of the environment that affect the nosis, and proposes treatment goals and objectives that
patient's ability to function optimally.’ can be achieved in a time frame prescribed by the
The initial evaluation is the foundation for selecting patient's insurance carrier. '°
treatment objectives and treatment methods.'’ Reevalu-
ation is essential to determining the effectiveness of
Identifying Treatment Model or Models
treatment, modifying treatment to suit the patient's
needs, and revising the treatment plan. Reevaluation The next step in the evaluation process is to select an ap-
may lead to the elimination of unattainable goals, the propriate treatment model or models and the specific
modification of goals that were partially or completely assessments that will yield the information needed as
achieved, and the adoption of new goals as additional the basis for clinical decision making consistent with
problems are identified or progress is made. the selected practice model. For example, for a patient
Evaluation and assessment provide therapists with who has rheumatoid arthritis, the therapist is likely to
specific methods for determining their effectiveness as a select the biomechanical and rehabilitation models.
planner and administrator of treatment.'’ Evaluation Using these models, the therapist assesses factors such
yields specific information that can be communicated as joint range of motion (ROM), muscle strength, and
to other members of the rehabilitation team. Further- physical endurance as well as activities of daily living
more, careful evaluation and assessment can enhance (ADL), work, and leisure activity performance. In
the development of OT instruments, programs, and pro- another example, for a patient who had suffered a cere-
tocols. Assessment data that are collected systematically brovascular accident (CVA) or stroke, the therapist
may be used for the development of standardized as- could select the neurodevelopmental model and plan to
sessments and thus contribute to a better understanding assess motor control, muscle tone, coordination, and
of the assessment and treatment methods that are effec- the postural reflex mechanism.
tive in OT practice.
To evaluate effectively, the therapist must be knowl-
Assessment
edgeable about the dysfunction, its causes, course, and
prognosis; familiar with a variety of assessment tools, After selecting an appropriate treatment model, the
their uses, and proper administration; and able to select therapist assesses occupational performance, perform-
assessments that are suitable to the patient and the dys- ance areas, and performance components. The primary
function. Thus, an understanding of possible dysfunc- focus of OT is to maximize occupational performance
tion in performance areas, performance components, by identifying deficits in occupational performance
and performance contexts is essential, as is a mastery of and providing intervention strategies to eliminate or
applicable treatment principles. When performing as- alleviate such deficits. A top-down approach to eval-
sessments, the therapist must approach the patient with uation proceeds first with occupation-based assess-
openness and without preconceived ideas about the in- ments and then with the assessment of performance
dividual’s limitations or personality. The therapist must components.
have good observation skills and must be able to gain The therapist assesses the patient by using structured
the trust ofthe patient in a short time.*° interviews, clinical observation, formal and informal
observations, standardized tests, and nonstandardized
EVALUATION PROCESS tests. The therapist studies assessment results to identify
deficits in the performance areas, performance compo-
Screening and Initial Evaluation
nents, and performance contexts. Identification of
The evaluation process (Fig. 5-1) is initiated with deficits is always somewhat provisional, and open to re-
screening, which includes reviewing the patient's vision because new information may alter the thera-
medical record and possibly discussing the patient with pist’s formulation of the patient's occupational per-
other staff.’ formance problems.
Following the screening, initial assessments are
conducted. The occupational therapist interviews the
Problem Identification
patient, administers selected screening tests, and makes
observations about the patient’s physical condition and Data necessary to plan treatment are interpreted and
affective state. The estimated duration of treatment and synthesized.* Assets are noted and deficits in perform-
the need to coordinate treatment with other services can ance areas, performance components, and performance
also be determined at this time.*’'” contexts that necessitate OT intervention are identified.
The initial evaluation establishes the patient's treat- The occupational therapist assesses the individual’s oc-
ment priorities, describes potential posttreatment cir- cupational roles and role dysfunction and makes an OT
 Occupational Therapy Evaluation and Assessment of Physical Dysfunction

Screening Initial Assessments

Review record, Interview, observe,

discuss with staff screening tests and tasks

Identify Treatment Models

Select appropriate assessments

Assessment

Structured interview, clinical

observation, administer tests and
tasks, study assessment results

Problem Identification

Interpret, synthesize assessment

data; identify deficits in performance
areas, performance components and
performance contexts; make
occupational therapy diagnosis

Develop Treatment Plan

Select goals, objectives, intervention

strategies based on occupational
therapy diagnosis

FIG. 5-1
The evaluation process. /

diagnosis.'° The occupational therapy diagnosis is a the occupational therapy diagnosis (i.e., problems and
list of occupational performance deficits and perform- deficits) are selected in conjunction with the patient and
ance skills deficits that describes the effects of the patient's family or significant others.
patient's medical or psychiatric condition on function
in essential and desired life roles.'°
CLINICAL REASONING
During the evaluation process the therapist uses clinical
Developing a Treatment Plan reasoning and clinical decision making to identify
The final stage of the evaluation process is to develop a problems and select intervention strategies.'’ Clinical
treatment plan. Goals, objectives, and evidence-based reasoning, described in Chapter 3, guides decisions
intervention strategies (see Chapter 7) that will address about the collection, classification, and analysis of data
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

and ultimately helps to determine appropriate goals also assess the patient's environment as a determinant
and intervention stratetgies.'® of occupational performance. The social, cultural, and
Clinical reasoning includes several forms of thinking physical environments are all performance contexts that
and ways of perceiving. It is the process of figuring out influence occupational functioning. The disabling and
how to select the most appropriate action in a particular enabling factors of the patient's environments and
case for the patient's well-being. Clinical reasoning person-environment relationships need to be assessed
combines theoretical principles with the knowledge and and considered in treatment planning.*’" This informa-
habitual ways of seeing and doing things that come tion should guide the therapist in selecting appropriate
from experience. Clinical reasoning improves as the and meaningful treatment objectives and methods.
therapist gains and applies findings from research data Structuring treatment on the basis of the patient's needs,
and experience.'”’’* values, and sociocultural milieu facilitates the patient's
The simple application of theoretical constructs to full participation in the treatment process.
alrive at answers to questions about appropriate inter-
vention strategies is only a part of the clinical reasoning METHODS OF ASSESSMENT
process. OT theory provides a starting place for clinical
Medical Records
reasoning but cannot provide all the answers for the
course of action in a particular case. Because each Data gathered from the medical record are impor-
patient is unique and complex, treatment must be in- tant parts of the evaluation process. The medical record
dividualized. This requires judgment, creativity, and can provide information on the diagnosis, progno-
improvisation. '*!? sis, medical history, precautions, current treatment
When occupational therapists teach their patients regimen, social data, psychological data, and other reha-
everyday activities they are confronted with the patients’ bilitation therapies. Daily notes from nurses and physi-
experiences of profound life changes brought about by cians give information about current medications and
the disability, the loss of capacities taken for granted, the patient’s reactions and responses to the hospital,
and reorientation to the world as a person with physical treatment regimen, and persons in the treatment facil-
and functional limitations. Thus the treatment is di- ity.'° Ideally, the occupational therapist will have the
rected not only to the dysfunction but also to the opportunity to study the medical record before seeing
human meaning of the dysfunction to the patient. OT the patient to begin the evaluation process. Knowing
treats the “illness experience.”'* The therapist's role is to the patient's diagnosis before beginning the evaluation
help patients confront the limitations, “claim the dis- can alert the occupational therapist to problems that are
ability,” reclaim a changed body and functioning, and likely, can suggest assessments that might be useful, and
develop a new sense of self with meaning, purpose, and may even indicate a likely treatment approach. The
value.'*’"* medical record indicates problem areas and helps the
therapist focus attention on the relevant factors of the
case.'°*° Occasionally, special circumstances make it
CONTENT OF THE EVALUATION
necessary for the therapist to begin the evaluation
During the initial OT evaluation, the therapist should without the benefit of the information in the medical
include an assessment of the patient's goals, functional record.
abilities in the occupational performance areas, per-
formance components, and performance contexts as rel-
Interview
evant to the individual and the clinical condition.*”
The therapist should also assess performance compo- The initial interview is a valuable step in the evalua-
nents, paying particular attention to the sensorimotor tion process. The interview is a shared experience in
component and cognitive integration and cognitive which both the therapist and client ask and answer
components in physical disabilities. The therapist also questions. An essential purpose of the interview is for
assesses or observes psychosocial skills and psychologi- the therapist to hear the client's story and know all of
cal components’ during the initial visits with the the particulars of the client’s situation. These data are
patient. The occupational therapist may need to plan re- the basis for meaningful treatment planning.’° The oc-
mediation or compensation for these latter compo- cupational therapist gathers information during the in-
nents, as well as for the more obvious sensorimotor terview on how the patient perceives his or her roles,
deficits. Alternatively, the therapist might refer the dysfunction, needs, and goals, and the patient can
patient to the appropriate service for remediation, de- learn about the role of the occupational therapist and
pending on the severity of the problems. The occupa- OT in the rehabilitation program.'’*° An important
tional therapist should obtain information about the outcome of the initial interview is the development of
patient's medical, educational, and work histories, collaboration, rapport, and trust between therapist and
family, and cultural background.* The therapist should patient."°
 Occupational Therapy Evaluation and Assessment of Physical Dysfunction

The initial interview should take place in an environ- be concluded with a summary of the major points
ment that is quiet and ensures privacy. The therapist covered, information gained, estimate of problems and
should plan the interview in advance, determining what assets, and plans for further OT evaluation.
information must be acquired and preparing some spe-
cific questions. The interviewer and patient should set
Observation
aside a specified period of time for the interview. The
first few minutes of the interview may be devoted to Some aspects of the evaluation will be based on the oc-
getting acquainted and orienting the patient to the OT cupational therapist's informal observation of the
clinic or service and to the role and goals of OT. patient during the interview and formal observation
The two essential elements for a successful interview during the assessment procedures that follow. The occu-
are a solid knowledge base and active-listening skills. pational therapist will base some of the reevaluation of
The therapist must acquire these abilities through study, the patient on observations during treatment.
practice, and preparation. The therapist's knowledge
will influence the selection of questions or topics to be Informal Observation
covered in the interview. The interview should cover the The occupational therapist can gain much information
areas that are relevant both to OT and to the construc- by observing the patient as he or she approaches or is
tion of a meaningful treatment plan. Active listening approached. What is the posture, mode of ambulation,
creates opportunities for genuine communication. The and gait pattern? How is the patient dressed and
interviewer who listens actively demonstrates respect for groomed? Is there an obvious motor dysfunction? Are
and a vital interest in the patient.’ The therapist tries to there apparent musculoskeletal deformities? What are
understand what the patient is feeling and the meaning the facial expression, tone of voice, and manner of
of the patient's message. The interview is an opportunity speech? How are the hands held and used? Are there
to establish a collaborative therapeutic relationship pain mannerisms, such as protection of an injured part
with the patient.’° or grimaces and groans? Are there apparent body odors?
Throughout the interview the therapist should listen
to ascertain the patient's attitude toward the dysfunc- Formal Observation
tion. The therapist invites the patient to express what he Occupational therapists use formal structured observa-
or she sees as the primary problems and goals for reha- tion to assess performance of self-care, home manage-
bilitation. These may differ substantially from the thera- ment, mobility, and transferring (see Chapters 13 and
pist’s judgment and must be given careful consideration 14). The therapist observes the patient perform these
when therapist and patient reach the point of setting skills in real or simulated environments. The therapist
treatment goals together. As the interview progresses, can determine the patient's level of independence,
there should be an opportunity for the patient to ask speed, skill, need for special equipment, and the feasi-
questions as well. The therapist must have good listen- bility of further training. The therapist can also observe
ing and observation skills to gather the maximum for the performance component deficits that may be
amount of information from the interview. Further, the causing difficulties with performance of essential life
therapist must have the patience to wait through tasks.
periods of silence for the patient to consider the ques- The rapport and trust that develop between the
tions and formulate responses. patient and the therapist flow out of the communica-
It will probably be necessary to take notes or record tion between them. The quality of communication in
the initial interview. The patient should be advised of the interview and observation phases of the evaluation
this method in advance, understand the reasons this is process is critical to all subsequent interactions and thus
done, know the uses to which the material will be put, to the effectiveness of treatment. The patient must sense
and be allowed to read the notes or listen to the tape if that he or she has been heard and understood by
he or she desires.'”’*° someone who is empathic and who has the necessary
During the initial phase of the interview, the therapist knowledge and skills to facilitate rehabilitation. The
should explain the purpose of the interview and how the therapist who is an effective communicator projects
information will be used. As the interview progresses, the self-confidence and confidence in the profession, setting
therapist may seek the desired information by asking ap- the tone for all future interaction with the patient and
propriate questions and guiding the responses and enhancing the development of the patient's trust in the
ensuing discussion so that relevant topics are addressed. therapist and in the potential effectiveness of OT.°°
The occupational therapist may wish to seek informa-
tion about the patient's family and friends, community
Assessments
and work roles, educational and work histories, leisure
and social interests and activities, and the living environ- The evaluation is carried out through assessments such
ment to which the patient will return. The interview can as tests and measurements in OT. Relevant and accurate
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

evaluation is critical to decision-making for planning Standardized instruments designed by other profession-
treatment, determining school and community living als for their own disciplines are sometimes used by oc-
placement, considering admission to and discharge cupational therapists.***
from clinical programs, and other dispositions that may In contrast to standardized tests, administration and
be based on test results. Thus, in reporting assessment scoring of nonstandardized assessments is more subjec-
data it is essential that the information be supported by tive. There may be no specific instructions for adminis-
relevant and accurate testing procedures.’ tration, criteria for scoring, or information on interpret-
Occupational therapists use both standardized and ing results of the assessment.’” The results and
nonstandardized assessments. The development of interpretation of nonstandardized tests depend on the
standardized OT assessments that are grounded in clinical skill, experience, judgment, and bias of the eval-
theory has been increasing in recent years. uator.’ Some nonstandardized assessments provide in-
structions for test administration and broad criteria for
STANDARDIZED TESTS. Standardized tests in- scoring and interpretation but still require the use of
clude specific instructions for administration and considerable subjective professional judgment.’ The
scoring and have statistical evidence of validity and reli- manual muscle test, described in Chapter 22, is an
ability. They are norm referenced—that is, norms are example of such a test.
used as standards for interpreting individual test scores.
Individual test scores are compared with scores of
SUMMARY
persons in the norm group.*’°’”””"
Occupational therapists have been encouraged to use The occupational therapy evaluation is a complex
standardized tests to record information obtained from process of data gathering and analysis that yields one or
patients. Using standardized tests can improve the more OT diagnoses that become the starting point for in-
ability to formalize OT evaluation based on quantitative tervention. Evaluation of the patient with physical dys-
assessment. Results of the initial assessments and function includes an examination of medical records, in-
follow-up assessments can be reported in a consistent, terview, observation, and the administration of specific
objective, and reliable manner. This approach requires formal and informal assessments. The evaluation of the
that occupational therapists increase their knowledge patient is based on an analysis of the data gathered from
and skill in testing. Use of standardized assessments en- the assessments. Those data are used to identify prob-
hances professional credibility.** To use standardized lems and assets relevant to the patient's occupational
tests effectively, the occupational therapist must have performance and to plan appropriate intervention goals
the necessary skills for competent test administration and strategies.
and should follow test protocols carefully.* Occupational therapists have developed many useful
Many standardized tests designed by professionals in informal assessments. These include tests, checklists,
disciplines other than OT are used by occupational ther- and rating scales. Some of these have been developed
apists to measure achievement, development, intelli- into standardized tests. Occupational therapists have
gence, manual dexterity, motor skills, personality, senso- recognized the need to identify and employ discipline-
rimotor function, and vocational skills.°* The Mental specific assessments to help establish the scientific base
Measurements Yearbook,'* Occupational Therapy Assessment of the profession. Many such tests have been designed
Tools: An Annotated Index® Occupational Performance As- and introduced in recent years.
sessment,” and Assessment and Evaluation: An Overview’? Selection of appropriate assessments will depend on
are excellent sources of information about standardized the patient's diagnosis, medical history, lifestyle, inter-
tests. Current health care journals and psychologic ab- ests, living situation, needs, values, and environment.
stracts also provide information about standardized as- Clinical reasoning in the OT evaluation is responsive to
sessments that may be relevant to OT.’ While it is desir- information gathered during the evaluation. Thus, the
able to have standardized and objective tests in OT, therapist is thoughtful and reflective in selecting treat-
professional judgment and interpretation are always an ment objectives, methods, and progression. Decisions
important part of the evaluation process.'” reached during evaluation lead to the construction of
the treatment plan, discussed in Chapter 6.7°
Nonstandardized Assessments
Many assessments that occupational therapists use are
REVIEW QUESTIONS
nonstandardized tests. That is, they have unknown reli-
ability and validity. Many are informal instruments de- 1. Define evaluation and assessment.
veloped by therapists to suit the needs of particular 2. List four purposes of occupational therapy evalua-
practice settings. Still others are adaptations of stan- tion.
dardized assessment instruments that are used with pa- 3. Which skills must the occupational therapist possess
tients other than those for whom they were designed. to be an effective evaluator?
 Occupational Therapy Evaluation and Assessment of Physical Dysfunction

List and describe the steps in the evaluation process. 8. Bowker A: Standardized tests utilized by therapists in the field of
PoeWhich specific occupational performance areas and physical disabilities, Physical Disabilities Special Interest Section
Newsletter 6:4, 1983. Published by the American Occupational
performance components are most likely to be as-
Therapy Association.
sessed by the occupational therapist when treating . Christiansen C: Occupational performance assessment. In Chris-
patients with physical dysfunction? tiansen C, Baum C, editors: Occupational therapy: overcoming
Describe four methods of assessment that occupa- human performance deficits, Thorofare, NJ, 1991, Slack.
tional therapists use in the evaluation process. 10. Henry AD: The interview process in occupational therapy. In Nei-
dstadt ME, Crepeau EB: Willard and Spackman’'s occupational
. Along with diagnosis and medical data, which other
therapy, ed 9, Philadelphia, 1998, JB Lippincott.
important factors about the patient should be con- Le Letts L et al: Person-environment assessment in occupational
sidered by the occupational therapist during the eval- therapy, Am J Occup Ther 48(7):608, 1994.
uation and in treatment planning? 12: Mattingly C: What is clinical reasoning? Am J Occup Ther
. Compare standardized and nonstandardized tests. 45(11):979, 1991.
13. Mattingly C, Fleming MH: Clinical reasoning, Philadelphia, 1994,
What are the characteristics of each?
FA Davis.
. What are the criteria for the effective use of standard- 14. Mitchell JV, editor: Mental measurements yearbook, ed 11, Highland
ized tests? Park, NJ, 1992, Rutgers University.
15. Mosey AC: Occupational therapy, configuration of a profession, New
York, 1981, Raven Press.
REFERENCES 16. Neistadt ME: Overview of evaluation. In Neidstadt ME, Crepeau
ile Allen C: The performance status examination: paper presented at EB: Willard & Spackman’s occupational therapy, ed 9, Philadelphia,
the American Occupational Therapy Association annual confer- 1998, JB Lippincott.
ence, San Francisco, October 1976. Cited in Hopkins HL, Smith I Opacich KJ: Assessment and informed decision-making. In Chris-
HD, editors: Willard and Spackman’s occupational therapy, ed 6, tiansen C, Baum C, editors: Occupational therapy: overcoming
Philadelphia, 1983, JB Lippincott. human performance deficits, Thorofare, NJ, 1991, Slack.
. American Occupational Therapy Association: Clarification of the 18. Rogers JC, Masagatani G: Clinical reasoning of occupational ther-
use of the terms assessment and evaluation, Am J Occup Ther apists during the initial assessment of physically disabled pa-
49:10, 1072, 1995. tients, Occup Ther
J Res 4:195, 1982.
. American Occupational Therapy Association: Standards of prac- Us Smith HD: Assessment and evaluation: an overview. In Hopkins
tice for occupational therapy, Reference manual of the official docu- HL, Smith HD, editors: Willard and Spackman’s occupational
ments of The American Occupational Therapy Association. Bethesda, therapy, ed 8, Philadelphia, 1993, JB Lippincott.
Md, 1996, The Association. 20. Smith HD, Tiffany EG: Assessment and evaluation: an overview.
. American Occupational Therapy Association: Uniform terminol- In Hopkins HL, Smith HD, editors: Willard and Spackman’s occupa-
ogy for occupational therapy, third edition. In Reference manual of tional therapy, ed 6, Philadelphia, 1983, JB Lippincott.
the official documents of the American Occupational Therapy Associa- PANE Tuckman BW: Conducting educational research, ed 2, New York,
tion, ed 6, Bethesda, Md, 1996, The Association. 1978, Harcourt Brace Jovanovich.
. American Occupational Therapy Association: Uniform terminol- oye Watson M: Analysis: standardized testing objectives, Physical Dis-
ogy for occupational therapy, third edition, Am J Occup Ther abilities Special Interest Section Newsletter 6:4, 1983. Published by
48(11):1047-1054, 1994. the American Occupational Therapy Association.
. Asher IE: Occupational therapy evaluation tools: an annotated in- 23% Watts JH et al: The assessment of occupational functioning: a
dex, ed 2, Bethesda, Md, 1996, American Occupational Therapy screening tool for use in long-term care, Am J Occup Ther 40:231,
Association. 1986.
. Atchison B: Selecting appropriate assessments, Physical Disabilities
Special Interest Section Newsletter 10:2, 1987. Published by the
American Occupational Therapy Association.
 LEARNING OBJECTIVES
Gradation After studying this chapter the student or clinician will
Treatment plan be able to do the following:
Data analysis 1. Define treatment plan.
Assets 2. Outline the steps in the treatment planning process.
Goals 3. List the reasons that writing treatment plans is
Objectives important.
Terminal behavior 4. List at least 10 questions therapists should ask
Conditions when writing a treatment plan.
Criterion 5. Describe why it is important to have one or more
Intervention strategies treatment models or approaches when planning
Discharge planning treatment.
Termination of treatment 6. Know the difference between a goal and an
objective.
7. Write comprehensive objectives.
oa Define three elements of a comprehensive objective.
9. Write a treatment plan for a real or hypothetical
patient.
10. List reasons to modify a treatment plan.

he purpose of occupational therapy (OT) is to help the “core of teaching” in the OT internship.® The treat-
clients learn or relearn essential occupational perform- ment plan is based on patient priorities, a critical analy-
ance tasks in the areas of activities of daily living (ADL), sis of performance deficits identified in the initial evalu-
work, and play or leisure that will enable them to live as ation, and the unique circumstances of the individual
independently as possible. Clients or their insurers fund patient. Occupational therapists also consider their
OT services. They want to see results in as short a time as clients’ physical and social performance contexts in
is reasonable and will pay only for treatment that results treatment planning.® These factors make OT interven-
in improvements in occupational performance.® A well- tion complex and treatment planning a challenge for
designed treatment plan is essential to the achievement therapists.
of these objectives. Effective treatment planning is possible if the thera-
A treatment plan is the design or proposal for a ther- pist has made a thorough and careful evaluation, has re-
apeutic program. Pelland described it as “the core of oc- viewed, analyzed, and summarized assessment data,
cupational therapy practice,”” and Day described it as has selected an appropriate practice model or models,
 Treatment Planning

has identified treatment goals and objectives, and has 14. In what time frame should the patient have met the
chosen appropriate treatment methods. Further, the objectives?
‘treatment plan should include ongoing reevaluation 15. What standards shall be used to determine whether
and data collection and the restatements of treatment the patient has reached an objective?
priorities.* In short, the treatment plan includes goals 16. How will the effectiveness of the treatment plan be
and objectives and treatment methods or intervention evaluated?
_ strategies based on identified problems and indicates The sequence of questions may vary, depending on
_ how the program should progress.* In this chapter the the reasoning process of the therapist, and may change
terms treatment methods and intervention strategies are as additional information about the patient is revealed.
used synonymously. Analyzing the course of action through a process of
Writing a treatment plan is necessary. Writing a plan planned and critical reasoning is essential in developing
yields specific objectives outlined in an orderly and se- an effective treatment plan. The treatment plan affirms
quential manner that will be clear to the therapist, the therapist’s competence and the professionalism of
patient, and other concerned persons. The treatment OT. It can provide a systematic method for gathering re-
plan guides the therapist to proceed efficiently and pro- search data. It also helps the therapist document the
vides a standard for measuring the progress of the purposes and effectiveness of OT services.
patient and the effectiveness of the plan.
Practicing therapists sometimes work intuitively, do
TREATMENT PLANNING PROCESS
not write out their treatment plans, and consequently
find it difficult to articulate the rationale for the work The purpose of OT treatment planning is to identify
they have done.* Such clinicians may be working in a problems and find solutions so as to promote health,
trial-and-error manner, wasting precious time and well-being, and optimal functioning in persons who are
money. They may be poorly prepared to defend their ill or disabled. Treatment planning is a problem-solving
course of action to themselves, the patient, the rehabil- process that follows a logical progression (Fig. 6-1).*
itation team, an insurance company, or even those Hopkins and Tiffany* described a problem-solving
involved in potential legal proceedings. They may process and applied it to treatment planning. The steps
convey uncertainty in their reports about the patients as- are as follows:
signed to them. Absence of a stated treatment plan can 1. Assess, analyze, and identify problems.
also present problems to other staff members who may 2. Explore prospective solutions and develop treatment
have to substitute in the absence of the treating clinician. goals and objectives.
Perhaps one of the most important purposes for 3. Design and implement a plan of action—the treat-
writing a treatment plan is to plan, analyze, and contin- ment plan.
ually reevaluate the proposed course of action. In so 4. Assess the outcomes of the plan and modify it if nec-
doing, the therapist should ask many questions. Some essary.
of these are as follows: 5. Terminate treatment when the objectives have been
1. What are the problems that this patient is experi- achieved or treatment is no longer feasible.*
encing?
. How does the patient view these problems?
Data Gathering
. In what other ways can the problems be defined?
. What are the patient's capabilities and assets? After the patient is referred for OT services, the therapist
. What are the patient's limitations and deficits? must gather data to develop an appropriate treatment
. What does OT have to offer this patient? plan. Sources for these data are the referral form; the
UW
ND
WN . Which needs does the OT treatment program aim to medical record; social, educational, vocational, and play
address? histories; interview of the patient or family and friends;
8. What is or are the most appropriate practice and results of the OT evaluation and those of other serv-
model(s) or treatment approach(es) on which to ices. The details of the evaluation process were outlined
base the treatment plan? in Chapter 5.
9. What are the goals of treatment?
10. What are specific treatment objectives?
Data Analysis and Problem Identification
11. Are the treatment objectives consistent with the
patient's needs and personal aspirations? After gathering the data, the therapist proceeds to data
12. If objectives are not compatible, how should they analysis and problem identification. Data are analyzed
be modified? to identify problems in occupational performance and
13. Which treatment methods are available to meet the determine if OT can be employed to alleviate the prob-
objectives? lems.'° From a careful analysis of all the data gathered,
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

Data collection: referral source; medical support system and living environment that can be con-
record; family, social, educational, sidered assets.
vocational, play histories
Interview OT Assessments Selecting a Practice Model
or Treatment Approach
Determine need for Data analysis; identify problems A treatment plan should be based on one or more OT
OT services/referral and assets; select treatment practice models or a specific treatment approach. The
to other services? model(s) and treatment model or approach suggests which evaluation procedures,
approach(es)9.19 objectives, and methods will be most appropriate.” The
practice model or approach also influences the problem-
solving process, since each has its particular philosophy,
Select Select body of knowledge, evaluation methods, and intervention
treatment treatment strategies. However, there is some overlap among models.
objectives methods Each practice model guides the clinical reasoning process
of treatment planning in particular ways.*
As an example of how the therapist selects a treatment
approach and how the approach in turn affects the ther-
Implement treatment plan apist’s reasoning, consider the patient with a fractured
arm resulting in limited joint motion and muscle weak-
ness from disuse. For such a patient the therapist might
Ongoing reevaluation of patient and select the biomechanical approach. Evaluation proce-
effectiveness of the treatment plan dures in this approach focus on joint range of motion
(ROM) measurement and muscle strength testing. Treat-
ment might involve therapeutic exercise and activities.
Ongoing revision of treatment plan
On the other hand, if the patient has hemiplegia,
the therapist might choose the neurodevelopmental
(Bobath) approach and evaluate muscle tone and pos-
Discharge planning/termination of treatment tural mechanisms. Treatment is directed to normalizing
tone through positioning, handling techniques, special
FIG. 6-1 movement patterns, and facilitating a more normal pos-
Schematic of the treatment planning process. tural mechanism through activities that demand weight
shifts and weight bearing. See Chapter 1 for a discussion
of practice models and treatment approaches.

Selecting and Writing Treatment Goals

the therapist develops a list of problems that forms the
and Objectives
basis of the treatment plan. Deficits in the performance
areas and performance components that may be Treatment goals and objectives are statements of what
amenable to OT intervention are noted. Limitations needs to happen or what is desirable to happen for the
that require intervention by other professional services patient. They are written to address the problems identi-
should be communicated through the appropriate refer- fied in the OT evaluation. After the therapist gathers data
ral process. and selects a practice model and one or more treatment
The therapist must also consider how assets in the approaches, some general kinds of intervention strate-
patient and the patient's social and living environments gies that would facilitate the patient's rehabilitation may
can be used to enhance progress toward independence. come to mind. For example, after the evaluation it may
Assets are the strengths in the patient's situation that be apparent that the patient could benefit from training
can contribute to the achievement of treatment objec- in activities of daily living (ADL). Having ideas for
tives. Good physical conditioning before disability, methods can facilitate the selection and writing of treat-
absence of concomitant medical problems, good psy- ment objectives. Writing objectives and selecting treat-
chological coping skills, a positive outlook, and deter- ment methods actually are concurrent and mutually de-
mination are examples of personal assets. A supportive pendent elements of the treatment planning process.
partner, family and friends, an accessible living environ-
ment, adequate financial resources for equipment or Goals
home modification, and good support services available Goals are general statements that describe global or
in the patient's community are all factors in the patient's general changes in function at some time in the future.
 Treatment Planning

For example, a goal might be: The patient will be inde- The terminal behavior is composed of an action verb
pendent in self-care. Since self-care encompasses many and the subject or object being acted upon. For
activities, it is not possible to achieve this goal without example: “To remove the blouse.” Remove is the action
many specific subordinate objectives. verb, and the blouse is the object of the action.

Objectives CONDITIONS. Conditions are the circumstances

Objectives are steps toward achieving goals. An required for the performance of the terminal behavior.
example of an objective toward reaching the goal of self- The conditions answer such questions as “Is special
care independence is: The patient will transfer to and from equipment necessary?” “Are assistive devices required?”
the toilet without assistance. The following narrative will “Are supervision, assistance, or verbal cues essential?”
focus on writing objectives. “Are special environmental arrangements needed?”®’
A treatment objective is a statement of intent describ- For example, the following condition might answer
ing a proposed change in a patient. The statement clearly such a question: “If given verbal cues, the patient will
conveys the change in function, performance, or behav- remove the blouse.” This indicates that the patient will
ior that the patient will demonstrate when the treatment be able to remove the blouse only when someone is
has been successfully completed. Whenever possible, the present to provide verbal cues. This represents a special
therapist should select objectives and plan the treatment circumstance that enables adequate performance of the
program in conjunction with the patient. The therapist terminal behavior: to remove the blouse.
and patient select objectives that are attainable within Patients can achieve many treatment objectives
the time frame of the treatment program. Treatment without any special devices, equipment, environmental
methods relevant to those objectives are also selected. modification, cues, or human assistance. Therefore, a
Objectives should reflect the patient’s needs and priori- statement of conditions is not necessary in many in-
ties and be consistent with both the general goals stated stances. It is an optional element of the objective and
on the referral and those determined by the evaluation. should be used only when some special circumstance is
The objectives should aim toward occupational per- required to enable the performance of the terminal be-
formance within the context that is customary or ex- havior. (Note that the intervention strategy and the time
pected for the individual patient. OT objectives should frame in which the treatment program is to take place
complement those of other rehabilitation services. Eval- are not conditions. )
uation of progress examines the extent to which the se-
lected objectives have been achieved. CRITERION. The criterion is the performance stan-
Novice therapists may wonder whether it is really dard or degree of competence the patient is expected to
necessary to state such detailed objectives, especially achieve, stated in measurable or observable terms.°’’
when the course of treatment seems obvious. When The criterion answers such questions as “how much,”
clearly defined objectives have not been stated, there is “how often,” “how well,” “how accurately,” “how com-
no sound basis for selecting appropriate intervention pletely,” and “how quickly.”° If it is possible to estimate
strategies or for evaluating the effectiveness of the treat- the patient's potential level of competence, it is impor-
ment program. It is important to state objectives to tant to include a criterion or performance standard in
measure the degree to which the patient is able to the objective. This is the only way the therapist can de-
perform in the desired manner. termine the achievement of the stated terminal behavior
with certainty. Like conditions, the criterion is an op-
Writing Treatment Objectives tional element in the treatment objective. Although
The method for writing treatment objectives, described stating a performance standard is desirable, it is not
below, is based on models for writing competency-based always necessary or possible.
educational objectives described by Mager and Kemp.” Muscle grades, increases in range of motion (ROM),
A comprehensive objective conveys an idea of what degree of competence in task performance, and speed of
the patient's performance will be like when the objec- performance are some examples of criteria. Although
tive has been achieved. The idea conveyed is identical to stating the length of the treatment program in an objec-
the one the therapist and the patient have in mind. It tive is sometimes necessary to satisfy reimbursement
succeeds in communicating their intent and describes agencies, length of treatment is not a criterion.
the terminal behavior of the patient well enough to pre-
clude misinterpretation. A comprehensive treatment Sample Objectives
objective has three elements. The following are some sample treatment objectives
and an analysis of their elements:
TERMINAL BEHAVIOR. Terminal behavior repre- 1. Given assistive devices, the patient will eat independ-
sents the physical changes, kind of behavior, or per- ently in 30 minutes. In this objective, the terminal
formance skill that the patient is expected to display.’ behavior is the statement, “the patient will eat.”
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

Here, the object of the action verb eat does not kinds of assistive devices, or standards of neatness, if
need to be explicitly stated, since the consumption these are important for the patient's situation and
of food is implicit. The condition is given assistive values.
devices. This statement indicates the special circum- 5. Given setup of mobile arm supports and assistive devices,
stances (the devices) that will make eating possible. the patient will feed himself independently. The state-
The performance standards are independently in 30 ment: “patient will feed himself” is the terminal
minutes. This statement reflects that the patient will behavior. The mobile arm supports and assistive
be able to eat without human assistance and will devices and their setup constitute the conditions for
achieve eating of a meal within 30 minutes. De- this behavior. The criterion for performance under
pending on the situation, this statement may require these conditions is “independently,” which indicates
further refinement and specificity. For example, the that once the equipment and devices are provided
kinds of devices and the kinds of foods could be and properly set up, the task of eating can be per-
specified. formed without further human assistance.
. The ROM of the left elbow flexion will increase. As There are many variables and unknown factors in the
written, this objective is a good statement of terminal performance and functions of persons with physical
behavior. It indicates the kind of change in physical dysfunction. Therefore, the degree to which they can
function that is expected as a result of the treatment benefit from, participate in, or succeed at rehabilitation
program. Conditions are not necessary, since no programs cannot be predicted with certainty. This
special circumstances are needed for the patient to sometimes makes it difficult for therapists to write
demonstrate or perform the increased ROM. How- comprehensive treatment objectives. However, the ther-
ever, the objective does need a criterion because the apist should attempt to write such objectives, using past
amount of increase in ROM is not stated, making experience with similar patients and knowledge gained
progress difficult to measure. The objective can be re- during the evaluation process to describe desired termi-
worded like this: “The ROM ofleft elbow flexion will nal behavior, conditions, and criteria for each treat-
increase from 115° to 135° so that eating finger ment objective. If this is not possible, it is recom-
foods is possible.” This adds the criteria of degrees of mended that a specific statement of terminal behavior
ROM to be increased and of an observable activity be used until applicable conditions and criteria become
that uses full elbow flexion. apparent. The stated terminal behaviors can then be
. The patient will operate the control systems of the left modified to become comprehensive objectives as treat-
above-elbow prosthesis without hesitation while perform- ment progresses.
ing bilateral ADL. In this objective, “operate the
control systems” is the terminal behavior. “Operate”
is the action verb, and “control systems” are the
Selecting Intervention Strategies
objects of the action. This is the skill (behavior) that When goals and objectives have been identified, the in-
is expected as a result of the prosthetic training tervention strategies that can help patients achieve
program. Conditions are not necessary, because the them are selected. This is probably one of the most dif-
desired goal is for the patient to be able to perform ficult steps in the treatment planning process. It is based
this skill under any circumstances. “Without hesita- on the selected practice model(s) and the clinical rea-
tion” and “while performing bilateral ADL” are the soning of the therapist, in collaboration with the
criteria. The level of skill in performance is observ- patient.
able. Further refinement of this objective might indi- For example, with a patient who has muscle weak-
cate exactly which bilateral activities are to be per- ness, the biomechanical approach might be selected.
formed, such as buttoning a shirt, cutting meat, or The objective is increasing muscle strength. A graded
tying shoes. therapeutic activity or exercise program would be the
. Given assistive devices, the patient will dress herself in 30 method of choice to reach this objective.
minutes or less. “The patient will dress” is the terminal In OT practice, many factors influence the selection
behavior. It is the action verb, and the implicit of intervention strategies. Some of those that should be
objects involved with the action are the patient's considered are the following:
clothes. The availability of assistive devices is a neces- 1. The patient's interests, psychosocial needs, and vo-
sary condition for this patient to perform this task, cational goals”
and so the statement of conditions, “given assistive 2. The patient’s physical and sociocultural environ-
devices,” is needed. The criterion or performance ment
standard is stated in terms of speed and indicates 3. The roles the patient will assume on return to the
that dressing in 30 minutes is a reasonable expecta- community
tion for this patient. Further refinement of this objec- 4. The general goals (in terms of functional outcomes)
tive might include the kinds of clothing and the for the patient
 Treatment Planning

5. Activities or exercises that are useful and meaning- In addition to these observations, the therapist may use
ful to the patient that can be used in the treatment the same assessments that were used during the initial
program” evaluation to reevaluate performance skills and per-
6. Precautions or contraindications that affect the OT formance components. Gains or losses may then be
program compared to evaluation data recorded at the outset. This
_7. The prognosis for physical and functional recovery validates the treatment plan and provides the objective
8. The results of the OT evaluation and those of other evidence of change that is required for reimbursement.
services Scrutinizing the treatment plan in this way will
9. Other treatment the patient is receiving enable the therapist to modify the plan as the need
10. The goals of treatment in other services, and how arises. The criterion for determining the effectiveness of
OT goals relate to these other goals the plan is the progress of the patient toward the stated
11. How much energy the patient expends in other objectives.
therapies
12. The state of the patient’s general health
13. Ways in which treatment can be graded to meet the
Revising the Treatment Plan
patient's changing needs as progression or regres- The information gained from observations and reeval-
sion occurs uation of the patient, as previously outlined, may ne-
14. Special equipment or adaptations of therapeutic cessitate some revision or modification of the initial
equipment needed for the patient to perform maxi- treatment plan. For example, the patient's progress
mally may be significant enough that it is beneficial to in-
When intervention strategies are selected, it should crease the duration, complexity, or resistance of the ac-
be clear to others reading the treatment plan exactly tivity. Conversely, a gradual decline of physical func-
how they will be used to reach specific objectives. Some- tion in degenerative diseases may necessitate a
times several methods may be needed to achieve one reduction in resistance, duration, and complexity of ac-
objective, or the same methods may be used to reach tivity. This is a common adjustment in conditions for
several objectives. which maintenance of optimal function is the primary
objective.
If the patient is unable to see the therapeutic
Implementing the Treatment Plan program as helpful or meaningful, a change in treat-
When at least some objectives and treatment methods ment approaches and methods may be necessary. On
have been selected, the treatment plan is implemented. the other hand, if the patient is highly motivated, the
The patient engages in the procedures that have been plan can sometimes be accelerated. The initial plan is
designed to ameliorate problems and capitalize on continually revised according to the patient’s needs and
assets (i.e., the patient’s personal strengths andthe pos- progress. This process of reevaluation, revision, and re-
itive aspects of the patient's physical, social, and living implementation of the treatment plan goes on through-
environment). A comprehensive treatment plan may out the course of the therapeutic program.””®
evolve over a period of time. For example, while a pro-
tracted assessment (e.g., of ADL) is in progress, the
Discharge Planning and Terminating
patient may have begun a program of therapeutic activ-
Treatment
ity to strengthen specific muscle groups. Therefore, as
the assessment is being completed, new problems may Ultimately, the whole treatment program is directed to
be identified and additional objectives and methods preparing the patient to return home or to another suit-
may be added to the treatment plan. able living arrangement. Discharge planning actually
occurs throughout the treatment program. All treatment
is directed to preparing the patient to return to the com-
Reevaluating the Patient and the munity. Often therapy will continue on a less intensive
Treatment Plan basis at home or in another living environment.
Once the treatment plan is implemented, the therapist
conducts an ongoing evaluation of its effectiveness Discharge Planning
through continuous observation and reevaluation. The As the treatment program in the primary health care
therapist must be an alert observer and ask the follow- facility is progressing, discharge planning should be
ing questions: (1) Are the objectives realistic and suit- initiated. This is a team effort that involves the patient,
able to the patient's needs and capabilities? (2) Are the the family, and all rehabilitation specialists concerned
methods most appropriate for achieving the treatment with the patient's care. Preparation for discharge in-
objectives? (3) Does the patient relate to the treatment cludes considering medical conditions, providing assis-
methods and see them as worthwhile and meaningful? tive devices and mobility equipment, planning a home
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

activity or exercise program, and making a home visit to = Community resources such as emergency care, self-
assess architectural barriers in the environment. Dis- help groups, respite care, and independent living
charge planning should include patient education and centers!*
education and training of caregivers for a smooth transi- Maintaining contact with the primary care facility as
tion. Arrangement for home care therapies and referral a resource for information or further treatment can be
to appropriate community agencies is another impor- reassuring and helpful."
tant aspect of discharge planning.”
The psychological preparation of the patient and Terminating Treatment
family members is essential. They may not be emotion- Termination of treatment involves a final evaluation of
ally prepared for or functionally capable of managing the patient. The clinician should clearly indicate objec-
the transition to the new environment. Generalizing tives achieved, partially achieved, or not achieved in the
learning from the health care facility to the home may treatment program. The discharge summary is written
be difficult for the patient. The family may not know the on the basis of these data and indicates the expected
patient's capabilities or how best to give assistance. Pro- future performance of the patient. Termination can
viding emotional support, education, training, counsel- affirm the success of the treatment program. In reality,
ing, and information about resources to the patient and however, termination is not always achieved. Patients
the family is helpful in easing the transition. The family may be discharged before objectives of treatment are
needs information about the following: met and treatment is concluded.* The patient may be re-
@ The patient's ADL status and performance expectations ferred to another facility or to home care where another
® Solutions to accessibility problems in the home, therapist assumes the continuity of the treatment
workplace, and community program. Careful communication between therapists
® Information on home modification and agencies is necessary to ensure a smooth transition
® How to obtain, use, and care for assistive devices or and continuity of care (see Chapter 4 for more informa-
mobility equipment tion on this point).

TREATMENT PLAN MODEL

Case

PERSONAL DATA

Name

Diagnosis Disability

Treatment goals stated in the referral

PRACTICE MODEL(S)/TREATMENT APPROACH(ES)

O.T. Evaluation Evaluation Summary
Occupational performance Problem List
Performance areas Assets
|. Activities of daily living Treatment Plan Outline
2. Work and productive activities |. Problem
3. Play or leisure activities 2. Objective
Performance contexts 3. Methods
|, Physical aspects 4. Grading
2. Temporal aspects
3. Sociocultural aspects
Performance components
|. Sensorimotor
2. Cognitive integration and cognitive
3. Psychosocial skills and psychological

FIG. 6-2
Treatment plan model.
 Treatment Planning

SUMMARY TREATMENT PLAN MODEL

A treatment plan is a proposal for the therapeutic The treatment plan model is useful for teaching and
program. It is based on the client's priorities and prob- learning treatment planning during academic prepara-
lems identified in the OT initial evaluation. Written treat- tion. It may be modified for clinical use (Fig. 6-2). The
ment plans are important for describing the treatment student is presented with a hypothetical case study or an
program to others, measuring progress objectively, and actual patient and is directed to complete the treatment
analyzing and reevaluating the course of action. The treat- plan, using the Treatment Planning Guide shown in Box
ment plan documents the effectiveness of OT services. 6-1. If given a hypothetical (rather than actual) patient,
Treatment planning follows a systematic process. the student is directed to complete the “Evaluation
After the initial OT evaluation the occupational thera- Summary” section of the treatment plan according to
pist identifies problems, explores and identifies poten- knowledge of the particular diagnosis and its resultant
tial solutions, selects goals and objectives, chooses treat- disability. See the Appendix on p.1021 for additional
ment strategies, and assesses the outcomes of the plan. case studies that can be used for treatment planning
Preparation for termination of treatment is an ongoing practice. A sample treatment plan developed according
process in the treatment plan. to this model follows below.

The treatment planning guide is a reference for filling out a treatment plan for either an actual or a hypothetical patient.

PERSONAL DATA
Fill in the requested information from the medical record or case study.

Nam

a a

Diagnosis

a I a cr cc

Treatment aims stated in the referral

PRACTICE MODEL AND APPROACH ’

State the practice model or treatment approach on which the treatment plan is based. More than one may be necessary.

OT EVALUATION
From the list below, select the performance areas and performance components that should be evaluated.
Performance Areas LJ Physical endurance
Self-care L} Standing tolerance
CL) Feeding LY Walking tolerance
Q) Dressing L) Sitting balance
[) Hygiene O Involuntary movement
Q Transferring Ci Movement speed
[4 Community mobility CL) Level of motor development
Work and productive activities LJ Equilibrium and protective responses
(4) Work habits and attitudes [} Coordination and muscle control
Q Potential work skills {1 Spasms
[¥ Work tolerance (I Spasticity
[1 Home management a State of motor recovery (stroke patient only)
Q Child care a) Postural reflex mechanism
Play and leisure QO Functional movement patterns
( Past and present leisure interests and play activities a Hand function
“I Modes of relaxation Ly Swallowing and cranial nerve functions
Performance Components | Sensation—touch, pain, temperature, proprioception,
Sensorimotor taste, smell
(4 Muscle strength | Body schema
LC} Range of motion Q) Motor planning

Continued
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

"TREATMENT PLANNING GUIDE—cont’d

M1 Stereognosis Psychosocial/psychological skills
Q Visual perception Q Self-identity
Q Visual fields CQ) Self-concept
(4) Spatial relations [) Coping skills
L) Position in space {4 Maturity (development level)
CQ) Figure/background [4 Adjustment to disability
C} Perceptual constancy QO Reality functioning
Q Visual-motor coordination LJ Interpersonal skills—dyadic and group interactions
[) Depth perception
EVALUATION SUMMARY
QL) Perception of vertical/horizontal elements
Summarize findings from assessments.
L) Eye movements
Q) Functional auditory perception PROBLEM LIST
Cognitive/cognitive integration Identify and list the problems that require occupational therapy
[1 Memory intervention,
Q) Judgment
() Safety awareness ASSETS
OQ Problem-solving ability List the assets of the patient and his or her situation that can be
Q Motivation used to enhance progress toward maximum independence.
CY Sequencing OBJECTIVES
Q) Rigidity Write specific treatment objectives in comprehensive form. Each
Q) Abstract thinking should relate to a specific problem in the problem list and be
{4 Functional language skills identified by the corresponding number.
{1 Comprehension of speech/writing
QO Ability to express ideas METHODS OF TREATMENT
[1 Reading Describe in detail appropriate treatment methods for the patient.
QO Writing GRADATION OF TREATMENT
Q) Functional mathematical skills Briefly state how treatment methods will be graded to enhance
{} Mental calculations the patient's progress.
CQ) Written calculations

Ere SAMPLE TREATMENT PLAN

CASE STUDY is capable of more activity ‘if only she would try’’ She says she is
Mrs. R. is 49 years old. She has two sons. One is 26 years old and willing to allow Mrs. R.to do some of the household work.
married, and the other is 17. Mrs. R. is divorced. She and her Mrs. R. was referred for OT services as an outpatient for
younger son live with her married son, his wife, and their 4-year- restoration or maintenance of motor functioning and increased
old boy. Before the onset of her illness, Mrs. R. lived in an apart- independence in ADL and home management.
ment with her younger son.
Mrs. R. had Guillain-Barré syndrome six months ago. She has TREATMENT PLAN
been left with residual weakness of all four extremities. Some ad- Personal Data
ditional gains in strength are anticipated, but full recovery is not Name: Mrs. R.
expected, Mrs. R. uses a standard wheelchair for mobility. Age: 49
Mrs. R. appears thin and frail. She speaks in a weak voice and Diagnosis: Guillain-Barré syndrome
appears to be passive and discouraged. She feels she cannot ac- Disability: Residual weakness, upper and lower extremities
complish anything. Mrs. R. does not communicate with her Treatment aims stated in referral: Restoration or maintenance of
daughter-in-law, and there are conflicts between the couple and motor functioning and increased independence in ADL, home
Mrs. R. concerning the management of the teenage son. Mrs. R. management, and leisure activities.
feels unable to assert her authority as his mother or to express Practice Models
her needs and feelings. The disability has brought about the loss of Biomechanical, rehabilitative
her independence and has changed her role in relation to her OT Assessments
younger son. Performance Areas
Her daughter-in-law reported that Mrs. R. is dependent for self- Self-care
care, never attempts to help with homemaking, and isolates herself Home management
in her room much of the time. She believes that her mother-in-law Leisure skills
 Treatment Planning

Yo) @ ry) SAMPLE TRE

Performance Contexts periods of mild depression before her illness but otherwise
Physical aspects seemed well adjusted.
Temporal aspects Sociocultural aspects: Mrs. R. is from a large Italian Catholic
Sociocultural aspects family. Her parents were first-generation Americans and retained
Performance Components many of the cultural practices of the “old country.’ Mrs. R. enjoyed
Sensorimotor cooking special ethnic foods such as pasta dishes and Italian
Muscle strength desserts. Her participation in church was mainly at holidays. She

: Active and passive ROM

Physical endurance
Movement speed
was not a member of a particular parish and did not belong to
any church organizations. Since the onset of her disability, Mrs. R.
oe,
has not done any cooking, nor has she attended church on holi-
a
Coordination days. She has avoided family gatherings.
Functional movement Performance Components
Sensation (touch, pain, thermal, proprioception) Sensorimotor
Cognitive/Cognitive Integrative Physical Endurance: Mrs. R's physical endurance is limited to |
Judgment hour of light upper-extremity activity before she needs a rest. She
Safety awareness uses a wheelchair for energy conservation and propels it using
Motivation both arms and legs.
Psychosocial/psychological skills Coordination: Slight incoordination is evident during fine hand
Coping skills activities such as buttoning, applying makeup, or using eating
Adjustment to disability utensils.
Social skills Strength/ROM: Muscle testing revealed that all muscles are the
Interpersonal relationships same grades bilaterally: scapula and shoulder muscles are F+ to
G (3+ to 4); elbow and forearm muscles are F+ to G (3+ to 4);
EVALUATION SUMMARY wrist and hand musculature is graded F+ (3+). Trunk muscles are
Performance Areas G (4); all muscles of the hip are G (4), except adductors and ex-
ADL: Mrs. R. manages some personal care such as washing her ternal rotators, which are F+ (3+). Knee flexors and extensors
face, hair care, and tooth care. She needs some assistance with are G (4).Ankle plantar flexors and dorsiflexors are F (3), and all
dressing and has difficulty with buttons and zippers. She requires foot muscles are F— (3—) to P (2). PROM of all joint motions is
an adaptive toothbrush and needs assistance in toilet transferring within normal limits.
and showering. Sensation: Sensory modalities of touch, pain, temperature, and
Work and Productive Activities: Mrs. R. does not perform any proprioception are intact
home management tasks but is potentially capable of light activi- Cognitive/Cognitive Integrative
ties such as table setting, dusting, and folding clothes. Mrs. R’s No cognitive deficits were observed.
daughter-in-law is willing to allow her mother-in-law séme house- Psychosocial Skills/Psychological
hold activities if understanding about their respective roles can be Mrs. R. seems discouraged about her disability. She feels she
established. cannot accomplish anything and tends to stay in her room alone.
Leisure Skills: Mrs. R. spends a lot of time alone in her room. The living arrangement is less than ideal. There are communica-
Her activities are limited to reading and watching television. tion problems and conflicts about the supervision of the teenage
Before the onset of her disability she liked visiting friends, shop- son. The disability has brought about the loss of Mrs. R's inde-
ping, and tending planter boxes on her outdoor patio. pendence and has changed her roles as homemaker and mother.
Performance Contexts She feels unable to assert her authority as mother of her |7-year
Physical aspects: The home is a one-level spacious ranch-style old or to express her needs and feelings
house. There are two steps up to the entry. Mrs. R's son has built
a ramp next to the steps for wheelchair access. Mrs. R's bedroom PROBLEMS
is at the rear of the home and looks out on the backyard garden. . Self-care dependence
Her bedroom is large enough to accommodate the wheelchair, . Homemaking dependence
and there is a rear exit at the end of the hallway, a short distance . Dependent transferring
from her bedroom. The bedroom was previously used as a guest . lsolation, apparent depression
room and sewing room by Mrs. R's daughter-in-law. The bathroom Reduced social interaction
is next to Mrs. R's bedroom and is wheelchair accessible. It has a . Muscle weakness
tub and shower combination that is enclosed by a shower curtain. . Low physical endurance
Temporal aspects: Mrs. R. has been divorced for 9 years. She . Mild incoordination
—ONKDOAWN
has had a few relationships since her divorce, but none was
serious. Mrs. R. had planned to support her son until the time he ASSETS
went to work or college. She looked forward to increased inde- Potential for good living situation
pendence and more involvement with her leisure activities and Presence of able-bodied adults who can assist
community charitable organizations. Mrs. R. tended to have Potential for some further sensorimotor recovery

Continued
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

Good sensation PROBLEMS 4,5

Some functional muscle strength Isolation, depression, reduced social interaction
Good joint mobility Objective
Mrs. R. will reduce time spent alone from 6 waking hours to 3
Intervention Strategies waking hours.
PROBLEM | Method
Self-care dependence Establish an acceptable graded activity schedule between Mrs. R.
Objective and son and daughter-in-law; include homemaking tasks and so-
Given assistive devices, Mrs. R. will be able to dress herself inde- cialization with family through playing games, watching
TV, prepar-
pendently within 20 minutes. ing and eating meals, and conversing; family members encourage
Method Mrs. R. to be with them but to be accepting if she refuses; have
Putting on bra: using a back-opening stretch bra, pass bra around Mrs. R. keep activities diary for review; determine how time is
waist so that opening is in front and straps are facing up; fasten spent and discuss how it could be more productive and enjoy-
bra in front at waist level; slide fastened bra around at waist level able. Initiate leisure activity, such as tending potted house plants;
so that cups are in front; slip arms through straps and work arrange with the family to have one of Mrs. R’s friends come to
straps up over shoulders; adjust cups and straps. Putting on shirt: visit.
place loose-fitting blouse on lap with back facing up and neck Gradation
toward knees; place arms under back of blouse and into arm Increase time spent out of own room; include friends, neighbors,
holes; push sleeves up onto arms past elbows; gather back mate- and family in household social activities; plan a community outing
rial up from neck to hem with hands and duck head forward and for shopping or lunch; include outdoor gardening such as tending
pass garment over head; work blouse down by shrugging shoul- herbs in raised containers.
ders and pulling into place with hands; use button hook to fasten
front opening. Putting on underpants and slacks: sitting on bed or PROBLEM 6
in wheelchair, cross legs, reach down, and place one opening over Muscle weakness
foot; cross opposite leg, place other opening over foot; uncross Objective
legs, work pants up over feet and up under thighs (a dressing Muscle strength of shoulder flexors will increase from F+ (3+)
stick may be used to pull pants up if leaning forward ts difficult); to G (4).
shift hips from side to side and work pants up as far as possible Method
over buttocks; stand, if possible, and pull pants to waist level, then |, Activities: reaching for glasses in overhead cupboard and
sit and pull zipper up with pre-fastened zipper pull; use Velcro at placing them on the table, replacing glasses in cupboard when
waist closure on slacks, Putting on socks; seated and using stretch dry; rolling out pastry dough on a slightly inclined pastry board;
socks, cross one leg, place sock over toes, and work sock up onto wiping table, counter, and cupboard doors, using a forward push-
foot and over heel; cross other leg and repeat. Putting on shoes: pull motion; Turkish knotting project with weaving frame set ver-
using slip-on shoe with Velcro fasteners, use procedure for socks. tically in front of her and tufts of yarn on right and left sides, at hip
Gradation level.
Progress to more difficult tasks such as pantyhose, tie shoes, 2. Light progressive resistive exercise to shoulder flexion: patient
dresses, pullover garments. is seated in a regular chair, wearing a weighted cuff above each
elbow that is one half the weight of her maximum resistance. Lifts
PROBLEM 2 arms alternately through |0 repetitions and then rests. Repeated
Homemaking dependence using three quarters maximum resistance, then full resistance.
Objective Gradation
Given assistive devices, Mrs. R. will perform light homemaking Increase activities, resistance, number of repetitions, and length of
activities, time as strength improves.
Methods
Using a dust mitt, patient dusts furniture surfaces easily reached PROBLEM 6
from wheelchair such as lamp tables and coffee table; sits at sink Muscle weakness
to wash dishes; practices folding small items of clothing such as Objective
panties, nylons, and children’s underwear while sitting at kitchen Strength of wrist flexors and extensors and finger flexors will in-
table; have Mrs. R’s daughter-in-law observe activities at treat- crease from F+ (3+) to G (4).
ment facility; work out an acceptable list of activities and a sched- Method
ule with both women. Discuss how Mrs. R. could make some |. Activities to improve finger flexors: tearing lettuce to make a
contributions to home management routines; ask Mrs. R. to keep salad; hand washing panties and hosiery. Progress to kneading soft
activity diary, noting any performance difficulties and successes clay or bread dough.
for review at next visit. 2. Light, progressive resistive exercises for wrist flexors and exten-
Gradation sors: patient is seated, side to table, with pronated forearm resting
Increase number of household responsibilities. Increase time on the table and hand extended over edge oftable; a hand cuff,
spent on household activities. with small weights equal to one half of her maximum resistance
 ernest icining

attached to the palmar surface, is worn on the hand; patient is supinated on the table, and the weights are suspended from
extends the wrist through full range of motion against gravity for the dorsal side of the hand cuff
“
10 repetitions, then rests. Exercise is repeated, using three quar- Gradation
ters maximum resistance and then full resistance. The same pro- Increase hand activities, resistance, repetitions, and time.
hs
cedure is used to exercise wrist flexors, except that the forearm

. Christiansen C: Occupational therapy: intervention for life per-

formance. In Christiansen C, Baum C: Occupational therapy, over-
. Define treatment plan. coming human performance deficits, Thorofare, NJ, 1991, Slack.
. Day D: A systems diagram for teaching treatment planning, Am J
. Why write a treatment plan? Occup Ther 27:239, 1973.
. Why base the treatment plan on a specific practice . Hopkins HL, Tiffany EG: Occupational therapy—a problem
model or approach? solving process. In Hopkins HL, Smith HD: Willard & Spackman’s
. List the steps in developing a treatment plan. occupational therapy, ed 8, Philadelphia, 1993, JB Lippincott.
. List, define, and give examples of the three elements . Hopkins HL et al: Therapeutic application of activity. In Willard &
Spackman’s occupational therapy, ed 6, Philadelphia, 1983, JB Lip-
of a comprehensive treatment objective. pincott.
. If a comprehensive objective cannot be written, . Kemp JE: The instructional design process, New York, 1985, Harper &
which one element would be most important to Row.
identify first? . Mager RF: Preparing instructional objectives, ed 2 (rev), Belmont,
Calif, 1984, David S. Lake.
. List six factors to consider when selecting treatment
. Neistadt ME: Overview of treatment. In Neistadt ME, Crepeau EB:
methods. Willard & Spackman’'s occupational therapy, ed 9, Philadelphia,
. Is it necessary to develop a complete comprehen- 1998, JB Lippincott.
sive treatment plan before treatment can begin? . Pelland MJ: A conceptual model for the instruction and supervi-
9. Why might it be necessary to change the initial sion of treatment planning, Am J Occup Ther 41:351, 1987.
. Smith HD: Assessment and evaluation: an overview. In Hopkins
treatment plan?
HL, Smith HD, editors: Willard & Spackman’s occupational therapy,
10. What is the criterion that is used to evaluate the ef- ed 8, Philadelphia, 1993, JB Lippincott.
fectiveness of a treatment plan? tie Spencer EA: Functional restoration: preliminary concepts and
11. How does the therapist know when to modify or planning. In Hopkins HL, Smith HD, editors: Willard & Spack-
change the plan? man’s occupational therapy, ed 8, Philadelphia, 1993, JB Lippincott.
12. Versluys HP: Family influences. In Hopkins HL, Smith HD: Willard
12. What are some of the concerns and preparations for
& Spackman’s occupational therapy, ed 8, Philadelphia, 1993, JB Lip-
termination of treatment? pincott.

REFERENCES
1. Baum C: Identification and use of environmental resources. In
Christiansen C, Baum C: Occupational therapy, overcoming human
performance deficits, Thorofare, NJ, 1991, Slack.
 : en ce-Based Practice for

LEARNING OBJECTIVES
Scientific inquiry After studying this chapter the student or practitioner
Evidence-based practice will be able to do the following:
Thinking processes 1. Articulate the need for evidence-based practice.
Action processes 2. List in sequence the steps of evidence-based
Inductive reasoning practice and detail the content and process of each
Deductive reasoning step.
Statement of problem 3. Distinguish between problem statements and need
Problem mapping statements.
Need statement 4. Analyze and map problems.
Goal 5. Identify needs based on empirical evidence.
Objective 6. Translate need statements into goals and
Process objective objectives.
Outcome objective 7. Distinguish between process objectives and
Specificity outcome objectives.
8. Develop interventions based on goals and
objectives.
9. Articulate process and outcome success criteria
based on goals and objectives.
10. Specify evidence that will be used to investigate
success criteria.
11. Develop and execute sound plans to assess
objective achievement.
12. Based on assessment, determine the extent to
which the needs were met and the problem was
resolved.
 A Model of Evidence-Based Practice for Occupational Therapy

informed by systematic thinking, action, and assess-

ment. Although evidence-based practice is not research
he importance of empirical analysis and identifica- in itself, it is the application of research thinking and
tion of the problems and needs that occupational action to the conceptualization, enactment, and investi-
therapy (OT) practitioners address has been emphasized gation of the process and outcome of intervention. “An
at local and national levels over the past two decades. Ed- evidence-based OT practice uses research evidence to-
ucators, scholars, and practitioners increasingly discuss gether with clinical knowledge and reasoning to make
and encourage the use of theoretically grounded and decisions about interventions that are effective for a spe-
supported OT interventions and the development of cific client(s).”'7
solid evidence of successful outcome of practice. Current What is meant by evidence? This question is not easily
evidence-based OT practice is needed at multiple levels answered. Synonyms for evidence include terms such as
(individual, group, community, agency, and govern- documentation, indication, sign, proof, authentication, and
ment) if OT is to be a viable and valued profession that confirmation. In this chapter, we will define evidence as
will flourish in the competitive environment of managed information that is used to support a claim. In this case, the
care and fiscal scarcity. Evidence-based practice involves claim is that OT interventions are beneficial. What in-
the integration of scientific inquiry into all domains of formation would be acceptable to us as evidence to
OT practice. This chapter provides a framework through support the claim about OT interventions? In the pro-
which readers may understand and learn the systematic, fessional world, belief is insufficient. We must look at
research-based thinking and action processes necessary information that is obtained or developed through sys-
to conduct all or part of the sequence of evidence-based tematic inquiry.
practice.° The chapter begins with identification and The model we propose in this chapter builds upon
clarification of the problems that OT addresses and pro- basic professional knowledge and skills to guide the
ceeds with intervention development, culminating in reader through each of the steps of evidence-based
outcomes assessment. practice. At this point, the reader may be asking why
evidence-based practice is even needed. Let us briefly
WHAT IS EVIDENCE-BASED PRACTICE turn to this point before going on with the model.
The emphasis on documenting the value of OT inter-
AND WBY IS IT NEEDED?
vention is not new. Our professional organizations have
Evidence-based practice is defined as “the integration been concerned for a long time with promoting the de-
of critical, analytic, scientific thinking and action velopment of educational programs and methods to
processes throughout all phases and domains of OT ensure that practitioners have the skills and knowledge
practice.” Let us look at this definition more closely. to document the value of their interventions. For
First, we distinguish thought and action from each example, in 1965 the American Occupational Therapy
other. In systematic inquiry, it is essential for the think- Foundation (AOTF) was established. The Foundation’s
ing sequence and rationale to be presented clearly. purpose in supporting research was to document the
Thinking processes are composed of the reasoning se- potency of occupation in restoring, maintaining, and
quence and logic that OT practitioners use to conceptu- enhancing health.” In 1998, the American Occupational
alize treatment and specify desired outcomes. Thinking Therapy Association (AOTA) Representative Assembly
processes involve the selection of a theoretical frame- approved a document titled Research Competencies for
work in which the OT practitioner plans the steps neces- Occupational Therapy. These competency guidelines
sary to assess problems, evaluate treatment, specify provide the support educators need to emphasize the
desired outcomes, and plan a research strategy to deter- inclusion of basic research skills at all levels of educa-
mine and systematically demonstrate the degree to tion. Incorporation of basic research competence in all
which outcomes were met for an individual receiving OT curricula provides a foundation for every practi-
OT services. Sometimes we are not fully aware of our tioner to appreciate and participate in evidence-based
thought processes, but they are there nonetheless and practice.’ In 1999, the AOTA and AOTF committed
are the foundation of evidence-based practice, as we will $300,000 to develop the Center for Outcomes Research
see later in this chapter. and Education (CORE), which will focus its research on
Action processes are the specific behaviors involved new developments in outcomes measurement.*
in implementing thinking processes.° Action processes Increasingly, cost containment drives service delivery.
are behavioral steps. In evidence-based practice, these Thus empirical evidence of the cost effectiveness,
steps are founded on scientific inquiry such that quality, processes, and outcome of OT services has
any claim is supported with empirically derived become essential for the survival of the profession in
information. current and future health care markets.’ Practitioners
Evidence-based practice is not a new phenomenon in must be conversant with and capable of evidence-based
OT practice. Rather, it is an approach to practice that is practice if they are to demonstrate the efficacy of OT to
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

multiple audiences, both internal and external to the As we proceed through the model of evidence-based
profession. practice, we will draw your attention to the skills and
Within the profession, OT practitioners use the infor- knowledge you already possess that are relevant to this
mation obtained from evidence-based practice not only conceptual approach. Let us now turn to the philosoph-
to improve the processes and outcomes of their prac- ical foundation and steps of the model.
tices, but also to engage in informed thinking when
choosing among possible interventions. A recent study
Theoretical and Logical Foundations
of practitioners’ perceptions of evidence-based practice
of Evidence-Based Practice
suggests that OT practitioners view scientific literature as
a valuable resource when supporting the effectiveness of Evidence-based practice is grounded in logic and the
OT interventions in conversations with persons other systematic thinking that undergirds all research think-
than clients. However, for informing intervention ing processes. Inductive and deductive reasoning form
choice, practitioners tended to consult and depend on the basis for these thinking processes. Moreover, the
trusted personal sources.’ Evidence-based practice sys- two major research design traditions, naturalistic and
tematically guides practitioners in determining which experimental-type inquiry, are based on these logic
interventions are effective to produce desired outcomes, structures.° Therefore OT practitioners must under-
which interventions need to be improved, and what stand them and use them to guide thinking and action
kinds of new knowledge need development. Addition- and to support claims regarding the outcomes of OT
ally, having credible evidence to demonstrate that the intervention.
interventions OT practitioners use produce desirable Inductive reasoning is a thinking process whereby
outcomes provides concrete feedback to the con- one begins with seemingly unrelated data and links
sumer.'’'” Finally, by systematically evaluating new in- these data together by discovering relationships and
terventions, OT practitioners can provide evidence for principles within the data set. Inductive reasoning
advancing new clinical practices in the profession. leads us to select naturalistic strategies, those in which
Pressures and demands on health practitioners from theory is derived from gathered evidence rather than
external sources render evidence-based practice even tested by scientific experimentation. Among the
more critical for three reasons. First, the location of methods used in naturalistic design are interview, ob-
service delivery and the time allowed for service delivery servation, and textual analysis.° Data are collected and
are in flux. Long-term hospital stays and treatments in themes that emerge from repeated examination of the
acute care settings are being replaced by community- data are named, defined, and placed in a theoretical
based treatment,* and the length of time for delivery of context.
treatment is shortening as third-party payers demand Deductive reasoning begins with a theory and
more efficient and cost-effective health care. Evidence- reduces the theory to its parts, which are then verified or
based practice guides the practitioner in choosing the discounted through examination. Deductive reasoning
most cost-effective intervention without sacrificing provides the foundation for experimental-type research,
quality in a fiscally driven health care environment. in which theories or parts are stated in measurable
Second, by systematically examining the processes and terms and objective measurement forms the basis of all
outcomes of current practice, OT practitioners can inquiry. Strategies used in deductive traditions include
provide an evidentiary basis for clinical thinking and sampling, measurement, and statistical analysis. Be-
action, which then can be presented to consumers, cause the rules of logic guide thinking, one can easily
other professionals, insurers, and policy makers. Third, follow thinking processes and identify the basis on
systematic inquiry transcends professional boundaries. which guesses, claims, decisions, and pronouncements
Therefore evidence-based practice provides a basis for are made and verified.
discussion with other members of the health care team.
It is no secret that OT practitioners have always had dif-
Complementarity With Contemporary
ficulty in clearly describing what they do to those
Practice Models
outside the profession. Moreover, OT practitioners have
typically placed more emphasis on providing direct Although it may seem difficult at first to engage in the
services than on publishing studies that document the formal, logical thinking processes that undergird re-
results or that attribute successful outcomes to OT inter- search, we do it every day. Let us look at how the
vention. In today’s increasingly complex and competi- decision-making skills we use in OT practice mirror the
tive health care environment, OT practitioners must logical thinking processes that form the foundation of
clearly demonstrate their contribution to achieving clin- evidence-based practice. Box 7-1 presents the steps of
ical outcomes. It is particularly critical to do this if refer- evidence-based practice, and Table 7-1 illustrates the
ral sources are to understand the benefits of OT to relationship between clinical decision-making and
diverse client groups.” evidence-based thinking processes.
 A Model of Evidence-Based Practice for Occupational Therapy

Feamework of Steps in Evidence-Based Relationship Between Clinical Reasoning

melaule) ind Evidence-Based Practice
Clinical Decision Making Evidence-Based Practice
Referral to OT Problem definition
Mi Identification and clarification of the problem to be
___ addressed by the intervention Evaluation and assessment of patient | Need statement
‘@ Understanding of need—what is needed to resolve all or or client (OT diagnosis)
part of the problem?
a Goals and objectives to address the need Process and outcome objectives Goals and objectives
® Intervention to achieve the goals and objectives OT intervention Intervention
™@ Process and outcome assessment to examine success of an
_ intervention. Reassessment of process Empirical assessment
and outcomes

Sequence of Evidence-Based Practice There are many ways to identify problems. Problem
Our model of evidence-based practice has five steps, as mapping is a method in which one expands a problem
listed in Box 7-1. The process begins with a conceptual- statement beyond its initial conceptualization by ask-
ization of the problem to be addressed. This leads to the ing two questions repeatedly: (1) What caused the
question, “What exactly is a problem?” problem? and (2) What are the consequences of the
problem? Let us apply the problem mapping method to
Statement of the Problem the statement, “Jane has limited short-term memory.”
Although we often see problems as entities existing To conduct problem mapping, we first need to concep-
outside ourselves, problems are contextually embedded tualize the problem as a river. Making the original state-
in personal and cultural values. A statement of the ment of the problem is analogous to stepping into the
problem is a statement of value, a statement of what is river and picking up one rock. As we look upstream, we
not desired or of what should be improved. Although it see causes of the problem, and as we look downstream,
seems simple to specify a problem, we often see prob- we see the problem’s consequences. How does this
lems stated in terms of a preferred solution; this limits work? See Fig. 7-1 to look at the problem map. Each box
our options in analyzing problem components and so- above the initial problem contains a possible answer to
lutions. Moreover, in evidence-based practice, problem the question of what caused the problem. Once we de-
statements must be derived from credible, systemati- termine first-level causes of the problem, we ask, “What
cally generated knowledge, including scholarly, lit- caused the cause of the problem?” and so on, until we
erature and inquiry. The following case serves as an reach cultural and social value statements. Keep in mind
example: that the knowledge that is used to identify causes and
consequences must be generated from credible,
Jennifer is an OT who has just evaluated a client with carpal
research-based sources such as empirical studies and
tunnel syndrome. Jennifer specifies the client's problem as
well-tested theory.®
“limited hand strength.” This problem statement suggests
only one solution—to increase hand strength. By systematic
Below the initial problem statement, we repeatedly
inquiry, Jennifer can expand her analysis of the problem to ask the question, “What is the consequence of the
“limited hand strength does not allow the client to participate problem?” As with the upstream map, this question
in work or self-care activity,” which allows her to generate ad- about the consequences of consequences is repeated
ditional potential solutions. For example, the client may take until we reach the effect of the problem on ourselves.
the following measures: look for alternative work, increase Thus the problem map expands the problem statement
hand strength, work with adaptive equipment, adapt the envi- from documented cultural, social, and environmental
ronment, and so forth. By expanding a problem statement, the causes to personal effect and suggests many different
OT practitioner moves beyond the obvious primary difficulty sites or targets for intervention. The problem map is a
and its solution and can capture the breadth of focus of the valuable tool that can help broaden the scope of OT
problem as revealed by systematically derived evidence from
intervention systematically beyond the level of the
literature, the client, or others.'? If the client did not want to
individual.
work on hand strength, but saw the solution as seeking alter-
native employment, the therapist would have missed the As you might imagine from this example of Jane,
essence of the client’s problem and thus would have selected many causes and consequences of problems cannot be
inappropriate interventions and outcomes. Thus it is critical to resolved by OT intervention. While many OT practition-
include the client and other sources of knowledge beyond ers will likely expand their efforts into political action or
practitioner guessing in formulating the problem statement. other areas at some point in their careers, others will
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

Lack of physician's awareness of OT

No referral

ea) No OT treatment

No compensatory
or remedial
No devices to assist her techniques

Jane has limited short term memory

Cannot take care of ADL Cannot get to work on time

Cannot function Cannot earn a living

| am not a good OT if Jane cannot function Cannot support herself

My taxes will be spent

FIG. 7-1
Problem map.

look for clinical interventions that can improve the level by promoting stricter legislation and cultural “zero
functional independence of individuals. Jane’s problem tolerance” of drunk driving, perhaps by educating ado-
map suggests numerous points of intervention for clini- lescents and young adults.
cal OT in cognitive remediation, compensatory training, Consider the initial problem statement focusing
and provision of assistive devices and services such as on Jane’s limited short-term memory. This is not a
assistive technology (AT). Two theory- and knowledge- problem that can be resolved by an OT practitioner as it
based performance areas on which the OT practitioner is stated. Therefore the OT practitioner must reconcep-
might focus intervention are (1) for Jane to work on tualize and restate the problem so that he or she can
self-care and (2) to address strategies that will enable intervene in meaningful and systematically docu-
Jane to arrive at work on time. The OT practitioner mentable ways within OT’s professional role. Problem
could also make a referral to a social service agency for mapping or other logical, evidence-based problem
Jane, who might be eligible for Social Security disability identification techniques help in examining and ana-
income; thus the OT practitioner would intervene at the lyzing problems beyond their initial presentation and
level of Jane’s inability to support herself financially. In identifying the strength of the evidence on which prob-
addition, as we look at the expanded problem, the OT lems are analyzed. In evidence-based practice, problem
practitioner may also want to intervene on the macro analysis and a careful statement of the part of the
 A Model of Evidence-Based Practice for Occupational Therapy

problem to be addressed are critical if the rest of the whether an area exists in which Jane would require spe-
steps are to be implemented. Including data from the cialized OT intervention. As we mapped the problem,
client's perspective in the process will help to formulate we found that OT did indeed have a critical role to play
the problem in a way that is meaningful and relevant in Jane’s treatment. Her ability to engage in meaningful
for the client. Furthermore, clarifying the problem will occupational performance is impaired in that she is
help the therapist ascertain what is needed to resolve unable to manage her time and be punctual as a result
the part of the problem that will be addressed. of her limited short-term memory.
Now let us move to the next step of evidence-based Given the problem statement, the therapist conducts
practice, determining need. a research-based needs assessment to determine what is
necessary to resolve the part of the problem that thera-
Ascertaining Need pist will address, to set goals and objectives to guide
After problem mapping, the next step is ascertaining the selection of intervention, and to determine what
need. In this step, one must clarify exactly what is processes and outcome should be expected.
needed to resolve the problem. Let us examine the dis- Using a systematic approach to data collection, the
tinction between problem and need. As discussed earlier, OT practitioner uses naturalistic techniques, including
a problem is a value statement about what is desired. For an interview and systematic observation of Jane, to as-
a problem to be relevant to OT practitioners, it must certain Jane’s desires and skills. The OT practitioner also
concern improvement or maintenance of occupational administers a standardized cognitive assessment and an
performance. Thus the problem area on the map that occupational performance assessment. In this instance
the OT practitioner would target for resolution would the OT practitioner is integrating qualitative and quanti-
be delimited and guided by the professional and theo- tative inquiry strategies to document a complete under-
retical domains of OT concern. A need statement is a standing of need and to provide the empirical basis for
systematic, evidence-based claim, linked to all or part of clinical decisions, as well as expected outcomes. One of
a problem, that specifies what conditions and actions the tools that the OT practitioner may use to collect data
are necessary to resolve the part of the problem to be ad- is the Canadian Occupational Performance Measure
dressed. Thus the identification of need involves collect- (COPM). This criterion-referenced measure is used to
ing and analyzing information such as assessment data identify client-perceived problem areas in daily func-
and the client interview to ascertain what is necessary to tioning in the areas of self-care, productivity, and
resolve a problem. leisure. By means of a semistructured interview format,
At this needs assessment stage of the evidence-based the COPM may be used to assess the performance com-
practice sequence, the one may already have information ponents the client identifies as interfering with the
on which to formulate need or may collect data in a sys- client's ability to function in a particular area.* The data
tematic fashion to clearly delimit and identify need. A from the COPM are credible, comparative, and accepted
need statement should specify who is the target of the as scientific evidence in the research world. See Chapters
problem, what changes are desired, what degree of 5 and 13 for further information regarding the COPM.
change is desired, and how one will recognize that the Systematic assessment reveals that Jane identifies re-
change has occurred. The need statement must be based turning to her job as a saleswoman in a boutique as her
on empirically derived data already contained in the lit- most important goal. Additionally, the results of the
erature or documentation or revealed in a needs assess- COPM interview reveal that Jane is not satisfied with her
ment inquiry. Can you see that the need statement uses ability to manage her time or her ability to be punctual
the research process to define the next steps of specify- and that she perceives these two issues as the greatest
ing goals and objectives, determining the intervention, barriers to achieving her desired goal of return to work.
and specifying the evaluative criteria to determine the She recognizes that her impaired short-term memory
success of an intervention? will affect her ability to do other work-related tasks, but
Let us advance our example from our problem state- she reports being most concerned about time manage-
ment again. As already mentioned, the problem as ment and promptness.
stated (limited short-term memory) is not a problem Standardized testing indicates that Jane’s short-term
that can be resolved by an OT practitioner. Yet it is memory is impaired but that her capacity to respond
common for referrals for OT intervention to identify appropriately to external cues remains intact. Addition-
problems such as this one. Thus the use of a problem ally, Jane’s performance on the Wisconsin Card Sorting
map or similar problem analysis strategy is not only a Test reveals that she is able to solve problems and that
reasonable thinking tool, but also is essential if we are she demonstrates abstract reasoning. The Wisconsin
to define the nature of our interventions more clearly Card Sorting Test is a standardized cognitive assessment
and thereby document the unique contributions and of executive function that was developed to assess
outcomes of OT. We thus choose to reason about the problem solving, abstract reasoning, and the ability to
causes and consequences of the problem to identify shift cognitive strategies.'° Standardized testing also
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

demonstrates that Jane is able to learn new behaviors chair heights were not adjustable. Thus the intervention
with specific, well-structured practice in the environ- he chose of body mechanics instruction and upper body
ment in which she will function. Based on this empiri- stretching may have been viable in some situations but
cally generated information, the therapist and Jane have did not address the specific needs, which had not been
a sound and credible basis for deciding that the inter- accurately assessed. Had he used inquiry skills to ascer-
vention will be directed to the need to find and teach tain the needs rather than guessing the needs and then
Jane compensatory strategies for time management and jumping from the problem to the intervention, he
promptness. Further, Jane indicated in her social history would quickly have identified the appropriate target
interview that she is married and that her husband areas.
would be supportive in helping her get to work. Based In any needs assessment, formal research strategies or
on this information generated from naturalistic inquiry, well-conducted a priori studies are useful for identifying
the therapist and Jane decide to include Jane’s husband and documenting needs. For individual clinical prob-
in the intervention and to work first in Jane’s home en- lems, strategies of single case design are indicated to
vironment and then transfer her treatment to the work reveal a comprehensive clinical assessment to guide and
environment. Can you see from this example how evi- test the efficacy of intervention decisions for a client. For
dence-based practice both provides the guidance and program development, the therapist may want to use
the documentation for clinical decisions and suggests “group” (also called nomothetic) designs, such as
future steps in the intervention and outcome assess- survey, interview, or standardized testing strategies, to
ment processes? Anyone who observes the intervention yield needed information on which to support a needs
process can easily see the rationale for decisions and claim. Naturalistic inquiry or integrated method may be
actions. Credible, research-based knowledge is struc- valuable to ascertain the perspectives of client groups
tured in a manner that provides a clear reasoning trail. whose problems and needs the therapist knows little
The desired outcomes are implicit in the need state- about. Many excellent research texts exist from which
ment, which provides a basis for formulating measura- to build research knowledge. (See the recommended
ble outcomes of intervention. What is needed is home- reading at the end of this chapter.)
based and then work site-based OT intervention to The next step in the process of evidence-based prac-
assist Jane with time management and promptness, as a tice is translating the needs into goals and objectives.
skill to facilitate her return to work. The evidence for tar-
geting this intervention, and for the goals and objectives Goals and Objectives
to follow, is clear and specified, as is the desired Goals and objectives are two words with which OT practi-
outcome. tioners are familiar, since the words are used to structure
Let us consider a different type of need statement that treatment. In evidence-based practice, goals and objec-
illustrates why evidence-based practice requires system- tives emerge from the need statement and are essential
atic inquiry. not only for structuring intervention, but also for speci-
fying how the process and outcome of intervention will
George, an OT practitioner, is asked by an employer to
be examined and supported.
address a problem involving several computer operators
A definition of the two terms is helpful. According to
whose ability to perform their jobs has been impaired or lost
as a result of neck pain. After constructing a problem map, Bloom and associates,’ goals “are statements about
based on literature about causes and consequences of neck what clients and relevant others would like to happen
pain, George formulates a need statement based on two areas or do or to be.” In other words, a goal is a vision state-
that he believes will address the problem: instruction in ment about future desires that is delimited by the need
proper body mechanics and instruction in a regularly sched- that it addresses. Objectives are statements about both
uled upper body stretching routine. He begins his intervention how to reach a goal and how to determine if all or part
by teaching proper body mechanics and upper body stretch- of the goal has been reached. The objective sets up the
ing techniques to the computer operators, but the problem is systematic approach to attaining the goal as well as the
not resolved. The computer operators continue to be unable empirical measurement or assessment thereof.'*
to do their jobs and their complaints of neck pain continue.
There are two basic types of objectives: process and
George’ intervention is not successful in resolving the problem
for which he was hired.
outcome. Process objectives define concrete steps nec-
essary to attain a goal. Process objectives are those inter-
What was missing from George’s reasoning? He ventions or services that will be provided or structured
based his problem map on educated but preconceived by the OT practitioner.'? Outcome objectives define the
guesses without fully assessing the situation. Had he criteria that must occur or exist to determine that all or
conducted an empirically based needs assessment that part of the goal has been reached; outcome objectives
included systematic interview, testing, and observation further specify how the criteria will be demonstrated.
of the workers in the process, he might have found that Outcome objectives indicate that a change has taken
the monitors were too high for the operators and the place as a result of participation in the OT process.'?
 A Model of Evidence-Based Practice for Occupational Therapy

To develop goal and objective statements in this promptly to her work schedule to her and her em-
model of evidence-based practice, the therapist exam- ployer’s satisfaction.
ines the need carefully, including the evidence to 8. Using the most effective strategy and devices, Jane
support the need. The therapist formulates conceptual will improve her promptness sufficient to work and
goal and objective statements that imply how the sufficient for her satisfaction.
‘process and outcomes of intervention will be assessed.
Goals are overall conceptual statements about what is GOAL NO. 2: COLLABORATIVELY ESTABLISH,
desired; objectives are statements that are operational- TEACH, AND HAVE CLIENT DEMONSTRATE LEARN-
ized (i.e., stated in terms of how they will be measured). ING OF A COMPENSATORY STRATEGY THAT SHE
Both are based on empirically generated knowledge WILL USE TO MANAGE HER TIME AT WORK (PER-
from the needs assessment. FORMANCE) TO HER SATISFACTION. The objectives
Let us now return to Jane to illustrate evidence-based we will use to attain this goal include the following:
goals and objectives. From the problem and need state- 1. Jane will be supplied with catalogues and assistive
ments, we have determined that an overall goal for devices from which to select a time management
Jane's intervention is to develop, teach, and have Jane strategy.
learn compensatory strategies for promptness and time 2. Jane will select the device or devices that she will use
management so she can improve her performance in as compensatory strategies for time management.
these areas and return to work. Based on the evidence 3. Jane and her husband will be trained to use the
given in the needs assessment, the OT intervention will device.
be carried out at first in Jane’s home with her husband 4. Jane will practice using the device until she is able to
participating, and then a transition will be made to the manage her time to her and her husband's satisfac-
workplace. tion.
One critical element of goal setting in evidence-based Once these two goals are reached in the home envi-
practice is specificity. The following example takes the ronment, goals and objectives specific to the workplace
previous treatment goal and uses it to write specific goal will be established and therapy will be transferred to the
and objective statements: work environment.
As you can see by reading these goals and objectives,
GOAL NO. 1: JANE WILL IMPROVE HER they are not new ideas but rather very directive, concep-
PROMPTNESS TO BE ABLE GET TO WORK ON TIME tual statements based on an empirical understanding of
(PERFORMANCE) AND TO HER SATISFACTION. need. As we will see in the section on process and
The objectives we will use to attain this goal include the outcome assessment, stating the goals and objectives as
following: demonstrated above determines what will be examined
1. Jane will be presented with assistive technology sup- to ascertain treatment success.
ports and services and catalogues of assistive devices
from which she can select those she thinks will be Intervention
most useful for her to achieve the goal. Specific goals and objectives help to define intervention
2. Given a choice of a variety of assistive devices (e.g., strategies and identify success markers. The process ob-
alarm watches, paging devices, and clocks), Jane will jectives specify the treatment steps and sequence.
choose one or more devices to use as an external cue Ongoing systematic assessment of process objectives
provider for promptness. monitors completion of actions within a time frame.
3. Jane will select one daily activity at home for which Periodic assessment of client progress on outcome ob-
she needs an external promptness cue. jectives provides empirical evidence of client progress to
4. With assistance from the OT practitioner, Jane and both the client and the therapist. Based on intermediate
her husband will configure the device to cue Jane to and ongoing data collection activities, intervention can
attend to this daily event. continue as planned, be revised in response to evidence,
5. Jane’s husband will monitor her promptness and or be terminated before desired outcomes are reached.
provide feedback to Jane and the therapist regarding Once intervention is terminated, final process and
the effectiveness of the assistive device in meeting the outcome assessment are conducted. Let us examine the
goal. final step of evidence-based practice.
6. Once Jane has demonstrated that she can promptly
attend to her schedule at home, she will begin to use Process and Outcome Assessment
the promptness cue to arrive at work on time and to To review, the process objectives are those that specify
her satisfaction. the steps of intervention and the outcome objectives are
7. Once Jane has demonstrated that she can arrive at those that delineate the desired outcome. In Box 7-2,
work on time, the therapist will work with Jane at the process objectives are identified with a “P” and outcome
work site so that she can use the device to attend objectives are identified with an “O.” These objectives
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

Evidence, Flare Success Criteria

Goal No. |: Jane will improve her promptness to be Criterion for success: significant improvement in Jane's
able to get to work on time (performance) and to promptness.
her satisfaction. ‘ Evidence: COPM score on this ttem, compared with
|. (P) Jane will be supplied with catalogues and assistive devices COPM score on pretest on this ttem.
from which to select those that she thinks will be most useful
for her to achieve the goal. Goal #2 Collaboratively establish, teach, and have
Criterion for success: completion of activity client demonstrate learning of a compensatory
Evidence: notes of each session documenting progress strategy that she will use to manage her time at work
toward goal (performance) to her satisfaction.
2. (P) Given a variety of assistive devices (e.g., alarm watches, |. (P) Jane will be supplied with catalogues and assistive devices
paging devices, and clocks), Jane will choose a device to use from which to select a time management strategy.
as an external cue provider for promptness. Criterion for success: completion of activity
Criterion for success: selection of device Evidence: notes of each session documenting progress
Evidence: notes of each session documenting progress toward goal
toward goal 2. (P) Jane will select the device or devices that she will use as
3. (P) Jane will select one activity at home for which she compensatory strategies for time management.
needs an external promptness cue. Criterion for success: completion of activity
Criterion for success: selection of activity Evidence: notes of each session documenting progress
Evidence: notes of each session documenting progress toward goal
toward goal 3, (P) Jane and her husband will be trained to use the device
4. (OQ) With assistance from the OT, Jane and her husband Criterion for success: completion of training
will configure the device to cue Jane to attend to this daily Evidence: notes of each session documenting progress
event. toward goal
Criterion for success: demonstration of completion of 4, (O) Jane will practice using the device until she is able to
objective by Jane and her husband manage her time to her and her husband's satisfaction.
Evidence: progress notes indicating mastery of task Criterion for success #1: significant improvement in Jane's
5. (P) Jane's husband will monitor her promptness and satisfaction from pretest on related COPM score
provide feedback to Jane and the therapist regarding the Criterion for success #2: report from Jane's husband of
effectiveness of the assistive device in meeting the goal. significant satisfaction with Jane's time management now
Criterion for success: daily record of Jane's promptness as compared with before
supplied to her each evening after dinner Evidence: COPM score and husband's self-report
Evidence: husband's written time charts
6. (O) Using the most effective strategy and devices, Jane will
improve her promptness sufficient to work and sufficient
for her satisfaction.

P Process; O, outcome.

can be assessed by using both quantitative and natura- from beginning to end will be used for outcome assess-
listic techniques and by applying systematic inquiry to ment. To assess outcome, the therapist will use ongoing
examine whether objectives have been attained. To documentation of objective completion. Box 7-2 illus-
brush up on inquiry, we suggest that you consult one of trates how each objective will be assessed.
the many excellent research method texts, some of Reexamine the table now in light of the need state-
which we list at the end of this chapter. You also may ment. The links among needs, goals and objectives, and
want to work collaboratively with other OT practition- process and outcome have been clearly illustrated. Each
ers, professionals, and clients to select measures and as- step of evidence-based practice emerges and is anchored
sessment strategies to provide evidence of successful in the previous step. Moreover, systematic inquiry pro-
completion of objectives. vides the specificity and empirical evidence supporting
To carry out outcome assessment of Jane’s intervention, the extent to which the intervention resolved the part of
a pre-post test design is selected. Although Jane’s interven- the problem that was identified as falling within the OT
tion will be measured multiple times, only the change domain.
 A Model of Evidence-Based Practice for Occupational Therapy

REFERENCES
SUMMARY 1. American Occupational Therapy Foundation Academic Develop-
ment Committee, Research Advisory Council: Research Competencies
This chapter presents research-based thinking and
for Occupational Therapy, 1999, the Foundation. On line at
action as valued tools in OT practice. A model of “http://www.aotf.org/html/research_competencies_for_occu.html”
evidence-based practice in which research rigor informs 2. American Occupational Therapy Foundation: About AOTF, 1999,
a sequence of systematically linked steps in reasoning the Foundation. On-line at “http://www.aotf.org/html/about
and action is proposed. This model begins with a clear _aotf.html.”
3. Baum C: Occupation-based practice, prevention, and policy:
problem statement that guides all of the remaining
issues for the new millennium. Paper presented at the Strategic
steps. Naturalistic and experimental research traditions Thinking Meeting, AOTA conference, Indianapolis, Ind, 1999.
are applied to clinical decision making to guide the sub- 4, Bergman A: Devolution continues: disability policy for the new
sequent steps of identifying and documenting need, millenium. Paper presented at the Leadership Seminar, Orono,
positing goals and objectives, selecting intervention, Me, 1998.
5. Bloom M, Fischer J, Orme JG: Evaluating practice: guidelines for the
and assessing the efficacy of the process and outcomes
accountable professional, ed 2, Boston, Mass, 1998, Allyn & Bacon.
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In closing, we encourage you to perform deliber- multiple strategies, St Louis, 1998, Mosby.
ately each of the steps of evidence-based practice and 7. Dubouloz C, Egan M, Vallerand J: Occupational therapists’ per-
to find a personal style for using empirical evidence in ceptions of evidence-based practice, Am J Occup Ther 53(5):445-
4537-19993
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8. Egan M, Dubouloz C, Von Zweck C, et al: The client-centered
only a valuable approach in direct intervention, but evidence-based practice of occupational therapy, Can J Occup Ther
also provides the empirical foundation for knowledge 65(3):136-143, 1998.
building and intervention development in the OT 9. Fine S: Surviving the health care revolution: rediscovering the
profession. meaning of “good work.” In Scott AH, editor: New frontiers in psy-
chosocial occupational therapy, New York, 1998, Harworth Press.
10. Haase B: Cognition. In Van Dusen J, Brunt D, editors: Assessment
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REVIEW QUESTIONS Saunders.
11. Jacobs K: Alignment: leading health care by sharing common
1. List three reasons why OT practitioners need to use dreams, Am J Occup Ther 53(5):429-433, 1999.
evidence-based practice to demonstrate the efficacy 12. Law M, Baum C: Evidence-based occupational therapy, Can J
Occup Ther 65(3):131-135, 1998.
of OT practice to external audiences.
13. Letts L, Law M, Pollack N, et al: A programme evaluation workbook
2. Name and describe each of the steps in the model for occupational therapists: an evidence-based practice tool, Ottowa,
of evidence-based practice. 1999, Canadian Association of Occupational Therapists.
3. Compare the steps in the model of evidence-based 14. Ottenbacher K, Christiansen CH. Occupational performance as-
practice with the steps in the clinical reasoning sessment. In Christiansen CH, Baum CM, editors: Occupational
therapy: enabling function and well-being, ed 2, Thorofare, NJ,
process. =) ag 1997, Slack.
4. Using a potential OT client as a case study, select a 15. Tickle-Degnan L: Communication with clients about treatment
problem and develop a problem map. outcomes: the use of meta-analytic evidence in collaborative treat-
5. Pose strategies to ascertain the need based on your ment planning, Am J Occup Ther 52(7):526-530, 1998.
problem statement.
6. Identify the need for your client based on your RECOMMENDED READING
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7. What is the difference between goals and objectives, York, 1990, Springer-Verlag.
and what is their relationship? Campbell DT, Stanley JC: Experimental and quasi-experimental design,
Chicago, 1963, Rand-McNally.
8. How do goals and objectives relate to need?
DeVellis RF: Scale development: theory and applications, Newbury Park,
9. How do goals and objectives relate to a problem? Calif, 1991, Sage.
10. Identify goals for your client. Glaser B, Strauss A: Grounded theory: strategies for qualitative research,
11. What are the two types of objectives described in New York, 1967, Aldine.
this chapter, and what are the differences between Kane RL: Understanding health care outcomes research, Gaithersburg,
Md, 1997, Aspen.
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Knoke D, Bohrnstedt GW: Basic social statistics, Itasca, Ill, 1991,
12. Based on your goals for your client, identify at least Peacock.
two process objectives and two outcome objectives. McDowell I, Newell C: Measuring health: a guide to rating scales and
Include criteria for success and evidence in your questionnaires, ed 2, New York, 1996, Oxford University Press.
objectives. Miles MB, Huberman AM: Qualitative data analysis: a source book of new
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13. Chose at least two interventions to achieve the goals
Miller D: Handbook of research design and social measurement, Newbury
and objectives you have established in question 12. Park, Calif, 1991, Sage.
14. Identify process and outcome assessment to Munro BH: Statistical methods for health care research, ed 3, Philadel-
examine the success of your interventions. phia, 1998, JB Lippincott.
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Ottenbacher K: Evaluating clinical change: strategies for occupational and Royse DD, Thyer BA: Program evaluation: an introduction, ed 2, Chicago,
physical therapists, Baltimore, 1986, Williams & Wilkins. 1996, Nelson Hall.
Patton M: Qualitative evaluation and research methods, ed 2, Newbury Shaffir WB, Stebbins RA, editors: Experiencing fieldwork: an inside view
Park, Calif, 1990, Sage. of qualitative research, Newbury Park, Calif, 1991, Sage.
Pyrezak F: Success at statistics, Los Angeles, 1996, Pyrczak Publishing. Strauss A: Qualitative analysis for social scientists, New York, 1987, Cam-
Reason P, Rowan J, editors: Human inquiry: a sourcebook for new para- bridge University Press.
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Royeen C, editor: Clinical research handbook, Thorofare, NJ, 1989,
Slack. _
 ! Therapy for Prevention of Injury
AllDysfunction

LEARNING OBJECTIVES
Primary prevention After studying this chapter the student or practitioner
Secondary prevention will be able to do the following:
Tertiary prevention 1. Discuss the involvement of occupational therapy
Secondary conditions (OT) in the prevention of injury and physical
__ Risk factors dysfunction, as related to political, social, economic,
Risk assessment and health care financing trends during the last four
Falls prevention decades of the 20th century.
_ Ergonomics 2. Describe important considerations for the future
Well elderly study expansion of OT roles in prevention.
ROM Dance Program 3. Define primary, secondary, and tertiary preventions
FAST: Families and Schools Together and discuss the roles played by OT practitioners at
j each level.
4. Describe three key factors in the practice of
prevention in OT.
net 4 5. Identify roles that OT practitioners play in primary,
secondary, and tertiary prevention of falls.
6. Define ergonomics and describe the roles that
occupational therapists play in the prevention of
injuries in the workplace.
7. Provide a general description of the interventions
provided in “The Well Elderly Study Occupational
Therapy Program,” and discuss implications of the
results of research.
8. Describe the ROM Dance program and discuss
methods for integrating ROM Dance exercise and
relaxation techniques in clinical practice.
9. Discuss the American Occupational Therapy
Association's (AOTA’s) initiatives in preventing
youth violence, and describe the FAST program.
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

his chapter provides a brief history of the role of oc-

cupational therapy (OT) in the prevention of injuries
and physical dysfunction, as related to general trends in
Intervention Approaches Focus of Intervention
health care financing. Primary, secondary, and tertiary in-
terventions are defined, and key factors in the provision Remediation and Restoration
of effective prevention services are identified. Tertiary Changing the biologic, Restoring or remediating
prevention techniques for specific physically disabling physiologic, psychologic, or impairments in performance
conditions are not covered here, since other portions of neurologic process components
this text provide extensive information in this area. Pre-
Teaching and training Establishing new skills, habits,
vention of falls, workplace injuries, and ergonomics are
or behaviors in performance
highlighted. In addition, three innovative primary and components
secondary intervention programs are summarized. Prac-
titioners are urged to maximize day-to-day opportunities Compensation and Adaptation
to more fully integrate prevention activities into practice. Changing the task Adapting the task
requirements, procedures,
task objects
BRIEF HISTORY OF PREVENTION MODEL
IN OCCUPATIONAL THERAPY Changing the context Modifying or adapting the
task environment
One of the basic assumptions of the OT profession is
that individuals develop and maintain health and Disability Prevention
prevent dysfunction through occupational performance. Primary prevention Occupations that prevent
The philosophical base statement of the American Oc- health problems
cupational Therapy Association (AOTA) asserts that Secondary prevention Safe task methods and task
“Occupational therapy is based on the belief that pur- objects
poseful activity (occupation) ... may be used to
prevent and mediate dysfunction.”’ Reitz®” stated that, Tertiary prevention Safe occupational
performance
“Since its inception, occupational therapy has recog-
nized the importance of both preventive action and the
Health Promotion
promotion of wellness.” Prevention of disability has Lifestyle redesign Purposeful and meaningful
been defined by the AOTA as “any activity intended to occupations
keep specific diseases or disabling conditions from oc- Balance of rest, work,
curring or worsening.” Promoting health and wellness play and leisure
is the basis of prevention efforts and should be the cor- Healthy interaction with the
nerstone of all therapeutic intervention.”” The ability to environment
integrate these factors into one’s clinical reasoning so as From Moyers PA: Am J Occup Ther 53: 274, 1999. Used with permission of the
to select appropriate assessments and develop an effec- American Occupational Therapy Association.
tive treatment plan is the art and the science of occupa-
tional therapy preventive intervention.
During the past four decades the prevention model @ Preventing deformity, weakness, and loss of motion,
has been explored in the OT literature.'°Varied roles and as in physical dysfunction
services appropriate for OT practitioners have been de- ®@ Preventing accidents by teaching safety practices, and
scribed. Direct involvement in preventive intervention, as preventing strains through instruction in proper body
opposed to remediation and compensation (see Table mechanics
8-1), has been dramatically affected by the changing m@ Preventing dependency, for a broad range of handi-
trends in health care financing and reimbursement trends. capping conditions, through the teaching of abilities
During the 1960s most occupational therapists were for daily living
employed in long-term care institutions. Such settings @ Preventing the need for institutional care, for the
often maintained statistics on service provision, but a pro- elderly or incapacitated, through adaptations of the
ductivity monitor was unheard of, and the cost of OT was home
seldom computed or charged directly to the patient. Al- ®@ Preventing invalidism of cardiac patients with energy-
though the majority of services provided were remedial, saving devices and procedures
compensatory, or diversional, some aspects emphasized @ Preventing vocational misfits, in terms of interest, at-
prevention.” The following OT prevention roles in physi- titude, or skill, through prevocational exploration
cal disabilities were identified in 1969 by Wilma West”: and evaluation
 Occupational Therapy for Prevention of Injury and Physical Dysfunction

@ Preventing misunderstanding and mistreatment of of stay. This provided unexpected opportunities for oc-
children with aberrant motor performance or social cupational therapists who were able to market their
behavior, by counseling their parents, siblings, and skills in facilitating patients’ independent functioning
teachers.°* in self-care, an important factor in decreasing lengths of
In the early 1970s, Lela Llorens*® edited a book of stay. OT functional evaluations and discharge recom-
collected papers highlighting the shift in the practice of mendations became more valued, in part because of the
OT from a remedial, institutionally based, medical financial losses that hospitals incurred if patients were
model to a health-oriented preventive model practiced readmitted shortly after discharge. It became increas-
in the community. At that time, providing OT in a ingly important to identify patients at risk for falls both
private clinic or the public school system was consid- during and after hospitalization. If a patient required
ered nontraditional. It was also not uncommon for pa- readmission for a fall-related injury, procedures might
tients with a physically disabling condition such as not be reimbursed if the fall was determined to be pre-
stroke to be detained in an acute care hospital for cipitated by a premature discharge. Since most falls
months before being transferred to a rehabilitation unit occurred during functional activity, occupational thera-
or hospital, where they might receive their first visit pists became actively involved in this aspect of preven-
from an occupational therapist. At the start of the tion, both in the hospital and through home safety eval-
decade OT was seldom available in acute care to prevent uations after discharge. Competitive marketing of
a disabling condition’s potential secondary effects such emerging health care systems through community-
as contractures, decubiti, and depression. At that time, based health education and wellness programs also in-
Medicare reimbursed hospitals and physicians on a fee- creased OT involvement in prevention since occupa-
for-service basis, creating a monetary incentive to main- tional therapists were recruited to design and often
tain patients in the acute care setting for lengthy implement outreach preventive health education. The
periods. As hospital administrators began to realize that ROM dance program'”° discussed in this chapter was
Medicare would reimburse charges for OT, the availabil- created as a result of such an initiative.
ity of acute care OT for physical disabilities increased, as During the 1990s the emerging dominance of health
did OT’s involvement in preventive intervention. The maintenance organizations (HMOs) and _ preferred
goal to “shift our point of entry’*® was realized in provider organizations (PPOs) had some positive
diverse ways, and by expanding the availability of serv- effects on OT involvement in prevention. These HMOs
ices in the community, therapists were able to focus on and PPOs have a vested interest in prevention activities
more primary and secondary levels of prevention (Box at all levels because keeping people well is more prof-
/ 8-1). In 1979, AOTA published an official position itable under these systems than is remediating health
paper that identified and illustrated OT’s expanding problems that could have been prevented. During the
roles in the area of primary and secondary levels of pre- past decade, OT literature has reflected the increasing
vention. ' ; importance of prevention, and Rothman and Levine*®
In 1984 Medicare reimbursement for acute care hos- have published an extensive text titled Prevention Prac-
pitalization shifted to a Diagnostic Related Grouping tice: Strategies for Physical Therapy and Occupational
(DRG) system that fiscally reinforced shortened lengths Therapy that focuses on incorporating the prevention of
physical dysfunction into daily practice. It emphasizes
“an expanded view of the roles of physical and occupa-
tional therapists . . . practicing in so-called ‘rehabilita-
tion’ [where OT practitioners] interact with clients who
are experiencing multichronicity. For example, we may
develop a plan of care related specifically to a patho-
Primary prevention logic condition such as a hip fracture. . . . However,
@ Employed before a critical event occurs that same client may also have a history of coronary
B Goal: Reduce incidence of disorder heart failure, chronic obstructive pulmonary disease,
and diabetes. In effect, the presence of multichronicity
Secondary prevention obligates us to be alert to make preventive interventions
@ Keep mild disorders from becoming severe ones
at any point along the health service spectrum.”*°
@ Avert disorder with an “at risk’ individual, group, or
OT literature also articulated the need for occupa-
population
tional therapists to expand awareness of and involve-
‘Tertiary prevention
ment in prevention activities on the local, state, and na-
@ Keep serious disorders from producing permanent disability tional levels. Kniepmann’’ provided a review of some
™@ Maximize function and minimize detrimental effects of a key national initiatives and resources and discussed
disabling condition their implications for OT. She noted that, “Occupa-
tional therapists must identify ways to move into the
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

day-to-day settings where health habits, illness, and and its associated costs will challenge employers to seek
injury occur. . . . A major challenge for occupational effective prevention programs, and OT workplace serv-
therapists is to find innovative, effective, and economi- ices such as those reviewed in this chapter should expand
cal ways to ‘move upstream’ by transferring the knowl- dramatically. In the future, we may see increasing
edge and skill base of occupational therapy to address numbers of referrals to OT by physicians who are con-
all levels of prevention. . . . Occupational therapists can cerned that aging patients’ physical or mental status may
act as consultants, program planners, staff trainers/ impair driving ability, which could pose a threat to
educators, researchers, community health advisors, public safety. Another societal concern is preventing
primary care providers, policy makers, case man- youth violence, which is a serious risk factor for injury
agers, and advocates—for individuals, groups, and and physical dysfunction. We hope that occupational
communities.””” therapists will be able to garner grant funding from the
armories of the “wars” on drugs and crime to develop,
FORECASTING THE FUTURE OF implement, and research activity-based programs for
preventing youth violence within high-risk populations.
PREVENTION IN OCCUPATIONAL
Such a program, FAST, is described later in this chapter.
THERAPY
It is highly desirable that occupational therapists
Looking forward to the first decade of the new millen- expand their scope of services to new settings and
nium, Baum and Law’ state that, “As the health system become increasingly involved in prevention planning
changes its focus to persons’ long-term health needs, and legislation on the local, state, and national levels.
issues surrounding occupation become central to pro- Nevertheless, therapists’ natural and immediate concern
moting health and reducing the cost of chronic disabil- will be the clients already in their care. The clinical rea-
ity.” Realizing the goal of reducing the cost of chronic soning questions regarding prevention will always be,
disability is one of the potential benefits of cost con- What risks does this client face? What interventions
tainment and managed care because it creates a context could be used to prevent these risks? What funding is
for the reimbursement of preventive OT services. This available? Will consumers adopt these recommenda-
theoretical opportunity creates the challenge to tions and take responsibility for implementation?
“package” OT services in a manner that fits into the
shifting health care delivery systems. It is also a chal-
PREVENTIVE INTERVENTION IN
lenge for those reflecting on current practice in the OT
OCCUPATIONAL THERAPY
literature to identify and work within new models of de-
livery of preventive care. One example of an emerging The 1999 Guide to Occupational Therapy Practice*® in-
model of care is “disease management.”* This “. . . isa cludes “disability prevention” as one of the four cate-
comprehensive, integrated approach to care and reim- gories of interventions employed by OT (Table 8-1). The
bursement . . . [which] attempts to encompass the Guide describes disability prevention by OT practition-
entire course of a disease, whether it is in an acute phase ers as preventing the occurrence of “impairments, activ-
or remission and whether the care is delivered in the ity limitations, and participant restrictions. . . .”*° It
hospital, the home, or the community. This approach also refers to three levels of intervention, described as
also considers the consequences of the condition across follows.
time. The purpose of disease management is to help
people develop healthy behaviors not only to improve
Primary Prevention
their health, but also to cut health care costs associated
with secondary conditions. In the United States, nurses Primary prevention is employed before a critical event
and health educators are carrying out much of this occurs. It involves protecting individuals or groups
work.”* Many opportunities exist for occupational ther- who are not at any greater risk from the negative effects
apists to provide services within such a model, espe- of identified health hazards than is the general popula-
cially with the management of rheumatic diseases and tion. The goal of primary prevention is to reduce the
those that frequently result in physical disability and incidence of disorder by altering the environment or
dysfunction, such as diabetes. by making the individual or group less susceptible to
Looking ahead, “Occupational therapists must con- stress. Public health programs and interventions that
tinue to identify high-risk populations and to design pre- support and protect “the health and well-being of the
vention services that promote healthy outcomes.”'® One society at large”?’ are considered primary prevention.
high-risk population is the large aging portion of the An example of community-wide primary prevention of
workforce. Combined with the expected increase in dis- physical disability is the passage of laws that require
abled workers, the advancing age of the workforce will the use of seat belts to prevent injuries caused by
increase risk factors for work-related injuries and result- motor vehicle accidents. Other examples include
ing physical dysfunction. The desire to reduce disability statewide laws and programs to promote the use of
 Occupational Therapy for Prevention of Injury and Physical Dysfunction

helmets to prevent head injuries while using motorcy- and assist in attaining desired productivity and partici-
cles and bicycles. pation in community life. Occupational therapists are
The occupational therapist providing services for considered experts in tertiary prevention, since the main
primary prevention of physical dysfunction may focus goal of this level is to maximize function and minimize
on consumer education regarding risk factors for in- the detrimental effects of a disabling condition.
juries caused by accidents or habitual stresses such as
repetitive motions. An important goal is to facilitate un- KEY FACTORS IN PRACTICE OF
derstanding of the linkages between one’s occupational
PREVENTION IN OCCUPATIONAL
behavior and the risks for injury. OT may also assist
THERAPY
consumers in clarifying their values about health and in
acquiring the knowledge, habits, and attitudes needed “Prevention is anticipatory action based upon knowl-
for preventive intervention. OT primary prevention also edge.”°* The knowledge essential to clinical reasoning
includes altering the environment or providing other and judgments about appropriate preventive interven-
interventions to reduce susceptibility to injury or physi- tion in OT patient care is grounded in three key areas.
cal dysfunction. To develop an appropriate plan for intervention, knowl-
edge of the following areas should be integrated with
data gained from a client-centered assessment of occu-
Secondary Prevention
pational performance:
The goal of secondary prevention is keeping mild dis- 1. Awareness of preventive intervention opportunities and re-
orders from becoming severe. Secondary prevention is sources. Therapists who are committed to implement-
most often practiced with individuals or groups that ing preventive intervention must be vigilant in main-
have been identified as at risk for a severe dysfunction. taining a current awareness of new clinical resources
Intervention is provided to assist in preventing a disor- and service and reimbursement pathways as they
der or retarding its progression to a more serious or emerge. Knowledge of current research on the effi-
chronic condition. Such activities may include screen- cacy of intervention techniques is also important for
ing, early diagnosis, appropriate referral, prompt treat- effective practice of prevention. The OT practitioner
ment, consultation, and community-based and home must empower clients and their families to acquire
health care. appropriate knowledge, skills, and equipment
An example of secondary prevention of physical dys- needed to incorporate preventive practices into their
function in OT clinical services is providing instruction lifestyles. This is as important as maintaining an
in joint protection, body mechanics, and work simplifi- awareness of the opportunities that arise to provide
cation techniques to clients with a newly diagnosed preventive intervention services in one’s current
condition that has the potential to be physically dis- practice.
abling, such as rheumatoid arthritis. Occupational ther- 2. Early identification and awareness of risk factors. Identi-
apists are also directly engaged in activities to reduce or fying risks is the first step in planning for the preven-
eliminate architectural barriers that restrict employment tion of secondary conditions, which are defined as
and mobility for people with physical disabilities. The pathology, impairments, or functional limitations
current trend is for occupational therapists to provide that derive from the primary disabling condition. In-
home safety evaluations for frail, elderly clients recently dividuals with disabling conditions have a “narrow
discharged from acute care hospitals or rehabilitation or margin of health’** and are at risk for accidents, in-
extended care facilities; this also would be considered juries, and secondary conditions that unnecessarily
secondary prevention. The client is identified as being at increase the severity of the disability and that require
risk for falls, and the OT safety evaluation and therapeu- attention to prevent.*? Maintaining a current aware-
tic intervention are intended to reduce the risk of future ness of the risk factors encountered by the popula-
falls that might result in a physically disabling injury. tion served is critical to planning preventive interven-
tion strategies within the scope of an occupational
therapist's practice. Many clinics have developed
Tertiary Prevention structured formats for evaluation of an individual's
The goal of tertiary prevention is to prevent a serious functional performance components related to spe-
disorder from producing permanent disability. OT terti- cific diagnoses. Equally helpful would be a risk as-
ary prevention aims to reduce the barriers to desired sessment checklist of risks and risk factors that an
occupational performance among physically disabled individual with a specific diagnosis would be ex-
individuals within present or future performance pected to encounter in the future. Checklists may
contexts. Tertiary prevention includes the provision of a include the risk of falls, contractures, decreased en-
wide range of rehabilitative services to improve func- durance, decubiti, and driving risks, among other
tional performance, prevent declines in performance, conditions. Such an assessment could be used to
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

guide consumer education and discharge planning. ability to understand the risks they face and their
In fact, a therapist's ability to effectively communi- beliefs about the need to implement preventive rec-
cate knowledge of risk factors and methods of pre- ommendations. Assisting consumers in addressing
vention to the client and family may be the key to fa- these questions will help in developing a collabora-
cilitating healthy behavioral change. Consumers tive, client-centered plan of care.
who fully understand the risks they face are much
more likely to implement recommendations. There- APPLYING PRINCIPLES OF PREVENTIVE
fore the consumers’ level of knowledge and beliefs
INTERVENTION
should be assessed; limited knowledge could be con-
sidered a risk factor (Box 8-2). Since the principles of prevention are applicable to such
. Assessment of consumers’ health belief risk factors. The a broad scope of physically disabling conditions, only a
health belief model was developed and expanded to few specific areas are used as examples.
help therapists understand and predict adoption of
preventive health behaviors in response to specific
Prevention of Falls
health risks.7* This model asserts that a number of
factors predict whether consumers are likely to im- Falls are a major source of physical dysfunction and
plement recommendations to adopt preventive mortality among the well elderly and physically disabled
health behaviors. The predictive factors relate to the populations.'* Preventing accidental falls by senior citi-
consumers’ assessment of the relative importance of zens has been a national health priority, and consider-
the risk factors, the value of the recommendations able research with implications for OT practice has been
for prevention, and the consumers’ ability to carry conducted in this area.*”*° One study indicated that re-
out the recommendations.***’ Consumers’ judg- ported falls were reduced by 60% after a community-
ments are often unconscious or not expressed to the based program to reduce hazards in the home environ-
therapist. Therefore the consumers’ implementation ments of senior citizens.*’ The interventions used in this
of a recommendation may be sabotaged by an un- study were similar to those typically provided by occupa-
conscious belief, and a therapist's effectiveness may tional therapists performing home safety assessments
depend on the ability to perceive and address such and modifications, such as securing rugs and electrical
unexpressed concerns. Box 8-2 provides a proposed cords, removing clutter, and installing hand rails, grab
format for structuring an assessment of consumers’ bars, and nonskid strips. An extensive review of the liter-
ature on the intrinsic and extrinsic factors related to
falls** in the elderly population was provided by Holli-
day, Cott, and Torresin?° and Cook and Miller.‘ Intrin-
sic risk factors include poor balance, gait impairment,
ents’ Attitudes Regarding muscle weakness, decreased range of motion (ROM),
Preventive Intervention visual and other sensory impairments, chronic disease,
physical disability, blood pressure changes, cognitive
impairment, and side effects of medications.
Personal threat assessment
Falls often occur during occupational performance.
What Is the chance that this (identified risk )can happen
Occupational therapists are providing a wide range of
to me?
If tt does, how bad will it be?
services in prevention of primary, secondary, and terti-
ary falls in diverse settings.
Personal cost-benefit analysis Primary prevention of falls can involve such activities
Will the short and long-term benefits of following the as controlling environmental hazards or providing edu-
therapist's recommendations be worth what it will cost me cational services to the well elderly’? who are no more
and my family in terms of such things as money, effort, social at risk for falls than their age mates. I participated in an
status, and self-concept? example of the latter at a number of Wisconsin state-
funded “Senior Expos.” This annual event draws thou-
Belief in self-efficacy sands of seniors who participate in educational pro-
Do | have what it takes (e.g., self-discipline, determination,
gramming designed to appeal to their interests and
knowledge, and skill) to pull it off?
needs, especially in the areas of prevention and health
Belief in resources promotion. Prevention of falls in the home has been a
Can the people and structures within my environments adapt popular topic. In addition to providing information on
and support these lifestyle changes? risk factors, adaptive equipment, and environmental
What new resources will be available to assist in following this modifications, occupational therapists have empha-
recommendation? sized the relationship between falls and occupational
behavior. Presentations have involved examples of fall
 Occupational Therapy for Prevention of Injury and Physical Dysfunction

hazards encountered by therapists providing OT serv- maintain strength and alertness, were monitored during
ices through the home health organization that spon- transfers, and were provided standby assistance during
sors the presentations. Since many healthy participants toileting whenever possible. The team implementing
are in attendance because of their concern for the safety this program found that the slippers given to patients
of infirm or disabled friends and relatives, these lectures were impeding ambulation because of the tacky tread,
have been an excellent opportunity to market OT home so new slippers were ordered for use throughout the
safety assessment services. hospital: Since a review of hospital data indicated that
An OT home safety assessment is a secondary preven- falls occurred when patients attempted to scale guard
tion program most frequently provided to clients who rails on the bed for toileting, the use of guard rails was
are at a greater risk for falls because of recent discharge decreased. The team’s occupational therapist proposed
from a hospital or nursing home. An occupational be- the use of female urinals, which were adopted through-
havior model is used to assess the person (intrinsic risk out the hospital. In addition, OT supplied each unit
factors), environment (extrinsic risk factors), and occu- with a box of video tapes of old comedies and Lawrence
pation fit. One important risk factor is the area of con- Welk shows, music audio tapes, long-handled reachers,
sumer attitudes (Box 8-2). Therefore the therapist assists games, and hand exercise equipment to lend to patients
clients and their families in conducting a personal and their families during admission; this was very well
threat assessment by highlighting the interaction of received. Additional prevention activities included
primary risk factors during specific high-risk activities monitoring the environment for hazards and initiating
such as going to the bathroom in the middle of the improvements. The hospital is gathering data to assess
night. This provides an opportunity to examine values the effectiveness of this approach.
and conduct a cost-benefit analysis about such simple Tertiary prevention is provided to clients who experi-
environmental or behavioral strategies as leaving a light ence falls on a recurrent basis. All too often, the
on. A new behavior such as leaving a light on may con- problem of repeated falls for elderly or disabled individ-
flict with strong values and ingrained habituation uals is not addressed effectively. One high-incidence
systems. Considerable therapeutic skill is needed to re- factor is the presence of a high-level spinal cord injury.
inforce the client's belief in self-efficacy to implement It is not uncommon for individuals with long-term
recommendations. Framing the change as a challenge is spinal cord injuries to incur physical injuries, including
often helpful because this acknowledges the effort re- fractures, as a result of caretaker error in assisting with
quired and facilitates mobilization of resources. For transfers. The strength of postural bones is compro-
example, if a family expresses the value of conserving mised by not bearing weight, causing individuals with
money, it may be helpful to engage in a brainstorming spinal cord injury to be more susceptible to fracture.
session on how to acquire recommended adapted This situation is further complicated by the frequent
devices at the lowest cost. This approach is valued by turnover of caregivers employed as personal assistants.
those who are in other disciplines in the home health OT literature emphasizes the importance of providing
organization and prefer to delegate this aspect of care to employer education to individuals and families respon-
OT practitioners, who usually complete the service in sible for hiring and training personal assistants.’ OT in-
one to three sessions. This approach also provides an ex- terventions include client and caregiver education and
cellent opportunity to identify other aspects of care that training concerning risk factors and interventions to
can be provided by an OT practitioner. prevent falls, but this education is not provided consis-
Service on multidisciplinary fall prevention teams in tently. Transfer training of newly employed personal as-
hospitals and nursing homes is another important con- sistants might be enhanced if the development of
tribution made by OT practitioners. A quality improve- training videos were routinely incorporated into the re-
ment team at St. Mary’s Hospital Medical Center in habilitation program. Videos should be developed
Madison, Wisconsin, created a hospital-wide program within the environment where the patient is likely to be
to identify acute care patients who met preestablished functioning on a long-term basis. Simple, clear, and
fall risk criteria. The admitting nurse administered a concise instructions with a viewing time of no more
falls assessment. Certain high-risk trigger factors gener- than 15 minutes would facilitate frequent use. A brief
ated automatic referrals to OT and physical therapy. explanation of the hazards and precautions may be
One of the most important risk factors identified was a helpful in preventing future injury. Maintaining or pro-
positive orthostatic test, which consists of a 20- to 30- viding an extra copy of the tape may also facilitate long-
mm change in a patient's blood pressure while the term use of such a valuable prevention resource.
patient is making the transition from lying to standing. Another resource that is helpful to OT practitioners is
Patients with this or other risk factors wore green-tinted Morse’s “Preventing Patient Falls,”*” which includes the
hospital identification bracelets so that all employees Morse Fall Scale and strategies for prevention.
were alerted to the risk for falls. Patients in this program “A Matter of Balance” is an award-winning preven-
received increased physical and cognitive activity to tion program designed to reduce the fear of falling and
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

increase the activity level of elders.”’** This community- require employers to have a plan to prevent ergonomic
based intervention provides nine 2-hour group sessions injuries and pay for treatment.*** Occupational thera-
that include activities to address physical, social, and pists have responded to the proactive corporate climate
cognitive factors involved in the fear of falling. The in unique, creative, and effective ways. Occupational
program is based on the premise that the fear of falling therapists affiliated with Bellin Memorial Hospital in
can lead to reductions in activity, mobility, and physical Green Bay, Wisconsin, market their occupational
conditioning, which may increase risk. Results of a ran- health services® to local industry on a fee-for-service
domized controlled trial of 434 older adults showed basis. Among the program elements they offer are the
that after 1 year, participants reported less fear of falling following:
and greater fall management than control subjects. 1. Preemployment functional testing to screen for
Other findings included a better mean score on the total propensities for carpal tunnel syndrome, back in-
sickness Impact Profile and scales for physical condi- juries, and lifting problems, as related to specifica-
tioning, mobility range, and social behavior. tions of the job description
. Acute treatment of work-related injuries
. Return-to-work programs
Ergonomics and Prevention of Injuries
. Functional capacity evaluations
in the Workplace . On-site services, including work hardening and a
Wh
MB

Ergonomics is the science of workplace design. Increas- video analysis of the ergonomic job site assessment
ingly, occupational therapists are involved in ergonom- 6. Task analysis for job descriptions to assist in comply-
ics and prevention of injuries in the workplace. AOTA’s ing with guidelines of the Americans with Disabili-
official statement on “Occupational Therapy Services in ties Act
Work Practice”® states that OT practitioners “play an im- 7. Education programs in cumulative trauma disorders,
portant role in promoting optimal levels of work per- back injury prevention, office ergonomics, stretch-
formance for all individuals... . . Occupational therapy ing, exercise, and high-risk factors for job duties
practitioners provide work-related services in many set- Another innovative service was developed by occupa-
tings, including. . . acute care and rehabilitation facili- tional therapist Michael Melnick, who provides consul-
ties, industrial and office environments, work evalua- tation to industry. One of Melnick’s clients reported that
tion and work hardening programs, sheltered work “costs for injuries dropped by 80% three years after
programs, school-to-work transition programs, psychi- Melnick redesigned factory workstations in St. Paul and
atric treatment centers, programs for the elderly, educa- Philadelphia [and] Minnesota Power went from having
tional systems, and home environments.”* The AOTA 10 or 12 back injuries a year to being cited by the Min-
statement provides guidelines for the provision of indi- nesota Safety Council for 1 million work hours without
vidual OT services to achieve goals in work disability a ‘medical attention back injury’”** Another successful
prevention and management programs. model was described by Hanson,’’ who reported on an
AOTA has also published a resource titled Preventing ergonomic intervention program in a Florida acute care
and Treating Carpal Tunnel Syndrome,?>* with clear de- hospital, with occupational therapists playing a central
scriptions and illustrations that can be helpful for con- role. The occupational therapist conducted work site
sumer education. Topics include description of the syn- analyses for injured workers and recommended im-
drome, testing methods, and exercises and tools to provements for the work environment. Patient handling
remediate and help prevent carpal tunnel syndrome. A was found to be the highest risk factor for sustaining
list of risk factors includes maintaining a constant grip work-related injury. New ergonomic patient lifting and
on tools, working in a cold environment, performing transfer equipment was purchased, and the occupa-
highly repetitive jobs, using poor body mechanics, and tional therapist was involved in training nurses in use of
working at a keyboard for extended periods. A variety of the equipment and evaluating their responses. OT plays
treatment techniques are explored, such as use of heat, a key role in assessing work tasks in this setting and of-
stretch, joint mobilization, edema management, and fering environmentally sound improvement options.
splinting. Although geared for the individual, informa- King and colleagues~° describe OT preventive interven-
tion in this resource may be used effectively in corporate tion for workers in a child care program. Carayon and
education and prevention programs. Smith” provide a thorough literature review and practi-
Corporate interest in establishing fitness and injury cal guidelines to prevent strain in computerized work-
prevention programs has increased, and the cost of places, and Claiborne and Williams”® illustrate the im-
self-insurance and reduction of purchased insurance portance of addressing the person, environment, and
have been influential.” The Occupational Safety and task performance fit when providing ergonomic com-
Health Administration (OSHA) proposal to set work- puter workstations for individual clients.
place ergonomic standards has stimulated many corpo- Ergonomics in the workplace will take on a new di-
rations to increase services. New standards would mension in the near future. In addition to expanding
 Occupational Therapy for Prevention of Injury and Physical Dysfunction

involvement of the elderly population in the workforce, cultural, community-dwelling elders... . The treat-
a much greater percentage of the disabled population ment ... emphasized the therapeutic process of
will be employed than ever before, as a result of recent lifestyle redesign in enabling the participants to actively
initiatives. The Wisconsin-based “Pathways to Indepen- and strategically select an individualized pattern of per-
dence” is the largest of the 12 federally funded state sonally satisfying and health promoting occupations.”**
programs designed to support employment of indi- The 361 participants were randomly assigned to three
_ viduals in four disability groups: physical disabilities, study groups for 9 months. The first group received pre-
mental illness, developmental disabilities, and acquired ventive OT, the second group was involved in a social
immune deficiency syndrome/human immunodefi- activities program led by nonprofessionals, and the
ciency virus (AIDS/HIV). This complex pilot program is third group served as the control group and did not
designed to eliminate the most significant barriers to receive any services. The OT intervention included a 2-
employment that result from public support policies. hour weekly group session involving 8 to 10 partici-
More than 6.6 million Americans have a permanent dis- pants. This was supplemented by a 1-hour monthly
ability and receive income support from Social Security individual session with the therapist. The aim of treat-
Disability Income (SSDI) or Supplemental Security ment was to reduce the health risks of older adulthood,
Income (SSI). Less than 1% of SSI or SSDI beneficiaries and the participants were encouraged to use occupation
leave those programs each year as a result of paid em- in a personalized way to adapt to their specific chal-
ployment. Beneficiaries claim that one of the most im- lenges associated with aging. The program consisted of
portant barriers to paid employment is the potential a series of eight “occupational self-analysis” content
loss of Medicaid and Medicare. These individuals areas, which included the following:
cannot afford to work because under current policies 1. Introduction to the power of occupations reviewed the
their coverage is jeopardized if they earn more than physical, social, emotional, cognitive, and temporal
$500 per month for 9 months. Pathways to Indepen- meaning and ritual dimensions of occupations. This
dence will provide these individuals with a clear-cut was related to the way in which participants’ occupa-
guarantee of continued health coverage and will also tional choices affected their past, present, and future
provide comprehensive assistance in achieving their experience of well-being.
employment goals.'° The program is designed to in- 2. Aging, health, and occupation explored expanded con-
crease tax revenues through the employment of large cepts of health and wellness and involved a self-
numbers of disabled individuals. The implications for analysis. Elders generated their own list of “25 Ways
the therapist are enormous, since these individuals to Stay Healthy,” in which participants included such
could benefit greatly from the OT services in the work- divergent elements as amusement, creation of love
place. The OT profession must monitor these national and support, maintenance of a positive mind-set, ex-
trends as they emerge to ensure optimum deployment ercise, and diet. Various tools were introduced to
of OT services, including prevention. improve health, such as skill development in reading
nutritional labels, games and puzzles for mental
alertness, and the ROM Dance that is described later.
RESEARCH ON OCCUPATIONAL THERAPY
The coordinator of the USC Well Elderly Study said,
PREVENTION PROGRAMS “We chose to use the ROM Dance for our program
One of the goals of the AOTA is to facilitate research on because the technique is framed within the context
the efficacy of OT services, including preventive inter- of occupation. The music and visual imagery encour-
vention programs. Although the OT literature reveals a aged relaxation, and we found the gentle movement
range of OT prevention programs, two are highlighted to be especially helpful for seniors with arthritis.”**
in this chapter because they focus on primary and sec- Many participants discovered new occupations (e.g,,
ondary prevention with targeted adult populations who using public transportation) or reinitiated old ones
may be at risk for injury and physical dysfunction. (e.g., table tennis). The focus of this content area was
to position the participant “to begin to thoughtfully
weave his or her occupations into a coherent, per-
Well Elderly Study Occupational Therapy sonalized health promoting pattern.”**
Program 3. The transportation content area helped participants
One of the most notable occupational therapy efficacy explore their individualized obstacles and inhibitory
studies of the 1990s was a rigorous experimental test of fears and assisted them in gaining a broader knowl-
a preventive occupational therapy intervention.'* The edge, experience, and skill base to help them develop
University of Southern California’s Well Elderly Study an image of themselves as urban travelers.
Occupational Therapy Program was “found to be highly 4. Safety education included videos and lectures on
successful in enhancing the physical and mental health, crime prevention and the actual practice of commu-
occupational functioning, and life satisfaction of multi- nity protection techniques during the OT outings.
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

Home safety stressed prevention of falls and burglary, simplification, splints, and coping techniques. Long-
and each participant conducted a personal home term efficacy studies demonstrated the therapeutic
evaluation and experimented with techniques and effects of the ROM Dance Program for ambulatory
equipment to improve safety and body mechanics. adults with rheumatoid arthritis.4°”°
5. The social relationships content area covered changes The ROM Dance is an example of a preventive inter-
caused by loss, relocation, or disability and the effect vention technique that can be incorporated easily into
of the changes on occupational routines. Program in- clinical practice. Since its creation the ROM Dance has
volvement facilitated the expansion.of participants’ been used with and adapted for adults and children
social relationships. with a wide variety of painful or limiting conditions. A
6. Cultural awareness allowed participants to open new series of video and audio tapes have been developed to
doors of cross-cultural understanding within the facilitate ease of use. In addition to the original Sunlight
context of occupation. The intent of this was to version, tapes are available for the Seated ROM Dance,
address the unexpected outcome of a preliminary adapted for those who use wheelchairs, and the Moon-
study detailing the extent to which interpersonal light Version, adapted for those with lupus and sun sen-
clashes between elderly members of different ethnic sitivity. A reclining version is under development for in-
groups impeded healthy living. This content area in- dividuals confined to bed. Harlowe and Yu’*’'” provide
cluded outings to multicultural museums, celebra- lesson plans for teaching the ROM Dance in a series of
tion of holidays, meals, music, and even elevator health education classes, and Johnson, Searles, and Mc-
etiquette. Namara~ provide a detailed description for use in
7. Finances included exploration of how to optimize oc- home health. The text, video tape, and audio tape re-
cupational experiences and enjoyment of life on a sources are designed for self-instruction, and continuing
marginal income. education programs are also available for OT practition-
8. The Integrative Summary: Lifestyle Redesign Journal ers. These resources assist in using the ROM Dance
allowed each participant to crystallize his or her oc- throughout a continuum of care, as well as throughout
cupational analysis by creating a book of ideas, pic- the management of a disease.
tures, and memories gathered during the 9-month
program. It was hoped that the book would con-
FUTURE INITIATIVES IN PREVENTION
tribute to long-term retention of the occupational
knowledge and adaptive patterns participants had AOTA is acting to increase future roles for OT in preven-
attained. tion. One example is in the area of prevention of youth
The results of the study showed that the elders who violence, an increasingly important risk factor for in-
received OT exhibited fewer declines in physical health, juries that result in physical dysfunction. A paper titled
physical and social functioning, vitality, mental health, Occupational Therapy's Role in Preventing Youth Violence'*
and life satisfaction than those assigned to the non- reviews the scope of the problem and the qualifications
professionally led activity or control groups. These fa- of OT practitioners to play an important role in preven-
vorable outcomes led to the conclusion that preventive tion. Since youth violence is currently considered a
OT is capable of reducing the health risks of older adult- grave public health problem in the United States, con-
hood, including the primary risk of physical dysfunc- siderable funding has been earmarked for the develop-
tion.”? ment, implementation, and research of programs that
target prevention of youth violence. One of the many
ways that AOTA is addressing this issue is by seeking
Maintaining Physical Mobility:
funding to evaluate OT’s role in the implementation of
The ROM Dance Program
the program described below.*!
The ROM Dance Program (Fig. 8-1) is a preventive ex-
ercise and relaxation intervention that was created in
Prevention of Youth Violence:
1981 by Diane Harlowe and Tricia Yu. The 7-minute
ROM Dance incorporates whole-body range of motion
FAST Program
with the movement principles of T’ai Chi Ch’uan. It is One highly successful, activity-based program that is well
performed while listening to soothing music and lyrics suited for involvement in and referral to by OT practi-
that employ the archetypal images of healing: warm tioners is titled Family and Schools Together (FAST). This
water, sunlight, and friendship. The ROM Dance was well-researched program was created by Lynn McDonald,
created as one of the three main elements of a preven- MSW, PhD, in 1988 and was showcased at the 1998 White
tive arthritis education program. The program consisted House Conference on School Safety. FAST addresses
of eight weekly 90-minute sessions that also included youth violence by enhancing relationships with families,
relaxation and pain management techniques and edu- peers, teachers, school staff, and other members of the
cation on joint protection, energy conservation, work community. The program is a secondary prevention
FIG. 8-1
Therapist instructing ROM dance. A, Dance instructed to a group. B, Assisting a client with align-
ment. (Photos by William J. Fritsch.)
«= OCCUPATIONAL THERAPY PROCESS AND PRACTICE

strategy for children ages 4 to 14 who have been identified parental power; playing responsively to create ‘goodness
as at-risk through a school-based screening. The intent is of fit/ and supporting the child’s delayed gratifica-
to intervene early to prevent children from dropping out tion.”** During involvement in the entire program,
of school and becoming delinquent or violent. After 10 parents spend 15 minutes a day in special play and peer
years of development and research, FAST was available in support. Thus the program successfully affects the fami-
more that 450 schools in 31 states and 5 countries. Cur- lies’ habituation systems (see Model of Human Occupa-
rently, it is also being provided to all interested families in tion in Chapter 1), which may be one of the main
three inner-city schools in Chicago and to a Native Amer- factors contributing to its success.
ican tribe on a reservation in Wisconsin. A wide variety of The third element of the program begins after fami-
funding sources have supported the program's cost per lies graduate from the weekly sessions and join an
family of $1,200 for 86 hours of service delivered in over ongoing, school-based collective of families who meet
30 sessions over a time span of 2 years.*° once a month for 2 years. This provides ongoing oppor-
FAST is composed of three main elements: identifi- tunities for community building and networking, which
cation and outreach, multifamily activity sessions, and are valuable protective factors.
ongoing, monthly parent-run meetings for 2 years. The efficacy with which this program uses activities
During the outreach phase, an experienced FAST parent to build protective factors for at-risk youth warrants at-
is paired with a professional to visit homes of identified tention and involvement from OT practitioners who
children and their primary caretakers, who are often iso- may, in turn, enhance the intervention. Studies on eval-
lated and stressed and have a low income. The entire uation of the effect of FAST on youth functioning
self-defined family is invited to join 10 to 15 other fam- include measures for conduct disorder and anxiety and
ilies for 8 to 10 weekly group meetings that comprise withdrawal (factors identified as underlying mental
the second element of the program. Group sessions are health correlates predictive of violent behavior). One
composed of carefully crafted, structured, interactive ac- study involving 104 FAST children showed a statistically
tivities that are repeated each week to establish ritual. significant reduction in measures for both conduct dis-
Activities include: order and anxiety withdrawal from the pretest to the
1. A FAST welcome and creation of a family flag di- posttest.°* In another study of 197 children, parents
rected by the parent and teachers reported statistically significant reductions
2. A meal where the parent delegates a child to serve of behaviors reflecting conduct disorder and anxiety
their family withdrawal.*' In the aforementioned studies, improve-
3. A family drawing and talking game where the parent ments were also shown in measures for attention span,
ensures each family member has a turn and inquires socialized aggression, and motor excess. Six-month and
positively about others 2-year follow-up data suggest that gains were main-
4. A “feeling charades” game with the parent directing tained over time.*° These results demonstrate FAST’s ef-
family members to “act out” or guess from selected fectiveness at reducing behaviors that can contribute to
feeling cards poor functioning in the school, social, and home envi-
5. Peer activities such as buddy time followed by a ronments where youth violence is apt to occur.
parent self-help group that builds an informal social
support network in age-appropriate groupings
6. Parent-child special play time during which the
SUMMARY
parent is nondirective and nonjudgmental, follow- OT prevention activities have expanded steadily during
ing the child’s lead for 15 uninterrupted minutes, the past four decades. Possibilities for continued growth
with active coaching from the FAST team in this area are greater than ever before. Contemporary
7. A fixed lottery and meal preparation with each health care values are more firmly rooted in prevention,
family highlighted as a “big winner,” then responsi- and occupational therapists are demonstrating the value
ble for cooking the meal the next week, thus encour- of the profession’s unique approach to intervention.
aging reciprocal and respectful support With predictable and ongoing shifts in funding mecha-
8. A closing circle and final ritual to build traditions nisms, identifying opportunities to meet the needs of
across families and community members. . .*” potential client populations will continue to be a chal-
Structured into these activities are opportunities for lenge. Nevertheless, history predicts the future, and the
families to “behaviorally rehearse requests for compli- adaptability and creativity inherent to the OT thought
ance from the child in gradually more complex behav- process will help in expanding the scope of OT preven-
iors without using coercion; organizing family commu- tion services in the decades to come. Accidents and ac-
nication through systematic turn-taking with positive tivities that cause injury and physical dysfunction occur
inquiry; repeated observation, identification, expression within the context of occupation, and prevention will
and labeling practices of eight basic emotions among continue to be a major focus of concern for occupa-
family members; appropriate use and delegation of tional therapy.
 Occupational Therapy for Prevention of Injury and Physical Dysfunction

8. Cancio LI, Cashman TM: Self-reported cumulative trauma symp-

REVIEW QUESTIONS toms among hospital employees: analysis of an upper-extremity
symptom survey, Am J Occup Ther 53(2):227-230, 1999.
. How does clinical reasoning facilitate the identifica-
. Carayon P, Smith RO: Physical and mental strain in computerized
tion and provision of OT preventive intervention workplaces: causes and remedies. In Rothman J, Levine R, editors:
for clients receiving OT services? Prevention practice: strategies for physical therapy and occupational
Describe disability prevention in OT. therapy, Philadelphia, 1992, WB Saunders.
AeWhy would the provision of instruction in joint 10. Claiborne D, Williams K: Cost-effective ergonomics, OT Practice
September 1998, pp 47-48.
protection and energy conservation to a client with
He Clark F, Azen SP, Zemke R, et al: Occupational therapy for inde-
inflammatory rheumatoid arthritis be classified as pendent-living older adults: a randomized controlled trial, JAMA
secondary prevention? 278:1321-1326, 1997.
. What is the first step in planning for the prevention 12; Cook A, Miller PA: Prevention of falls in the elderly. In Larson KO,
of secondary conditions for OT clients who have a Stevens-Ratchford RG, Pedretti L, et al: ROTE: the role of OT with
the elderly, ed 2, Bethesda, Md, 1996, American Occupational
physical disability?
Therapy Association.
Summarize the main points of the “Health Belief 13. Czaja SJ: Safety and security of the elderly: implications for smart
Model,” and describe how these issues affect the house design, Int JTechnol Aging 1(1):49-48, 1988.
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 @ah cela bom @laqulpy-Vereyer-VaaWelate-}
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LEARNING OBJECTIVES
Activity analysis After studying this chapter the student or practitioner
Activity adaptation will be able to do the following:
Activity synthesis 1. Identify a variety of situations in which occupational
Training versus learning therapists analyze, adapt, and synthesize activities.
Skill acquisition 2. Discuss specific outcome goals for which
Skill retention occupational therapists teach activities.
Skill generalization 3. Distinguish between training and learning in terms
Closed tasks of therapeutic goals and intervention strategies.
Open tasks 4. Analyze how therapeutic interventions will differ,
Procedural versus declarative learning depending on the various types of learning
Implicit and explicit learning processes processes a client needs to develop.
Strategy 5. Apply current knowledge about factors that
Metacognition influence the teaching-learning process to
Intrinsic and extrinsic feedback occupational therapy interventions.
Knowledge of performance feedback 6. Implement occupational therapy treatment
Knowledge of results feedback designed to promote active strategy development.
Contextual interference 7. Provide appropriate instruction, feedback, and
Blocked and random practice schedules practice tailored to individual tasks and client goals.
Whole versus part practice 8. Promote generalization of learning to real-life situations
Practice context through effective approaches to teaching activity.

ACTIVITY: A CRITICAL COMPONENT 3. Synthesize activities

OF OCCUPATIONAL THERAPY 4. Teach activities
INTERVENTION
Activity Analysis, Adaptation,
Occupational therapists are activity experts. Regardless
of diagnosis or treatment setting, enhanced activity per-
and Synthesis
formance is an ultimate goal of occupational therapy Occupational therapists perform an activity analysis for
(OT) intervention. In addition, activity performance the activities that clients are required or wish to perform.
often serves as a tool in the intervention process to help One reason for such analysis is to determine an activity’s
clients meet their OT goals."® long-range effect on the client's health. A detailed assess-
In the context of intervention for clients with physical ment of an activity’s ergonomic effects on musculoskele-
disabilities, occupational therapists do the following: tal function enables the therapist to recommend or in-
1. Analyze activities stitute appropriate adaptations to the environment and
2. Adapt activities the procedure in order to prevent repetitive stress
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

injuries. Analysis of an activity’s energy requirements individual's ability to remember procedures and pre-
provides a foundation for adaptations designed to max- cautions associated with tasks of daily living, occupa-
imize the client's cardiovascular and muscular en- tional therapists reteach familiar activities.
durance capabilities. New ways of performing familiar activities are taught
A second reason occupational therapists analyze ac- to clients with a wide spectrum of illnesses, injuries, and
tivities is to determine the extent to which specific per- disabilities. Often, these new procedures are taught to
formance components are needed. After this analysis help clients compensate for short- or long-term per-
the therapist determines which performance compo- formance component impairments or restrictions. In
nent deficits are contributing to the client's difficulties other situations the new procedures are designed to
performing selected activities in specific contexts. Next, enhance the activity’s safety for clients with specified
the therapist determines the client's potential to risks or vulnerabilities. An office worker is taught new
improve these performance components. If there is real- strategies for using her computer to prevent repetitive
istic potential for improvement, the occupational thera- stress injury and reduce musculoskeletal pain. A client
pist develops a program to improve the performance recovering from coronary bypass surgery learns new
components. The ultimate goal is that the client will use ways of performing familiar activities to minimize car-
the enhanced skills and be able to perform the identi- diovascular demands. After hip replacement surgery a
fied activities, as well as a myriad of unanticipated tasks. client learns alternative methods that allow him or her
At times a review of medical data and evaluation to continue performing daily tasks within the con-
findings indicates a low potential for improvement in straints of temporary orthopedic contraindications. A
an identified performance component. In these situa- client with balance impairments caused by neuromus-
tions occupational therapists teach performance of se- cular disease learns to perform upright activities in ways
lected activities with adaptations that enable individu- that will minimize the risk of falls.
als to engage in desired occupations despite continuing Occupational therapists teach new activities for
limitations in performance components. meeting medical or therapeutic goals. Persons with
Activity adaptation is the modification of well-recog- newly acquired disabilities and illnesses need to learn
nized tasks. Occupational therapists are skilled at adapt- activities that were not in their previous repertoire of re-
ing the context, materials, or rules of familiar activities quired tasks. Often they must learn to perform these
to achieve two general goals. First, therapists adapt ac- tasks within the constraints of performance component
tivities to make performance easier or safer, based on limitations. Such activities range from managing a
knowledge of individual clients’ available performance bowel and bladder routine after spinal cord injury to
components and health risks. Second, therapists adapt self-administering insulin injections with hemiparesis.
activity features when activity engagement is designed Performing home exercise routines, managing personal
as a therapeutic challenge to help the client develop im- care attendants, maneuvering a wheelchair, using assis-
proved function in selected performance components. tive technology, and donning orthotic devices are other
Activity synthesis is the development of new and examples of these activities.
often unfamiliar activities. As with activity adaptation, Finally, occupational therapists teach activities that
occupational therapists synthesize new activities for two will serve as therapeutic challenges to help individuals
general purposes. First, a newly synthesized activity may improve performance components. Before engaging in a
be designed to create a unique option for accomplish- board game that will elicit repetitive, resisted muscle
ing a given occupation or satisfying specific rule require- contractions, the client who is recovering from a periph-
ments. Second, synthesized activities such as short-term eral nerve injury needs to learn how the activity should
games or novel challenges provide therapeutic opportu- be performed. The therapist teaches the client how to
nities for clients to practice meeting performance com- position his or her body, the game board, and the game
ponent goals. pieces so that the activity will have the maximum thera-
Students and therapists who are reading this text have peutic impact. Before beginning a kitchen activity that
already learned the foundations of activity analysis, has been designed to provide balance and cognitive chal-
adaptation, and synthesis in previous OT course work. lenges to a client coping with residual impairments from
The goal of this chapter is to introduce principles and a brain injury, the therapist teaches the client the salient
guidelines to enhance the effectiveness of teaching activ- features of the therapeutic task. This may include adapta-
ities in the context of occupational therapy intervention. tions that enhance the activity’s relevant challenges to
the client's performance components, as well as strategic
When and Why Occupational Therapists recommendations for maximizing performance.
Teach Activities When occupational therapists teach activities, the ul-
timate goal is functional task performance. At the very
A significant portion of OT intervention entails teach- least this requires that the client learn to perform the ac-
ing activities. When cognitive impairments limit an tivity outside of the treatment setting and apart from the
 Teaching Activities in Occupational Therapy

therapist's supervision. The goals of teaching will vary, evidence that skill acquisition and retention can be trans-
depending on the severity of each individual's physical ferred to contexts other than the training situation.”’7"**
and cognitive limitations. If caregiver supervision will Frequently, the OT goal is that a client will generalize,
always be needed, it is the therapist's responsibility to or transfer, skills learned in the therapy setting and use
include caregivers in the process of activity learning. For them in multiple real-life contexts. Several principles
clients who expect to resume independent function, the presented later in this chapter guide the therapist's
therapist's teaching methods must ensure generaliza- teaching. strategies when generalization of learning is
tion of learning to a variety of contexts and related tasks. the outcome goal.
Furthermore, a successful occupational therapist uses
learning principles that are appropriate to meeting the Gentile’s Taxonomy of Task Categories
selected goals. One scheme for classifying activities is based on two di-
mensions of task-related environmental features. First,
the supporting surfaces and task objects may be either
PRINCIPLES OF TEACHING ACTIVITY
stationary or in motion. Second, the environmental fea-
Occupational therapists structure the environment, the tures may vary between one performance of the task to
task goals, and interactions with each client to maxi- the next or remain unchanged between trials.* Occupa-
mize the teaching-learning process (Fig. 9-1). tional therapists can use this task classification system to
guide the choice of teaching strategies.'°
The use of repetitive practice (training) as a strategy
Types of Learning Processes
for learning is effective only with closed tasks, or activi-
Training Versus Learning Outcomes ties in which the supporting surfaces and task objects
The goal of training is for the client to memorize a pre- are stationary and do not vary between performance
scribed solution to a selected task challenge, whereas trials. Most daily activities, however, necessitate adapta-
the goal of learning is for the client to develop his or tion to changing environmental conditions in different
her own solution, which can be applied in a variety of situations and at different times. In Gentile’s taxonomy,
situations.’ Based on each client's abilities and role these are categorized as variable motionless tasks. For
demands, the occupational therapist determines example, motor requirements for drinking beverages
whether the teaching goal will be to promote training or will vary, depending on the type of mug, cup, or glass
learning. Both training and learning entail skill acquisi- that is used, as well as on how much the container is
tion and skill retention (Table 9-1). filled. Independent dressing requires that a person
Skill acquisition occurs during initial instruction achieve mastery over putting on clothing of varying
and practice. Skill retention, which is demonstrated styles, dimensions, and fabrics.
after the initial practice session, is often referred to as Open tasks are characterized by an unpredictable
carryover. A major distinction between training and motion of supporting surfaces or task objects during
learning is that skill generalization is an outcome of task performance. These activities necessitate the appro-
learning, but not of training. When the occupational priate timing of responses, as well as spatial anticipation
therapist chooses a training approach, task practice of where relevant objects will be moving. For example,
must occur in the actual setting in which the individual when sitting in a moving train, a passenger must main-
plans to perform the task. Unless the person actively tain balance when the supporting surface is moving un-
develops a personal performance strategy, there is no predictably. When crossing a street, an individual must
anticipate the speed and rhythm of both pedestrians
and oncoming traffic. When playing most ball games,
competitors must predict the speed and direction of the
Environment Task ball to position themselves in the right place at the right
time. Research has shown that the skills required for

SkillDevelopment
Training Learning
Client-Therapist Interactions Stage one: skill acquisition Stage one: skill acquisition
Stage two: skill retention Stage two: skill retention
Fig. 9-1 Stage three: skill generalization
Teaching-learning process in occupational therapy.
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

successful open-task performance cannot be learned Factors That Influence the Teaching-
through repetitive practice in a stationary environment.° Learning Process
The literature about skill development presents several
Procedural Versus Declarative Learning
A popular categorization of memory~* has been concepts that are helpful in guiding occupational thera-
adapted” to represent the degree to which awareness, pists when teaching activities to clients (Box 9-1).
attention, or other cortical processes are used during
skill acquisition, retention, and performance. Declara- Learner's Active Participation
tive learning is needed for tasks in which language Learning is an active process. Although passive interven-
skills are used to organize and practice complex se- tions such as massage or physical manipulation may be
quences of action. Learning a new recipe or a multistep useful procedures for achieving some OT goals, they do
dance routine may require that a person be able to con- not contribute to the learning process. Clients are most
sciously express the processes to be performed. Mental likely to learn new skills when they are active partici-
rehearsal is an effective technique for enhancing declar- pants in setting and clearly understanding the outcome
ative learning. During mental rehearsal the individual goals. When declarative learning is the appropriate
practices the sequence by reviewing it silently or articu- mechanism for both the task and the client, it may be
lating the process orally or in writing. helpful for the therapist to periodically ask the client to
Procedural learning is accomplished without a sig- rephrase the objectives and procedures for task perform-
nificant language component and is effective when ance.
learning tasks that are typically performed automati-
cally. Procedural learning is developed through task Strategy Development
practice in a series of varying contexts. An individual Strategies are organized plans or sets of rules that
learns to maneuver a wheelchair through a process of guide action in a variety of situations.’ Motor strategies
procedural learning. Verbal instruction alone is of little include the vast repertoire of kinematic and kinetic link-
value. Rather, a person learns the procedures for per- ages that underlie performance of skilled, efficient
forming this novel motor activity through opportuni- movement. Cognitive strategies include the multiple and
ties, while sitting in the wheelchair, to experiment with varied tactics people use to facilitate processing, storage,
different combinations of arm or arm and leg move- retrieval, and manipulation of. Interpersonal strategies
ments to achieve propulsion in a variety of directions help in social interactions with other individuals.
and speeds. It is the occupational therapist's responsi- Coping strategies allow people to adapt constructively to
bility to determine whether procedural or declarative stress.
learning is most appropriate for each specific goal and Strategies provide individuals with foundational
individual. skills that can be adapted to the ever-changing demands
of occupations within the infinite variations of multiple
Implicit Versus Explicit Learning Processes environments. Thus learning is more likely to be gener-
Gentile* proposes that individuals use two distinct but alized to new situations when people are given oppor-
interdependent processes during the acquisition of tunities to develop foundational strategies.*" People
functional motor skills. An explicit learning process, develop strategies through a process of encountering
which is consciously driven, guides the kinematics of problems, implementing solutions, and monitoring the
the movement. Gentile hypothesizes that people use an effects of these solutions. Occupational therapists use
explicit process to develop a “ballpark” match between
the shape or direction of their movements and the envi-
ronmental requirements for achieving the goal. External
feedback is likely to have a beneficial effect on the ex- at Support Generalization
plicit learning process.
An implicit learning process guides the kinetics of
the movement, or the dynamics of force generation.
This aspect of movement requires appropriate selection Active participation
of muscle contraction patterns, determined by accurate Strategy development
Externally focused instruction
predictions of how external forces will affect the move-
Intrinsic feedback
ment. Gentile hypothesizes that “the refinement of
Practice conditions
force dynamics is due to a self-organizing process of im- Contextual interference
plicit learning.”* This self-organizing process may take Random practice schedules
longer to develop than explicit learning. Furthermore, Naturalistic contexts
implicit learning lies beyond conscious awareness and Whole-task practice
is unlikely to be augmented by external feedback.
 Teaching Activities in Occupational Therapy

activities to help clients develop useful strategies by internal focus) are less effective than instructions related
structuring tasks, within a safe environment, that to the effect of a performer's action on the environment
provide individuals with opportunities to try out differ- (an external focus). Occupational therapists are particu-
ent solutions to the challenges that arise.'* larly skillful at structuring therapeutic tasks so that a
Self-awareness and self-monitoring skills are critical critically selected effect of a movement, rather than a
prerequisites to a person’s ability to generate and apply feature of the movement itself, becomes the instruc-
appropriate strategies. Metacognition is the knowledge tional focus. For example, when the performance com-
and regulation of personal cognitive processes and ca- ponent goal is to promote scapular abduction to
pacities.* It includes an awareness of personal strengths improve the efficiency of forward reach, better out-
and limitations and the ability to evaluate task diffi- comes are achieved when clients with traumatic brain
culty, plan ahead, choose appropriate strategies, and injury are instructed to externally focus on reaching to
shift strategies in response to environmental cues. control a game panel, as compared with when they are
Toglia’s dynamic interactional model**”* for indi- instructed to internally focus on how far they can reach
viduals with cognitive impairments after brain injury an arm forward.*° Similarly, Nelson and colleagues”
emphasizes the importance of metacognition. Self- have shown that treatment designed to improve coordi-
review of performance and guided planning for tackling nated forearm pronation-supination is more effective in
the challenges of future tasks are key factors in the ther- stroke rehabilitation when clients are instructed to ex-
apeutic process. ternally focus on turning an adapted dice-thrower in the
Although metacognition is typically discussed in re- context of a game, as compared with when they are in-
lation to improving cognitive skills, self-awareness and structed to internally focus on the movement itself. Wu
monitoring of relevant performance components may and colleagues*’ found that intervention to improve
be equally important prerequisites to developing effec- symmetrical posture in adults with hemiplegia had sig-
tive motor, interpersonal, and coping strategies. Specifi- nificantly better outcomes when an external focus of at-
cally, intervention directed toward helping clients tention, integrated into wood sanding and bean bag
develop enhanced awareness of body kinematics and toss games, was elicited by the activity synthesis and
alignment may be an important component to motor therapeutic instruction.
learning.’
Feedback
Instruction Feedback, or information about a response,’* can be in-
Therapeutic instruction provides cues that orient the trinsic or extrinsic, concurrent or terminal, and can
client to selected performance guidelines. Instruction can provide knowledge of performance or results. Intrinsic
be presented verbally, visually, or tactokinesthetically. feedback is a result of an individual's proprioceptive,
Verbal instruction related to activity performance may tactile, vestibular, visual, and auditory sensory systems.
be most useful when words are kept to a minimum. Par- A person learning to use a computer keyboard first uses
ticularly when clients exhibit language or other cogni- visual feedback to see if his or her fingers are positioned
tive impairments, excessive banter from a therapist may properly and if he or she is depressing the correct keys.
distract clients from attending to relevant visual and so- Quickly, the individual progresses to relying on tactile
matosensory cues from the environment and from their and proprioceptive feedback about finger alignment
own bodies. and keystrokes. This frees the individual to look at the
Visual instruction may be provided through the thera- manuscript while typing.
pist’s own performance of the task. In addition, photo- Extrinsic feedback is information from an outside
graphs and line drawings provide powerful visual cues source. The typed manuscript, as projected on the
about optimal postural alignment or the appropriate se- monitor or printed on hard copy, provides extrinsic
quence required for task performance. feedback about the results of the typist’s actions.
Somatosensory instructions provide cues through tactile Another person can provide extrinsic feedback about
and kinesthetic channels. Manual guidance? is often an task performance by giving information to the typist
effective technique for providing specific instructions about body alignment, hand positioning, and key selec-
about the recommended direction and speed (kinemat- tion. Although extrinsic feedback may be helpful early
ics) of a functional movement. Manual guidance may in the learning process, the typist will achieve greater in-
be more effective than verbal or visual instructions dependence and efficiency in computer activities by de-
when procedural, rather than declarative learning, is the veloping the ability to continue learning through intrin-
outcome goal. sic, rather than extrinsic, feedback.
Regardless of the sensory channel, instructions for Occupational therapists often work with clients
learning may elicit either an internal or an external whose sensory recognition or processing abilities have
focus of attention.*® A considerable amount of research been impaired. In these situations, extrinsic feedback
evidence’®*”® suggests that body-related instructions (an from a therapist or technological device can provide
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

useful supplementary information to facilitate early performance during the retention and _ transfer
awareness and learning. stages.'”*° Similarly, bandwidth KR, in which feedback
Therapists need to remember that inaccurate feed- is provided only when the performance response is
back provides confusing information to clients about outside a given range of acceptable performance, leads
the outcome of their attempts at task performance. Clear to better generalization of learning.*° Schmidt'® hy-
differences between praise for effort and positive verbal pothesizes that, when limited KR is provided during ac-
feedback about performance must be established. quisition, individuals are forced to rely on relevant cues
Technological feedback mechanisms include elec- provided by intrinsic mechanisms to improve their per-
tromyographic and electrogoniometric biofeedback formance on future trials. Thus they tend to depend less
systems, as well as digital displays of pertinent kinetic or on extrinsic feedback.
cardiovascular data on computerized exercise equip- How can occupational therapists help clients develop
ment. These feedback systems provide information that effective intrinsic feedback mechanisms? First, thera-
is more timely, more consistent, and more accurate than pists can provide clients with effective models of action”
feedback from a human therapist. However, true gener- and awareness of what proprioceptive and tactile feed-
alization of learning can never occur unless a person back should accompany appropriate performance
learns to generate and respond to intrinsic feedback. strategies. '* Therapists can achieve this with clear visual
Therefore, extrinsic feedback must be gradually de- and proprioceptive instruction through manual guid-
creased if the client's goal is independent performance ance, visual modeling, and understandable figures or
in a wide variety of unanticipated task situations. photographs. Next, therapists can provide clients with
Concurrent feedback, provided in an ongoing active opportunities to perform tasks under varying
fashion during task performance, may be intrinsic or ex- contextual conditions. In addition, therapists strive to
trinsic. Terminal, or summary, feedback is given after achieve a balance between providing extrinsic feedback
task completion. There are no published studies that and requiring that clients continually assess their own
compare the effectiveness of concurrent and terminal performance. Finally, therapists help clients actively set
feedback. their own goals and determine strategies for improving
future task performance.
KNOWLEDGE OF PERFORMANCE AND KNOWL-
EDGE OF RESULTS. Knowledge of performance Practice Conditions
feedback (KP) is information about the processes used Practice is a powerful component of the occupational
during task performance.’ Performance factors of inter- therapy process. The ways in which a therapist structures
est to occupational therapists include kinetic and kine- the practice conditions can influence a client's success in
matic components of movement, as well as specific cog- meeting performance goals.
nitive and interpersonal strategies. KP may play a role in
dynamically guiding performance as it occurs. Knowl- CONTEXTUAL INTERFERENCE. Contextual in-
edge of results feedback (KR) is feedback about the terference refers to factors in the learning environ-
outcome of an action in terms of accomplishing an in- ment that increase the difficulty of initial learning.
tended goal.’ KR can serve as a basis for more effective Limited KR is one example of contextual interference
performance in future trials. In the computer keyboard that has already been discussed. As shown by studies
example presented earlier, KP was illustrated by the of KR, these factors tend to promote more effective re-
typist’s intrinsically generated information about finger tention and generalization. One explanation for this
alignment and keystrokes, as well as by the extrinsically finding is that a high level of contextual interference
generated feedback about these performance factors forces a person to “use multiple and variable processes
that was provided by another person. KR was illustrated to overcome the difficulty of practice.”?? Furthermore,
by the information about typing accuracy, as provided people develop more elaborate memory representa-
by the soft copy or print version of the text the typist tions of the underlying strategies that were used for
produced. Typing speed, measured in words per minute, task achievement during the acquisition phase of
also provides KR. learning.
Extrinsic KR has been more widely studied than KP;
however, most published research has been related to BLOCKED AND RANDOM PRACTICE SCHED-
normal subjects performing contrived tasks in labora- ULES. Blocked and random practice schedules are ex-
tory settings. Results of laboratory research with normal amples of low and high contextual interference, respec-
subjects supports the view that intrinsic feedback is tively. During blocked practice, clients practice one task
more critical than extrinsic feedback to skill generaliza- until they master it. This is followed by practice of a
tion. Studies have shown that frequent, accurate, imme- second task until it is also mastered. In random prac-
diate KR tends to promote improved performance tice, clients attempt multiple tasks or variations of a task
during the acquisition phase of learning, but poorer before they have mastered any one of the tasks. A
 Teaching Activities in Occupational Therapy

random practice schedule may be used in an OT purposes of activity-based intervention are to enhance
program designed to teach wheelchair transfer skills. specific activity performance and help clients improve
The client is introduced to several transfer situations performance components that will enable them to
and asked to practice each of them during the course of perform a vast number of anticipated and unanticipated
a single session. For example, the client will practice tasks. Occupational therapists reteach familiar activities,
moving between the wheelchair and a therapy mat, teach new ways of performing familiar activities, teach
_ between wheelchair and chair, and between a toilet and new activities for meeting therapeutic goals, and teach
the wheelchair. Blocked practice schedules are generally activities that will serve as therapeutic challenges to help
chosen when training is the long-term goal. However, clients improve performance components.
when a client shows potential to generalize learning, a Occupational therapists implement a variety of
random practice schedule is preferred. teaching strategies designed to promote skill acquisi-
tion, retention, and generalization. Teaching methods
WHOLE VERSUS PART PRACTICE. Therapists are based on principles developed from research on
may intuitively believe that it will be easier for a client learning and are selectively chosen on an individual
to learn small segments of a task before learning how basis. Different principles will be integrated into OT
to perform the task in its entirety. However, breaking a treatment, based on a variety of factors:
task into its component parts for teaching purposes is 1. Whether training or learning is the outcome goal
useful only if the task can naturally be divided into 2. The type of task an individual needs to learn
recognizable units.*” This is because continuous skills 3. The learning processes associated with the task goals
(or whole task performance) are easier to remember Active participation and strategy development are
than discrete responses.'® For example, once a person key features of effective learning. Occupational thera-
has learned to ride a bicycle, he or she will retain this pists maximize the learning process by (1) helping
motor skill even without practicing for many years. On clients develop self-awareness and _ self-monitoring
the other hand, segmented laboratory-type motor skills skills, (2) providing effective instruction tailored to
may be acquired easily but are less likely to be retained individual needs, (3) implementing feedback strate-
over time. Therapists are advised to teach such tasks in gies that augment each individual’s learning goals,
their entirety rather than in artificial segments. For and (4) conducting therapeutic interventions in prac-
example, for best retention and generalization, it is tice contexts that maximize skill generalization and
better to teach putting on a shirt as a complete task task performance in each client's expected real-life
than to practice a different portion of the task during environment.
each therapy session. If it is difficult for a client to
master all the steps at once, the therapist may provide
REVIEW QUESTIONS
cuing or manual guidance for selected aspects of the
task. This way, the client experiences completion of the 1. Provide examples, other than those described in the
task on each trial, and the therapist gradually gives less chapter, of how occupational therapists analyze,
assistance as practice sessions continue. adapt, synthesize, and teach activities in interven-
tions for clients with physical disabilities.
PRACTICE CONTEXTS. Only closed tasks* are 2. What is the difference between skill acquisition, re-
always performed under identical environmental condi- tention, and generalization? Apply these terms to
tions. All other activities necessitate that the individual describe the learning stages in a client you have
demonstrate versatility of performance. Practice under observed.
variable contexts enhances generalization of learning and 3. What is the difference between closed tasks, vari-
helps the individual achieve this versatility. For example, able motionless tasks, and open tasks? How will
wheelchair mobility is practiced on a variety of indoor teaching methods differ between these types of
and outdoor surfaces. Self-feeding is practiced with a tasks?
variety of utensils and types of food. Furthermore, if self- 4. When are declarative learning and procedural learn-
feeding is a particularly difficult challenge for a client ing processes used? How will teaching methods
because of severe physical or cognitive limitations, OT differ when declarative or procedural processes are
feeding practice will occur in a variety of environments— required?
alone in one’s hospital room or home kitchen, as well as 5. How can occupational therapists help clients
in group settings, such as a cafeteria or a restaurant. develop metacognitive skills? Why are these skills
important in the learning process?
6. In which situations is extrinsic feedback valuable to
SUMMARY the therapeutic process? What are some advantages
Occupational therapists analyze, adapt, synthesize, and and disadvantages to providing extrinsic feedback
teach activities to clients with physical disabilities. The to clients?
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

How will a therapist structure a therapeutic activity IN Nelson DL et al: The effects of an occupationally embedded exer-
cise on bilaterally assisted supination in persons with hemiplegia,
to present instructions that elicit an external, rather
Am J Occup Ther 50(8):639-646, 1996.
than an internal, focus of attention? v2) Poole J: Application of motor learning principles in occupational
. What is the difference between KP and KR feed- therapy, Am J Occup Ther 45(6):530, 1991.
back? Give an example of how KP feedback can be iS: Ryerson S, Levit K: Functional movement reeducation, New York,
provided by using an external, rather than an inter- 1997, Churchill Livingstone.
14. Sabari J: Using activities as challenges to facilitate development of
nal, focus of attention.
functional skills. In Hinojosa J, Blount ML, editors: Activities, the
. Why does contextual interference contribute to gen- texture of life: describing purposeful activities, Bethesda, Md, 2000,
eralization of learning? Think of an example, other American Occupational Therapy Association.
than those described in the chapter, of how contex- 15. Sabari J: Application of learning and environmental strategies
tual interference can be incorporated into an OT to activity based treatment. In Gillen G, Burkhardt A, editors:
Stroke rehabilitation: a function-based approach, St Louis, 1998,
session.
Mosby.
10. Differentiate between random and blocked practice 16. Sabari J: Motor learning concepts applied to activity-based inter-
schedules. In which situations would each of these vention with adults with hemiplegia, Am J Occup Ther 45(6):523-
practice schedules be chosen? 530; 1991:
Lie Provide examples of how a therapist might structure Nee Salmani AW, Schmidt RA, Walter CB: Knowledge of results and
motor learning: a review and critical reappraisal, Psych Bull 95:
whole practice versus part practice. In which situations
355-386, 1984.
might each of these types of practice be appropriate? 18. Schmidt RA: Motor performance and learning: principles for practi-
125 In which ways can occupational therapists enhance tioners, Champaign, Ill, 1992, Human Kinetics.
the variability of practice contexts? Give practical Los Shumway-Cook A, Woollacott M: Motor control: theory and practical
examples of how occupational therapists working applications, Baltimore, 1995, Williams & Wilkins.
in inpatient settings can provide treatment in 20. Sietsema JM et al: The use of a game to promote arm reach in
persons with traumatic brain injury, Am J Occup Ther 47( ):19-24,
natural contexts. 19935
Dalle Singer RN, Cauraugh JHL: The generalizability effect of learning
REFERENCES strategies for categories of psychomotor skills, Quest 37:103-119,
Dy: Carr JH, Shepherd RB: Neurological rehabilitation: optimizing motor 1985.
performance, Oxford, Eng,1998, Butterworth Heinemann. FER. Toglia J: A dynamic interactional model to cognitive rehabilita-
. Carr JH, Shepherd RB: A motor relearning program for stroke, ed 2, tion. In Katz N, editor: Cognition and occupation in rehabilitation:
Rockville, Md, 1987, Aspen. cognitive models for intervention in occupational therapy, Bethesda,
Gentile AM: Implicit and explicit processes during acquisition of Md, 1998, American Occupation Therapy Association.
functional skills, Scand J Occup Ther 5:7-16, 1998. ASK Toglia JT: Generalization of treatment: a multicontext approach to
Gentile AM: A working model ofskill acquisition with application cognitive perceptual impairment in adults with brain injury, Am J
to teaching, Quest 17:3-23, 1972. Occup Ther 45(6):505-515, 1991.
Higgins S: Motor skill acquisition, Phys Ther 71(2):123-139, 1991. 24. Tulving E: Elements of episodic memory, Oxford, Eng, 1983, Claren-
Higgins JR, Spaeth RK: Relationship between consistency of move- don Press.
ment and environmental condition, Quest 17:61-69, 1972. Zor Winstein CJ: Designing practice for motor learning clinical impli-
. Jarus T: Motor learning and occupational therapy: the organiza- cations. In Lister MJ, editor: Contemporary management of motor
tion of practice, Am J Occup Ther 48(9):810-816, 1994. control problems: proceedings of the II STEP conference, Alexandria,
Katz N, Hartman-Maier A: Metacognition: the relationships of Va, 1991, Foundation for Physical Therapy.
awareness and executive functions to occupational performance. 26. Winstein CJ: Knowledge of results and motor learning—implica-
In Katz N, editor: Cognition and occupation in rehabilitation: cogni- tions for physical therapy, Phys Ther 71(2):140-149, 1991.
tive models for intervention in occupational therapy, Bethesda, Md, Mf. Wu SH, Huang HT, Lin CF et al: Effects of aprogram on symmet-
1998, American Occupational Therapy Association. rical posture in patients with hemiplegia: a single-subject design,
Magill RA: Motor learning: concepts and applications, ed 4, Madison, Am J Occup Ther 50(1):17-23, 1996.
Wis, 1993, Brown & Benchmark. 28. Wulf G, Hob M, Prinz W: Instructions for motor learning: differ-
10. Moyers P: The guide to occupational therapy practice, Am J Occup ential effects of internal versus external focus of attention, J Motor
Ther 53(3):247-322, 1999. Behav 30(2):169-179, 1998.
 10
ration of Occupational Therapy

LEARNING OBJECTIVES
iwee Peterral Study of this chapter will allow the student or clinician
Database to do the following:
Baseline iy Briefly describe what is meant by documentation
Premorbid functional status of occupational therapy services.
Performance baseline Zs Identify when the documentation process is
i
ae
) Initial evaluation report initialized.
Occupational therapy file ie Identify at least five purposes of documentation.
Permanent legal medical record Briefly summarize the content of the initial
Reassessment evaluation report.
Interim assessment report Explain how goals are established.
Discharge summary Identify the importance of patient inclusion in goal
Progress note setting.
Subjective Objective Assessment Plan (SOAP) . Explain how the treatment plan is established,
Occupational Therapy Sequential Client Care Record including its relationship to problems and goals.
(OTSCCR) . Describe the contents of an interim assessment
Problem-Oriented Medical Record (POMR) report.
Automated documentation systems . Identify the key elements of a discharge summaty.
10. Identify the four components of a SOAP note.
Jk. Describe the OTSCCR documentation system and
its relationship to the problem-oriented medical
record.
b2. Describe how the Problem-Oriented Medical
Record is structured.
i: List the advantages and disadvantages of an
automated documentation system.
14. Identify six documentation guidelines that help
ensure that the therapist meets legal and ethical
obligations
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

3. Providing clear, objective data about the patient on

which future treatment can be based
ocumentation of occupational therapy (OT) 4. Providing justification to utilization reviewers for
refers to all information recorded about the patient from continued treatment
the time of referral to the time of discharge from OT. 5. Ensuring payment by third-party payers for services
Documentation is initiated upon receipt of the referral 6. Complying with the law and aiding in litigation
and includes acknowledgment of the referral, initial 7. Providing a method to ensure patient rights and
evaluation, progress notes, periodic interim reassess- advocacy
ments, and a discharge summary. Justifications for assis- 8. Interpreting the treatment program to the patient,
tive technology may also be included in OT documenta- family, and other concerned individuals or agencies
tion. Backup documentation, not usually entered into 9. Evaluating the effectiveness of OT intervention
the medical record, may include evaluation test results, 10. Ensuring facility accreditation from such organiza-
checklists, or patient worksheets. Backup documenta- tions as the Joint Commission for the Accreditation
tion is typically kept in the OT therapy file. The medical of Healthcare Organizations (JCAHO) or the Com-
record contains pertinent information about the mission for Accreditation of Rehabilitation Facili-
patient's status, progress, and performance. ties (CARF)
There is no standard or single method within the 11. Providing data for research and advancement of the
profession for documenting OT services. Funding agen- profession of occupational therapy
cies and treatment facilities may prescribe the types of 12. Facilitating training and student education pro-
records kept and reports to be written.*° Regardless of erams*2>
the method of documentation, it is critical that all
entries be clear, concise, objective, accurate, and com- RECORDS AND REPORTS
plete. Inaccuracies in the medical record may lead to
miscommunication and result in inappropriate treat-
Permanent Legal Record
ment. Documentation is part of a legal record; omis- The permanent legal record contains defined informa-
sions or errors in documentation may cause doubts tion from the entire treatment team. The documents in
about the accuracy of the entire record.’ The occupa- a particular record are considered the only official infor-
tional therapist is responsible for ensuring that all docu- mation related to that particular patient or client. Each
mentation requirements are met in a timely fashion. facility determines the contents of this record, which
Documentation directed toward patient-centered may be based on requirements set by internal systems,
goals that are meaningful to the patient and agreeable licensing agencies, accrediting bodies, and third-party
to the clinician can effectively meet most purposes for payers. This record will be used within the facility by the
documentation. To engage the patient in the establish- treatment team to understand the full patient treatment
ment of mutually agreeable goals, the therapist must picture, by utilization reviewers to determine justifica-
explain the purposes of OT, ask questions and solicit in- tion for continued treatment, and by quality assurance
formation that identifies patient concerns and desires teams to assess overall patient outcomes and services.
for therapeutic outcomes, and help the patient and This record may also be used by third-party payers to de-
family identify realistic expectations of therapy. The termine payment for services, by the court system for lit-
process of engaging patients in goal setting, although igation, and by outside agencies for continued treat-
time consuming, can provide a framework for OT treat- ment or services after discharge from the facility.
ment and documentation while engaging the patient in The OT documents contained in the permanent legal
the therapeutic process. '7 record consist of the physician’s referral, initial evalua-
tion, ongoing progress notes, interim reassessments, and
the discharge summary. These items provide a concise
PURPOSES OF DOCUMENTATION
summary of all tests and observations, treatment goals,
Documentation is the major avenue through which and treatment plans and measurements of progress
health care providers communicate about a client or toward the established goals. In addition, the occupa-
patient to others. A broad target audience, each with its tional therapist may be required to provide entries in
own purpose, reviews the medical record. Effective other sections of the permanent record, such as the inter-
documentation serves many purposes, including the disciplinary care plan or the patient care conference note.
following:
1. Communicating patient status and response to
treatment to the physician and other health care
Records and Reports Process and Formats
team members Referral
2. Promoting continuity of treatment when staff OT evaluation and treatment are usually initiated by
changes occur receipt of a patient (client) referral (Fig. 10-1). This
 Documentation of Occupational Therapy Services

nician educates the client about the role of OT and facil-

itates the identification of mutually agreeable func-
2/1/2000 - Occupational Therapy referral received. tional goals. These goals will form the framework for all
Evaluation initiated. documentation. '*
Report to follow.
Step 2: Establishing the Performance Baseline
The second step in the initial evaluation involves assess-
ments and tests to establish the performance baseline.
FiG. 10-1
Sample of referral receipt. Accuracy in the administration of tests and recording of
test results is critical. Future evaluation results will be
compared with initial findings to determine progress.
referral is generally, but not always, received from the The degree of improvement may determine the course,
physician and may specify the reason the referral was duration, and extent of treatment approved by the
requested. When a physician’s referral is required, it physician and third-party payers.
should include the following: the OT treatment diag- The occupational therapy file should contain de-
nosis and onset date, precautions, the date of any tailed results of all evaluations completed. This file aug-
recent change in level of function, a request for evalua- ments the permanent medical record and contains de-
tion and any other specific treatment orders, the physi- tailed information and test results. The items in the file
cian’s signature, and the date.' The first entry into the may include: (1) range of motion (ROM) measure-
permanent record may be an acknowledgment of ments, (2) manual muscle testing, sensory testing, and
receipt of the referral and the initial plan of action. The perceptual and cognitive evaluation results, and (3) ac-
response time is established by each facility but is tivities of daily living (ADL), functional mobility, home
usually within 24 to 48 hours of receipt of the referral. management, vocational, and avocational assessment
findings. A summary of normative data and an organ-
ized presentation of abnormal findings are typically de-
Initial Evaluation
lineated in the permanent legal record.
The initial evaluation is a three-step process. The first
step is to gather information about the patient and Step 3: Establishing the Treatment Plan
identify the patient's premorbid functional status. The The final step involves using the data gathered in the
second step is to complete the assessment and establish previous two steps to establish a clear plan of action.
a baseline of current patient performance. The final Drawing on goals important to the client, the clinician
step is to use the information obtained in steps one identifies problems amenable to OT intervention,
and two and apply clinical reasoning skills to draw defines goals more clearly, and establishes a plan of
sound conclusions and establish the treatment goals treatment to accomplish those goals. The refined prob-
and plan. . lems, plans, and goals are reintroduced to the client to
verify that the course of action is agreeable.
Step 1: Building the General Information
Database
Initial Evaluation Report
The therapist begins the initial evaluation process by re-
viewing data obtained from the permanent record. He Initial evaluation report formats vary greatly from
or she also interviews referring sources, the patient, and setting to setting. Most facilities have printed forms that
family members and observes patient performance and the therapist fills in; others require a complete narrative
behavior to build a general information database. This report. There are pros and cons for either format. Forms
database includes the patient's name and address, im- ensure that information is complete. The subheadings
portant phone numbers, information on _ family trigger a written response for all evaluation areas. A
members, third-party payers (both primary and second- form's limited space encourages brevity and concise-
ary), and family, educational, and work histories. In ad- ness. In general, the form saves time, and most team
dition, the database contains pertinent medical, physi- members find it faster for gleaning needed information.
cal, and mental status information related to specific The form also presents a ready format for computer key-
primary and secondary diagnoses, as well as other board input. Using forms makes it easier to gather ag-
related information about prior levels of function. Ex- gregate data for use in outcome studies. The form may
pected treatment outcomes and discharge plans are also not meet the specialized documentation needs of all di-
pertinent to the database. Information obtained will be agnoses, however, or provide sufficient space for impor-
integrated into the initial evaluation. Nonessential in- tant information not covered in the subheadings. A
formation may be kept in the OT file for reference form may also elicit more information than is needed to
during treatment. During the interview process the cli- capture the clinical picture.
 ee. Santa Clara Valley Medical Center Name: Room #
Y, 751 South Bascom Avenue Chart #: Acct #
SANTA CLARA San José, California 95128 :
VALLEY DOB: : Age: Mee
MEDICAL CENTER
Date of onset:
OCCUPATIONAL THERAPY EVALUATION Date of referral:

LJ Initial 1 Interim L] Discharge Date O.T. initiated:

Reason for consult:

Medical Hx/Dx:

Precautions:

Social Hx: THERAPY

OCCUPATIO

Clinical Status (ROM, Strength, Sensation, Other):

Functional Status (Mobility, Transfers, Self care):

Equipment/Splinting/Positioning Needs:

Problems: Goals/Recommendations:

Frequency/Duration:

OTR —___ Date es |!| eee ee |S)11

©... REV17/87 Disposition: | Medical Chart - Perm Canary - To Division File SCVMC 6041-53-12

FIG. 10-2
Occupational therapy evaluation form. From Therapy Services Division, Santa Clara Valley Medical
Center, San José, Calif.
 Documentation of Occupational Therapy Services

The greatest advantage of the narrative format is its results or use standardized rating scales for easy inter-
adaptability to the special needs of the individual pretation by others. Standardized scales also ensure reli-
patient. However, the narrative format generally takes able replication of the evaluation process at reassess-
longer to complete and to read and is prone to errors of ment and discharge times. The evaluations performed
omission because the form does not provide clinicians will depend upon the specific diagnosis. For example, a
with prompts to cover all subjects. patient with a brain injury may require a physical as-
The initial evaluation, whether it is in form (Fig. 10-2) sessment (ROM, motor function, and sensory), as well
or narrative format, can be divided into several distinct as perceptual and cognitive testing. For a mental disor-
sections as follows: (1) general information, which in- der such as depression, the assessment may focus pri-
cludes the patient's identifying information, medical marily on behavior and cognitive parameters.
history, and prior level of function; (2) clinical evalua-
tion and interpretation; (3) functional status assessment; Functional Status Assessment
and (4) evaluation summary, which includes problem The functional status assessment section covers the eval-
identification, objectives and goals, and treatment plan. uation of the functional performance of the patient. The
clinical evaluation results have substantial bearing on
General Information these assessments; a standardized scale is imperative to
The first section of a report in the narrative format con- ensure reliability of results through the treatment
sists of basic identifying information about the patient. process. The scope of this OT assessment will depend on
This includes the patient's name, the medical record or the defined roles of the department within the facility.
account number, the referring physician, and the refer- In the sample form (Fig. 10-2), bed mobility, transfers,
ral and evaluation dates. This section of the report and daily living skills are assessed. A “levels of assis-
details pertinent medical history, including the primary tance” scale is provided in Table 10-1.
treatment diagnosis and any related secondary diag-
noses with their onset dates. The general information Evaluation Summary
section should list any precautions or contraindications The evaluation summary is the most important section
to be observed during treatment. The patient's prior of the report. In this section, the previously recorded in-
level of function, prior living situation, and previous vo- formation is analyzed and a problem list is developed.
cational and leisure activities level of function are also The problems listed are those that might impede the
noted (Fig. 10-2). patient's efforts to attain maximal independence. It
should be noted that the list might include problems
Clinical Evaluation that OT intervention would not directly affect (e.g., a
The clinical evaluation section is a synopsis of evalua- spouse’s disability or financial constraints). These prob-
tion results (Fig. 10-2). It is helpful to relay standardized lems will influence the treatment approach taken by the

Level of Assistance Abbreviation Definition

Independent Ind. Patient requires no assistance or cueing in any situation.
Patient is trusted in all situations 100% of the time to do the task safely.

Supervision Sup. Caregiver is not needed to provide hands-on guarding but may need to give
verbal cues for safety.

Contact guard/standby Con. Gd./Stby Caregiver must provide hands-on contact guard or be within arm's length for
the patient's safety.

Minimum assistance Min. Caregiver provides physical and cueing assistance in 25% of the task.

Moderate assistance Mod. Caregiver assists the patient with 50% of the task; assistance can be physical
and cueing.

Maximum assistance Max. Caregiver assists the patient with 75% of the task; assistance can be physical
and cueing.

Dependent Dep. Patient is unable to assist in any part of the task; caregiver performs |00% of the
task for the patient physically and cognitively.
eee
eee ee ee

Adapted from Occupational therapy evaluation form, Therapy Services Division, Santa Clara Valley Medical Center, San José, Calif.
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE
Discharge Summary Report
occupational therapist. Using this problem list, the ther-
apist must set realistic and functional therapy goals. The At the completion of the treatment regimen, a dis-
goals are predictions of the patient outcome. The thera- charge summary is necessary. The format of the
pist must apply theoretical knowledge and clinical rea- summary can be the same as that used for the initial
soning skills to predict one or more treatment outcomes evaluation and interim assessments. This summary de-
for the patient. Establishing goals that are meaningful, scribes the final status of the patient at the time of dis-
realistic, and mutually agreeable to the patient and ther- charge from the particular setting. Documentation of
apist is the most critical part of the initial evaluation progress from the initial assessment to the time of dis-
process. These initial goals are the indicators that will be charge must be objective, accurate, and understandable.
used to measure the effectiveness of the therapy inter- Key elements required in a discharge summary include
vention and the success for the patient. identification of goals attained, a statement of goals
Therapy goals can be subdivided into goals and objec- not attained and why they were not attained, and dis-
tives. Goals are the maximal predicted outcomes ex- charge recommendations. Additional interventions and
pected for a patient after the full treatment program has follow-up care needed to ensure ongoing improvement
been completed. Objectives describe the level of function or maintenance of function should be clearly defined
expected after a predesignated period of treatment inter- in the discharge recommendations.
vention, usually 1 week or 1 month. Each goal must The discharge summary is a key document because it
reflect a measurable, realistic, and functional outcome reflects all progress and accomplishments achieved in
for the patient. For example, a long-term goal for a the case. The data can be used for many purposes.
patient currently requiring maximum assistance for Quality assurance committees may use the data to eval-
eating might read, “Using modified utensils, the patient uate the effectiveness of the treatment. The data may
will eat independently.” An objective (1-week or short- also be used for outcome studies to prove the efficacy of
term goal) might read, “The patient will require modi- treatment within certain diagnostic categories. In addi-
fied assistance for eating, using adapted utensils.” tion, insurance payers may use the report to determine
Finally, a treatment plan must be established. The payment for the service, and other service agencies such
treatment plan indicates the treatment interventions as outpatient clinics may use the data to help establish
that the therapist will employ to help the patient goals and treatment plans in the new treatment setting.
achieve predetermined goals. This plan establishes the
treatment frequency and duration. Daily eating retrain-
Progress Note
ing and upper extremity functional! strengthening for 2
weeks may be a treatment plan established to achieve Progress notes may be required on a per-treatment,
increased independence in eating. daily, or weekly basis. Generally, daily notes are very
The summary section may also include a discharge brief and reflect treatment provided, patient response to
plan once therapy has been completed, as well as a the treatment, and progress noted. Revision of the treat-
checkbox to note that the goals have been discussed and ment plan and goals is not always necessary (Fig. 10-3).
reflect those of the patient and family. Finally, a physi- Weekly progress notes are more thorough and should
cian’s review of the plan and verifying signature may be summarize the treatment provided, the treatment
necessary. frequency, the patient's response to treatment, and
progress toward goals or lack of progress, with justifica-
tion. The objectives should be updated and the treat-
Interim Assessment Report
ment plan revised. The new objectives and treatment
If treatment occurs over an extended time, it may be plans are established to reflect the expected outcome for
necessary to complete a full reassessment. The format of the following week’s treatment regimen (Fig. 10-4).
the reassessment is often the same as that of the initial
evaluation. The main difference is that this report re-
flects the changes from the initial evaluation results to
the present clinical findings. The interim report reflects
progress made toward the predicted goals and is a
measure of success of the treatment intervention. The Patient was seen for dressing retraining. Patient
new evaluation results may present an opportunity for required moderate assistance for upper body dressing
revising initial goals and treatment timelines. Interim and maximal assistance for lower body dressing. Plan
assessments are an important tool for the ongoing uti- to continue w/ established treatment plan.
lization review process. They allow the therapist to
justify continued treatment intervention by clearly out-
lining the effectiveness and efficiency of the treatment FIG. 10-3
that has occurred. Brief daily note sample.
 Documentation of Occupational Therapy Services

Problem: Rider ict reac oN

Patient has been seen daily for dressing retraining. Progress: Patient now dresses upper body with
Patient has progressed from moderate to minimal minimal assistance and lower body with
assistance needed in dressing upper body and from moderate assistance. Last week patient
maximal to moderate assistance required in lower
required moderate assistance for upper
body dressing. ROM limitations, left neglect, and body dressing and maximal assistance
decreased endurance are primary contributors to for lower body dressing.
functional deficits. The patient will progress to standby Program: ADL retraining.
assistance for upper body dressing and to minimal Plan: Achieve standby assistance in upper body
assistance in lower body dressing in one week. and minimal assistance in lower body
dressing in one week.

FIG. 10-4
Weekly progress note sample. FIG. 10-6
Problem-focused problem notes sample.

JUSTIFICATION FOR ASSISTIVE

TECHNOLOGY
Patient states he can put on shirt by himself.
O: Patient required assistance of therapist to orient Occupational therapists are frequently called on to help
shirt correctly and guide shirt over shoulders. justify the use of assistive technology, such as bath
Moderate assistance was needed to start items equipment, wheelchairs, and environmental controls.
over feet and to clear clothing over hips. When justifying such equipment, clinicians must famil-
Previously needed moderate assistance for iarize themselves with the unique requirements of the
donning shirt and maximal assistance for lower third-party payer. A medical insurance company might
body dressing. consider use of equipment justified if it will eliminate
A: Visual spatial deficits and poor endurance inhibit dependency. The vocational rehabilitation agency may
independence.
require that use of the equipment allow the client to
P: Continue guided dressing training with emphasis
realize vocational potential or be able to return to work.
on paced activity. Patient to require standby
assistance in upper body dressing and minimal
For the educational system, the key issues would be
assistance for lower body dressing in one week. access to education or improved ability to learn. Justifi-
cation of the need for equipment in terms acceptable to
the third-party payer is critical to securing payment for
FIG. 10-5
assistive technologies.”
SOAP notes sample.
OCCUPATIONAL THERAPY FILE
It is common practice for the OT services to maintain sep-
arate departmental files. Supporting records, notes, and
Various styles or formats for progress notes are used worksheets, as well as copies of documentation prepared
to ensure consistency of the content of the notes. SOAP for the permanent medical record, can be found in such
notes are one of the most frequently used formats. The files. Supporting data may include test results such as
acronym stands for Subjective (the patient's view of the range of motion forms, treatment checklists, samples of
problem), Objective (the clinical findings about the the patient's writings, ADL checklists, informal team con-
problem), Assessment (relevant data from reevalua- ference notes, treatment plan approaches, and other sup-
tions), and Plan (therapeutic interventions and goals) porting materials that guide treatment. The supporting
(Fig. 10-5).° This method of recording information data form the framework that will become part of the
is based on the system designed by Weed” in the permanent medical record.
Problem-Oriented Medical Record. Another format The OT file improves treatment efficiency and pro-
for short daily notes states the problem, progress, de- vides other advantages. The permanent medical record
scription of the treatment program, and future plans is used by many team members and is not always
(Fig. 10-6). Still another possibility is to enter similar in- readily available for review; the therapy record is more
formation in a format dictated by a computerized docu- available for updating of data and clarification ofearlier
mentation system. treatment procedures and findings. The OT file provides
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

detailed information to a substitute clinician in the tion in the manner he or she sees fit. Each facility has
absence of the primary therapist, ensuring continuity of procedures outlining how a patient might look at the
treatment. The record is also available for review during medical record. The therapist should follow the facility's
formal and informal conferences or during any treat- procedures if a patient asks to view the medical record.
ment session. It is important to remember that the legal written
record is the only acceptable proof of the treatment in-
tervention. If something is not written, in the eyes of
QUALITY OF DOCUMENTATION CONTENT
outside reviewers (e.g., third-party payers or jurors) it
The quality of the documentation content is of the did not happen. Box 10-1° provides documentation
utmost importance. Documentation must be well or- guidelines to help ensure that the therapist meets legal
ganized, objective, and accurate and must contain only and ethical obligations.
pertinent information. Conciseness and brevity are dic-
tated by time constraints for both the writer and the REPORTING SYSTEMS
reader. The therapist must consider who will read the
Problem-Oriented Medical Record
report, which may influence what needs to be reported
and how the report will be written.* The target audi- The Problem-Oriented Medical Record (POMR) was
ence, be it other clinicians, insurance payers, or a lay devised by Dr. Lawrence L. Weed at Case Western
person, will influence the use of medical terminology or Reserve University. '° It provides a computer-compatible
medical abbreviations, as well as the amount of detail model that follows a systematic progression from evalu-
provided for the reader's understanding. ation to progress reporting. It is a problem-solving
The content of documentation is governed by law. model that is readily accepted by occupational thera-
Laws have been enacted to ensure quality care and cost pists and can be implemented in any setting. It offers a
containment. The written record is the primary means method by which evaluation and treatment standards
of justifying appropriate treatment by the appropriate can be documented and enforced.’
clinician in the most cost-effective environment. To pre- The POMR encourages an interdisciplinary model in
serve the rights of the patient, the record must be factual which all health care services integrate information into
and include no value judgments that might be prejudi- one document. The database is composed of physical,
cial to the patient.”" social, and demographic information contained in one
Health records may be used in litigation for settling report. From this database, a problem list is formulated
insurance claims and may be examined by third-party and kept at the front of the record. The list serves as an
payers, fiscal intermediaries, and other utilization index to all problems and may also include anticipated
review boards.°*”' The review of the records is governed problems. Each problem is numbered and named, and
by principles of ethical practice in relation to confiden- these designations remain the same for each hospital-
tiality, and the records are under strict control of the ization of the patient. All of the treatment plans must
physician or health care agency. No privileged informa- be titled and numbered according to the problem list,
tion, oral or written, can be released without the signed then dated and signed. To illustrate how the POMR
consent of the patient.* In addition, the patient has the works, by reading all of the notes that refer to problem
right to know what is in the record and can ask to see it. three, the health care worker can learn what each service
The physician is responsible for providing the informa- is contributing to the patient's total rehabilitation at any
given time.
All progress notes are dated, numbered, and titled
according to the problem to which they refer. All
progress notes are recorded in the same section of the
ion Guidelines chart, following the previously mentioned SOAP
outline. Progress notes are written whenever a staff
member has relevant information to record. The fre-
|. Date all entries for accurate sequencing of the treatment. quency of entries to the record may reflect policies of
2, Document missed treatments.
the treatment facility, the acuteness of the patient's con-
3. Document at the time of the treatment so the entry will
dition, or the need for continued evaluation.’ The
completely and accurately reflect the treatment session.
4, Document in specific facts rather than in general terms.
record concludes with a problem-oriented discharge
5. Do not point blame to other care providers in the record. summaty.
6. Do not change a legal record after the fact without The POMR facilitates communication among
clarifying the time and nature ofthe change. health disciplines because all progress notes are inter-
De mixed and all personnel are bound by the same crite-
From Acquaviva J,editor: Effective documentation for occupational therapy, ed 2, ria for recording. All service providers are up to date
Rockville, Md, 1998, American Occupational Therapy Association. on progress in other areas, and treatment can be ad-
 Documentation of Occupational Therapy Services

justed accordingly. The patient can be educated about handling abilities are far more advanced and accurate
his or her condition and progress in an organized than with manual systems. Disadvantages of automated
manner that focuses on the problems from an inter- systems include the following:
disciplinary approach. The POMR allows documenta- 1. Difficulty of securing a system that meets all the needs
tion adequate for quality assurance and third-party of the program or requests from outside agencies
payer requirements, specifically with regard to coordi- 2. Cost of hardware sufficient for the needs of the
nation of care across disciplines. The POMR offers a facility
recording system that can improve the standards of . Cost of training
documentation.’ Unwillingness of staff to accept the system
. Difficulty of maintaining patient confidentiality
OCCUPATIONAL THERAPY SEQUENTIAL . Insufficient access for all users®
CLIENT CARE RECORD
SUMMARY
The Occupational Therapy Sequential Client Care
Record (OTSCCR) created by Llorens* is unique to OT. Documentation of OT services consists of written
Rather than using medical or psychologic reporting records and reports that contain pertinent information
systems, it is organized according to a theoretical frame- about the patient’s status, progress, and performance.
work consistent with the characteristics, goals, and ob- The occupational therapist is responsible for keeping ac-
jectives of OT. As the field of OT has developed, in- curate records to document the patient’s evaluation
creased attention has been given to measuring the results, the identified problems, the treatment goals and
quality of care, achieving autonomy in decision making, plan, and the patient's progress toward the established
providing accountability to patients and funding agen- plan.
cies, and assuming professional responsibility for serv- Documentation is necessary for administrative, reim-
ices. Llorens described the client care record as the “key bursement, communication, quality assurance, educa-
document for determining quality and effectiveness of tional, and legal purposes. Documentation is essential
care.”* The OTSCCR system combines the theoretical in justifying the necessity and expense of treatment. Ac-
framework of Llorens’ Occupational Therapy Develop- curate and objective documentation creates a record of
mental Analysis, Evaluation, and Intervention Schedule the efficacy of OT.
with the scientific method of the POMR for document- OT documentation includes the referral, evaluation
ing care in OT. The OTSCCR includes a database, infor- data, initial evaluation, progress notes, interim reassess-
mation about the evaluation process, problem identifi- ments, and the discharge summary. Records and reports
cation, an OT plan, progress notes, and a discharge should reflect clear, concise, accurate, and objective in-
summaty. It is based on the developmental frame of ref- formation about the patient. To prevent misinterpreta-
erence and occupational performance model, and data tion and misunderstanding, the report writer must
are recorded and analyzed according to the perform- consider the reader of the documents. Documentation
ance areas and performance components of the occupa- should be well organized and developed according to
tional performance model. The OTSCCR documents an agreed-on system for internal consistency of the
factual information about the client based on actual be- record. Most important, documentation should reflect a
havior. It is designed to span the time the client is served treatment plan that has engaged the patient in the ther-
by OT from admission to discharge. It is retained by the apeutic process by the establishment of therapeutically
OT department for use in preparing reports and com- meaningful and mutually agreeable goals.
municating with the client and other interested persons
or agencies.* REVIEW QUESTIONS
What is meant by documentation of OT services?
Automated Documentation Systems When is the documentation process initialized?
The availability of therapy documentation software has List at least five purposes of documentation.
increased. These systems range from primary documen- What is the difference in content between the OT
apes
tation formats to integrated systems that provide not file and the permanent legal record? What kinds of
only basic documentation but also billing mechanisms, documents are contained in each?
administrative tracking information, and protocols for 5. Briefly summarize the content of the initial evalua-
generating outcome data. tion report and explain how goals are established.
The ultimate advantage of using an automated 6. How is the treatment plan developed?
system is that it saves time, not only in documentation ay What is contained in an interim assessment report?
but also in collating data for outcome studies and other 8. What is contained in the discharge summary
required administrative reports. In addition, data- report?
100 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

ee List two formats for progress notes. . Luebben AJ: Documentation for assistive technology. In Acqua-
10. What should be considered in justifying assistive viva J, editor: Effective documentation for occupational therapy, ed 2,
Rockville, Md, 1998, American Occupational Therapy Association.
technology?
. McCann KD, Steich T: Legal issues in documentation: fraud,
1 Why is accurate, complete, and concise documenta- abuse, and confidentiality. In Acquaviva J, editor: Effective docu-
tion important? mentation for occupational therapy, ed 2, Rockville, Md, 1998, Amer-
123 Describe the POMR and OTSCCR recording systems. ican Occupational Therapy Association.
iS. What are the advantages of an automated docu- . Potts LR: The problem oriented record: implications for occupa-
tional therapy, Am J Occup Ther 26:6(288), 1972.
mentation system?
. Robertson S$: Why we document. In Acquaviva J, editor: Effective
documentation for occupational therapy, ed 2, Rockville, Md, 1998,
REFERENCES American Occupational Therapy Association.
i Allen C, Foto M, Moon T, et al: Understanding the medical review . Tiffany EG: Psychiatry and mental health. In Hopkins HL, Smith
process. In Acquaviva J, editor: Effective documentation for occupational HD, editors: Willard and Spackman’s occupational therapy, ed 6,
therapy, ed 2, Rockville, Md, 1998, American Occupational Therapy Philadelphia, 1983, JB Lippincott.
Association. 10. Weed LL: Medical records, medical education and patient care,
. Baum CM, Luebben AJ: Prospective payment systems, Thorofare, NJ, Chicago, 1971, Year Book Medical Publishers.
1981, Slack. 11. Wells C: The implications of liability: guidelines for professional
. Gleave GJ: Medical records and reports. In Willard HS, Spack- practice, Am J Occup Ther 23:1(18), 1969.
man SC, editors: Occupational therapy, ed 4, Philadelphia, 1971, IPE Wilson D: If I had known then what I know now. In Acquaviva J,
JB Lippincott. editor: Effective documentation for occupational therapy, ed 2,
. Llorens LA: Occupational therapy sequential client care record manual, Rockville, Md, 1998, American Occupational Therapy Association.
Laurel, Md, 1982, Ramsco Publishing.
 Getraeuleys! Se} niexe)| and Safety Issues in the Clinic

LEARNING OBJECTIVES
if Acquired immune deficiency syndrome After studying this chapter the student or practitioner
Antiseptic will be able to do the following:
Apnea 1. Recognize the role of occupational therapy
Arterial monitoring line personnel in preventing accidents.
Autoclave 2. Identify recommendations for safety in the clinic.
Endotracheal tube 3. Describe preventive positioning for patients with
Catheter lower extremity amputations, total hip
Fistula replacements, rheumatoid arthritis, burns, and
Fowler's position hemiplegia.
Human immunodeficiency virus 4. Describe the purposes of special equipment.
Hyperalimentation 5. Identify precautions when treating patients who
Immunization require special equipment.
Infusion pump 6. Identify universal precautions and explain the
Intravenous importance of following them with all patients.
Isolation 7. Describe proper techniques of hand washing.
Nasogastric tube 8. Recognize the importance for all health care
Total parenteral nutrition workers to understand and follow isolation
Universal precautions procedures used in patient care.
Dyspnea 9. Identify procedures for handling patient injuries.
10. Describe guidelines for handling various
emergency situations.

ak. occupational therapist must make sure pa- for use with a variety of patients. It identifies precau-
tients remain safe within the health care setting. tions to consider when encountering equipment com-
Medical technology and cost control pressures have monly used with patients. Guidelines for handling
made it necessary for rehabilitation professionals to various emergency situations are reviewed. The chapter
treat seriously ill patients early in their illness and for is only an overview and cannot substitute for training in
shorter periods. These situations increase the potential specific procedures used in many facilities. In addition
for injuries to the patients. Occupational therapy (OT) to following these procedures, the occupational thera-
personnel are legally liable for negligence if a patient is pist should teach patients and their families applicable
injured because staff failed to follow proper proce- techniques that the families can follow at home.
dures.* This chapter reviews specific safety precautions

101
102 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

SAFETY RECOMMENDATIONS need for specific positioning techniques. It is important

FOR THE CLINIC to review these principles with both the patient and the
Prevention of accidents and subsequent injuries begins caregiver.
with consistent application of basic safety precautions Patients with lower extremity amputations (above-knee)
for the clinic: should avoid hip flexion and hip abduction. Limit the
1. Wash your hands for at least 30 seconds® before and length of time the patient may sit to 30 minutes per
after treating each patient to reduce cross-contami- hour. When the patient is supine, do not elevate the
nation. stump on a pillow for more than a few minutes. Prone
2. Make sure space is adequate to maneuver equip- lying is recommended to help avoid contracture of the
ment. Avoid placing patients where they may be hip flexor muscles.
bumped by equipment or passing personnel. Keep Patients with lower extremity amputations (below-knee)
the area free from clutter. should avoid prolonged hip and knee flexion to prevent
3. Do not attempt to transfer patients in congested contractures. Limit the length of time the patient may sit
areas or in areas where your view is blocked. to 30 minutes per hour. When the patient is supine, do
4. Routinely check equipment to be sure it is working not elevate the stump on a pillow for more than a few
properly. minutes. When the stump is elevated, keep the knee in
5. Make sure the furniture and equipment in the clinic extension. Instruct the patient to keep the knee extended
are stable. When not using items, store them out of throughout the day. Again, prone lying is recommended.
the way of the treatment area. Patients with total hip replacements should avoid posi-
6. Keep the floor free of cords, scatter rugs, litter, and tions of instability. For the posterolateral approach, this
spills. Ensure that the floors are not highly pol- includes hip adduction, internal rotation, and flexion
ished, because polished floor may be very slippery. over 90°. For the anterolateral approach, positions to
7. Do not leave patients unattended. Use restraint avoid include adduction, external rotation, and exces-
belts properly to protect patients when they are not sive hyperextension.
closely observed. To prevent contractures because of muscle spasticity,
8. Have the treatment area and supplies ready before patients with hemiplegia should avoid the following po-
the patient arrives. sitions for prolonged periods: shoulder adduction and
9. Allow only properly trained personnel to provide internal rotation, elbow flexion, forearm supination or
patient care. pronation, wrist flexion, finger and thumb flexion and
10. Follow the manufacturer's and facility's procedures adduction, hip and knee flexion, hip external rotation,
for handling and storing potentially hazardous ma- and ankle plantar flexion and inversion. Both the arm
terial. Be sure such materials are marked and stored and leg should be moved through the available range of
in a place that is in clear view. Do not store such motion several times per day.
items above shoulder height. Patients with rheumatoid arthritis should avoid pro-
11. Clearly label emergency exits and evacuation routes. longed immobilization of the joints of the affected ex-
12. Have emergency equipment, such as fire extinguish- tremity. Gentle active or passive range of motion of the
ers and first aid kits, readily available. joints should be performed several times per day, pro-
viding the joints are not acutely inflamed.
As burns heal, scars and contractures are likely to
PREVENTIVE POSITIONING
form. Therefore it is important to avoid prolonged static
FOR SPECIFIC DIAGNOSES
positions of the joints affected by the burn or skin graft,
Many patients require proper positioning to prevent especially positions of comfort. The positions comfort-
complications and maintain function. Staying in one able to the patient do not produce the needed stress or
position for a long time can lead to the development of tension to the wound, which must be kept mobile.
contractures and bedsores (decubitus ulcers). When the burn is located on the flexor or adductor
Specific patient conditions such as impaired sensation, surface of a joint, positions of flexion and adduction
paralysis, poorskin integrity, poor nutrition, impaired cir- should be avoided. Passive or active exercise should be
culation, and spasticity require special attention. Inspect performed frequently on both the involved and unin-
the patient's skin, especially bony prominences over the volved joints. The patient will probably have to endure
sacrum, ischium, trochanters, elbows, and heels. Red- a great amount of pain to restore normal joint function.
dened areas may develop from pressure within 30
minutes. Other indicators of excessive pressure are com- PRECAUTIONS WITH SPECIAL
plaints of numbness or tingling and localized swelling.
EQUIPMENT
Pillows, towel rolls, or similar devices may be used to
provide comfort and stability but should be used cau- Before seeing a patient at bedside, the OTR should
tiously to prevent secondary complications. The follow- contact the nursing department to determine whether
ing examples of patient conditions demonstrate the they have any specific instructions regarding position-
 Infection Control and Safety Issues in the Clinic 103

ing. For example, a patient may need to follow a turning ports. The frames on which the patient is positioned
schedule and may be limited in the length of time move the patient vertically from supine to prone or
allowed to remain in one position. If the patient's from prone to supine. The circular support frames are
current position in bed is not suitable for treatment, the moved by an electric motor and can be stopped at any
treatment might be rescheduled. Other options would point within their half-circle range. The patient or other
_ be to temporarily change the position of the patient or persons can use a control switch to adjust the position.
to treat the patient as much as possible in the current The circular turning bed has uses similar to the Stryker
position. If the patient's position is changed, the patient frame and also provides the benefit of frequent position
should be returned to the preferred position at the end changes to relieve skin pressure. However, a patient is
of treatment. still at risk for skin problems because of the pressure
forces that may occur when the bed is turned or rotated
vertically. Patients may experience symptoms of motion
Hospital Beds
sickness such as vertigo, nausea, or hypotension when
Two of the beds most commonly used in hospitals are being turned.
the standard manually operated and electrically oper- The air-fluidized support bed (Clinitron) is an expen-
ated beds. Both beds are designed to make it easier to sive bed that contains 1600 pounds of silicone-coated
support the patient and to change a patient's position. glass beads called microspheres. Heated, pressurized
Other, more specialized beds are needed for more trau- air flows through the beads to suspend a polyester cover
matic cases. Whatever type is used, the bed should be po- that supports the patient. When set in motion, the mi-
sitioned so that the patient is easily accessed and the crospheres develop the properties associated with fluids.
therapist can use good body mechanics (see Chapter 14). Patients feel as if they are floating on a warm waterbed.
Most standard adjustable beds are adjusted by means of The risk for skin problems is reduced because of the
electrical controls attached to the head or the foot of minimal contact pressure between the patient's body
the bed or to a special cord that allows the patient to and the polyester sheet. This bed is used with patients
operate the controls. The controls are marked according who have several infected lesions or who require skin
to their function and can be operated with the hand or protection and whose position cannot be altered easily.
foot. The entire bed can be raised and lowered, or the Care should be taken to prevent puncturing the poly-
upper portion of it can be raised while the lower ester cover (which would allow the microspheres to be
portion remains unchanged. When the upper portion is expelled).
raised slightly, the patient's position is referred to as
Fowler's position. Most beds allow the lower portion to
Ventilators
be adjusted to provide knee flexion, with associated hip
flexion. Ventilators (respirators) move gas or air into the
Side rails are attached to most beds as a protective patient's lungs and are used to maintain adequate air
measure. Some rails are lifted upward to engage the exchange when normal respiration is decreased. Two
locking mechanism, whereas others are moved toward frequently used types of ventilators are the volume-cycled
the upper portion of the bed until the locking mecha- ventilators and the pressure-cycled ventilators. Both ventila-
nism is engaged. If a side rail is used for patient security, tors deliver a predetermined volume of gas (air) during
the OTR should be sure the rail is locked securely before inspiration and allow for passive expiration. The gas de-
leaving the patient. The rail should be checked to ensure livered by the ventilator usually will be induced into the
it does not compress, stretch, or otherwise interfere with patient through an endotracheal tube (ET). When the
any IV or other tubing. tube is in place, the patient is intubated. Insertion of the
A turning frame (e.g., Stryker wedge frame) has front ET will prevent the patient from talking. When the ET is
and back frames that are covered with canvas. The removed, the patient may complain of a sore throat and
support base allows elevation of the head or foot ends may have a distorted voice for a short period. It is im-
of the frames or of the entire bed. One person can easily portant to avoid disturbing, bending, kinking, or oc-
turn the patient horizontally from prone to supine or cluding the tubing or accidentally disconnecting the
from supine to prone. This bed is used most frequently ventilator tube from the ET. The patient who uses a ven-
with patients who have spinal cord injuries and require tilator may participate in various bedside activities, in-
immobilization. The turning frame allows access to the cluding sitting and ambulation. Make sure the tubing is
patient and permits the patient to be moved from one sufficiently long to allow the activity to be performed.
place to another without being removed from the Because the patient will have difficulty talking, ask ques-
frame. Because of the limited number of possible posi- tions that can be answered with head nods or other
tions, the skin of patients using this type of bed should nonverbal means. A patient using a ventilator may have
be monitored frequently. a lower tolerance for activities and should be monitored
The circular turning frame (Circ-o-lectric bed) has a for signs of respiratory distress such as a change in the
front and a back frame attached to two circular sup- respiration pattern, fainting, or blue lips.
104 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

Monitors
provided with an A line in place, but care should be
Various monitors are used to observe the physiologic taken to avoid disturbing the catheter and inserted
state of patients who need special care. Therapeutic ac- needle.
tivities can be performed by patients who are being
monitored, provided care is taken to prevent disrup-
Feeding Devices
tion of the equipment. Many of the units have an au-
ditory and a visual signal that are activated by a Special feeding devices may be necessary to provide nu-
change in the patient's condition or position or by a trition for patients who are unable to ingest, chew, or
change in the function of the equipment. It may be swallow food. Some of the more commonly seen
necessary for a nurse to evaluate and correct the cause devices are the nasogastric tube, gastric tube, and intra-
of the alarm unless the OTR has received special venous feedings.
instruction. The nasogastric (NG) tube is a plastic tube inserted
The electrocardiogram (EKG or ECG) monitors the through a nostril, terminating in the patient's stomach.
patient's heart rate, blood pressure, and respiration rate. The tube may cause the patient to have a sore throat or
Acceptable or safe ranges for the three physiologic indi- an increased gag reflex. The patient will not be able to
cators can be set in the unit. An alarm is activated when eat food or drink fluids through the mouth while the
the upper or lower limits of the ranges are exceeded or if NG tube is in place. Movement of the patient's head and
the unit malfunctions. A monitoring screen provides neck, especially forward flexion, should be prevented.
a graphic and digital display of the values so that The gastric tube (G tube) is a plastic tube inserted
health care staff can observe the patient's responses to through an incision in the patient’s abdomen directly
treatment. into the stomach. The tube should not be disturbed or
The pulmonary artery catheter (PAC) (e.g., Swan-Ganz removed during treatment.
catheter) is a long, plastic intravenous tube that is in- Intravenous feeding, total parenteral nutrition
serted into the internal jugular or the femoral vein and (TPN), or hyperalimentation devices permit infusion
passed through to the pulmonary artery. It provides ac- of large amounts of nutrients needed to promote tissue
curate and continuous measurements of pulmonary growth. A catheter either is inserted directly into the
artery pressures and will detect subtle changes in the subclavian vein or is passed into the subclavian vein
patient's cardiovascular system, including responses to after being inserted into another vein. The catheter may
medications, stress, and activity. Activities can be per- be connected to a semipermanently fixed cannula or
formed with the PAC in place, providing they do not in- sutured at the point of insertion. The OTR should care-
terfere with the location of the catheter’s insertion. For fully observe the various connections to be certain they
example, if the catheter is inserted into the subclavian are secure before and after treatment. A disrupted or
vein, elbow flexion should be avoided and shoulder loose connection may result in the development of an
motions restricted. air embolus, which could be life threatening.
The intracranial pressure (ICP) monitor measures the The system usually includes an infusion pump,
pressure exerted against the skull by brain tissue, blood, which will administer fluids and nutrients at a prese-
or cerebrospinal fluid (CSF). It is used to monitor ICP lected, constant flow rate. An audible alarm will be acti-
in patients with a closed head injury, cerebral hemor- vated if the system becomes imbalanced or when the
rhage, brain tumor, or overproduction of cerebrospinal fluid source is empty. Treatment activities can be per-
fluid. Some of the complications associated with this formed as long as the tubing is not disrupted, discon-
device are infection, hemorrhage, and seizures. Two of nected, or occluded and as long as undue stress to the
the more commonly used ICP monitoring devices are infusion site is prevented. Motions of the shoulder on
the ventricular catheter and the subarachnoid screw. the side of the infusion site may be restricted, especially
Both are inserted in a hole drilled in the skull. Physical abduction and flexion.
activities should be limited when these devices are in Most intravenous (IV) lines are inserted into superfi-
place. Activities that would cause a rapid increase in ICP, cial veins. Various sizes and types of needles or catheters
such as isometric exercises, should be avoided. Positions are used, depending on the purpose of the IV therapy,
to avoid include neck flexion, hip flexion greater than the infusion site, the need for prolonged therapy, and
90 degrees, and the prone position. The patient's head site availability. Care should be taken during treatment,
should not be lowered more than 15 degrees below hor- to prevent any disruption, disconnection, or occlusion
izontal. Care must be taken to avoid disturbing the of the tubing. The infusion site should remain dry, the
plastic tube. needle should remain secure and immobile in the vein,
The arterial monitoring line (A line) is a catheter and no restraint should be placed above the infusion
that is inserted into an artery to continuously site. For example, a blood-pressure cuff should not be
measure blood pressure or to obtain blood samples applied above the infusion site. The total system should
without repeated needle punctures. Treatment can be be observed to be certain it is functioning properly
 Infection Control and Safety Issues in the Clinic 105

when treatment begins and ends. If the infusion site is routinely treated have specific protocols for catheter
in the antecubital area, the elbow should not be flexed. care.
The patient who ambulates with an IV line in place Two types of internal catheters that are frequently
should be instructed to grasp the IV support pole so that used are the Foley catheter and suprapubic catheter. The
the infusion site will be at heart level. If the infusion site Foley catheter is a type of indwelling catheter that is
is allowed to hang lower, blood flow may be affected. held in place in the bladder by a small balloon in-
Similar procedures to maintain the infusion site in flated with air, water, or sterile saline solution. For
proper position should be followed when the patient is removal of the catheter, the balloon is deflated and
treated while in bed or at a treatment table. Activities in- the catheter is withdrawn. The suprapubic catheter is
volving elevation of the infusion site above the level of inserted directly into the bladder through incisions in
the heart for a prolonged period should be avoided. the lower abdomen and the bladder. The catheter may
Problems related to the IV system should be reported to be held in place by adhesive tape, but care should be
nursing personnel. Simple procedures such as straight- used to avoid its removal, especially during self-care
ening the tubing or removing an object that is occluding activities.
the tubing may be performed by the properly trained
therapist.
INFECTION CONTROL
Infection control procedures are used to prevent the
Catheters
spread of disease and infection among patients, health
A urinary catheter is used to remove urine from the care workers, and others. They are designed to interrupt
bladder when the patient is unable to satisfactorily or establish barriers to the infection cycle. Universal
control retention or release. The urine is drained precautions (Box 11-1 and Fig. 11-1) were first estab-
through plastic tubing into a collection bag, bottle, or lished by the Centers for Disease Control and Preven-
urinal. Any form of trauma, disease, condition, or disor- tion (CDC) to protect the health care worker from in-
der affecting the neuromuscular control of the bladder fectious agents such as the human immunodeficiency
sphincter may necessitate the use of a urinary catheter. virus (HIV) and diseases such as acquired immune de-
The catheter may be used temporarily or for the remain- ficiency syndrome (AIDS) and hepatitis B. However, to
der of the patient's life.
A urinary catheter can be applied internally (in-
dwelling catheter) or externally. Female patients require
an indwelling catheter inserted through the urethra
and into the bladder. Males may use an external
catheter. A condom is applied over the shaft of the ry of Universal Precautions
penis and is held in place by an adhesive applied to the
skin or by a padded strap or tape encircling the proxi-
mal shaft of the penis. The condom is connected to a . Use extreme care to prevent injuries caused by sharp
instruments.
drainage tube and bag.
2. Cover minor, nondraining, noninfected skin lesions with an
When patients with urinary catheters are treated,
adhesive bandage.
several precautions are important. Disruption or stretch- 3. Report infected or draining lesions and weeping dermatitis
ing of the drainage tube should be prevented, and no to your supervisor :
tension should be placed on the tubing or the catheter. 4. Avoid personal habits (e.g,, nailbiting) that increase the
The bag must not be placed above the level of the bladder potential for oral mucous membrane contact with body
for more than a few minutes. The bag should not be surfaces.
placed in the patient's lap when the patient is being 5. Perform procedures involving body substances carefully to
transported. The production, color, and odor of the urine minimize splatters and aerosols.
should be observed. The following observations should 6. Cover environmental surfaces with moisture-proof
be reported to a physician or nurse: foul-smelling, barriers whenever splattering with body substances is
possible.
cloudy, dark, or bloody urine, or a reduction in the flow
7. Wash hands regularly, especially after gloves are worn.
or production of urine. The collection bag must be
8. Avoid unnecessary use of protective clothing. Use
emptied when it is full. alternate barriers whenever possible.
Infection is a major complication for persons using 9. Wear gloves to touch the mucous membrane or
catheters, especially for those using indwelling catheters. nonintact skin of any patient and whenever direct contact
Everyone involved with the patient should maintain with body substances is anticipated.
cleanliness during treatment. The tubing should be re- 10. Wear protective clothing (e.g., gown, mask, and goggles)
placed or reconnected only by those properly trained. when splashing of body substances is anticipated.
Treatment settings in which patients with catheters are a er en I ETA EE EI IB SI RA
106 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

GOWN/APRON MASK/EYEWEAR

Before touching blood, body fluids, Wash hands immediately after gloves Masks and protective eyewear or face
mucous membranes, non-intact skin or are removed. Wash hands and other For procedures likely to generate shields for procedures likely to
performing venipuncture. Change skin surfaces immediately if contami- splashes of blood or other body fluids. generate splashes of blood or other
gloves after contact with each patient. nated with blood or other body fluids. body fluids.

SHARPS NO HAND RECAP RESUSCITATION WASTE/LINEN

Dispose of needles with syringes and Mouthpieces or resuscitator bags

W
Waste and soiled linen should be
Do not recap needles or otherwise
other sharp items in puncture-resistant manipulate by hand before disposal. should be available to minimize need for handled in accordance with hospital
container near point-of-use. emergency mouth-to-mouth resuscitation. Foe) [oaVar-Tale MColer-] mtLua

Universal Precautions apply to blood, visibly bloody fluid, semen, vaginal secretions, tissues and to cerebrospinal, synovial, pleural, peritoneal, pericardial and amniotic fluids.

FIG. I1-1
Universal blood and body fluid precautions. (Courtesy Brevis Corp., Salt Lake City, Utah.)

be effective, they must be used with all patients, not just 1. Using protective equipment and clothing provided
those identified as infected. by the facility whenever the employee contacts, or
The Occupational Safety and Heaith Administration anticipates contact, with body fluids
(OSHA) has issued regulations to protect the employees 2. Disposing of waste in proper containers, applying
of health care facilities. All health care settings must do knowledge and understanding of the handling of
the following to comply with federal regulations:
1. Educate employees on the methods of transmission
and the prevention of hepatitis B and HIV.
2. Provide safe and adequate protective equipment and
teach employees where the equipment is located and
how to use it.
t pEPosit Tt
3. Teach employees about work practices used to prevent
occupational transmission
but not limited to, universal precautions, proper
of disease, including,
2)
handling of patient specimens and linens, prop- ay meeacal
waste
er cleaning of body fluid spills (Fig. 11-2), and proper
waste disposal.
4. Provide proper containers for the disposal of waste
and sharp items, and teach employees the color
coding system used to distinguish infectious waste.
5. Post warning labels and biohazard signs (Fig. 11-3).
6. Offer the hepatitis B vaccine to employees who are at
substantial risk of occupational exposure to the hep-
FIG. 11-2
atitis B virus.
Spills of body fluids must be cleaned up by a gloved employee,
7. Provide education and follow-up care to employees using paper towels, which should then be placed in an infectious
who are exposed to communicable disease. waste container. Afterward, 5.25% sodium hypochlorite (house-
OSHA has also outlined the responsibilities of hold bleach) diluted 1:10 should be used to disinfect the area.
health care employees. These responsibilities include (From Zakus SM: Clinical procedures for medical assistants, ed 3, St
the following: Louis, 1995, Mosby.)
 Infection Control and Safety Issues in the Clinic

WD cinique for Effective Hand Washing

. Remove all jewelry, except plain band-type ring. Remove

7
watch or move it up. Provide complete access to area to
be washed.
2. Approach the sink and avoid touching the sink or nearby
objects,
3. Turn on the water and adjust it to a lukewarm
temperature and a moderate flow to prevent splashing.
BIOHAZARD 4. Wet your wrists and hands with your fingers directed
downward and apply approximately | teaspoon of liquid
soap or granules.
FIG. I 1-3 5. Begin to wash all areas of your hands (palms, sides, and
Biohazard label. (From Zakus SM: Clinical procedures for medical as- backs), fingers, knuckles, and between each finger, using
sistants, ed 3, St Louis, 1995, Mosby.) vigorous rubbing and circular motions (Fig. | 1-4). If
wearing a band, slide it down the finger a bit and scrub
skin underneath it. Interlace fingers and scrub between
each finger
infectious waste, and using color-coded bags or
6. Wash for at least 30 seconds, keeping the hands and
containers forearms at elbow level or below, with hands pointed
3. Disposing of sharp instruments and needles into down. Wash longer if you have treated a patient known to
proper containers without attempting to recap, have an infection.
bend, break, or otherwise manipulate them before 7. Rinse hands well under running water.
disposal 8. Wash wrists and forearms as high as contamination is
4. Keeping the work environment and patient care area likely.
clean 9. Rinse hands, wrists, and forearms under running water
5. Washing hands immediately after removing gloves (Fig. | 1-5).
10. Use an orangewood stick or nail brush to clean under
and at any other times mandated by hospital or
each fingernail at least once a day when starting work and
agency policy
each time hands are highly contaminated. Rinse nails well
6. Immediately reporting any exposures such as needle under running water (Fig. | |-6).
sticks or blood splashes or any personal illnesses to ||. Dry your hands, wrists, and forearms thoroughly with
immediate supervisor and receiving instruction paper towels. Use a dry towel for each hand. The water
about any further follow-up action should continue to flow from the tap as you dry your
Although it is impossible to eliminate all pathogens hands.
from an area or object, the likelihood of infection can |2. Use another dry paper towel to turn water faucet off (Fig.
be greatly reduced. The largest source of preventable | 1-7). Discard all towels in an appropriate container.
patient infection is contamination from the hands of 13. Use hand lotion as necessary,
health care workers. Hand washing (Box 11-2 and Figs.
11-4 to 11-7) and the use of gloves are the most effective Modified from Zakus SM: Clinical procedures for medical assistants, ed 3, St
Louis, 1995, Mosby.
barriers to the infection cycle. Additional measures
include wearing caps, face masks, and gowns and prop-
etly disposing of sharp instruments, contaminated
dressings, and bed linens. is used to destroy all forms of microbial life, including
In the clinic, general cleanliness and proper control highly resistant bacterial spores. An autoclave is used to
of heat, light, and air are also important for infection sterilize items by steam under pressure. Ethylene oxide,
control. Spills should be cleaned up promptly. Work dry heat, and immersion in chemical sterilants are other
areas and equipment should be kept free from contami- methods of sterilization.
nation. A variety of disinfectants may be used to clean en-
To decontaminate is to “remove, inactivate, or vironmental surfaces and reusable instruments. When
destroy blood-borne pathogens on a surface or item to liquid disinfectants and cleaning agents are used,
the point where they are no longer capable of transmit- gloves should be worn to protect the skin from re-
ting infectious particles and the surface or item is ren- peated or prolonged contact. The CDC, local health de-
dered safe for handling, use, or disposal.”* Items to be partment, or hospital infection control department can
sterilized or decontaminated should first be cleaned provide information about the best product and
thoroughly to remove any residual matter. Sterilization method to use.
 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

FIG. I 1-4 FIG. 11-5

Handwashing technique. Interlace fingers to wash between them. Rinse hands well, keeping fingers pointed down. (From Zakus SM:
Create a lather with soap. Keep hands pointed down. (From Zakus Clinical procedures for medical assistants, ed 3, St Louis, 1995, Mosby.)
SM: Clinical procedures for medical assistants, ed 3, St Louis, 1995,
Mosby.)

FIG. 11-6 FIG. I 1-7

Use blunt edge of an orangewood stick to clean under the finger- After drying your hands, turn water faucet off, using a dry paper
nails. (From Zakus SM: Clinical procedures for medical assistants, ed 3, towel. (From Zakus SM: Clinical procedures for medical assistants, ed
St Louis, 1995, Mosby.) 3, St Louis, 1995, Mosby.)

Instruments and equipment used to treat a patient Therapists should routinely clean and disinfect per-
should be cleaned or disposed of according to institu- sonal items such as pens, keys, and clipboards because
tional or agency policies and procedures. Contaminated these objects are touched frequently and may become
reusable equipment should be placed carefully in a con- contaminated.
tainer, labeled, and returned to the appropriate depart-
ment for sterilization. Contaminated disposable items
Isolation Systems
should be placed carefully in a container, labeled, and
disposed of. Isolation systems are designed to protect a person or
Contaminated or soiled linen should be disposed of object from becoming contaminated or infected by
with minimal handling, sorting, and movement. It can transmissible pathogens. Various isolation procedures
be bagged in an appropriate bag and labeled before are used in different institutions. It is important for all
transport to the laundry, or the bag can be color coded health care workers to understand and follow the isola-
to indicate the type or condition of linen it contains. tion approach used in their facilities so protection can
Other contaminated items such as toys, magazines, per- be ensured.
sonal hygiene articles, dishes, and eating utensils should Generally, a patient is-isolated from other patients
be disposed of or disinfected. They should not be used and the hospital environment when he or she has a
by others until they have been disinfected. transmissible disease. Isolation involves placing the
 Infection Control and Safety Issues in the Clinic 109

STRICT ISOLATION

VISITORS: REPORT TO NURSES’ STATION BEFORE ENTERING ROOM

1. Masks are indicated for all persons entering the room.
2. Gowns are indicated for all persons entering the room.
3. Gloves are indicated for all persons entering the room.
4. HANDS MUST BE WASHED AFTER TOUCHING THE PATIENT OR POTENTIALLY
CONTAMINATED ARTICLES AND BEFORE TAKING CARE OF ANOTHER
PATIENT.
. Articles contaminated with infective material should be discarded or bagged and labeled
before being sent for decontamination and reprocessing.

FIG. 11-8
Strict isolation procedures sign. Card will be color-coded yellow and placed on or next to the door
of the patient’s room.

RESPIRATORY ISOLATION

VISITORS: REPORT TO NURSES’ STATION BEFORE ENTERING ROOM

1. Masks are indicated for those who come close to the patient.
2. Gowns are not indicated.
3. Gloves are not indicated.
4. HANDS MUST BE WASHED AFTER TOUCHING THE PATIENT OR POTENTIALLY
CONTAMINATED ARTICLES AND BEFORE TAKING CARE OF ANOTHER
PATIENT.
. Articles contaminated with infective material should be discarded or bagged and labeled
before being sent for decontamination and reprocessing.

FIG. 11-9
Respiratory isolation procedures sign. Card will be color-coded blue and placed on or next to the
door of the patient’s room.

patient in a room either alone or with one or more pa- the transmission of pathogens to the patient. The se-
tients with the same disease to reduce the possibility of quence and method of donning the protective garments
transmitting the disease to others. Specific infection are more important than the sequence used to remove
control techniques must be followed by all who enter them.
the patient's room. These requirements are listed on a
color-coded card and placed on or next to the door of
INCIDENTS AND EMERGENCIES
the patient's room. Strict isolation and respiratory isola-
tion procedures are shown in Figs. 11-8 and 11-9. Pro- Occupational therapists should be able to respond to a
tective clothing, including gown, mask, cap, and gloves, variety of medical emergencies and to recognize when it
may be needed. When leaving the patient, the caregiver is better to get assistance from the most qualified indi-
must remove the garments in the proper sequence. vidual available, such as a doctor, emergency medical
Occasionally, a patient's condition (e.g., burns or a technician, or nurse. This should be relatively easy in a
systemic infections) make him or her more susceptible hospital but may require an extended period if the treat-
to infection. This patient may be placed in protective iso- ment is conducted in a patient's home or outpatient
lation. In this approach, persons entering the patient's clinic. It is a good idea to keep emergency telephone
room may have to wear protective clothing to prevent numbers readily available. The therapist will need to
110 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

determine at the time of the incident whether it is wiser body or to sit on your thigh. You may need to lower the
to ask for assistance before or after beginning emer- patient into a sitting position on the floor using the gait
gency care.In most cases, it will be best to call for assis- belt and good body mechanics.
tance before initiating emergency care, unless the delay
is life threatening to the patient.
Burns
Consistently following safety measures will prevent
many accidents. However, the therapist should always Generally, only minor, first-degree burns are likely to
be alert to the possibility of an injury and expect the un- occur in occupational therapy. These can be treated with
expected to happen. Most institutions have specific poli- basic first aid procedures. Skilled personnel should be
cies and procedures to follow. In general, the therapist contacted for immediate care if the burn has any
should do the following when there is an injury to a charred or missing skin or shows blistering. The follow-
patient: ing steps should be taken for first-degree burns in which
1. Ask for help. Do not leave the patient alone. Prevent the skin is only reddened:
further injury to the patient and provide emergency 1. Rinse or soak the burned area in cold (not iced)
care. water.
2. When the emergency is over, document the incident 2. Cover with a clean or sterile dressing or adhesive
according to the institution's policy. Do not discuss bandage. In some instances a moist dressing will be
the incident with the patient or significant others or more comfortable for the patient.
express information to anyone that might indicate 3. Do not apply any cream, ointment, or butter to the
negligence.” burn because this will mask the appearance and may
3. Notify the supervisor of the incident and file the inci- lead to infection or a delay in healing.
dent report with the appropriate person within the
organization.
Bleeding
A laceration may result in minor or serious bleeding.
Falls
The objectives of treatment are to prevent contamina-
The therapist can prevent injuries from falls by remain- tion of the wound and to control the bleeding. The fol-
ing alert and reacting quickly when patients lose their lowing steps should be taken to stop the bleeding:
balance. Proper guarding techniques must be practiced. 1. Wash your hands and apply protective gloves. Con-
In many instances it is wise to resist the natural impulse tinue to wear protective gloves while treating the
to keep the patient upright. Instead, the therapist can wound.
carefully assist the patient to the floor or onto a firm 2. Place a clean towel or sterile dressing over the wound
object. and apply direct pressure to the wound. If no dress-
If a patient begins to fall forward, the following pro- ing is available, use your gloved hand.
cedure should be used: Restrain the patient by firmly 3. Elevate the wound above the level of the heart to
holding the gait belt. Push forward against the pelvis reduce blood flow to the area.
and pull back on the shoulder or anterior chest. Help 4. In some instances the wound can be cleansed with
the patient stand erect once it is determined there is no an antiseptic or by rinsing it with water.
injury. The patient may briefly lean against you for 5. Encourage the patient to remain quiet and avoid
support. If the patient is falling too far forward to be using the extremity.
kept upright, guide the patient to reach for the floor 6. If there is arterial bleeding (demonstrated by spurt-
slowly. Slow the momentum by gently pulling back on ing blood), it may be necessary to apply intermittent,
the gait belt and the patient's shoulder. Step forward as direct pressure to the artery, above the level of the
the patient moves toward the floor. Tell the patient to wound. The pressure point for the brachial artery is
bend the elbows when the hands contact the floor to on the inside of the upper arm, midway between the
help cushion the fall. The patient's head should be elbow and armpit. The pressure point for the femoral
turned to one side to avoid injury to the face. artery is in the crease of the hip joint, just to the side
If the patient begins to fall backwards, the following of the pubic bone.
procedure should be used: Rotate your body so one side 7. Do not apply a tourniquet unless you have been
is turned toward the patient's back and widen your trained to do so.
stance. Push forward on the patient's pelvis and allow
the patient to lean against your body. Then assist the
Shock
patient to stand erect. If the patient falls too far back-
ward, to stay upright continue to rotate your body until Patients may experience shock as a result of excessive
it is turned toward the patient's back and widen your bleeding, as a reaction to the change from a supine to
stance. Instruct the patient to briefly lean against your an upright position, or as a response to excessive heat.
 Infection Control and Safety Issues in the Clinic 111

Signs and symptoms of shock include pale, moist, and 5. After the convulsions cease, have the patient rest. It
cool skin, shallow and irregular breathing, dilated may be helpful to cover the patient with a blanket or
pupils, a weak or rapid pulse, and dizziness or nausea. screen to provide privacy.
Shock should not be confused with fainting, which 6. Get medical help.
would result in a slower pulse, paleness, and _per-
spiration. Patients who faint will generally recover
Insulin-Related Illnesses
‘promptly if allowed to lie flat. If a patient exhibits
symptoms of shock, the following actions should be Many patients seen in occupational therapy have
taken: insulin-related episodes. It is important for the OTR to
1. Determine the cause of shock and correct it if possi- be able to differentiate between the conditions of hypo-
ble. Monitor the patient's blood pressure and pulse glycemia (insulin reaction) and hyperglycemia (acido-
rate. sis) as shown in Table 11-1.
2. Place the person in a supine position, head slightly An insulin reaction can be caused by too much sys-
lower than the legs. If there are head and chest in- temic insulin, the intake of too much food or sugar, or
juries or if respiration is impaired, it may be neces- too little physical activity. If the patient is conscious,
sary to keep the head and chest slightly elevated. some form of sugar (e.g., candy or orange juice) should
3. Do not add heat, but prevent loss of body heat if be provided. If the patient is unconscious, glucose may
necessary by applying a cool compress to the have to be provided intravenously. The patient should
patient's forehead and covering the patient with a rest, and all physical activity should be stopped. This
light blanket. condition is not as serious as acidosis, but the patient
a . Keep the patient quiet and do not allow exertion. should be given the opportunity to return to a normal
5. After the symptoms are relieved, gradually return the state as soon as possible.
patient to an upright position and monitor the Acidosis can lead to a diabetic coma and eventual
patient's condition. death if not treated. It should be considered a medical
emergency requiring prompt action, including assis-
tance from qualified personnel. The patient should not
Seizures
be given any form of sugar. Usually, an injection of
Seizures may be caused by a specific disorder, brain insulin is needed, and a nurse or physician should
injury, or medication. The OTR should be able to recog- provide care as quickly as possible.
nize a seizure and take appropriate action to keep the
patient from getting hurt. A patient having a seizure will
Respiratory Distress
usually become rigid for a few seconds and then begin
to convulse with an all-over jerking motion. The patient Dyspnea control postures may be used to reduce
may turn blue and may stop breathing for up to 50 to 70 breathlessness in patients in respiratory distress. The
seconds. A patient's sphincter control may be lost
during or at the conclusion of the seizure, so the patient
may void urine or feces involuntarily. When a patient
shows signs of entering a seizure, the following steps
should be taken:
1. Place the person in a safe location and position away
s and Symptoms of Insulin-
from anything that might cause injury. Do not
attempt to restrain or restrict the convulsions.
Insulin Reaction Acidosis
2. Assist in keeping the patient's airway open, but do
not attempt to open the mouth by placing any Onset Sudden Gradual
object between the teeth. Never place your finger or
Skin Moist, pale Dry, flushed
a wooden or metal object in the patient’s mouth,
and do not attempt to grasp or position the Behavior Excited, agitated Drowsy
tongue. Breath odor Normal Fruity
3. If the patient’s mouth is open, place a soft object
between the teeth to prevent the patient from acci- Breathing Normal to shallow Deep, labored
dentally biting his or her tongue. A tongue depressor Tongue Moist Dry
wrapped with several layers of gauze and fastened
Vomiting Absent Present
with adhesive tape or a sturdy cloth object may be
used. Hunger Present Absent
4. When the convulsions subside, turn the person’s
Thirst Absent Present
head to one side as a precaution against vomiting.
1 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

patient must be responsive and have an unobstructed

airway. The high-Fowler’s position (Fig. 11-10) may be used
for patients in bed. The head of the bed should be in an
upright position at a 90° angle. If available, a footboard
should be used to support the patient's feet. The orthop-
neic position (Fig. 11-11) may be used for patients who are
sitting or standing. In either case the patient bends
forward slightly at the waist and supports the upper body
by leaning the forearms on a table or counter.

Choking and Cardiac Arrest

All health care practitioners should be trained to treat
patients who are choking or suffering from a cardiac
arrest. Specific training courses are offered by both the
American Heart Association and the American Red
Cross. The following information is presented as a reminder
of the basic techniques and is not meant to be substituted for FIG. 11-11
training. Orthopneic position.
The urgency of choking cannot be overemphasized.
Immediate recognition and proper action are essential.
When assisting a conscious adult or a child who is more 5. Seek medical assistance.
than 1 year old, the following steps should be taken: When assisting an unconscious adult or child who is
1. Ask the patient, “Are you choking?” If the patient can more than 1 year old, the following steps should be taken:
speak, or cough effectively, do not interfere with the i Place the person in a supine position and call for
patient's own attempts to expel the object. medical help.
. If the patient is unable to speak, cough, or breathe, 2. Open the person’s mouth and use your finger to
check the mouth and remove any visible foreign attempt to locate and remove the foreign object
object. (finger sweep).
. If the patient is unable to speak or cough, position 3. Open the airway by tilting the head back and lifting
yourself behind the patient. Clasp your hands over the chin forward. Attempt to ventilate using the
the patient’s abdomen, slightly above the umbilicus mouth-to-mouth technique. If unsuccessful, deliver
but below the diaphragm. up to five abdominal thrusts (Heimlich maneuver),
. Use the closed fist of one hand, covered by your repeat the finger sweep, and attempt to ventilate. It
other hand, to give three or four abrupt thrusts may be necessary to repeat these steps. Be persistent
against the person’s abdomen by compressing the and continue these procedures until the object is
abdomen in and up forcefully (Heimlich maneuver). removed or medical assistance arrives.
Continue to apply the thrusts until the obstruction It may be necessary to initiate cardiopulmonary re-
becomes dislodged or is relieved or the person suscitation (CPR) techniques to stabilize the person's
becomes unconscious. cardiopulmonary functions after the object has been
removed. The following procedures are recommended
for CPR’:
1; Determine the patient's condition by gently shaking
the patient and asking, “Are you all right?” or, “How
do you feel?”
2. If there is no response, place the patient in a supine
a position on a firm surface. Open the patient's airway
by lifting up on the chin and pushing down on the
A ey) y forehead to tilt the head back.
a A 3. Check for respiration by observing the chest or
abdomen for movement, listen for sounds of breath-
ing, and feel for breath by placing your cheek close to
the person’s mouth. If no sign of breath is present,
FIG. 11-10 the patient is not breathing, and you should initiate
High-Fowler’s position. breathing techniques.
 Infection Control and Safety Issues in the Clinic 113

4. Pinch the patient's nose closed and maintain the 7. If you perform all CPR procedures without assistance,
head tilt to open the airway. Place your mouth over you should perform 15 chest compressions and then
the patient's mouth and form a seal with your lips. perform two breaths. You must compress at the rate of
Perform two full breaths, then evaluate the circula- 80 to 100 times per minute. Continue these proce-
tion. Some persons prefer to place a clean cloth over dures until qualified assistance arrives or the patient is
the patient's lips before initiating mouth-to-mouth able to sustain independent respiration and circula-
respirations. If available, a plastic intubation device tion. If you are alone, attempt to gain assistance from
can be used to decrease the contact between the care- other persons by calling loudly for help. If a second
giver's mouth and the patient's mouth and any saliva person is present, the person should contact an ad-
or vomitus. vanced medical assistance unit before beginning to
. Palpate the carotid artery for a pulse. If there is assist with CPR. In most instances the patient will
no pulse, you must begin external chest compres- require hospitalization and evaluation by a physician.
sions. (Note: Extreme care must be used to open the airway
6. To initiate chest compressions, kneel next to the of a person who may have experienced a cervical spine
patient, place the heel of one hand on the inferior injury. In such cases, use the chin lift, but avoid the head
portion of the sternum just proximal to the xiphoid tilt. If the technique does not open the airway, the head
process, and place your other hand on top of the first should be tilted slowly and gently until the airway is
hand. Position your shoulders directly over the open.)
patient’s sternum, keep your elbows extended, and These procedures are appropriate to use for adults
press down firmly, depressing the sternum approxi- and for children 8 years of age and older. Performing
mately 11/2 to 2 inches with each compression. Relax CPR is contraindicated if patients have clearly expressed
after each compression, but do not remove your their desire for “do not resuscitate” (DNR). This infor-
hands from the sternum. The relaxation and com- mation should be clearly documented in the medical
pression phases should be equal in duration. This chart. A pamphlet or booklet containing diagrams and
can be accomplished by mentally counting “one instructions for CPR techniques (Fig. 11-12) can be ob-
thousand one,” “one thousand two,” “one thousand tained from most local offices of the American Heart As-
three,” and so on for each phase. sociation or from a variety of web sites.

STEP 1 STEP 4

CALL 911 CHECK

PULSE

STEP 2 SPER

TILT HEAD, POSITION

LIFT CHIN, HANDS IN THE
CHECK CENTER OF
BREATHING THE CHEST

STEP 3 STEP 6

GIVE TWO FIRMLY

BREATHS PUSH DOWN
TWO INCHES
ON THE CHEST
15 TIMES

CONTINUE WITH TWO BREATHS

AND 15 PUMPS UNTIL HELP ARRIVES

FIG. 11-12
Standard CPR. (From www.learncpr.org/pocket.html.)
114 OCCUPATIONAL THERAPY PROCESS AND PRACTICE

4. Describe positions to avoid for patients with above-

SUMMARY. and below-knee lower extremity amputations, total
All occupational therapy personnel have a legal and hip replacements, hemiplegia, rheumatoid arthritis,
professional obligation to promote safety for self, the and burns.
patient, visitors, and others. The OTR should be pre- 5. Define the following: IV line, A line, NG tube, TPN
pared to react to emergency situations quickly, deci- or hyperalimentation, and ventilator.
sively, and calmly. The consistent use of safe practices 6. Describe universal precautions.
helps reduce accidents for both patients and workers 7. Why is it important to follow universal precautions
and reduces the length and cost of treatment. with all patients?
8. Demonstrate the proper technique for hand-
RECOMMENDED READINGS oN
9. How should you respond to a patient emergency?
|
Information on infection control can be obtained from 10. Describe how you would help a patient who is
the CDC, OSHA, and the Environmental Protection falling forward and one who is falling backward?
Agency (EPA). 11. Which emergency situations might require getting
Information on first aid, choking, and CPR can be advanced medical assistance and which situations
obtained from most local offices of the American Heart could a therapist handle alone?
Association and from the American National Red Cross.
In addition, information on emergency procedures may REFERENCES
be found at a variety of web sites. 1. Adult basic life support, JAMA 268(16):2184-2198, 1992.
2. Occupational Safety and Health Administration: Occupational
exposure to blood-borne pathogens: final rule, Federal Register
REVIEW QUESTIONS : 56:64175, 1991.
3. Pierson FM: Principles and techniques of patient care, ed 2, Philadel-
1. Why is it important to teach the patient and signifi- phia, 1999, WB Saunders.
cant others guidelines for handling various emer- 4. Steich TJ: Malpractice and occupational therapy personnel, Occup
gency situations? Ther News 39(6):8, 1985.
2B. Describe at least four behaviors you can adopt to 5. Zakus SM: Clinical procedures for medical assistants, ed 3, St Louis,

improve patient safety. aoa>aMosby.

3. Describe the consequences of improper positioning
of patients.
Occupational Performance

LEARNING OBJECTIVES
Occupation Study of this chapter will enable the student or
Occupational performance areas practitioner to do the following:
Performance components 1. Define occupation.
Performance context 2. Provide a detailed analysis of the complex nature of
Identity occupation.
Client-centered evaluation and intervention 3. Describe methods used to elicit occupational
Narrative interviews information from patients and clients.
Canadian Occupational Performance Measure 4. Discuss the importance of occupation in the
Occupational Performance History Interview, Version II formation and maintenance of a sense of identity.
Activity Configuration 5. Discuss approaches for evaluating occupational
Remediation performance.
Compensation 6. Explain how to set client-centered goals related to
Environmental modification occupational performance.
Environmental management 7. Compare and contrast various approaches to
improve occupational performance.
8. Identify ways to measure progress in reaching
occupational performance goals.

I. chapter introduces the chapters on the occupa- familiar things that people do every day.”’ The ability
tional performance areas (activities of daily living, work, to pursue and perform a person’s customary occupa-
and leisure) and on specific aspects of occupational per- tions is taken for granted so long as a person is well.
formance (mobility, sexuality, the Americans With Dis- Injury and disease may disrupt occupation temporar-
abilities Act, and assistive technology) that are of particu- ily, but most people seek or are referred for the serv-
lar concern to persons who have physical disabilities. ices of an occupational therapist only when they en-
The present chapter frames the content of Part Three and counter significant difficulty resuming or enacting
advises the student and reader to keep the focus on occu- (carrying out) occupations that are important to
pation when evaluating and treating persons with physi- them.
cal dysfunction. On meeting the patient, how should the occupa-
tional therapist approach occupation? How does the
therapist evaluate difficulties in occupational perfor-
OCCUPATION AND PHYSICAL
mance? Are there preferred methods for the therapist to
DYSFUNCTION
assist a person to engage in occupations? These are
The American Occupational Therapy Association some of the questions that will be considered in this
(AOTA) has defined occupation as “the ordinary and chapter.

117
0 Re, OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

ANALYZING OCCUPATIONAL
occupational performance is a unique enactment of the
PERFORMANCE occupational form.
According to the Uniform Terminology, third edition,* Occupational performance depends on the individ-
occupations may be classified within three occupa- ual’s (1) perception of occupational form and (2) sense
tional performance areas: activities of daily living of purpose in this performance.'* Does the form have
(ADL), work and productive activities, and play and meaning to the individual? This affects quality of per-
leisure. Further, performance in occupations may be formance and, indeed, whether performance is initiated
considered in terms of the performance components, and sustained.
the underlying skills or functions (such as muscle Does the occupational form elicit purpose from the
strength, balance, or memory) that support the ability individual? What is the nature of this purpose? Purpose
to perform. Occupation also occurs within a perform- must come from the actor, not from outside (i.e., from
ance context, which has temporal and environmental the therapist). For example, the purpose may be to
dimensions. (The reader is encouraged to review Chap- create something, to fulfill a duty, to please someone
ter 1 for further detail on the organization of occupa- else, or to get money. Each performance influences sub-
tional performance.) sequent performances'* and also affects the individual
The patient with a physical problem who is referred in a variety of ways.
for occupational therapy almost always has obvious Breines* observed that the purpose of occupation is
deficits in performance components. These deficits to make a difference and to have an effect on the world.
(limited range of motion [ROM], reduced muscle The therapist's role is, then, to facilitate performance for
strength, impaired balance, and perceptual difficulties) those who are unable to perform.*
may be so prominent as to distract both patient and Occupations contribute to a person’s sense of iden-
therapist from considering occupation itself. However, tity. People frequently define who they are by their occu-
interventions that seek to improve performance compo- pation and their abilities. This is true not only of occupa-
nent function without evaluating and improving occupa- tions that are “jobs,” but also of leisure and daily living
tional performance cannot be considered occupational occupations. A person may say, “I am a homemaker,”
therapy. Thus, even when it seems obvious that the and also “I am a left-midfielder” or “I drive everywhere,
patient needs (for example) to improve sitting balance and I don’t even know where the bus routes are.”
and increase active ROM and muscle strength in the Identity is significantly challenged by the inability to
right upper extremity, the therapist is required to look at perform occupational roles. Dickerson and Oakley”
the “bigger picture” of occupational functioning—not found that persons with physical disabilities living in
just occupational functioning in general, but the specific the community reported that they did not expect to
and highly individual functioning desired and required resume roles of student, worker, or hobbyist. They
for that individual in his or her chosen and valued oc- noted that treatment of physical dysfunction tradition-
cupations. ally focuses on functional restoration (of performance
components used in daily living tasks) and not on the
less tangible goals of performing in occupational roles.
HIDDEN DIMENSIONS OF OCCUPATION
Competence in occupations is highly valued and
Occupations have personal meaning, as well as cultural, central to feelings of self-worth. Taking pride in perform-
temporal, psychologic, social, spiritual, and symbolic ance of even mundane tasks is the norm. Consider the
dimensions.~” Clark and associates® state that occupa- following statements that indicate valuing of occupa-
tion is “chunks of meaningful activity in which humans tional competence. A 3-year-old declares, “I get dressed
engage.” The examples given are “dressing, attending a all by myself!” A taxi driver says, “I keep my car very clean
party, gardening, watching television, making love, and and neat. My customers always comment.” An 80-year-
preparing a meal.”° Occupation must be viewed as old proudly states, “I still garden 4 hours.every day, up
complex, highly specific, having symbolic attributes, and down, on my hands and knees, everything.”
and often charged with emotion. Context modifies occupational performance. Expec-
Nelson’* makes a distinction between occupational tations and relative valuing of occupational perform-
form and occupational performance. Occupational form ance are set not just by the individual, but also by the
has an objective nature, independent of the person culture, the family, and society in general. This becomes
engaged in the occupation. Occupational form is influ- important when the therapist envisions the future occu-
enced by sociocultural and physical characteristics. pational performance of a patient. The therapist must
Thus, it is not a medium such as weaving or cooking, but find out whether it is important to the patient and
a form such as weaving on a Navajo blanket loom in a family that the patient perform the particular occupa-
hogan or cooking chapatis on a cookfire fueled by cow tion. Further, the therapist must learn the contextual el-
patties. Occupational performance is the action that is ements (e.g., environment and objects) that will frame
structured or elicited by the occupational form.'* Each the performance of the occupation.
 Occupational Performance Be ay
fe

OBTAINING INFORMATION ABOUT

momentum and entrapment. They may say, for ex-
OCCUPATIONAL PERFORMANCE
ample, that they felt “stuck” or “trapped” or that “it was
How does the therapist collect data about the occupa- hard to get going.”
tional performance of a patient with physical dysfunc- Structured interviewing tools such as the Canadian
tion? Occupational performance is assessed by the Occupational Performance Measure,” Activity Configu-
_ patient's self-report, by the report of an informed family ration,”’'* and the Occupational Performance History
member or caregiver, and by naturalistic and structured Interview’ may be used. (See Table 12-1 for these and
observation of occupational performance tasks that are others.)
important to the patient.
Evaluation of occupational performance necessitates that
Interview-Based Assessments
the patient be asked to identify problems, needs, and priori-
of Occupational Performance
ties. In traditional settings, it may appear that protocol
dictates the use of particular forms to assess specific The Canadian Occupational Performance Measure
components of performance (e.g., joint ROM). Such (COPM) is a standardized, semistructured interview
forms will not reveal the particular occupational experi- that has specific instructions and methods for adminis-
ences that cause distress. On the other hand, interview- tering and scoring. It encompasses the areas of self-care,
ing the patient, whether formally using a structured in- productivity, and leisure and is designed to “detect
terview format, or less formally in the course of other change in a client's self-perception of occupational per-
assessments, will elicit those tasks and areas that the formance over time.”® It measures self-perception of oc-
patient finds most troublesome. Beginning with these cupational performance, is client centered, and can be
troublesome and valued tasks is a more direct route to used with a variety of disabilities and all developmental
meaningful functional outcomes. stages.®
The therapist gathers information about how the The COPM asks clients to identify issues in occupa-
patient spends and manages time and perceives his or tional performance, rate their problems in terms of im-
her own occupational performance. Narrative inter- portance, and self-rate their level of functioning. The
views invite patients to speak at length, expanding COPM yields self-report scores of performance and of
on their occupational experiences and revealing their satisfaction. The scores on the COPM are not norm ref-
feelings and understanding of present and past oc- erenced. Instead, they are referenced to the unique
cupational difficulties. Mallinson, Kielhofner, and Mat- problems of each individual patient. The comparison of
tingly” note that patients may use themes relating to the individual’s scores from assessment to reassessment

Interview-Based Assessments of Occupational Performance

Assessment Description
Activity Configuration*® Semi-structured interview yielding data on education, work, leisure, and
values, as well as a daily schedule. Interview also elicits occupational roles
and balance of activities.

Assessment of Occupational Functioning (AF)! Screening tool, interview format. Measures occupational functioning. Related
to Model of Human Occupation (MOHO). Developed for long-term
care settings.

Canadian Occupational Performance Measure (COPM)* Interview-based rating scale of client's perception of occupational
performance and satisfaction with performance. Multiple ratings over
time yield outcome data.

Occupational Performance History Interview, Version 2 Semistructured interview with rating scales for occupational identity,
occupational competence, and impact of environment or context. Also
includes creation oftime line from life history of patient.
*Cykin S: Occupational therapy: toward health through activities, Boston, 1979, Little, Brown
tKielhofner G, Mallinson T, Crawford C, et al: A user's manual for the occupational performance history interview, version 2, Chicago, 1998, University of Illinois at
Chicago.
+Law M, Baptiste S, Carswell A, et al: Canadian occupational performance measure, ed 3, Ottawa, Ontario, 1998, CAOT Publications
SWatanabe S: The activities configuration, 1968 Regional Institute on the Evaluation Process, New York, 1968, American Occupational Therapy Association.
Watts JH, Kielhofner G, Bauer DF, et al: The assessment of occupation functioning: a screening tool for use in long term care, Am J Occup Ther 40(4):23 1-240, 1986.
120 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

Assessment of Occupational Performance

is viewed as the most appropriate measure of change
When Referral Is More Restricted
and progress.® The COPM targets client-identified prob-
lems and is intended to facilitate treatment collabora- Where therapy services require referral or doctor's
tion between client and therapist.'* orders, the therapist must start from the deficit noted in
The Occupational Performance History Interview, the original order but is also obliged to consider the
Version II (OPHI-II),"° includes a semistructured inter- patient more globally. In other words, the challenge
view, rating scales, and a life history narrative. The life may be to find a way to identify and obtain permission
history narrative invites the patient to tell his or her life to address other occupational performance areas and
story and explain how and why the various events tasks that are troublesome to the patient, without ex-
occurred. This contributes to the storytelling, story- ceeding the spirit of the original order.
making process of narrative reasoning (see Chapter 3)
and helps the therapist view the disability from the
SETTING GOALS RELATED TO
patient's perspective.
OCCUPATIONAL PERFORMANCE
The COPM and the OPHI-II each require 45 to 60
minutes to administer and score, but this time is justi- Goals must be defined jointly by the patient and the
fied by the functional data yielded. Either may be used therapist. These goals must identify steps toward realiz-
as a starting point for assessment and intervention ing occupations that are valued by the patient. The ther-
related to occupational performance. apist will be skilled at refining the client’s broad goal
The Activity Configuration (Fig. 12-1) yields infor- statements into treatment objectives that are achievable,
mation about the patient's values, educational history, understandable, observable, measurable, and stated in
work history, leisure interests and activities, vocational behavioral terms. Thus the therapist can help the
interests, and plans.”’'* From the activity configuration, patient who says, “I want to go home” to identify and
the therapist can construct a daily schedule of activities, work toward a more immediate (but related) objective
a list of life roles, and an analysis of activity balance in such as, “The patient will transfer from wheelchair to
the person’s life. As with the COPM and the OPHI-II, toilet without assistance.” Using a client-centered ap-
administration of the activity configuration is time con- proach, the therapist can develop a succession of goals
suming but worthwhile because it yields rich and leading to the “big goal.” The therapist thus creates “the
detailed data. See Table 12-1 for other interview-based big picture” of “where we are going with therapy” and
assessments. can remind the patient of the importance and place of
the immediate goal.
Performance-Based Assessment The therapist must avoid setting goals that indicate
functional restoration in the absence of an occupa-
of Occupational Performance
tional dimension. A goal statement such as, “Increase
Interview instruments yield important data concerning elbow flexion by 20°” focuses on functional restora-
patient and family perception of the patient's occupa- tion but does not say why this is important. The thera-
tional performance. Interviews must be augmented by pist provides an occupational dimension and a func-
direct observation of patient performance, so that the tional context by writing instead, “Increase elbow
therapist can evaluate the safety, accuracy, efficiency, flexion by 20° so that patient can eat finger foods in-
and completeness of the performance. Many structured dependently.” See Chapter 6 for further examples of
assessment instruments are available for assessing spe- goal statements.
cific areas of occupational performance, and these are
described in their corresponding chapters (see Chapters
TREATING DEFICITS IN OCCUPATIONAL
13 to 16 and 19).
Notwithstanding the value of these structured assess-
PERFORMANCE
ments, naturalistic observation is sometimes more rele- Deficits in occupational performance are addressed by a
vant to the needs of a particular individual in a specific variety of methods detailed in Chapters 13 through 19.
performance context. Consider, for example, the needs These methods are based on the following broad con-
of amultiple amputee who must don an unusual ortho- cepts and principles:
pedic appliance, or another person who must manage 1. Occupational performance deficits are rarely amenable to
to get up onto a toilet that is in a tight and awkward direct remediation. In other words, while a muscle
corner. In these cases the patient's performance on a (e.g., biceps brachii) can be strengthened through ex-
standard ADL evaluation may miss entirely the specific ercise and graded resistance, performance of more
occupational performances most likely to cause diffi- complex occupational tasks (e.g., feeding self with a
culty. It is the therapist's responsibility to carefully spoon) may require more than practice and repeti-
review the goals of the patient and make sure that the tion. Remediation is useful to alleviate performance
evaluation sufficiently addresses areas of concern. component dysfunction that may limit occupational
 Occupational Performance 121

ACTIVITY CONFIGURATION AND DAILY SCHEDULE: OUTLINE FOR INTERVIEW

Background Information
NS Oe é=Pationtisage’ Patient's sex
Patient's life stage

Educational History
. Highest educational level achieved
. Location and type of schools (e.g, public, private, parochial)
. Subjects of greatest interest
. Subjects of least interest
. Average grades achieved
. Likes and dislikes about school
. Leisure interests during school years
. Social groups to which subject belonged
. Educational level of parents, siblings
. Future educational plans
CO
—-
—
WH. Career aspirations
vowmNnoanmns

Work History
|. Most recent work or job performed
. Previous jobs
. Special job training (past, present)
. Likes and dislikes about jobs, past and present
. Most preferred jobs (real or imagined)
. Preferences for working alone or with others
. Works alone or with others
. Socializes with coworkers (on the job, off the job)
. Job supervisor
. Type of supervision received (close, distant)
. Most effective or desirable type of supervision
. Plans for future work or job changes

Leisure Interests and Activities

|, Interest in sports, games, hobbies (specify)
2. Participation in sports, games, hobbies (when, how long)
3, Other leisure interests that would be pursued given adequate time
4. Are leisure skills considered important to life? Why or why not?

Values and Cultural Influences

. Cultural group with which the patient identifies
. Describe cultural customs which are important (e.g., celebrations, holiday festivals, foods, religious practices, garments, family traditions)
. Health practices unique to this culture; special beliefs about health and illness; respective roles of ill and well members of family;
if raised in another country, attitudes toward health care system in United States; experiences with United States health care system
. Describe things (concrete and abstract) that are most valued (e.g,, cars, jewels, toys, pictures, family traditions, honesty, integrity,
fairness).
Why are they valuable?

Daily Schedule
Construct a daily schedule for a typical weekday and typical weekend day in the patient's life. Give details for hour-by-hour activities.

Life Roles
List all occupational roles of the patient (e.g, worker, father, brother, sportsman, gardener).

Life Balance
Approximate percent of time spent by the patient in each of the performance areas of self-maintenance, home and child management,
work, and play and leisure.

FIG. 12-1
Activity configuration/daily schedule. Outline for interview. (Adapted from Cynkin: Occupational therapy: toward health through activities, Boston, 1979,
Little, Brown.)
22 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

performance. In terms of functional outcomes, reme- terms. Direct observation (either naturalistic or struc-
diation is valuable only if it improves the ability to tured), using the same assessment procedures employed
perform desired occupations. in the initial evaluation, is the accepted method of
2. Adaptation of tools, equipment, and methods may measuring progress. Immediately upon the patient's
improve performance, but adaptations must be acceptable reaching a goal or objective, the therapist must identify
to the patient and family. Much adaptive equipment or (if the goal has already been identified) refine the
for feeding, hygiene, bathing, grooming, personal next goal or objective. Selection and discussion of ob-
care, work, and leisure is available commercially to jectives and methods should be done in collaboration
therapists and also directly to consumers. People are with the patient. Motivation is enhanced when the ther-
sensitive to appearances and reject adaptive equip- apist maintains an ongoing sense of forward momen-
ment because they believe it stigmatizes them. This tum and progress toward “the big goals” the patient has
applies not just to equipment, but also to methods. identified.
Most activities can be done in many ways other than
the one that seems customary. For example, a person
SUMMARY
with a recent hip replacement who finds it difficult to
place and retrieve food bowls for pets from their cus- Occupational therapists assist individuals who are ex-
tomary location (on the floor) might adapt by periencing impaired ability to carry out desired daily
placing the bowls on the countertop. However, sani- occupations. Occupations are multidimensional and
tary concerns may make this solution unacceptable. complex; therapy must focus on the occupational goals
The therapist must help the patient identify accept- the patient identifies as important. A top-down, client-
able solutions. centered approach is recommended, employing a narra-
3. Compensation by the individual or by a caregiver may be tive interview assessment that yields statements of
necessary to enable performance. When customary pro- patient goals and patient perceptions of problems and
cedures (those normally employed by the able obstacles. Development of intermediate objectives and
bodied) are prevented or rendered awkward by dis- selection of methods and approaches must include the
ability, the patient may use a different method, or the patient. Although it is necessary to break down long-
deficit in performance may be compensated for by the term goals into smaller steps or objectives, each step
actions of another person. Consider, for example, a must lead toward success in occupational performance.
cognitively impaired individual who must be left Continual reassessment and setting of new goals main-
alone during the day while the caregiver is at work. tain a sense of forward momentum and increase moti-
This patient can still have a hot lunch if the caregiver vation. Therapy does not end when the therapist has
prepares it in advance, leaves it on a specific accessible helped the patient reach his or her highest functional
shelf in the refrigerator, and provides simple direc- level. Therapy includes helping patients acquire a sense
tions for reheating it in an accessible microwave oven. of occupational competence and identity regardless of
4. Modifying the environment or features of the environment how their present functional level compares with their
may be used to enable performance. Obvious environ- prior level or with “the norm.”
mental modifications such as wheelchair ramps, key-
board supports, and grab bars are only the beginning.
REVIEW QUESTIONS
Many less obvious but equally helpful modifications
are possible, such as removing area rugs, positioning 1. What is occupation? How would you define occu-
frequently used items closer, and switching items pation when speaking to a patient?
from left to right or vice-versa, depending on domi- 2. Choose a favorite occupation. Describe the occupa-
nance. Any modifications must be agreeable to the tional form. Analyze a recent occupational perform-
patient, family, and others in the situation (e.g., ifin a ance, including the following dimensions: physical,
workplace, then to employer and other employees). cultural, temporal, psychologic, social, spiritual,
5. Patients and caregivers can contribute ideas to improve and symbolic.
performance and will often arrive at creative and work- 3. Using the occupation named in question 2, analyze
able solutions. An important therapist role is to facili- an occupational performance by someone other
tate and empower problem identification and than yourself.
problem solving by patients and caregivers. 4. How are occupation and identity related? List your
occupations. Describe how your perception of self
MEASURING PROGRESS TOWARD might change if you could not perform these occu-
pations.
OCCUPATIONAL PERFORMANCE GOALS
5. What methods are used for evaluating occupational
Progress is easy to measure when goals and objectives performance?
are carefully designed to be achievable, understandable, 6. What is the COPM and what does it yield?
observable, and measurable and are stated in behavioral 7. What is the OPHI-II and what does it yield?
 Occupational Performance 1

. What is the Activity Configuration and what does it . Clark FA, Parham D, Carlson ME, et al: Occupational science: aca-
yield? demic innovation in the service of occupational therapy’s future,
Am J Occup Ther 45:300-310, 1991.
Contrast structured and naturalistic observation. In
. Cynkin S: Occupational therapy: toward health through activities,
what situations would you prefer one over the Boston, 1979, Little, Brown.
other? . Law M, Baptiste S, Carswell A, et al: Canadian occupational perform-
. Describe the procedure and criteria for setting goals ance measure, ed 3, Ottawa, Ontario, 1998, CAOT Publications.
related to occupational performance. . Dickerson AE, Oakley F: Comparing the roles of community-
living persons and patient populations, Am J Occup Ther 49:221-
. How can one measure progress toward goals in oc- 228, 1995.
cupational performance? 10. Kielhofner G, Mallinson T, Crawford C, et al: A user's manual for
the occupational performance history interview, version 2, Chicago,
1998, Model of Human Occupation Clearinghouse, University of
REFERENCES
Illinois at Chicago.
lb American Occupational Therapy Association: Position paper:
te Mallinson T, Kielhofner G, Mattingly C: Metaphor and meaning
occupation, Am J Occup Ther 49:1015-1018, 1995.
in a clinical interview, Am J Occup Ther 50:338-346, 1996.
2 American Occupational Therapy Association: Statement-funda-
12 Neistadt ME: Teaching clinical reasoning as a thinking frame, Am J
mental concepts of occupational therapy: occupation, purposeful
Occup Ther 52:221-229, 1998.
activity, and function, Am J Occup Ther 51:864-866, 1997.
1053) Nelson DL: Occupation: form and performance, Am J Occup Ther
. American Occupational Therapy Association: Uniform terminol-
42:633-641, 1988.
ogy, ed 3, Am J Occup Ther 48:1047-1054, 1994.
14. Watanabe S: The activities configuration, 1968 Regional Institute on
. Breines EB: Making a difference: a premise of occupation and
the Evaluation Process, New York Report RAS-123-&-68, Rockville,
health, Am J Occup Ther 43:51-52, 1989.
Md, 1968, American Occupational Therapy Association.
. Canadian Association of Occupational Therapists: Occupational
therapy guidelines for client-centred practice, Toronto, 1991, the Asso-
ciation.
 LEARNING OBJECTIVES
Activities of daily living After reading this chapter the student or practitioner
Instrumental activities of daily living will be able to do the following:
Top-down approach 1. Define ADL and IJ-ADL.
Bottom-up approach 2. Name two standardized tests of ADL.
Maximal level of independence 3. Describe a bottom-up versus top-down approach
Levels of independence to evaluation.
Home assessment 4. Define levels of independence.
Accessibility 5. Explain the usual procedures for ADL and I-ADL
Medication management assessments.
Backward chaining 6. Explain the benefits of a home evaluation.
Assistive technology 7. Explain how to record and summarize results of
the ADL assessment and training program.
8. Discuss various methods of teaching ADL.
9. Discuss considerations for selecting adaptive
equipment.
10. Describe, perform, and teach ADL techniques for
individuals with limited ROM and strength,
incoordination, paraplegia, quadriplegia, and low
vision.

tivities of daily living (ADL) and instrumental The role of OT is to assess ADL and I-ADL perform-
activities of daily living (I-ADL) are tasks of self-care, ance skills, determine problems that interfere with inde-
functional mobility, functional communication, home pendence, determine treatment objectives, and provide
management, and community living that enable an in- training to increase independence. The OT practitioner
dividual to achieve personal independence.'®*° Eval- may also be involved in removing or reducing physical,
uation and training in the performance of these im- cognitive, social, and emotional barriers that are inter-
portant life tasks have long been important aspects of fering with performance. The need to learn new
occupational therapy (OT) programs in virtually every methods or use assistive devices to perform daily tasks
type of health care service. Loss of ability to care for may be temporary or permanent, depending on the par-
personal needs and to manage the environment can ticular dysfunction and the prognosis for recovery.
result in loss of self-esteem and a deep sense of de-
pendence. Family roles are also disrupted, requiring
DEFINITIONS OF ADL AND I-ADL
partners to assume the function of caregiver when
one loses the ability to perform ADL or J-ADL inde- Daily activities can be separated into two areas: activi-
pendently. *° ties of daily living (ADL) and instrumental activities

124
 Activities of Daily Living

Activities in ADL and I-ADL

\ctivities of Daily Living (ADL)

i Instrumental Activities of Daily Living (Il-ADL)

Home Management
Clothing Care
Cleaning
Meal preparation
Money management ~
_ Feeding and eating Household maintenance
Medication routine Care of others
Health maintenance
_ Emergency response
Community mobility
_ Functional Mobility Community Living Skills
Bed mobility Shopping
Wheelchair mobility Access to recreation
Transfers
Functional ambulation

Functional Communication
Writing
Typing/computer use
Telephoning
Augmentative communication devices

Environmental Hardware Environmental Hardware

Keys Vacuum cleaner
Faucets Can opener
Light switches Stove/oven
Windows/doors Refrigerator
Telephone Microwave
Computer Nee
‘

Modified from American Occupational Therapy Association: Uniform terminology for occupational therapy, third edition, Am | Occup Ther 48(1 1):1047-1054,
1994,

of daily living (I-ADL). ADL require basic skills, ductive activities, and (3) play and leisure. The role of
whereas I-ADL require more advanced problem-solving the OT practitioner is to facilitate skill in performance
skills, social skills, and more complex environmental of these essential tasks of living. It is important to help
interactions. ADL tasks include functional mobility, the individual with a disability to balance activity in
self-care, functional communication, management of each of these three performance areas according to his
environmental hardware and devices, and sexual ex- or her personality, skills, limitations, needs, cultural
pression.* I-ADL tasks include home management and values, and lifestyle.
community living skills (Box 13-1). Home manage- The therapist may consider using a top-down ap-
ment is classified with work and productive activities in proach to the evaluation process in order to understand
the Occupational Performance Model. the client's occupational history and interests. A top-
down approach may include the charting of a daily or
weekly schedule (see Chapter 12), an activities configu-
EVALUATION OF PERFORMANCE AREAS
ration, an interest checklist, or an occupational role
ADL is one of the major performance areas in the occu- history.’ !43°?>*9 The activities configuration protocol
pational performance model discussed in Chapter 1. A can be used to gather data about the client's values, edu-
comprehensive evaluation of performance skills should cation, work history, and vocational interests and plans.
include assessment of the client's abilities and limita- The interest checklist can be used to determine the
tions in (1) ADL or self-maintenance, (2) work and pro- degree of interest in five categories of activities—manual
 126 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

skills, physical sports, social recreation, ADL, and cul- iar with the client's culture and the culture's values in re-
tural and educational activities.*° The occupational role lation to self-care, the sick role, family assistance, and
history is used to indicate the balance between work independence. The values of the client and the client's
and leisure roles.'* Although the interest checklist and peer group and culture should be important considera-
the occupational role history were developed for a psy- tions in selecting objectives and initial activities in the
chiatric population, they can be adapted for application ADL program. The demands of time and energy for the
to clients with a physical dysfunction. balance of activities in the client’s day may influence
A bottom-up approach to the evaluation process how many ADL can be performed independently.
focuses on identifying problems in specific performance The environment to which the client will return is an
components. This approach may fail to-identify how a important consideration. Will the client live alone or
performance component deficit affects the client's occu- with his or her family or a roommate? Will the client go
pational performance.'” For example, a therapist deter- to a skilled nursing facility or to a board and care home,
mines that a client has impaired fine motor control. A and will the client go permanently or temporarily? Will
general evaluation may indicate that the client has diffi- the client return to work and community activities? The
culty with simple tasks such as tying shoes and button- type and amount of assistance available in the home en-
ing clothes. After completing an interest checklist and vironment must be considered if the caregiver is to
occupational role history, the occupational therapist receive training to provide assistance and supervision.
also determines that the fine motor control deficit will The finances available for assistant care, special equip-
affect the client's job as a computer operator and limit ment, and home modifications are important considera-
her ability to continue with a hobby of jewelry making. tions. For example, a wheelchair-bound client who is
Although these two approaches to evaluation are dis- wealthy may be willing and able to make major modifi-
cussed separately, a skilled clinician blends the two in cations in the home, such as installing an elevator, lower-
practice. Once a functional deficit is identified, the per- ing kitchen counters, widening doorways, and replacing
formance component deficit that causes the functional carpeting to accommodate a wheelchair lifestyle. A client
deficit is identified. The therapist can then determine if with fewer financial resources may need the assistance of
it is possible to improve or provide remediation for the an occupational therapist in making less costly modifica-
performance component or if a compensatory method tions, such as removing scatter rugs and door sills, in-
will be needed to improve occupational performance. stalling a ramp at the entrance, and attaching a handheld
An interview and performance evaluation can yield a shower head to the bathtub faucet.
well-rounded picture of the client’s occupational per- The ultimate goal of any ADL and I-ADL training
formance. Deficits and imbalances in occupational per- program is for the client and family to learn to adapt to
formance will be apparent. The performance evaluation the life changes that necessitated a referral to the occu-
is fundamental to the development of a comprehensive pational therapist. For the individual who values inde-
treatment plan. The performance evaluations to be ad- pendence, the goal may be to achieve the maximal level
dressed in this chapter are for ADL and I-ADL. Work eval- of independence. It is important to note that this level
uation is assessment of specific work skills using real or is different for each client. For the client with mild
simulated work situations” and is discussed in Chapter muscle weakness in one arm, complete independence
16. Leisure activities are discussed in Chapter 18. in ADL may be the maximal. In contrast, for the indi-
vidual with a high-level quadriplegia, self-feeding, oral
CONSIDERATIONS IN ADL AND I-ADL hygiene, and communication activities with devices and
EVALUATION AND TRAINING assistance may be the maximal level of independence
that can be expected.
The ADL/I-ADL evaluations include a performance eval- For the individual whose culture does not value inde-
uation, assessment of performance components, and pendence as highly as does Western culture, the occupa-
evaluation of the client's psychosocial and physical en- tional therapist may focus primarily on teaching the
vironment. Physical performance components such as client and family to adapt. The focus would be on family
strength, range of motion (ROM), coordination, sensa- training and identifying the activities of highest value to
tion, and balance should be assessed to determine the the client. The potential for independence depends on
potential for remediation and possible need for adap- each client's unique personal needs, values, capabilities,
tive equipment. Perceptual and cognitive functions limitations, and social and environmental resources.
should be assessed to determine the potential for learn-
ing ADL skills. General mobility in bed or wheelchair or
ambulation should also be assessed and are discussed
ADL AND I-ADL ASSESSMENT
in more detail in Chapter 14. Assessment of ADL and I-ADL is initiated with an inter-
In addition to these relatively concrete and objective view, using a checklist as a guide for questioning and
assessments, the occupational therapist should be famil- selection of performance activities. Several types of ADL
 Activities of Daily Living 127,

and I-ADL checklists and standardized tests are avail- For example, a dressing assessment could be arranged
able. They all cover similar categories and performance early in the morning in the treatment facility when the
tasks.” The use of a standardized test will ensure a client is dressed by nursing personnel, or in the client's
more objective assessment and provide a standard home. Self-feeding assessment should occur at regular
means of measurement. A standardized assessment meal hours. If this timing is not possible, the assessment
tool can be used at a later time for reevaluation, and may be conducted during regular treatment sessions in
some assessments allow for comparison to a norm the OT clinic under simulated conditions. Requiring the
group. Asher* has developed an annotated index of as- client to perform routine self-maintenance tasks at irreg-
sessment tools, which can be used as a resource for se- ular times in an artificial environment may contribute
lecting appropriate tools for evaluation. Some exam- to a lack of carryover, especially for clients who have dif-
ples of standardized ADL and I-ADL assessments are ficulty generalizing learning.
listed in Table 13-1. The occupational therapist should The therapist should select relatively simple and safe
review the literature periodically to learn about new as- tasks from the ADL and I-ADL checklist and should
sessments developed by occupational therapists and progress to more difficult and complex items, including
about those that have been developed as interdiscipli- some that involve safety measures. The ADL assessment
nary assessments, such as the Functional Independence should not be completed at one time because this ap-
Measure (FIM).*” proach would cause fatigue and create an artificial situa-
tion. Tasks that would be unsafe or obviously cannot be
performed should be omitted and the appropriate nota-
General Procedure
tion made on the assessment form (see Chapter 20).
When data have been gathered about the client's physi- During the performance assessment the therapist
cal, psychosocial, and environmental resources, the fea- should observe the methods the client is using or at-
sibility of ADL assessment or ADL training should be de- tempting to use to accomplish the task and try to deter-
termined by the occupational therapist in concert with mine causes of performance problems. Common causes
the client, supervising physician, and other members of include weakness, spasticity, involuntary motion, per-
the rehabilitation team. In some instances, ADL training ceptual deficits, cognitive deficits, and low endurance. If
should be delayed because of limitations of the client or problems and their causes can be identified, the thera-
in favor of more immediate treatment objectives that pist has a good foundation for establishing training ob-
require the client's energy and participation. jectives, priorities, methods, and the need for assistive
The interview may serve as a screening device to help devices.
determine the need for further assessment by observa- Other important aspects of this assessment that
tion of performance. This need is determined by the should not be overlooked are the client's need for
therapist based on knowledge of the client, the dysfunc- respect and privacy and the ongoing interaction
tion, and previous assessments. A partial or complete between the client and the therapist. The client's feel-
performance evaluation is invaluable in assessing ADL ings about having his or her body viewed and touched
performance. The interview alone can lead to inaccurate should be respected. Privacy should be maintained for
assumptions. The client may recall performance before toileting, grooming, bathing, and dressing tasks. The
the onset of the dysfunction, may have some confusion therapist with whom the client is most familiar and
or memory loss, and may overestimate or underesti- comfortable may be the appropriate person to conduct
mate individual abilities because there has been little ADL assessment and training. As the therapist interacts
opportunity to perform routine ADL since the onset of with the client during performance of daily living tasks,
the physical dysfunction. it may be possible to elicit the client's attitudes and
Ideally, the occupational therapist assesses perform- feelings about the particular tasks, priorities in training,
ance when and where the activities usually take place. dependence and independence, and cultural, family,

of Standardized Assessments for ADL and I-ADL

ADL Assessments 1-ADL Assessments Measures ADL and I-ADL

Klein-Bell ADL Scale? Assessment of Motor and Process Skills Canadian Occupational Performance Measure
(AMPS)'? (COPM)*°
Functional Independence Measure Kitchen Task Assessment (KTA)° Kohiman Evaluation of Living Skills (KELS)**
(FIM)??
12.) OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

and personal values and customs regarding perform- minimal assistance. These quantitative terms have little
ance of ADL. meaning to health care professionals unless they are
defined or supporting statements are included in
progress summaries to give specific meanings for each.
Recording Results of ADL Assessment It also should be specified whether the level of inde-
During the interview and performance assessment the pendence refers to a single activity, a category of activi-
therapist makes appropriate notations on the checklists. ties such as dressing, or all ADL. In designating levels of
If a standardized assessment is used, the standard termi- independence, an agreed-on performance scale should
nology identified for that assessment is used to describe be used to mark the ADL checklist. The following
or measure performance. Nonstandardized tests may general categories and their definitions are suggested:
include separate checklists for self-care, home manage-
Pay Mente 4th) Tr r }
Sui

ment, mobility, and home environment assessments.

When describing levels of independence, occupational
therapists often use terms like maximum, moderate, and

CASE STUDY 13-1!

Case Stupy—*“‘J.V.””
JV. is a 72-year-old married woman who suffered a cerebral tongue coordination and minimal delay with a swallow. J.V. has
thrombosis resulting in a cerebrovascular accident (CVA) 3 already modified her diet by selecting very soft foods and slightly
months ago. She lives in a modest home with her husband. J.V. thickened liquids.
was active before her CVA, volunteering |0 hours a week at a
local charity thrift store, walking a mile a day with friends, and Progress Report
caring for her husband, who is diabetic and has poor vision. She JV. has attended occupational therapy two times a week for 4
was independent with all of the indoor home management activ- weeks. She is generally cooperative and motivated, although peri-
ities. She and her husband have a gardener, but J.V. enjoyed gar- odically she becomes discouraged as she continues to have an
dening with potted plants. ataxic gait and requires the use of the wheelchair for independ-
The CVA resulted in an ataxic gait, mild dysarthria (slurred ent mobility. Treatment has focused on lower extremity dressing,
speech), dysphagia (swallowing deficit), and slight hand incoordi- oral-motor exercises to improve swallowing, and simple meal
nation. J.V. is easily frustrated and concerned about how she and preparation. J.V. has made significant progress in the treatment
her husband will manage, since her adult children live 5 hours program. She has progressed from maximum assistance with
away. She was referred to occupational therapy for evaluation lower extremity dressing to independent while seated. She has
and training in ADL and I-ADL and for treatment of dysphagia. improved from chairlevel grooming to standing with one-hand
The initial evaluation involved an interview with the client and stabilization while using the other to brush her hair and teeth.
her husband, use of the Kitchen Task Assessment, and an ADL per- Progress has been made from maximum assistance with bathing
formance evaluation. The evaluation was completed in a |-hour to supervised with transfer to a shower seat. From moderate dif-
session. |.V.became restless after 15 minutes, but with redirection ficulty with use of phone, she has progressed to independent and
continued to attend to the tasks. J.V. is independent with eating, from dependent with oral-motor exercises she has progressed
upper body dressing, and grooming while seated. J.V.is independ- to supervised. J.V. is now independent in cold meal preparation
ent with toileting. She has been receiving maximum assistance for after initially requiring maximum assistance.
lower body dressing and bathing. She has difficulty with handwrit- JV. continues to require a soft diet and slightly thickened
ing, use of the telephone, and handling keys. She requires moder- liquids because of swallowing difficulties. She is consistent with
ate assistance to walk, using a front-wheeled walker (FVVW), but is use of safety techniques for swallowing. She continues to have
independent with wheelchair mobility on flat surfaces. Her visual impaired hand coordination but is learning compensatory tech-
fields are intact. She has no visual-spatial deficit. Her upper ex- niques to adapt her method of performing various ADL tasks as
tremity strength and range of motion are WNL (within normal demonstrated with her progress in ADL.
limits). Hand coordination is mildly impaired, as demonstrated Occupational therapy has coordinated treatment and goals
with moderate difficulty pushing buttons on the phone and shoe with the physical therapist and social worker The therapist has
tying. She is able to stand while holding on to a stable surface but recommended that the social worker refer the client's husband
cannot use her hands for a task while standing. to a low vision center for evaluation, since he was dependent on
Results of the Kitchen Task Assessment? demonstrated deficits his wife and never received instruction in low vision training. His
in organization of the task, at which point she required physical independence will relieve some ofJ.V's burden of care giving.
assistance. J.V. is highly motivated and has the potential to do Occupational therapy will focus on hot meal preparation, bed
simple, hot meal preparation and basic self-care independently, making, and exploring leisure interests with gardening, along with
except for showering, for which she requires supervision. continuing to work toward improvement of oral-motor and hand
A swallow assessment demonstrated moderately impaired coordination.
 Activities of Daily Living 1p)

2.
Supervised:
can perform the activity alone but needs Home management skills apply to women, men, and
sometimes adolescents and children. Individuals may
live independently or share home management respon-
sibilities with their partners. In some homes it is neces-
sary for a role reversal to occur after the onset of a phys-
ical disability, and the partner who usually stays at
home may seek employment outside the home, while
the disabled individual remains at home.
If a client will be home alone, there are several basic
ADL and I-ADL skills needed for safety and independ-
ence. Minimal ADL skills include independence with
toileting and transfers, allowance for rest periods, and
use of the telephone or special call system in case of
emergency. Minimal I-ADL skills required to stay at
These definitions are broad and general. They can be home alone include the ability to (1) prepare or retrieve
modified to suit the approach of the particular treat- a simple meal, (2) employ safety precautions and
ment facility. exhibit good judgment, (3) take medication, and (4) get
Information from the ADL assessment is summa- emergency aid if needed. The occupational therapist can
rized succinctly for inclusion in the client's permanent assess potential for remaining at home alone through
records so that interested professional coworkers can the activities of home management assessment. Safety
refer to it. A sample case study, with ADL and home management as listed in Box 13-1 is part of the home
management checklists, and summaries of an initial as- management assessment.
sessment and progress report are included in Figs. 13-1 A child with a permanent disability also needs to be
and 13-2. When reviewing these, the reader should keep considered for assessment and training for I-ADL skills
in mind that the assessment and progress summaries as he or she develops and matures with a growing need
relate only to the ADL portion of the treatment for independence.
program.
Home Assessment
INSTRUMENTAL ACTIVITIES
OF DAILY LIVING When discharge from the treatment facility is anticipated,
a home assessment should be carried out to facilitate the
Home Management Assessment client's maximal independence in the living environ-
Home management tasks are assessed similarly to self- ment. Ideally, the physical and occupational therapists
care tasks. First the client should be interviewed to should perform the home assessment together. During
elicit a description of the home and of former and the home visit, the client and family members or house-
present home management responsibilities. Tasks the mates must be present. Budget and time factors may not
client needs to perform when returning home, as well allow two professional workers to go to the client's home,
as those that he or she would like to perform, should however. Therefore either the physical or occupational
be ascertained during the interview. If the client has a therapist should be able to perform the assessment, or
communication disorder or a cognitive deficit, aid the assessment may be referred to the home health
from friends or family members may be enlisted to get agency that will provide home care services to the client.
the information needed. The client may also be ques- The client and a family member should be inter-
tioned about his or her ability to perform each task on viewed to determine the client’s and family’s expecta-
the activities list. The assessment is much more mean- tions and the roles the client will assume in the home
ingful and accurate if the interview is followed by a and community. The cultural or family values regarding
performance assessment in the ADL kitchen or apart- a disabled member may influence role expectations and
ment of the treatment facility or in the client's home if whether independence will be encouraged. Willingness
possible. and financial ability to make modifications in the home
The therapist should select tasks and exercise safety can also be determined.*®
precautions consistent with the client's capabilities and Sufficient time should be scheduled for the home
limitations. The initial tasks should be simple one- or visit so that the client can demonstrate the required
two-step procedures that are not hazardous, such as transfer and mobility skills. The therapist may also
wiping a dish, sponging a table top, and turning the wish to ask the client to demonstrate selected self-care
water on and off. As the assessment progresses, tasks and home management tasks in the home environ-
graded in complexity and involving safety precautions ment. During the assessment the client should use the
should be performed, such as making a sandwich and a ambulation aids and any assistive devices that he or
cup of coffee and vacuuming the carpet. she is accustomed to using. The therapist should bring
Text continued on pg. 136
 OCCUPATIONAL THERAPY DEPARTMENT
ACTIVITIES OF DAILY LIVING

Name d/ Age 72 Diagnosis C/A

Disability atavia, dysarthria, dysphagia, hand ixcoordination
Activity Precautions _sae
Mode of Ambulation «/2; (WW with mod A Hand Dominance &
Previous Functional Level _/rdependent _
Social
/ home environment Ft. é@ caregiver to husband,
Goes inown home
Grading Key: le Independent
°° = Supervised
Min A = Minimal Assistance
Mod A= Moderate Assistance
Max A= Maximum Assistance
Dies Dependent
N/A= Not applicable
N/T= Not tested

TRANSFERS AND AMBULATION

Remarks

on flat surfaces

tS
a pote

eee

Butter bread
Cut meat

Eat with fork / /

Drink w/ straw if /
Drink w/ glass if i
/ /
MW/T
UNDRESS
Date 29 L248 | Remarks
aA /

Shit
Skirt
Blouse/Shirt
UA
N/A
Mic /
UA
N/A ae
Slacks/Jeans | Mao PN ee | i a
ee
Necktie | WA BNA WA | a

FIG. 13-1
ADL evaluation form. (Adapted from Activities of daily living evaluation form 461-1, Hartford, Conn,
1963, The Hartford Easter Seal Rehabilitation Center.)

130
UNDRESS (continued
ere eee | oh |e eth -Remaks| =
[Nylons sid N/T WA maine
A a~~|
i nee i ea a
keel a a es eee Ek
WA WA cl
ieee
SUE ce al SR oe Bn,
ai aye ee
sal RES a eae
PC wsbinewe igor | fF Fl TLRS ge cee |
se (eee 7s ae eite Pome tet Sst)
nee) en rae | Pare ee | Rm rs net ee
RTs cea kor fe nrc oe rien tl ne eee ee
et Say ne SS eS Se) ARG pa os ye ee |
W/T- ee ee ae]
DRESS
a ee ee ee Remarks

eee iy | ee
SS ea i 7 ed a a
Difficabty with battons
/
SE ee 7 |
|[Housecoat/Robe
| =§»MwA | | Cd ope mabe DOWN
/ /
MWA WA
/
/
oi Galle 7 a
/
MWA
/
Max /
Max A MW Pan
Fs "|
FASTENERS
Remarks
Button MirA / |
MA /
Zipper if /

HYGIENE
[___|_Remarks
i Pe |
[Washface/fhands
| 7 | | While coated
fWashupperbody
| 7 —*(| 7 Si SSSSCS~*dCS te
Washlowerbody
| Aw# | 7 | _~+s
[Brushteeth | | stand, | | Whileseated
Mmemmentures | 4AA |= WA

FIG. 13-1, cont’d

ADL evaluation form. (Adapted from Activities of daily living evaluation form 461-1, Hartford, Conn,
1963, The Hartford Easter Seal Rehabilitation Center.) Continued
[Dato > me | ee | | Remarks
[Brushicombhair | Sid CS etary =| | Wired
CA
‘Culhar eS ee
Shave | CMA WA | eee
[Applymakeup | ACC dL | ee
[Cleanfingemais |) A ee
Trimnaiis: | A |ee
pApplydeodorant ___[ gf fii ted—______
Min AA te needs items in reach

[Use tampons/napkins _| WA

po
i (a
| ee
waa ER
ee
oa anomeric
a A a a en
i a a eee
a
i,
a, 7 a
SE
COMMUNICATION

Tac
7 ||
ee
Write Mod A Pan legibill
Use telephone Mod A fig

pee a
eee

Remarks
Open/close door
Remove/replace
objects
Carry objects while from wheebehaie
walking/wheeling
Retrieve object from floor with reacher

OPERATE
Date 29 2/24 Remarks
Light switches / i
Doorbell le /
Door locks/handles / / from wheete hai
Faucets eee / from wheelohare
Shades/curtains N/T N/T
Open/close window Wen ae N/T a
Hang up garment N/T / from wheebehaie

SUMMARY OF EVALUATION RESULTS

SENSORY STATUS
| ve ae Remarks ee
Intact (IN) orImpaired (IM) _f| IN| IM || IN | IM[[fIN | IM fo
[Touch Rms
ee

FIG. 13-1, cont’d

ADL evaluation form. (Adapted from Activities of daily living evaluation form 461-1, Hartford, Conn,
1963, The Hartford Easter Seal Rehabilitation Center.)
i S| | |
Intact (IN) or Impaired (IM | | IM | |
IM |
—— lc CY cane eee
a |a | a |
[Proprioception =—=s—“<s<a<é$s st Rarae| ea
Stereognosis | | |
Visual Fields |
PERCEPTUAL/COGNITIVE
a |
[Intact (IN) orImpaired (IM) __{| IN| IM [| IN [IM | |
|Followsdirections =} wW | CUT | “EE Sas nae
tS FZ ERR SE PE | (a a
ee ee ee ee aeey eT
Attentionspan ft Pw eed nec after15min |
Problem solving I fw te | | AR probleme withanganicatin
tol SSRIS Se | EE RE a |
Left/right discrimination S28 Bae RS eS 2 a
iB SSR |S RE | ZA RD: | |

Intact (IN) or Impaired (IM

Feed self
Fasten buttons
[Pullupbackofpants
sss] |
4
a eae |
estos ROM WNC; inpaived balance
Reach self epee eae From wheelehair
i ) DP 7” iA Balance inpaired
STRENGTH: indicate muscle grade
—— | ce |__Remarks
fEeft(Lyornight(R)
| LOT RO] LE |]
Ro
[Head/ineck | WAL |W || WE | WE |
[Shoulder flexion || WAL | Wie ||WE | WA | |
[Shoulder extension || WAL |_WAN ||WA | WA | |
[Elbow flexion | WAL | WAL||We | We) ~~]
[Elbowextension || WAL | WAL ||WA | Wiel |S
[Supination | WAL |W ||We | We | |
[Pronation, | WAL |W ||WE | WA | |
[Wristextension eee |
[Wristflexion | WML | We ||WE | Wel |S
[Grossgrasp_ CW WA | We WM | We | SC
COORDINATION

Left (L) or right (R

FIG. 13-1, cont’d

ADL evaluation form. (Adapted from Activities of daily living evaluation form 461-1, Hartford, Conn,
1963, The Hartford Easter Seal Rehabilitation Center.)
 OCCUPATIONAL THERAPY DEPARTMENT
ACTIVITIES OF HOME MANAGEMENT

Name _7/ Date 729 ((tilenef) =

Address Argtown, USA
Age _7 Role in family_w«
Diagnosis _C/A
Activity Precautions _xore

DESCRIPTION OF HOME
Owns home _X Ap artment Board & Care
No. of rooms _Z Bathroom description
No. of floors _7 Small 27" wide door
Stairs 3 to enter Tab - Shower combination
Elevator WMA clased sink

Will client be required to perform the following activities? If not, who will perform? x = yes
Meal preparation _Y
Serving
Wash dishes
Shopping will need assist as she isn ¢ diving
Child care
Laundry
Housecleaning will hive housekecper
Pet care
Sewing
Hobbies volunteer work.

Does the client really like housework?

Grading Key: bee: Independent

Sy Supervised
Min A = Minimal Assistance
Mod A = Moderate Assistance
Max A = Maximum Assistance
) = Dependent
N/A = Not applicable
N/T = Not tested

MEAL PREPARATION
| Date V29 Remarks
Manage faucets bi
es / id to stand
Handle stove controls
Open packages
Carry items : aN
it
Pa pss | from wheelehaire
Open cans WT |
Open jars N/T / 7,
Handle milk carton (bs
Empty garbage N/T N/T
G /
S / ee | ee
iCutsafely ae |

FIG. 13-2
Activities of home management. (Adapted from Activities of home management form, Occupational
Therapy Department, University Hospital, Ohio State University, Columbus.)
 MEAL PREPARATION (continued
ae ee
TE ee a/c a
aE | Vapi Viele sae
ee
MONEE 7 eels
Cai oRene t|cerromeiemmete a
ES 7a A
(ee aaa oe a EA So eee
iA CL ShS Ee el ne rato ror 4
SET UP/CLEAN UP FOR MEAL PREPARATION
SS
les
Ge ci nae tee
ea ne Mee i
oaee
|2Reman
th halla
Fatigaed,rapidly
to stand

i
[Pick upobject fromfloor |
a7 [7eZ id SCS
Remarks
«sea ee
Sh a eae ae Se eee
MT MT
MT N/T
MT MT
WT
Sweep M/T Ca ee |
«(se ae 7
Vacuum N/T N/T
Clean tub and toilet N/T N/T
Change sheets MEA P/E
Carry pail of water N/T N/T
Carry cleaning tools N/T N/T ee
Sun ar)

Remarks

lron

HEAVY HOUSEHOLD ACTIVITIES, WHO WILL DO THESE?

Date Remarks
Clean stove and oven
Clean refrigerator_ ModA
Shopping ModA

FIG. 13-2, cont’d

Activities of home management. (Adapted from Activities of home management form, Occupational
Therapy Department, University Hospital, Ohio State University, Columbus.) Continued
136 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

HEAVY HOUSEHOLD ACTIVITIES, WHO WILL DO THESE?

LAUNDRY/CLEANING ACTIVITIES (continued
2/24 Remarks
Put away groceries ModA fs apse ena ee
Wash windows oo ee rel
Change light bulbs 2
Wash bathtub ere
Maintain smoke alarms BEE
Recycle/compost ese
NT ModA eee

Retrieve newspaper
Retrieve mail
Feed pet LlTa |
Manage pet waste SAT 2
Let pet in and out
Reach thermostat See
Thread needle/knot
Sew on button Pe ane
Use scissors ae! Ae
Water houseplants N/T

WORK HEIGHTS (Indicate best height) 7/29 - evataation

lroning N/A
Cutting Wheelehaie level appron 31"
Dish washing standard sink adequate
General work EFp

Maximal depth of counter (reach) 76" (for side reach)

Maximal height of work surface
Maximal reach for high cupboards 43"
Maximal reach for low cupboards
Best height for chair 20-23"

SUGGESTIONS FOR HOME MODIFICATION:

- Transfer tub bench /bathtub mat / grab bar in shower
= SA
hower hose

-3 in 1 commode for ase at night beside bed & wer toilet daring day
- Widen bathy-oom door to 32"

FIG. 13-2, cont’d

Activities of home management. (Adapted from Activities of home management form, Occupational
Therapy Department, University Hospital, Ohio State University, Columbus.)

a tape measure to measure the width of doorways, the sketch the size and arrangement of rooms for later refer-
height of stairs, the height of the bed, and other di- ence and attach these sketches to the home assessment
mensions. checklist (Fig. 13-3). For more information on a variety
The therapist can begin by explaining the purposes of checklists, see Letts and associates.”° Next, the client
and procedure of the home assessment to the client and demonstrates mobility and transfer skills and essential
others present, if this has not been done before the visit. self-care and home management tasks. The client's
The therapist can proceed to take the required measure- ability to use the entrance to the home and to transfer to
ments while surveying the general arrangement of and from an automobile, if it is to be used, should be
rooms, furniture, and appliances. It may be helpful to included in the home assessment.
 HOME EVALUATION CHECKLIST

Name. _ Date. Bed:

Address. Q twin
Diagnosis. Q double
Q queen
QO king
Mobility Status Q ambulatory, no device Q walker
Q cane Q wheelchair O hospital bed
Overall height Accessible? Qyes (Ono

Exterior Would hospital bed fit into room if needed? Qyes Qno

Home located on Q level surface Clothing:

Ohill Are drawers accessible? ( yes Qno
Q on right Qon left
Type of House Q owns house Q mobile home
Q apartment O board and care Is closet accessible? Q yes Qno
Q on right O on left
Number of floors Qone story Q split level Comments:
Q two story
Bathroom
Driveway surface Q inclined Qsmooth
Door:
Q level Qrough width
Is the DRIVEWAY negotiable? Qyes Qno threshold height Negotiable? Oyes Qno
Is the GARAGE accessible? OQ yes Qno Tub:
height, floor-rim
Entrance height, tub bottom rim
tub width inside
Accessible entrances Q front Q side glass doors? Q yes Qno
Q back width of tub doors
Steps number
overhead shower? Q yes QGno
height of each
width Is tub accessible? OQ yes Ono
depth Stall Shower: @ yes Qno

Are there HANDRAILS? QO yes Ono door width

height of bottom rim
If yes, where are they located? Q left Oright accessible? Q yes Qno
ink:
HANDRAIL height from step surface?
height
faucet type
Ifno, how much room is available for HANDRAILS?
Q ~~ open
QO closed
Are landings negotiable? QO yes Qno accessible? Q yes Qno
Briefly describe any problems with LANDINGS: Toilet:
height from floor
Ramps QO yes Qno location of toilet paper
O front QO back
height distance from toilet to sidewall L
width
length Grab bars: OQ yes Qno
Location
Are there HANDRAILS? Q yes Ono
Comments:
If yes, where are they located? Oleft Qright height__
Ifno ramp, how much room isavailableforone?_ Kitchen
Porch Door:
width width
length a threshold height Negotiable? Qyes Qno
Level at threshold? QO yes Ono
Stove:
Door height ,
width Location of controls Qftront back
threshold height Negotiable? OQyes Ono \s stove accessible for use? QO yes Qno
Q swing in
Q swing out Oven:
Q sliding Height from floor to door hinge & door handle
Location of oven as
Interior
Sink:
Living Room Will w/c fit underneath? QO yes Ono
Type of faucets
Is furniture arranged for easy maneuverability? OQ yes Ono
Cupboards:
Is frequently used furniture accessible QO yes Qno accessible from w/c? Q yes Ono
Type of floor covering:
Refrigerator:
Comments hinges on Qleft QO right
Hallways accessible from w/c? Qyes Qno

Can wheelchair or walking aide be maneuvered in hallway? Qyes Qno Switches / Outlets:
accessible? QO yes Ono
hall width
door width Kitchen Table:
height from floor
Sharpturns Qyes Qno accessible? Q yes Qno
Steps? Qyes Ono Comments: ee. ed
number
Are there HANDRAILS? Qyes Qno
Laundry
If yes, where are they located? (left Oright height.
Door: width
Bedroom
Q single threshold height Negotiable? OQyes Ono
Q shared
Steps: Qyes Ono
Isthere room for a W/C? OQ yes Qno number
height
Door width
width
threshold height Negotiable? OQyes Ono Are there HANDRAILS? Oyes Ono
Q swing in
Q swing out If yes, where are they located? Q left Q right height

FIG. 13-3
Home visit checklist. (Adapted from Occupational/physical therapy home evaluation form, San Fran-
cisco, 1993, Ralph K. Davies Medical Center, and Occupational therapy home evaluation form, Albany,
Calif, 1993,Alta Bates Hospital.) Continued

137
138 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

Q Topload
Location ea
Q Front load
Insulated hot water pipes: O yes Ono
accessible? Q yes Qno Location

Cluttered areas?
Q Topload Qyes Qno
Location
Q Front load
accessible? QO yes Qno
Fire
extinguisher?
Q yes Qno
Location
Safety Equipment_present:
Throw rugs
QO yes ano
Location
Phone Probl list:
accessible? Q yes Ono
Location
Emergency
phone numbers
OQ yes Qno
Location
ndati i
Mailbox
accessible? Q yes Ono
Location

Thermostat
accessible? O yes Qno
Location
Electric Outlets / switch
accessible?
Imperfect floor?
QO yes Qno
Location

FIG. 13-3, cont’d

Home visit checklist. (Adapted from Occupational/physical therapy home evaluation form, San Fran-
cisco, 1993, Ralph K. Davies Medical Center, and Occupational therapy home evaluation form, Albany,
Calif, 1993, Alta Bates Hospital.)

During the performance assessment the therapist tub, and also may be used in a shower. A transfer tub
should observe safety factors, ease of mobility and per- bench (Fig. 13-5) is recommended for individuals who
formance, and limitations imposed by the environ- cannot safely or independently step over the edge of the
ment. If the client needs assistance for transfers and tub. Installation of a hand-held shower hose increases
other activities, the caregiver should be instructed in the access to the water and also eliminates risky turns and
methods that are appropriate. The client may also be in- standing while bathing.
structed in methods to improve maneuverability and When the home assessment is completed, the thera-
simplify performance of tasks in a small space. pist should write a report summarizing the information
At the end of the assessment the therapist can make a on the form and describing the client's performance in
list of problems, modifications recommended, and ad- the home. The report should conclude with a summary
ditional safety equipment and assistive devices needed. of the environmental barriers and the client's functional
The most common changes are the following®®: limitations encountered. Recommendations should
1. Installation of a ramp or railings at the entrance to include equipment or alterations needed with specific
the home details about size, building specifications, costs, and
2. Removal of scatter rugs, extra furniture, and bric-a- sources. Recommendations may also include further
brac functional goals to improve independence in the indi-
3. Removal of doorsills vidual’s home environment.
4. Addition of safety grab bars around the toilet and The therapist should carefully review all recommen-
bathtub dations with the client and family. This review should
5. Rearrangement of furniture to accommodate a be done with tact and diplomacy in a way that gives the
wheelchair client and family options and the freedom to refuse
6. Rearrangement of kitchen storage them or consider alternative possibilities. Family fi-
7. Lowering of the clothes rod in the closet. nances may limit implementation of needed changes.
Access into the bathroom and maneuvering with a The social worker may be involved in working out
wheelchair or walker are common problems. Frequently funding for needed equipment and alterations, and the
a bedside commode is recommended until a bathroom client should be made aware of this service when cost is
can be made accessible or modified to allow independ- discussed.**
ence with toileting (Fig. 13-4). Shower seats can be used The therapist should include recommendations re-
in the tub, if a client can transfer over the edge of the garding the feasibility of the client's discharge to the
FIG. 13-4
All-purpose commode. A, In shower. B, At bedside. C, Over toilet. (Courtesy Sammons Preston.)
 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

ing a checkbook, or making a budget. If a physical limi-

tation is involved, the therapist may introduce adaptive
writing devices to allow the client to handle the paper-
work aspects of money management.

Community Mobility
Some clients are fortunate enough to be able to drive and
to adapt their own vehicle or purchase an adapted van
(see Chapter 14). The client who does not meet these cri-
teria must learn to use public transportation or to get
around the community on foot or in a wheelchair. In this
case, the occupational therapist must assess the client's
physical, perceptual, cognitive, and social capabilities to
be independent and safe with community mobility.
Physical capabilities to be considered are (1) whether
the client has the endurance to be mobile in the com-
munity without fatigue and (2) whether the client is
sufficiently independent with the walker, cane, crutch,
or wheelchair skills and transfers needed to go beyond
the home environment. These skills include managing
uneven pavement, curbs, and inclines and crossing the
street. Other skills to be evaluated before considering
community mobility are how to (1) handle money,
(2) carry objects in a wheelchair or with a walker, and
FIG. 13-5 (3) manage toileting in a public rest room.
Transfer tub bench. (Courtesy Sammons Preston.) Cognitive skills include the ability to be geographi-
cally oriented; if taking a bus, to know how to read a
home environment or remaining in or managing the schedule and map or know how to get directions; and to
home alone, if applicable. If there is a question regarding have good problem-solving skills if a problem should
the client's ability to return home safely and independ- occur in the community. If the disability is new, the
ently, the home assessment summary should include the client may be developing new social skills. At first, these
functional skills the client needs to return home. skills will be stretched to the limit once the client is out
If a home visit is not possible, much of the informa- in the community—for example, learning how to be as-
tion can be gained by interviewing the client and family sertive to get an accessible table at a restaurant, obtain-
member(s) following a trial home visit. The family ing assistance with unreachable items in the grocery
member or caregiver may be instructed to complete the store, and becoming comfortable with a new body
home visit checklist and provide photographs or image within the able-bodied community.
sketches of the rooms and their arrangements. Problems The therapist should also assess the client's commu-
encountered by the client during the home visit should nity environment. For example, is the neighborhood
be discussed and the necessary recommendations for safe enough for an individual who might be vulnerable
their solution made, as described earlier.*® because of physical limitations? What is the terrain like?
Are there curb cut-outs? Are the sidewalks smooth and
even? How far away are the closest store and bus stop?
Money and Financial Management
Accessibility of community transportation should
If the client is to resume management of money and fi- also be considered. Some communities have door-to-
nancial matters independently, a cognitive and percep- door cab and van service, which have certain restric-
tual assessment that accurately tests these skills should tions. Some of these restrictions include the need to
be implemented. Because some persons with physical arrange transportation 1 week in advance, the ability to
disabilities also have concurrent involvement of cogni- get out the front door and to the curb independently,
tion and perception, the level of impairment should be and the ability to transfer independently into the
determined. Caregivers may require training if the role vehicle. If a public bus is to be used by the client, he
of financial manager is new and must be assumed. The must learn how to use the electric lifts and how to lock
client may be capable of handling only small amounts a wheelchair into place. Because not all bus stops are
of money or may need retraining in activities that wheelchair accessible, the neighboring bus stops should
require money management, such as shopping, balanc- be surveyed.
 Activities of Daily Living 141

Community mobility requires preplanning by the oc- assessment and on the client's priorities and potential for
cupational therapist and the client, accurate assessment independence. The following sequence of training for
of the client's abilities, and knowledge of potential self-care activities is suggested: feeding, grooming, conti-
physical, cognitive, and social barriers that may be nence, transfer skills, toileting, undressing, dressing, and
encountered. A valuable resource by Armstrong and bathing. This sequence is based on the normal develop-
Lauzen, Community Integration Program,’ provides prac- ment of self-care independence in children.** It provides
tical treatment protocols to establish a community a good guide but may have to be modified to accommo-
living skills program. Attaining independence in com- date the specific dysfunction and the capabilities, limita-
munity mobility is worth the investment because it tions, and personal priorities of the client.
allows the client to expand life tasks beyond those in The occupational therapist should estimate which
the home and interact with the community. ADL and I-ADL tasks are possible and which are impos-
sible for the client to achieve. The therapist should
Medication Management and Health explore with the client the use of alternative methods of
performing the activities and the use of any assistive
Maintenance
devices that may be helpful. He or she should deter-
Medication management and health maintenance mine for which tasks the client requires assistance and
include the client's ability to understand the medical how much should be given. It may not be possible to es-
condition and make decisions to maintain good health. timate these factors until training is under way.
The client's ability to handle medications, know when to The ADL and I-ADL training program may be graded
call a physician, and know how to make a medical ap- by beginning with a few simple tasks and gradually
pointment is a practical aspect of health management. increasing the number and complexity of tasks. Training
The evaluation of the client's ability to perform these ac- should progress from dependent to assisted to super-
tivities may be completed solely by the occupational vised to independent, with or without assistive de-
therapist but will probably include other team members vices.°® The rate at which grading can occur depends on
such as the nurse and the physician. the client’s potential for recovery, endurance, skills, and
Performance components must be assessed in light motivation.
of the skills required for each task. The OT assessment
can be helpful in determining which aspects of the task
Methods of Teaching ADL
need to be modified for the client to be independent.
For example, the occupational therapist can work The therapist must tailor methods of teaching the client
jointly with a nurse to ensure that a client with hemi- to perform daily living tasks to suit each client's learning
plegia and diabetes can manage insulin shots. The OT style and ability. The client who is alert and grasps in-
evaluation considers the client's cognitive and percep- structions quickly may be able to perform an entire
tual abilities to make judgments about drawing the process after a brief demonstration and oral instruction.
insulin out of the bottle, measuring the insulin, and in- Clients who have perceptual problems, poor memory,
jecting the insulin. Physical concerns include how to and difficulty following instructions of any kind need
stabilize the insulin bottle and handle the syringe with a more concrete, step-by-step approach, reducing the
one hand. Other medication management may involve amount of assistance gradually as success is achieved.
how the client is able to open the medication and For these clients it is important to break down the activ-
measure it, if the medication is a liquid. The occupa- ity into small steps and progress through them slowly,
tional therapist may also evaluate and train the client in one at a time. A slow demonstration of the task or step
other skills that affect health management. Examples by the therapist in the same plane and in the same
include using the phone, finding the appropriate phone manner in which the client is expected to perform is
numbers, and providing the needed information to helpful. Oral instructions to accompany the demonstra-
make a medical appointment. tion may or may not be helpful, depending on the
Health maintenance is an issue for the client and client's receptive language skills and ability to process
entire health care team. The occupational therapist and integrate two modes of sensory information simul-
plays an important role because of the scope of the ADL taneously.
and I-ADL assessments, which may identify and help Touching body parts to be moved, dressed, bathed,
tesolve problems related to health maintenance. or positioned, passive movement of the part through
the desired pattern to achieve a step or a task, and gentle
manual guidance through the task are helpful tactile
ADL AND I-ADL TRAINING and kinesthetic modes of instruction (see Chapter 9).
If it is determined after an assessment that ADL and These techniques can augment or replace demonstra-
I-ADL training are to be initiated, it is important to estab- tion and oral instruction, depending on the client's best
lish appropriate short- and long-term goals, based on the avenues of learning. It is necessary to perform a step
142 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

or complete a task repeatedly to achieve skill, speed, the initial evaluation, it should be used in the reevalua-
and retention of learning. Tasks may be repeated several tion process to determine the level of progress the client
times during the same training session if time and the has made.
client’s physical and emotional tolerance allow, or they Progress is usually summarized for inclusion in the
may be repeated daily until the desired retention or medical record. The progress record should summarize
level of skill is achieved. changes in the client's abilities and current level of inde-
The process of backward chaining can be used in pendence and should also estimate the client's potential
teaching ADL skills. In this method the therapist assists for further independence, attitude, motivation for ADL
the client until the last step of the process is reached. training, and future goals for the ADL program. The in-
The client then performs this step independently, which formation about the client’s level of assistance needed
affords a sense of success and completion. When the for ADL and I-ADL will help with the discharge plan-
last step is mastered, the therapist assists until the last ning. For example, if a client continues to require mod-
two steps are reached and the client then completes erate assistance with self-care, he or she may need to
these two steps. The process continues, with the thera- hire an attendant, or the occupational therapist may
pist offering less and less assistance and the client per- justify ongoing treatment when the client has potential
forming successive steps of the task, from last to first, for further independence.
independently. This method is particularly useful in
training clients with brain damage.*®
Assistive Technology and Adaptive
Before beginning training in any ADL, the therapist
Equipment
must prepare by providing adequate space and arrang-
ing equipment, materials, and furniture for maximal Assistive technology is defined as any item, piece of
convenience and safety. The therapist should be thor- equipment, or product system, whether acquired com-
oughly familiar with the task to be performed and any mercially, off the shelf, modified, or customized, that is
special methods or assistive devices that will be used in used to increase or improve functional capabilities of
its performance. The therapist should be able to individuals with disabilities. This is a definition pro-
perform the task, as he or she expects the client to vided in PL (Public Law) 100-47, the Technical Assis-
perform it, skillfully. After preparation the activity is tance to the States Act, in the United States.” The terms
presented to the client, usually in one or more of the assistive technology, adaptive equipment, and assistive de-
modes of guidance, demonstration, and oral instruc- vices are generally used interchangeably throughout the
tion described earlier. The client then performs the ac- profession. Adaptive equipment is used to compensate
tivity either along with the therapist or immediately for a physical limitation, to promote safety, and to
after being shown, with the amount of supervision and prevent joint injury. Physical limitations may include a
assistance required. Performance is modified and cor- loss of muscle strength, loss of range of motion (ROM),
rected as needed, and the process is repeated to ensure incoordination, or sensory loss. An example of using
learning. adaptive equipment to improve safety is the use of a bed
Because other staff or family members are fre- or door alarm to alert a caregiver that a patient with im-
quently the individuals reinforcing the newly learned paired cognition is wandering. The use of adaptive
skills, family training is critical to reinforce learning equipment to prevent joint injury is indicated for the
and ensure that the client carries over the skills from person with rheumatoid arthritis.
previous treatment sessions. In the final phase of in- Before recommending a piece of adaptive equip-
struction, when the client has mastered one or more ment, the OT practitioner must complete a thorough as-
tasks, he or she is asked to perform them independ- sessment to determine the client's functional problems
ently. The therapist should check performance in and causes of the problems. The OT practitioner may
progress and later arrange to check on the adequacy of also consider practical solutions first, before settling on
performance and carryover of learning with nursing adaptive equipment as the solution. Some practical so-
personnel, the caregiver, or the supervising family lutions would be to avoid the cause of the problem, use
members.'® a compensatory technique or alternative method, get as-
sistance from another person, or modify the environ-
ment. An example of these considerations is the follow-
Recording Progress in ADL Performance
ing case study:
The ADL checklists used to record performance on the
Mrs. S. is 75 years old and living in a nursing home. The
initial assessment usually have one or more spaces for occupational therapist receives a referral for a self-feeding as-
recording changes in abilities and the results of reassess- sessment because the client has recently lost weight and the
ment during the training process. The sample checklist nursing aides are reporting that she needs assistance with
given earlier in this chapter is so designed and filled in eating. The nurse mentioned that she thought Mrs. S. needed a
(Fig. 13-1). If a standardized assessment is used during built-up handle utensil to eat.
 Activities of Daily Living 143

The OT assessment included observation of Mrs. S eating methods. The following categories of physical deficits
lunch in her usual location (in her room with use of an are addressed in this chapter:
over-bed table), physical assessment (MMT, ROM, sensa- m ADL for the person with limited ROM or strength
tion, coordination), gross cognitive and perceptual assess- ® ADL for the person with incoordination
ments, and an interview with Mrs. S. The results indicated
m ADL for the person with hemiplegia or use of only
Mrs. S had problems with sitting properly in her wheelchair.
one upper extremity
The over-bed table was too high and limited her ability to
reach the plate. Her strength, ROM, coordination, and sen- m™ ADL for the person with paraplegia
sation were within normal limits, except that bilateral @ ADL for the person with quadriplegia
shoulder flexors and abductors were F- (3-). Mrs. S’s cogni- @ ADL for the person with low vision
tion and perception were adequate to relearn simple self- The following ADL and I-ADL are addressed with each
care tasks. of the physical deficits listed above:
Treatment involved working on wheelchair positioning, Dressing activities
lowering the over-bed table, and then teaching the client how Eating activities
to use a compensatory technique of elbow propping to bring Hygiene and grooming activities
her hand to her mouth during eating. The OT assessment did Communication and environmental adaptations
not indicate a need for adaptive equipment at this time;
Mobility and transfer skills
instead, the environment was adapted, wheelchair positioning
Home management activities
modified, and a compensatory method taught.
If the results of the assessment had indicated that Mrs. S.
had a weak grasp and hand incoordination, a built-up handle ADL for the Person With Limited ROM
utensil and plate guard might have been used to promote in- or Strength
dependence with self-feeding.
The major problem for persons with limited joint ROM
Other factors to consider when selecting adaptive is compensating for the lack of reach and joint excur-
equipment are whether the disability is short term or sion through such means as environmental adaptation
long term, the client's tolerance for gadgets, the client's and assistive devices. Individuals who lack muscle
feelings about the device, and the cost and upkeep of strength may require some of the same devices or tech-
the equipment. niques to compensate and to conserve energy. Some
adaptations and devices are outlined here.*°°77°'7®
SPECIFIC ADL TECHNIQUES
Lower Extremity Dressing Activities
In many instances, specific techniques to solve specific 1. Use dressing sticks with a neoprene-covered coat
ADL problems are not possible. Sometimes the occupa- hook on one end and a small hook on the other (Fig.
tional therapist has to explore a variety of methods or 13-6) for pushing and pulling garments off and on
assistive devices to reach a solution. It is occasionally feet and legs.
necessary for the therapist to design a special device, 2. For socks, use a commercially available sock aid (Fig.
method, splint, or piece of equipment to make a partic- 13-7):
ular activity possible for the client to perform. Many of 3. Eliminate the need to bend to tie shoelaces or to use
the assistive devices available today through rehabilita- finger joints in this fine motor activity by using
tion equipment companies were first conceived and elastic shoelaces or other adapted shoe fasteners. Use
made by occupational therapists and clients. Many of Velcro-fastened shoes.
the special methods used to perform specific activities 4. Use reachers (Fig. 13-8) for picking up socks and
also evolved through the trial-and-error approaches of shoes, arranging clothes, removing clothes from
therapists and their clients. Clients often have good sug- hangers, picking up objects on the floor, and
gestions for therapists, because they live with the limita- donning pants.
tion and are confronted regularly with the need to adapt
the performance of daily tasks.
The purpose of the following summary of techniques
is to give the reader some general ideas about how to
solve ADL problems for specific classifications of dys-
function. The focus is on compensatory strategies in-
volving changing the method in which an activity is per-
formed, changing the environment, or using an assistive
device. If the client has the potential for improvement
of specific deficits, treatment that includes remedia-
tion should be considered. The references at the end FIG. 13-6
of this chapter provide more specific instruction in ADL Dressing stick or reacher. (Courtesy Sammons Preston.)
 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

FIG. 13-7 FIG. 13-8

Sock aid. (Courtesy Sammons Preston.) Extended handled reacher.

Built-up handles
for limited grasp

Suction cup
Clip-on button hook
for absent for one-handed
grasp

Amputee
buttonhook

FIG. 13-9
Buttonhooks to accommodate limited or special types of grasp or amputation.

Upper Extremity Dressing Activities 3. Long plastic straws and straw clips on glasses or cups
Lf Use front-opening garments that are one size larger can be used if neck, elbow, or shoulder ROM limits
than needed and made of fabrics that have some hand-to-mouth motion or if grasp is inadequate to
stretch. hold the cup or glass.
Use dressing sticks (Fig. 13-6) to push a shirt or . Universal cuffs or utensil holders can be used if grasp
blouse over the head. is very limited and built-up handles do not work
Use larger buttons or zippers with a loop on the (Fig. 13-12).
pull tab. . Plate guards or scoop dishes may be useful to prevent
Replace buttons, snaps, hooks, and eyes with Velcro food from slipping off the plate.
or zippers (for those clients who cannot manage tra-
ditional fastenings). Hygiene and Grooming Activities
Use one of several types of commercially available 1. A hand-held flexible shower hose for bathing and
buttonhooks (Fig. 13-9) if finger ROM is limited. shampooing hair can eliminate the need to stand in
the shower and offers the user control of the direc-
Eating Activities tion of the spray. The handle can be built up or
Ee Use built-up handles on eating utensils that can ac- adapted for limited grasp.
commodate limited grasp or prehension (Fig. 13-10). 2. A long-handled bath brush or sponge with a soap
a Elongated or specially curved handles on spoons and holder (Fig. 13-13) or long cloth scrubber can allow
forks may be needed to reach the mouth. A swivel the user to reach legs, feet, and back. A wash mitt
spoon or spoon-fork combination can compensate (Fig. 13-14) and soap on a rope can aid limited
for limited supination (Fig. 13-11). grasp.
 FIG. 13-10 FIG. 13-11
Eating utensils with built-up handles. Swivel spoon compensates for limited supination or incoordina-
tion.

FIG. 13-12 FIG. 13-13

Utensil holders and universal cuffs. (Courtesy Sammons Preston.) Long-handled bath sponges. (Courtesy Sammons Preston.)

FIG. 13-14
Terry cloth bath mitt. (Courtesy Sammons Preston.)

145
146 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

3. A wall-mounted hair dryer may be helpful. This to pants or panties, preventing them from slipping
device is useful for clients with limited ROM, upper to the floor during use of the toilet.
extremity weakness, incoordination, or use of just . Safety rails (Fig. 13-16) can be used for bathtub
one upper extremity. The dryer is mounted to allow transfers, and safety mats or strips can be placed in
the user to manage his or her hair with one arm or the bathtub bottom to prevent slipping.
position himself or herself to compensate for . A transfer tub bench (Fig. 13-5), shower stool, or
limited ROM.'* regular chair set in the bathtub or shower stall can
. Long handles on a comb, brush, toothbrush, lip- eliminate the need to sit on the bathtub bottom or
stick, mascara brush, and safety or electric razor stand to shower, thus increasing safety.
may be useful for clients with limited hand-to-head i Grab bars can be installed to prevent falls and ease
or hand-to-face movements. Extensions may be transfers.
constructed from inexpensive wooden dowels or
pieces of PVC pipe found in hardware stores. Communication and Environmental
. Spray deodorant, hair spray, and spray powder or Hardware Adaptations
perfume can extend the reach by the distance the iN Extended or built-up handles on faucets can accom-
material sprays. Special adaptations may be re- modate limited grasp.
quired by some persons to operate the spray mech- 2. Telephones should be placed within easy reach, or
anism (Fig. 13-15). portable phones can be used and kept with the
. Electric toothbrushes and a Water-Pik may be easier client. A clip-type receiver holder (Fig. 13-17), ex-
to manage than a standard toothbrush. tended receiver holder, or a speaker phone may be
. A short reacher can extend reach for using toilet necessary. A dialing stick is helpful if individual
paper. Several types of toilet aids are available in finger movements are not possible.
catalogues that sell assistive devices. . Built-up pens and pencils can be used to accom-
. Dressing sticks can be used to pull garments up modate limited grasp and prehension. A Wanchik
after using the toilet. An alternative is the use of a writer and several other commercially available or
long piece of elastic or webbing with clips on each custom-fabricated writing aids are possible (Fig.
end that can be hung around the neck and fastened 13-18).

FIG. 13-15 FIG. 13-16

Spray can adapters. (Courtesy Sammons Preston.) Bathtub safety rail. (Courtesy Sammons Preston.)
 Activities of Daily Living

4. Personal computers, word processors, and book

holders can facilitate communication for those with
limited or painful joints.
5. Lever-type doorknob extensions (Fig. 13-19), car
door openers, and adapted key holders can compen-
sate for hand limitations.

Mobility and Transfer Skills

The individual who has limited ROM without signifi-
cant muscle weakness may benefit from the following
assistive devices:
1. A glider chair that is operated by the feet can facilitate
transportation ifhip, hand, and arm motion is limited.
2. Platform crutches can prevent stress on hand or
finger joints and can accommodate limited grasp.
3. Enlarged grips on crutches, canes, and walkers can
accommodate limited grasp.
4. A raised toilet seat can be used if hip and knee
motion is limited.
5. A walker with padded grips and forearm troughs can
be used if marked hand, forearm, or elbow joint lim-
itations are present.
6. A walker or crutch bag or basket can facilitate the car-
tying of objects.

Home Management Activities

Home management activities can be facilitated by a
wide variety of environmental adaptations, assistive
FIG. 13-17 devices, energy conservation methods, and work simpli-
Telephone clip holder. (Courtesy Sammons Preston.) fication techniques.**”*° The principles of joint protec-
tion are essential for those with rheumatoid arthritis.
These principles are discussed in Chapter 43. The fol-
lowing are suggestions to facilitate home management
for persons with limited ROM:
1. Store frequently used items on the first shelves of
cabinets, just above and below counters or on coun-
ters where possible.

FIG. 13-18 FIG. 13-19

Wanchik writing aid. (Courtesy Sammons Preston.) Rubber doorknob extension. (Courtesy Sammons Preston.)
148 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

2. Use a high stable stool to work comfortably at Wheelchair users can benefit from front-loading ap-
counter height, or attach a drop-leaf table to the pliances.
wall for planning and meal preparation area if a 14. Use an adjustable ironing board to make it possible
wheelchair is used. to sit while ironing, or eliminate ironing with the
3. Use a utility cart of comfortable height to transport use of permanent press clothing.
several items at once. 15. Elevate the playpen and diaper table and use a
4. Use reachers to get lightweight items (e.g., a cereal bathinette or a plastic tub on the kitchen counter
box) from high shelves. for bathing to reduce the amount of bending and
5. Stabilize mixing bowls and dishes with nonslip mats. reaching by the ambulatory parent during child
6. Use lightweight utensils, such as plastic or alu- care. The crib mattress can be in a raised position
minum bowls and aluminum pots. until the child is 3 or 4 months of age.
7. Use an electric can opener and an electric mixer. 16. Use larger and looser fitting garments with Velcro
8. Use electric scissors or adapted loop scissors to fastenings on children.
open packages (Fig. 13-20). 17. Use a reacher to pick up clothing and children’s
9. Eliminate bending by using extended and flexible toys.
plastic handles on dust mops, brooms, and dustpans. 18. Use a comforter instead of a top sheet and blanket
10. Use adapted knives for cutting (Fig. 13-21). to increase the ease of making the bed.
11. Use pull-out shelves to organize cupboards and
eliminate bending.
ADL for the Person With Incoordination
12. Eliminate bending by using a wall oven, countertop
broiler, microwave oven, and convection oven. Incoordination in the form of tremors, ataxia, or
13. Eliminate leaning and bending by using a top- athetoid or choreiform movements can be caused by a
loading automatic washer and elevated dryer. variety of central nervous system (CNS) disorders, such
as Parkinson’s disease, multiple sclerosis, cerebral
palsy, and head injuries. The major problems encoun-
tered in ADL performance are safety and adequate sta-
bility of gait, body parts, and objects to complete the
tasks,<<"
Fatigue, emotional factors, and fear may influence
the severity of incoordinated movement.”® The client
must be taught appropriate energy conservation and
work simplification techniques along with appropriate
work pacing and safety methods to prevent the fatigue
and apprehension that could increase incoordination
and affect performance.
Stabilizing the arm reduces some of the incoordina-
FIG. 13-20
tion and may allow the individual to accomplish
Loop scissors. (Courtesy Sammons Preston.)
gross and fine motor movements without assistive
devices. A technique that can be used throughout all
ADL tasks is the stabilization of the involved upper
extremity. This technique is accomplished by propping
the elbow on a counter or table top, pivoting from the
elbow, and only moving the forearm, wrist, and hand
in the activity. When muscle weakness is not a major
deficit for the individual with incoordination, the use
of weighted devices can help with stabilization of
objects. A Velcro-fastened weight can be attached to
the client's arm to decrease ataxia, or the device being
used (eg., eating utensils, pens, and cups) can be
weighted.*®

Dressing Activities
To avoid balance problems, the client should attempt to
dress while sitting on or in bed or in a wheelchair or
FIG. 13-21 chair with arms. The following adaptations can reduce
Right-angle knife. (Courtesy Sammons Preston.) dressing difficulties:
 Activities of Daily Living 149

1. Use of front-opening garments that fit loosely can fa- Weighted cuffs may be placed on the forearm to de-
cilitate their donning and removal. crease involuntary movement (Fig. 13-23).
2. Use of large buttons, Velcro, or zippers with loops on . Use long plastic straws with a straw clip on a glass, or
the tab can facilitate opening and closing fasteners. A use a cup with a weighted bottom to eliminate the
buttonhook with a large, weighted handle may be need to carry the glass or cup to the mouth, thus
helpful. avoiding spills. Plastic cups with covers and spouts
. Elastic shoelaces, Velcro closures, other adapted shoe may be used for the same purpose.****
closures, and slip-on shoes eliminate the need for . Use a resistance or friction feeder similar to a mobile
bow tying. arm support, which was shown by Holser and associ-
. Trousers with elastic tops for women or Velcro clo- ates’ to help control patterns of involuntary move-
sures for men are easier to manage than trousers with ment during feeding activities of adults with cerebral
hooks, buttons, and zippers. palsy and athetosis. These devices may help many
. Using brassieres with front openings or Velcro re- clients with severe incoordination to achieve some
placements for the usual hook and eye may make it degree of independence in feeding. The device
easier to don and remove this garment. A slipover is available in adaptive equipment catalogs and
elastic-type brassiere or bra-slip combination also is listed as a Friction Feeder MAS (Mobile Arm
may eliminate the need to manage brassiere fasten- Support) Kit.
ings. Regular brassieres may be fastened in front at
waist level, then slipped around to the back and the Hygiene and Grooming Activities
arms put into the straps, which are then worked up Stabilization and handling of toilet articles may be
over the shoulders. achieved by the following suggestions:
6. Men can use clip-on ties.’”*® 1. Articles such as a razor, lipstick, and a toothbrush
may be attached to a cord if frequent dropping is a
Eating Activities problem. An electric toothbrush may be more easily
Eating can be a challenge for clients with problems of managed than a regular one.
incoordination. A lack of control during eating is not 2. Weighted wrist cuffs may be helpful during the finer
only frustrating, but can also cause embarrassment and hygiene activities, such as hair care, shaving, and ap-
social rejection. It is important to make eating safe, plying make-up.*®
pleasurable, and as neat as possible. The following are 3. A wall-mounted hair dryer described earlier for
some suggestions for achieving this goal: clients with limited ROM can also be useful for
1. Use plate stabilizers, such as nonskid mats (Dycem), clients with incoordination.
suction bases, or even damp dishtowels. . An electric razor, rather than a blade razor, offers
2. Use a plate guard or scoop dish to prevent pushing stability and safety.°* A strap around the razor and
food off the plate. The plate guard can-be carried hand can prevent dropping.
away from home and clipped to any ordinary dinner
plate (Fig. 13-22).
3. Prevent spills during the plate-to-mouth excursion
by using weighted or swivel utensils to offer stability.

FIG. 13-23
FIG. 13-22 Weighted wrist cuff and swivel utensil can sometimes compensate
A, Scoop dish. B, Plate with plate guard. C, Nonskid mat. for incoordination or involuntary motion and limited supination.
 150 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

5. A suction brush attached to the sink or counter can Communication and Environmental Hardware
be used for nail or denture care (Fig. 13-24). Adaptations
6. Soap should be on a rope. It can be worn around the 1. Doorknobs may be managed mote easily if adapted
neck or hung over a bathtub or shower fixture during with lever-type handles or covered with rubber or
bathing to keep it within easy reach. A bath mitt friction tape (Fig. 13-19).
with a pocket to hold the soap can be used for washing 2. Large button phones, speaker phones, or a holder for
to eliminate the need for frequent soaping and rins- a telephone receiver may be helpful.
ing and wringing a washcloth. A leg from a pair of 3. Writing may be managed by using a weighted, en-
pantyhose with a bar of soap in the toe may be tied larged pencil or pen. A personal computer with a
over a faucet to keep soap within reach and will keyboard guard is a helpful aid to communication. A
stretch for use. Liquid soap with a soft nylon scrubber computer mouse may frequently be substituted for
may be used to minimize the handling of soap. Bath the keyboard.*® A voice-recognition program may be
gloves can be worn and liquid soap applied to elimi- used with a personal computer to minimize use of
nate the dropping of the soap and washcloth.*® the keyboard or mouse.
7. An emery board or small piece of wood with fine 4. Keys may be managed by placing them on an
sandpaper glued to it can be fastened to the table adapted key holder that is rigid and offers more
top for filing nails.*° A nail clipper can be stabilized leverage for turning the key. Inserting the key in the
in the same manner. keyhole may be difficult, however, unless the incoor-
8. Large roll-on deodorants are preferable to sprays or dination is relatively mild.
creams.°*° 5. Extended lever-type faucets are easier to manage than
9. Sanitary pads that stick to undergarments may be knobs that turn and push-pull spigots. In order to
easier to manage than tampons.*® prevent burns during bathing and kitchen activities,
10. Nonskid mats should be used inside and outside the the person with incoordination should turn cold
bathtub during bathing. Their suction bases should water on first and add hot water gradually.
be fastened securely to the floor and bathtub before 6. Lamps that can be turned on and off with a wall
use. Safety grab bars should be installed on the wall switch, a light, or a signal-type device can eliminate
next to the bathtub or fastened to the edge of the the need to turn a small switch.
bathtub. A bathtub seat or shower chair provides
more safety than standing while the individual is Mobility and Transfers
showering or transferring to a bathtub bottom.*® Clients with problems of incoordination may use a
Many clients with incoordination require supervi- variety of ambulation aids, depending on the type and
sory assistance during this hazardous activity. severity of incoordination. Clients with degenerative
Sponge bathing while seated at a bathroom sink may diseases sometimes need help to recognize the need for
be substituted for bathing or showering several times and to accept ambulation aids. This problem may mean
a week. moving gradually from a cane to crutches to a walker,
and finally to a wheelchair for some persons. The fol-
lowing suggestions can improve stability and mobility
for clients with incoordination:
1. Instead of lifting objects, slide them on floors or
counters.
2. Use suitable ambulation aids.
3. Use a utility cart, preferably a heavy, custom-made
cart that has some friction on the wheels.
4. Remove door sills, throw rugs, and thick carpeting.
5. Install banisters on indoor and outdoor staircases.
6. Substitute ramps for stairs wherever possible.

Home Management Activities

It is important for the occupational therapist to carefully
assess performance of homemaking activities to deter-
mine (1) which activities can be done safely, (2) which
activities can be done safely if modified or adapted, and
FIG. 13-24 (3) which activities cannot be done adequately or safely
Suction brush attached to bathroom sink for dentures or finger- and should be assigned to someone else. The major
nails. Can also be used in kitchen to wash vegetables and fruit. problems are stabilization of foods and equipment to
 Activities of Daily Living Gra

prevent spilling and accidents and the safe handling of cutting. When the board is not in use, the nails
appliances, pots, pans, and household tools to prevent should be covered with a large cork. The bottom of
cuts, burns, bruises, electric shock, and falls. The follow- the board should have suction cups or should be
ing are suggestions for the facilitation of home manage- covered with stair tread, or the board should be
23,28,38,
ment tasks placed on a nonskid mat to prevent slippage when
1. Use a wheelchair and wheelchair lapboard, even if in use.
ambulation is possible with devices. The wheelchair ie. Use heavy dinnerware, which may be easier to
saves energy and increases stability if balance and handle because it offers stability and control to
gait are unsteady. the distal part of the upper extremity. (On the
If possible, use convenience and prepared foods to other hand, unbreakable dinnerware may be
eliminate as many processes (e.g., peeling, chop- more practical if dropping and breakage are
ping, slicing, and mixing) as possible. problems.)
Use easy-opening containers or store foods in plastic 3: Cover the sink, utility cart, and countertops with
containers once opened. A jar opener is also useful. protective rubber mats or mesh matting to stabilize
. Use heavy utensils, mixing bowls, and pots and items.
pans to increase stability. 14. Use a serrated knife for cutting and chopping
. Use nonskid mats on work surfaces. because it is easier to control.
. Use electrical appliances such as crock pots, electric Ae Use a steamer basket or deep-fry basket for prepar-
fry pans, toaster-ovens, and microwave or convec- ing boiled foods to eliminate the need to carry and
tion ovens because they are safer than using a range- drain pots containing hot liquids.
top stove. 16. Use tongs to turn foods during cooking and to
. Use a blender and countertop mixer because they serve foods because tongs may offer more con-
are safer than handheld mixers and easier than trol and stability than a fork, spatula, or serving
mixing with a spoon or whisk. spoon.
. If possible, adjust work heights of counters, sink, ee Use blunt-ended loop scissors to open packages.
and range to minimize leaning, bending, reaching, 13; Vacuum with a heavy upright cleaner, which may be
and lifting, whether the client is standing or using a easier for the ambulatory client. The wheelchair
wheelchair. user may be able to manage a lightweight tank-type
. Use long oven mitts, which are safer than pot- vacuum cleaner or electric broom.
holders. 1: Use dust mitts for dusting.
10. Use pots, pans, casserole dishes, and appliances 20. Eliminate fragile knickknacks, unstable lamps, and
with bilateral handles because they may be easier to dainty doilies.
manage than those with one handle. a he Eliminate ironing by using no-iron fabrics or a timed
11. Use a cutting board with stainless steelnails (Fig. dryer or by assigning this task to other members of
13-25) to stabilize meats and vegetables while the household.
pe Use a front-loading washer, a laundry cart on wheels,
and premeasured detergents, bleaches, and fabric
softeners.
233 Sit when working with an infant and use foam-
rubber bath aids, an infant bath seat, and a wide,
padded dressing table with Velcro safety straps to
offer enough stability for bathing, dressing, and di-
apering an infant. (Child care tasks may not be pos-
sible unless the incoordination is mild.)
24. Use disposable diapers with tape or Velcro fasten-
ers, because they are easier to manage than cloth
diapers and pins.
aoe Do not feed the infant with a spoon or fork unless
the incoordination is very mild or does not affect
the upper extremities. This task may need to be per-
formed by another household member.
FIG. 13-25 26. Children’s clothing should be large, loose, and
Cutting board with stainless steel nails, suction cup feet, and made of nonslippery stretch fabrics, and should
corner for stabilizing bread is useful for patients with incoordina- have Velcro fastenings.
tion or use of one hand. (Courtesy Sammons Preston.) Die Use front infant carriers or strollers for carrying.
 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS
ADL for the Person With Hemiplegia
2. Position shirt on lap with inside up and collar
or Use of Only One Upper Extremity toward chest (Fig. 13-26, B).
Suggestions for performing daily living skills apply to 3. Position sleeve opening on affected side so opening
persons with hemiplegia, unilateral upper extremity is as large as possible and close to affected hand,
amputations, and temporary disorders such as fractures, which is resting on lap (Fig. 13-26, C).
burns, and peripheral neuropathic conditions that can 4. Using normal hand, place affected hand in sleeve
result in the dysfunction of one upper extremity. opening and work sleeve over elbow by pulling on
The client with hemiplegia needs specialized methods garment (Fig. 13-26, D1, D2).
of teaching, and many such clients have greater difficulty 5. Putnormal arm into its sleeve and raise arm to slide or
learning and performing one-handed: skills than do shake sleeve into position past elbow (Fig. 13-26, E).
those with orthopedic or lower motor neuron dysfunc- 6. With normal hand, gather shirt up middle of back
tion. Because the trunk and leg are involved, as well as from hem to collar and raise shirt over head (Fig.
the arm, ambulation and balance difficulties may exist. 13-26, F).
Sensory, perceptual, cognitive, and speech disorders may 7. Lean forward, duck head, and pass shirt over head
be present in a mild to severe degree. These disorders (Fig. 13-26, G).
affect the ability to learn and retain learning and per- 8. With normal hand, adjust shirt by leaning forward
formance. Finally, the presence of apraxia sometimes and working shirt down past both shoulders. Reach
seen in this group of clients can have a profound effect in back and pull shirt tail down (Fig. 13-26, H).
on the potential for learning new motor skills and re- 9. Line up shirt fronts for buttoning and begin with
membering old ones. Therefore the client with normal bottom button (Fig. 13-26, I). Button sleeve cuff of
perception and cognition and the use of only one upper affected arm. Sleeve cuff of unaffected arm may be
extremity may learn the techniques quickly and easily.*® pre-buttoned if cuff opening is large. Button may be
The client with hemiplegia needs to be assessed for sewn on with elastic thread or sewn onto a small tab
sensory, perceptual, and cognitive deficits to determine of elastic and fastened inside shirt cuff. A small
the potential for ADL performance and to establish ap- button attached to crocheted loop of elastic thread is
propriate teaching methods to facilitate learning. another option. Slip button on loop through button-
The major problems for the one-handed worker are hole in garment so that elastic loop is inside. Stretch
reduction of work speed and dexterity, and stabiliza- elastic loop to fit around original cuff button. This
tion to substitute for the role normally assumed by the simple device can be transferred to each garment and
nondominant arm.***® The major problems for the in- positioned before shirt is put on. Loop stretches to
dividual with hemiplegia are balance and precautions accommodate width of hand as it is pushed through
relative to sensory, perceptual, and cognitive losses. end of sleeve.*”
Removing Shirt
Dressing Activities 1. Unbutton shirt.
If balance is a problem, the client should dress while 2. Lean forward.
seated in a locked wheelchair or sturdy armchair. Cloth- 3. With normal hand, grasp collar or gather material up
ing should be within easy reach. A reacher may be in back from collar to hem.
helpful for securing articles and assisting in some dress- 4. Lean forward, duck head, and pull shirt over head.
ing activities. Assistive devices should be used mini- 5. Remove sleeve from normal arm and then from af-
mally for dressing and other ADL. Compensatory tech- fected arm.
niques are preferable. For the client with hemiplegia, METHOD II
dressing techniques that employ neurodevelopmental Donning Shirt. Clients who get their shirts twisted
(Bobath) treatment principles are discussed in Chapter or have trouble sliding the sleeve down onto the
36. The following one-handed dressing techniques* normal arm can use method II.
can facilitate dressing for persons with use of only one 1. Position shirt as described in method I, steps 1 to 3.
upper extremity. A general rule is to begin with the af- 2. With normal hand, place involved hand into the
fected arm or leg first when donning clothing. Start with sleeve opening and work sleeve onto hand, but do
the unaffected extremity when removing clothing. not pull up over elbow.
3. Putnormal arm into sleeve and bring arm out to 180°
SHIRTS. One of the three following methods can be of abduction. Tension of fabric from normal arm to
used to manage front-opening shirts. The first method can wrist of affected arm will bring sleeve into position.
also be used for jackets, robes, and front-opening dresses.
METHOD I
: : 3 *Summarized from Activities of daily living for clients with incoordina-
Donning Shirt. See Fig. 15-26: tion, limited range of motion, paraplegia, quadriplegia, and hemiplegia,
1. Grasp the shirt collar with normal hand and shake Cleveland, 1989, Metro Health Center for Rehabilitation, Metro
out twists (Fig. 13-26, A). Health Medical Center, Unpublished.
 Activities of Daily Living 153

FIG. 13-26
Steps in donning a shirt: method |. (Courtesy Christine Shaw, Metro Health Center for Rehabilita-
tion, Metro Health Medical Center, Cleveland, Ohio.)

. Lower arm and work sleeve on affected arm up over

elbow.
. Continue as in steps 6 through 9 of method I.
Removing Shirt
. Unbutton shirt.
. With normal hand, push shirt off shoulders, first on
affected side, then on normal side. .
. Pull on cuff of normal side with normal hand.
. Work sleeve off by alternately shrugging shoulder
and pulling down on cuff.
. Lean forward, bring shirt around back, and pull
sleeve off affected arm.
FIG. 13-27
METHOD III
Steps in donning a shirt: method Ill. (Courtesy Christine Shaw,
Donning Shirt. See Fig. 13-27.
Metro Health Center for Rehabilitation, Metro Health Medical
. Position shirt and work onto arm as described in Center, Cleveland, Ohio.)
method I, steps 1 to 4.
. Pull sleeve on affected arm up to shoulder (Fig. 13-
oa).
. With normal hand, grasp tip of collar that is on Variation for Donning Pullover Shirt
normal side, lean forward, and bring arm over and 1. Position shirt on lap, bottom toward chest and label
behind head to carry shirt around to normal side facing down.
(Fig. 13-27, B). 2. With normal hand, roll up bottom edge ofshirt back
. Put normal arm into sleeve opening, directing it up up to sleeve on affected side.
and out (Fig. 13-27, C). 3. Position sleeve opening so it is as large as possible
. Adjust and button as described in method I, steps 8 and use normal hand to place affected hand into
and 9. sleeve opening. Pull shirt up onto arm past elbow.
Removing Shirt. The shirt may be removed using the 4. Insert normal arm into sleeve.
procedure described previously for method II. 5. Adjust shirt on affected side up and onto shoulder.
154 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

6. Gather shirt back with normal hand, lean forward, 2. Position normal leg in front of midline of body with
duck head, and pass shirt over head. knee flexed to 90°. Using normal hand, reach for-
7. Adjust shirt. ward and grasp ankle of affected leg or sock around
Variation for Removing Pullover Shirt ankle (Fig. 13-28, B1). Lift affected leg over normal
1. Gather shirt up with normal hand, starting at top back. leg to crossed position (Fig. 13-28, B2).
2. Lean forward, duck head, and pull gathered back 3. Slip trousers onto affected leg up to position where
fabric over head. foot is completely inside trouser leg (Fig. 13-28, C).
3. Remove from normal arm and then affected arm. Do not pull up above knee, or difficulty will be en-
Trousers may be managed by one of the following countered in inserting normal leg.
methods, which may be adapted for’shorts and wom- 4. Uncross affected leg by grasping ankle or portion of
en’s panties as well. It is recommended that trousers sock around ankle (Fig. 13-28, D).
have a well-constructed button fly front opening, which 5. Insert normal leg and work trousers up onto hips as
may be easier to manage than a zipper. Velcro may be far as possible (Fig. 13-18, E1 and E2).
used to replace buttons and zippers. Trousers should be 6. To prevent trousers from dropping when pulling
worn in a size slightly larger than worn previously and pants over hips, place affected hand in pocket or
should have a wide opening at the ankles. They should place one finger of affected hand into belt loop. If
be put on after the socks have been put on but before able to do so safely, stand and pull trousers over hips
the shoes are put on. If the client is dressing in a wheel- (Fig. 13-28, Fl and F2).
chair, feet should be placed flat on the floor, not on the 7. If standing balance is good, remain standing to pull
footrests of the wheelchair. up zipper or button (Fig. 13-28, F3). Sit down to
button front (Fig. 13-28, G).
TROUSERS Removing Trousers
METHOD I 1. Unfasten trousers and work down on hips as far as
Donning Trousers. See Fig. 13-28. possible while seated.
1. Sit in sturdy armchair or in locked wheelchair (Fig. 2. Stand, letting trousers drop past hips, or work
13-28, A). trousers down past hips.

f f, f, “
FIG. 13-28
Steps in donning trousers: method I. (Courtesy Christine Shaw, Metro Health Center for Rehabilita-
tion, Metro Health Medical Center, Cleveland, Ohio.)
 Activities of Daily Living 155

3. Remove trousers from normal leg. arm through its strap and work up over shoulder by
4. Sit and cross affected leg over normal leg, remove directing arm up and out and pulling with hand.
trousers, and uncross leg. 4. Use normal hand to adjust breasts in brassiere cups.
METHOD II Note: It is helpful if the brassiere has elastic straps and
Donning Trousers. Method II is used for clients who is made of stretch fabric. If there is some function in the
are in wheelchairs with brakes locked and footrests affected hand, a fabric loop may be sewn to the back of
swung away, who are in sturdy, straight armchairs posi- the brassiere near the fastener. The affected thumb may
tioned with the back against the wall, and for clients be slipped through the loop to stabilize the brassiere
who cannot stand independently. while the normal hand fastens it. All elastic brassieres,
1. Position trousers on legs as in method I, steps 1 prefastened or without fasteners, may be put on by
through 5. adapting method I for pullover shirts described previ-
2. Elevate hips by leaning back against chair and ously. Front-opening bras may also be adapted with a
pushing down against the floor with normal leg. As loop for the affected hand with some gross arm function.
hips are raised, work trousers over hips with normal REMOVING BRASSIERE
hand. . Slip straps down off shoulders, normal side first.
3. Lower hips back into chair and fasten trousers. . Work straps down over arms and off hands.
Removing Trousers . Slip brassiere around to front with normal arm.
1. Unfasten trousers and work down on hips as far as Bm
Re
WN . Unfasten and remove.
possible while sitting.
2. Lean back against chair, push down against floor NECKTIE
with normal leg to elevate hips, and with normal DONNING NECKTIE. Clip-on neckties are attractive and
arm work trousers down past hips. convenient. If a conventional tie is used, the following
3. Proceed as in method I, steps 3 and 4. method is recommended:
METHOD III 1. Place collar of shirt in “up” position and bring
Donning Trousers. Method III is for clients who are in necktie around neck and adjust so that smaller end is
a recumbent position. It is more difficult to perform than at desired length when tie is completed.
those methods done sitting. If possible, the bed should 2. Fasten small end to shirt front with tie clasp or spring
be raised to a semireclining position for partial sitting. clip clothespin.
1. Using normal hand, place affected leg in bent posi- 3. Loop long end around short end (one complete
tion and cross over normal leg, which may be par- loop) and bring up between “V” at neck. Then bring
tially bent to prevent affected leg from slipping. tip down through loop at front and adjust tie, using
2. Position trousers and work onto affected leg first, up ring and little fingers to hold tie end and thumb and
to the knee. Then uncross leg. forefingers to slide knot up tightly.
3. Insert normal leg and work trousers up onto hips as REMOVING NecktTiE. Pull knot at front of neck until
far as possible. small end slips up enough for tie to be slipped over
4. With normal leg bent, press down with foot and head. Tie may be hung up in this state and replaced by
shoulder to elevate hips from bed. With normal arm, slipping it over head around upturned collar, and knot
pull trousers over hips or work trousers up over hips tightened as described in step 3 of donning phase.
by rolling from side to side.
5. Fasten trousers. SOCKS OR STOCKINGS
Removing Trousers DONNING SOCKS OR STOCKINGS
1. Hike hips as in putting trousers on in method III, 1. Sit in straight armchair or in wheelchair with brakes
step 4. locked, feet on the floor, and footrest swung away.
2. Work trousers down past hips, remove unaffected 2. With normal leg directly in front of midline of body,
leg, and then remove affected leg. cross affected leg over normal leg.
3. Open top of stocking by inserting thumb and first
BRASSIERE two fingers near cuff and spreading fingers apart.
DONNING BRASSIERE 4. Work stocking onto foot before pulling over heel.
1. Tuck one end of brassiere into pants, girdle, or skirt Care should be taken to eliminate wrinkles.
waistband and wrap other end around waist (wrap- 5. Work stocking up over leg. Shift weight from side to
ping toward affected side may be easiest). Hook side to adjust stocking around thigh.
brassiere in front at waist level and slip fastener 6. Thigh-high stockings with an elastic band at the top
around to back (at waistline level). are often an acceptable substitute for panty hose, es-
2. Place affected arm through shoulder strap, and then pecially for the nonambulatory individual.
place normal arm through other strap. 7. Panty hose may be donned and doffed as a pair of
3. Work straps up over shoulders. Pull strap on affected slacks, except that the legs would be gathered up one
side up over shoulder with normal arm. Put normal at a time before placing feet into the leg holes.
 156 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

REMOVING SOCKS OR STOCKINGS 2. AFO and shoe are placed on the floor between the
1. Work socks or stockings down as far as possible with legs but closer to the affected leg, facing up (Fig.
normal arm. 13-30;°C}:
2. Cross affected leg over normal one as described in 3. With the unaffected hand, lift the affected leg behind
step 2 of process of putting on socks or stockings. the knee and place toes into the shoe (Fig. 13-30, D).
3. Remove sock or stocking from affected leg. Dressing 4. Reach down with unaffected hand and lift AFO by
stick may be required by some clients to push sock or the upright. Simultaneously use the unaffected foot
stocking off heel and off foot. against the affected heel to keep the shoe and AFO
4. Lift normal leg to comfortable height or to seat level together (Fig. 13-30, E).
and remove sock or stocking from foot. 5. The heel will not be pushed into the shoe at this
point. With the unaffected hand, apply pressure di-
SHOES rectly downward on the affected knee to force the
If possible, select slip-on shoes to eliminate lacing and heel into the shoe, if leg strength is not sufficient
tying. If an individual uses an ankle-foot orthosis (AFO) (Fig. 13-30, F).
orshort
leg brace, shoes with fasteners are usually needed. 6. Fasten Velcro calf strap and fasten shoes (Fig. 13-30,
1. Use elastic laces and leave shoes tied. G). The affected leg may be placed on a footstool to
2. Use adapted shoe fasteners. assist with reaching shoe fasteners.
3. Use one-handed shoe-tying techniques (Fig. 13-29). 7. To fasten shoes, one-handed bow-tying may be used;
4. It is possible to learn to tie a standard bow with elastic shoelaces, Velcro-fastened shoes, or other
one hand, but this requires excellent visual, percep- commercially available shoe fasteners may be re-
tual, and motor planning skills along with much quired if the client is unable to tie shoes.
repetition. METHOD II. Steps 1 and 2 are the same as the posi-
tioning required for donning pants.
ANKLE-FOOT ORTHOSIS. The individual with 1. Sit in sturdy armchair or in locked wheelchair.
hemiplegia who lacks adequate ankle dorsiflexion to 2. Position normal leg in front of midline of body with
walk safely and efficiently frequently uses an ankle-foot knee flexed to 90°. Using normal hand, reach forward
orthosis (AFO). It can be donned in the following and grasp ankle of affected leg or sock around ankle.
manner. Lift affected leg over normal leg to crossed position.
METHOD I. See Fig. 13-30. 3. The fasteners are loosened and tongue of the shoe
1s Sit in straight armchair or wheelchair with brakes pulled back to allow the AFO to fit into the shoe;
locked and feet on the floor (Fig. 13-30, A). The fasten- Velcro fastener on upright is unfastened.
ers are loosened and tongue ofthe shoe pulled back to . Using normal hand, hold heel of shoe and work over
allow the AFO to fit into the shoe (Fig. 13-30, B). toes of affected foot and leg. Once toes are in shoe,
work top part of AFO around the calf.
. Pull heel of shoe onto foot with hand or place foot on
floor, place pressure on knee, and push heel down
into shoe.
. Fasten Velcro calf strap and fasten shoes.
REMOVING ANKLE-FOOT ORTHOSIS
Variation I
. While seated as for donning an AFO, cross affected
leg over normal leg.
. Unfasten straps and laces with normal hand.
. Push down on AFO upright until shoe is off foot.
Variation II
. Unfasten straps and laces.
. Straighten affected leg by putting normal foot behind
heel of shoe and pushing affected leg forward.
. Push down on AFO upright with hand and at same
time push forward on heel of AFO shoe with normal
foot.

FIG. 13-29 Eating Activities

One-hand shoe-tying method. (Courtesy Christine Shaw, Metro The main problem encountered by the one-handed in-
Health Center for Rehabilitation, Metro Health Medical Center, dividual is managing a knife and fork simultaneously
Cleveland, Ohio.) for cutting meat. This problem can be solved by the use
 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

Communication and Environmental Hardware

Adaptations.
1. The primary problem with writing is stabilization of
the paper or tablet. This problem can be overcome by
using a clipboard, paperweight, or nonskid surface
such as Dycem or by taping the paper to the writing
surface. In some instances the affected arm may be
positioned on the table top to stabilize the paper
FIG. 13-31 passively.
One-handed rocker knife. (Courtesy Sammons Preston.) 2. If dominance must be shifted to the nondominant
extremity, writing practice may be necessary to im-
prove speed and coordination. One-handed writing
and typing instruction manuals are available.
of a rocker knife for cutting meat and other foods (Fig. 3. Book holders may be used to stabilize a book while
13-31). This knife cuts with a rocking motion rather reading or holding copy for typing and writing prac-
than a back-and-forth slicing action. Use of a rocking tice. A soft pillow will easily stabilize a book while
motion with a standard table knife or a sharp paring the person is seated in an easy chair.
knife may be adequate to cut tender meats and soft 4. The telephone is managed by lifting the receiver to
foods. If such a knife is used, the client is taught to hold listen for the dial tone, setting it down, pressing the
the knife handle between the thumb and the third, keys, and lifting the receiver to the ear. To write
fourth, and fifth fingers, and the index finger is extended while using the telephone, a stand or shoulder tele-
along the top of the knife blade. The knife point is phone receiver holder must be used. A speaker-
placed in the food in a vertical position, and then the phone can also leave hands free to take messages.
blade is brought down to cut the food. The rocking One-touch dialing using preprogrammed phone
motion, using wrist flexion and extension, is continued numbers eliminates pressing as many keys, simpli-
until the food is cut. fies sequencing, and may help compensate for
The occupational therapist should keep in mind that memory deficits.
one-handed meat cutting involves learning a new motor
pattern. This skill may be difficult for clients with hemi- Mobility and Transfers
plegia and apraxia. Principles of transfer techniques for clients with hemi-
plegia are described in Chapter 14.
Hygiene and Grooming Activities
Clients with the use of one hand or one side of the body Home Management Activities
can accomplish hygiene and grooming activities by Many assistive devices are available to facilitate home
using assistive devices and alternative methods. The management activities. Various factors determine how
following are suggestions for achieving hygiene and many home management activities can realistically be
grooming with one hand: performed, which methods can be used, and how many
1. Use an electric razor rather than a safety razor. assistive devices can be managed. These factors include
2. Use a shower seat in the shower stall or a transfer tub (1) whether the client is disabled by the loss of function
bench in a bathtub-shower combination. Also use a of one arm and hand, as in amputation or a peripheral
bath mat, wash mitt, long-handled bath sponge, safety neuropathic condition, or (2) whether both arm and leg
rails on the bathtub or wall, soap on a rope or suction are affected along with possible visual, perceptual, and
soap holder, and suction brush for fingernail care. cognitive dysfunctions, as in hemiplegia. The references
3. Sponge bathe while sitting at the lavatory, using the listed at the end of this chapter provide details of home
wash mitt, suction brush, and suction soap holder. management with one hand. The following are some
The uninvolved forearm and hand may be washed suggestions for home management for the client with
by placing a soaped washcloth on the thigh and use of one hand*?:
rubbing the hand and forearm on the cloth. 1. Stabilizing items is a major problem for the one-
4. Use a wall-mounted hair dryer. Such a device frees handed homemaker. Stabilize foods for cutting and
the unaffected upper extremity to hold a brush or peeling by using a cutting board with two stainless
comb to style the hair during blow-drying. steel or aluminum nails in it. A raised corner on the
5. Care for fingernails as described previously for board stabilizes bread for making sandwiches or
clients with incoordination. spreading butter. Suction cups or a rubber mat
6. Use a suction denture brush for care of dentures. The under the board will keep it from slipping. A
suction fingernail brush may also serve this purpose nonskid surface or rubber feet may be glued to the
(Fig. 13-22). bottom of the board (Fig. 13-25).
 Activities of Daily Living 159

. Use sponge cloths, nonskid mats or pads, wet dish- . Use a utility cart to carry items from one place to
cloths, or suction devices to keep pots, bowls, and another. For some clients a cart that is weighted or
dishes from turning or sliding during food pre- constructed of wood may be used as a minimal
paration. support during ambulation.
. To open a jar, stabilize it between the knees or in a 10. Transfer clothes to and from the washer or dryer by
partially opened drawer while leaning against the using a clothes carrier on wheels.
drawer. Break the air seal by sliding a pop bottle 11. Useelectrical appliances, such asa lightweight electri-
opener under the lid until the air is released, then cal hand mixer, blender, and food processor, that can
use a Zim jar opener (Fig. 13-32). be managed with one hand and save time and energy.
. Open boxes, sealed paper, and plastic bags by stabi- Safety factors and judgment need to be evaluated
lizing between the knees or in a drawer as just de- carefully when electrical appliances are considered.
scribed, and cut open with household shears. 12. Floor care becomes a greater problem if, in addition
Special box and bag openers are also available from to one arm, ambulation and balance are affected.
ADL equipment vendors. For clients with involvement of only one arm, a stan-
. Crack an egg by holding it firmly in the palm of the dard dust mop, carpet sweeper, or upright vacuum
hand. Hit it in the center against the edge of the cleaner should present no problem. A self-wringing
bowl. Then using the thumb and index finger, push mop may be used if the mop handle is stabilized
the top half of the shell up and use the ring and under the arm and the wringing lever operated with
little finger to push the lower half down. Separate the normal arm. Clients with balance and ambula-
whites from yolks by using an egg separator, funnel, tion problems may manage some floor care from a
or large slotted spoon. sitting position. Dust mopping or using a carpet
. Eliminate the need to stabilize the standard grater sweeper may be possible if gait and balance are fairly
by using a grater with suction feet, or use an electric good without the aid of a cane.
countertop food processor instead. These are just a few of the possibilities for solving home
7. Stabilize pots on the counter or range for mixing or management problems for one-handed individuals. The
stirring by using a pan holder with suction feet (Fig. occupational therapist must evaluate each client to de-
13-33). termine how the dysfunction affects performance of
8. Eliminate the need to use hand-cranked or electric homemaking activities. One-handed techniques take
can openers, which necessitate the use of two more time and may be difficult for some clients to
hands, by using a one-handed electric can opener. master. Activities should be paced to accommodate the
client's physical endurance and tolerance for one-
handed performance and use of special devices. Work
simplification and energy conservation techniques
should be employed. New techniques and devices
should be introduced on a graded basis as the client
masters first one technique and device and then

FIG. 13-32 FIG. 13-33

Zim jar opener. Pan stabilizer.
 160 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

another. Family members need to be oriented to the REMOVING TROUSERS. Remove pants or underwear by
client's skills, special methods used, and work schedule. reversing procedure for putting on. Dressing sticks may
The therapist, with the family and client, may facilitate be helpful for pushing pants off feet.
the planning of homemaking responsibilities to be
shared by other family members and the supervision of SOCKS OR STOCKINGS. Soft stretch socks or stock-
the client, if that is needed. If special equipment and as- ings are recommended. Panty hose that are slightly large
sistive devices are needed for ADL, it is advisable to may be useful. Elastic garters or stockings with elastic
acquire these through the health agency,.if possible. The tops should be avoided because of potential skin break-
therapist can then train the client and demonstrate use down. Dressing sticks or a stocking device may be helpful
of the equipment to a family member before these to some clients.
items are used at home. After training, the occupational DONNING SOCKS OR STOCKINGS
therapist should provide the client with sources to 1. Put on socks or stockings while seated on bed.
replace items independently, such as a consumer cata- 2. Pull one leg into flexion with one hand and cross
logue of adaptive equipment. over the other leg.
3. Use other hand to slip sock or stocking over foot and
pull sock or stocking on.
ADL for the Person With Paraplegia
REMOVING SOCKS OR STOCKINGS. Remove socks or
Clients who are confined to a wheelchair need to find stockings by flexing leg as described for donning,
ways to perform ADL from a seated position, to trans- pushing sock or stocking down over heel. Dressing sticks
port objects, and to adapt to an environment designed may be needed to push sock or stocking off heel and toe
for standing and walking. Given normal function in the and to retrieve sock.
upper extremities, the wheelchair ambulator can proba-
bly perform independently. The client should have a SLIPS AND SKIRTS. Slips and skirts slightly larger
stable spine, and mobility precautions should be clearly than usually worn are recommended. A-line, wrap-
identified. around, and full skirts are easier to manage and look
better on a person seated in a wheelchair than narrow
Dressing Activities* skirts.
It is recommended that wheelchair-bound clients put DONNING SLIPS AND SKIRTS
on clothing in this order: stockings, undergarments, 1. Sit on bed, slip garment over head, and let it drop to
braces (if worn), trousers or slacks, shoes, shirt, or dress. waist.
2. In semireclining position, roll from hip to hip and
TROUSERS pull garment down over hips and thighs.
DONNING Trousers. Trousers and slacks are easier to REMOVING SLIPS AND SKIRTS
fasten if they button or zip in front. If braces are worn, 1. Insitting or semireclining position, unfasten garment.
zippers in side seams may be helpful. Wide-bottom 2. Roll from hip to hip, pulling garment up to waist
slacks of stretch fabric are recommended. The procedure level.
for putting on trousers, shorts, slacks, and underwear is 3. Pull garment off over head.
as follows:
1. Use side rails or a trapeze to pull up to sitting position, SHIRTS. Fabrics should be wrinkle-resistant,
back supported with pillows or headboard of the bed. smooth, and durable. Roomy sleeves and backs and full
2. Sit on bed and reach forward to feet, or sit on bed shirts are more suitable styles than closely fitted gar-
and pull knees into flexed position. ments.
3. Holding top of trousers, flip pants down to feet. DONNING Suirts. Shirts, pajama jackets, robes, and
4. Work pant legs over feet and pull up to hips. Crossing dresses that open completely down the front may be put
ankles may help get pants on over heels. on while the client is seated in wheelchair. If it is neces-
5. In semireclining position, roll from hip to hip and sary to dress while in bed, the following procedure can
pull up garment. be used:
6. A long-handled reacher may be helpful for pulling 1. Balance body by putting palms of hands on mattress
garment up or positioning garment on feet if there is on either side of body. If balance is poor, assistance
impaired balance or range of motion in the lower may be needed or bed backrest may be elevated. (If
extremities or trunk. backrest cannot be elevated, one or two pillows may
be used to support back.) With backrest elevated,
both hands are available.
*Summarized from Activities of daily living for clients with incoordina-
tion, limited range of motion, paraplegia, quadriplegia, and hemiplegia, 2. If difficulty is encountered in customary methods of
Cleveland, 1989, Metro Health Center for Rehabilitation, Metro applying garment, open garment on lap with collar
Health Medical Center, Unpublished. toward chest. Put arms into sleeves and pull up over
 Activities of Daily Living 161

elbows. Then hold on to shirttail or back of dress, 1. Use a hand-held shower hose and keep a finger over
pull garment over head, adjust, and button. the spray to determine sudden temperature changes
REMOVING SHIRTS in water.
1. Sitting in wheelchair or bed, open fastener. 2. Use long-handled bath brushes with soap insert for
2. Remove garment in usual manner. ease in reaching all parts of the body.
3. If usual manner is not feasible, grasp collar with one 3.. Use soap bars attached to a cord around the neck, or
hand while balancing with other hand. Gather mate- use liquid soap.
rial up from collar to hem. 4. Use shower chairs or bathtub seats.
4. Lean forward, duck head, and pull shirt over head. 5. Increase safety during transfers by installing grab
5. Remove sleeves, first from supporting arm and then bars on wall near bathtub or shower and on
from working arm. bathtub.
6. Fit bathtub or shower bottom with nonskid mat or
SHOES adhesive material.
DONNING Suoes. If an individual has sensory loss 7. Remove doors on the bathtub and replace with a
and is at risk for bruising during transfers, shoes should shower curtain to increase safety and ease of trans-
be donned in bed. fers.
Variation I
1. In sitting position on bed, pull one knee at a time Communication and Environmental Hardware
into flexed position with hands. Adaptations
2. While supporting leg in flexed position with one With the exception of reaching difficulties in some situ-
hand, use free hand to put on shoe. ations, use of the telephone should present no problem.
Variation II Short-handled reachers may be used to grasp the re-
. Sit on edge of bed or in wheelchair for back support. ceiver from the cradle. A cordless telephone can elimi-
. Bend one knee up to flexed position, while support-
or nate reaching, except when the phone needs recharging.
ing leg with arm, and slip shoe onto foot with free The use of writing implements, typewriter, tape re-
hand. corder, and personal computer should be possible.
Variation III Managing doors may present some difficulties. If the
1. Sit on edge of bed or in wheelchair for back support. door opens toward the person, it can be opened by the
2. Cross one leg over other and slip shoe onto foot. following procedure:
3. Put foot on footrest and push down on knee to push 1. If doorknob is on right, approach door from right
foot into shoe. and turn doorknob with left hand.
REMOVING SHOES 2. Open door as far as possible and move wheelchair
1. Flex or cross leg as described for appropriate varia- close enough so that it helps keep door open.
tion. 3. Holding door open with left hand, turn wheelchair
2. For variations | and II, remove shoe with one hand with right hand and wheel through door.
while supporting flexed leg with other hand. 4. Start closing door when halfway through.
3. For variation III, remove shoe from crossed leg with If the door is very heavy and opens out or away from the
one hand while maintaining balance with other person, the following procedure is recommended’:
hand, if necessary. 1. Back up to door so knob can be turned with right
hand.
Eating Activities 2. Open door and back through so that big wheels keep
Eating activities should present no special problem for it open.
the wheelchair-bound person with good to normal arm 3. Also use left elbow to keep door open.
function. Wheelchairs with desk arms and swing-away 4. Wheel backward with right hand.
footrests are recommended so that it is possible to sit
close to the table. Mobility and Transfers
Principles of transfer techniques are discussed in
Hygiene and Grooming Chapter 14.
Facial and oral hygiene and arm and upper body care
should present no problem. Reachers may be helpful for Home Management Activities
securing towels, washcloths, make-up, deodorant, and When homemaking activities are performed from a
shaving supplies from storage areas, if necessary. Special wheelchair, the major problems are work heights, ade-
equipment is needed for using tub baths or showers. quate space for maneuverability, access to storage areas,
Transfer techniques for toilet and bathtub are discussed and transfer of supplies, equipment, and materials from
in Chapter 14. The following are suggestions for facili- place to place. If funds are available for kitchen remod-
tating bathing activities: eling, lowering counters and range to a comfortable
162 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

height for wheelchair use is recommended. Such exten- 6. Fasten a drop-leaf board to a bare wall, or install a
sive adaptation is often not feasible, however. The fol- slide-out board under a counter to provide a work
lowing are some suggestions for home management’: surface that is a comfortable height in a kitchen that
Fr. Remove cabinet doors to eliminate the need to ma- is otherwise standard.
neuver around them for opening and closing. Fre- Fit cabinets with custom- or ready-made lazy susans
quently used items should be stored toward the or pull-out shelves to eliminate the need to reach to
front of easy-to-reach cabinets above and below the rear space (Fig. 13-36).
counter surfaces. . Ideally, ranges should be at a lower level than stan-
If entrance and inside doors are not wide enough, dard height. If this arrangement is not possible,
use a device to reduce wheelchair width or make place the controls at the front of the range, and hang
doors slightly wider by removing strips along the a mirror angled at the proper degree over the range
door jambs. Offset hinges can replace standard so that the homemaker can see contents of pots.
door hinges and increase the door jamb width by 2 . Substitute small electric cooking units and mi-
inches (Fig. 13-34). crowave ovens for the range if the range is not safely
. Use a wheelchair cushion to increase the user's manageable.
height so that standard height counters may be used. 10. Use front-loading washers and dryers.
. Use detachable desk arms and swing-away detach- ili Vacuum carpets with a carpet sweeper or tank-type
able footrests to allow the wheelchair user to get as cleaner that rolls easily and is lightweight or self-
close as possible to counters and tables and also to propelled. A retractable cord may be helpful for pre-
stand at counters, if that is possible. venting tangling of cord in wheels.
. Transport items safely and easily with a wheelchair
lap board. The lap board may also serve as a work
surface for preparing food and drying dishes. It also
ADL for the Person With Quadriplegia
protects the lap from injury from hot pans and pre- In general, persons with muscle function from spinal
vents utensils from falling into the lap (Fig. 13-35). cord levels C7 and C8 can follow many of the methods

FIG. 13-34
A, Offset door hinges. B, Offset hinges widen doorway for wheelchair user. (Courtesy Sammons
Preston.)
 Activities of Daily Living

FIG. 13-35 FIG. 13-36

Wheelchair lapboard is used to transport items. Lazy Susan in kitchen storage cabinet.

just described for paraplegia, except for fine motor Additional criteria for dressing the lower extremities are
tasks such as buttoning or typing. Individuals with as follows’®:
muscle function from C6 can be relatively independent 1. Fair to good muscle strength in pectoralis major and
with adaptations and assistive devices, whereas those minor, serratus anterior, and rhomboid major and
with muscle function from C4 and C5 will require con- minor
siderable special equipment and assistance. Clients 2. ROM of 0° to 120° in knee flexion, 0° to 110° in hip
with muscle function from C6 may benefit from the flexion, and 0° to 80° in hip external rotation
use of a wrist-driven flexor hinge splint. Externally 3. Body control for transfer from bed to wheelchair
powered splints and arm braces or mobile arm sup- with minimal assistance
ports are recommended for C3, C4, and C5 levels of 4. Ability to roll from side to side, balance in side-lying,
muscle function. ' or turn from supine position to prone position and
back
Dressing Activities 5. Vital capacity of 50% or better
Training in dressing can be commenced when the spine Dressing is contraindicated if any of the following
is stable.°*° Minimum criteria for upper extremity dress- factors are present®”°:
ing are as follows: 1. Unstable spine at site of injury
1. Fair to good muscle strength in deltoids, upper and 2. Pressure sores or tendency for skin breakdown
middle trapezii, shoulder rotators, rhomboids, during rolling, scooting, and transferring
biceps, supinators, and radial wrist extensors Go Uncontrollable
. muscle spasms in legs
2. ROM of 0° to 90° in shoulder flexion and abduc- 4. Less than 50% vital capacity
tion, 0° to 80° in shoulder internal rotation, 0° to
30° in external rotation, and 15° to 140° in elbow SEQUENCE OF DRESSING. The recommended se-
flexion quence for training to dress is to put on underwear and
3. Sitting balance in bed or wheelchair, which may be trousers while still in bed, then transfer to a wheelchair
achieved with the assistance of bed rails, electric hos- and put on shirts, socks, and shoes.*° Some clients may
pital bed, or wheelchair safety belt wish to put the socks on before the trousers because
4. Finger prehension achieved with adequate tenodesis socks may help the feet slip through the trouser legs
grasp or wrist-driven flexor-hinge splint more easily.
164 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

EXPECTED PROFICIENCY. Clients with spinal small loop and one large loop. The small loop is
cord lesions at C7 and below can achieve total dressing, hooked around the foot and the large hoop is an-
which includes dressing skills for both the upper and chored over the knee. The band is measured for indi-
lower extremities. Clients with lesions at C6 can also vidual client so that its length is appropriate to main-
achieve total dressing, but lower extremity dressing may tain desired amount of knee flexion. Once the
be difficult or impractical in terms of time and energy trousers are in place, knee loop is pushed off knee
for these clients. Clients with lesions at C5 to C6 can and dressing band is removed from foot with dress-
achieve upper extremity dressing, with some exceptions. ing stick."
It is difficult or impossible for these clients to put on a 3. Work trousers up legs, using patting and sliding
brassiere, tuck a shirt or blouse into a waistband, or motions with palms of hands.
fasten buttons on shirt fronts and cuffs. Factors such as 4. While still sitting, with pants to midcalf height,
age, physical proportions, coordination, concomitant insert dressing stick in front belt loop. Dressing stick
medical problems, and motivation will affect the degree is gripped by slipping its loop over wrist. Pull on
of proficiency in dressing skills that can be achieved by dressing stick while extending trunk, returning to
any client.® supine position. Return to sitting position and repeat
this procedure, pulling on dressing sticks and ma-
TYPES OF CLOTHING. Clothing should be loose neuvering trousers up to thigh level.*° If balance is
and have front openings. Trousers need to be a size adequate, an alternative is for client to remain sitting
larger than usually worn to accommodate the urine col- and lean on left elbow and pull trousers over right
lection device or leg braces if worn. Wrap-around skirts buttock, then reverse process for other side. Another
and incontinence pads are helpful for women. The fas- alternative is for client to remain in supine position
teners that are easiest to manage are zippers and Velcro and roll to one side; throw opposite arm behind
closures. Because the client with quadriplegia often uses back; hook thumb in waistband, belt loop, or
the thumb as a hook to manage clothing, loops at- pocket; and pull trousers up over hips. These maneu-
tached to zipper pulls, undershorts, and even the back vers can be repeated as often as necessary to get
of the shoes can be helpful. Belt loops on trousers are trousers over buttocks.°
used for pulling and should be reinforced. Brassieres 5. Using palms of hands in pushing and smoothing
should have stretch straps and no wires in them. Front- motions, straighten the trouser legs.
opening brassiere styles can be adapted by fastening 6. In supine position, fasten trouser placket by hooking
loops and adding Velcro closures; back-opening styles thumb in loop on zipper pull, patting Velcro closed,
can have loops added at each side of the fastening. or using hand splints and buttonhooks if there are
Shoes can be one-half size to one size larger than buttons or a zipper pull for zippers.°*°
normally worn to accommodate edema and spasticity VARIATION. Substitute the following for step 2: Sit up
and to avoid pressure sores. Shoe fasteners can be and lift one knee at a time by hooking right hand under
adapted with Velcro, elastic shoelaces, large buckles, or right knee to pull leg into flexion, then cross the foot
flip-back tongue closures. Loose woolen or cotton over the opposite leg above the knee. This position frees
socks without elastic cuffs should be used initially. the foot to place the trousers more easily and requires
Nylon socks, which tend to stick to the skin, may be less trunk balance. Continue with all other steps.
used as skill is gained. If neckties are used, the clip-on REMOVING TROUSERS AND UNDERSHORTS
type or a regular tie that has been preknotted and can 1. Lying supine in bed with bed rails up, unfasten belt
be slipped over the head may be manageable for some and placket fasteners.
clients.”°° 2. Placing thumbs in belt loops, waistband, or pockets,
work trousers past hips by stabilizing arms in shoul-
TROUSERS AND UNDERSHORTS der extension and scooting body toward head of bed.
DONNING TROUSERS AND UNDERSHORTS . Use arms as described in step 2 and roll from side to
. Sit on bed with bed rails up. Trousers are positioned side to get trousers past buttocks.
at foot of bed with trouser legs over end of bed and . Coming to sitting position and alternately pulling
front side up.*° legs into flexion, push trousers down legs.*°
. Sit up and lift one knee at a time by hooking right . Trousers can be pushed off over feet with dressing
hand under right knee to pull leg into flexion, then stick or by hooking thumbs in waistband.
put trousers over right foot. Return right leg to exten-
sion or semiextended position while repeating pro- CARDIGANS OR PULLOVER GARMENTS. Cardi-
cedure with left hand and left knee.° If unable to gan and pullover garments include blouses, vests,
maintain leg in flexion by holding with one arm or sweaters, skirts, and front-opening dresses.°°° Upper ex-
through advantageous use of spasticity, use a dressing tremity dressing is frequently performed in the wheel-
band. This device is a piece ofelasticized webbing that chair for greater trunk stability. The procedure for
has been sewn into a figure-eight pattern, with one putting on these garments is as follows:
 Activities of Daily Living 165

DONNING CARDIGANS OR PULLOVER GARMENTS internal rotation, rotate brassiere around body so
. Position the garment across thighs with back facing that front of brassiere is in front of body.
up and neck toward knees. . While leaning on one forearm, hook opposite thumb
. Place both arms under back of garment and in arm- in front end of strap and pull strap over shoulder,
holes. then repeat procedure on other side.®*°
. Push sleeves up onto arms, past elbows. REMOVING BRASSIERE
. Using a wrist extension grip, hook thumbs under . Hook thumb under opposite brassiere strap and
garment back and gather material up from neck push down over shoulder while elevating shoulder.
to hem. . Pull arm out of strap and repeat procedure for other
. To pass garment over head, adduct and externally arm.
rotate shoulders and flex elbows while flexing head 35 Push brassiere down to waist level and turn around
forward. as described previously, to bring fasteners to front.
. When garment is over head, relax shoulders and 4. Unfasten brassiere by hooking thumbs into the
wrists and remove hands from back of garment. adapted loops near the fasteners.
Most of material will be gathered up at neck, across Alternatives for a back-opening bra are (1) a front-
shoulders, and under arms. opening bra with loops for using a wrist extension grip
. To work garment down over body, shrug shoulders, or (2) a fully elastic bra that has no fasteners and can be
lean forward, and use elbow flexion and wrist exten- donned like a pullover sweater.
sion. Use wheelchair arms for balance, if necessary.
Additional maneuvers to accomplish task are to hook SOCKS
wrists into sleeves and pull material free from under- DONNING SOCKS
arms, or lean forward, reach back, and slide hand . Sit in wheelchair, or on bed if balance is adequate, in
against material to aid in pulling garment down. cross-legged position with one ankle crossed over
. Garment can be buttoned from bottom to top with opposite knee.
aid of button hook and wrist-driven flexor hinge . Pull sock over foot with wrist extension grip and
splint if hand function is inadequate. patting movements with palm of hand.°*°
REMOVING CARDIGANS OR PULLOVER GARMENTS . If trunk balance is inadequate and cross-legged posi-
. Sit in wheelchair and wear wrist-driven flexor hinge tion cannot be maintained, balance by propping
splints. Unfasten buttons (if any) while wearing foot on stool, chair, or open drawer, while opposite
splints and using buttonhook. Remove splints for re- arm is around upright of wheelchair. Using a wheel-
maining steps. chair safety belt or leaning against wheelchair
. For pullover garments, hook thumb in back of neck- armrest on one side are options to maintain balance.
line, extend wrist, and pull garment over head while . Use stocking aid or sock cone (Fig. 13-7) to assist in
turning head toward side of raised arm. Maintain putting on socks while in this position. Powder sock
balance by resting against opposite wheelchair cone (to reduce friction) and apply sock to cone by
armrest or pushing on thigh with extended arm. using thumbs and palms of hands to smooth sock
. For cardigan garments, hook thumb in opposite out on cone.
armhole and push sleeve down arm. Elevation and de- . With the cord loops of sock cone around the wrist or
pression of shoulders with trunk rotation can be used thumb, throw cone beyond foot.
to get garment to slip down arms as far as possible. . Maneuver cone over toes by pulling cords using
. Hold one cuff with opposite thumb while elbow is elbow flexion. Insert foot as far as possible into cone.
flexed to pull arm out of sleeve. . To remove cone from sock after foot has been in-
serted, move heel forward off wheelchair footrest.
BRASSIERE (BACK-OPENING) Use wrist extension (of hand not operating sock
DONNING BRASSIERE cone) behind knee and continue pulling cords of
. Place brassiere across lap with straps toward knees cone until it is removed and sock is in place on foot.
and inside facing up. Use palms to smooth sock with patting and stroking
. Using a right-to-left procedure, hold end of brassiere motion.*°
closest to right side with hand or reacher and pass . Two loops can also be sewn on either side of the top
brassiere around back from right to left side. Lean of the sock so that thumbs can be hooked into the
against brassiere at back to hold it in place, while loops and the socks pulled on.
hooking thumb of left hand in a loop that has been REMOVING SOCKS
attached near brassiere fastener. Hook right thumb . While sitting in wheelchair or lying in bed, use a
in a similar loop on right side and fasten brassiere in dressing stick or long-handled shoehorn to push
front at waist level. sock down over heel. Cross the legs if possible.
. Hook right thumb in edge of brassiere. Using wrist . Use dressing stick with cup hook on end to pull sock
extension, elbow flexion, shoulder adduction, and off toes.‘
 166 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

SHOES The spoon plate is an option for independent feeding

DONNING SHOES for clients with high spinal cord injuries. The plate is a
1. Use same position for donning socks as for putting portable device that can be adjusted in height to the
on shoes. level of the client's mouth. The plate is made of a high-
2. Use long-handled dressing aid and insert aid into temperature thermoplastic and is formed over a mold
tongue of shoe. Place shoe opening over toes. that has a rim bowled to the approximate depth and
Remove dressing aid from shoe and dangle shoe on length of a spoon. The client rotates the device with
toes. mouth and neck control. Food is removed from the rim
3. Using palm of hand on sole of shoe, pull shoe of the plate with the mouth. Successful use of the device
toward heel of foot. One hand is used to stabilize leg depends on adequate oral control, head and trunk
while other hand pushes against sole of shoe to work control, and motivation. The reader is referred to the
shoe onto foot. Use thenar eminence and sides of original source for information on making or obtaining
hand for this pushing motion. this device.*’ Also available for clients who have no use
4. With feet flat on floor or on wheelchair footrest and of their upper extremities is the electric self-feeder,
knees flexed 90°, place a long-handled shoehorn in which requires only slight head motion and is activated
heel of shoe and press down on flexed knee. by a chin switch (Fig. 13-38).
5. Fasten shoes.*° A regular or swivel spoon-fork combination can be
REMOVING SHOES used when there is minimal muscle function (C4 toC5).A
1. Sitting in wheelchair with legs crossed as described long plastic straw with a straw clip to stabilize it in the cup
previously, unfasten shoes. or glass eliminates the need for picking up these drinking
2. Use shoehorn or dressing stick to push on heel vessels. A bilateral or unilateral clip-type holder ona glass
counter of shoe, dislodging it from heel. Shoe will or cup makes it possible for many persons with hand and
drop or can be pushed to floor with dressing stick.*° arm weakness to manage liquids without a straw.
Built-up utensils may be useful for those with some
Eating Activities functional grasp or tenodesis grasp. Food may be cut
Eating may be assisted by a variety of devices, depend- with a quad-quip knife if arm strength is adequate to
ing on the level of muscle function.’ An injury at C5 or manage the device (Fig. 13-39).
above necessitates mobile arm supports or externally
powered splints and braces. A wrist splint and universal Hygiene and Grooming
cuff may be used together if a wrist-driven flexor hinge 1. Use a shower or bathtub seat and transfer board for
splint is not used. The universal cuff holds the eating transfers.
utensil, and the splint stabilizes the wrist. A nonskid 2. Extend reach by using long-handled bath sponges
mat and a plate with plate guard may provide adequate with loop handle or built-up handle.
stability of the plate for pushing and picking up food 3. Eliminate need to grasp washcloth by using bath
(Fig. 13-37). mitts or bath gloves.

FIG. 13-37
Self-feeding with aid of universal cuff, plate guard, nonskid mat, and FIG. 13-38
clip-type cup holder to compensate for absent grasp. Electric self-feeder. (Courtesy Sammons Preston.)
 Activities of Daily Living

FIG. 13-39 FIG. 13-40

Quad-quip knife. Skin inspection mirror.

4. Hold comb and toothbrush with a universal cuff.’ to push the button to initiate a call. The operator
5. Use a wall-mounted hair dryer. Use a universal cuff assists with dialing.
to hold brush or comb for hair styling while using . Use personal computers, word processors, or electric
this mounted hair dryer.'* typewriters. A computer mouse may be substituted
6. Use a clip-type holder for electric razor. for use of the keyboard. A variety of different mouse
7. Persons with quadriplegia can use suppository in- designs and sizes are available. Speech recognition
serters to manage bowel care independently. programs are available for individuals with little or
8. Useskin inspection mirror with long stem and looped no arm movement.
handle for independent skin inspection (Fig. 13-40). . Built-up pencils and pens or special pencil holders
Devices and methods selected must be adapted ac- are needed for clients with hand weakness. The
cording to the degree of weakness of each client. Wanchik writer is an effective adaptive writing device
9. Adapted leg-bag clamps to empty catheter leg-bags (Fig. 13-18).
are also available for individuals with limited hand . Sophisticated electronic communications devices
function. Elastic leg-bag straps may also be replaced operated by mouth, pneumatic controls, and head
with Velcro straps. controls are available for clients with no function in
the upper extremities.*®
Communication and Environmental Hardware . Kelly’? describes a cassette tape holder and two
Adaptations mouth-sticks that allow C3, C4, or C5 quadriplegic
1. Turn pages with an electric page-turner, mouth stick, clients to operate a tape recorder or radio independ-
or head wand if hand and arm function are inade- ently. The first mouth-stick, with a friction tip, is used
quate (Fig. 13-41). to depress the operating buttons and adjust the
2. For typing, writing, operating a tape recorder, and volume and selector dials of the radio. The second
painting, insert pen, pencil, typing stick, or paint- mouth-stick is used to move the cassettes from the
brush in a universal cuff that has been positioned cassette holder to the tape recorder and to remove
with the opening on the ulnar side of the palm for the cassettes from the recorder. The cassette tape
typing (Fig. 13-42). stand has eight levels and is designed to hold eight
3. Touch telephone keys with the universal cuff and a tapes. The reader is referred to the original source for
pencil positioned with eraser down. The receiver may specifications on construction of these devices and to
need to be stationed in a telephone arm and posi- develop methods for a client to be able to manage a
tioned for listening or adapted with a telephone clip CD player.'”
holder (Fig. 13-17). Special adaptations are available . Environmental controls allow for easy operation
to substitute for the need to replace the receiver in from a panel designed to run multiple devices such
the cradle. For clients with no arm function, a as televisions, radios, lights, telephones, intercoms,
speaker phone can be used along with a mouth-stick and hospital beds (see Chapter 19).
 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

ronmental adaptation outlined for the paraplegic apply

here as well. In addition, clients with upper extremity
weakness need to use lightweight equipment and
special devices. The Mealtime Manual for People With
Disability and the Aging compiled by Judith Lannefeld
Klinger~* contains many excellent specific suggestions
FIG. 13-4] that apply to homemakers with weak upper extremities.
Wand mouth stick is provided by Sammons Preston,
An Ability-
One Company. ADL for the Person With Low Vision
The environmental modifications described in the fol-
lowing section are appropriate when performing ADL
for all persons with low vision.

Lighting and Magnifiers

1. Improve lighting by aiming light at the work area,
not into the eyes.
2. Reduce glare by having adjustable blinds, sheer cur-
tains, or tinted windows. Wearing dark glasses in-
doors may also reduce glare.
3. Maximize contrast by providing a work surface that is
in contrast to the task. For example, serve a meal ona
white plate if the table is dark. Paint a white edge on
a dark step. Replace white wall switches with black to
contrast with the wall.
4. Simplify figure-ground perception by clearing path-
ways and eliminating clutter.
5. Work in natural light by placing a chair by a
window.**”47
6. Use magnifiers with lights. These come in a variety of
sizes and degrees of magnification. Specialists in low
vision can determine the appropriate degree of mag-
nification needed. Some magnifiers are portable,
FIG. 13-42
others are attached to stands to do needle work or
Typing with aid of utensil holder and typing stick. fine work, and others are sheets of plastic to magnify
an entire page of print.*”

Mobility and Transfers Dressing Activities

Principles of wheelchair transfer techniques for the indi- 1. Light closet to improve acuity. Hang matching
vidual with quadriplegia are discussed in Chapter 14. clothes together.
Mobility depends on degree of weakness. Electric wheel- 2. Pin socks together when placing them in the washer
chairs operated by hand, chin, or pneumatic controls and dryer so they will stay matched.
have greatly increased the mobility of persons with
severe upper and lower extremity weakness. Vans fitted Eating Activities
with wheelchair lifts and stabilizing devices permit such 1. Provide high contrast. Ensure that plates contrast
clients to be transported to pursue community, voca- with table surface or place mats. Avoid patterned
tional, educational, and leisure activities with an assis- tablecloths.
tant. In addition, adaptations for hand controls have 2. Arrange food on the plate in a clockwise fashion and
made it possible for many clients with function of at orient the person with low vision to the arrangement.
least C6 level to drive independently.
Hygiene and Grooming Activities
Home Management Activities . Reduce clutter in bathroom drawers and cabinets.
Clients with muscle function of C6 or better may be in- . Use electric razor.
dependent for light homemaking with appropriate . Use magnified mirrors.
devices, adaptations, and safety awareness. Many of the . Use high-contrast bath mat in bathtub.
suggestions for wheelchair maneuverability and envi- RR
WN
MB . Install high-contrast grab bars in shower.
 Activities of Daily Living 169

Communication and Environmental Hardware 5. Indicate number of minutes needed for microwave
Adaptations cooking by placing rubber bands on the items. Two
. Use talking watches or clocks to tell time. rubber bands would indicate that the item should be
. Use talking scale to determine weight. cooked for 2 minutes. Assistance will be needed for
. Use large-print magnification screen on computer. initial setup.
. Technology for reading print is changing rapidly. io»). Use liquid level indicator to determine when hot
SG
bn
Become familiar with the various types of adapta- liquid reaches 1 inch from top of cup or container.*’
tions for reading print.”’ 7. Use cutting guides or specially designed knives to cut
5. Use high-contrast door knobs. Paint the door frame a meat or bread.*”
color that contrasts highly with the door to improve 8. Use a tape recorder to make reminder lists or grocery
ease of identifying the door.** lists.
6. Use speaker phones, preprogrammed phone num-
bers, or phone with large print and high contrast Medication Management
numbers. Identify phone buttons with contrasting 1. Use medication organizer to organize pills.
tape or Velcro dot to teach client how to turn phone 2. For diabetic management, there are many different
on and which buttons to push. products available for individualized evaluation of
7. Use writing guides to write letters, checks, or signa- the client (e.g., syringe magnifiers, talking or large-
tures.*” print glucometers, and a device to count the insulin
8. To read, use books on tape or Talking Books. dosages).
3. Use talking scales to evaluate weight.”"
Mobility and Transfer Skills
Mobility is eased with the clearing of pathways and Money Management
the minimizing of clutter and furniture. Lighting in 1. Use a consistent method of folding money to iden-
hallways and entryways is also needed. The person tify denominations, as in the following example:
with low vision needs to optimize visual scanning
$1.00 Keep flat
abilities by learning to turn and position the head fre-
$5.00 Fold in square half
quently when mobile or participating in an activity.** $10.00 Fold lengthwise
The OT practitioner may need to refer a client to a spe- $20.00 Fold in half and then lengthwise.
cialist in low vision who is specifically trained in
teaching mobility to persons with low vision or legal 2. Keep different denominations in different sections of
blindness. the wallet. Learn to recognize coins by size and type
of edge (smooth or rough).**
Home Management Activities
A variety of devices are available to compensate for low
SUMMARY
vision while managing the home. Organization and
consistency are critical to the safe and efficient perform- ADL and I-ADL are tasks of self-maintenance, mobil-
ance of home management tasks. Family members need ity, communication, home management, and commu-
to remember to replace items where they were found nity living skills that enable a person to function in-
and not reorganize items without assistance from the dependently and assume important occupational
person with low vision. roles.
1. For safety, place cleaning supplies separate from food ADL is one of the performance areas in the occupa-
supplies. tional performance model. Occupational therapists rou-
2. Eliminate extra hazardous cleaning supplies and tinely assess performance in ADL to determine clients’
replace with one multipurpose cleanser. Place this levels of functional independence. Interview and obser-
cleaning agent in a uniquely shaped bottle or in a vation of performance are used to carry out the assess-
specific location. ment. Results of the assessment and ongoing progress
3. Mark appliance controls with high-contrast tape or are recorded on one of many available ADL checklists or
paint to identify start and stop buttons or posi- with a standardized assessment, the content of which is
tions. Place Velcro tabs to mark frequently used po- summarized for the permanent medical record.
sitions on dials (e.g., on the 350° position for stove Treatment is directed at training in independent
or for the wash and wear cycle on the washer or living skills with activities such as eating, dressing, mo-
dryer). bility, home management, communication, and com-
4. Label cans by using rubber bands to attach index munity living skills. The occupational therapist can
cards with bold, dark print to each can. When the include in the treatment program special equipment
can is used, the card may be placed into a stack to and many methods for performing ADL with specific
create a shopping list. functional problems.
170 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

55 Prepare a meal using only one hand and write about

REVIEW QUESTIONS
your experience.
. Define ADL and I-ADL. List three classifications of
tasks that may be considered in each category. REFERENCES
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Medical Center (unpublished).
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must consider before commencing ADL perform- Washington, 1994, Idyll Arbor.
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the ADL checklist. tiansen C, Baum C, editors: Occupational therapy: overcoming
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List the steps in the activities of home management
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assessment? toward health through activities, Boston, 1990, Little, Brown.
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the home assessment and make the necessary rec- . Fisher AG: Assessment of motor and process skills (AMPS), Fort
Collins, Colo, 1995, Three Star Press.
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16. Describe three approaches to teaching ADL skills to cupation as means, Am J Occup Ther 52:354, 1998.
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24. Kohlman-Thomson L: The Kohlman evaluation of living skills
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 Activities of Daily Living 171

25) Law ML, Baptiste S, Carswell A, et al: Canadian occupational per- 315): The Professional Manual Subcommittee of the Educational Com-
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CH

LEARNING OBJECTIVES
SECTION 1 After studying each section the student or practitioner
Functional Ambulation will be able to do the following:
Functional ambulation Section 1
Gait training 1. Define functional ambulation.
Pathological gait 2. Discuss the role of the occupational therapy (OT)
Ambulation aids practitioner in functional ambulation.
SECTION 2 3. Identify appropriate interventions to promote
Wheelchair Assessment and Transfers functional ambulation within OT treatment.
Rehabilitation technology supplier 4. Identify safety issues in functional ambulation.
Durable medical equipment 5. Recognize basic lower extremity orthotics and
Spasticity ambulation aids.
Contractures Section 2
Skin breakdown 1. Identify the components necessary to perform a
Vital capacity wheelchair evaluation.
Medical necessity 2. Understand the process of wheelchair measurement
Body mechanics and prescription completion.
Positioning mass Identify wheelchair safety considerations.
Pelvic tilt Follow guidelines for proper body mechanics.
Apply principles of proper body. positioning.
SECTION 3
ete Identify the steps necessary in performing various
ae
beh
SBN
Transportation, Community Mobility, and Driving
transfer techniques.
Assessment
7. Identify considerations necessary to determine the
Transportation
appropriate transfer method based on the patient's
Paratransit
clinical presentation.
Americans With Disabilities Act
Section 3
Specialized training
1. Recognize transportation as a valued skill.
Clinical evaluations
2. Recognize how occupational roles affect the
Cognition
evaluation process and equipment selection.
Driver competence
. Identify safety issues in driver evaluation.
Vision
eoState the purpose of passenger and driver evaluation.
Perception
5. Understand the complexity of the driver referral and
Assistive technology
evaluation process.
Primary controls
6. List the recommended practice components for the
Secondary controls
driver evaluator.
On-road evaluation
7. Discuss the effect the loss of a driver's license has on
Driver training
both the individual and society.

LAs
 Mobility 173

with disabilities has improved access and has yielded an

increasing range of options for adapting motor vehicles
alking, climbing stairs, traveling within one’s for individual needs. Public transportation has also
neighborhood, and driving a car are so universal and become increasingly accessible. Driving is a complex ac-
customary that most people would not consider these to tivity, requiring multiple cognitive and perceptual skills.
be complex activities. The basic capacities to move Evaluation of individuals with medical conditions and
within the environment, to reach objects of interest, to physical limitations is thus important for the safety of
explore one’s surroundings, and to come and go at will the disabled person and the public at large.
appear natural and easy. For persons with disabilities, Mobility is an aspect of OT practice that requires
however, mobility is rarely taken for granted or thought close coordination with other health care providers,
of as automatic. A disability may prevent a person from particularly physical therapists and providers of durable
using the legs to walk or using the hands to operate con- medical equipment. Improving and maintaining the
trols of motor vehicles. Cardiopulmonary and medical functional mobility of persons with disabilities can be
conditions may limit aerobic capacity or endurance, re- one of the most gratifying practice areas. Consumers ex-
quiring the person to take frequent rests and to curtail perience tremendous energy and empowerment when
walking to cover only the most basic of needs, such as they are able to access and explore wider and more in-
toileting. Deficits in motor coordination, flexibility, and teresting environments.
strength may seriously impair movement and may make
difficult any activities that require a combination of mo-
aa a
bility (e.g., walking or moving in the environment) and
SECTION 1
stability (e.g., holding the hands steady as one must
when carrying a cup of coffee or a watering can). Functional Ambulation
Occupational therapy (OT) practitioners help persons
TERU A. CREEL
with mobility restrictions to achieve maximum access to
environments and objects of interest to them. Typically,
OT practitioners provide remediation and compensa- Functional ambulation is a goal for many OT clients.
tory training. In so doing, therapists must analyze the Functional ambulation, a subcomponent of functional
activities most valued and environments most used by mobility, is the purposeful application of the mobility
their clients and must consider any future changes that training taught to the client to enable movement from
can be predicted from an individual's medical history, one position or place to another. Functional ambulation
prognosis, and developmental status. involves achieving a goal such as carrying a plate to the
This chapter guides the practitioner in evaluation and table or carrying groceries from the car to the house. If
treatment of persons with mobility restrictions. Three the individual is using an assistive aid to ambulate and
main topics are explored. The first section addresses func- simultaneously has a need to carry an object, solving the
tional ambulation, which combines the act of walking problem is more complex. Functional ambulation is ap-
within one’s immediate environment (i.e., home orwork- plicable for individuals with a variety of diagnoses, such
place) with other activities chosen by the individual. as lower extremity amputation, cerebrovascular accident,
Feeding pets, preparing a meal and carrying it to a table, acquired brain injury, or total hip replacement.
and doing simple housework are tasks that may involve Functional mobility allows collaboration between
functional ambulation. Functional ambulation may be the occupational therapist and the physical therapist.
conducted with aids such as walkers, canes, or crutches. Together, the OT practitioner and the physical therapy
The second section concerns wheelchairs, their selec- (PT) practitioner provide the most appropriate tech-
tion, measurement, fitting, and use. For many persons nique and ambulation aid for use during functional am-
with disabilities, mobility becomes possible only with a bulation. The physical therapist performs gait training
wheelchair and specific positioning devices. Conse- (the treatments used to improve walking and ameliorate
quently, individual evaluation is needed to select and fit deviations from normal gait) and makes recommenda-
this essential piece of personal medical equipment. tions for ambulation aids. The occupational therapist
Proper training in ergonomic use will allow the wheel- applies these recommendations during functional activ-
chair-dependent individual many years of safe and ities and provides feedback to the PT practitioner re-
comfortable mobility. Safe and efficient transfer tech- garding functional outcomes using the recommended
niques based on the individual's clinical status are in- techniques and devices.
troduced in this chapter. Attention is also given to the
body mechanics required to safely assist an individual.
BASICS OF AMBULATION
The third section covers community mobility, which
for many in the United States of America is synonymous Ambulation or bipedal locomotion is a very complex
with driving. Increased advocacy by and for persons function. Locomotion is the act of getting from one
174 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

place to another. For two-legged and four-legged an- ambulation with an aid that provides maximal sup-
imals, gait is the means of achieving locomotion. port or stability and then may be progressed to an aid
Leonard’ stated the following: that provides less support or stability. Once again, it is
essential that the OT practitioner communicate with
The central nervous system (CNS) somehow must generate the the physical therapist to be kept abreast of any changes
locomotor pattern, generate appropriate propulsive forces, modu- in the individual's ambulation aids and the use of
late changes in center of gravity, coordinate multi-limb trajecto-
such aids.
ries, adapt to changing conditions and changing joint positions,
The basic ambulation techniques recommended by
coordinate visual, auditory, vestibular and peripheral afferent
information, and account for the viscoelastic properties of the physical therapist will vary from client to client,
muscles.* depending on the individual’s goals, strengths, and
weaknesses. General techniques may be applied to
The OT practitioner should have a basic understand- various clients based on the clinical judgment of the
ing of ambulation terminology and techniques and of physical therapist. The OT practitioner reinforces the
assistive aids commonly used during functional ambu- physical therapist's recommendations, incorporating
lation. these general techniques into functional ambulation
Locomotion is the act of getting from one place to activities.
another. Gait is the means of achieving this action. Gait During functional ambulation on a level surface, the
training is treatment used to improve gait. OT practitioner is positioned slightly behind and to one
The individuals seen by the OT-PT team may exhibit side of the client. The therapist may position himself or
pathological gait because of biomechanical or neuro- herself to the stronger or weaker side of the client, based
physiological deficits. Problems noted may include de- on the recommendations and preference of the physical
creased walking velocity, decreased weight bearing, in- therapist. The therapist maintains contact with the
creased swing time of the affected lower extremity, or an client by using the gait belt. The therapist places his or
abnormal base of support. Functional deficits may her feet in an anterior-posterior position, with the out-
include unsafe ambulation and insufficient energy. As ermost foot positioned between the client's lower ex-
the physical therapist evaluates the causes of the gait tremity and the ambulation aid, and the innermost foot
problems, orthotics and ambulatory aids may be recom- posterior to the patient’s nearest lower extremity.°
mended. It is important that the OT practitioner rein- During ambulation, the therapist moves with (in the
force the gait training by following the appropriate same direction as) the client. The therapist's outermost
recommendations. lower extremity moves with the ambulation aid, and the
The OT practitioner should be familiar with basic therapist's inside foot moves forward with the client's
lower extremity (LE) orthotics. Should it be determined lower extremity.
that the individual has abnormal posture of the ankle,
an ankle-foot orthosis (AFO) may be recommended.
FUNCTIONAL AMBULATION
An AFO, according to Mosby's Medical, Nursing, and
Allied Health Dictionary,‘ is a protective external device, Functional ambulation integrates ambulation into ac-
commonly made of lightweight thermoplastic splinting tivities of daily living (ADL) and instrumental activities
material and applied to the ankle area to protect or of daily living (I-ADL). Using an occupation-based ap-
compensate for joint instability. Should it be deter- proach, the OT practitioner assesses the client's abilities
mined that the individual has knee collapse or hyper- within the performance context. What role(s) does the
extension, an external means of knee control such as a client desire to perform? What tasks does this role
knee-ankle-foot orthosis (KAFO) may be recom- require of the client? Based on the answers to these
mended. A KAFO includes offset knee joints and a questions, the occupational therapist plans for func-
rigid AFO.* tional mobility activities with the goal of confident and
An ambulation aid may be recommended for use safe functional ambulation in valued occupational roles
during ambulation to compensate for impaired balance, and tasks.
decreased strength, pain during weight bearing on one or When assessing the individual’s needs based on roles
both lower extremities, or absence of a lower extremity. and desired tasks, the OT practitioner performs a task
An ambulation aid may be needed to help with fracture analysis, analyzing the relationship between the client
healing, to enhance body functions, or to improve func- and his or her occupations and environment.’ A task
tional mobility.° analysis serves the purpose of determining goals and
Ambulation aids are numerous. Basic ambulation targeting health outcomes. The task analysis identifies
aids, from those providing the most support to the and examines meaningful and purposeful occupations.”
least, are a walker, crutches, a single crutch, bilateral Table 14-1 provides guidelines for such an analysis as it
canes, and a single cane.° The individual may begin relates to functional ambulation.
 Functional Mobility Analysis
SITUATION: 53-year-old homemaker with ankle amputation ambulating with a cane
mn skAnalysis Approach Example
e |. Identify the task(s) and specify the long- and short-term goals. Task: Meal preparation; LTG:To prepare meal for family; STG:
To prepare muffins from a mix
_ 2.Gather necessary information concerning: Necessary information specific to this client:
~ a. The action, including classification of the action and the What motor skills are needed for this activity? What is the client's
movement endurance level?
b. The environment, including the influence of both direct and What are the environmental conditions for conducting this task?
indirect conditions What supplies, people, and setting are required?
c. The client, including his or her interests, abilities, and whether What information is known about the client? Interests and
the minimal prerequisite skills for success are present activities? VWhat are the strengths and weaknesses from the OT
assessment?
Bc The prerequisite skills or performance components required What performance components are needed for functional
— ofthe client — ambulation to successfully bake muffins?
e. The expectations of outcome and movement Client will successfully bake muffins while ambulating with cane
3. Develop a strategy to make up for any deficits identified in #2. Strategy: What adaptations will be necessary to accommodate
availability of unilateral UE to'carry supplies because of use of an
ambulation aid?
4. Plan the intervention strategy based on the preceding Arrange supplies on countertop near oven to limit need for long
information concerning the individual-activity-environment distances of ambulation while carrying objects; use countertop or
interaction. wheeled cart to transport bowls, pans, and other items.
5. Effect the strategy. Implement the task with the client.
a. Observe task and performance of the patients. Observe and record outcomes.
b. Record what happened: What was the outcome and what
was the approach and effect of the movement solution?

6, Evaluate the observation. Evaluate:

a. Compare expectations and what happened. Was client successful in baking muffins?
b. Provide feedback based on the comparison above and assist Provide feedback to the client.
the patient in making decisions about the next attempt.
c. With the client, plan the next activity. Plan next activity with client.
Adapted from Higgins JR, Higgins S:The acquisition of locomotor skill.in Craik RL, Oatis CA, editors: Gait analysis: theory and application, St Louis, 1995, Mosby.

PRACTICAL INSTRUCTION AND SAFETY

therapist may have a wheelchair, chair, or stool readily
Before beginning functional ambulation, evaluation, or available for use at appropriate intervals or in case of
training, the OT practitioner should know basic client need.
information. The therapist reviews the medical record To prepare the client for functional ambulation, the
or pertinent notes reporting the client's current status therapist begins with safe and appropriate footwear. The
and precautions. As part of this review, the therapist client should don nonskid shoes that fit well to avoid
confers with the PT team member regarding the client's slipping. To increase the client’s sense of security and to
current ambulatory status, gait techniques, and ambula- prevent a loss of balance or falls, the client should be in-
tion aids or orthosis to be used. Throughout the activity, structed to avoid slippers or ill-fitting shoes or stocking
the therapist reinforces the prescribed ambulation tech- feet.
niques and aids. The client's physiological responses should be moni-
Another key to safe and successful functional ambu- tored during the functional ambulation activity. The
lation is awareness of the client’s endurance level. How therapist should be aware of the client's precautions and
easily does the client fatigue? What distance is the respond appropriately. Physiological responses may
client able to ambulate? With this information in include a change in breathing patterns, perspiration,
mind, the therapist can plan ahead for the functional reddened skin, a change in mental status, and decreased
ambulation activity. If the client may fatigue easily, the responsiveness.
 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

must apply the gait training techniques established by

the physical therapist in combination with the treat-
ment plan to accomplish meal preparation and cleanup
tasks. For example, if the client has left hemiplegia and
is ambulating with a quad-cane, the OT practitioner
|. Know the client (e.g, status, orthotics and aids, and
must problem solve to determine how the client will
precautions).
successfully accomplish the meal preparation activity.
2. Use appropriate footwear.
3. Monitor physiological responses.
In this example, the therapist may guide the individual
4. Use a gait belt to guide the client. Do foruse
6 the client's to ambulate to the left of the oven door so as to be able
clothes or upper extremity to guide the client. to open the oven door using the unaffected right upper
5. Think ahead for the unexpected. extremity. The same concept should be kept in mind for
6. Do not leave the client unattended. opening cabinet doors or drawers or refrigerator doors.
7. Clear potential hazards. Transporting items such as food, plates, and eating
utensils during functional ambulation invites creative
problem-solving on the part of the occupational thera-
pist, particularly when the client is using an ambulation
During functional ambulation, the OT practitioner aid (Figs. 14-1 and 14-2). Walker baskets, rolling carts,
should be positioned slightly behind and to one side of
the individual. Rather than grasping the individual’s
clothing, the therapist should maintain contact with the
individual by using a gait belt to grasp with one hand,
leaving the other hand free to assist with the functional
activity.
The therapist should think ahead to be prepared for
the unexpected. As with monitoring for fatigue level, the
therapist must be prepared in case the unplanned occurs.
Preparation includes having a wheelchair, walker, chair,
or stool available should the activity need to be adjusted
to a lower level of difficulty. Being prepared for the unex-
pected also involves watching for any obstacles or
moving objects that may come into the path of the client,
such as other individuals and therapists.
The occupational therapist must not leave the client
unattended during functional ambulation, because the
client may be unstable and a fall could result. The area
being used should be cleared of potential safety haz-
ards. The therapist should be certain that the area to be
used for functional ambulation is free of any potential
risks such as obstacles and that the floor is dry. Box 14-1
provides a summary of these important points.

FUNCTIONAL AMBULATION APPLICATION

There are numerous opportunities for functional ambu-
lation based on the individual and the specific require-
ments of the client's roles and desired tasks to be per-
formed. Several typical functional ambulation activities
follow. The activities may be modified for the individual
clients. Functional ambulation may be incorporated
during ADL, work and productive activities, and play or
leisure activities.

Kitchen Ambulation
Functional ambulation may occur during meal prepara- FIG. 14-1
tion and cleanup within a kitchen. The OT practitioner Functional ambulation with a walker and walker basket.
 Mobility

manner. First, approach as close to the sink as possible.

This enables the client to perform grooming and
hygiene activities. If the walker has a walker basket or if
a countertop or cabinets prohibit the client from posi-
tioning himself or herself close enough to use the sink
safely, the client may need to cautiously maneuver the
walker to one side, then carefully move forward toward
the sink.
Ambulation to the toilet is another opportunity for
OT intervention. The transfer to the toilet should be an-
ticipated upon entering the bathroom, and the client
should be guided toward the toilet. Upon parallel align-
ment in front of the toilet, guide the client to maneuver
himself or herself and the ambulation aid by pivoting to
position the client to be able to sit on the toilet. Guide
the client to pivot the least distance possible, to prevent
losing balance. If the toilet is to the left of the client,
pivot clockwise approximately 90°. If the toilet is on the
right, pivot counterclockwise.
With ambulation to the edge of the bathtub or
shower, the use of the bathtub or shower should be an-
ticipated upon entering the bathroom. The client
should be guided toward the tub edge. Whether the
client is ambulating with a walker, crutches, or cane or
with no ambulation aid, the client should be aligned to
prepare for a safe transfer as the client nears the edge. If
a transfer tub bench, shower chair, or other equipment
is necessary for the client, the client should be guided to
position himself or herself before the transfer, limiting
the risk of losing balance by using a technique requiring
the least distance or extraneous movement.

Home Management Ambulation

Functional ambulation within the house during home
management activities such as clothing care, cleaning,
and household maintenance is another area for OT
FIG. 14-2
intervention. With clothing care, functional ambula-
Functional ambulation with a straight cane.
tion may be necessary during sorting, laundering, and
storing of clothing. Cleaning, including picking up, vac-
uuming, sweeping and mopping floors, and dusting
or the use of countertops may be appropriate in these and making beds, is an ideal activity for including am-
situations. Any such adaptation should be discussed to bulation where appropriate. Household maintenance,
determine if the client finds it acceptable. which includes maintaining the home, yard, garden, ap-
pliances, and vehicles, may also incorporate functional
ambulation. As with any OT intervention, the client
Bathroom Ambulation
should be consulted to determine the home manage-
Functional ambulation to the sink, toilet, or edge of the ment activity most valued by the client before begin-
bathtub or shower is an important concern for OT. ning the functional activity.
Great care should be taken during functional ambula- Making the bed is an example of a homemaking ac-
tion within the bathroom because of the many risks as- tivity. If the client uses a cane during ambulation, the
sociated with water and hard surfaces. Spills on the floor client may stabilize himself or herself with the cane
and loose bath mats present tripping hazards. It is es- while using the other arm to straighten and pull up
sential to educate clients about these dangers. sheets and bedcovers. The client then moves around the
Functional ambulation to the sink, using a walker bed to the other side to repeat the process. The client
in this example, may be performed in the following should be careful, because he or she may lose balance
178 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

while bending and straightening from bed height to a suring process, the use and care of the wheelchair,
standing position throughout the activity. and, importantly, the process by which this equip-
Adaptations may be made to perform functional am- ment is funded.
bulation activities during household maintenance tasks Wheelchairs have evolved considerably in recent
such as yard work. For example, a client using a walker, years, with significant advances made in powered and
crutches, or a cane may carefully ambulate, with assis- manual wheelchair technology by manufacturers and
tance as needed, to the location in the yard needing service providers. Products are constantly changing.
weeding or pruning. Small yard tools may be carried in Many of the improvements result from user and thera-
a walker basket or in a plastic shopping bag hung over pist recommendations.
the arm. During stationary activities such as weeding or Occupational therapists and physical therapists, de-
pruning, the client may use a gardening stool. A stool pending on their respective roles at their treatment facil-
may be used and moved to the next location as the yard ities, are usually responsible for evaluating, measuring,
work progresses. and selecting a wheelchair and seating system for the
patient. They also teach wheelchair safety and mobility
skills. The constant evolution of technology and variety
SUMMARY
of manufacturers’ products make it advisable to include
Functional ambulation is the purposeful application of an experienced, knowledgeable, and certified rehabili-
the mobility training taught to the client to enable tation technology supplier (RTS) on the ordering
movement from one position or place to another. Func- team. The RTS is a durable medical equipment (DME)
tional ambulation is applicable for clients with a variety supplier who is proficient in ordering custom items and
of diagnoses, both biomechanical and neurological, can offer an objective and broad mechanical perspective
across the age span. on the availability and appropriateness of the options
Functional ambulation is an area in which the OT being considered. The RTS will be the patient’s resource
and PT practitioners have an opportunity to collaborate. for insurance billing, repairs, and reordering when re-
The physical therapist provides the gait training and am- turning to the community.
bulation aid recommendations, and the OT practitioner Whether the patient requires a noncustom rental
reinforces and integrates these recommendations wheelchair for temporary use or a custom wheelchair
during purposeful activities. for use over many years, an individualized prescrip-
Functional ambulation may be incorporated during tion clearly outlining the specific features of the chair
ADL, work and productive activities, and play or leisure is needed to ensure optimal performance, mobility,
activities. The OT practitioner may have an opportunity and enhancement of function. A wheelchair that has
to incorporate functional ambulation frequently during been prescribed by an inexperienced or nonclinical
I-ADL. person is potentially hazardous to the patient. An ill-
fitting wheelchair can, in fact, contribute to unneces-
a ere eee | eee Bee ee sary fatigue, skin breakdown, and trunk or extremity
SECTION 2 deformity and can inhibit function.* A wheelchair is
an extension of the patient's body and should act to
Wheelchair Assessment and Transfers facilitate rather than inhibit good alignment, mobility,
CAROLE ADLER and function.
MICHELLE TIPTON-BURTON

WHEELCHAIR EVALUATION
WHEELCHAIRS
The therapist has considerable responsibility in recom-
A wheelchair can be the primary means of mobility mending the wheelchair appropriate to meet not only
for someone with a permanent or progressive disabil- immediate needs, but also long-term needs. When eval-
ity such as cerebral palsy, brain injury, spinal cord uating for a wheelchair, the therapist must know the
injury, multiple sclerosis, or muscular dystrophy. It patient and have a broad perspective of the patient's
may be needed as a temporary means of mobility clinical, functional, and environmental needs. Careful
by someone with a short-term illness or orthopedic evaluation of physical status must include the follow-
problem. In addition to mobility, the wheelchair can ing: the specific diagnosis, prognosis, and current and
substantially influence the total body positioning, skin future problems (e.g., age, spasticity, loss of range of
integrity, overall function, and general well-being of motion [ROM], muscle weakness, and reduced en-
the patient. Regardless of the diagnosis of the patient's durance) that may affect wheelchair use. Functional use
condition, the occupational therapist must understand of the wheelchair in a variety of environments must be
the complexity of wheelchair technology, available considered. Box 14-2 lists questions to ask before
options and modifications, the evaluation and mea- making specific recommendations.
 Mobility 179

To ensure that payment for the wheelchair is author-

ized, the therapist should have an in-depth awareness of
eae to Ask Before Making Specific the patient's insurance benefits and must provide docu-
Recommendations for a Wheelchair mentation with thorough justification of the medical
necessity of the wheelchair and any additional modifi-
cations. Therapists must explain clearly why particular
Who will pay for the wheelchair? features of a wheelchair are being recommended. They
Vho will determine the preferred DME provider:The
must be aware of standard versus “up charge” items, the
Insurance company, the patient, or the therapist?
What isthe specific disability? cost of each item, and how these items will affect the
What isthe prognosis? end product.
__ Isrange of motion limited?
_ Isstrength or endurance limited? WHEELCHAIR ORDERING
_ How will the patient propel the chair? CONSIDERATIONS
How old is the patient?
~ How long is the patient expected to use the wheelchair? Before determining a specific brand and specifications
_ What was the patient's lifestyle, and how has it changed? of a wheelchair and the wheelchair’s specifications, the
_ Is the patient active or sedentary? therapist should carefully analyze the following se-
How will the dimensions of the chair affect the patient's ability quence of evaluation considerations.'"*”
___ to transfer to various surfaces?
What is the maneuverability of the wheelchair in the patient's
home,or in the community (e.g., entrances and egress, door Propelling the Wheelchair
width, turning radius in bathroom and hallways, and floor
surfaces)? The wheelchair may be propelled in a variety of ways,
What is the ratio of indoor to outdoor activities? depending on the physical capacities of the user. If the
Where will the wheelchair be primarily used—in the home, at patient is capable of self-propulsion using his or her
school, at work, or in the community? arms on the rear wheels of the wheelchair, it should be
Which mode of transportation will be used? Will the patient assumed that there is sufficient bilateral grasp, arm
be driving a van from the wheelchair? How will it be loaded strength, and physical endurance to maneuver the chair
and unloaded from the car? independently over varied terrain throughout the day.’
Which special needs (e.g., work heights, available assistance, An assortment of push rims is available to facilitate self-
accessibility of toilet facilities, and parking facilities) are
propelling, depending on the user's arm and grip
recognized in the work or school environment?
strength. A patient with hemiplegia may propel a wheel-
Does the patient participate in indoor or outdoor sports
activities?
chair using the unaffected arm and the ipsilateral leg to
How will the wheelchair affect the patient psychologically? maneuver the wheelchair.
Can accessories and custom modifications be medically If independence in mobility is desired, a power
justified, or are they luxury ttems? wheelchair should be considered for those who have
What resources does the patient have for equipment minimal or no use of the upper extremities or limited
“maintenance (e.g,, self, family, and caregivers)? endurance. Power chairs are also preferred in situa-
tions involving inaccessible outdoor terrain.’ They
have a wide variety of features and can be pro-
grammed, driven by foot, arm, head, or neck, or pneu-
matically controlled. Given today’s sophisticated tech-
All data must be considered before recommenda- nology, assuming intact cognition and perception,
tions are made. Before the final prescription is prepared, even a person with the most severe physical limita-
collected information must be analyzed for an under- tions is capable of independently driving a power
standing of advantages and disadvantages of recom- wheelchair.
mendations based on the patient's condition and how If the chair is to be propelled by the caregiver, consid-
all specifics will integrate to provide an optimally effec- eration must be given to ease of maneuverability and
tive mobility system. handling, as well as to the positioning and mobility
The therapist must develop a good working relation- needs of the patient.
ship with the equipment supplier (RTS) and the reim- Regardless of the method of propulsion, serious con-
bursement sources to facilitate payment of the most sideration must be given to the effect the chair has on
appropriate mobility system for the patient. Oral and the patient's current and future mobility and position-
written skills must be developed to communicate ing needs. In addition, lifestyle and environment, avail-
clearly the medical necessity, appropriateness, and cost- able resources such as ability to maintain the chair,
effectiveness of each item throughout the assessment transportation options, and available reimbursement
and recommendation process. sources are major determining factors.
1Kei0) OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

RENTAL VERSUS PURCHASE of each, and how these features will affect the patient in
The therapist should estimate how long the patient will every aspect of his of her life, from both a short- and
need the chair and whether the chair should be rented or long-term perspective.
purchased, which will affect the type of chair being con-
sidered. This decision is based on several clinical and
WHEELCHAIR SELECTION
functional issues. A rental chair is appropriate for short-
term or temporary use, such as when the patient's clinical The following questions regarding patient needs should
picture, functional status, or body size is changing. Rental be considered carefully before the specific type of chair
chairs may be necessary when the permanent wheelchair is determined:'
is being repaired. A rental wheelchair also may be useful
when the patient has difficulty accepting the idea of using
Manual Versus Electric Wheelchair
a wheelchair and needs to experience it initially as a tem-
porary piece of equipment. Often the eventual func-
(Fig. 14-3)
tional outcome is unknown. In that case a chair can be Manual Wheelchair (Fig. 14-3, A)
rented for several months until a reevaluation deter- ® Does the user have sufficient strength and endurance
mines whether a permanent chair will be necessary. ' to propel the chair?
A permanent wheelchair is indicated for the full-time ® Does manual mobility enhance functional independ-
user and for the patient with a progressive need for a ence and cardiovascular conditioning of the wheel-
wheelchair over a long period. It may be indicated when chair user?
custom features are required and also when body size is @ Does the user demonstrate insufficient cognitive
changing, such as in the growing child.' ability to propel an electric wheelchair safely?
#@ Will the caregiver be propelling the chair at any time?
Frame Style
Electric Wheelchair (Fig. 14-3, B)
Once the method of propulsion and the permanence of ™ Does the user demonstrate insufficient endurance
the chair have been determined, there are several wheel- and functional ability to propel a manual wheelchair
chair frame styles to consider. The frame style must be independently?
selected before specific dimensions and brand names ™ Does the user demonstrate progressive functional
can be determined. The therapist needs to be aware of loss, making powered mobility an energy-conserving
the various features, the advantages and disadvantages option?

FIG. 14-3
Manual versus electric wheelchair. A, Rigid frame chair with swing-away footrests. B, Power-driven
wheelchair with hand control. (A courtesy of Quickie Designs; B courtesy of Invacare Corporation.)
 Mobility
m@ Is powered mobility needed to increase independ- @ Are there resources for care and maintenance of the
ence at school, at work, and in the community? equipment?
@ Does the user demonstrate cognitive and percep- ® Does the user have significant spasticity that is facili-
tual ability to operate a power-driven system safely? tated by hip and knee extension during the recline
@ Does the user or caregiver demonstrate responsibility phase?
for care and maintenance of equipment? @ Does the user have hip or knee contractures that pro-
@ Isa van available for transportation? hibit his or her ability to recline fully?
@ Will a power recline or tilt decrease or make more ef-
ficient use of caregiver time?
Manual Recline Versus Power Recline
@ Will a power recline or tilt reduce the need for trans-
Versus Tilt Wheelchairs (Fig. 14-4)
fers to the bed for catheterizations and rest periods
Manual Recline Wheelchair (Fig. 14-4, A) throughout the day?
@ Is the patient unable to sit upright because of hip @ Will the patient require quick position changes in the
contractures, poor balance, or fatigue? event of hypotension and/or dysreflexia?
@ Is a caregiver available to assist with weight shifts and m™ Has a reimbursement source been identified for this
position changes? costly add-on feature?
@ Is relative ease of maintenance a concern?
@ Is cost a consideration?

Power Recline Versus Tilt (Fig. 14-4, B and C)

™ Does the patient have the potential to operate inde-
pendently?
m@ Are independent weight shifts and position changes
indicated for skin care and increased sitting tolerance?
® Does the user demonstrate safe and independent use
of controls?

FIG. 14-4
Manual recline versus power recline wheelchair. A, Reclining back on folding frame. B, Low-shear
power recline with collar mount chin control on electric wheelchair. C, Tilt system with head
control on electric wheelchair. (A courtesy of Quickie Designs; B and C courtesy of Luis Gonzalez,
SCVMC.)
182 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

Folding Versus Rigid Manual Wheelchairs

thetics. These chairs are usually custom ordered; avail-
(Fig. 14-5) ability and expertise are usually limited to custom reha-
Folding Wheelchairs (Fig. 14-5, A) bilitation technology suppliers.
Does the patient prefer a traditional-looking chair?
# Is the folding frame needed for transport, storage, or Lightweight (Folding or Nonfolding)
home accessibility?
Versus Standard Weight (Folding)
@ Which footrest style is necessary for transfers, desk
clearance, and other daily living -skills? Elevating
Wheelchairs
footrests may be available only on folding frames. Lightweight Wheelchairs: Under 35 Pounds
@ Is the patient or caregiver able to load and fit the chair (Fig. 14-5, A)
into necessary vehicles? @ Does the user have the trunk balance and equilibrium
Equipment suppliers should have knowledge and a necessary to handle a lighter frame weight?
variety of brands available. Frame weight can range B® Does the lighter weight enhance mobility by reducing
between 28 and 50 pounds depending on size and ac- the user's fatigue?
cessories. Frame adjustments and custom options @ Will the user's ability to propel the chair or handle
depend on the model. parts be enhanced by a lighter weight frame?
@ Are custom features (e.g., adjustable height back, seat
Rigid Wheelchair (Fig. 14-5, B) angle, and axle mount) necessary?
@ Does the user or caregiver have the upper extremity
function and balance to load and unload the non- Standard Weight Wheelchairs: Over 35 Pounds
folding frame from a vehicle if driving independ- (Fig. 14-6)
ently? @ Does the user need the stability of a standard weight
@ Will the user benefit from the improved energy effi- chair?
ciency and performance of a rigid frame? ™ Does the user have the ability to propel a standard
Footrest options are limited and the frame is lighter weight chair?
(20 to 35 pounds). Features include an adjustable seat @ Can the caregiver manage the increased weight when
angle, rear axle, caster mount, and back height. Efficient loading the wheelchair and fitting into a vehicle?
frame design maximizes performance. There are options @ Will the increased weight of parts be unimportant
in frame material composition, frame colors, and aes- during daily living skills?
Custom options are limited, and these wheelchairs
are usually less expensive (except heavy-duty models re-
quired for users over 250 pounds).

FIG. 14-5
Folding versus rigid wheelchair. A, Lightweight folding frame with swing-away footrests. B, Rigid alu-
minum frame with tapered front end and solid foot cradle. (A courtesy of Quickie Designs; B cour-
tesy of Invacare Corporation.)
 Mobility 183

Standard Available Features Versus

@ Will this be the primary wheelchair?
Custom, Top-of-the-Line Models
@ Is the user active both indoors and outdoors?
The price range, durability, and warranty within a spe- m Will this frame style improve prognosis for independ-
cific manufacturer’s model line must be considered. ent mobility?
m Is the user a growing adolescent, or does he or she
Standard Available Features have a progressive disorder requiring later modifica-
@ Is the chair required only for part-time use? tion of the chair?
™ Does the user have a limited life expectancy? m Are custom features, specifications, or positioning
@ Is the chair needed as a second or transportation devices required?
chair, used only 10% to 20% of the time? Top-of-the-line wheelchair frames usually have a life-
@ Will the chair be primarily for indoor or sedentary use? long warranty. A variety of specifications, options, and
@ Is the user dependent on caregivers for propulsion? adjustments are available. Many manufacturers will
@ Will the chair be propelled only by the caregiver? work with therapists and providers to solve a specific
@ Are custom features or specifications not necessary? fitting problem. Experience is essential in ordering top-
@ Is substantial durability unimportant? of-the-line and custom equipment.
For standard wheelchairs, a limited warranty is available
on the frame. These chairs may be indicated because of WHEELCHAIR MEASUREMENT
reimbursement limitations. Limited sizes and options
PROCEDURES (FIG. 14-7)
and adjustability are available. These cost considerably
less than custom wheelchairs. The patient is measured in the style of chair and with
the seat cushion that most closely resembles those be-
Custom and “Top-of-the-Line” Models ing ordered. If the patient will wear a brace or body
@ Will the patient be a full-time user? jacket or need any additional devices in the chair, these
@ Is there a likely prognosis for long-term use of the should be in place during the measurement. Observation
wheelchair? skills are important during this process. Measurements
alone should not be used. The therapist should “eye-
ball” the entire body position every step of the way.'’°

Seat Width (Fig. 14-7, A)

Objectives
1. Distributing the patient's weight over the widest pos-
sible surface.

A Es Deke
FIG. 14-7
What and where to measure. A, Seat width. B, Seat depth. C, Seat
FIG. 14-6 height from floor. D, Footrest clearance. E, Back height. F, Armrest
Standard folding frame (over 35 pounds) with swing-away foot- height. (Adapted from Wilson A, McFarland SR: Wheelchairs: a pre-
rests. (Courtesy of Everest & Jennings, Inc.) scription guide, Charlottesville,
Va, !986, Rehabilitation Press.)
184 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

Seat Height from Floor and Foot

2. Keeping the overall width of the chair as narrow as
Adjustment (Fig. 14-7, C, and D)
possible.
Objectives
Measurement 1. Supporting the patient's body while maintaining the
Measure across the widest part of either the thighs or thighs parallel to the floor (Fig. 14-5, C)
hips while the patient is sitting in a chair comparable to 2. Elevating the foot plates to provide ground clearance
that expected. over varied surfaces and curb cuts (Fig. 14-7, D)

Wheelchair Clearance Measurements

Add 1/2 to 1 inch on each side of the hip or thigh mea-
surement taken. Consider how increasing the overall Measure the top of the seat post to the floor and the
width of the chair will affect accessibility. popliteal fossa to the bottom of the heel.

Checking Wheelchair Clearance

Place the flat palm of the hand between the pa- The patient's thighs are kept parallel to the floor so the
tient’s hip or thigh and the wheelchair skirt and body weight is distributed evenly along the entire depth
armrest. of the seat. The lowest point of the footplates must clear
the floor by at least 2 inches.
Considerations
User's potential weight gain or loss Checking
Accessibility of varied environments Slip fingers under the patient's thighs at the front
Overall width of wheelchair edge of the seat upholstery. Note: A custom seat
height may be needed to obtain footrest clearance.
An inch of increased seat height raises the footplate 1
Seat Depth (Fig. 14-7, B) inch.
Objective
The objective is to distribute the body weight along the Considerations
sitting surface by bearing weight along the entire length If the knees are too high, increased pressure at the
of the thigh to just behind the knee. This approach is ischial tuberosities puts the patient at risk for skin
necessary to help prevent pressure sores on the buttocks breakdown and pelvic deformity.
and lower back and for optimal muscle tone normaliza- Sitting too high off the ground can impair the
tion throughout the body. patient's center of gravity, seat height for transfers,
and visibility if driving a van from the wheel-
Measurement chair.
Measure from the rear of the buttocks to the inside of
the bent knee; the seat edge clearance needs to be 1 to 2
Back Height (Fig. 14-7, E)
inches less than this measurement.
Objective
Checking Providing back support consistent with physical and
Check clearance behind the knees to prevent contact of functional needs. The chair back should be low enough
the front edge of the seat upholstery with the popliteal for maximal function and high enough for maximal
space. support.

Considerations Measurements
Braces or back inserts that may be pushing the patient For full trunk support, measure from the top of the
forward. seat post to the top of the shoulders. For minimum
Postural changes throughout the day from fatigue or trunk support, the top of the back upholstery should
spasticity. permit free arm movement, not irritate the skin or
Thigh length discrepancy; the depth of the seat may be scapulae, and provide good total body alignment.
different for each leg.
If considering a power recliner, assume the patient will Checking
slide forward slightly throughout the day and make Ensure that the patient is not being pushed forward
depth adjustments accordingly. because the back of the chair is too high or leaning
Seat depth may need to be shortened to allow inde- backward over the top of the upholstery because the
pendent propulsion with the lower extremities. back is too low.
 Mobility 185

Considerations dard wheelchair base. Considerations are the child’s

Adjustable-height backs (usually offer a 4-inch range) ability to propel the chair relative to the developmental
Adjustable upholstery level and the parent's preference for a stroller or a
Lumbar support or another commercially available or wheelchair.
custom back insert to prevent kyphosis, scoliosis, or Many variables must be considered when customiz-
other long-term trunk deformity ing a wheelchair frame. An experienced RTS or the
wheelchair manufacturer should be consulted to ensure
Arm Height (Fig. 14-7, F) that a custom request will be successful.

Objectives
ADDITIONAL SEATING AND
1. Maintaining posture and balance
2. Providing support and alignment for upper extrem-
POSITIONING CONSIDERATIONS
ities A wheelchair evaluation is not complete until the seat
3. Allowing change in position by pushing down on cushion, back support, and any other positioning
armrests devices and the integration of those parts are carefully
thought out, regardless of the diagnosis. It is essential
Measurements that the therapist appreciate the effect that optimal
With the patient in a comfortable position, measure body alignment has on skin integrity, tone normaliza-
from the seat post to the bottom of a bent elbow. tion, overall functional ability, and general well-being
(Fig. 14-8)."
Wheelchair Clearance The following are the goals of a comprehensive
The height of the top of the arm rest should be 1 inch seating and positioning assessment.
higher than the height from the seat post to the patient's
elbow.
Prevention of Deformity
Checking Providing a symmetrical base of support preserves
The patient's posture should look correct. The shoul- proper skeletal alignment and discourages spinal curva-
ders should not slouch forward or be subluxated or ture and other body deformities.
forced into elevation when the patient is in a normal
sitting posture, with flexed elbows slightly forward on
Tone Normalization
armrests.
By providing proper body alignment, as well as bilateral
Considerations weight bearing and adaptive devices as needed, tone
Other uses of armrests, such as increasing functional normalization can be maximized.
reach or holding a cushion in place
Certain styles of armrests can increase the overall eridth
Pressure Management
of the chair.
Whether armrests are necessary at all Pressure sores can be caused by improper alignment
The patient's ability to remove and replace the armrest and an inappropriate sitting surface. The proper seat
from the chair independently cushion can provide comfort, assist in trunk and pelvic
Review all measurements against standards for a partic- alignment, and create a surface that minimizes pressure,
ular model of chair. Manufacturers have lists of the stan- heat, moisture, and shearing, the primary causes of skin
dard dimensions available and the cost for custom breakdown.
modifications.
The goals of pediatric wheelchair ordering, as of
Promotion of Function
all wheelchair ordering, should be obtaining a pro-
per fit and facilitating optimal function. Rarely does Pelvic and trunk stability is necessary to free the upper
a standard wheelchair meet the fitting requirements extremity for participation in all functional activities, in-
of a child. The selection of size is variable; therefore cluding wheelchair mobility and daily living skills.
custom seating systems specific to the pediatric
population are available. A secondary goal is to
Maximum Sitting Tolerance
consider a chair that will accommodate the child's
growth. Wheelchair sitting tolerance will increase as support,
For children under 5 years of age a decision must be comfort, and symmetrical weight-bearing are pro-
made about whether to use a stroller base or a stan- vided.
186 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

FIG. 14-8
A, Stroke patient seated in wheelchair. Poor positioning results in kyphotic thoracic spine, posterior
pelvic tilt, and unsupported affected side. B, Stroke patient seated in wheelchair with appropriate
positioning devices. Seat and back insert facilitate upright midline position with neutral pelvic tilt and
equal weight bearing throughout.

evaluation, the scope of seating and positioning equip-

Optimal Respiratory Function ment is much greater than can be addressed in this
Support in an erect, well-aligned position can decrease chapter. The suggested reading list at the end of this
compression of the diaphragm and thus increase vital chapter gives additional resources.
capacity.
ACCESSORIES
Provision for Proper Body Alignment
Once the measurements and the need for additional po-
Good body alignment is necessary for prevention of sitioning devices have been determined, a wide variety
deformity, normalization of tone, and promotion of of accessories are available to meet a patient's individual
movement. The patient should be able not only to needs. It is extremely important to understand the func-
propel the wheelchair, but also to move around within tion of each accessory and how an accessory interacts
the wheelchair. with the rest of the chair and with seating and position-
A wide variety of seating and positioning equipment ing equipment.'’”
is available for all levels of disability. Custom modifica- Armrests come in fixed, flip-up, detachable, desk,
tions are continually being designed to meet a variety of standard, reclining, and tubular styles. The fixed armrest
patient needs. In addition, technology in this area is is a continuous part of the frame and is not detachable.
ever growing, and interest in wheelchair technology as a It limits proximity to table, counter, and desk surfaces
professional specialty also is growing. However, the skill and prohibits side transfers. Flip-up, detachable desk
of clinicians in this field ranges from extensive to negli- and standard-length arms are removable and allow side-
gible. Although it is an integral aspect of any wheelchair approach transfers. Reclining arms are attached to the
J
-
“
.

FIG. 14-8, cont’d

C, Spinal cord-injured patient sitting with back poorly supported results in posterior pelvic tilt,
kyphotic thoracic spine, and absence of lumbar curve. D, Spinal cord-injured patient with rigid back
support and pressure-relief seat cushion, resulting in erect thoracic spine, lumbar curve, and ante-
rior tilted pelvis.

back post and recline with the back of the chair. Tubular behind the calf is necessary. Other accessories are seat
arms are available on lightweight frames. belts, various brake styles, brake extensions, anti-tip
Footrests may be fixed, swingaway detachable, solid devices, caster locks, arm supports, and head supports.
cradle, and elevating. The fixed footrests are attached to
the wheelchair frame and are not removable. These
PREPARING THE PRESCRIPTION
footrests prevent the person from getting close to coun-
ters and may make some types of transfers more diffi- Once specific measurements and the need for modifica-
cult. The swingaway detachable footrests can be moved tions and accessories have been determined, the wheel-
to the side of the chair or removed entirely. This allows chair prescription must be completed. It should be
a closer approach to bed, bathtub, and counters, and concise and specific so that everything requested can be
when the footrests are removed, reduces the overall accurately interpreted by the DME supplier, who will be
wheelchair length and weight for easy loading into a submitting a sales contract for payment authorization.
car. Detachable footrests lock into place on the chair Before-and-after pictures can be helpful in illustrating
with a locking device.’ A solid cradle footrest is found medical necessity. It is important that the requirements
on rigid, lightweight chairs and is not removable. Ele- for payment authorization from a particular reimburse-
vating leg rests are available for patients with such con- ment source are known so that medical necessity can be
ditions as lower-extremity edema, blood pressure demonstrated. The therapist must be aware of the cost
changes, and orthopedic problems. of everything being requested and of the reason each
The footplates may have heel loops and toe straps to item is necessary. Payment may be denied if clear
aid in securing the foot on the footplate.’ A calf strap can reasons are not given to substantiate the need for every
be used on a solid cradle or when additional support item and modification requested.
 188 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

Before the wheelchair is delivered to the patient, the back, and pushing the foot down on the tipping
therapist should check the chair to the specific prescrip- levers, thus lifting the front casters onto the curb and
tion and ensure that all specifications and accessories pushing forward. The large wheels then are in
are correct. When a custom chair has been ordered, it is contact with the curb and roll on with ease as the
recommended that the patient be fitted by the ordering chair is lifted slightly onto the curb.
therapistto ensure that the chair fits and that it provides 8. To descend the curb using a forward approach, the
all the elements that were expected when the prescrip- wheelchair is tilted backward and the large wheels
tion was generated. are rolled off the curb in a controlled manner while
the front casters are tilted up. When the large wheels
are off the curb, an assistant can slowly reduce the tilt
WHEELCHAIR SAFETY
of the wheelchair until the casters are once again on
Elements of safety for the wheelchair user and the care- the street surface. The curb may also be descended
giver are as follows: using a backward approach. An assistant can move
1. Brakes should be locked during all transfers. himself or herself and the chair around as the curb is
_2. The patient should never stand on the foot plates, approached and pull the wheelchair to the edge of
which are placed in the “up” position during most the curb. Standing below the curb, the assistant can
transfers. guide the large wheels off the curb by slowly pulling
3. In most transfers, it is an advantage to have footrests the wheelchair backward until it begins to descend.
swung away if possible. After the large wheels are safely on the street surface,
4. Ifa caregiver is pushing the chair, he or she should be the assistant can tilt the chair back to clear the
sure that the patient's elbows are not protruding casters, move backward, lower the casters to the street
from the armrests and that the patient's hands are surface, and then turn around.®
not on the hand rims. If approaching from behind to With good strength and coordination, many patients
assist in moving the wheelchair, the caregiver should can be trained to manage curbs independently. To
inform the patient of this intent and check the posi- mount and descend a curb, the patient must have a good
tion of the patient's feet and arms before proceeding. bilateral grip, arm strength, and balance. To mount the
5. To push the patient up a ramp, he or she should curb, the patient tilts the chair onto the rear wheels and
move in a normal, forward direction. If the ramp is pushes forward until the front wheels hang over the
negotiated independently, the patient should lean curb, then lowers them gently. The patient then leans
slightly forward while propelling the wheelchair up forward and forcefully pushes forward on the hand rims
the incline.® to bring the rear wheels up on the pavement. To
6. To push the patient down a ramp, the caretaker descend a curb, the patient should lean forward and
should tilt the wheelchair backward by pushing the push slowly backward until the rear and then the front
foot down on the tipping levers to its balance posi- wheels roll down the curb.*
tion, which is a tilt of approximately 30°. Then the The ability to lift the front casters off the ground and
caregiver should ease the wheelchair down the ramp balance on the rear wheels (“pop a wheelie”) is a bene-
in a forward direction, while maintaining the chair in ficial skill and expands the patient's independence in
its balance position. The caregiver should keep his or the community with curb management and in rural
her knees slightly bent and the back straight.® The settings with movement over grassy, sandy, or rough
caregiver may also move down the ramp backward terrain. Patients who have good grip, arm strength, and
while the patient maintains some control of the large balance usually can master this skill and perform safely.
wheels to prevent rapid backward motion. This ap- The technique involves being able to tilt the chair on the
proach is useful if the grade is relatively steep. Ramps rear wheels, balance the chair on the rear wheels, and
with only a slight grade can also be managed in a move and turn the chair on the rear wheels. The patient
forward direction if the caregiver maintains grasp and should not attempt to perform these maneuvers
pull on the hand grips and the patient again main- without instruction and training in the proper tech-
tains some control of the big wheels to prevent rapid niques, which are beyond the scope of this chapter. Spe-
forward motion. If the ramp is negotiated independ- cific instructions on teaching these skills can be found
ently, the patient should move down the ramp facing in the references.*
forward while leaning backward slightly and main-
taining control of speed by grasping the hand rims.
TRANSFER TECHNIQUES
The patient can descend a steep grade by traversing
the ramp to slow the chair. Gloves may be helpful to Transferring is the process of a patient's moving from
reduce the effect of friction.® one surface to another. This process includes the se-
7. A caregiver can manage ascending curbs by ap- quence of events that must occur both before and after
proaching them forward, tipping the wheelchair the move, such as the pretransfer sequence of bed mo-
 Mobility

bility and the posttransfer phase of wheelchair position-

ing. Assuming that a patient has some physical or cogni-
tive limitations, it will be necessary for the therapist to
assist in or supervise a transfer. Many therapists are
unsure of the transfer type and technique to employ or
feel perplexed when a particular technique does not
~ succeed with the patient. It is important to remember
=
that each patient, therapist, and situation are different.
This chapter does not include an outline of all tech-
niques but presents the basic techniques with general-
ized principles. Each transfer must be adapted for the
particular patient and his or her needs. The discussion
a in this chapter includes directions for some transfer
techniques that are most commonly employed in prac-
tice. These techniques are the stand pivot, bent pivot,
and one-person and two-person dependent transfers.

Préliminary Concepts | It is important for the therapist to be familiar with as

The therapist must be aware of the following concepts many types of transfers as possible so that each situa-
when selecting and carrying out transfer techniques to tion can be resolved as it arises.
ensure safety for both the patient and self: Many classifications of transfers exist, based on the
amount of therapist participation. Classifications range
from dependent, in which the patient is unable to partic-
ipate and the therapist moves the patient, to independ-
ent, in which the patient moves independently while the
therapist merely supervises, observes, or provides input
for appropriate technique as related to the patient's dis-
ability.
Before attempting to move a patient, the therapist
must understand the biomechanics of movement and
the effect the patient's center of positioning mass has
on transfers.

Principles of Body Positioning

The therapist should be aware of the following princi- Pelvic Tilt
ples of basic body mechanics’: Generally, after the acute onset of a disability or pro-
longed time spent in bed, patients assume a poste-
rior pelvic tilt (i.e, a slouched position with lumbar
flexion). In turn, this posture moves the center of
mass back toward the buttocks. The therapist may
need to verbally cue or assist the patient into a neutral
or slightly anterior pelvic tilt position to move the
center of mass forward over the center of the patient's
body.”

Trunk Alignment
It may be observed that the patient's trunk alignment is
shifted to either the right or the left side. If the therapist
assists in moving the patient while the patient's weight
is shifted to one side, the movement could throw both
the patient and the therapist off balance. The patient
may need verbal cues or physical assistance to come to
and maintain a midline trunk position before and
during the transfer.
\ AE OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

Weight Shifting 2. Assist the patient in clasping the strong hand around
The transfer is initiated by shifting the patient's weight the wrist of the weak arm, and lift upper extremities
forward, removing weight from the buttocks. This toward the ceiling.
movement allows the patient to stand, partially stand, 3. Flex the patient's knees.
or be pivoted by the therapist. This step must be per- 4. You may assist the patient to roll onto his or her side
formed regardless of the type of transfer. by moving the arms, then the legs, and by holding
one hand at the scapula area and the other at the hip,
Extremity Positioning guiding the roll.
The patient's feet must be placed firmly on the floor
with ankles stabilized and with knees aligned at 90° of Side-Lying to Sit Up at the Edge of Bed
flexion over the feet. This position allows the weight to 1. Bring the patient's feet off the edge of the bed.
be shifted easily onto and over the feet. Heels should be 2. Stabilize the patient's lower extremities.
pointing toward the surface to which the patient is 3. Shift the patient's body to an upright sitting position.
transferring. The patient should either be barefoot or 4. Place the patient's hands on the bed at the sides of
have shoes on to prevent slipping out of position. The his or her body to help maintain balance.
feet can easily pivot in this position, and the risk of
twisting or injuring an ankle or knee is minimized. Scooting to the Edge of the Bed
When working with a patient who has stroke or trau-
Upper Extremities matic brain injury, walk the patient's hips toward the
The patient's arms must be in a safe position or in a po- edge of the bed. Shift the patient's weight to the unaf-
sition in which he or she can assist in the transfer. If one fected side, position your hand behind the opposite
or both of the upper extremities is nonfunctional, the buttock, and guide the patient forward. Shift the
arms should be placed in a safe position that will not be patient's weight to the affected side and repeat the pro-
in the way during the transfer (e.g., in the patient's lap). cedure if necessary. Move forward until the patient's feet
If the patient has partial or full movement, motor are flat on the floor.
control, or strength, he or she can assist in the transfer In the case of an individual with spinal cord injury,
either by reaching toward the surface to be reached or by grasp the patient's legs from behind the knees and pull
pushing off from the surface to be left. The therapist's the patient forward, placing the patient's feet firmly on
decision is based on prior knowledge of the patient's the floor and being sure that the ankles are in a neutral
motor function. position.

Preparing Equipment and Patient STANDING PIVOT TRANSFERS

for Transfer
The standing pivot transfer requires the patient to be
The transfer process includes setting up the environ- able to come to a standing position and pivot on one or
ment, positioning the wheelchair, and helping the both feet. It is most commonly used with patients who
patient into a pretransfer position. The following is a have hemiplegia, hemiparesis, or a general loss of
general overview of these steps. strength or balance.

Positioning the Wheelchair Wheelchair to Bed or Mat Transfer

1. Place the wheelchair at approximately a 30° angle to
(Fig. 14-9)
the surface to which the patient is transferring. 1. Help the patient scoot to the edge of the surface and
2. Lock the brakes. put his or her feet flat on the floor. The patient's
3. Place both of the patient's feet firmly on the floor, ankles should be pointed toward the surface to
hip width apart and with knees over the feet. which the patient is transferring.
4. Remove the armrest closer to the bed. 2. Stand on the patient's affected side with hands
5. Remove the wheelchair seatbelt. either on the patient's scapulae or around the
patient's waist or hips. Stabilize the patient's foot
and knee with your own foot and knee. Provide as-
Bed Mobility in Preparation for Transfer
sistance by guiding the patient forward as the but-
Rolling the Hemiplegic Patient tocks are lifted up and toward the transfer surface
1. Before rolling the patient, you may need to put your (Fig. 14-9, A).
hand under the patient’s scapula on the weak side 3. The patient either reaches toward the surface to
and gently mobilize it forward to prevent the patient which he or she is transferring or pushes off the
from rolling onto the shoulder, potentially causing surface from which he or she is transferring (Fig.
pain and injury. 14-9, B).
 FIG. 14-9
Standing pivot transfer; wheelchair to bed, assisted. A, Therapist stands on patient's affected side and
stabilizes patient's foot and knee. She assists by guiding patient forward and initiates lifting buttocks
up. B, Patient reaches toward transfer surface. C, Therapist guides the patient toward transfer
surface. (Courtesy of Luis Gonzalez, SCVMC.)

4. Guide the patient toward the transfer surface and

gently help him or her down to a sitting position
(Fig. 14-9, C).

Variations: Standing and/or

Stepping Transfer
A standing and/or stepping transfer is generally used
when a patient can take small steps toward the surface
goal and not just pivot toward the goal. The thera-
pist’s intervention may range from physical assistance
to accommodate for potential loss of balance to facil-
itation of near normal movement, equal weight bear-
ing, and maintenance of appropriate posture for pa- ys

tients with hemiplegia or hemiparesis. If a patient he Is.a we,

demonstrates impaired cognition or a behavior deficit,
including impulsiveness and poor safety judgment, FIG. 14-10
the therapist may need to provide verbal cues or phys- Positioning sliding board. Lift leg closest to transfer surface. Place
board midthigh between buttocks and knee, angled toward oppo-
ical guidance.
site hip. (Courtesy of Luis Gonzalez, SCVMC.)

SLIDING BOARD TRANSFERS ity amputations or individuals with spinal cord in-
Sliding board transfers are best used with those who juries.
cannot bear weight on the lower extremities and who
have paralysis, weakness, or poor endurance in their
Method (Fig. 14-10)
upper extremities. The patient should have good
upper extremity strength for this transfer. It is most 1. Position and set up the wheelchair as previously
often employed with persons who have lower extrem- outlined.
12 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

Procedure
2. Lift the leg closer to the transfer surface. Place the
board midthigh between the buttocks and knee, 1. Help the patient scoot to the edge of the bed until
angled toward the opposite hip. The board must be both of the patient's feet are flat on the floor. Grasp
firmly under the thigh and firmly on the surface to the patient around the waist or hips, or even under
which the patient is transferring. the buttocks if a moderate or maximal amount of as-
Qo . Block the patient's knees with your own knees. sistance is required.
4. Instruct the patient to place one hand on the edge of 2. Guide the patient's trunk into a midline position.
the board and the other hand on the wheelchair seat. 3. Shift the weight forward from the buttocks toward
5. Instruct the patient to lean forward. and over the patient's feet (Fig. 14-11, A).
6. The patient should transfer his or her upper body 4. Have the patient either reach toward the surface he or
weight in the direction opposite to which he or she is she is transferring to or push from the surface he or
going. The patient should use both arms to maneu- she is transferring from (Fig. 14-11, B).
ver along the board. The patient uses upper extremity 5. Assist the patient by guiding and pivoting the patient
strength and trunk balance to scoot along the sliding around toward the transfer surface (Fig. 14-11, C).
board. Depending on the amount of assistance required, the
7. Help the patient by putting your hands on the pivoting portion can be done in two or three steps, with
patient's buttocks or scapulae and helping the the therapist repositioning himself or herself and the
patient either shift weight forward or slide across the patient's lower extremities between steps. The therapist
board, as needed. has a variety of choices of where to hold or grasp the
patient during the bent pivot transfer, depending on the
BENT PIVOT TRANSFER: BED TO weight and height of the patient in relation to the thera-
WHEELCHAIR (FIG. 14-11) pist and the patient's ability to assist in the transfer. Vari-
ations include using both hands and arms at the waist,
The bent pivot transfer is used when the patient cannot or trunk, or one or both hands under the buttocks. The
initiate or maintain a standing position. A therapist therapist never grasps under the patient's weak arm or grasps
often prefers to keep a patient in the bent knee position the weak arm, an action that could cause significant injury
to maintain equal weight bearing, provide optimal because of weak musculature and poor stability around the
trunk and lower extremity support, and perform a safer shoulder girdle. The choice is made with consideration to
and easier therapist-assisted transfer. proper body mechanics. Trial and error of technique is

FIG. 14-11
Bent pivot transfer; bed to wheelchair. A, Therapist grasps patient around trunk and assists in shift-
ing patient’s weight forward over feet. B, Patient reaches toward wheelchair. C, Therapist assists
patient down toward sitting position. (Courtesy Luis Gonzalez, SCVMC.)
 Mobility
One-Person Dependent Sliding Board
advised to allow for optimal facilitation of patient in-
dependence, safety, and the therapist's proper body
Transfer (Fig. 14-12, A-F)
mechanics. The procedure for transferring the patient from wheel-
chair to bed is as follows:
1. Set up the wheelchair as described previously.
DEPENDENT TRANSFERS
2. Position the patient's feet together on the floor, di-
The dependent transfer is designed for use with the rectly under the knees, and swing the outside
patient who has minimal to no functional ability. If this footrest away. Grasp the patient's legs from behind
transfer is performed incorrectly, it is potentially haz- the knees, and pull the patient slightly forward in
ardous for both therapist and patient. This transfer the wheelchair so that the buttocks will clear the big
should be practiced with able-bodied persons and ini- wheel when the transfer is made (Fig. 14-12, A).
tially used with the patient only when another person is 3. Place a sliding board under the patient's inside
available to assist.” thigh, midway between the buttocks and the knee,
The purpose of the dependent transfer is to move the to form a bridge from the bed to the wheelchair.
patient from surface to surface. The requirements are The sliding board is angled toward the patient's op-
that the patient be cooperative and willing to follow in- posite hip.
structions. The therapist should be keenly aware of 4. Stabilize the patient's feet by placing your own feet
correct body mechanics, as well as his or her own physi- laterally around the patient's feet.
cal limitations. With heavy patients, it is always best to 5. Stabilize the patient's knees by placing your own
use the two-person transfer or at least to have a second knees firmly against the anterolateral aspect of the
person available to spot the transfer. patient's knees (Fig. 14-12, B).

FIG. 14-12
One-person dependent sliding board transfer. A, Therapist positions wheelchair and patient and
pulls patient forward in chair. B, Therapist stabilizes patient's knees and feet after placing sliding
board. Continued
194 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

FIG. 14-12, cont’d

One-person dependent sliding board transfer. C, Therapist grasps patient’s pants at lowest point of buttocks.
D, Therapist rocks with patient and shifts patient’s weight over patient’s feet, making sure patient’s back
remains straight. (Courtesy of Luis Gonzales, SCVMC.)

. Help the patient lean over the knees by pulling him pendicular to the edge of the mattress and as far
or her forward from the shoulders. The patient's back as possible. This step usually can be achieved
head and trunk should lean opposite the direction of in two or three stages (Fig. 14-12, F).
the transfer. The patient’s hands can rest on the lap. 11. You can secure the patient on the bed by easing him
. Reach under the patient's outside arm and grasp the or her against the back of an elevated bed or on the
waistband of the trousers or under the buttock. On mattress in a side-lying position, then by lifting the
the other side, reach over the patient's back and grasp legs onto the bed.
the waistband or under the buttock (Fig. 14-12, C). The one-person dependent sliding board transfer can be
. After your arms are positioned correctly, lock them adapted to move the patient to other surfaces. It should
to stabilize the patient's trunk. Keep your knees be attempted only when therapist and patient feel
slightly bent and brace them firmly against the secure with the wheelchair-to-bed transfer.
patient's knees.
. Gently rock with the patient to gain some momen-
Two-Person Dependent Transfers
tum, and prepare to move after the count of three.
Count to three aloud, with the patient. On three, Bent Pivot: With or Without a Sliding Board
holding your knees tightly against the patient's Bed to Wheelchair (Fig. 14-13)
knees, transfer the patient's weight over his or her A bent pivot transfer is used to allow increased therapist
feet. You must keep your back straight to maintain interaction and support. It allows the therapist greater
good body mechanics (Fig. 14-12, D). control of the patient’s trunk and buttocks during the
10. Pivot with the patient and move him or her onto transfer. This technique can also be employed during a
the sliding board (Fig. 14-12, E). Reposition your- two-person dependent transfer. It is often used with
self and the patient's feet and repeat the pivot until neurologically involved patients because trunk flexion
the patient is firmly seated on the bed surface, per- and equal weight bearing are often desirable with this
 FIG. 14-12, cont’d
One-person dependent sliding board transfer. E, Therapist pivots with patient and moves patient
onto sliding board. F, Patient is stabilized on bed. (Courtesy of Luis Gonzales, SCVMC.)

diagnosis. The steps in this two-person procedure are as 7. As the therapist in front shifts the patient's weight
follows: forward, the therapist in back shifts the patient's but-
t Set the wheelchair up as described previously. tocks in the direction of the transfer. This can be
2. One therapist assumes a position in front of the done in two or three steps, making sure the patient's
patient and the other in back. buttocks land on a safe, solid surface. The therapists
a. The therapist in front assists in walking the patient's reposition themselves and the patient to maintain
hips forward until the feet are flat on the floor. safe and proper body mechanics (Fig. 14-13, C).
. The same therapist stabilizes the patient's knees and 8. The therapists should be sure they coordinate the
feet by placing his or her knees and feet lateral to time of the transfer with the patient and one another
each of the patient's. by counting to three aloud and instructing the team
. The therapist in back positions himself or herself to initiate the transfer on three.
squarely behind the patient's buttocks, grasping
either the patient's waistband or placing his or her
Mechanical Lift Transfer
hands under the buttocks. Maintain proper body
mechanics (Fig. 14-13, A). Some patients, because of body size, degree ofdisability,
. The therapist in front moves the patient's trunk into or the health and well-being ofthe caregiver, require the
a midline position, grasps the patient around the use of a mechanical lift. A variety of mechanical lifting
waist or hips, and guides the patient to lean devices can be used to transfer patients of any weight
forward and shift his or her weight forward, over (Fig. 14-14, A and B). A properly trained caregiver, even
the feet and off the buttocks. The patient's head and one who is considerably smaller than the patient, can
trunk should lean in the direction opposite the learn to use the mechanical lift safely and independ-
transfer. The patient's hands can rest on the lap ently.° The patient's physical size, the environment in
(Fig. 14-13, B). which the lift will be used, and the uses to which the lift
 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

FIG. 14-13
Two-person dependent transfer, bed to wheelchair. A, One thera-
pist positions self in front of patient, blocking feet and knees. The
therapist in back positions self behind patient's buttocks and
assists by lifting. B, Person in front rocks patient forward and un-
weights buttocks as the back therapist shifts buttocks toward
wheelchair. C, Both therapists position patient in upright, midline
position in wheelchair. Seat belt is secured and positioning devices
are added. (Courtesy Luis Gonzales, SCVMC.)

will be put must be considered to order the appropriate the armrest or back of the chair because this action may
mechanical lift. The patient and caregiver should cause the chair to tip over. When moving from a chair to
demonstrate safe use of the lift to the therapist before the wheelchair, the patient should use a hand to push
the therapist prescribes it. off from the seat of the chair as he or she comes to
standing. Standing from a chair is often more difficult if
TRANSFERS TO HOUSEHOLD SURFACES the chair is low or the seat cushions are soft. Dense
cushions may be added to increase height and provide a
Sofa or Chair (Fig. 14-15)
firm surface to which to transfer.
Wheelchair-to-sofa and wheelchair-to-chair transfers are
similar to wheelchair-to-bed transfers; however, a few
Toilet
unique concerns should be assessed. The therapist and
patient need to be aware that the chair may be light and In general, wheelchair-to-toilet transfers are difficult
not as stable as a bed or wheelchair. When transferring because of the confined space in most bathrooms and
to the chair, the patient must be instructed to reach for the inability and lack of support of a toilet seat. The
the seat of the chair. The patient should not reach for therapist and patient should attempt to position the
 Mobility AS4

FIG. 14-14
A, Traditional boom-style mechanical lift. B, Patient lift useful in transferring individuals with spinal
cord injury. (A courtesy of Trans-Aid Lifts, Sunrise Medical; B courtesy of EZ-Pivot, Rand-Scott.)

wheelchair next to or at an appropriate angle to the motor control of the upper extremities (e.g., patients
toilet. The therapist should analyze the space around with paraplegia and lower extremity amputation). A
the toilet and wheelchair to ensure no obstacles are commercially produced bath bench or bath chair or a
present. Adaptive devices such as grab bars and raised well-secured straight-back chair is commonly used by
toilet seats can be added to increase the patient's inde- therapists for seated bathing. Therefore, whether a
pendence during this transfer. (Raised toilet seats are standing-pivot, bent-pivot, or sliding board transfer is
poorly secured to toilets and may be unsafe for some performed, the technique is similar to a wheelchair-to-
patients.) The patient can use these devices to support chair transfer. However, the transfer may be complicated
himself or herself during transfers and maintain a level by the confined space, the slick bathtub surfaces, and
surface to which to transfer. the bathtub wall between the wheelchair and the
bathtub seat.
If a standing-pivot transfer is employed, it is recom-
Bathtub
mended that the locked wheelchair be placed at a 45°
The occupational therapist should be cautious when as- angle to the bathtub if possible. The patient should
sessing or teaching bathtub transfers because the stand, pivot, sit on the bathtub chair, and then place the
bathtub is considered one of the most hazardous areas lower extremities into the bathtub.
of the home. Transfers from the wheelchair to the If a bent-pivot or sliding board transfer is used, the
bottom of the bathtub are extremely difficult and used wheelchair is placed next to the bathtub with the
with patients who have good bilateral strength and armrest removed. The transfer tub bench may be used,
 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

1. Car seats are often much lower than the standard

wheelchair seat height, which makes the uneven
transfer much more difficult, especially from the car
seat to the wheelchair.
2. Occasionally, patients have orthopedic injuries that
necessitate the use of a brace such as a halo body
jacket or lower extremity cast or splint. The therapist
often must alter technique to accommodate these
devices.
3. The therapist may suggest use of the sliding board for
this transfer, to compensate for the large gap between
transfer surfaces.
4. Because uphill transfers are difficult and the level of
assistance may increase for this transfer, the therapist
may choose a two-person assist instead of a one-
person assist transfer to ensure a safe and smooth
technique.

SUMMARY
A wheelchair that fits well and can be managed safely
and easily by its user and caregiver is one of the most
important factors in the patient's ability to perform ADL
with maximal independence.® Each wheelchair user
must learn the capabilities and limitations of the wheel-
chair and safe methods of performing all self-care and
mobility skills. If there is a caregiver, he or she needs to
be thoroughly familiar with safe and correct techniques
FIG. 14-15
of handling the wheelchair, positioning equipment,
Stroke patient in midtransfer reaches for seat of chair, pivots, and
and the patient.
lowers body to sitting. (Courtesy of Luis Gonzales, SCVMC.)
Transfer skills are among the most important activi-
ties that must be mastered by the wheelchair user. The
which removes the need for a sliding board. This ap- ability to transfer increases the possibility of mobility
proach allows the wheelchair to be placed right next to and travel. However, transfers can be hazardous. Safe
the bench, allowing a safe and easy transfer of the but- methods must be learned and followed.® Several basic
tocks to the seat. Then the lower extremities can be as- transfer techniques are outlined in this chapter. Addi-
sisted into the bathtub. tional methods and more detailed training and instruc-
In general, the patient may exit by first placing one tions are available, as cited previously.
foot securely outside the bathtub on a nonskid floor It should be recognized that many wheelchair users
surface and then performing a standing or seated trans- with exceptional abilities have developed unique
fer back to the wheelchair. methods of wheelchair management. Although such in-
novative approaches may work well for the person who
has devised and mastered them, they cannot be consid-
CAR TRANSFERS
ered basic procedures that everyone can learn.®
A car transfer is often the most challenging for therapists
because it involves trial-and-error methods to develop a
| ee ee eS
technique that is not only safe, but also easy for the
patient and caregiver to carry out. The therapist often uses SECTION 3
the patient's existing transfer technique. The patient's Transportation, Community Mobility,
size, degree of disability, and vehicle style (two-door and Driving Assessment
versus four-door) must be considered. These factors will
affect level of independence and may necessitate a change SUSAN M. LILLIE
in the usual technique to allow a safe, easy transfer.
In general, it is difficult to get a wheelchair close
IMPORTANCE OF TRANSPORTATION
enough to the car seat, especially with four-door vehi-
cles. The following are some additional considerations Mobility is a universal need at any age. Special trans-
when making wheelchair-to-car transfers: portation needs may have been present at birth or may
 Mobility JS)

have been caused later by illness or a motor vehicle acci- compliant, a transit agency must meet minimum service
dent or fall. When basic mobility needs such asvisits to area and service requirements. The ADA also specifies
the grocery store, pharmacy, and physician cannot easily only curb-to-curb service, although door-to-door service
be met, too often the result is social isolation, depres- may be provided. One associate or attendant is able to
sion, and diminishment or loss of life roles.””” accompany a person with a disability on the paratransit
For those with mobility restrictions, accessible trans- vehicle.
portation is essential to quality of life, enabling individ-
uals to engage in meaningful activities and roles, to
benefit from social and emotional interactions, and to Treatment Implications for Fixed Transit
increase independence. In essence, accessible transport Because the actual usable space on an ADA-compliant
allows people to maintain their self-respect. lift varies by manufacturer and lift model, the therapist
Different systems of transportation can be catego- cannot assume that a mobility aid device will automati-
rized as either public or private. Each system has bene- cally be compatible with an ADA-compliant platform
fits and limitations. The therapist is uniquely suited to lift.
assist persons with disabilities in meeting their needs Knowing platform lift and end flap dimensions is
through both the public transportation system and use critical when ordering a power wheelchair or scooter.
of a private vehicle. For example, when a power wheelchair’s footrests are
lower than the lift’s end flap or roll stop, the functional
length of the wheelchair can exceed 48 inches and will
PUBLIC TRANSPORTATION
not fit onto an ADA-compliant lift. Scooters, which gen-
Provided by public and private agencies, public trans- erally can fit on the lift platform, may be unable to ne-
portation “provides the general public with a general or gotiate the tight turn required either to enter the coach
special service on a regular and continuing basis.”’° or park in the designated area. When a specific power
Public transportation includes two key systems—fixed wheelchair or scooter is incompatible with the local
route and paratransit. transit system, paratransit and private transportation
Fixed route systems use defined routes and desig- systems are the only transportation options.
nated stops and run on a schedule. The paratransit Fixed-route training includes common elements such
system, sometimes known as the dial-a-ride system, pro- as navigating between the designated stop and destina-
vides demand-response service within a prescribed geo- tion, flagging the bus, boarding and exiting the bus,
graphical area; vehicle dispatch occurs only in response dealing with the fare box, and handling spontaneously
to a rider's request. occurring situations. Bus fleets often have a variety of
Inconvenience and fear for personal safety are fre- bus designs, including different lift locations, which ne-
quently cited as a barrier to the use of public transporta- cessitates learning different boarding techniques.
tion” and must be addressed to increase its viability
among the disabled populations.
Treatment Implications for Paratransit
Awareness of local paratransit service features enables
Transportation Improvements: Americans
the therapist to provide appropriate transportation in-
With Disabilities Act terventions. Curb-to-curb service places more physical,
The Americans With Disabilities Act (ADA) of 1990 visual, perceptual, and cognitive demands on a rider
bans discrimination in public transportation. The ADA than door-to-door service. The rider must navigate from
regulates buses, trains, ships, and other means of trans- the drop-off point to the final destination and may need
portation that use both fixed and demand-response more training for this. Contingency planning and orien-
systems. The ADA does not regulate air travel, public tation and training in the use of the reservation system
school transportation at the K-12 level, or privately may also be needed.
owned over-the-road buses, which have a raised passen- Another characteristic of the paratransit system is
ger compartment over a baggage storage area.” that rider trips are combined to fill vehicles. Travel
Newly purchased or leased buses must be modified takes much longer than with private transportation and
with a 30-inch-wide by 48-inch-long platform lift, se- can pose hardships to riders with certain medical
curements for mobility aid devices, priority seating, and symptoms, such as urinary urgency and frequency
a host of other features designed to facilitate navigation problems or pain with prolonged immobility. It is also
of the transportation system by disabled persons. important to know that drop-off points may not have
The ADA also regulates paratransit, which is desig- amenities such as restrooms, phone access, food, or
nated for disabled persons unable to access or navigate water; there are even occasions when miscommunica-
a fixed route system.” Paratransit is designed to provide tion or errors arise, delaying or inadvertently canceling
the disabled person with the same essential transit cov- a ride. As with fixed transit, the unaccompanied para-
erage that is available to the able-bodied rider. To be transit rider needs a certain degree of resourcefulness
PAUY) OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

Specialized Training Needs

and problem-solving skill to navigate the system safely
for the Therapist
and efficiently.
Driving is a complex task, requiring continuous in-
PRIVATE TRANSPORTATION tegration of visual, motor, cognitive, and perceptual
Passengers and Drivers
skills at a high level of functioning.*° A driver must
continually search, identify, predict, decide, and exe-
Private transportation relies on consumer vehicles that cute driving decisions in response to the surrounding
are privately owned by passengers and/or drivers. The environment.'*
advantages of private transportation include 24-hour Driving presents a greater possibility of personal and
availability of a personally owned vehicle, immediate public harm than does any other ADL. It is essential that
origin-to-destination travel, the flexibility to add or therapists receive specialized training, because none is
delete destinations on a given trip, and a strong sense of provided within basic OT education. Therapists must be
control over one’s life. The primary disadvantages are mindful of the industry standard for other professionals
that the individual is responsible for his or her own who provide driver training—a standard that usually in-
access needs and that a high level of responsibility is re- volves state licensing as a driver instructor. Therapists
quired for ongoing maintenance and repair for both the need to seek basic and equivalent driver education and
vehicle and its modifications. Individuals preferring the training through recognized entities, such as universities
convenience of private transportation must also plan for or state-approved courses, in order to provide quality
replacement costs of the vehicle, including any equip- services, teach proper driver education techniques, and
ment or vehicle upgrades needed to keep pace with minimize on-road risk and liability exposure. One
future changes in function. measure of entry-level knowledge is the Association for
Driver Rehabilitation Specialists’ (ADED) driver certifi-
cation process (Box 14-3). The Certified Driver Rehabil-
Passenger Evaluations
itation Specialist (CDRS) requires passage of an exami-
Passenger evaluations should not be overlooked as a nation that covers driver education, disabilities, and
treatment intervention. A trained therapist can signifi- adaptive driving education.
cantly improve the safety of the caregiver and the person
being transported. Supplemental trunk and head support
are needed when an individual has inadequate motor
control or strength to overcome gravitational or centrifu-
gal forces in a moving vehicle. Occupant restraint systems
provide safety by securing the wheelchair and passenger
to the vehicle to prevent unwanted movement or injury.
When a patient is using respiratory equipment such
as a ventilator or portable suction device, a backup Websites for pertinent associations
power supply should be recommended as an essential
life-saving modification. An inverter is a device that con- AAA Foundation for Traffic Safety
verts DC, 12-volt car battery power to AC, 110-volt Publishers of consumer pamphlets and products
http://www.aaafts.org
household power, providing an alternate, plug-in source
of power for respiratory equipment should the batteries
ADED, the Association for Driver Rehabilitation
fail. Young children may also need specialized products Specialists
or modifications to accommodate a permanent or tem- CDRS information, disability fact sheets, bulletin board for
porary disability. driver evaluators
http://www.driver-ed.org
DRIVER EVALUATION PROGRAM
American Association of Retired Persons
Driving: Relevance to Society Information and publication on older driver issues
Driving is an essential ADL in most locations in the http://www.aarp.org
United States, playing a pivotal role in personal inde-
National Mobility Equipment Dealers Association
pendence, employment,’’ and aging in place. A driver's
Product manufacturers and equipment installers
license symbolizes a rite of passage to adulthood for the
http://www.nmeda.org
teenager, independence to pursue leisure activities and
employment opportunities for the adult, and wellness National Highway Traffic Safety Administration
and competence for the mature driver. The ability to Airbag on-off switch and consumer information
drive is regarded as instrumental in obtaining and main- http://www.nhtsa.dot.gov
taining an independent lifestyle” and in aging in place.”
 Mobility
Occupational Therapists and Driving though driver evaluations are not routinely covered, ap-
Occupational therapists make up the overwhelming provals for service are becoming more common.
majority of professionals conducting driver evaluations
for the disabled population.'* The State of California
Department of Rehabilitation recommends that occu-
Purpose of a Driving Evaluation
pational therapists conducting driving evaluations have Driving competence can be disrupted by a single dis-
a minimum of 2 years of experience in physical disabil- ability, multiple medical conditions, or factors of aging.
ities and knowledge of adaptive equipment, driving Even experienced drivers are susceptible to these condi-
systems, and equipment vendors.7° Knowledge and tions. Driver evaluations provide a safe arena in which
training in implications of medical conditions and to observe driving performance under real conditions
disease processes, ADL, adaptive devices, and occupa- and determine what restorative, compensatory, or pre-
tional theory make OT practitioners uniquely qualified ventive interventions may be needed for safe driving.
to provide quality driver rehabilitation services. The ex-
perienced OT assistant (OTA) may also acquire the
Recommended Practices
specialized training needed to properly conduct driver
evaluations. Vehicle entry and exit training, phone Comprehensive services in a driver evaluation program
screenings, on-road evaluation, and driver training are should include clinical, stationary, and on-road per-
other roles appropriate for the OTA. Achieving CDRS formance testing in a special evaluation vehicle (Fig.
14-16 yorese
status or status as a state-licensed driver instructor pro-
vides even further opportunities. Recommended practices from ADED include a clini-
Even at the national level of government, therapists cal evaluation followed by (1) an on-the-road evalua-
are recognized as having unique skills for driver rehabil- tion in an actual driving environment, (2) subsequent
itation. The National Highway Traffic Safety Adminis- vehicle modification recommendations and wheelchair
tration (NHTSA) is looking to therapists to provide measurements, (3) recommended driver training and
future services for older adult drivers. Working in part- education, and (4) a final fitting.* The State of Califor-
nership with both the ADED and the American Occupa- nia’s Department of Rehabilitation guidelines also man-
tional Therapy Association (AOTA), NHTSA hopes to date that the recommendations for adaptive equipment
increase the availability of driver evaluation training be made only when a driver can demonstrate the ability
materials, workshops, and programs. With nearly 27 to use the equipment or a similar device in a behind-
million baby boomers turning 65 in the year 2010, the the-wheel assessment.’ An on-road evaluation is criti-
need to train additional therapists is significant.” cal; the context of an actual driving environment is the
key to preventing costly and potentially life-threatening
mistakes.
Driving Program Structure
Driving programs are provided in private industry as well
as in hospital-based settings. In some states the Depart-
ment of Vocational Rehabilitation sets up its own driving
program, hiring therapists to conduct evaluations and
training. Some programs do not have trained staff to
conduct on-road evaluations but rather provide these
services by contracting with licensed driver instructors
from outside the program. Other programs provide clin-
ical evaluations or screening services, which can identify
driving-related impairments that may not have been
evident in other ADL or productive work activities.
Pre-program screenings can benefit drivers by provid-
ing the information needed for making informed
choices. As one client stated after hearing that the pro-
jected cost for the evaluation, training, and equipment in
a high-tech van would exceed $100,000, “That would buy
mea lot of rides.” This client chose not to pursue driving. FIG. 14-16
Program structure depends greatly on referral sources, Evaluation van equipped with Electronic Mobility Controls (EMC),
payment sources, and available equipment and vehicles. including a left-side electronic gas-brake with wrist support, left
Worker's compensation, vocational rehabilitation pro- elbow secondary control button, 7-inch remote steering wheel
grams, school systems, private insurance, Medicaid, and with a tripin device, and membrane switch consoles for functions
Medicare are primary potential sources for funding. Al- such as electric gear shift, ramp, and windows.
202 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

Referral Process rig ;

Each program needs to set criteria for accepting a re-
Healthcare professionals, including physicians, thera- ferral for driver evaluation. The following are items gen-
pists, and case managers, help determine which individ- erally included as part of the criteria:
uals could benefit from a driver evaluation. The referral 1. Receipt of a physician’s referral or prescription for
process is complex and cannot always be completed in a evaluation
seamless fashion (Fig. 14-17). 2. Receipt of a patient's medical records

Initial Screening

Vision/Hearing Screening C.A.D.A.S

Cognitive Screening
Reaction \ Time Measurement Motion Analyzer
Ability to Transfer Functional Strength
Driver Performance Test Tracking Simulator
Active Range of Motion
Manual Muscle Test

Borderline candidate:
Requires further therapy Good candidate Deficit noted in
to improve skill some area

Referred for further

Thera Small-scale vehicle
diagnosis and
PY evaluation
possible treatment

Full-scale vehicle Diagnosis and

Re-assessment
evaluation treatment

Adaptive device Re-assessment

prescription

Driver education

¢ Classroom
* Driving range
¢ Behind the wheel

Follow-up

FIG. 14-17
A flow chart detailing the complexity of the driver evaluation referral process. (From Hale PN, Shipp
M: Driver assessment, education and training for the disabled. In Proceedings of the |Oth annual
RESNA conference, Washington, DC, 1987, RESNA Press.)
 Mobility 203

3. Proof that the patient has a valid driver's license or 3. Accessible horn, dimmer, and wiper controls
driving permit 4. A parking brake extension
4. Confirmation of a source of payment An extensively modified van may be needed when trans-
A referral to a qualified driver evaluation is recom- fers are overly exerting or when assistance is required for
mended when (1) there are concerns about the driver's a transfer.*° If a person needs to drive from the wheel-
safety, judgment, or competence; (2) physical limita- chair, additional wheelchair modifications may be
tions impair the driver's ability to use a normal driving needed for trunk stability. Structural modifications to
pattern or equipment; or (3) the driver has a neurologi- the van (e.g., a raised door, raised roof, or lowered floor)
cal, neuromuscular, or visual impairment. may be necessary to accommodate the wheelchair and
driver.'° Thanks to current technologies, some clients
DRIVING EVALUATIONS AND with C4-5 quadriplegia are able to drive with extensive
DISABILITIES evaluation and training.

Spinal Cord Injuries

A driving evaluation for the client with a spinal cord Neurological Conditions
injury focuses on the following items: Acquired or traumatic brain injuries, cerebral palsy, and
1. The client's method of mobility other neurological conditions cause disturbances in vol-
2. The client's transfer ability, wheelchair management, untary movement, muscle tone, cognition, perception,
and trunk stability and even vision, potentially affecting driving safety.® The
3. The presence of spasticity in the client ability to physically operate the vehicle, make traffic deci-
4. The client's available strength and ROM sions, and respond to the surrounding driving environ-
5. The client's positioning at the driver's station ment may be mildly or severely impaired. Equipment
Most paraplegics and some C7-8 quadriplegics can drive and training are based on the areas affected. Unresolved
a car that has the following modifications (Fig. 14-18): or poor insight greatly reduces chances of safe driving,
1. Hand controls for the accelerator and brake since impairments cannot be successfully treated or com-
2. Aspecially designed steering device pensated for unless they are first recognized. Chapter 27
provides additional information on cognition.

ailisacqa a? ae Neuromuscular Conditions

4
The neuromuscular diseases (polio, muscular dystro-
phy, and multiple sclerosis) impair motor control, en-
durance, and joint stability. Multiple sclerosis and some
forms of muscular dystrophy can affect cognition, per-
ception, and vision. Each diagnosis has a strikingly dif-
ferent pattern of symptoms and progression, and only
certain parts of the body may be affected. To the extent
possible, the recommended equipment must meet both
current and anticipated future needs. Drivers may am-
bulate with or without devices, push a wheelchair, or
use a scooter or even a power wheelchair. Driving equip-
ment is just as varied.

Older Drivers—A Growing Population

The driving ability of older adults changes as they age, but
most remain safe drivers. Most older drivers adapt by
gradually limiting their driving, such as by omitting travel
during rush hour and the evening.'® Others experience an
abrupt change in driver status because of amedical event
FIG. 14-18 ‘
such as a stroke. Lacking specific training, the physician
Basic setup for paraplegic includes spinner knob steering device may be reluctant to address driver SCIUDEIEHCE in the
for right-hand steering, push right-angle pull hand control to older adult, fearing that such discussions might Pe
operate accelerator and brake, extended brake handle to set manently destroy even long-standing physician-patient
shod 2
parking brake, and horn switch relocated to hand control. relationships.
204 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

Visual Functioning
To date, research has not identified the skills or quali-
ties that make an older driver competent, rendering large- A comprehensive vision screening is important
scale epidemiological screening difficult.2’'71*'”7* because vision is the primary sense used to gather in-
Older adults with multiple medical conditions are prob- formation needed for driving-related decision making.
ably most at risk and in need of driver evaluation and Vision testing is completed before other testing to
intervention. eliminate impaired acuity as a factor. A comprehensive
When assessing the older adult with limited driving vision screening includes near and far acuities, phoria
competence, the therapist should consider graded li- or alignment, saccades, oculomotor pursuits, range
censing, which permits driving under certain limita- of motion, convergence, and field of vision.° "77
tions (e.g., dawn to dusk or no freeway). A recommen- Glare recovery is relevant to assess for the older adult
dation for a graded license extends the older adult's evaluation.
ability to function independently.’
Physical Measurements
Theoretical Constructs
Muscle strength, active ROM, grip, and reaction time
Occupational role and activity analysis frameworks are frequently cited as the basic abilities that must be
provide a strong foundation for a thorough driver eval- measured.*°?”*? Head and trunk control, sitting and
uation. The therapist assesses performance components standing balance (dynamic and static), and coordina-
individually. During the on-road test, the therapist then tion are also important. When neurological distur-
evaluates the client’s ability to perform component bances are present, quality of selective movement,
skills in an integrated fashion, within the performance muscle tone, and muscle fatigue should be included as
context of actual driving conditions. well.
Occupational role theory is also helpful in driver as- Force readings with a torque wrench or Chatillon
sessment. Occupational roles may carry specific needs scale provide data that help determine the level of re-
related to transportation equipment and parking envi- sistance required for steering or braking, which helps in
ronments. A construction site inspector may enter or more complex modifications for driving.
exit a vehicle over 10 times daily and thus may need to
consider a transfer seat or using a wheelchair in a van. A COGNITIVE AND VISUAL-PERCEPTUAL
certified public accountant audits businesses that may
SKILLS
have parking structures or covered parking, thus necessi-
tating that the accountant’s minivan not exceed certain The driver must have adequate, reliable perception of a
height restrictions. In each example the selection of the rapidly changing environment, blending both cognitive
vehicle and its modifications are based largely on occu- and visual-perceptual skills. Cognitive areas requiring
pational roles. assessment include selective and sustained attention,
initiation, decision making, safety judgment, problem
DRIVING EVALUATION COMPONENTS solving and planning, insight, and the ability to shift
focus at will.
Clinical Assessment
The ability to multitask or divide attention is also a
The clinical assessment is also referred to as a screening critical driving skill.7* Multitasking is the simultane-
or predriving evaluation. The clinical assessment can be ous performance and monitoring of two or more
performed solely by the occupational therapist?”~° or equally important activities, such as maintaining lane
by many members of the rehabilitation team together.’ positioning while turning one’s head for a visual
Used to identify strengths and impairments related to traffic check.
driving, the clinical assessment begins with a review Visual-perceptual components include visual organi-
of medical information, medication and side effects, zation, visual searching and scanning, spatial relations,
episodes of seizure or loss of consciousness, mobility directionality, and visual processing speed.'**®*° Visual
status, social history, vocational history, driving history, memory is also important in driving.
and purpose of the evaluation. The interview process Recommendations for driver's license status should ~
often results in unexpected, pertinent findings related to not be made on the basis of test scores alone. There
the driver evaluation. is still no clear evidence that any one test iden-
It should be clear whether a patient's condition is tifies at-risk drivers or predicts driving compe-
stable or improving. A history should be taken to de- tence.'”?° Properly used and selected, however, cogni-
termine and document the rate of progression; with- tive and visual-perceptual testing helps the driver
out this information, it is difficult to establish ade- evaluator identify impairments, improve behind-the-
quate safety margins to accommodate future changes wheel risk management, and plan treatment for
in condition. driver rehabilitation.
 Mobility 205
Vehicle Options
14-20). Each lift has unique characteristics that must
Car Considerations be considered.*"
A basic level of service for the majority of driving pro- Minivans have fully automatic mechanical side
grams is the car evaluation. A car is generally appropriate ramps for independent exit and entry (Fig. 14-21). Mini-
ifa person can enter and exit the vehicle and load mobility vans have limited interior space but much appeal
equipment devices independently. The standard car rec- because they drive like a car, are easier to park, and get
ommendation is a four-door, midsize vehicle with power better gas mileage.
steering, power brakes, and an automatic transmission.
If loading a manual wheelchair into a car is not feasi-
STATIONARY ASSESSMENT
ble, independence can sometimes be obtained by using
a mechanical device such as a car top loader. Limited The stationary component of the assessment involves
ambulators may be able to continue using their stan- an evaluation of the pre-driving activities and the equip-
dard minivan, sport utility vehicle, or truck with the as- ment setup in the static position. Stationary perform-
sistance of a power hoist (Fig. 14-19). ance alone is inadequate to predict either on-road per-
formance or final equipment needs. The stationary
evaluation, results in determination of a proposed
Van Considerations
driving setup adjusted for a driver. If subsequent on-
Drivers must choose between full-size vans and mini- road results are not satisfactory, the stationary process is
vans. Providing information on the differences between repeated with the next level of equipment. This trial-
minivans and full-size vans, including accessibility, and-error approach is an expected and necessary step in
ground clearance, load capacity, durability, and cost, assistive technology evaluation.®
enables clients to make educated choices that suit their
needs, budget, and lifestyle. In any van, wheelchair
drivers’ needs are more complex and they require more
Predriving Tasks
highly skilled evaluation than other drivers because of Predriving tasks include achieving mobility to the
increased variables that affect driving performance and vehicle, inserting and turning a key (or keyless entry op-
equipment selection. eration), opening and closing the door, entering and
Full-size vans require an automatic mechanical lift exiting the vehicle, loading and unloading mobility
for the wheelchair or scooter. Mechanical lifts can be devices (e.g., cane, walker, and wheelchair), adjusting
mounted on the rear or side of a full-size van or the the driver seat, adjusting the mirrors, and fastening the
side of a minivan. Lifts fall into two basic styles, plat- seatbelt (and chest strap when needed). Adaptive
' form-style lifts and rotary or swing in-style lifts (Fig. devices to facilitate independence in predriving tasks
include special key holders, loops for lower extremity
management, a strap to extend reach for wheelchair
loading, and modifications for independent retrieval of
the seatbelt.

FIG. 14-19 FIG. 14-20

The Curbsider, by Bruno, hoists a scooter or fully assembled Platform-style lift can be located at side or rear of van. Additional
power wheelchair, up to 250 pounds, from the sidewalk and lifts it entry headroom, obtained through lowered floor, provides client
into the back of a standard minivan. adequate field of view when driving from power wheelchair.
 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

FIG. 14-21
Minivan conversion with side ramp access and lowered |0-inch floor. The vehicle can be lowered to
decrease the ramp angle for easier entry and exit.

Primary Control Setup

More involved steering modifications include ex-
The first step in the primary control assessment phase is tended steering columns, steering wheels with smaller
to position the driver to obtain optimal upper extremity diameters, and reduced levels of steering resistance.
function, proper field of view, and trunk stability. Poor High-tech options include a 7-inch remote steering
trunk stability may necessitate special positioning de- wheel that can be placed anywhere, shown in Fig. 14-16.
vices. The upper torso support or chest strap is a com- The final level of current driving technology includes the
monly used positioning device.** Equipment setups unilever and joystick systems, which combine steering,
then begin with the primary controls—those devices acceleration, and brake operations on a single lever. Van
that control the steering, accelerator, and braking of a modifications, especially at this final level, necessitate ex-
vehicle. tensive additional training for the driver. Only after the
stationary steering setup is determined does the process
Steering Control move to the accelerator and brake controls.
When a driver cannot use two hands to steer, a steering
device is recommended. One-handed steering by Accelerator and Brake Controls
palming the wheel provides inadequate control, espe- Modified accelerator and brake controls can be installed
cially in sharp, fast turns and evasive maneuvers. The in most vehicles. Simple modifications such as pedal ex-
use of adaptive steering devices—the spinner knob, V- tensions can be installed on both the accelerator and
grip, tripin, palmar cuff, or amputee ring—improves brake pedals to compensate for limited reach. More
control of the steering wheel (Fig. 14-22).° drivers need extended pedals with airbags because
A new, critical step in steering assessment developed maintaining proper distance from the airbag prevents
as a result of airbags. The distance between a driver's fully reaching the accelerator and brake pedals.
sternum to the center of the steering wheel must be a With a significant right hemiplegia, the right foot is
minimum of 10 inches, as recommended by the unable to operate the standard pedals. A left-sided ac-
NHTSA, to prevent serious injury or death from airbag celerator pedal can be placed to the left of the standard
inflation.'’ gas pedal to compensate for this condition.
 Mobility 207

FIG. 14-22
These steering devices accommodate a variety of hand and upper extremity impairments. (Courtesy
of Mobility Products and Design.)

When the driver lacks adequate motor control in the ment is commonly referred to as the behind-the-wheel
lower extremities or when the driver's lower extremities or on-road portion ofthe evaluation. The current indus-
are paralyzed, a device called a “hand control” allows try standard is to accept the on-road driving test as the
the driver to operate the accelerator and brake pedals optimal measure of driving competence.®!*'*'”° The
with an upper extremity. Hand controls use rotary, on-road evaluation should be a minimum of 45
push-pull, push-pull down, or push-rocker motions to minutes long and no longer than 2 hours of actual
activate the accelerator and the brake. High-tech acceler- driving time. A shorter period is inadequate for obtain-
ator and brake controls have servo motors activated by ing required information.
vacuum, hydraulic, or electronic means and require The driving instructor orients a driver in the use of
minimal strength and ROM. Trunk stability is even adaptive driving equipment, maintains vehicle control
more critical if such controls are used (Fig. 14-23). by intervening for safety when necessary, and directs the
route. A score sheet is recommended. Driving perform-
Secondary Controls ance scores should reflect physical management of the
All other controls are secondary controls. There are vehicle, ability to use the adaptive equipment,’ interac-
four secondary controls that a driver must be able to ac- tion with other traffic, adherence to rules of the road,
tivate at will when the vehicle is in motion—turn signal and safety judgment. '7*”7*
indicators, horn, dimmer, and windshield wipers.**
These can be activated through a variety of switches that Driving Route
either can be placed on the hand control or can be con- Driving routes used in assessment should incorporate
trolled through elbow motion. a sampling of road conditions, traffic patterns, and un-
usual settings common to the local region. The driving
route initially should allow the driver time to become fa-
On-Road Assessment miliar with the evaluation vehicle and adaptive equip-
Once the driver has been set up with primary controls in ment in a low-stimulation environment. This period of
the evaluation vehicle, the ability to use these controls learning and accommodation will be longer for the
must be assessed through actual driving. This assess- novice or apprehensive driver. The assessment route
 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

report should include recommendations on the type of

follow-up services required, what to look for, and who
is best suited to provide the follow-up services. The
report should also estimate the amount (duration, fre-
quency and total length) of driver training needed, what
specific areas of training should be emphasized, and
where the training is available.”°

Driver Training
Driver training is a key part of the comprehensive
driver evaluation process and assistive technology deliv-
ery system.® Those with cognitive and perceptual im-
pairments will often need to relearn driving behaviors
or implement compensatory skills to obtain consistent
driving performance, even though adaptive equipment
may not be needed.® The use of high-tech equipment
also necessitates extensive training, with a greater focus
on the vehicle control and recovery, especially in unex-
pected situations and at high speeds.

Follow-Up Services
Follow-up services include midfit and final fitting ses-
sions in the newly modified vehicle. A quality assurance
and safety measure, follow-up service ensures that the
FIG. 14-23 equipment is located and adjusted to meet the client's
Because of the progression of multiple sclerosis, client changed functional needs. Follow-up service is important because
from driving a car with her feet to driving from her wheelchair delivery of the system to a driver marks the first time the
using EMC’s electronic gas-brake in a minivan. The device, in com- system has been operated and adjustment is almost
bination with low-effort steering, successfully reduced fatigue and always needed.® An on-road session is recommended to
pain while driving. make sure adjustments are adequate for function when
dynamic forces within the driving environment come
into play (Fig. 14-24).
should progress through faster and more congested
traffic and various traffic conditions to elicit informa-
Unsafe Driver
tion on the driver's skills in a wide variety of condi-
tions. “Bailout” points are needed along the route for One of the most difficult tasks facing a driver evaluator
safety. is notifying a driver candidate that he or she is not able
to drive safely. Such decisions need to be carefully re-
viewed and then communicated to the driver with com-
Driver Recommendations
passion and understanding. Referring the driver to the
and Interventions
motor vehicle department for a photo ID card in ex-
After the driving test is completed, the driving team change for the driver's license and immediately provid-
reviews the results with the driver. Asking the driver for ing materials on alternative transportation can prove
feedback before reviewing results provides a valuable helpful at a difficult time.
perspective on the driver's insight. Involvement with
professional organizations helps the therapist obtain LEGAL ISSUES AND PUBLIC POLICY
knowledge to develop criteria for various recommenda-
tions. (See Box 14-3 for more information.)
State Laws Pertaining to Therapists
The comprehensive driving report should contain a Therapists and physicians need to be aware of their
summary of the clinical assessment and a statement of state’s laws concerning medical conditions and driving.
the client's potential to be a safe and independent Most states do not require the reporting of medical con-
driver. The report should specify the type of vehicle nec- ditions, seizures, or loss of consciousness to the motor
essary, the modifications needed, information about vehicle department.'”** Instead, most states rely on vol-
mobility equipment, dealer sources for providing the untary reporting of medical conditions by the driver
modifications, and other pertinent information. The who has the condition. Although some states advocate
 RSET 9 aes ay Tisaa

Mobility | pl its

FIG. 14-24
Client, who must negotiate a steep hill near his home, completes a follow-up evaluation in his new
Driving Systems, Inc. (dSi), unilever. A drive test in the foothills resulted in additional adjustments to
the system before vehicle delivery.

reporting by the family, physician, or law enforcement . What is the role of the OT practitioner in functional
officials, not all states provide immunity for such re- ambulation?
porting. Once identified to the motor vehicle depart- How do the OT and PT practitioners collaborate in
ment, the patient undergoes a license review that varies functional ambulation?
from state to state. List and describe safety issues for functional ambu-
lation.
AN s & Name five basic ambulation aids in order of most
EY 7
supportive to least supportive.
Community mobility, whether achieved by using public Discuss why great care should be taken during func-
transportation or by driving one’s own vehicle, is an im- tional ambulation within the bathroom.
portant ADL. Individual evaluation, with consideration . List at least three diagnoses for which functional
of valued occupational roles and local transportation ambulation may be appropriate as part of OT serv-
options, provides a foundation for intervention. Many ices.
possibilities exist, given the range of ADA-mandated . What purpose does a task analysis serve in prepara-
services, as well as available assistive technology, for as- tion for functional ambulation?
sisting mobility-restricted individuals to move freely 10. What suggestions could be made regarding carrying
within their communities. items during functional ambulation when an am-
bulation aid is used?

SECTION 1
. What is the objective in measuring seat width?
1. Define functional ambulation. List three activities . What is the danger of having a wheelchair seat that
of daily living or instrumental activities of daily is too deep?
living in which functional ambulation may occur. . What is the minimal distance for safety from the
2. Who provides gait training? floor to the bottom of the wheelchair step plate?
pALY OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

4. List three types of wheelchair frames and the ll. Why is driver training recommended?
general uses of each. 12. What legal issues must be considered by the occu-
£4 Describe three types of wheelchair propulsion pational therapist performing a driving assessment?
systems and tell when each would be used. 13. How can the OTA be utilized in a driver evaluation
. What are the advantages of detachable desk arms program?
and swing-away footrests? 14. What additional credentials can therapists obtain in
. Discuss the factors for consideration before wheel- the field of driver rehabilitation?
chair selection.
. Name and discuss the rationale for at least three
general wheelchair safety principles. REFERENCES
SO eee
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wheelchair with the help of an assistant. SECTION 1
10. Describe or demonstrate how to descend a ramp in a Anderson KN, editor: Mosby's medical, nursing and allied health dic-
a wheelchair with the help of an assistant. tionary, ed 5, St Louis, 1998, Mosby.
LY List four safety principles for correct moving and 2h Esquenazi A, Hirai B: Gait analysis in stroke and head injury. In
Craik RL, Oatis CA, editors: Gait analysis: theory and application, St
lifting technique during wheelchair transfers.
Louis, 1995, Mosby.
Les Describe or demonstrate the basic standing-pivot . Higgins JR, Higgins S: The acquisition of locomotor skill. In Craik
transfer from a bed to a wheelchair. RL, Oatis CA, editors: Gait analysis: theory and application, St Louis,
Ly Describe or demonstrate the wheelchair-to-bed 1995, Mosby.
transfer, using a sliding board. . Leonard CT: The neurophysiology of human locomotion. In Craik
RL, Oatis CA, editors: Gait analysis theory and application, St Louis,
14. Describe the correct placement of a sliding board
1995, Mosby.
before a transfer. . Moyers PA: Scope of occupational therapy, Am J Occup Ther
1: In what circumstances would you use a sliding 53(3):258-262, 1999.
board transfer technique? . Pierson FM: Principles and techniques of patient care, Philadelphia,
16. List the requirements for patient and therapist 1994, WB Saunders.
. Watson DE: Task analysis: an occupational performance approach,
to perform the dependent transfer safely and
Bethesda, Md, 1997, American Occupational Therapy Association.
correctly.
1%. List two potential problems and solutions that can
occur with the wheelchair-to-car transfer. ee Eee
18. When is the mechanical lift transfer most appro- SECTION 2
priate?
1 . Adler C: Wheelchairs and seat cushions: a comprehensive guide for eval-
uation and ordering, San Jose, Calif, 1987, Santa Clara Valley
a es ee eee ee ee eee oe Medical Center, Occupational Therapy Department.
SECTION 3 . Adler C, Musik D, Tipton-Burton M: Body mechanics and transfers:
multidisciplinary cross training manual, San Jose, Calif, 1994, Santa
Le What are the differences between public and private Clara Valley Medical Center.
. Bromley I: Tetraplegia and paraplegia: a guide for physiotherapists, ed 3,
transportation?
London, 1985, Churchill Livingstone.
What are the treatment implications for transporta- . Pezenik D, Itoh M, Lee M: Wheelchair prescription. In Ruskin AP:
tion training on fixed routes? For paratransit? Current therapy in physiatry, Philadelphia, 1984, WB Saunders.
Qo . Who should be referred for a driver evaluation? . Santa Clara Valley Medical Center, Physical Therapy Department:
What are the elements of vision screening for Lifting and moving techniques, San Jose, Calif, 1985, Santa Clara
Valley Medical Center.
driving?
. Wheelchair prescription: measuring the patient (Booklet no. 1), Ca-
. Which physical capacities are evaluated in the pre- marillo, Calif, 1979, Everest & Jennings.
driving assessment? . Wheelchair prescription: wheelchair selection, (Booklet no. 2), Camar-
. What cognitive skill is most predictive of poor illo, Calif, 1979, Everest & Jennings.
driver safety and outcome? . Wheelchair prescription: safety and handling (Booklet no. 3), Camar-
illo, Calif, 1983, Everest & Jennings.
. Why is palming the wheel not advisable for steer-
. Wilson AB, McFarland SR: Wheelchairs: a prescription guide, Char-
ing? How does a steering device assist the disabled lottesville, Va, 1992, Rehabilitation Press.
driver?
Ifacar is selected as the vehicle of choice, what type
is usually recommended? SUGGESTED READINGS
. How long should the behind-the-wheel evaluation Adler C: Equipment considerations. In Whiteneck et al: Treatment of
session be? high quadriplegia, New York, 1988, Demos Publications.
Bergen A, Presperin J, Tallman T: Positioning for function, Valhalla, NY,
10. How would the experience level of a driver or diag- 1990, Valhalla Rehabilitation Publications.
nosis of a driver's condition affect the session length Davies PM: Steps to follow: a guide to the treatment of adult hemiplegia,
or total number of sessions needed? New York, 1985, Springer-Verlag.
 Mobility 211

Ford JR, Duckworth B: Physical management for the quadriplegic patient, iy, Latson LF: Overview of disabled drivers’ evaluation process, Physi-
Philadelphia, 1974, FA Davis. cal Disabilities Special Interest Section Newsletter 10(4), 1987.
Gee ZL, Passarella PM: Nursing care of the stroke patient: a therapeutic ap- 16. Linden M, Sprigle S: Development of instrumentation and proto-
proach, Pittsburgh, Pa, 1985, A.R.E.N. Publications. col to measure the dynamic environment of a modified van, J
Hill JP, editor: Spinal cord injury: a guide to functional outcomes in occu- Rehabil Res Dev 33(1):23-29, 1999.
pational therapy, Rockville, Md, 1986, Aspen. U7 National Highway Traffic Safety Administration: Air bags and
Outcomes following traumatic spinal cord injury: clinical practice guidelines on-off switches: information for an informed decision, Pub No DOT
for health-care professionals, consortium for spinal cord medicine, 1999, HS 808 629, Washington, DC, 1999, US Department of Trans-
Paralyzed Veterans of America. portation.
18. Odenheimer GL: Cognitive dysfunction and driving abilities, Presen-
tation to the annual meeting of the American Geriatrics Society,
i Atlanta, May 18, 1990.
SECTION 3 193 Odenheimer GL et al: Performance-based driving evaluation of
the elderly driver: safety, reliability, and validity, Gerontol Med Sci
1. American Association of Retired Persons: Graduated driver licensing 49(4):M153-M159, 1994.
creating mobility choices, Pub No D15109, Washington, DC, 1993, 20. Owen MM, Stressel DL: Motor-free visual perception test as a
The Association. screening tool for driver evaluation and rehabilitation readi-
2. Association of Driver Rehabilitation Specialists: Recommended ness, Physical Disabilities Special Interest Section Quarterly 22:3-4,
practices for driver rehabilitation services. In Members resource 1999"
guide, Edgerton, Wisc, 1996, The Association. PA Perr A, Barnicle K: Van lifts: the ups and downs and ins and outs,
3. Babirad J: Considerations in seating and positioning severely dis- Team Rehabil Rep 49-53, 1993.
abled drivers, Assist Technol 1:31-37, 1989. 22. Persson D: The elderly driver: deciding when to stop, Gerontologist
4. Blanc C, Hunt JT: Getting in gear, Team Rehab Report 33-39, 33(1): 88-91, 1993.
August, 1994. 235 Reuben DB, St George P: Driving dementia: California’s approach
5. Beverly Foundation: Community effectiveness in safeguarding at-risk to a medical and policy dilemma, West J Med 164:111-121, 1996.
senior drivers, Interim Report, Pasadena, Calif, February, 1998, The 24. Roush L, Koppa R: A survey of activation importance of individual sec-
Foundation. ondary controls in modified vehicles, 1992, Human Factors Program,
6. Bouska MJ, Gallaway M: Primary visual deficits in adults with Safety Division, Texas Transportation Institute, Texas A & M
brain damage: management in occupational therapy, Occup Ther University.
Pract 3(1):1-11, 1991. 25% Sabo S, Shipp M: Disabilities and their implications for driving,
7. Breske S: The drive for independence, Adv/Rehabil 3(8):10-19, Ruston, 1989, Louisiana Tech University Center for Rehabilitation
1994. Sciences and Biomedical Engineering.
8. Cook AM, Hussey SM: Assistive technologies: principles and practice, 26. State of California Department of Rehabilitation, Mobility Evalu-
St Louis, 1995, Mosby. ation Program: Statement of assurances for providers of driver evalua-
9. Eberhard J: A national perspective on older adult transportation: safe tion services, Downey, 1990.
mobility for life. Presented at Older Adults and Transportation: The Dil. Strano CM: Driver evaluation and training of the physically dis-
New Millennium Regional Forum, Los Angeles, July 22, 1999. abled driver: additional comments, Physical Disabilities Special In-
10. Golden M et al: Explanation of the contents of the Americans With terest Section Quarterly 10(4), 1987.
Disabilities Act of 1990, Washington, DC, 1990, Disability Rights 28. Summary of proceedings of the Conference on Driver Compe-
Education and Defense Fund. tency Assessment, CAL-DMV-RSS-91-132, Sacramento, 1993, State
11. Hopewell CA: Head injury rehabilitation: adaptive driving after of California Department of Motor Vehicles, Program and Policy
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matic brain injury, No 5, Houston, 1988, HDI. Piss Taira ED, editor: Assessing the driving ability of the elderly, Bingham-
12. Janke MK: Age-related disabilities that may impair drivers and their as- ton, NY, 1989, Hayworth Press.
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Motor Vehicles. the new competitive advantage: expanding the participation of
13. Kalina T: Starting a driver rehabilitation program, Work 8:229- people with disabilities in the American work force. Reprinted
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 LEARNING OBJECTIVES
Sensuality After studying this chapter the student or practitioner
Sexuality will be able to do the following:
Self-perception 1. Justify sexuality as a concern of the occupational
Emasculation therapist.
Sexual harassment 2. List at least five possible reactions of the person
Sexual values with physical disability to his or her sexuality.
Sexual history 3. List some attitudes and assumptions that the able-
New body bodied population may make about the sexuality
Sexual abuse of people with physical disability.
Erogenous 4. Discuss how sexuality and sensuality are related to
Vaginal atrophy self-esteem and a sense of attractiveness.
Reflexogenic erection 5. Define sexual harassment and describe how to
Sexually transmitted diseases handle a situation in which clients harass staff in
Autonomic dysreflexia the treatment facility.
Permission, limited information, specific suggestions, 6. Describe the effects that such items as mobility
and intensive therapy aids and splints can have on sexuality.
Basic sex education 7. List signs of potential sexual abuse of adults.
a a 8. List at least two treatment goals that are designed
to improve sexual functioning.
9. Discuss ways in which the occupational therapist
can provide a safe environment for discussing
sexual issues.
10. Describe how sexual values can be communicated.
11. List at least five effects that physical dysfunction
can have on sexual functioning and possible
solutions for each.
12. Discuss the potential hazards of birth control.
13. List the potential complications of pregnancy and
childbirth for a woman with disability.
14. Discuss methods of sex education.
15. Define PLISSIT.
 Sexuality and Physical Dysfunction 213

sexuality. This chapter examines issues related to sexual-

ity and sensuality with physical disability.
fi 5... and sexuality are important aspects of
everyone's activities of daily living (ADL) and directly
REACTIONS TO SEXUALITY
relate to the quality of each person’s life. As an ADL,
AND DISABILITY
sexual functioning is in the domain of occupational
therapy (OT). Occupational therapists work with clients The many obstacles encountered by people with disabil-
in all areas related to sensuality and sexuality (Box 15-1). ity should not interfere with the expression of sensuous
Physical limitations may cause the client to question and sexual needs. As an informed professional, each
his or her ability to experience sexual pleasure. With the therapist can help the adult client eliminate unneces-
ealonset
ee
ie
iat
ree
Ss
—
= of physical disability, the client undergoes a sig- sary obstacles, overcome anxieties, and appreciate per-
nificant change in the commonly held roles and prac- sonal uniqueness. The expression of sexuality or sensu-
‘
Me tices of the able-bodied population.°*®*° The individ- ality is a sign of self-confidence, self-validation, and a
ual with disability may be regarded by able-bodied sense of being lovable. When a person acquires a dis-
persons as asexual, an object of pity, and unattrac- ability or is born with a disability, he or she can feel less
tive.*° Being perceived as unattractive and possibly positive about self and less lovable.***°
unlovable can cause the client to believe that he or she Sexuality can symbolize how a person is dealing with
can never be intimate with anyone. Holding this belief the world. If a person feels inadequate as a sexual,
can lead the client and related others to a sense of sensual, and lovable human being, the motivation to
despair. pursue other avenues of life can be affected. When an
Charlifue and associates’ and Kettl and associates** individual has a negative self-image, coping with life's
found that females with acquired spinal cord injuries re- problems is difficult. Because sexuality is often used as a
ported feeling less than half as attractive after they had barometer of how one feels about oneself, it is produc-
acquired the disability, even though spinal cord injury is tive for the therapist to help the client feel as positive as
a disability in which there is little observable physical possible about his or her physical and personal quali-
change in body appearance. These studies showed that ties. A healthy attitude toward one’s sexuality enhances
there was a major decrease in the self-perception of at- motivation for all aspects of therapy. The therapist must
tractiveness. Another study found that with the advent try to help the client adjust self-perceptions enough to
of a disability, males felt a loss of their sense of mas- function positively in life.
culinity and sensed a threat to the male role.*” Sexuality has been found to be a predictor of marital
These are just a few examples of the feelings and per- satisfaction, adjustment to physical disability, and suc-
ceptions that affect the sensuality and sexuality of the cess of vocational training. In society, people are often
person who has a physical disability. To accomplish judged by physical attractiveness.*° In Western civiliza-
comprehensive rehabilitation with the client, the occu- tion, physical intimacy is closely associated with love.
pational therapist and other health professionals must Therefore, if a person perceives himself or herself as inca-
address self-perception, beliefs, and needs related to pable of expressing sensuality or sexuality, it is possible
that he or she feels incapable of loving and being loved.
Without the capability of loving and being loved, there
may be a sense ofisolation and of being valueless.*°”**
Adaptive devices such as braces, wheelchairs, and
so Related to Sexuality and Sensuality communication aids can be a detriment to one’s per-
ceived attractiveness and sexuality. For example, it may
Quality of life be hard to perceive oneself as sexual when there is an in-
Role delineation dwelling catheter or when braces are worn. By dis-
Cultural aspects cussing the effects of these devices on social interaction,
Impulse control the client can get some ideas about how to handle diffi-
Energy conservation cult situations when they arise.'"7°°**7
Muscle weakness The treatment goals are to facilitate an increase in
Hypertonicity and hypotonicity self-esteem and enable the client to feel lovable. The
Appreciation of body therapist's role is to foster feelings of self-worth and pro-
Psychosocial issues
ductivity and to help minimize feelings of worthless-
M@ Range of motion
B Joint protection
ness and hopelessness.*’!”**°° Feeling lovable engen-
@ Motor control ders a sense of self-worth, attractiveness, sensuality,
@ Cognition sexuality, and being capable of intimacy. Achieving this
@ Increased or decreased sensation goal enhances the development of a healthy and realis-
tic life balance (Fig. 15-1).
214 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

SEXUALITY AND DISABILITY Women experience many of the same feelings but
probably interpret and react to them in a different way.
Women with disability report feeling unattractive and
undesirable. This can lead to despair if a woman feels
ig anes pineal Ra et that she cannot achieve some of her major goals in life.
Thus, the female client may flirt to see if she is still at-
INTIMACY tractive to others.

Z
It is important for the therapist to realize that the
client is seeking confirmation of his or her sexuality. The
therapist should not be surprised by flirtations or sexual
x=IA7rOSmrmMMH LOVABILITY advances and should deal with them in a positive and
professional manner. All of the therapist’s interactions
should be directed toward creating an environment that
numZzm<—A0rPwAaHs>
promotes the client's self-esteem, positive and appropri-
FIG. 15-1 ate sexuality, and adjustment to disability.
Sexuality and disability.
When responding to the client, the therapist should be
alert to the client's current sexuality issues to prevent
Whether sex is still possible is a concern that arises doing further damage to the client's sense of self. If the
after the onset of physical disability. This concern is therapist rejects or ridicules the client, the client might
often set aside in the immediacy of coping with the ad- hesitate to attempt such confirmation of personal attrac-
justment to hospital life and activities that make up tiveness in future situations that are more socially appro-
the daily routine. But the concern is not forgotten. A priate. If the therapist rejects the client, the client might
common complaint made about medical staff by deduce that if someone who is familiar with persons who
people with disabilities is that the staff never deal with have disabilities is rejecting, then one who is unfamiliar
or let people with disability deal with the topic of their with them would not be likely to be accepting either.
sexuality. People with disabilities feel that if their sensu- Inappropriate sexual advances, sexual harassment,
ality and sexuality are negated, a significant facet of their or exploitation of either the therapist or the client
personhood is negated. This lack of acceptance causes cannot be permitted.*°*! Behavior is considered harass-
the person with a disability to lose the feeling that he or ment when it causes the therapist to feel threatened, in-
she is treated as a whole person. timidated, or treated as a sexual object. If sexual harass-
For both men and women with disabilities, the in- ment is allowed, it can be damaging to the client and to
creased dependence on an able-bodied partner results staff morale.'® The therapist should provide direct feed-
in a decrease in sex life.'* One possible explanation is back explaining that he or she feels offended and that
that the able-bodied partner is less inclined to be the behavior is inappropriate and must cease. All of the
aroused when he or she has just bathed the partner or staff should be informed and develop and implement a
assisted the partner with toileting. The therapist must be plan to modify the client's behavior if it persists.
sensitive to the possibility of these perceptions and help
the client deal appropriately with the feelings they
evoke.
Therapeutic Communication
The client’s sense of masculinity or femininity may Conversations regarding sexuality can be good occa-
be threatened by the disability.*°’**** Men who have re- sions for discussing personal feelings and perceptions.
cently acquired a disability report that they feel emascu- One way to approach discussion of intimate matters is
lated.*”** Feelings of emasculation can be reinforced by asking the client how she will perform breast self-
by physical limitations. For example, lifting weights may examination with her disability. A male client can be
no longer be possible, sports participation might not be asked how he will perform self-examination of the testi-
possible without adaptations, and attendance at sport- cles. If the treatment facility does not have information
ing events may be limited by lack of access. The neces- about these examinations, the client can obtain them
sity to look up at others from a wheelchair and ask for from the local Planned Parenthood Association. Each of
assistance can engender feelings of dependency. these activities falls into the domain of health mainte-
A man with a disability may react to feelings of de- nance and may not have been discussed by health team
pendency and emasculation®” by flirting to prove his members. This interaction will set the stage for discus-
masculinity. The client may attempt to flirt or make sion of other personal matters, impress upon the client
passes at a therapist. Because it is estimated that up to the necessity for concern about personal health, and
10% of the population is homosexual, the therapist can reaffirm the client's sexual identity.
expect that at some time there may be sexual advances Clients often feel safe asking the occupational thera-
from clients of the same sex. pist about sexual matters related to their disabilities,
 Sexuality and Physical Dysfunction 215

because the therapist deals with other intimate activities correct assumptions that have negative results."’ One of
such as bathing, dressing, and toileting. It is also impor- the most direct ways of gaining information is by taking
tant to discuss sexual hygiene as an ADL. The trust built a sexual history.'"’**° The purpose of a sexual history
up in the relationship encourages this communication. is to learn how a person thinks and feels about sex and
The therapist should be prepared with information and bodily functions as well as to discover the needs of
resources. The therapist does not need to know every- those concerned.'’?”**® According to some researchers,
thing or be a sex counselor but should see that the client many individuals with a disability had a sexual dysfunc-
gets the necessary information or referral. tion before they acquired the physical disability. Taking
The occupational therapist is the most appropriate the sexual history can help to identify such a problem.7®
professional to solve some problems, such as motor
performance needed for sexual activity.* For example,
SEXUAL HISTORY
discussing positioning to reduce pain or spasticity or to
enable the client to more comfortably engage in sexual When taking a sexual history, the therapist should create
relations will help the client deal with problems before an environment that will allow for confidentiality,
they occur.”’7°? comfort, and self-expression. In early intervention, the
During all aspects of the rehabilitation process, the therapist should ask about the client's concerns regarding
client needs to work on communication with the thera- contraception, safe sex, homosexuality, masturbation,
pist, staff, and his or her sexual partner. The therapist sexual health, aging, menopause, and physical changes.
can facilitate this process simply by giving the client per- Following are some questions that could be asked.
mission to discuss feelings and potential problems, es- All questions should not be asked at the same time, nor
pecially sexual problems. The client needs to learn how would all questions be asked of every client.
to accurately communicate sexual needs, desires, and @ How did you first find out about sexuality?
position options to a partner, either verbally or nonver- @ When and how did you first learn about heterosexu-
bally, to have a mutually satisfactory sexual relation- ality and homosexuality?
ship.** Each client will have unique problems or issues ® Who furnished you with information about sexuality
that are related to the nature of the disability. An when you were young?
example is a client with Parkinson’s disease in whom @ Were you ready for the information when you first
the lack of facial expression impedes the nonverbal heard about sexuality?
communication of intimacy. The client can be taught to = How important is sexuality at this time in your life?
communicate feelings verbally that were previously @ How would you describe your sexual activities at this
conveyed with facial expressions. time?
Discussion of sexuality is a way to explore feelings of ™ How do you feel sexuality expresses your feelings and
dependency, identity, attractiveness, and unattractive- meets your needs and those of others?
ness. Communication must be established-regarding @ If you could change aspects of your current sexual sit-
the feelings of sexual role changes. If a client's perceived uation, what would you change and how would you
roles are threatened, this situation should be dealt with change it?
as early as possible in treatment. If it is not, the effects @ What concerns do you have about birth control,
could persist throughout the client's life. disease control, and sexual safety?
@ What physical, medical, or drug-related concerns do
you have relating to your sexuality?
VALUES CLARIFICATION m@ Have you ever been pressured, threatened, or forced
Sexual values of the client, the partner, and the thera- into a sexual situation?
pist must be examined for the therapist to interact with B® Which sexual practices have you engaged in, in the
the client in the most effective and positive man- past (e.g., oral, anal, and genital)?
ner.*’'*:79°?°° Many professional schools do not train ® Do you consider certain sexual activities “kinky”?
health care workers on the subject of sexuality and dis- How do you feel about participating in such activi-
ability.*’”°**? In-service training can be arranged to ties?
help the staff be aware of the sexual needs of people @ How important do you think sexuality will be in your
with disability.'°** Books, articles, videotapes, and future?
training packets are available for professional educa- @ What concerns do you have about your sexuality?
tion.” !2/13-38
@ Are there questions or concerns that you have regard-
Unless the staff is educated about the significance of ing this interview?
sexuality and related issues, they could have negative After taking the sexual history, the therapist can often
feelings about dealing with these matters.*”’**’*° If the ascertain whether there is guilt connected with the sex
therapist is not aware of the thoughts and feelings of all act, body parts, or sexual alternatives (such as masturba-
of the individuals involved, the therapist could make in- tion, oral sex, sexual positions, or sexual devices). For
216 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

example, some clients report feelings of guilt or fear in be available. These are major problems for a person
relation to having sex after a heart attack or a stroke— who is dependent on others for care.
fear that sex can cause a stroke or guilt at the notion that Therapists usually do not suspect caregivers, medical
it might have caused the first episode. Another fear is staff, aides, transportation assistants, or volunteers of
that the partner will not accept the presence of catheters, sexual abuse, but the therapist should be alert to signs
adaptive equipment, or scars. Performance is often an of possible abuse even from these sources.°” It is a fact
issue. “Can the person with a disability do it?” is the of life that some individuals prey on adults and chil-
question asked by able-bodied persons and persons dren with disabilities and are drawn to the health fields
with disability alike. with this motive.’ The therapist should watch for signs
The therapist can furnish the necessary information of potential abuse, such as clients usually being upset
by (1) directing the client to other professionals, (2) pro- after interacting with a specific person, caregivers
viding magazines and books that discuss the subject, taking clients off alone for no apparent reason, exces-
(3) showing movies, or (4) suggesting role models. The sive touching in a sensual manner by caregivers, the
therapist must be tactful and remember that the client is client being agitated when around a particular individ-
probably questioning his or her own values and previ- ual, and the client being overly compliant with a spe-
ous notions about sexuality. Personal care such as toilet- cific individual.
ing, personal hygiene, menstrual hygiene, bathing, and Therapists must increase their awareness of what con-
birth control are all issues that can evoke reflection on stitutes sexual abuse. Children with disabilities have
values regarding sex and body image. long been expected to undress and be examined or
Self-care issues usually are not emphasized enough treated as part of their medical care. This treatment is
during acute illness and rehabilitation. Discussing sometimes necessary, but the preferences and dignity of
such issues once or twice is not enough. The circum- the client should be respected at all times. A person of
stances and environment in which these issues are dis- any age should not be forced to endure humiliation.
cussed should also be considered. The therapist must The therapy session should help the client develop a
create an environment that will allow personal discus- sense of personal ownership of his or her body. This
sions to occur. A personal conversation cannot take goal may be neglected when working with adults and is
place in a crowded treatment room, during a rushed often neglected in working with children. For example,
and impersonal treatment session, or with a therapist a child who believes that he or she does not have the
with whom there is not a good personal rapport. right to say no to being touched, who cannot physically
Building rapport is a problem in health care facilities resist unwanted advances, and who may not be able to
in which therapists are frequently rotated or work on communicate that abuse has taken place makes a good
a per-diem basis. victim.’
A discussion of feelings will also help the client The therapist should ask permission before touching
explore his or her new body or adapt to ongoing degen- the client and should touch with respect and maintain
eration of the body if there is a progressive disability. the client's sense of dignity. If the therapist does not ask
These conversations may take place while other thera- permission to touch a client, the client can lose the
peutic activities are in progress, so that billing insurers sense of control over being touched by others. The ther-
for time is not a barrier. apist should guard against communicating this notion
to the client.
Naming body parts and body processes is a good way
SEXUAL ABUSE
of helping clients take charge of their bodies. Once the
The sexual abuse of adults with disabilities is a consid- body parts and processes are named, using correct ter-
erable problem.'*°*~*° Some people who have disabil- minology rather than slang, there is the possibility for
ities have reported being approached by pimps repre- the client to communicate and to relate in an appropri-
senting prostitution rings that specialize in providing ate manner.'’'”*"’°? The use of the proper terms has the
people with disabilities for their customers. Clients effect of helping the client view the body in a more pos-
should be made aware of the possibility of this type of itive way, whereas slang tends to communicate negative
exploitation. Others have reported that medical staff images.”
took inappropriate liberties with them and that atten-
dants on whom they depended demanded sexual
EFFECTS OF PHYSICAL DYSFUNCTION
favors. Clients can and should report such abuse to
Adult Protective Services. The therapist also must report Specific physical problems that may create difficulties in
cases of suspected sexual abuse. The client may be reluc- sexual performance for people with disabilities and
tant to report abuse because of a concern that it will not their partners and suggestions for management of the
be possible to get another aide or that, during the time problems are outlined below and summarized in
it takes to hire another aide, essential assistance will not Table 15-1.
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218 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

Hypertonia Joint Degeneration

Hypertonia can increase when muscles are stretched. To Conditions such as arthritis can cause pain, damage to
prevent quick stretching of muscles involved in a move- the joints, and contractures. Avoiding stress and repeti-
ment pattern, motion should be performed slowly. It is tive weight bearing on the joints can decrease joint
advisable to incorporate rotation into the movement to damage. Activity analysis is needed to reduce joint stress
break up the spasticity. Slow rocking can be used to and excessive weight bearing on the joints. It is neces-
inhibit hypertonic musculature. Gentle shaking or slow sary to find a position, such as that shown in Fig. 15-2,
stroking (massage) can also be inhibitory. Heat or cold that takes weight and stress off the knees or hips. A po-
can also be used to inhibit tone. Clients with hyperto- sition with limited hip adbuction might not be accept-
nia should review options for different positions able for the client, in which case a side-lying position
in which to have sexual intercourse. Alternative ways may be more acceptable. If hip abduction is limited, the
of dealing with personal hygiene (e.g., toileting, insert- woman should avoid positions such as those shown in
ing tampons, gynecological examinations, and birth Figs. 15-2, 15-5, and 15-9.
control) may also need to be explored in relation to hy-
pertonicity.
Pain
Pain limits the enjoyment of sexual activities.” There is
Hypotonia
usually a time of day at which pain is diminished and
Clients with low muscle tone (hypotonia) need physical energy is at its highest. Sexual activities can be sched-
support during sexual activity. Pillows, towels, or bol- uled for such times. After pain medication has taken
sters may be used to support body parts, allowing for effect, many people find that sexual activity is possible.
endurance and protecting the body from overstretching Communication between partners is especially impor-
and fatigue. Sexual positions that allow support of the tant when pain is involved. An unaffected partner who
joints involved should be explored. The client and his does not understand the negative effects of pain may
or her partner should also explore their attitudes about believe that the affected partner is not considering his or
the positions. her personal needs. A referral to a counselor who un-
derstands the effects of pain can help work out emo-
tional aspects of this problem. The occupational ther-
Low Endurance
apist can help the client think of acceptable ways of
Prolonged sexual activity can be intolerable because of meeting the partner’s sexual needs without causing
low physical endurance. Some techniques for dealing pain. Masturbation and mutual masturbation with
with low endurance are employing principles of work sexual fantasy are possible ways of meeting sexual
simplification to sexual activity, using timing to engage
in sex when the client has the most energy, and assum-

|
ing positions in which sexual performance uses less
energy.

Loss of Mobility and Contractures

Limited mobility and contractures prohibit many move-
ment patterns and limit the number of positions for sex.
Activity analysis must be done to find positions that will
allow sexual activity. This system often requires creative
problem solving on the part of the client, the partner,
and the responsible professional counselor.

FIG. 15-3
Vaginal entry of B requires no hip abduction, and hip flexion tight-
ness would not impede performance. Energy requirements for
both parties is minimal. Bladder pressure, catheter safety, and
FIG. 15-2 stoma appliance safety should not be an issue in this position for B.
This position places pressure on female's bladder and requires hip This position may be recommended if B has back pain or is para-
abduction but little energy expenditure for her. lyzed, especially if roll is used to support lumbar spine.
 Sexuality and Physical Dysfunction 219

needs in these circumstances. In this way the partners municating that sex may be a possibility in the future. It
are interacting and neither person feels isolated. should be pointed out to clients that there has never
been a time in human history that people with disabili-
ties did not exist in society, that they are a part of society,
Loss of Sensation
and that it is not “abnormal” to have disability. All
The loss of sensation can affect the sexual relationship people who live long enough will acquire a disability to a
in several ways. The lack of erogenous sensation in the greater or lesser extent at some time.
affected area can block proper warning that an area is
being abraded (e.g., the vagina not being sufficiently lu-
Medication
bricated) or damaged (e.g., bladder or even bones if the
partner is on top and being too forceful). A lack of sen- Potential side effects of medication are impotence,
sation may be a sign of disruption of the reflex loop re- delayed sexual response, or other problems. Diuretics
sponsible for sensation and erections in the male and and antihypertensives can cause impotence, decreased
sensation and lubrication in the female. libido, and loss of orgasm. Tranquilizers and antide-
pressants can contribute to decreased libido and even
impotence in some individuals.*® Side effects of med-
Aging and Sexuality
ication should be discussed with the physician and the
With aging, changes take place that can affect sexuality. pharmacist to see whether medications can be altered
Menopause and the resulting hormonal changes cause or changed. If they cannot, acknowledging that the
vaginal atrophy and slower reactions to sexual stimula- problem is organic can be helpful to the client.
tion. In the male, greater stimulation may be needed to
develop and maintain an erection, and reaction time
Performance Anxiety
between erections may be greater. Partners can be in-
formed of ways to increase stimulation and can be At times of great emotional stress, a male client might
helped to understand that it is the quality, not the quan- find that the erection is inhibited. This problem can
tity, of sexual activity that is important in the relation-
ship. The client should be made aware of the matura-
tion process and its normal effect on sexuality so that
the disability is not blamed for all of the problems.

Isolation
The environment is composed of objects, persons, and
events. In all activities there is an interaction between
the person and environment. Some of the objects. with
which people with disabilities interact are wheelchairs,
braces, canes, crutches, and splints. These objects are all
hard, cold, and angular. They can communicate a hard
exterior and a fragile interior and can convey the notion
that there is no softness, that it is not safe to hug, and
that a person in a wheelchair or in braces or on crutches
can get hurt or toppled if touched. As a result of these
ideas, the individual with a disability may feel isolated
by the appliances.
Some people tend to withdraw from the objects
around the client. This may reinforce the client's notion
of a lack of sensuousness and increase the client's sense
of isolation. Clients often feel isolated and different from
the “normal” population. This phenomenon is more
common among clients who have been out of the health
care facility for a period of time. In the early phases of the
disability, the therapist and the client can role-play about
how to deal with a new partner or how to explain equip- FIG. 15-4
ment used, such as a catheter. This approach may help Partner A needs little hip abduction but good strength. Partner B
ease the client's fears and increase the client's comfort may find decreased strain on his back. Hip, knee, or ankle joint de-
with such issues. At the same time the therapist is com- generation would preclude this position for either partner.
220 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

lead to increased anxiety in relation to sexuality and

create a cycle of dysfunctional inhibition. It can be
helpful for the client and his partner to take the focus
off erection and genital intercourse and focus on sensu-
ality and making each other feel good. A massage is one
possibility that will allow for more normal physiologi-
cal reactions. If this approach does not work, a trained
counselor may be needed to help deal with the pro-
blem, if it has been determined that the problem is not
organic in nature.

Skin Care
FIG. 15-5
The person with a disability should be informed that Person A must have hip abduction, balance, and endurance but
positioning modifications might be needed to protect pressure is off of bladder and stoma. If catheter is used it would be
the skin, prevent skin breakdown, and increase pleas- unrestricted. Back pain may be avoided by keeping trunk vertical.
ure. If a sexual position causes repeated rubbing on the Person B’s hip flexors could be contracted. If low back pain is a
problem, legs should be flexed and roll placed under low back. If
skin, this friction can cause abrasions and result in skin
stoma appliance is used, this position would prevent interference.
damage. The therapist and client can discuss methods to
If low endurance is a problem, this position can be used effectively
prevent the friction—through an alternative position, for B.
for example. Pressure on bony prominences or pressure
exerted in a specific area by a partner can also cause
problems with skin irritation and must be avoided. the normal reflex arc is interrupted, it is usually not pos-
sible to achieve an erection, and alternative methods
must be explored.
Lubrication
Alternative methods can be forms of sex that do not
Stimulating natural lubrication in female clients is im- require an erect penis, such as using a vibrator or trying
portant. It might be overlooked in a woman with paral- oral or digital sex. If the client feels that penile inter-
ysis because she may not be able to feel the stimulation course is the only acceptable method, there are other
or lack of natural lubrication. There should be stimula- possibilities.* Injections of hormones that stimulate
tion to cause reflexive lubrication even when the erections can be used, but this practice might have
woman does not feel it. Without proper lubrication, adverse reactions or lead to problems if the client does
damage may occur without awareness of the problem. If not have good judgment or lacks hand dexterity. The use
needed, artificial water-based lubricants (such as K-Y of a vacuum tube is sometimes effective and is one of
Jelly) should be introduced. The individual should be the less invasive techniques.*” Surgical implants can be
warned that only water-based lubricants are appropriate used but have disadvantages, such as the possibility of
because petroleum-based lubricants can cause irritation infection and skin breakdown. With a physician's pre-
and can attack latex condoms, causing condom failure. scription the use of Viagra is a possibility for some
This is a major concern, since the female partner is more clients.
likely than the male to become infected with the human
immunodeficiency virus (HIV) in any given heterosex-
Birth Control
ual encounter.
The client should consult with his or her physician
in weighing the pros and cons of various methods of
Erection
birth control. People with disabilities must consider
Many men regard the ability to achieve an erection as a number of factors when planning birth con-
one of the most significant signs of masculinity.*? If trol.*"!”°! Since most disabling conditions do not
awareness of sensory stimulation to the penis is blocked impair fertility (especially for women), it is important
by the sensory loss associated with paralysis and the for the client to be aware of birth control and potential
male client does not try to stimulate a reflexogenic erec- complications of the use of birth control.
tion, he might believe that he is impotent. This is not Condoms require good use of the hands. An applica-
necessarily true, and the client may go through much tor can be adapted in some cases, but someone with
needless anguish. The client should be encouraged good hand dexterity must assemble the device before-
to explore his body. Rubbing the penis, the thighs, or the hand. Diaphragms are not very feasible for people who
anus can be effective ways to evoke a reflexogenic erec-
tion. Even rubbing the big toe has been reported by An excellent discussion of these alternatives can be found in Sexuality
some men with quadriplegia to stimulate an erection. If and Disability 12:1, 1994.
 Sexuality and Physical Dysfunction 221

Safe Sex
have poor hand function unless the partner does have
hand function and both parties feel comfortable about The issue of safe sex has increased considerably since
inserting the diaphragm as part of foreplay. The contra- the advent of acquired immune deficiency syndrome
ceptive sponge also requires good use of hands. (AIDS). Safe sex is important to protect against all forms
Using birth control pills can increase the risk of of sexually transmitted diseases (STDs).'? Clients need
thrombosis, especially when the client is paralyzed or to be advised that this is an important issue. If there is a
has impaired mobility. If the client has decreased sensa- sensory impairment in and around the genital area, the
tion, the intrauterine device (IUD) can result in compli- person might not be aware of an abrasion or infection.
cations from bleeding, cramping, puncturing of the Having any genital irritation or infection allows easy en-
uterus, or infection. The use of spermicides requires trance for STDs. The person with disability must be in-
good control of the hands or the assistance of the formed of the increased risk for HIV and STDs so that
partner who has normal hand function. In using any extra caution can be taken.
method of birth control, the client must always be con-
cerned with decreasing the chance of infection and with
Hygiene
practicing safe sex.
Catheter care is a concern, especially when hand func-
tion is impaired. Questions may be raised regarding
Adaptive Aids
how or if a person with an indwelling catheter can
There might be a need to make use of adaptive aids, have sex. Sex is possible for both men and women,
especially if the client lacks hand function. One aid is but some precautions should be taken. If the catheter
a vibrator for foreplay or masturbation.'’ Special becomes kinked or closed off (which will definitely
devices have been adapted for men and women.""*°*! happen in the case of a catheterized man having
Pillows may be used for positioning, and other equip- vaginal intercourse), pressure should not be placed on
ment may be used for clients who have special needs. the bladder. The bladder should be fully voided
The therapist must prepare the client for the concept before sexual activity. Urine flow should be restricted
of using sexual aids before suggesting the option to for as short at time as possible and no more than 30
the client. For example, the therapist can suggest that minutes. Damage to the bladder and kidneys could
the client privately explore the sensation that the vi- result if these precautions are not followed. The client
brator produces in the lower extremities. The client should not drink fluids for at least 2 hours before sex
might discover the possible use of the vibrator for to prevent the bladder filling during this time. Sexual
sexual stimulation or at least, when told how it can be positions that avoid placing pressure on the bladder
used, may be more open to the idea of using a vibra- should be used (Figs. 15-3 to 15-10). Many of the
tor as a sexual aid. same positions can be used if the client uses a stoma
appliance.
A person with an impairment of bowel or bladder
function may have an occasional episode of inconti-
nence during sexual activities. If the client and the ther-
apist discuss this possibility and how to deal with it,
some embarrassment can be averted when it occurs. The
client and therapist can do role-playing to explore
various scenarios such as, “You are planning intimacy

Bn
FIG. 15-6
This position keeps pressure off bladder, lessens chance of tubing FIG. 15-7
becoming bent, reduces pressure on back (especially if small roll is Partner B need not expend much energy in this position. Both
used under low back), and does not require B to use much energy. partners may avoid swayback in this position. Either person may
Legs do not need to be as high as is shown, but if hip flexors are have hemiparesis. Person B will not need hip abduction, and pres-
contracted, this position may be comfortable. sure on stoma bag may be avoided.
222 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

FIG. 15-8
This position can be used if either partner has hemiparesis. If low
endurance is a problem, this position can be used. Person A may
avoid swayback in this position.

FIG. 15-10

i
Rear vaginal entry of B, who does not need much energy because
of support and little or no abduction of hips. Flexion tightness of
hips does not affect performance. Because of weight on B’s knees,
hips, and back, as well as inevitable repetitive movement at hips,
this would not be a good position for individuals with back, hip, or
knee joint degeneration.

the wheelchair. The client will need consultations to

achieve an optimal level of function in the parenting
role.”
FIG. 15-9
Partner B can be paralyzed or have limited range of motion. His METHODS OF EDUCATION
back may need roll for support, and he must be concerned with
pressure on his bladder. The following techniques or approaches have been used
effectively to deal with the emotional aspects of sex ed-
ucation of people with disability.
with a new partner. How will you explain your catheter
and appliances to the person?” These might be awkward
Repeat Information
conversations for the therapist and the client, but
dealing with these issues beforehand is usually easier Mentioning sexual issues just once is not enough. Most
than waiting for the situation to arise. Such topics must people, whether they have disability or not, need to
be approached with caution and discretion. hear information more than once. This fact is especially
true for people who are in crisis or who are in the
process of adjustment. Too much information, or more
Pregnancy, Delivery, and Child Care
than is asked for, should not be offered at one time.
Before becoming pregnant, women must weigh the risks Whenever possible, the therapist should try to say some-
and benefits of pregnancy, childbirth, and child care. thing positive in every conversation. Holding out hope
Complications of pregnancy might affect the client's for the restoration of function or alternative function is
function and mobility. These include the potential for important. The therapist should not assume that the
respiratory or kidney problems. The effect of the in- client understands all of the information. To verify that
creased body weight on transfers, an increased possibil- the information is understood, the therapist should
ity of autonomic dysreflexia, and the need for in- invite the client to ask questions and to paraphrase
creased bladder and bowel care should all be considered what has been said.
when pregnancy is contemplated.** Labor and delivery
can present some special problems, such as a lack of
awareness of the beginning of labor contractions. In-
Discovery of the “New” Body
duction of labor might be contraindicated if a person With any disability, the client’s body image and percep-
has a spinal cord injury at T6 or above and the medical tion of the body are altered. In effect, the client has a
staff is not trained to deal with the respiratory problems new body and must find altered ways of moving, inter-
or dysreflexia that can result. After delivery, the parent preting sensations, and performing ADL. A large part of
with disability will need to have modifications made to the therapeutic experience is directed toward helping
 Sexuality and Physical Dysfunction 223

the client discover how to use this new body as effec- that not all partners had sex on a daily, weekly, or even
tively as possible. The therapist can facilitate this discov- yearly basis before the onset of the disability. The thera-
ery of the new body by creating situations that encour- pist’s values and biases should not be imposed on the
age awareness of the body through the input of client. Same-sex partners, multiple partners, masturba-
sensation and function.*® The client alone or with his or tion, or a preference for no sexual activities are some of
her sexual partner can accomplish this awareness the client's practices that could evoke bias.
through exercises that encourage exploration of the
body. Exercises such as the gentle tapping or rubbing of
Basic Sex Education
a specific area can be developed to see if there is sensa-
tion or if the stimulation causes a change in muscle Some clients need basic sex education if they didn’t
tone. Many people with a disability such as paralysis have the information before the onset of disability.
report that they have experienced nongenital orgasms~* Some clients may not have been informed because of
by stimulating other new erogenous areas, often in the the disability, or they may be misinformed about sexual
area just above where sensation starts to appear. The practices.'"° Research has shown that people with
therapist may suggest ways to use this sensation or hearing impairments have substantially less informa-
change in tone in ADL or may ask the client to think of tion regarding sex than do those without hearing im-
ways this change in tone could be used, such as trigger- pairments.* If the occupational therapist is not the one
ing reflex leg extension to help putting on pants. This to educate the client or the client's partner, the therapist
discussion will stimulate problem solving by the client. should anticipate the need for information and have
knowledge of the resources available for the client to
acquire the information. It is not advisable to recom-
PLISSIT
mend only books about sexuality and people with dis-
The acronym PLISSIT stands for permission, limited infor- abilities. Such books are useful, but their focus on the
mation, specific suggestions, and intensive therapy. PLISSIT disability may be discouraging to some. Books written
is a progressive approach to guide the therapist in for the able-bodied, such as The Hite Report on Male Sex-
helping the client deal with sexual information.” Permis- uality,** The Hite Report,?? and How to Satisfy a Woman
sion refers to allowing the client to feel new feelings and Every Time,*° can be helpful. These books will not only
experiment with new thoughts or ideas regarding sexual give the client an understanding of sex, but will also
functioning. Limited information refers to explaining show the client that he or she is normal, while minimiz-
what effect the disability can have on sexual function- ing the focus on the disability. Excellent books written
ing. An explanation with great detail is not usually nec- for individuals with disabilities also can be recom-
essary early in the counseling process. The next level of mended. Some of these are Choices: A Guide to Sexual
information is providing specific suggestions. It might be Counseling with the Physically Disabled,*! Reproductive
in the therapist's domain to give specific suggestions on Issues for Persons with Physical Disabilities,‘°The Sensuous
dealing with specific problems that relate to the disabil- Wheeler,** Sexuality and the Person with Traumatic Brain
ity, such as positioning. This is the highest level of input Injury,'® Sex and Back Pain,” Sexuality and Disabilities,*°
the average occupational therapist should attempt Sexual Function in People with Disability and Chronic
without advanced education and training in sexual Illness,*® and Enabling Romance.*°
counseling. Intensive therapy should be reserved for the
rare client who has an abnormal coping pattern in
SUMMARY
dealing with sexuality. An extensive counseling back-
ground is needed to provide intensive therapy. Occupational therapists are concerned with the sexual-
ity of their clients because sexuality is related to self-
esteem and influences the adjustment to disability and
Activity Analysis because sexual functioning is an activity of daily living.
To assess the client's positioning needs, the therapist As with other ADL, a physical dysfunction can necessi-
must analyze the components of the particular activity. tate some change in performance of sexual activities.
This analysis entails looking at the physical, psychologi- Education, counseling, and activity analysis can be used
cal, social, cultural, and cognitive components of the to solve many common sexual problems confronted by
client's functioning. The activity analysis should be im- persons with physical dysfunction.
plemented using an objective and professional perspec- Occupational therapists can provide information
tive. The therapist must realize that the sex act itself, if and referrals to clients who are concerned with sexual
there is one, is only a small part of the act of making issues. Trained therapists can provide counseling. Issues
love and should be treated as just one more ADL that of sexual function, sexual abuse, and values need to be
must be analyzed and with which the client needs pro- considered in providing sex education and counseling.
fessional assistance. The therapist must also remember Through activity analysis and problem solving, physical
224 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

limitations that affect sexual functioning can usually be OE Boyle PS: Training in sexuality and disability: preparing social
workers to provide services to individuals with disabilities, J Soc
managed. A wide variety of sexual practices, modes of
Work Human Sexuality 8(2):45-62, 1993.
sexual expression, and expressions of sensuality are pos- . Braithwaite DO: From majority to minority: an analysis of cul-
sible. The client needs the opportunity to explore her or tural change from able-bodied to disabled, Int J Intercultural Rela-
his needs and acceptable options to meet those needs. tions 14:465-483, 1990.
The occupational therapist is one of the members of the . Charlifue SW, Gerhart KA, Menter RR, et al: Sexual issues of
women with spinal cord injuries, Paraplegia 30(3):192-199,
rehabilitation team who has something to offer the
1992.
cl ient in the area of rehabilitation ahd sexuality and . Choquet M, Du Pasquier Fediaevsky L, Manfredi R, National Insti-
sensuality. tute of Health and Medical Research (INSERM), Unit 169, Ville-
juif, France: Sexual behavior among adolescents reporting chronic
conditions: a French national survey, J Adolesc Health 20(1):62-67,
REVIEW QUESTIONS ISIS PA
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1. List at least five areas related to sensuality or sexual- persons with disabilities. In Haseltine FP, Cole SS, Gray DB,
ity that are usually the concerns of the occupational editors: Reproductive issues for persons with physical disabilities, Balti-
therapist. more, 1993, Paul H Brooks.
2. What are some common attitudes of the able- 10. Cole SS, Cole TM: Sexuality, disability, and reproductive issues
through the life span, Sexuality and Disability 11(3):189-205, 1993.
bodied population about the sexuality of persons
. Cole TM: Gathering a sex history from a physically disabled adult,
with physical dysfunction? Sexuality and Disability 9(1):29-37, 1991.
3. How do these attitudes affect the disabled person’s 12: Cornelius DA, Chipouras S, Makas E, et al: Who cares? A handbook
perception of self and attitudes toward his or her on sex education and counseling services for disabled people, Baltimore,
own sexuality? 1982, University Park Press.
4. How is sexuality related to self-esteem and a sense ish Ducharme S, Gill KM: Sexual values, training, and professional
roles, J Head Trauma Rehabil 5(2):38-45, 1991.
of attractiveness? 14. Edwards DE, Baum CM: Caregivers’ burden across stages of de-
5. Describe some typical questions for taking a sexual mentia, Occup Ther Practice 2(1):13-31, 1990.
history. How can these questions be used to clarify 15. Froehlich J: Occupational therapy interventions with survivors of
values about sexuality? sexual abuse, Occup Ther in Health Care 8(2-3):1-25, 1992.
6. How do mobility aids and assistive devices affect 16. Gender AR: An overview of the nurse’s role in dealing with sexual-
ity, Sexuality and Disability 10(2):71-70, 1992.
sexual functioning? How can this concern be ie Goldstein H, Runyon C: An occupational therapy education
managed? module to increase sensitivity about geriatric sexuality, Phys Occup
7. What are some signs of potential sexual abuse of Ther Geriatrics 11(2):57, 1993.
adults? 18. Griffith ER, Lemberg S: Sexuality and the person with traumatic brain
8. What are some suggestions for dealing with the fol- injury: a guide for families, Philadelphia, 1993, FA Davis.
iIDY. Haseltine FP, Cole SS, Gray DB: Reproductive issues for persons with
lowing physical symptoms during sexual activity: physical disabilities, Baltimore, 1993, Paul H Brooks.
hypertonia, low endurance, joint degeneration, and 20. Hayden N: How to satisfy a woman every time, New York, 1982,
loss of sensation. Bibli O’Phile.
9. List some medications that may cause sexual dys- 21; Hebert L: Sex and back pain, Bloomington, Minn, 1987, Educa-
function. tional Opportunities.
wD Hite S: The Hite report, New York, 1976, Macmillan.
10. Discuss some issues and precautions relative to birth Day Hite S: The Hite report on male sexuality, New York, 1981, Knopf.
control for the woman with a physical disability. 24. Kettl P, Zarefoss S, Jacoby K, et al: Female sexuality after spinal
11. How is a catheter managed during sexual activity? cord injury, Sexuality and Disability 9(4):287-295, 1991.
12. What are some potential problems in pregnancy, 253 Krause JS, Crewe NM: Chronological age, time since injury, and
delivery, and child care? time of measurement: effect on adjustment after spinal cord
injury, Arch Phys Med Rehabil 72:91-100, 1991.
13. Discuss some techniques for educating a person
26. Kroll K, Klein EL: Enabling romance, New York, 1992, Harmony
about sexual issues. Books
14. How should sexual harassment of staff members by 27a Lefebvre KA: Sexual assessment planning, J Head Trauma Rehabil
clients be handled? 5(2):25-30,1990.
28. Lemon MA: Sexual counseling and spinal cord injury, Sexuality
and Disability 11(1):73-97, 1993.
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oP Annon JS: The behavioral treatment of sexual problems, vol 1-2, Hon- and practicing physical therapists with inappropriate patient
olulu, 1974, Enabling Systems. sexual behavior, Phys Ther 73(11):762-769, 1993.
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tiences of women with physical disabilities: a qualitative study, cally disabled adults, Malabar, Fla, 1987, Krieger.
Arch Phys Med Rehabil 78(12) (Suppl 5):S26-S33, 1997. 2 Nosek M, Rintala D, Young M, et al: Psychological and psychoso-
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 Sexuality and Physical Dysfunction 225

33. Rabin BJ: The sensuous wheeler, Long Beach, Calif, 1980, Barry J Leyson JF: Sexual rehabilitation of the spinal-cord-injured patient, Totowa,
Rabin. NJ, 1991, Humana Press.
34. Rintala D, Howland C, Nosek M, et al: Dating issues for women Mackelprang R, Valentine D: Sexuality and disabilities: a guide for human
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EDT. Sandowski C: Sexual concern when illness or disability strikes, Springfield,
35. Romeo AJ, Wanlass R, Arenas S: A profile of psychosexual func- Ill, 1989, Charles C Thomas. In Resources for people with disabilities
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36. Sandowski C: Responding to the sexual concerns of persons with Shortridge J, Steele-Clapp L, Lamin J: Sexuality and disability: a
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38. Sipski M, Alexander C: Sexual function in people with disability and chronic illness, Gaithersburg, Md, 1997, Aspen.
chronic illness, Gaithersburg, Md, 1997, Aspen Publishing. Sobsey D, Gray S, editors: Disability, sexuality, and abuse, Baltimore,
39. Smith M: Pediatric sexuality: promoting normal sexual develop- 1991, Paul H Brooks.
ment in children, Nurse Pract 18(8):37-44, 1993.
40. Sobsey D, Randall W, Parrila RK: Gender differences in abused
children with and without disabilities, Child Abuse Negl 21(8):707- ADDITIONAL RESOURCES
72071997. American Association of Sex Education Counselors and Therapists
41. Stockard S: Caring for the sexually aggressive patient: you don't 435 N. Michigan Avenue, Suite 1717, Chicago, IL 60611
have to blush and bear it, Nursing 21(11):72-73, 1991. (312) 644-0828
42. Suris JC, Resnick MD, Cassuto N, et al: Sexual behavior of adoles- Association for Sexual Adjustment in Disability
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1993: Sex Information and Education Council of the United States
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ery, Sexuality and Disability 11(3):29-43, 1993. 130 West Forty-second Street, Suite 2500, New York, NY 10036
45. Yim SY, Lee IY, Yoon SH, et al: Quality of marital life in Korean (212) 819-9770
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47. Zani B: Male and female patterns in the discovery of sexuality (313) 936-7067
during adolescence, J Adolesc 14:163-178, 1991. The Task Force on Sexuality and Disability of the American
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Gregory MF: Sexual adjustment: a guide for the spinal cord injured,
Bloomington, Ill, 1993, Accent On Living.
Kempton W, Caparulo F: Sex education for persons with disabilities that
hinder learning: a teacher's guide, Santa Barbara, Calif, 1989, James
Stanfield.
CH

ind Work Hardening

LEARNING OBJECTIVES
Work therapy After studying this chapter the student or practitioner
Work injury prevention will be able to do the following:
Work hardening 1. Discuss the role of occupational therapy in the
Industrial injuries development of work therapy programs.
Job modification 2. Identify occupational therapists instrumental in
Work samples the development of work therapy services.
Work simulation 3. Identify settings in which work hardening services
Work conditioning are currently provided and discuss the advantages
Physical tolerances and disadvantages of each setting.
Secondary gains 4. Describe the work hardening process.
Job analysis Nn Identify the goals of work hardening.

Critical job demands 6. Identify socioeconomic and psychological issues

Work tolerance baseline that can have an effect on successful completion of
Functional capacity evaluations a work hardening program.
Work tolerance screenings ae Identify components of a job analysis.
Body mechanics 8. Outline a plan for completing a functional capacity
evaluation.
9. Develop a work hardening plan based on a job
analysis and functional capacity evaluation of an
injured worker.
10. Describe an appropriate work hardening milieu.

American society, identity and self-worth are closely ment of occupational therapy (OT). In its early years,
tied to one’s role as a competitive wage earner. Inability OT was described as “any activity, mental or physical,
to perform in the worker role can lead to role reversals medically prescribed and professionally guided to aid
within the family and to lifestyle changes caused by a patient in the recovery from a disease or injury.”*°
economic hardship, forced inactivity and dependence, After World War I, the focus of OT was the rehabilitation
depression, and maladaptive psychosocial responses. of wounded veterans to help them achieve functional
These problems can become barriers to returning to levels necessary to gain employment. Today, work ther-
work, resulting in permanent disability with high eco- apy has expanded to a full range of industrial therapy
nomic and social costs. Restoring the worker role can services. The work injury prevention and management
reduce these costs for both the individual and society. spectrum includes acute treatment, job analysis, job
The importance of work as a life role within an in- placement, functional capacity evaluation, work hard-
dustrial society was recognized early in the develop- ening, and work conditioning.

226
 Work Evaluation and Work Hardening 227

Occupational therapists have played a major role in Amendments to the federal Vocational Rehabilita-
the development of work evaluation and work retrain- tion Act in 1954 provided for the establishment of
ing services. This chapter reviews the historical role of prevocational services within medical facilities. These
OT in work therapy, describes current models of prac- amendments increased the prominence of the profes-
tice, and presents the work therapy process. sion in the vocational rehabilitation field.”
In the 1950s, Lillian Wegg was the first health care pro-
HISTORY OF OCCUPATIONAL THERAPY fessional to describe a multidisciplinary program involv-
ing an occupational therapist, vocational counselor,
INVOLVEMENT
physician, and industrial engineer. Work hardening ac-
Work hardening has been a core component of work tivities included newly evolving work samples, work
therapy throughout the evolution of occupational tests, and job simulations. Formal discharge reports pro-
therapy and practice.*® In the 1800s, patients with tu- vided recommendations for adaptive equipment, modi-
berculosis were prescribed graded exercise and work tol- fied work schedules, and potential job placement.”
erance activities as part of a medical regimen that also Wegg revised and expanded components of the program
included good food and fresh air. Functional activities, during the next decade, moving away from a medical
including woodworking and graded clerical tasks, were model and closer to a vocational model. Work hardening
added in the final stages of treatment. Activities were de- was regarded as a vocationally oriented program with the
signed to increase physical and emotional tolerances purpose of improving deficient work habits and skills.”°
necessary for return to work.*° A physician's prescription was no longer required for re-
In 1919, George Barton stated that the purpose of ferral. Wegg’s approach was mirrored by occupational
work was to divert the mind, exercise the body, and therapist Florence Cromwell. Cromwell emphasized the
relieve the monotony and boredom of illness.°* World evaluation of work habits, intellectual and attitudinal
War I reconstruction workers, the first occupational factors, and work quality issues such as safety.'”
therapists, taught crafts in military hospitals as “work Many OT work programs in the 1950s followed the
cure.” Their goal was to rehabilitate wounded veterans leadership of Wegg and Cromwell and emphasized real-
to help them achieve the functional level necessary to istic work and the production of marketable work prod-
sustain employment.°® Crafts were regarded as thera- ucts. Patients worked in hospital or community set-
peutic modalities used to foster a sense of intrinsic pro- tings, producing items for sale while building self-
ductivity and fulfillment.” esteem, developing work habits, and increasing physi-
Programs of “habit training” with the goal of restor- cal tolerances.”
ing work habits impaired by disease or accident were In the 1970s, work hardening emerged as a primary
implemented in the 1920s. The federal Vocational Reha- industrial injury management service.’° Chronic pain,
bilitation Act of 1923 required the inclusion of OT in particularly low back pain, became a major focus of
general hospitals serving persons with industrial in- therapeutic intervention. Programs adopted a multidis-
juries and illnesses. This legislation marked the begin- ciplinary approach incorporating medicine, therapy,
ning of the formal involvement of OT in the vocational psychology, vocational counseling, and rehabilitation
rehabilitation movement.” engineering.~*~’*° Behavioral factors received increased
The psychiatric literature of the 1940s described work attention. Abnormal illness behaviors, depression, ex-
hardening as a program to prepare the patient for return cessive anger, lack of responsibility, and submaximal
to competitive life after the sheltered environment of effort were found to be important factors for projecting
the hospital. Realistic work environments were used, in- return to competitive employment.’*
cluding the hospital laundry, barber shop, and carpen- In the 1980s, work hardening programs incorporated
try shop. Personality traits considered important for the use of standardized work simulation equipment.
harmonious working, such as cooperation and friendli- Computerized equipment provided precise objective in-
ness, were evaluated.”° formation to measure such factors as effort, force, and
Physical disability practice literature in the 1940s endurance. Therapists combined realistic work activities
also stressed the importance of realistic work experi- with high-tech equipment to measure and analyze
ences for return to productive employment. Treatment results.®
programs allowed job modification to accommodate In 1989, the Commission on Accreditation of Reha-
variation in worker traits such as speed or productivity bilitation Facilities (CARF) drafted work hardening stan-
while maintaining quality standards.*” dards requiring an interdisciplinary approach.'* These
In the 1950s, a program at Massachusetts Gen- standards were updated in 1992.'* Work hardening was
eral Hospital incorporated the first use of objective defined as “a highly structured, goal oriented, individual-
evaluation of progress.’* Objective strength measures ized treatment program designed to maximize a person's
were used to track improvements and measure out- ability to return to work.”'* Interdisciplinary in nature
comes. and comprehensive in scope, work hardening used work,
228 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

defined as real or simulated job tasks, as the treatment hardening are closely tied to the requirements of the
modality. Job tasks were combined with injury-specific worker's preinjury job. When return to the original job
strengthening and flexibility training in a supportive en- is not feasible, the worker must be retrained for new em-
vironment to develop behaviors necessary for successful ployment and enters the vocational rehabilitation phase
return to competitive employment. of the industrial therapy process. Rehabilitation may be
more complex and difficult in this phase because of
worker fears, forced career changes, and difficulty enter-
CURRENT MODELS OF WORK
ing an unfamiliar work environment as a novice worker.
HARDENING PRACTICE
Occupational therapists traditionally have provided
The worker role remains a major focus of OT interven- industrial therapy services in a hospital or rehabilitation
tion. Any activity that contributes to the goods and serv- facility. Current practice has expanded this list of service
ices of society, whether paid or unpaid, is considered a locations to include the provision of services at the
work activity. Work must be purposeful and have injured worker's work site.°*”°? These on-site programs
meaning for both the individual and society. Engaging have many benefits. They provide immediate access to
in work is considered a productive activity and, as such, rehabilitation services, facilitate early return to work, and
a goal of OT intervention.*'* allow convenient scheduling and access to therapy while
Today’s work hardening program models draw on working. Communication between injured employees,
the historical role of work while integrating a variety of supervisors, and care providers is facilitated. On-site pro-
current concepts and principles.'’ These include occu- grams control employee access to services and are useful
pational and career development models, medical inter- in managing both the quality and the cost of care. Pos-
vention models, ergonomic and anthropomorphic prin- itive effects on morale can also result if employees view
ciples, and technology.®* the program as concerned with their welfare.
The Work Hardening Guidelines were published by the The recent expansion of hospital-based industrial
American Occupational Therapy Association (AOTA) in programs to community-based, on-site facilities reflects
1986, summarizing the use of basic OT practice princi- the transition of services to community settings. OT ed-
ples.* These guidelines gave a basic structure for services ucators and leaders have promoted this transition for
provided in a variety of settings and encompassed the last two decades. On-site industrial programs may
several frames of reference represented in OT practice. include acute treatment, work conditioning, work hard-
In 1992, the Work Practice Statement was developed by ening, functional capacity evaluations, preemployment
AOTA to further clarify the role of OT in the rehabilita- screenings, and wellness and prevention programs. Oc-
tion process of injured workers.” cupational therapists have the training and expertise to
Work hardening is one of many industrial therapy continue leading the expansion of work services into
services. Industrial therapy is diverse and involves a these new settings. In the continuum of industrial serv-
wide range of professionals. These include, but are not ices, work hardening can restore worker function when
limited to, occupational therapists, physical therapists, provided as part of either a hospital-based or an on-site
physicians, occupational health nurses, vocational industrial program.
counselors, safety or risk engineers, and insurance case
managers. Industrial therapy services provided by occu-
GOALS OF WORK HARDENING
pational therapists include, but are not limited to, job
analysis, functional capacity evaluations, and work re- Work hardening goals are focused on the ultimate ob-
training, including work conditioning and work hard- jective of maximizing the individual worker's ability to
ening. Work conditioning is limited to the physical return to work. Goals include (1) attaining optimal
components of flexibility, strength, coordination, and physical tolerances and abilities, (2) maximizing cog-
endurance for return to work. The behavioral and voca- nitive and psychosocial functioning, (3) developing ap-
tional components of the return-to-work process are propriate worker behaviors, (4) reducing fear and in-
not integrated within the work conditioning process. creasing confidence for the resumption of productive
Work hardening is a multidisciplinary, comprehensive work, and (5) identifying problems that may necessitate
program combining work simulation with strengthen- placement in an alternative job.
ing and behavioral components.*’”7°
Work conditioning is most often provided as part of
POTENTIAL BARRIERS TO SUCCESSFUL
the acute medical phase of the rehabilitation process. It
WORK HARDENING OUTCOMES
is frequently provided as part of the traditional acute
care therapy program. Work hardening services are gen- Several physiological and psychological factors may in-
erally provided in the later part of the medical phase of terfere with the attainment of work hardening goals.
the rehabilitation process, after traditional physical or These potential barriers to success must be recognized
occupational therapy is completed. The goals of work and addressed as part of the intervention plan.
 Work Evaluation and Work Hardening 229

Age and Gender Employer Attitudes

Age and gender have been shown to affect the potential The successful return to work of an injured worker can
tisk of injury and return-to-work status. Older workers be affected by an employer's attitudes and relation-
and female workers are less skilled than younger ships with workers. Employers often fear possible re-
workers and male workers in dynamic balance, climb- injury and reduced productivity of returning injured
ing, and lifting ability.*” This places older workers and workers.* These fears can reduce the motivation for
female workers at higher risk of injury than their employers to assist injured workers with the return-to-
younger, male counterparts. Once injured, these indi- work process. Employees who reported poor relation-
viduals may be more challenging to rehabilitate and ships with their supervisors had higher injury rates than
more susceptible to reinjury.*° In a retrospective study employees reporting good relationships with their man-
of over 24,000 Michigan workers’ compensation cases, agers.’
the relative risk of back injury was demonstrated to be
higher for women than for men in white-collar occupa-
Culture
tions.** Age was determined to be a barrier to work for
individuals with rheumatoid arthritis.°” Cultural norms and personal attitudes toward work can
be critical factors in successful work injury rehabilita-
tion. The value of work within a culture can be crucial in
Secondary Gains
motivating workers to return to work.
Injured workers can derive benefits known as secondary
gains as a result of a work-related injury. The injured
Pain
worker can perceive disability payments and the poten-
tial for financial gain, time off from work, avoidance of Chronic pain is defined as pain lasting longer than
responsibility, or sympathy and attention received from 6 months. Chronic pain can result in psychologi-
others as secondary gains. These secondary gains can cal disturbances, including insomnia, anxiety, de-
delay recovery.**°°*”*° Role changes within the family pression, and feelings of helplessness.°°?”**°* Psy-
structure may be incentives for family members to rein- chosocial problems, including alcohol and drug
force the injured worker's sick role.’* A newly employed abuse, weight fluctuations, difficulties with relation-
wife might like her new role as breadwinner and rein- ships, and sexual dysfunction, can result from these
force her husband's sick role. A father may suddenly disturbances.*°
have time to spend with his family and wish to avoid re-
turning to work.
Alcohol and Drug Abuse
A high incidence of alcohol and drug abuse is fre-
Litigation
quently reported among workers with high pain levels.
Injured workers with pending litigation frequently Abuse can precede the injury, be related to attempts to
improve at a slower rate than workers not involved in the control pain, or result from attempts to reduce or avoid
legal system.** Financial opportunities, including unem- stress. Participation and success can be negatively af-
ployment benefits, welfare benefits, and workers’ com- fected by active drug abuse behavior.
pensation, can all adversely influence return to work.”
WORK HARDENING PROCESS
Delayed Intervention Work hardening provides a holistic and realistic link
Successful completion of a work hardening program is between an injured worker's physical capacities and
related to the length of time the client has had the dis- limitations and essential physical job demands. The
ability before program initiation. The longer the period development of an individualized work hardening
of disability, the less likely that the individual will suc- program begins with a specific job analysis to deter-
cessfully return to work.” mine critical job duties. The ability of an injured
worker to perform these duties must then be deter-
mined by completing a baseline work tolerance evalua-
Confidence Level tion. Finally, information from the job analysis and the
Positive relationships and meaningful work tasks have baseline work tolerance evaluation is consolidated to
been found to increase self-confidence and motivation develop an individualized work hardening program.
for return to work. The level of worker confidence in his Functional limitations can then be specifically ad-
or her ability to do the same quantity and quality of dressed with a work hardening program designed to
work as coworkers is an important factor affecting moti- develop the tolerances required for completing critical
vation for return to work.*’ job duties.
230 i }=OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

Step One: Job Analysis

JOB ANALYSIS

The occupational therapist must clearly understand an Job Title

injured worker's specific job requirements to plan a Location
Work Hours to Overtime Per Wk
meaningful, relevant, and measurable program for the General Job Description:

worker. This understanding is gained through a job Equipment, tools, work aids:
analysis. Based on critical job demands, the job analy-
sis provides the foundation for development of a work Primary job functions:

hardening plan. A job analysis includes detailed infor-

Time spent:
mation on all critical job tasks, including physical work Standing hrs Sitting hrs Inside hrs Outside

demands and the use of equipment, tools, and materi- ACTIVITY YES | NO REPETITIVE CONTINUOUS COMMENTS
ae (# Hours)
als. Physical job demands include walking, balancing,
|Stoop/tend
Stoop/tend =|
climbing, standing, sitting, crouching, bending, lifting,
carrying, pushing and pulling, reaching, handling, and
fingering. Sensory components (e.g., vision, hearing,
fa er
Kneel

and smell) and environmental conditions (e.g., noise,

cold, heat, dust fumes, and vibration) are important en
considerations. Unique psychosocial demands such as
the need to interact effectively with angry customers or
imac! os [os | pa
tolerance of distracting environments should be consid- Grasp

ered if they are critical job functions. UFT/CARRY HRS/REPS/POSITION LIFT/CARRY HRS/REPS/POSITION

The increased reporting of work-related muscu-

loskeletal disorders has made it necessary to identify all
high-risk job factors, including frequency, force, dura- Environmental Conditions: (check if present)

tion, posture, and exposure to vibration and cold. Devel- Cold_____ Dampness_______ Heat
Psychological Requirements:
Dust/Fumes,

opment of worker tolerance for activities involving these

factors is imperative for a successful return to work. Analyst
The work hardening therapist does not have to com-
plete the job analysis if an employer, insurance carrier, FIG. 16-1
rehabilitation nurse, vocational counselor, or other pro- Sample job analysis form.
fessional involved in the case has already done so. If the
job analysis is available, the therapist can review and
validate primary job functions with both employer and such as diabetes, hearing loss, and hypertension are im-
employee. portant if they are relevant for task performance.
If a job analysis is not available, the therapist should The work tolerance baseline can be established
visit the work site to observe primary job tasks. Occupa- using a variety of assessment instruments. Both com-
tional therapists are qualified by their basic training to mercial and facility-specific assessment systems are
perform these on-site job task analyses. However, addi- available and are known by a variety of names, includ-
tional expertise and training is often needed to ade- ing functional capacity evaluations, physical capacity
quately complete medical and legal documentation re- evaluations, work tolerance screenings, or work capac-
quirements. Several government publications can serve ity evaluations. The purpose of the evaluation is to
as references to assist the therapist in developing a doc- provide a systematic process for observing, measuring,
ument suitable for legal purposes. These include the analyzing, and recording the ability of an injured
Dictionary of Occupational Titles,°° Revised Handbook for worker to perform specific job tasks.
Analyzing Jobs,°’ and A Guide to Job Analysis.** A simpli- CARF has listed components that should be included
fied sample of a job analysis form is shown in Fig.16-1. in the work tolerance baseline evaluation.'? These
include functional work capacity and musculoskeletal,
Step Two: Establishing Work Tolerance cardiovascular, cognitive, vocational, behavioral, and at-
titudinal status. The AOTA Commission on Practice Of-
Baseline
ficial Statement on Work Practice Services expands these
Determination of the worker's current level of function- components to include consideration of the injured
ing is as important as the job analysis in individual worker's age, interests, values, culture, and motivation
program planning. All pertinent physical, cognitive, and for change.'*
behavioral factors must be included in an assessment of A work tolerance baseline evaluation should
the worker's functional abilities. A factor is pertinent if it include the following components:
is (1) a requirement of the job and (2) subject to im- ® Medical history. An efficient evaluation process in-
pairment as a result of the injury. Medical conditions cludes a review of relevant medical records, informa-
 Work Evaluation and Work Hardening 231

tion concerning both current and past injuries, med- The physical assessment includes the following areas
ical interventions received, and relevant medical con- of focus:
ditions such as cardiac status and diabetes. Any or- @ Work postures and mobility. Flexibility is evaluated to
thopedic conditions such as previous fractures and determine functional range of motion of the trunk
soft tissue problems and any psychiatric conditions and lower and upper extremities. Postural strength
and treatment are important to consider. Work re- can be evaluated using the Krause-Weber Test.*' The
strictions must be obtained from the referring source VALPAR. Work Sample #9 (Whole Body Range of
and noted. Motion)’ is used to measure gross body movements
Worker interview. The worker's perception of the as they relate to the functional ability to perform
injury, work history, functional abilities, education, work tasks.
pain level, and vocational goals can be obtained m@ Strength. A variety of standardized and functional
through an initial interview. This interview provides tests may be used to measure strength. Dynamome-
the evaluator with insight into the worker's attitude, ters and pinch gauges are used to measure hand
fear of reinjury, motivation for rehabilitation, and vo- strength. The Baltimore Therapeutic Equipment
cational goals. Program goals and rules should be es- (BTE) Quest System and Work Simulator,’ Cybex II,”
tablished with the worker at this time. Lido WorkSet,** ERGOS,’® WEST 2A,*° and WEST
@ Job description with critical job demands. A job analysis 4A°° are several commercially available devices used
identifies critical job demands. If a job analysis is un- to measure strength. Endurance can be evaluated
available, the evaluator can ask the worker to describe with such devices as the Upper Body Ergometer,”*
job functions and can validate this information with Fitron/Lifecycle,?* and treadmill. Endurance is ob-
the employer or case manager. In this situation, the served throughout the evaluation. An evaluation of
therapist can also obtain generic job descriptions cardiovascular function can be completed as a pre-
with physical work demands from the Dictionary of measure and postmeasure test during the endurance
Occupational Titles°® to help determine critical job testing using a treadmill or the Upper Extremity
demands. Ergometer.~°
Pain assessment. The location, type, quality, and in- @ Sensation. The evaluation of sensation is vital for
tensity of pain must be determined during the work workers with hand injuries. The Semmes-Weinstein
tolerance baseline evaluation. The frequency of pain, Monofilament Test (Von-Frey Monofilaments) is used
activities that increase or reduce pain, and tech- to determine tactile discrimination.°* Other consid-
niques used for pain control, including modalities erations include edema and coordination. The
and medications, are important. Many pain ques- Schultz Upper Extremity Pain Assessment is a com-
tionnaires and charts are available for clinical use. prehensive test of hand function used by many clini-
These include topographic pain representations or cians.°°"*"
“pain drawings,” analog pain scales, and pain rating @ Coordination. Coordination and dexterity tests are
scales such as the McGill-Melzack Pain Question- used to determine the worker's ability to complete
naire.~’ Chapter 29 provides a further discussion of physical work tasks such as handling, manipulating,
pain assessment. and fingering. Commonly used tests include the
Physical assessment. The physical assessment is used to Crawford Small Parts Dexterity Test,’” Bennett Hand-
evaluate the worker's abilities to perform critical job Tool Dexterity Test,° Purdue Pegboard,®? and the
duties as described in the job analysis. These can Minnesota Rate of Manipulation Test.’ Work samples
include, but are not limited to, functional range of such as the VALPAR #1 Small Tools Mechanical,”
motion, strength, endurance, sensation, coordina- VALPAR #4 Upper Extremity Range of Motion,” and
tion, and dexterity. The physical assessment compares VALPAR #8 Simulated Assembly’* and the BTE Bolt
physical functions of the worker to critical job Box* are used to measure upper extremity coordina-
demands, identifying any discrepancies. Because tion and dexterity.
many injured workers are involved in litigation, it is @ Lifting, reaching, and carrying. Lifting, reaching, and
important to use standardized evaluation tools when- carrying tasks are inherent in most jobs. The worker's
ever possible. The evaluator should complete a basic ability to lift on a frequent or infrequent basis is de-
work tolerance screening of physical abilities before termined by work simulation or with specific work
assessing specific physical abilities to make sure the samples. Floor, knee, waist, shoulder, and overhead
injured worker is physically capable of completing level lifting abilities should be assessed, along with
the baseline work tolerance evaluation. The screening one- and two-handed lifting ability. Carrying tasks are
should include generalized testing of range of assessed in terms of weight loads by distance and
motion, gross manual muscle testing, sensory screen- time. Reaching is reported in terms of frequency and
ing, and testing of general ability to complete re- location or position (e.g., frequently reaches above
quired movements in a safe manner.”” head). Monitoring body mechanics of the worker is
pe 9 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

imperative during this assessment to prevent reinjury.

Work samples such as the WEST 2A,*° VALPAR Work
Sample #9 (Whole Body Range of Motion),’* and
WEST 3 (Comprehensive Weight System)*” can assess
lifting, reaching, and carrying abilities. Frequent lift
tests include the Progressive Inertial Lift Evaluation
(PILE)” and the EPIC 1 Lift Capacity.*’ Lifting and
carrying are considered primary physical job factors
along with pushing and pulling. Physical job factors
are divided into five levels of physical demands, in-
cluding sedentary, light, medium, heavy, and very
heavy work. These levels are specifically outlined in
the Dictionary of Occupational Titles°° and the Revised
Handbook for Analyzing Jobs.°’
@ Pushing and pulling. Pushing and pulling tasks should
simulate actual work conditions such as surface fric-
tion, handle height, and incline angles. Push-pull
sleds can simulate tasks that involve moving and con-
veying equipment and materials on carpet, linoleum,
or concrete floors. A Chatillon force gauge can test
actual push-pull force generated.’ Comparisons of
actual force can be made against specific tasks if
measures required to complete the tasks are given in
terms of pounds of force.
B Stooping, bending, kneeling, and crawling. Stooping,
bending, and kneeling can be assessed by observing
the patient’s completion of simulated work tasks or
samples such as the VALPAR #9 (Whole Body Range
of Motion)’* or the WEST 2A.*° The ability to crawl FIG. 16-2
can be assessed in a simulated work environment if it Reaching and climbing.
is considered a primary work demand.
@ Sitting and standing. The therapist can observe the
functional ability to sit and stand throughout the determine specific problem areas when evaluating a
functional capacity evaluation. The initial interview worker during completion of a cluster trait work
and dexterity tests provide the evaluator with oppor- sample.
tunities to observe the worker in a variety of positions When they are used to assess worker performance
over a long period. Sitting and standing tolerances and potential for return to work, baseline work toler-
can be observed while the worker is performing func- ance evaluations must be based on valid clinical re-
tional tasks. search to ensure that they will stand up in court if chal-
B Work task simulation. Critical job demands of the lenged. A variety of products are available, with widely
worker's job are evaluated using work task simulation differing levels of objective research backing their devel-
and work samples. Job demands may include the use opment, including programs designed by Matheson,*°
of tools, materials handling, or activities that require Blankenship,’ and Isernhagen.*° Proprietary systems in-
repetitive movement or maintenance of prolonged cluding both equipment and training are also available
postures (Fig. 16-2). The therapist should also evalu- and include the Functional Capacities Assessment by
ate pertinent environmental factors such as vibration, Polinsky Medical Rehabilitation Center,’ the Matheson
cold, noise, dust, and heat. A variety of clinic-made Function Capacity Evaluation,*° and the KEY Func-
devices can be used to simulate work demands. These tional Assessment.*” Jacobs published a comprehensive
devices include birdcages, boxes, sleds, and pipe tree review of work assessments in the second edition of
assemblies. Standardized work samples are also Occupational Therapy, Work-Related Programs and Assess-
widely used to evaluate the ability to complete work ments.*’ Selection of a system should be based on indi-
tasks. Work samples can be used to evaluate single vidual needs, as well as financial and time constraints.
worker traits or clusters of traits. Many of the WEST The final step in the work tolerance baseline evalua-
and VALPAR samples measure clusters of traits, such tion process is summarizing the worker's functional
as strength, endurance, and range of motion, that are abilities and identifying problems that interfere with
inherent in a job. Therapists must use task analysis to work performance. Issues such as pain behaviors,
 Work Evaluation and Work Hardening RA a He

symptom magnification, limited materials handling that is difficult to interrupt. Chronic pain syndromes
skills, poor posture and body mechanics, and level of can develop if this cycle is not broken. The treating
active participation are important to identify. Recom- physician may be consulted regarding alteration of
mendation for work hardening is made by comparison medication regimens or substitution of other pain
of the results of the work tolerance baseline evaluation control methods.
with job-specific duties. = Develop problem-solving skills for self-management at the
The work tolerance baseline evaluation can be used work site. Injured workers often have poor judgment
for a variety of purposes. The evaluation can establish and lack the ability to set reasonable limits. Injured
the baseline for work hardening or help to determine workers must learn to recognize and work safely
safe return-to-work levels, establish modified work within tolerance levels and to ask for assistance when
duties, or identify a disability rating.°° indicated to prevent reinjury.’
Evaluations range in length from several hours to @ Facilitate appropriate worker behaviors. Punctuality and
several days, depending on their purpose. Evaluations es- attendance issues should be addressed as needed.
tablishing baselines for work hardening programs are 3 Maladaptive patterns such as sleeping late must be
to 6 hours long and are usually completed on the first or eliminated. The worker must develop appropriate in-
second day of treatment. Assessing other factors such as teraction skills with supervisors and peers if these
general aptitudes and worker traits may require a longer skills are deficient. To meet competitive worker levels,
time to permit sufficient observation and evaluation. it is important to monitor and improve work behav-
iors, including task completion, quality standards,
and productivity.
Step 3: Individual Work Hardening Plan
Real or simulated work tasks are the primary treatment
After the job analysis and functional capacity evaluation modalities used to develop physical tolerances in a work
are completed, an individualized work hardening plan hardening program. Work tasks and activities selected
is developed. To be successful, the plan should deter- must be based on the worker's specific job demands and
mine specific work goals and function as a contract functional deficits as established in the functional ca-
between the worker and the therapist. The goals and in- pacity evaluation.
terests of the worker and questions of the referring It is not always possible to duplicate every job task in
agency are considered essential. The following are ex- the work hardening setting. Activities that require
amples of typical work hardening goals: similar physical and cognitive levels of function can be
@ Increase duration of daily participation. The worker's substituted for actual work tasks. Although it is not fea-
program should begin at a comfortable level that is sible for a worker to replace automobile mufflers in a
based on the findings of the functional capacity eval- standard work hardening setting, it is possible to design
uation. As tolerance for activity improves, hours of a simulated activity requiring tool use in a prolonged
participation increase incrementally until they reach overhead reaching position.
the level required for full participation in work duties. Work hardening activities must be compatible with
™ Increase physical tolerances to the level of critical job the worker's beginning level of function and must be
demands. Work activities requiring identified toler- progressed safely in graded increments until function
ances should be introduced in graded fashion and reaches the level required for work reentry. Symptoms
replicate, as closely as possible, the actual tasks re- associated with the injury must be managed as the
quired for the worker's job. worker reaches competitive work levels.
@ Improve body mechanics and postures. The therapist may A good work hardening program includes training in
teach and coach the worker to integrate postural body mechanics and materials handling techniques to
awareness and body mechanics skills into functional protect the worker from further injury (Fig. 16-3). The
movement and activities. Newly learned skills are therapist must teach back-injury prevention, pacing
practiced and reinforced in all phases of the program. techniques, and safety principles in a manner consistent
@ Develop pain management strategies. The worker must with the worker's level of education and background.
be encouraged to explore strategies for managing The worker must apply the principles taught to his or
pain so that functional performance is maximized. her job demands and practice the principle consistently
The therapist should note pain behaviors and give while performing job tasks. Skills must become auto-
feedback to the worker. A fear of movement because matic and be integrated into all daily life tasks.
of pain may lead to dysfunctional pain behaviors,
such as bracing, guarding, rigidity, rubbing and Work Hardening Milieu
holding of affected body parts, and other abnormal Work hardening programs can be found in a variety of
postures.*’° These abnormal postures can lead to in- settings, ranging from hospitals to industrial settings.
creased muscle tension, resulting in increased pain, These include outpatient facilities, workshops, private
leading to more tension, and finally becoming a cycle practices, rehabilitation centers, industrial medical
234 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

FIG. 16-3
Training in proper body mechanics.

programs, and on-site industrial services within facto- if measurable improvements are not demonstrated and
ries and work environments. Regardless of setting, a if these services are likely to be beneficial.
work hardening facility must replicate a realistic work
environment, providing actual and simulated work
Reporting Results
tasks. Using work that is relevant and meaningful is vital
in helping the injured worker understand and accept his Work hardening professionals must be skilled at com-
or her abilities and limitations. pleting objective, quantifiable, and defensible reports.
A realistic work hardening program replicates actual Program results must be reported in accordance with fa-
work schedules and environmental conditions. A cility protocols and accrediting agency requirements
typical program duplicates the work schedule of the and must include measurable progress toward specific
worker, including work breaks, meal breaks, and split goals. Progress reports must be clear, concise, free of
shifts if appropriate. It is important to simulate environ- technical jargon, and submitted to referral agencies in a
mental aspects such as working inside versus outside timely manner.°’ Periodic case conferences may be used
and exposure to dust and noise. to promote interdisciplinary communication and coor-
Work hardening services are best presented in a dination.
group format with a number of workers present who Referral sources require that a discharge report be
may be facing similar difficulties and fears. The desire to submitted at the end of work hardening services. Rec-
be competitive with one’s peers can be invaluable in fa- ommendations may include the use of adaptive equip-
cilitating the rehabilitation process. An atmosphere of ment, modified work techniques, and any other reason-
peer understanding and support can also be beneficial able accommodations to help the injured worker return
to the worker. The therapist should offer necessary to his or her previous level of employment.
support while making suggestions for compensatory
techniques, providing adaptive tools, and reinforcing
SUMMARY
new learning and skills.
Work hardening programs typically range from 2 to 6 Occupational therapy has been involved in work hard-
weeks in duration. Continual progress toward return-to- ening since the beginnings of the profession in the early
work goals should be observed throughout the program. 1900s. The profession’s use of holistic concepts, task
Services are terminated when goals are met or when analysis, and activities as therapeutic modalities are
measurable progress toward goals is not demonstrated reasons for its successful history and pivotal role in
or expected. The therapist should consider referral to work programs. Occupational therapists are trained in
other services in the industrial rehabilitation continuum physical, cognitive, and behavioral sciences and have
 Work Evaluation and Work Hardening 235

the skills necessary to play a vital role in industrial 6. What are the three steps in the work hardening
therapy. Industrial therapy continues to be a growing process and how are they related to each other?
area of occupational therapy practice. 7. What type of tasks or activities should be used to
develop physical tolerances in a work hardening
program?
8. Describe the various settings and components of a
work hardening program.
Case Stupy—J.D. 9. Discuss at least five goals that a work hardening
J.D., a 36-year-old brick mason, sustained a lumbar spine strain plan could include.
while lifting a bag of cement mix. He was referred for work hard- 10. What should the therapist do to protect the worker
ening to regain the physical ability required for his job. A job
from further injury during the work hardening
analysis identified the following critical job demands: (1) the
process?
ability to lift and carry masonry materials weighing up to 85
pounds on a frequent basis for distances of up to 50 feet; (2) the 11. When should a work hardening program be termi-
ability to stoop, crouch, and reach horizontally and vertically on a nated?
frequent basis for up to 8 hours; (3) the ability to stand and walk
intermittently during an 8-hour work day.
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age, gender, occupation, and industry: do they relate to return-to- May 1999.
work experience? Spine 14:1572, 1998. 60. Schultz KS: The Schultz structured interview for assessing upper
30. Greenberg SN, Bello RP: The work hardening program and subse- extremity pain, Occup Ther Health Care 1:69, 1984.
quent return to work of the client with low back pain, J Orthop 61. Schultz KS: Schultz upper extremity pain assessment, Glenwood
Sports Phys Ther 24:37, 1996. Springs, Colo, 1993 , Upper Extremity Technology.
Sill. Harvey-Krefting L: The concept of work in occupational therapy: a 62. Semmes J, Weinstein S: Semmes-Weinstein Monofilament Test,
historical review, Am J Occup Ther 39(5):301-307, 1985. Houston, 1994, Research Designs.
Bo: Heck C: Job site analysis for work capacity programming, Physical 63. Smith PC, Bohmfalk JS: Work related programs in occupational
Disabilities Special Interest Section Newsletter (American Occupa- therapy, New York, 1985, Haworth Press.
tional Therapy Association) 10:2, 1987. 64. Smith PC, McFarlane B: A work hardening model for the 80's: pro-
538). Hopkins H: An introduction to occupational therapy. In Hopkins ceedings of the national forum on issues in vocational assessment,
HL, Smith HD, editors: Willard and Spackman’s occupational Menomonie, Wis, 1984, Materials Development Center.
therapy, Philadelphia, 1993, JB Lippincott. 65. Straaton KV et al: Barriers to return to work among persons un-
34. Hunter SJ et al: Predicting return to work: a long-term follow-up employed due to arthritis and musculoskeletal disorders, Arthritis
of railroad workers after low back injuries, Spine 21:2319, 1998. Rheum 1:101, 1996.
315). Isernhagen SJ: Work injury: management and prevention, Rockville, 66. Superintendent of Documents: Dictionary of occupational titles, ed
Md, 1988, Aspen. 4, Washington, DC, 1991, US Government Printing Office.
36. Jacobs K: Occupational therapy: work related programs and assessment, 67. Superintendent of Documents: Revised handbook for analyzing jobs,
Boston, 1985, Little, Brown. Washington, DC, 1991, US Government Printing Office.
3% Jacobs K: Occupational therapy: work related programs and assess- 68. Taylor SE: Industrial rehabilitation. In Hopkins HL, Smith HD,
ments, ed 2, Boston, 1991, Little, Brown. editors: Willard and Spackman’s occupational therapy, Philadelphia,
38. Guide to job analysis, Indianapolis, 1991, JIST Works. 1993, JB Lippincott.
39. Key Functional Assessment, Minneapolis, 1987, KEY Systems. 69. Tiffin J: Purdue pegboard, Chicago, 1968, Science Research Associ-
40. Key G: Introduction to industrial therapy. In Key G, editor: Indus- ates.
trial therapy, St Louis, 1994, Mosby. 70. VALPAR #1 Small tools mechanical, Tucson, Ariz, 1988, VALPAR
4]. Kraus H: Backache, stress and tension: cause, prevention and treat- Corporation.
ment, New York, 1965, Simon & Schuster. ZA VALPAR #4 Upper extremity range of motion, Tucson, Ariz, 1988,
42. Lacerte M, Wright GR: Return to work determination, Phys Med VALPAR Corporation.
Rehabil State Art Rev 4:283, 1992. A225 VALPAR #8 Simulated assembly, Tucson, Ariz, 1988, VALPAR Cor-
43. Lido Workset, Sacramento, Calif, 1993, Loredan Biomedical. poration.
44. Loeser JD, Egan KJ: Managing the chronic pain patient, New York, Usy VALPAR #9 Whole body range of motion, Tucson, Ariz, 1988,
1989, Raven Press. VALPAR Corporation.
45. Main C: The modified somatic perception questionnaire (MSPQ), 74. Watkins AL: Prevocational evaluation and rehabilitation in a
J Psychosom Res 27:503, 1983. general hospital, JAMA 171:4, 1959.
46. Matheson LN et al: Work hardening: occupational therapy in in- Ta: Wegg L: Role of the occupational therapist in vocational rehabili-
dustrial rehabilitation, Am J Occup Ther 39:314, 1985. tation, Am J Occup Ther 11:4, 1957.
47. Matheson R et al: EPIC 1, Keene, Ohio, 1994, Roy Matheson and 76. Wegg L: Essentials of work evaluation, Am J Occup Ther 14:65,
Associates. 1960.
48. Matheson R et al: WEST 2A whole body range of motion and lifting DHE Wood DJ: Design and evaluation of a back injury prevention
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49. Matheson R et al: WEST 3 comprehensive weight system, Keene, 78. Ergos, Tucson, Ariz, 1990, Work Recovery.
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Keene, Ohio, 1994, Roy Matheson and Associates.
 17
Arne akWith Disabilities Act:
Accomn Odating Persons With Disabilities

LEARNING OBJECTIVES
Reasonable accommodation After studying this chapter the student or practitioner
Essential function will be able to do the following:
Ergonomics 1. List the types of disabilities and conditions that
Participatory ergonomics qualify a person for protection under the ADA.
Administrative control 2. Recognize and define specific terms as they are used
Job restructuring in the law.
Architectural barrier 3. Discuss the process for determining essential
Accessibility functions of job.
4. Recognize reasonable accommodations that are
possible and appropriate for employment settings.
5. Describe the role of participatory ergonomics in the
provision of reasonable accommodations.
6. Describe the step-by-step process of evaluating a
building for accessibility.

HISTORY OF LEGISLATION
I,is estimated that 43 million Americans have physi-
cal or mental disabilities. This number is expected to in- The Civil Rights Act of 1964 prohibited discrimination
crease as the population ages. Many of these people against handicapped persons who were (1) benefici-
were employed before the onset of disability, but few re- aries of programs or activities receiving federal funds
turned to their former place of employment or to a new or (2) employees of federal contractors or (3) federal
employment setting. Although the majority of people employees. The Americans With Disabilities Act (ADA),
with disabilities want to work, two thirds of all dis- signed into law on July 26, 1990, gives persons with dis-
abled Americans between the ages of 16 and 64 are not abilities civil rights protection similar to that provided
working.’ to all persons on the basis of race, sex, national origin,
Barriers to the employment of people with disabili- age, and religion.* The ADA does not preempt any
ties and to their use of transportation, public services, federal, state, or local law that provides greater or equal
and telecommunications have significant economic and protection for the rights of persons with disabilities. The
social costs. When barriers are removed, society benefits ADA guarantees equal opportunity for persons with dis-
from the skills, talents, and purchasing power of these abilities in public accommodations such as employ-
workers, who are able to lead more productive and ful- ment, transportation, state and local government serv-
filling lives. ices, and telecommunications.

237
238 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

The ADA provides for monetary and injunctive relief, significantly limited in the ability to perform an activity,
back pay, future pay, lost benefits, and attorneys’ fees for compared with an average person in the general popula-
persons proving discrimination. In addition to compen- tion. Major life activities are activities that an average
sation for actual dollar losses, damages might include person can perform with little or no difficulty. Examples
awards for emotional pain and suffering and for loss of of major life activities listed in the law include walking,
enjoyment of life. An employer who is shown to have speaking, breathing, performing manual tasks, seeing,
acted with malice and indifference to these federally hearing, learning, caring for oneself, working, sitting,
protected rights may also be subject to fines of up to standing, lifting, and reading.
$300,000 if the employer has more than 500 employ- Three factors should be considered in determining
ees. Smaller employers are also subject to large fines if whether an impairment constitutes substantial limita-
they do not make good faith efforts to comply with tion: the nature and severity of the limitation, the length
the law. or expected length of the limitation, and permanence or
expected effect. All of these factors are considered,
because simply identifying the name of the condition or
AMERICANS WITH DISABILITIES ACT
the diagnosis does not indicate whether it is substan-
The ADA comprises five sections, called titles.? Title I tially limiting to the life of an individual. An individual
concerns employment, Title II concerns public services, would be protected under the ADA if he or she has two
Title HI covers public accommodations, Title IV relates or more impairments that together cause substantial
to telecommunications, and Title V deals with a wide limitation, even if neither one substantially limits a
range of other topics concerning implementation of the major life activity by itself.
law. As of July 26, 1992, Title I applies to employers Other classes of individuals are covered by the provi-
with 25 or more employees, and as of July 26, 1994, it sions of the act. Persons who have successfully com-
affects employers with 15 or more employees. pleted or are participating in a drug rehabilitation
The ADA is broad and inclusive in its provisions. It program or have otherwise been successfully rehabili-
encompasses many areas of intervention appropriate tated and are no longer engaged in the illegal use of
for occupational therapists. The U.S. Equal Employ- drugs are covered on the basis of past addiction. The
ment Opportunity Commission (EEOC) has clearly intent of this provision is to protect people from dis-
defined and described the employment provisions in crimination based on myths, stereotypes, and fears
the Technical Assistance Manual of the Employment Provi- about disability.
sions (Title I) of the Americans with Disabilities Act.'* Any Persons who have a record of a disability or who are
occupational therapy (OT) practitioner who is inter- regarded as having a disability are protected by the ADA,
ested in providing services in regard to this portion of even if they are not currently limited in a major life ac-
the ADA should obtain and become familiar with this tivity.* This provision brings up a host of possible sce-
publication and associated documents and resources. narios. The law protects people with a history of cancer,
heart disease, mental illness, or other conditions whose
illnesses are cured, controlled, or in remission. The law
TERMS USED IN THE LAW
also protects people who have been erroneously classi-
A person with a disability is defined as someone who fied as having a disability or who have had a disability
has a physical or mental impairment that “substantially misdiagnosed. The perception of disability also entitles
limits” one or more “major life activities”; has a record a person to protection. Facial scars, for instance, may
of such an impairment; or is regarded as having such an create the perception of disability and thus carry protec-
impairment. According to the ADA, an impairment is a tion under the law.
physiological or mental disorder. A physical condition,
such as pregnancy, that is not the result of a physiologi-
TITLE 1: EMPLOYMENT PROVISIONS
cal disorder is not an impairment. Similarly, personality
OF THE ADA
traits such as poor judgment or a quick temper are not
impairments. Environmental, cultural, or economic dis- A goal of legislators in drafting the bill was to ensure
advantages such as a prison record or a lack of educa- that qualified individuals would have equal access to
tion also are not qualifying impairments.” An illustra- the rights and privileges of employment. Title I specifi-
tive example given by the EEOC is that dyslexia, a cally states that it is against the law to discriminate
specific learning disability, is an impairment, whereas against qualified job applicants or employees on the
an inability to read because of dropping out of school is basis of disability. This protection covers all areas of
not considered an impairment. employment, including the job application process,
An impairment is a disability only if it substantially testing, hiring, job assignment, promotion, discharge,
limits one or more major life activities. To be consid- wages, job training, disciplinary actions, leave, benefits,
ered disabled, a person must be unable to perform or be and several other aspects of employment.
 Americans with Disabilities Act: Accommodating Persons with Disabilities 239

As defined by the ADA, a qualified individual with a to do so would fundamentally alter the nature of the
disability is an individual with a disability who meets business.
the skill, experience, education, and other job-related Several other concepts must be understood to appre-
requirements of a position held or desired and who, ciate the effect of this law. An employer is not required
with or without reasonable accommodation, can per- to accommodate an applicant or employee if doing so
form the essential functions of the job.”'* For an indi- would pose a “direct threat” to the health and safety of
vidual to be deemed substantially limited in working, the individual or others in the workplace and if this
he or she need not be totally unable to work. The indi- threat cannot be eliminated or reduced by reasonable
vidual must be significantly restricted in the ability to accommodation. This threat must create “a significant
perform a broad range of jobs compared with average risk of substantial harm,” according to EEOC regula-
persons with similar training, skills, and abilities. tions. The risk of harm must be determined individu-
ally, considering severity, duration, and imminence of
the potential harm. For example, if there has never been
Persons Not Covered by Title I of the ADA
a fire in the building, it is not lawful to cite concern for
Current illegal drug use does not qualify a person for fire evacuation safety in denying employment to a
protection under the ADA. The act specifically states that person who uses a wheelchair. The law states that con-
the following are not covered disabilities: transvesti- siderations of “direct threat” must rely on objective,
tism, transsexualism, pedophilia, exhibitionism, voy- factual evidence and not on subjective perceptions, irra-
eurism, gender identity disorders, compulsive gam- tional fears, patronizing attitudes, or stereotypes.” This
bling, kleptomania, and pyromania. presents another opportunity for OT practitioners to
educate employers about the true nature of functional
limitations a person with a disability may or may not
Specific Provisions of the Employment
have.
Title
Once a threat is identified, the employer must evalu-
The primary intent of the ADA is to allow qualified ate whether the threat poses a significant risk of sub-
persons with disabilities to participate in the work force stantial harm. For individuals with mental or emotional
to the same degree as those without disabilities. It is not disabilities, the employer must identify the specific be-
a preference law, nor is it a quota law. Qualified persons haviors on the part of the individual that pose the
with disabilities must have equal access to employment direct threat. It is obviously the intent of the federal
opportunities, provided they are able to perform the law that persons-with disabilities not be denied employ-
“essential functions of a job with or without reasonable ment because of risks that are not truly significant and
accommodation.”* threatening.
By definition, a person with a disability cannot per- Occupational therapists are always concerned about
form tasks in the same manner as people without a dis- the safety and health of persons with disabilities. Thera-
ability; he or she needs some type of accommodation. pists must take care to ensure that individuals are not
The ADA requires “reasonable accommodation,” mean- barred unfairly in any way from employment because of
ing that the accommodation is effective for accomplish- overly protective concern for their safety and well-being.
ment of the task.7 These accommodations can take The requirement to accommodate reasonably applies
many forms, such as a restructuring of the job, an alter- again to this area of employment. An employer must
ation of the work schedule, the provision of a signing consider whether a reasonable accommodation might
interpreter, the provision of assistive aids or equipment, sufficiently reduce or eliminate the potential risk of
the widening of doors, and a host of other modifica- harm. Ifno accommodation is possible, the employer is
tions. However, the obligation of the employer does not not required to hire the individual. For example, an em-
extend to providing items that may be for the personal ployer may be seeking to hire someone for a carpentry
benefit of the individual, on or off the job, such as a per- position. An essential function ofthis position is the use
sonal attendant. of power saws and other potentially dangerous equip-
The ADA also states that making accommodations ment. For this position, the employer would not be re-
must not pose an “undue hardship” for the employer.” quired to hire an individual who has narcolepsy and
This means that the employer is not required to provide unexpectedly loses consciousness.
an accommodation that poses substantial difficulty or The concept of essential functions is new to many em-
expense. An accommodation that is unduly expensive, ployers who traditionally write job descriptions that de-
extensive, substantial, or disruptive or that fundamen- scribe the means to accomplishing the end product. Ina
tally alters the nature of operation of the business 1981 case filed under the Rehabilitation Act, the U.S.
would be deemed a hardship. For example, a dance Postal Service required each employee to be able to use
club would not be required to accommodate a visually both arms when performing the job of distribution
impaired employee by raising the light level because clerk. One employee with limited mobility of one arm
240 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

demonstrated that he was able to perform the essential modation. Physical agility tests are not considered med-
function of lifting and moving mail, although with one ical; therefore they may be given at any point in the
arm rather than two. In this case the court found that application or employment process. However, if a deter-
the essential function was lifting and moving mail, not mination of employment is based on the results of such
using two arms, and the employee was determined to be tests, the tests must be related to the job and consistent
a qualified individual with a disability.' with business necessity.
The term essential function means the fundamental
job duties of the employment position. In determining
Opportunities for Occupational
the essential functions of a job, the employer must
Therapists to Assist Employers
consider all relevant evidence. This evidence includes:
(1) the employer's judgment as to which functions are Given the broad provisions of Title I of the ADA, it is ap-
essential; (2) a written job description prepared before parent that employers, physicians, workers’ compensa-
interviewing applicants for a job; (3) the amount of tion insurance carriers, and other parties involved in the
time spent performing the function; (4) the conse- employment of persons with disabilities may need
quences of not requiring a person to perform the func- special expertise to fulfill their obligations lawfully. One
tion; (5) the terms of collective bargaining agreements; important mandate is that the employer show good
and (6) the experience of people who have performed faith efforts to comply with the law. Many employers
and currently perform similar jobs. lack the in-house knowledge and resources to meet this
A function cannot be deemed essential if it is in obligation. The unique training of occupational thera-
reality marginal or peripheral. For instance, a secretary pists, especially pertaining to functional performance,
may be requested to drive to the post office to buy adaptation, daily life activities, and knowledge of com-
stamps, but this task may be an incidental one that munity resources, equips them well to provide assis-
could be performed by another employee and is not es- tance. Several activities that may be unfamiliar to practi-
sential to the position of secretary. The example of an tioners are not so much new as they are different
airline pilot is often used to illustrate the reason for applications of therapists’ skills.
considering all relevant evidence and not just certain
aspects such as the amount of time spent performing Determination of Essential Functions
the function. An airline pilot may spend only 5% of the The ADA requires employers to examine the precise
work shift landing and taking off, but this function is functional physical activities required to perform work-
certainly essential for pilots. Likewise, a firefighter may related tasks. It is the right and responsibility of the em-
only occasionally carry an unconscious person from a ployer to determine which functions of their employees’
burning building, but the consequences of not requir- jobs are essential, though they may seek the assistance
ing performance of this function would be serious. of an occupational therapist to understand the precise
Employers are permitted to use physical agility tests, physical nature of the essential functions.
medical examinations, aptitude and ability tests, and To determine the physical demands of essential func-
tests for illegal drug use. There must be no disparate tions, a specialized type of task or job analysis is per-
impact—that is, the test must not screen out and dis- formed. The Essential Function Analysis Worksheet is a sys-
criminate against persons with disabilities.* It is not tematic way to perform this type of task analysis.® For
permissible, for instance, to give a written test to a each essential function of the job, a worksheet is com-
person with the specific learning disability dyslexia pleted by the occupational therapist in collaboration
unless reading itselfisan essential function of the job. with the employer and possibly with input from employ-
If testing is required for employment, all persons ees currently doing the job (Fig. 17-1). As with many
being considered for the job category must be tested in areas of the ADA, terms are used precisely. Bending refers
the same manner. It is not permissible to require a to stooping and bending forward at the waist while
medical examination or screening of physical ability keeping the knees straight. Squat (also called crouch)
only for persons with disabilities. Reasonable accom- refers to lowering oneself toward the floor while bending
modation is required in the testing process and testing the knees. Kneel refers to working at floor or ground level,
environment, if notice of the need for accommodation placing weight on one or both knees. Climb includes.
is received before administration of the test. ladders, stairs, scaffolding, and the like. Pull/push refers to
It is not permissible to require testing or examination pushing objects away from the body or pulling objects
or ask questions about disability before an offer of em- toward the body, such as when pushing a cart or pulling
ployment is made. The offer of employment may be re- a chain hoist. Using foot controls may include driving, as
scinded upon results of the examination or inquiry. well as activating foot switches. Hand manipulation
Aside from testing, the employer is permitted to ask the refers to gross hand grasp or manipulation, while fine
applicant to describe or demonstrate how a job-related finger manipulation denotes precise finger use and may
function would be performed with or without accom- include the use of small tools and parts.
 ESSENTIAL FUNCTION ANALYSIS WORKSHEET

Seeememine. TC SsDate of Analysis

Address of Job Site

eer CC... Hours per Week

1. General job description

2. Essential function

3. Time spent doing essential function

Activity Total hours doing the activity Hour continuous Can it be

performance? modified?
0 <1 71 O ts Sed Yes No

Recoil oe.
init Ses ae
aR
ae
eee tb feito Te |
RS
oe ++}
strat bare!
=e ileal
fom
4. Handmanipulation required [ ]lyes [ Jno [ Jright [ Jleft [ ]both [ Jintermittent [ ]continuous
Total time continuous Can function be modified? [ yes [ Jno

5. Fine manipulation required [ ]yes [ Jno [ Jright [ Jleft [ ]both [ Jintermittent [ Jcontinuous
Total time continuous Can function be modified? [ ]yes [ Jno

S Lift [ ]<1lb[ ]1-10lbs[ ]11-20 lbs[ ]21-30lbs[ ]31-40 lbs[ ]41-50 Ibs[ ]51-75 lbs
[ ]76-100 lbs [ ]>100lbs [ lintermittent [ Jcontinuous Total time continuous
Can function be modified? [ lyes [ Jno

7. Carry [ ]<1lb[ ]1-10 lbs[ ]11-20lbs[ ]21-30 lbs[ ]31-40 lbs[ ]41-50 lbs[ ]51-75 lbs
[ ]76-100 lbs [ ]>100lbs [ l]intermittent [ Jcontinuous Total time continuous
Can function be modified? [ lyes [ Jno

8. Psychological requirements

9. Employer confirmation signature Date

10. Analysis performed by Date

FIG. 17-1
Essential Function Analysis Worksheet. (From Isom R, Boyle K, Smith P: ADA compliance system,
Athens, Ga, 1993, Elliot & Fitzpatrick.)

241
242 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

The therapist should indicate on the form how much may assist the employer in purging employment appli-
time is spent continuously doing the activity at any one cations, interview procedures, and other employment
time (i.e., without taking a break or changing or alter- practices of discriminatory language, both overt and
nating activity). If the work is done intermittently with subtle. All employment documents should be free of
other activities, the therapist should indicate the negative wording such as the following: confined to a
maximum period of continuous performance at any wheelchair, wheelchair-bound, victim of, suffering from, af-
one time. flicted with, and crippled.
During the process of analyzing the essential func- The ADA encourages self-identification by persons
tions, the therapist also gathers information about with disabilities. Occupational therapists may train
whether a function can be modified and how this might hiring personnel to practice nondiscriminatory behavy-
be accomplished. This is discussed further in the later iors and procedures. Persons unaccustomed to interact-
section of the chapter pertaining to reasonable accom- ing with individuals with disabilities may benefit from
modation and participatory ergonomics. role-playing, mock interviewing, and the provision of
A task analysis for ADA purposes must be focused on information about various disabilities and their seque-
the precise nature of activities, such as weights of loads lae. For instance, hiring personnel need to know that
handled, hand functions, duration of effort, and num- HIV and AIDS are not contracted by casual contact and
ber of repetitions of physical movements. When per- that to deny equal employment opportunities to quali-
forming the essential function analysis, the therapist fied persons with these disorders constitutes illegal dis-
must understand the distinction between the process crimination.
used for production of a product and the physical activ- Occupational therapists may wish to develop a hand-
ity required for that production process. For instance, al- book of basic tips and suggestions for communicating
though a job function may be to load boxes of machine with people who have hearing impairments and distrib-
parts into a truck, this may not require manually lifting ute this handbook to managers and coworkers. Among
the box with two hands, carrying the box using its the general principles included in the handbook should
handles, and climbing into the truck. In other words, it be talking directly to the hearing-impaired person and
should not be assumed that manual lifting, using the maintaining eye contact, even when an attendant or in-
handles, and climbing are essential functions. In con- terpreter is present. Managers and coworkers should be
trast, using the hands to type on a computer keyboard reminded that although the communication skills of
may be an essential function for a secretary. Each job people with speech and hearing impairments may be
needs to be analyzed separately to determine these weak, this weakness is not a measure of intelligence or
factors accurately. An example of a completed work- self-confidence. The handbook should also remind
sheet pertaining to one of the essential functions of the managers and coworkers to keep their voices at normal
job of delivery driver illustrates how a single function is volume and not to raise or exaggerate the tone of their
analyzed and documented (Fig. 17-2). After each essen- voices, when speaking to speech- and hearing-impaired
tial function of a job has been analyzed and docu- individuals.
mented in this way, all of the worksheets pertaining to Language used in training materials should be free of
the job are combined and become a comprehensive jargon. Information should be presented with the intent
document for use by the employer—a document that to inform objectively, rather than to depict persons with
serves as evidence of good faith compliance with the disabilities as deserving of pity or as fortunate and
ADA. “chosen.” Community resources and social service
Employers may think that all functions of their jobs agencies can be tapped for information and referral.
are essential, when in reality some functions can be Disability advocacy groups in the community may be
distributed among other workers, some can be elimi- pleased to come to the work site and address groups of
nated or combined, and some are marginal, not essen- employees. Special interest organizations such as the
tial, functions. This situation presents another opportu- Arthritis Foundation, Cancer Society, Heart Association,
nity for an occupational therapist to help employers and many others can usually provide pamphlets and
understand the true nature of their jobs from the speakers.
standpoint of physical, cognitive, and mental require- Integration of employees can be fostered by forming
ments. work groups to promote contact between workers with
disabilities and their coworkers. Assigning tasks to a
Elimination ofDiscriminatory Questions, work group rather than to an individual encourages
Language, and Behaviors mainstreaming and reduces the social isolation that fre-
Human resources personnel and hiring managers may quently occurs for persons with disabilities.’ Removing
not be familiar with preferred terminology with respect the mystique of disability and promoting comfort in the
to persons with disabilities and may be insensitive to interview situation and everyday working environment
issues of nondiscriminatory language. The therapist can be especially beneficial for all involved.
 ESSENTIAL FUNCTION ANALYSIS WORKSHEET

EmployerName__411 American Office Place |= Date of Analysis __5/22/1992

Address of Job Site 10129 Bay Blvd. San Francisco, CA 94134

eriemee os? Very Driver Hours per Week _4°

1. General job description
Deliver office supplies and small equipment to customers in local counties.

2. Essential function toad, unload and deliver office supplies and small equipment.

3. Time spent doing essential function

ooh , oe Hour continuous Can it be

Activity Total hours doing the activity performance? moditied?

Dee Ll kee 4 OD Gieste Sites Yes No

4. Handmanipulation required [x]yes [ Jno [ Jright [ Jleft [x]both [x]intermittent [ ]continuous

Total time continuous _ less than 1 hr. Can function be modified? [ ]yes [x]no

5. Fine manipulation required [ ]yes [x]no [ Jright [ Jleft [ ]both [ Jintermittent [ Jcontinuous
Total time continuous Can function be modified? [ Jyes [ ]no

6. Lift [ ]<1Ib[ ]1-10bs[ ]11-20 Ibs[ ]21-30 Ibs [x]1-40 Ibs[ ]41-50 Ibs[ ]51-75 Ibs |
[ ]76-100 lbs [ ]>100lbs [kX ]intermittent [ Jcontinuous Total time continuous
__3° ™n-
Can function be modified? [xlyes [ ]no

7. Carry [ ]<1lb[ ]1-10lbs[ ]11-20 lbs[ ]21-30 Ibs [x ]31-40 Ibs[ ]41-50 lbs[ ]51-75 Ibs
[ ]76-100 lbs [ ]>100lbs [x Jintermittent [ Jcontinuous Total time Eantuuoise 2 ne
Can function be modified? [x]yes [ ]no

8. Psychological requirements

9. Employer confirmation signature Date

10. Analysis performed by Date

FIG. 17-2
Partially completed Essential Function Analysis Worksheet. (From Isom R, Boyle K, Smith P: ADA
compliance system, Athens, Ga, 1993, Elliot & Fitzpatrick.)

243.0
244 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

Medical Inquiries, Examinations,

leges of employment.* ADA regulations require a sys-
and Post-Offer Screenings tematic investigation of reasonable accommodations to
When an employee is ready to return to work after an achieve this goal.'* The investigation is to be conducted
injury or illness, the employer may require passage of a on an individual basis and should include the participa-
job-related examination (sometimes referred to as a tion of the person with the disability. The occupational
fitness-for-duty exam) as a condition of returning to therapist who is familiar with ergonomic interventions
work. The examination must evaluate only the ability to will recognize that this is an ideal opportunity to incor-
perform the essential functions of the job with or porate an ergonomic perspective to facilitate the fit
without reasonable accommodation. . between the worker and the job.
The employer may also require passage of an exami- Ergonomics is the study of the relationship between
nation by job applicants; however, different regulations the worker and the work environment. It is concerned
apply for a new applicant than for a returning em- with the problems and processes involved in designing
ployee. An applicant for a job may be required to partic- and, in some cases, modifying the environment for ef-
ipate in an examination only after a conditional offer of fective and suitable human working and living. Partici-
employment has been made. Such an applicant exami- pation of the person who is occupied in the environ-
nation or screening of physical ability does not have to ment has been called participatory ergonomics. This
be related to the job. However, if a person with a dis- practice maximizes the chance that the worker's motiva-
ability is screened out, the reason for disqualification tions, preferences, and beliefs will be considered and
must be related to the job and of business necessity. The incorporated into any ergonomic solutions. To leave
job-related screening activity must be a valid and legiti- out these elements invites a lack of cooperation and
mate measure of qualification for a specific job. Ifa test perhaps ultimate failure of the intervention or accom-
or activity does not relate to the essential functions of modation. Occupational therapists are especially skilled
the specific job, it is not consistent with business neces- in communicating with people with disabilities and en-
sity. All persons applying for the job must be examined, couraging their inclusion and participation.
irrespective of disability. An employer may give follow- The ADA mandates the provision of an effective ac-
up tests or examinations if the initial examination indi- commodation—not necessarily the best solution, but
cates a problem that may affect job performance.° one that will enable a qualified employee to perform
The post-offer screening should be preceded by a the essential functions to meet employer standards of
thorough essential function analysis to ensure that the production, quality, and safety. The EEOC has given
screening is based on the physical and mental require- several examples of possible accommodations.’* Pro-
ments of performing the essential functions of the job. viding physical access to the work site is a fairly obvious
The screening protocol should be matched to the spe- accommodation. The employer should remove struc-
cific job and should include the physical requirements tural barriers to any areas where the employee will
of each essential function, the frequency with which perform the essential functions of the job, as well as to
each function is performed, and the use of customary adjacent areas such as rest rooms, break rooms, lunch
tools, protective clothing, or equipment such as a rooms, recreational spaces, and any other areas an em-
helmet or gloves. The screening protocol also should ployee may expect to use. More suggestions about
replicate the work environment as much as possible. barrier removal for physical access are given later in this
Chapter 16 provides further information about devel- chapter as they pertain to Title III of the ADA.
oping a similar protocol, referred to as a “Work Toler- When reasonable accommodation strategies are
ance Screening.” The screening may be performed in a being developed, the simplest and least costly should be
clinical setting or at the work site. The screening also considered first. For instance, the therapist should first
may be quite brief if only a select number of essential investigate whether there is a way to modify how the
functions are included. This would be the case if only a function is performed, a strategy referred to as an ad-
few functions present substantial challenges in terms of ministrative control. This strategy satisfies the needs of
physical functional performance. It is important to re- the worker with disability and the employer's business
member that a screening is a measure of current per- needs at the same time. Energy conservation techniques
formance and does not predict risk of future injury. may be appropriate for many people and should usually
be considered. If these simple interventions are not suf-
ficient, it may be necessary to consider modifying tools
Reasonable Accommodation Investigation
or purchasing equipment and aids. Buying commer-
and Participatory Ergonomics
cially available equipment and aids rather than those
The ADA requires that persons with disabilities be ac- that are custom made is less expensive. Custom-made
commodated to ensure their equal opportunity to be devices and assistive technology may be necessary when
considered for a job, to enable them to perform the es- these previous administrative and ergonomic solutions
sential functions of a job, and to participate in all privi- are not adequate. Employers who are not knowledge-
 Americans with Disabilities Act: Accommodating Persons with Disabilities 245

able about other creative and cost-effective solutions formance rather than for other areas of functioning such
often have the perception that the more expensive as personal care. The employer's responsibility does not
options are the only ones available. usually extend to durable medical equipment such as
Job restructuring is another reasonable accommoda- wheelchairs. Ethical dilemmas may arise for occupa-
tion that may be considered. This approach includes ex- tional therapists about employee needs for such per-
amining an essential function analysis and rearranging, sonal care equipment; however, it is essential for the OT
adding, or deleting requirements in terms of tasks per- practitioner working in this area of practice to maintain
formed. This step may involve combining several tasks focus on the rights and responsibilities of the employer,
the individual with disability is able to perform or re- as well as those of the person with a disability.'*
moving tasks that cannot be performed and transferring Persons with psychiatric disabilities may need any of
them to another employee. Perhaps the job can be mod- the types of accommodation already discussed, as well
ified so that the hours of work are flexible to allow as other types of accommodations to enable them to be
needed breaks in the day, or perhaps the job may be successfully employed. Interpersonal communication
changed to part time. All of these changes are consid- may be especially difficult. It may be helpful to train su-
ered possible and desirable accommodations in the pervisors to provide written instructions or feedback for
view of the EEOC. the person who becomes anxious and confused when
Another accommodation might be reassigning a given spoken instructions. Added time, structure, and
person with a disability to a vacant position. The ADA organization may be helpful. Removing distraction may
does not require the employer to create a position; be useful and readily achievable by positioning room
however, the employer is required to consider place- dividers or facing workstations away from open areas.
ment of the person in a vacant position if one is avail- Extra support and reassurance may be necessary for the
able. The occupational therapist may assist the em- person reentering the work force after psychiatric hospi-
ployer in determining appropriate vacant positions talization.
within the company and evaluating the functional abil-
ities of candidates to perform the essential functions of
TITLE I! OF THE ADA: PUBLIC SERVICES
the available positions. What may appear appropriate to
the employer because it is light in nature may be inap- Title Il of the law pertains to all state and local govern-
propriate for a given individual because of the precise ment activities, services, and programs, including
nature of the activities required. courts, police and fire departments, town meetings, and
Modifying equipment, providing assistive aids, and employment offices.” Unlike section 504 of the Rehabil-
training in adaptive methods can also constitute reason- itation Act of 1973, which covers only programs receiv-
able accommodation. Products designed for other pur- ing federal funds, Title II extends to all the activities of
poses can be combined in creative and new ways. The state and local governments, whether or not they receive
Job Accommodation Network (JAN) is a service of the federal funds. This title prohibits state and local govern-
President's Committee on Employment of People with ments from denying participation in any service,
Disabilities? JAN provides information about resources program, or activity on the basis of disability. All pro-
and reasonable accommodations. By sending follow-up grams, services, and activities must be integrated and
questionnaires to callers who have used JAN services, must not have unnecessary eligibility standards or rules
the organization has been able to compile data about that deny participation to persons with disabilities.
the costs of accommodations. JAN determined that two Newly constructed buildings and alterations to exist-
thirds of accommodations cost less than $500. In a ing facilities must be structured to ensure access. New
1982 study for the Department of Labor by Berkeley buses and rail vehicles must also be accessible. Effective
Planning Associates, it was found that half of all accom- communication must be ensured.* Occupational thera-
modations cost nothing and more than two thirds cost pists may have opportunities in this area similar to
less than $100.” Many products that are readily avail- those afforded by Title III. A more complete explanation
able for consumer use are extremely useful for persons of potential opportunities is presented later in this
with disabilities. For example, telephones with oversize chapter.
buttons are thought of as decorative and trendy, but
they are also useful for persons with visual or motor im-
TITLE II: PUBLIC ACCOMMODATIONS
pairments.
Occupational therapists are becoming increasingly Title III of the ADA covers all buildings used by the
proficient in locating and applying assistive technology. public, such as restaurants, hotels, theaters, retail stores,
Detailed information about assistive technology can be museums, libraries, parks, private schools, day care
found in Chapter 19. Title I of the ADA pertains only to centers, and facilities used by social service agencies
employment issues; in these cases the concern of the cli- and health care service providers. This section of the
nician is confined to assistive technology for job per- law requires that existing facilities remove architectural
246 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

barriers where such removal is “readily achievable,” a strength requirements, and dexterity demands. Next, the
standard that has been defined as “easily accomplish- therapist performs an analysis of the person with dis-
able and able to be carried out without too much diffi- ability and his or her capabilities and limitations with
culty or expense.”* Barriers must be removed to allow respect to particular tasks. The therapist should keep in
access to the premises and use of the facilities, including: mind that persons with disabilities are experts about
parking areas, walkways, ramps, entrances, display racks, their own needs and capabilities and possible solutions
signage, doors, alarms, restrooms, toilet stalls, grab to their problems.
bars, and other features. If a barrier cannot readily be When the therapist is beginning an audit of accessi-
removed, other methods of providing access may be sub- bility, it is helpful to think in terms of the sequential
stituted. Examples include providing curb service or a steps taken by an individual seeking access to a facility
drive-up window, providing home delivery, having em- or service. Upon arriving at the facility, the individual
ployees retrieve items that are beyond reach, and moving must approach the entrance. If arriving by private
certain activities to accessible areas of the facility. vehicle, the person will need a drop-off spot or parking
Title III also mandates access to communication. area. The individual must have a means to enter the fa-
Persons with disabilities must be given the opportunity cility. Once inside, the individual must continue past a
to see, hear, and understand what is occurring in the en- receptionist or building directory and may pass through
vironment.’ Facilities remodeled after January 26, 1992, corridors, stairs, and an elevator.
must be readily accessible and usable by persons with All of the activities and movements in and about the
disabilities to the “maximum extent feasible.” Specific facility should be determined and noted in this system-
requirements apply to “key conveniences.” These are atic manner so that any barriers become evident. The
listed as the path of travel to the altered area (e.g., curb therapist may be accompanied on this excursion by the
cuts, ramps, doors, and elevators), rest rooms, tele- person with disability and by persons familiar with the
phones, and drinking fountains. These key conven- facility and the access alternatives that may be feasible.
iences must be accessible to the maximum extent feasi- Perhaps another route is more suitable or a different en-
ble unless the cost and scope is “disproportionate to the trance door is more easily used. It must be kept in mind
cost of the overall alteration.”” that facilities for persons with disabilities must be en-
New facilities must be “readily accessible to and abling and not discriminatory or segregated. For in-
usable by” persons with disabilities, regardless of cost. stance, access via a freight elevator on the loading dock
Certain implementation dates and exceptions apply to is not usually considered a suitable entrance for a
new construction. Detailed information about compli- person who uses a wheelchair.
ance can be found in the Americans with Disabilities General standards of accessibility have been devel-
Act Accessible Guidelines for Building and Facilities.” oped by various organizations and regulatory agencies.
The mandates of Title II and Title II] create numer- These standards are reviewed and revised periodically.
ous opportunities for occupational therapists to be of The most current information can usually be obtained
assistance. Whereas Title II mandates access for persons from local sources such as the building department of
with disabilities to travel to their destinations, Title III the city or county. If local regulations are more strin-
requires access for them to participate fully once they gent than the ADA, the local regulations take prece-
arrive. Various references have been and are being de- dence. Some general sequential guidelines are pre-
veloped to provide specific guidelines regarding acces- sented here as a basis for beginning to think about
sibility.’ '4 opportunities for occupational therapists to contribute
General principles of accessibility are part of the in this area.
basic training of occupational therapists. The process of
determining appropriate solutions begins with an Step 1: Entering the Building
analysis of the tasks to be performed or accessibility that Parking spaces or a drop-off zone should be located
is desired, often referred to as an accessibility audit. An near an accessible building entrance and connected to
audit of the facilities may have been performed previ- that entrance by walkways. Handicapped parking spaces
ously and should be obtained if available. The therapist should be designated and reserved. Parking spaces
should perform an audit if none has been done previ- should be 12 feet wide and have an access aisle for
ously. Information from the audit forms the basis of the loading and unloading. Curb cuts should be textured
services and recommendations to be provided. and should meet the street surface with as little lip as
possible. Walkways and ramps should be sloped at no
more than 2° to the side (cross slope) and 5° in rise and
Step-by-Step Audit of Facilities have a nonslip surface. A handrail should be provided
The therapist should begin an audit by clearly indicat- on at least one side; railing on both sides is preferred.
ing the physical activities required for access to the facil- The rail should extend beyond the top and bottom of
ity, determining such things as the means of travel, the ramp.
 Americans with Disabilities Act: Accommodating Persons with Disabilities 247

Ramps to doorways should have a 5-foot level surface conducted. Unique or unusual environments must be
at the top and bottom. Entrance doors should have at carefully inspected and questioned. For instance, if
least 32 inches of clear opening and should be power voice communication must occur through an opening
operated or easy to grasp and to push or pull open. in a glass security window, is there some way to
Doors in a series should have adequate space between augment communication for the user who is seated or
them to permit door swing into the space. Revolving very short in stature? Is there appropriate provision for
doors and turnstiles are not considered accessible en- persons using crutches or walkers to enjoy a sporting
trances. Appropriate directional signs pointing to the event from the grandstand? It is important to consider
nearest accessible entrance should be posted on any en- energy expenditure of persons with disabilities, as well
trance doors that are not accessible.” as the needs of elderly persons who may have decreased
endurance. The opportunity to sit and rest may be es-
Step 2: Building Interiors sential for participating in activities.’
All essential areas should be accessible without requir- All of these issues of access and accommodation
ing the individual to leave the building or negotiate require expert and sensitive advice from trained profes-
steps. Corridors should be at least 48 inches wide and sionals such as occupational therapists. The therapist
free of obstructions such as drinking fountains, support- often can recommend low-cost modifications for up-
ing columns, telephones, and decorative plants. Floors grading existing facilities. The occupational therapist
should have a hard, nonslip surface or low-pile carpet. If may also give advice during the design phase of new
public telephones are provided, at least one should be construction. Further information about minimal re-
mounted not more than 48 inches high. Drinking foun- quirements for access can be found in recently pub-
tains, if available, should be no more than 36 inches lished guidelines and local government publications, as
high to the level of water flow. The path of travel in all well as on Internet sites dealing with these areas.
areas, such as between desks, should be adequate in Additional information also can be obtained from
width. Identifying signs and labels should be of suffi- the online service maintained by the American Occupa-
cient size and color contrast for easy viewing. The use of tional Therapy Association. The ADA/Assistive Technol-
tactile letters and numbers and Braille letters is advis- ogy/Home Modification Resource Network is an online
able, as is an auditory signal in elevators to identify the list of occupational therapists who specialize in pro-
floor level. Elevator controls should not exceed a height moting the ADA. Technical advances such as voice-syn-
of 60 inches. Interior doors to public areas should have thesized direction signs and traffic signals, infrared
at least 30 inches of clear opening. Any stairs should be sensors in buildings, and other devices are being devel-
amply lit and should not have abrupt or open risers that oped and are becoming increasingly prevalent.
may catch toes or braces."°
TITLE IV: TELECOMMUNICATION
Step 3: Rest Rooms
Rest rooms present special challenges in terms of pro- Title IV requires that all intrastate and interstate tele-
viding for safety, especially because they are often small. phone companies establish relay systems for use by
In general, each building should have a minimum of hearing- and speech-impaired persons 24 hours per day.
one rest room for women and one for men that are ac- These services must be available at no additional cost.
cessible to persons using wheelchairs. All doors and This title also requires that television public service an-
Passageways should be wide enough to permit a wheel- nouncements produced or funded by the federal gov-
chair to make any required turns. Toilet stalls should be ernment include closed captioning.
of sufficient width to permit a front or side transfer.
Handrails should be appropriately located and capable
SUMMARY
of supporting a 250-pound load. Dispensers, hand
dryers, and other fixed items should not impede move- The ADA mandates a broad range of services to ensure
ment and should be positioned for easy reach, generally equal opportunities for persons with disabilities. The
not higher than 48 inches. Mirrors should be full length act's various titles, particularly the portions pertaining
or tilted downward. Sinks should have easy-to-operate to employment and to access to public services and fa-
handles and knee clearance underneath the fixture. cilities, encourage participation in society by the esti-
Drains and hot water pipes should be insulated to mated 43 million persons with disabilities in the
prevent burns.’° United States. As employers, public agencies, and serv-
ices strive to comply with the provisions of the ADA,
Step 4: Other Considerations many exciting opportunities are created for knowledge-
All areas of facilities used by the public should be free of able occupational therapists.
barriers to physical movement and impediments to The therapist's basic training must be augmented
hearing, seeing, and understanding the business being with a thorough study of the law and its regulations and
248 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

interpretations. To this base of knowledge should be 7. How can a person with a specific learning disability
added (1) experience with persons with all types of be tested for ability to perform the essential func-
qualifying disabilities and (2) expertise in ergonomic tions of a job?
accommodations to compensate for the impairments 8. How can occupational therapists help employers
that may be associated with these disabilities. Finally, develop employment application forms and inter-
the therapist must understand the business and human view questions that comply with the ADA?
resources needs of employers. Armed with this knowl- 9. What are some of the ways qualified persons with
edge and experience, occupational therapists are disabilities can be accommodated if they are unable
uniquely qualified to provide consulting and direct serv- to perform an essential function of a job?
ices to aid in compliance with the ADA. 10. Must all job applicants or only applicants with dis-
abilities be required to pass a screening of physical
ability before they begin a new job?
CASE STUDY 17 11. Does public access to buildings apply only to gov-
ernment facilities, or does it also apply to buildings
Case Stupby—Mnkr. G. owned by private parties?
Mr. G. has a congenital orthopedic condition and requires the use 12. Access is required to what parts of the building?
of awheelchair He is a technical writer and has accepted a posi-
13. How should an occupational therapist plan an eval-
tion with a new employer. The company is located in a historic
building that cannot be extensively modified.
uation of a building for accessibility?
Mr G. arrives at work by car enters the building unassisted, 14. Are telecommunications companies required to
and takes the elevator to his floor He cannot reach the elevator provide any particular services according to the
buttons and cannot open the door to his company suite. His ADA? If so, what are those accommodations?
cubicle is fully accessible for him; however, he has difficulty using
the telephone because he tires of holding the receiver for pro- REFERENCES
longed periods. 1. American Management Association: Special report: ADA in
In collaboration with Mr G. and his employer, the occupational action, HR focus, special report, 1992.
therapist developed and fabricated a small reaching device to use 2. Americans With Disabilities Act of 1990 (PL 101-336), 42 U.S.C.
for pressing the elevator buttons. Mr G. carries the device with 12101, Federal register, 56:144, 35543-35691, 1990.
him. The door to his company suite is made of glass and is too 3. Bachelder JM, Hilton CL: Implications of the Americans With Dis-
heavy for him to open. A receptionist is always seated in the abilities Act of 1996 for elderly persons, Am J Occup Ther 48:73,
lobby. An arrangement was made for the receptionist to open 1994.
the door for Mr. G. each morning and evening. A doorbell-type 4. Carbine M, Schwartz G: Strategies for managing disability costs,
Washington, DC, 1987, Washington Business Group on Health.
buzzer was installed outside the door, and Mr. G. uses the buzzer
5. Civil Rights Act of 1991 (PL 101-166), 42 U.S.C., Congressional
to ring the reception desk when he desires access. Because Mr. G.
Record 137:191, 1991.
works in an open cubicle, it was decided that a speaker tele- 6. Ellexson M: ADA compliance: to screen or not to screen? Work
phone would not be feasible; however, a lightweight headset will Programs Special Interest Section Newsletter, American Occupa-
enable him to use the telephone hands-free. With these simple, tional Therapy Association 8:1, 1994.
low-cost accommodations, Mr G. is able to perform the essential 7. International Center for the Disabled: ICD survey of disabled
functions of his job as a technical writer. Americans: bringing disabled Americans into the mainstream,
New York, 1986, The Center.
8. Isom R, Boyle K, Smith P: ADA compliance system, Athens, Ga,
1993, Elliot & Fitzpatrick. ;
9. Job Accommodation Network: The truth about accommodations,
Morgantown, W Va, 1994, The Network.
REVIEW QUESTIONS 10. National Rehabilitation Association: Revised manual for accessibil-
ity, Alexandria, Va, 1988, The Association.
1. Does the ADA pertain to small employers or only to 11. National Rehabilitation Hospital-ADA Compliance Program:
very large employers? Answers to questions commonly asked by hospitals and health care
2. What qualifies a person for protection under the providers: ADA, Washington, DC, 1993, The Hospital.
ADA? 12. President's Committee on Employment of People With Disabili-
3. What is meant by “substantially limits a person”? ties: ADA and the health professions, Washington DC, 1993, U.S.
Government Printing Office.
4. What are the major life activities to which the law 13. Rein J: Reasonable accommodation in the workplace, Work pro-
refers? grams special interest section newsletter, 1992, American Occupa-
5. Can a person be prevented from participating in a tional Therapy Association.
job if the supervisor has any concern about his or 14. U.S. Equal Employment Opportunity Commission: Technical as-
her ability to safely perform the job? sistance manual of the employment provisions of the Americans With
Disabilities Act, Washington DC, 1992, Equal Employment Oppor-
6. What six categories of evidence should be consid- tunities Commission.
ered in determining the essential functions ofa job?
 18
WakjernayaCaahwnelas

LEARNING OBJECTIVES:
Recreation After studying this chapter the student or practitioner
Leisure will be able to do the following:
Coordinated leisure 1. Discuss the benefits of leisure for adults.
Complementary leisure 2. Contrast various forms of leisure.
Social roles 3. Identify factors that may interfere with leisure
exploration and activity.
4. Describe a comprehensive leisure evaluation.
5. Identify specific strategies to promote leisure activity
for persons with disabilities.

RECREATION AND LEISURE

community but we must tap the resiliency of our own
IN ADULT LIFE
spirit.”*
Leisure takes on different aspects of importance Adult play is classified as recreation and leisure. Recre-
throughout the adult years. For young adults, issues of ation regenerates energy to support the worker role.’*
time and financial resources, as well as extensive work Leisure is freely selected activity pursued simply for the
and family responsibilities, may limit access to mean- pleasure of the activity, with a minimum of social role
ingful leisure. Until very recent years, adults with physi- obligations and freedom from constraint.* Activities
cal disabilities would have had difficulty finding the that are not clearly work or leisure are called coordinated
adaptations necessary to continue with past leisure pur- leisure and complementary leisure.'* Coordinated leisure
suits or develop new interests. The aging process affects is work-related activity that has the element of being
leisure pursuits with the decline in physical abilities, freely chosen; reading a professional journal is an
sensory changes, and the perceptions of not being as example of coordinated leisure. Complementary leisure
capable at an endeavor as in previous years. However, as is role related. Involvement in a professional association
one expert reminds seniors, “If we draw on our own re- relates to the work role; being a scout leader relates to
sources to eat right, exercise, and keep active and in- community and family roles.*
volved, our older years can be the most rewarding years. Activity provides for structure and routine in daily
Our later years must be infused with expectations and life and is individualized. Routine and structure estab-
meaningful activity based on our past successes, not on lish a secure base for need fulfillment and support social
self-pity over past failures. The secret of successful aging roles when there is a balance of work and play.'* This
is more than being able to tap the resources in our balance enables people to use time effectively and adapt

249
250 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

to life changes as they arise. Leisure skills may be devel- @ Demographic material
oped and incorporated into the changing pattern of @ Social information
daily activity. Both work and play generate social roles, @ Educational history
which support involvement in a stimulating, caring @ Occupational history
network of family and friends. Social roles in leisure fill @ Military involvement
needs for belonging and affection and generate a posi- # Community and church involvement
tive sense of well-being. Active involvement in leisure @ Typical daily routine
keeps people feeling young and interested in life. @ Interests and hobbies
Leisure activities can be an arena in which to vent =@ Mealtime interests
feelings and drives in a socially acceptable way. These ® Abilities
activities can provide an avenue for people to satisfy @ Sensorimotor components
their individual needs: the need to express or create, the @ Cognitive components
need to have a sense of achievement, the need for relat- ™@ Psychosocial components
edness to others and to the environment, the need to
render some socially useful service, and the need to
PROBLEM IDENTIFICATION
belong and be considered part of a community. Leisure
AND GOAL SETTING
activities give people an opportunity to be productive
and contributing members of society, to have identities The evaluation process must identify any problems that
and to see themselves as unique individuals, to gain would inhibit successful participation in the chosen
recognition, and to have new experiences. People act leisure activities. Once the overt problem is identified,
out their life’s roles and succeed or fail in satisfying their the OT practitioner must explore the components of the
needs through their work and their leisure activities. problem and their causative factors and determine
whether environmental issues complicate the problem.
Thorough problem identification is the most important
PRINCIPLES OF WORKING
step in finding solutions and thereby empowering the
WITH THE OLDER ADULT
client to participate successfully in the leisure activity.
When the medical model guides treatment decisions, Within this process the individual and the therapist
social and occupational roles are not generally consid- must collaborate in goal setting and become invested in
ered. The focus is on diagnosing a specific disease; per- the accomplishment of the goal.
sonal mobility, independent living skills, and other
social factors may not be addressed. Dealing with the
CULTURAL INFLUENCES
aging process and subsequent institutionalization
reduces opportunities for individuals to exert control As the OT practitioner determines these activities that
over many daily tasks, including choices and opportuni- had been meaningful to the client, he or she must be
ties for leisure tasks. This often leads to a decreased sense aware of the client's culture. This includes knowing
of competence, decreased motivation, and depression. what value or lack of value is placed on leisure. The
Since occupational therapy (OT) is directed at an client’s values can dictate what tasks are important and
older adult's ability to function independently in all how to incorporate these tasks in goal setting. Leisure
aspects of daily living, whether work, self-care, play, or pursuits may then be adapted to fit the needs of the in-
leisure, the therapist should be involved in the evalua- dividual receiving service and be incorporated into the
tion of the client's lifelong interests, priorities in pursuit treatment plan to stimulate cognitive awareness and
of those interests, and physical, psychosocial, and cog- perceptual processing abilities.
nitive ability to pursue those interests. Achieving suc-
cessful outcomes in the pursuit of leisure activities may
COMMUNITY RESOURCES
require and elicit coordination between the individual’s
sensory motor, cognitive, and psychosocial systems in When a disability challenges an individual’s work skills
the context of interpersonal, cultural, and environmen- and the individual does not have well-developed leisure
tal conditions." interests, the therapist is even more challenged to facili-
tate involvement in leisure to satisfy needs. A wide
variety of community recreation activities are available,
EVALUATION AND INTERVENTION
encompassing many areas of interest for physically chal-
FOR LEISURE ACTIVITIES
lenged adults. Theater, concert, and dining groups that
To ensure successful performance of leisure activity, the provide accessible transportation open new opportuni-
OT practitioner needs a comprehensive approach to ties. The availability of active and passive sporting
evaluation. The important components include the events, including sailing, skiing, and swimming pools
following: with special lifts and well-controlled water temperature,
 Leisure Activities 251

has dramatically changed accessibility of these pursuits.

ACTIVITY ANALYSIS
Public transportation is more readily available to meet OT education addresses activity analysis and synthesis,
the needs of people with disabilities as they pursue which enables the therapist, in collaboration with the
leisure activities. Therapy must address the ability to client, to design occupational experiences that offer the
take part in community-based leisure activities, starting individual opportunities for effective action. These ac-
with the identification of resources and the develop- tivities are considered purposeful because they assist
ment of skills to get to the activity and participate in the and build on the individual's abilities and lead to
activity. Clients must achieve security in these abilities if achievement of personal goals."
they are to tolerate the extreme risk taking that partici- An OT practitioner analyzes activity from two major
pation may involve. perspectives. First, the practitioner examines an activity
to identify its component parts and determine which
skills are necessary to complete the task. Second, he or
DISENGAGEMENT OF THE ELDERLY
she examines the activity within the context in which it
A literature review focusing on social gerontology, OT, must be performed. The practitioner considers the inter-
and quality-of-life issues reveals that disengagement is personal and environmental components, including
frequently a function of depression. “Rolelessness,” “use- the individual’s age, occupational roles, cultural back-
lessness,” and “old age” as a devalued status cause stress ground, interests, and gender, that affect the perform-
and loss of life satisfaction. Isolation occurs, bringing de- ance of the activity. All this information considered
terioration of the sensory receptors, and symptoms of de- together allows the OT practitioner to synthesize (i.e.,
mentia may appear. As these changes occur, the person's adapt, grade, and combine) activities for therapeutic
sense of self begins to change and is influenced by the purposes” so as to allow the client to succeed in his or
kind of valuing and social labeling he or she experiences. her chosen leisure time activity.
Productivity is related to life satisfaction,'* and the loss
of productive roles may precipitate a decline in other
ABILITY AND INTEREST EVALUATION:
areas. The person may begin to view self as deficient and
LOOKING AT PERFORMANCE AREAS
incompetent.
Practitioners teach skills that relate to performance
components and occupational performance areas; if
WELLNESS CONCEPT
this is not entirely successful, they adapt the task and
Activity is orienting and physically, socially, and educa- the environment to facilitate performance. Throughout
tionally stimulating. Leisure activities can (1) minimize a purposeful activity, the OT practitioner modifies the
losses, (2) provide development of compensatory tech- setting, the method of personal interaction, and the
niques that allow increased effectiveness and support physical handling” to achieve success in pursuit of the
competence, and (3) help maintain self-esteem and leisure time activity. Practitioners of OT also use sup-
prevent an individual from being thrown into’ the portive or assistive devices or techniques to ensure
vortex of a degenerative spiral of senility. Building on success. Such techniques or devices are considered to
existing strengths, adaptations, and coping mecha- facilitate or prepare for the performance of purposeful
nisms, the OT practitioner can facilitate the develop- activity and are used to enhance the effectiveness of
ment of leisure skills that will improve health and life an activity.'”'° The successful performance of leisure
satisfaction for the aging person. Leisure activities can activity can promote feelings of personal competence
contribute to successful adaptation to old age through and enable persons to achieve mastery of their envi-
the establishment of new roles and valued activities. ronment.°
These activities must be those that participants find
personally meaningful and that allow individuals to MOTIVATION: MATCHING INTERESTS
focus on strengths that deemphasize limitations.
AND ABILITIES
Deane Davis, when he was the 84-year-old former gov-
ernor of Vermont, put this idea in modern vernacular: The process of motivation begins with an identification
“There's a vast difference between aging and growing of the individual's abilities, strengths, and interests
old. There’s not much you can do about aging. . . but through the evaluation. Once identified, these items are
there’s a whole lot you can do about growing old.” matched with the type and task demands of an activity.
Davis knew a man who was so ready to die that he Matching by evaluation and analysis of the components
never bought green bananas. “That's not the way to and context of that activity, OT practitioners can create
live. Go out and buy green bananas. Make sure every opportunities for individuals to be successful and find
single day is full of life, full of adventure, and full of satisfaction in the task. Success is an important motiva-
function. Life is acting, thinking, doing, being, and tor, as are individual needs and values. The therapist
growing.”* must identify what is important to an individual at this
Tl OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

particular time of life. OT practitioners cannot motivate receiving treatment or other services. Practitioners of OT
people directly but can stimulate them to become moti- can sometimes be reimbursed by Medicare for one to
vated by their own needs and desires. Practitioners can two visits for leisure evaluation and program planning
adjust the environment to set the stage for a person to in the home health setting. However, it is recommended
self-motivate. To cause a person to do something, the that the development of a leisure-based program be
therapist must cause them to want to do it. Stirring up combined with other activities, particularly ones involv-
interest and desire leads to mental and physical motion. ing ADL skills or physical components that occur during
The therapist becomes the force or influence in the a treatment session focusing on leisure routines. The
process. Pleasure and satisfaction come from the person’s practitioner should document both the physical and
accomplishment, and the involvement becomes self- leisure components of the activity.’
motivating.
GROUP PROCESS
THERAPEUTIC USE OF SELF
The OT practitioner can use group skills and leadership
The therapist's means of helping the person to become expertise to help members of a group achieve need sat-
motivated will often set the stage for the future action. isfaction. Many of the individual’s needs that were pre-
Each person must be approached differently, and each viously mentioned, especially the needs to belong and
approach to the same person also may need to be differ- to have meaningful relationships with others, may be
ent. The practitioner of OT must be sincere in what he satisfied through group dynamics and task or social
or she does and says; the practitioner cannot “fudge” roles. Those roles may include the following.*
this. The first contact with a person will often set the
stage for future participation in the leisure activity the
Task Roles
practitioner is presenting. The practitioner must “make
haste slowly” because older persons may be resistant to @ The initiator-contributor, who suggests new ideas
change and slow to accept new leisure ideas. They need @ The information seeker, who asks for clarification of
time to think and react. The therapist must remember facts
that progress comes by inches and be sure that each ™ The opinion seeker, who asks for clarification of
inch is in the direction the therapist wants to go. opinions
The attitudes of the therapist and the older person @ The information giver
are vital. The therapist must be encouraging, must @ The opinion giver
conceal any concerns but still be sincere, and must m@ The elaborator, who spells out suggestions
avoid blaming the client for failures while at the same @ The coordinator, who clarifies relationships
time giving pleasure and individual satisfaction. The m@ The evaluator-critic, who compares the accomplish-
elder must maintain a positive attitude, satisfy individ- ments of the group to a standard
ual needs, and motivate himself or herself in order to m The energizer, who gets things moving
pursue and enjoy leisure activities. m™ The procedural recognizer, who performs routine
tasks
VARIED SETTINGS FOR LEISURE
ACTIVITIES Social Roles
Occupational therapists may be involved with the geri- m@ The encourager, who praises and accepts contribu-
atric client in many medical and social settings. The tions
practitioner's involvement with leisure will vary in @ The harmonizer, who mediates differences
scope and intensity in each setting. At any given time, m@ The compromiser, who changes behavior to maintain
95% of all elders will reside in the community. Settings harmony
in which the client may receive some leisure interven- m@ The standard setter, who expresses standards
tions include home health care services, adult day care, ™@ The group observer, who interprets and presents in-
senior centers, and outpatient rehabilitation. The geri- formation about what is happening
atric client may move through different aspects of the @ The follower, who goes along with the group
system: a rehabilitation hospital or rehabilitation unit
of a hospital, subacute care, a long-term transitional
CATEGORIES OF LEISURE ACTIVITIES
hospital, a nursing home, assisted living, or a retirement
home. Participation in leisure activities may take place in large
Leisure routines are an important aspect in any and groups, small groups, or individually. The activities may
all settings in which an elderly person may be living or be classified as arts and crafts, active recreation, social
 Leisure Activities 253

recreation, religious, intellectual or educational, com- tributes, including expertise in the needs of the elderly, a
munity, or service to others, to name just a few. Each can capacity for self-direction, the ability to focus on tasks,
offer many psychosocial and physical benefits, such as the composure needed to remain objective, and the in-
the following. terpersonal skills to negotiate effectively.
As consultants, OT practitioners must make recom-
Psychosocial Benefits mendations to improve services to the client; however,
they do not have the authority to enforce the imple-
@ Increased sense of self-worth mentation of those recommendations. All recommen-
@ Release of hostility and aggression dations and activities should be documented for each
@ Shared control of self and environment consultation visit. The occupational therapist's holistic
m@ Experience of choice educational background, coupled with experience, is
_@ Increased socialization valuable preparation for the role of consultant. Knowl-
@ Development of leadership edge of the process of aging and the focus on quality-of-
™@ Practice in adaptive behavior and coping skills life issues for all people, including those with dementia,
@ Increased attention span is indispensable.’
@ Adjustment to living arrangements
@ Increased tolerance of groups and other people
DEMENTIA CARE AND LEISURE SKILLS
@ Experience of intellectual stimulation
Activity involvement in dementia care must be defined
as broadly as possible, so as to include the entire inter-
Physical Benefits
action between the individual and the environment.
@ Increased circulation The environment defined in its broadest terms includes
= Promotion of gross, fine, bilateral, and eye-hand co- the physical, social, and cultural environments. All tasks
ordination that give people meaning and purpose are included in
Provision of vestibular stimulation the concept of activity. These tasks include routine and
Provision of sensory stimulation overlearned procedures that everyone performs without
Promotion of motor planning much thought, as well as leisure pursuits. All daily
Improvement or maintenance of perceptual abilities events are defined as activities.
Maintenance or improvement of adaptive and coping When OT practitioners are involved with activities in
skills a dementia-specific setting, they need to apply the
Increased strength, range of motion, and physical broad definition of activity involvement as they involve
tolerance staff in meeting the clients’ needs. Activities are now
Improved balance defined as any task or encounter. Hellen” states, “Any-
# Provision of opportunity to grade activities — thing residents do or are involved with is their activity at
that moment. Using activities as a frame around all that
the resident does allows a freedom for entertaining nu-
CONSULTATION TO ACTIVITY PROGRAMS
merous possibilities. Shifting focus from doing an activ-
Acting as consultants, occupational therapists can help ity for the resident to one of doing with the resident or al-
develop activity programs throughout the whole contin- lowing them independent involvement stimulates
uum of geriatric care. Therapists have many roles. wellness.” With this philosophy, OT practitioners can
Knowledge and experience enable OT practitioners to help increase clients’ self-esteem.
give professional advice and guidance and make recom- Dementia-related activity focuses on what an indi-
mendations. Therapists’ expertise is used to recognize vidual can do rather than on what he or she cannot do.
and solve problems, and these abilities may be critical A diagnosis of Alzheimer’s disease suggests that the
to their success as consultants.” The ability to communi- person cannot learn. Nonetheless, if the occupational
cate and to work with people in order to facilitate therapist evaluates the person’s specific abilities and
change is vital. A thorough understanding of the rules alters the task and how it is presented so as to use abili-
and regulations governing the setting is also a necessity. ties and avoid deficits, the task can often be accom-
One of the functions of the consultant therapist is to plished successfully.
evaluate the physical environment, the programs, and Depression, which is common especially in the
the staff. In this capacity therapists may have the roles of earlier stages of Alzheimer’s disease, may contribute to
educator and trainer and may develop programs. They an apparent inability to accomplish tasks. Stress is
must be flexible and have the knowledge to adjust to the another factor that may influence the achievement of
needs of the individual setting. To be a successful con- tasks. A vicious circle may develop in which dysfunc-
sultant, the OT practitioner must have many special at- tion leads to stress and stress leads to depression and
254 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

further dysfunction. Identification of the specific

SUMMARY
causative factors leading to stress is the important first
step in developing a holistic focus. A reduction in the Leisure activities are important to all people. Work and
number or intensity of incidents that increase stress play situations provide opportunities to act out life’s
can result in more successful involvement with activi- roles and succeed or fail in satisfying needs. When
ties of any kind. The most common stress-related inci- needs cannot be satisfied through work, leisure activities
dents are those that magnify losses. These incidents provide alternatives. Leisure experiences must gratify
include losses of the familiar, such ‘as routines, envi- the needs and be directed toward the goals of a specific
ronment, relationships, communication skills, privacy, individual.
dignity, and abilities. Providing obvious and easily The OT practitioner has the ability to administer
identifiable purposes for tasks while offering familiar, assessments and analyze data regarding perform-
overlearned activities that target procedural memory ance areas, performance components, and performance
may increase opportunities for success and thus reduce context. He or she can then relate these findings to
stress. Supportive one-to-one interaction and multi- an individual’s priority of needs and interests and
sensory input may improve communication. Other thereby help the individual succeed in chosen leisure
helpful strategies include limiting decision-making and occupation.
reducing time demanded for attention to task. Individ- Idleness and lack of purposeful activity are great
ualizing tasks and breaking them down into manage- enemies of aged persons with physical limitations that
able steps with proper cueing may allow the person to necessitate adaptation and intervention to enable par-
complete the tasks successfully. Organization, consis- ticipation. Idleness does much more than kill time. It
tency in routines, calmness, and reduction in inappro- kills initiative and self-respect and increases feelings of
priate distractions are especially important for the defeatism. Absence of meaningful occupation encour-
person with dementia.® ages mental and physical deterioration and invalid-
ism. The OT practitioner can stimulate occupational
PROBLEM BEHAVIORS AFFECTING performance and help individuals to function at their
highest possible levels so they may live life to the
ACTIVITY PARTICIPATION
fullest.
Behavior affects performance. Problem behaviors must
be managed through careful analysis, which includes
REVIEW QUESTIONS
the following questions:
. What is the behavior? 1. Name five needs that can be satisfied through
. Why it is a problem? leisure occupation.
. When it is a problem? 2. Name eight important components of a compre-
. Where it is a problem? hensive evaluation.
Re
MB
WN . To whom it is a problem? 3. Why is it important for the client to be involved in
Perhaps the most critical question is, “What situa- setting his or her own goals?
tions precede the problem behavior—what is the possi- 4. Why is the client's cultural background important?
ble cause or antecedent?” Alleviation of the possible an- 5. What does the therapist need to address in determin-
tecedent or satisfaction of needs associated with the ing access to community-based leisure activities?
behavior may prevent the situation from arising. For 6. From what two major perspectives does the OT
example, if a person finds large groups overstimulating, practitioner analyze activity?
activities should be done one-on-one or in small 7. How can a therapist motivate a person?
groups. If a person identifies too closely with characters 8. Name five psychosocial benefits and five physical
in a television show, soap operas on television are not a benefits of leisure activities
good leisure activity for that person. If messy activities 9. What are some roles and responsibilities of a con-
cause a catastrophic reaction, finger painting would not sultant?
be the activity of choice. If there is no outlet for excess 10. What authority does the consultant possess?
energy and the person paces or wanders, the therapist 11. What components of the OT educational curricu-
must channel the energy into an acceptable activity and lum prepare a therapist to be a consultant?
plan activities that incorporate rather than accentuate 12. What two factors influence achievement of tasks for
the negative aspects of the behavior. If the individual the person with dementia?
cannot initiate an activity independently and boredom 13. In dealing with problem behaviors, what aspects of
causes problem behaviors, the individual must be con- the behavior must the therapist analyze?
stantly redirected to activities that accommodate those 14. How can the therapist help a person with dementia
decreased attending skills.® achieve success at a task?
 Leisure Activities 255

15. What type of activity could the therapists suggest for Born B: Occupational therapy and long term care position paper, Rockville,
a person with excess energy who paces and wanders? Md, 1993, American Occupational Therapy Association.
Cornelius E, Perschbacker R, Reublinger V, et al: Resident assessment
16. What can absence of meaningful occupation lead to?
protocol: activities. In Resident assessment instrument training manual
and resource guide, for use with the Health Care Financing Adminis-
tration’s minimum data set, resident assessment protocols and Uti-
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Association. Petty BJ, Moeller TP, Campbell RZ: Support groups for elderly persons
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Rowles GD: Prisoners of space? Exploring the geographical experience of Tickle LS, Yerxa EJ: Need satisfaction of older persons living in the
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—
Sheridan C: Failure-free activities for the Alzheimer's patient, Oakland, Ther 1981a.
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Assistive Technology

LEARNING OBJECTIVES
Assistive technology After studying this chapter the student or practitioner
Rehabilitation technology will be able to do the following:
Universal design & Describe the range of assistive technology options
Human Activity Assistive Technology currently available for persons with physical
Human Environment Technology Interface disabilities.
Human Interface Assessment . Discuss and compare three different theoretical
Electronic aids to daily living models for the interface between humans and
Power switching technology.
X-10 system . Identify common solutions for enabling control of
Infrared daily living devices through technology.
Feature control . Discuss options for augmentative and alternative
Subsumed devices communications.
Augmentative and alternative communications . Analyze input and output options for assistive
User control system technologies and match these to the needs of
Message composition system consumers.
Message transmission system
Graphical communication
Physical keyboard
Virtual keyboard
Pointing systems
Dynamic display
Eye-tracking
Morse code
Speech input
Scanning input
Rate enhancement
Prediction
Compression/expansion
Screen enlargement programs
Speech output
Tactile output

257
258 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

sistive technology so long as task performance is possi-

ble without the technology.
A. discussion of assistive technology should Assistive technologies replace or support an impaired
begin with a description of the general limits of the topic. function of the user but do not change the intrinsic
This is difficult because the legal definitions of assistive functioning of the individual. For example, a wheelchair
technology are not uniform. Assistive technologies are replaces the function of walking but does not teach the
sometimes included in the category of rehabilitation user to walk. Similarly, forearm crutches support inde-
technology. In other cases, rehabilitation technology is pendent standing but do not, of themselves, improve
considered an aspect of assistive technologies. A third strength or bony integrity and so will not change the
category, technologies that employ universal design, ability of the user to stand without them.
doesn’t seem to fit into either of the first two categories. The design of assistive technologies reflects their in-
tended use over prolonged periods by individuals with
limited training and possibly with limited cognitive
TOWARD DEFINING ASSISTIVE
skills. Assistive technology must not inflict harm on the
TECHNOLOGY
user through casual misuse. The controls of the device
The category into which an enabling technology falls must be readily understood; some training may be nec-
depends largely on its application, not on a specific essary to use the device, but the need for retraining
device being used. What is merely a convenience for should be minimal. An effective assistive technology
some people may be an assistive technology for others. device should not require deep understanding of its
For purposes of this discussion, the following categories principles and functions to be useful.
and definitions will apply. Assistive technology devices go home with the client;
rehabilitation technology devices generally remain in a
clinic. Some technologies may overlap categories, since
Rehabilitation Technology
they may be used differently with different clients. For
The term rehabilitation technology should be used to example, clinicians may use assisted communication as
identify those technologies that are intended to restore a tool to train unassisted speech for their clients; in this
an individual to a previous level of function after the case the technology is rehabilitative. However, assisted
onset of a pathologic condition. Rehabilitative tech- communication may also be used to support or replace
nologies are generally intended to be used within a speech for clients who will not be able to resume
therapy setting by trained professionals over a short speech; in this case the technology is assistive.
time. Because they are meant to be used by trained pro-
fessionals, these technologies may have fairly complex
or cryptic controls. It is expected that the professional
Universal Design
will have significant training before applying these tech- Universal design is the newest category of technology.
nologies. The professional guiding the use of such tech- The principles of universal design were published by the
nologies is expected to ensure their correct application Center for Universal Design at North Carolina State Uni-
and to protect the safety of the individual using the versity in 1997, and their application is still limited.* The
device. Physical agent modalities such as ultrasound, concept of universal design is simple: if devices are de-
diathermy, paraffin, and functional electric stimulation signed with the needs of people with disabilities in
are examples of rehabilitative technologies. When these mind, they will be more usable for all users, with and
technologies have done their job, the client will have without disabilities.
better intrinsic function and use of the technology will In some cases the universal design philosophy could
be discontinued. make assistive technology unnecessary. A can opener
that has been designed for one-handed use by a busy
housewife also will be usable by the cook who has had
Assistive Technology
a cerebrovascular accident (CVA) and now has the use of
Assistive technologies help a person with a disability only one hand. Another example is that of electronic
perform tasks. More specifically, assistive technologies books now under development that will include fea-
allow a person who has a disability to perform tasks tures to allow them to be used as “talking books.” The
that an able-bodied person can perform without tech- goal of this technology is to provide a hands-free, eyes-
nological assistance. Such devices may be designed free interface so that commuters can use the books
specifically for a person with a disability or designed for while driving. However, the same interface will meet the
a mass market and subsequently used by a person with needs of the individual who is blind and cannot see the
a disability. An able-bodied person may prefer to use a screen or who has mobility limitations and cannot
technology (such as a television remote control) to operate the manual controls. No further adaptation
perform a task, but this does not rise to the level of as- would be necessary because the product's design already
 Assistive Technology 259

accommodates the special needs of the person with a for the person. Removing the technology portion of the
disability. figure will result in an incomplete image but does not
appear to remove the person from the activity. A modi-
THREE MODELS OF ASSISTIVE fied representation of this model might look somewhat
different (Fig. 19-2). The modified HAAT model shows
TECHNOLOGY INTERFACE
that assistive technologies may link the person and the
Assistive technology interface is the relationship activity and may make the activity possible. Removing
between assistive technology, the user, and the environ- the assistive technology may separate the person from
ment. Three models deal with this relationship: the performing the activity.
human activity assistance technology model of Cook
and Hussey,” the human environment technology inter-
Human Enviroment Technology Interface
face model of Roger Smith, and the human interface as-
sessment model of Anson. On casual examination, the Roger Smith’s human environment technology inter-
three models appear to be quite different; however, all face (HETI) model® (Fig. 19-3) focuses in more detail
three models examine the same elements in differing on the interface between the human and the assistive
degrees of detail, and nest within one another. technology. This model shows that human use of assis-
tive technology requires a complete cycle of perform-
ance. The human must receive sensory input from the
Human Activity Assistive Technology
environment about the task to be performed. Through
The human activity assistive technology (HAAT) model cognitive processing, the human decides on a course of
by Cook and Hussey” (Fig. 19-1) emphasizes the impor- action and produces an output. The motor output of the
tance of the person, the activity, and the context in the se- human serves as input to the assistive technology;
lection of assistive technology. Specifically, one using through internal processing the assistive technology
this model considers the context of the person who will produces a performance that should match the desired
be using the technology, the activity that the technology action of the human. The technology performs the
will be used to perform, and the environment in which action, which is apparent to the human, and the cycle
the technology will be used. Changes in any of these begins anew. If the cycle is to be complete, the human
components can require a change of technology, since must be able to observe the action of the technology
the overall conditions may no longer fit correctly. and produce the motor output that the technology
The standard representation of the model, Fig. 19-1,
fails to clarify that the technology enables the activity

Environment
Environment

Assistive
Assistive Technology
Person Technology

FIG. 19-1 FIG. 19-2

HAAT model. Modified HAAT model.
 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

Environment

rechnolonsssistive Techn ogy

put, <—

FIG. 19-3 FIG. 19-4

HETI model. HAAT/HETI model.

input expects; otherwise, the assistive technology will

not be functional. Assistive
The HETI model is a detailed look at one aspect of Technology
the HAAT model, the interface between the human and
the assistive technology. The two models are integrated
in Fig. 19-4.

Human Interface Assessment

Anson's human interface assessment (HIA) model is a
still more detailed look at the skills and abilities of the
human in motor output and sensory input, with some
consideration of cognitive processing. This model (Fig.
19-5) looks in detail at the abilities of the human
in Smith’s model to match these abilities with the
demands of assistive technologies.’ The HIA model sug-
gests that assistive technology is required only when the
demands of a task exceed the skills and abilities of an
individual; this is so even when a functional limitation FIG. 19-5
HIA model.
exists. However, an assistive technology device may be
used to bridge the gap between demands and abilities
whenever task demands exceed the native abilities of matching is necessary if assistive technologies are to —
the individual. provide effective interventions for individuals.
The HIA provides for guided assessment of the skills As Fig. 19-6 shows, the HAAT, HETI, and HIA models
and abilities of the intended user and matches those are actually nested examinations of the relationship
skills and abilities to the demands of the technology between a person, an activity, the environment, and the
under consideration. The assessment of abilities in assistive technology that makes it possible for the person
sensory perception, cognitive processing, and motor to perform the activity. These three models examine dif-
output yields data that are compared with the input and ferent portions of the relationship between humans and
output capabilities of assistive technologies. Careful activities and are complementary to each other.
 Assistive Technology

Assistive Feature Control

Technology

User Input Subsumed Devices

ay?

Power Switching

FIG. 19-7
Classification of EADL by control options.

dren with severe disabilities would formally be consid-

ered EADL. Primitive EADL systems may be as simple as
Environment a set of electrical switches and outlets in a box, con-
nected to devices within a room via extension cords.
FIG. 19-6 Such primitive devices may be unsafe. Extension cords
Combining the HAAT and HETI and HIA models. pose safety hazards to people in the environment
through the risk of falls (tripping over the extension
cords) and fires (overheated or worn cords). Further, the
TYPES OF ELECTRONIC ENABLING devices may match inadequately the needs of con-
sumers. Because of these limitations, EADL technology
TECHNOLOGIES
moved toward remote switching technologies.
It is useful to categorize assistive technologies by the Second-generation EADL systems use various remote
particular situations or general uses in which they are control technologies to switch power by remote control
applied. This chapter deals only with electronic assistive to electrical devices in the environment. The technolo-
technologies, which in their primary applications may gies employed include ultrasonic pulses, infrared light,
be considered to fall into one of three categories: elec- and electrical signals propagated through the electrical
tronic aids to daily living, alternative and augmentative circuitry of the home. All of these switching technolo-
communications, and general computer applications. gies remain in use, and some are used for much more
elaborate control systems. Only power switching is dis-
cussed here.
Electronic Aids to Daily Living
The most prevalent power-switching EADL control
Electronic aids to daily living (EADL) are devices that system is that produced by the X-10 Corporation.* The
can be used to control electrical equipment in the X-10 system uses electrical signals sent over the wiring
client's environment. Many therapists and rehabilita- of a home to control power modules that are plugged
tion engineers have learned to call items in this class of into wall sockets in series with the device to be con-
device “environmental control units,” although techni- trolled. (In a series connection the power module is
cally this terminology should be reserved for furnace plugged into the wall and the remotely controlled
thermostats and similar controls. The more generic device is plugged into the power module.) The X-10
EADL applies not only to control of lighting and tem- system supports up to 16 channels of control, with up
perature, but also to control of radios, televisions, tele- to 16 modules on each, for a total of up to 256 devices
phones, and other electrical and electronic devices in controlled by a single system.
the client's environment. The signals used to control X-10 modules will not
EADL systems may be classified further in terms of travel through the home’s power transformer, so users
the degree and types of control they provide to the user. in single-family dwellings will not interfere with devices
These classifications are simple power switching, control of in a neighbor's home. This is not necessarily true in an
device features, and subsumed devices (Fig. 19-7). apartment setting, where it is possible for two X-10

Power Switching
The simplest EADL provide only power switching of
the electrical supply for devices in a room. The switch *Retail Sales Division, 15200 52nd Avenue South, Seattle, WA, 98188-
adaptations for switch-adapted toys provided to chil- 2335; Phone: (206) 241-3285; Fax: (206) 242-4644.
262 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

users to inadvertently control each other's devices. The ability because they require fine motor control and
general setup of early X-10 modules was intended to good sensory discrimination.
control up to 16 devices on an available channel so that To provide a person with a disability with control of
such interference would not occur. In some apartments the features of home electronic devices, EADL systems
the power within a single unit may be on different frequently have hybrid capabilities. A means of directly
“phases” of the power supplied to the building. (These switching power to remote devices, often using X-10
phases are required to provide 220-volt power for some technology, allows control of devices such as lights,
appliances.) If this is the case, the X-10 signals from a fans, and coffee pots, as well as electrical door openers
controller plugged into one phase will not cross to the and other specialty devices. To this capability is added
second phase of the installation. A special “phase cross- some form of infrared remote control, which will allow
over” is available from X-10 to correct this problem. the EADL system to mimic the signals of standard
X-10 modules can be used with special lighting remote control devices. This control will be provided
modules to dim and brighten room lighting. These either (1) by the manufacturer of the device, program-
modules work only with incandescent lighting but add ming in the standard sequences for all commercially
a degree of control beyond simple switching. For per- available VCRs, televisions, and satellite decoders or
manent installation the wall switches and receptacles of (2) through teaching systems, in which the EADL
the home may be replaced with X-10-controlled units. “learns” the codes beamed at it by the conventional
Because X-10 modules do not prevent local control, remote. The advantage of the latter approach is that the
these receptacles and switches work like standard units, EADL can learn any codes, even those that have not yet
with the added advantage of remote control. been invented. The disadvantage is that the controls
After their introduction in the late 1970s, X-10 must be taught, requiring more setup and configuration
modules revolutionized the field of EADL. Before this, time for the user and caregivers.
remote switching was a difficult and expensive en- Hope for better and simpler control of home audio-
deavor, restricted largely to applications for people with visual devices is on the horizon. In November 1999, a
disabilities and to industrial applications. The X-10 consortium of eight home electronics manufacturers re-
system, however, was intended as a convenience for leased a set of guidelines for home electronics. These
able-bodied people who did not want to walk across a guidelines are called HAVi.* The HAVi specification will
room to turn on a light. Because the target audience was allow compliant home electronics to communicate so
able to perform the task without remote switching, the that any HAVi device can control the operation of all of
technology had to be inexpensive enough that it was the HAVi devices sharing the standard. A single remote
easier to pay the cost than get out of a chair. X-10 made control will be able to control all of the audiovisual
it possible for an able-bodied person to remotely devices in the home through a single interface. The In-
control electrical devices for under $100, in contrast to frared Data Association (IrDA)t is working on specifica-
disability-related devices that could cost as much as tions focusing purely on infrared controls. The IrDA
several thousand dollars. Interestingly, the almost uni- standard will allow an infrared remote control to
versal adoption of X-10 protocols by disability-related control features of computers, home audiovisual equip-
EADL has not led to sudden price drops in the disability ment, and appliances with a single, standard protocol.
field, so many clinicians continue to adapt mass-market Having a single standard for home electronics will allow
devices for individuals with disabilities. much easier design of EADL systems for people with
disabilities.
Feature Control The relationship between EADL and computers is
As electronic systems have become more pervasive in one interesting aspect of feature control by EADL.
the home, simple switching of lights and coffee pots no Some EADL systems include features that allow the user
longer meets the needs of the individual with a disabil- to control a personal computer. Other EADL are de-
ity who wants to control the immediate environment. signed to accept control inputs from a personal com-
Wall current control allows a person with a disability to puter. The goal in both cases is to use the same input
turn radios and televisions on and off but provides no method to control a personal computer as to control
control of features beyond that. A person with a disabil- the EADL. In general, the control demands of an EADL
ity may want to surf cable channels as much as an able- system are much less stringent than are those of a com-
bodied person with a television remote control. When puter. An input method that is adequate for EADL
advertisements are blaring from the speakers, a person control may be tedious for general computer control. A
with a disability may want to turn down the sound or system that allows fluid control of a computer will not
tune to another radio station. Although most consumer
electronic devices are now delivered with a remote
control (generally using infrared signals), most of these *http://www.havi.org/home.html
remote controls are not usable by a person with a dis- "http://www. irda.org/about/index.asp
 Assistive Technology 263

Augmentative and Alternative

be strained by the further need to control an EADL. The
Communications
proper source of control will probably have to be
decided on a case-by-case basis. This topic is discussed The term augmentative and alternative communica-
further in the section on augmentative communica- tions (AAC) is used to describe systems that supple-
tions. ment (augment) or replace (alternative) communica-
tion by voice or gestures between people. Formally
Subsumed Devices speaking, AAC incorporates all assisted communica-
The incorporation of an available consumer technology tion, including tools, such as pencils and typewriters,
into an EADL is termed a subsumed device. Modern used to communicate over time (as in leaving a message
EADL frequently incorporate common devices such as for someone who will arrive at a location after you
the telephone. Because of the pervasiveness of tele- leave) or over distance (sending a letter to Aunt May).
phones, incorporating telephone electronics into the However, as used in assistive technology, AAC denotes
EADL is less expensive than inventing special systems to the use of technology to allow communication by a
control a standard telephone. person with a disability in ways that an able-bodied in-
Many EADL systems include a speakerphone that dividual would be able to accomplish without assis-
allows the user to originate and answer telephone calls tance. Thus using a pencil to write a letter to Aunt May
using the electronics of the EADL as the telephone. would not be an example of AAC for a person who is
Because of the existing standards, these systems are unable to speak, since an able-bodied correspondent
generally analog, single-line telephones, electronically would use the same technology (pencil and paper) for
similar to those found in the typical home. Many busi- the same purpose (social communication). However,
ness settings now use multiline sets, which are not com- when a nonvocal person uses a pencil to tell the doctor
patible with home telephones. Some businesses are about sharp pains in the right leg, the pencil is consid-
converting to digital interchanges, which are also in- ered an AAC device, since an able-bodied person would
compatible with conventional telephones. Because of talk about the pains.
this, the telephone built into a standard EADL may not AAC devices range from extremely low technology to
meet the needs of a client with a disability in an office extremely high technology. In hospital intensive care
setting. Before recommending an EADL as an access so- units, low-tech communication boards (Fig. 19-8) can
lution for a client in the workplace, the therapist should allow a person using a respirator to communicate basic
determine whether the system is compatible with the needs. A low-tech communication board can allow a
telecommunications systems in that environment. client to deliver basic messages or spell out more in-
Other systems designed for individuals with disabili- volved messages in a fashion that can be learned
ties are so difficult to control remotely that the EADL quickly. For a person with the capacity for only yes or no
must generate an entire control system. For example, responses, another person can indicate the rows of the
hospital bed controls have no provisions for remote board one at a time, asking if the desired letter is in the
control but should be usable by a person with a disabil- row. When the correct row is selected, the assisting
ity. Some EADL systems can be used as hospital bed person can move across a row until the person with the
controllers. This is important for the client who, for disability indicates the correct letter. This type of com-
reasons of limited endurance or mobility, must spend a munication is inexpensive and quick to teach, but slow
significant portion of the day in bed. These systems to use. It is adequate when communication needs are
allow the user to adjust head and foot height independ-
ently, extending the time the user can be independent of
assistance for positioning. As with telephone systems,
different brands of hospital beds use different styles of
controls. The clinician must match the controls pro-
vided by the EADL with the inputs required for control
of the bed.’

Control of EADL
EADL systems are designed to allow the individual with
limited physical capability to control devices in the im-
mediate environment. As such, the method used to
control the EADL must be within the capability of the
client. Since these controls have many features in
common with other forms of electronic enablers, the
control strategies are discussed later in a separate FIG. 19-8
section. A communication board.
264 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

limited but will not serve for long-term or fluent com- 20 minutes the client was able to communicate that the
munication needs. client's ears were the same shape as Cary Grant's! Even a
Clinicians frequently recommend electronic AAC basic communication aid, such as the ICU aid described
devices to meet the communication needs of a person above, would have allowed much faster transfer of this
who will be nonvocal for a long time. In selecting a information.
communication device, the clinician must consider the Most development in AAC seems to focus on com-
type of communication the individual will use, as well munication of basic needs and transfer of information.
as the settings in which communication will take place. Information transfer presents some of the most difficult
Light® describes four types of human communica- technological problems because the content of informa-
tion: expression of needs and wants, information trans- tion to be communicated cannot be predicted. The de-
fer, social closeness, and social etiquette. In the inten- signer of an AAC device probably would not anticipate
sive care setting noted above, most communication will the need to discuss the shape of Cary Grant's ears during
occur at the first two levels. The individual with disabil- vocabulary selection. To meet such needs, AAC devices
ity will want to express basic needs of hunger, thirst, and must have the ability to generate any concept possible
relief of pain. He or she will wish to communicate with in the language being used. Making these concepts
the doctor providing care and convey information available for fluent communication is the ongoing chal-
about where it hurts and whether treatment seems to be lenge of AAC development.
working. In work or school settings, more communica- Social communication and social etiquette present
tion is needed to convey information. For example, a significant challenges for users of AAC devices. Al-
student participating in a classroom discussion may though the information content of these messages tends
want to be able to describe the troop movements in the to be low and based on convention, the dialog should
Battle of Gettysburg. In math class the student may need be varied and spontaneous. Some AAC systems have
to present a proof involving oblique and parallel lines. provision for preprogrammed messages that can be re-
Such an information exchange may be spontaneous, trieved for social conversation, but providing both
when the person is called on in class, or planned, as ina fluency and variability of social discourse through AAC
formal presentation. In a social or interpersonal setting, remains a challenge. Current devices allow somewhat
communication has a markedly different flavor. Teen- effective communication of wants. These devices are not
agers may spend hours on the telephone, exchanging nearly so effective in discussing dreams.
very little “information” but communicating shared
feelings and concerns. At a faculty tea much of the com- Parts of AAC Systems
munication is formulaic, such as, “How are you today?” In general, electronic AAC systems have three compo-
Such queries are not intended as questions about nents: a user control system, a message composition
medical status but are simply recognition of another's system, and a message transmission system (Fig. 19-9).
presence and an indication of wishing that person well. The user control system allows the user to generate
The planning and fluency of communication in each messages and control the device. The message compo-
domain are substantially different, and the demands on sition system allows the user to construct messages to
AAC systems in each type of communication are like- be communicated to others. The message transmission
wise different. system allows the communication partner to receive the
An AAC system used solely for expression of needs message from the user. The issues of user control of AAC
and wants can be fairly basic. The vocabulary used in devices are essentially the same as those for other elec-
this type of communication is limited; because the ex- tronic assistive technologies and are discussed with
pressions tend to be fairly short, the communication access systems in general.
rate is not of paramount importance. In some cases the
entire communication system is a buzzer used to indi-
cate that the individual is in need and to summon a Message Composition
caregiver. The low-tech communication systems de-
scribed earlier may meet basic communication needs
for individuals whose physical skills are limited to eye
blinks or directed eye movement.
User Control
Low-tech devices may enable expression of more
complex ideas. For example, a therapist became aware
that a client with aphasia wanted to communicate
something. Since no AAC was available for this client,
the therapist began attempting to guess what the client Message Transmission
wanted to communicate. After exhausting basic needs
(“Do you need a drink? Do you need to use the bath- FIG. 19-9
room?”), the therapist was floundering. Over the next Components of AAC systems.
 Assistive Technology 265

MESSAGE COMPOSITION. In natural communica- voice. In settings such as a classroom discussion, voice
tion, most of the time, a person plans a message before communication may be the most appropriate method of
speaking. An AAC device should allow the user to con- communication. In other settings, such as a busy side-
struct, preview, and edit utterances before they become walk or a noisy shop, voice output may be drowned out
apparent to the communication partner. This gives the or unintelligible and printed output may result in more
user of an AAC device the ability to think before speak- effective communication. In a setting where speaking
ing. It also allows compensation for the rate difference may disturb others, printed output may again be the
between message composition via AAC and communi- transmission method of choice.
cation between able-bodied individuals. In settings in which speaking is the preferred method
Able-bodied individuals typically speak between 150 of communication, voice quality must be considered.
and 175 words per minute.® Augmentative communica- Early AAC devices used voices that, to novice listeners,
tion rates are more typically 10 to 15 words per minute, were only slightly more understandable than the com-
resulting in a severe disparity between the rate of com- municator’s unassisted voice. As speech synthesis tech-
munication construction and expected rate of reception. nology has improved, AAC voices generally have become
Although the input techniques discussed offer some im- more intelligible. The high-quality voices of modern
provement in message construction rates, the rate of speech synthesizers have vastly improved intelligibility
message assembly using AAC is such that many listeners but continue to provide only a narrow range of variation
will lose interest before an utterance can be delivered. If and vocal expression. Although the AAC user has the
words are spaced too far apart, an able-bodied listener option of deciding what she or he wants to sound like,
may not be able to assemble them into a coherent the choices are few.
message.
The message construction area of an AAC device Communication Structure
allows the individual to assemble a complete thought Communications to be augmented may be categorized
and then transmit it as a unit. A typical AAC device in- in terms of their intent, as well as in the content as
cludes a display in which messages can be viewed before Light’ proposed. At the top level, communications may
transmission. This area allows the communicator to be categorized, with the conditions discussed above, as
review and edit the message that is being composed primarily oral or primarily written. In these cases, the
before transmitting it to the communication partner. categorization would be based on the mode of commu-
This has two beneficial effects: the communicator can nication that typically would be used by an able-bodied
select words with care before communicating them, and person, not on the form that is being used by the aug-
the communication partner does not have to be con- mented communicator.
stantly attentive to the conversation.
Communication between able-bodied people gen- SPOKEN OR VOICED COMMUNICATIONS. One
erally happens quickly enough to hold. attention. category of spoken communication is conversation.
When an able-bodied person is communicating with a Conversation implies a two-way exchange of informa-
person using an AAC device, the time between utter- tion. This includes face-to-face communication with a
ances may be too long to hold the attention. The friend, oral presentation when question-and-answer
able-bodied person may focus and not be able to sessions are included, small group discussions, and con-
maintain attention to the conversation. If messages versation over a telephone. In all of these cases rapid
come as units, the communication partner can communication is required and the user is expected to
respond to a query and then busy himself or herself compose and respond immediately. If the composition
in another activity while the communicator composes rate is too slow, communication will break down and
the next message. This is not unlike having a conver- the conversation will cease. The augmented communi-
sation via e-mail. cator may use “telegraphic” speech styles, but this
results in primitive language that may be taken to indi-
MESSAGE TRANSMISSION. When the communi- cate poor cognition.
cator has finished composing a message, it can be trans- Another form of spoken communication is the oral
mitted to the communication partner. The means of presentation in which no question-and-answer compo-
transmission varies with the device and the setting. nent is included or in which such a component is con-
Some AAC devices use printed transmission exclusively. sidered separately. In these cases the augmented com-
The message may be printed on paper tape, standard municator has ample time to prepare communications
typewriter paper, or an electronic display that is made before delivery. An entire presentation may be stored in
visible to the communication partner. Other systems a communication device before the time of delivery. Al-
use audible communication, speaking the message though the time taken to prepare the message may be
aloud by means of speech synthesis. There is a tendency long in such cases, this does not inhibit the delivery of
to think of voice output as more appropriate than text, the message, as long as the device has adequate storage
since able-bodied people generally communicate by for the entire presentation. Stephen Hawking orally
266 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

presents papers at conferences, just as his colleagues do, document, and the abbreviations used in note taking
in spite of his use of an AAC device. However, his ability and messaging are not allowed.
to respond to questions is severely constrained. The most difficult formal communication for AAC
may be mathematical notation. The early target of AAC
GRAPHICAL COMMUNICATIONS. The category of devices was narrative text as used in messaging and
graphical communications includes all forms of com- written prose. Such language is commonly linear and
munication that are mediated by graphic symbols. This can be composed in the order in which it is to be read.
includes writing using paper and pencil, typewriter, Mathematical expressions, on the other hand, may be
computer or word processor, calculator, or drawing two dimensional and nonlinear. Simple arithmetic,
program. Within the realm of graphical communica- such as “2 + 2 = 4,” is not excessively difficult. But al-
tions, a wide range of conditions and intents of com- gebraic expressions such as
munication may influence the devices selected for the —b + Vb?
— 4ac
user. x=

2a
One type of graphical communication is note taking.
Note taking is a method of recording information as it can be much more difficult for an AAC device to create.
is being transmitted by a speaker, so that the listener can A relatively basic calculus equation, such as
recall it later. The intended recipient of this form of Fo(—
iy 1-3 oot %
communication is the person who is recording the
n=1 PEELS o 3 0A)
notes. It is a violation of social convention to ask the
speaker to speak more slowly to accommodate the note can be impossible to write, much less solve, for the user
taker, so a note-taking system must allow rapid record- of an AAC device. While current technology allows
ing of information. However, since the listener is also prose construction with some facility, an AAC user will
the intended recipient, notes can be cryptic and may be have marked difficulty with higher mathematics.
meaningless to anyone other than the note taker.
Messaging is a form of graphical communication that
General Computer Access
shares many characteristics with note taking. Although
the intended recipient is another person, shared abbre- The third category of electronic enabler is general com-
viations and nongrammatical language are common in puter access. Computer use is ubiquitous among able-
messaging. The language that is common in adolescent bodied individuals. It is an assistive technology for indi-
e-mail (Fig. 19-10) is barely recognizable as English but viduals with a wide range of disabilities because it
is a form of graphical messaging that communicates to allows them to perform tasks for which they have no al-
its intended audience. Messaging does not demand the ternative method. Computers can be used to write mes-
speed of input of note taking, since encoding and re- sages or to research school subjects. For the person with
ceiving are not linked in time. a print impairment the computer can provide access to
The most language-intensive form of graphical com- printed information either through electronic docu-
munication is formal writing. This includes writing ments or through the use of optical character recogni-
essays for school, writing for publication, and writing tion, which can convert the printed documents into
business letters or contracts. Formal writing differs from electronic documents. Once a document is stored elec-
the previously discussed forms of graphical communi- tronically, it can be presented as large type for the
cation in that it must follow the rules of written person with a visual acuity limitation or read aloud for
grammar. The communicator is expected to spend sig- the person who is blind or profoundly learning dis-
nificant time and effort in preparing a formal written abled. Computers can allow the manipulation of
“virtual objects” to teach mathematical concepts, form
constancy, and spatial relations skills that are com-
Hey, wuz"? N2MH. | have a surprise 4 U when we get monly learned by manipulation of physical objects. Per-
back to skool. What's UR mom's name? B/c I'm sonal digital assistants (PDAs) may be merely useful for
making a list of my friends' phone#s and 'rents 4 my the busy executive but may be the only means available
‘rents. for a person with attention deficit disorder to get to
CU later! meetings on time. For the executive a PDA is a conven-
LYLAS, ience, but for the person with ADHD it is an assistive
Rachael:-P technology.
Individuals using computers can locate, organize,
and present information at levels of complexity not pos-
sible without electronic aids. Through the emerging area
FIG. 19-10 of cognitive prosthetics, computers can be used to
Example of messaging encryption in adolescent e-mail. augment attention and thinking skills in people with
 Assistive Technology 267

cognitive limitations. Computer-based biofeedback can telephones, and microwave ovens. In these applications,
monitor and enhance attention to task. Research in tem- sequences of keys are used to generate meaningful units
poral processing deficits has led to the development of such as words, checkbook balances, telephone numbers,
computer-modified speech programs that can be used and the cooking time for a baked potato. Other key-
to enhance language learning and temporal processing boards are designed so that pressing a key results in
skills.°" immediate action. For example, the television remote
Beyond such rehabilitative applications, the perform- control has keys that switch power or raise volume when
ance-enhancing characteristics of the conventional pressed.
computer can allow a person with physical or perform- Physical keyboards can be adapted in a variety of
ance limitations to participate in activities that would ways. For example, most alphanumeric keyboards are
otherwise be too demanding. An able-bodied person arranged in the pattern of the conventional typewriter.
might be annoyed at having to retype a document to ac- Fig. 19-11 illustrates a conventional computer keyboard
commodate editing changes; thus the cut-and-paste from myKey. This pattern was designed, for reasons re-
abilities of the computer are a convenience. A person lating to mechanical limitations, to slow down the user.
with a disability may lack the physical stamina to com- Most individuals with disabilities do not need artificial
plete the task without the cut-and-paste abilities of the restraints to slow them down, so this pattern of keys is
computer. For the person with a disability the computer seldom optimal for assistive technologies. Alternative
is an assistive technology because the task is impossible keyboard patterns include the Dvorak Two-Handed,
without it. Applications of the computer for a person Dvorak One-Handed, and Chubon (Fig. 19-12). These
with a disability include all the applications an able- patterns offer improvements in efficiency of typing,
bodied person would use. Additionally, computers may which may allow a person with a disability to perform
be used as cognitive prosthetics for the person with a for functional periods of time.
disability. The standard keyboard is designed to respond imme-
diately when a key is pressed and, in the case of com-
puter keyboards, to repeat when held depressed. This
CONTROL TECHNOLOGIES
design benefits the individual with rapid fine motor
All of the electronic enabling technologies discussed in control but penalizes the individual with delayed motor
this chapter depend on the ability of the individual to response. Fortunately, on many devices the response of
control them. Although functions of the various devices the keyboard can be modified. “Delayed acceptance”
differ, the control strategies have common characteris- provides a pause between the instant a key is pressed
tics. Most electronic devices were designed for use by and the instant the key-press takes effect. Releasing the
able-bodied persons. Controls of assistive technologies key during this pause will prevent the key from taking
may be categorized by the ways in which they are effect. If carefully calibrated, this adaptation can allow a
adapted from standard controls. Electronic controls person to type with fewer mistakes, resulting in higher
may be divided into three broad categories: input adap- accuracy and, sometimes, higher productivity.
tations, output adaptations, and performance enhance- The scale of the standard keyboard provides a
ments. balance between the fine motor control and range of

Input to Assistive Technologies

A wide range of input strategies are available to control
electronic enablers; these can be more easily under-
stood by considering them in subcategories. Different
authors have created different taxonomies to categorize
input strategies. The categorization presented here is
one variation. For our purposes input strategies will be
classified as those using physical keyboards, those using
virtual keyboards, and those using scanning techniques.

Physical Keyboards
Physical keyboards typically provide an array of
switches, with each switch having a unique function.
On more complex keyboards modifier keys may change
the base function of a key, usually to a related function.
Physical keyboards appear on a wide range of electronic FIG. 19-11
devices, including typewriters, computers, calculators, Physical keyboard with adaptive features—the myKey keyboard.
PA Te) OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

select from the array of options through a unique

action, but without physical switches demanding motor
action. Instead, the meaning of the “selection” action
may be encoded spatially, via pointing, or temporally,
via sequenced actions.

POINTING SYSTEMS. The use of pointing systems

is analogous to the use of a physical keyboard with a
physical pointer such as a head-stick or mouth-stick. In
these systems a graphical representation of a keyboard is
presented to the user, who makes selections by pointing
to a region of the graphical keyboard and performing a
selection action. The selection action is typically either
the operation of a single switch (e.g., clicking the mouse)
or the act of holding the pointer steady for a period of
The Right-Handed Dvorak Layout time.
The pointer used for pointing systems may consist of
FIG. 19-12
Alternative keyboard patterns. a beam of light projected by the user, the reflection of a
light source from the user, or sound waves received by a
microphone that the user carries. Changing the orienta-
motion (ROM) of an able-bodied individual. The client tion or position of the sensor moves an indicator over
with limitations in either ROM or motor control may the graphical image of the keyboard, informing the user
find the conventional keyboard difficult to use. If the of the current meaning of the selection action.
client has limitations in motor control, a keyboard with Several augmentative communication systems now
larger keys or additional space between keys may allow use a dynamic display on which the graphical keyboard
independent control of the device. This adaptation may can be changed as the user makes selections, so that the
also assist the person with a visual limitation. However, meaning of each location of the keyboard changes as a
providing an equivalent number of options on larger message is composed. Dynamic displays free the user
keys increases the size of the keyboard, which may make from having to remember the current meaning of a key
it unusable for a person with limitations in ROM. or decode a key with multiple images on it.
To accommodate limitations in ROM, the keyboard Pointing systems behave very much like physical key-
controls can be reduced in size. Smaller controls, placed board systems, and many of the considerations of phys-
closer together, will allow selection of the full range of ical keyboards apply. The key size must balance the
options with less demand for joint movement. demands for fine motor control with the ROM available
However, the smaller controls will be more difficult to to the client. The keyboard pattern should be selected to
target for the person with limited motor control. A enhance, not hinder, function. The selection technique
mini-keyboard is usable only by a person with good should facilitate intentional selections while minimiz-
fine motor control and may be the only scale of key- ing accidental actions.
board usable by a person with limited ROM. The current state-of-the-art pointing system uses eye-
A keyboard can be designed with fewer options to ac- tracking input. Eye-tracking systems generally are based
commodate both limited ROM and limited fine motor on reflected infrared light from the surface of the eye. In
control. Many augmentative communication devices can general, these systems require extreme stability in the
be configured with 4, 8, 32, or 64 keys on a keyboard ofa physical location of the eye and the camera observing
single size. Modifier or “paging” keys can allow access to the reflections. Traditionally, this has meant that the
the full range of options for the keyboard, but with an at- user must hold his or her head extremely still for the
tendant reduction in efficiency. In this approach the system to be usable. Because of cost considerations, this
person uses one or more keys of the keyboard to shift the input method has not been a reasonable option for a
meanings of all of the other keys of the keyboard. Unless person who could produce head movement, so the re-
this approach is combined with a dynamic display, the quirement of head stabilization has not been a major
user must remember the meanings of the keys. issue. However, there may be changes in these require-
ments as eye-gaze moves into mainstream technologies.
Virtual Input Techniques The first mainstream products that incorporated eye-
When an individual lacks the motor control to use an tracking were hand-held camcorders, which had eye-
array of physical switches, a virtual keyboard may be tracking built into the-view-finder. By tracking the
used. Virtual keyboards provide the functionality of a portion of the screen being focused on, this eye-tracking
physical keyboard system, allowing the user to directly allowed the camera to focus on the part of the display
 Assistive Technology 269

that was of special interest to the person taking the How totype the letter Mwith 2 tongue strokes using the UCS 1000 and theApple® Macintosh
computer with Micracie Typer™software
video. (Miracle Typer graphic as displayed
Two divergent approaches to eye-tracking exist in on the Macintosh screen)

mainstream products. In the first approach, personal

computer developers are exploring eye-tracking as a
means of detecting the action that the user would like to
perform. This tracking would allow the computer to an-
ticipate the needs of the user. To work as a mainstream
product, the system must be able to track the user’s gaze
anywhere in front of the computer monitor. Develop- rst Tongue Stroke: F Second Tongue Stroke: _
Push the TK button associated with the
ment of the technology to allow free movement while ush the button associated
with the sector Gorkarng the sector containing the letter M. Mwill be
letters jthrough r ed into the Macintosh application
tracking eye gaze is delaying the introduction of such where the cursor has been placed

products.
The second approach to using eye-tracking is more FIG. 19-13
similar to video cameras with built-in eye tracking; MiracleTyper enabling character selection by selection history.
these worked because the camera was held to the eye
and moved with the eye. An eye-tracking system would Morse is similar, except that two switches are used: one
be much easier to use if it were small enough to be head to produce the “dit” element and a second to produce
mounted because the system would remain in fixed re- the “dah.” Because the meaning of the switches is un-
lationship to the eyes. Currently, systems that combine ambiguous, it is possible for the dit and dah to be the
head-mounted displays with eye-tracking are being same length, potentially doubling typing speed. Three-
made available for the development of future products. switch Morse breaks the time dependence of Morse by
A number of possibilities are opened by this combina- using a third switch to indicate that the generated set of
tion. For example, a head-mounted display might pro- dits and dahs constitutes a single letter.
ject a control system that the user looked at to control Morse code is a highly efficient method of typing for
devices, and looked through for other activities. With a person with severe motor control limitations and has
binocular eye-tracking combined with head-tracking, the advantage over other virtual keyboard techniques of
an EADL system might be constructed that would eventually becoming completely automatic. Many
allow the user to control devices simply by looking at Morse code users indicate that they do not “know”
them. Currently, no affordable, easy-to-use, and effec- Morse code. They think in words, and the words
tive eye-gaze input systems exist. Now that engineers of appear on the screen, just as happens in touch-typing.
mainstream devices have discovered this technology, it Many Morse code users type at speeds approaching 25
will probably become less costly and more effective in words per minute, making this a means of functional
the future. p writing. The historical weakness of Morse has been that
each company creating a Morse interface for assistive
SWITCH ENCODING INPUTS. The individual who technology has used slightly different definitions of
lacks the ROM or fine motor control necessary to use a many of the characters. To address this issue, and to
physical or graphical keyboard may be able to use a promote application of Morse code, the Morse 2000
switch encoding input method. In switch encoding, a organization has created a “standard” for Morse devel-
small set of switches (from one to nine) is used to di- opment, which is available on the World Wide Web
rectly access the functionality of the device. The at http://www.uwec.edu/academic/hss-or/Morse2000/
meaning of the switch may depend on the length of MorseSpecification.doc.”
time it is held closed, as in Morse code, or on the imme- Another variant of switch encoding involves switches
diate history of the switch set, as in the tongue touch that monitor their immediate history for selection. The
keypad. Tongue Touch Keypad from newAbilities* uses a set of
In Morse code, a very small set of switches is used to nine switches on a keypad, which is built into a mouth-
type. In single-switch Morse, a short switch closure piece that resembles a dental orthotic, and an on-screen
produces an element called a “dit,” which is typically keyboard (Fig. 19-13).
written as an “*.” A long switch closure produces the
My

When the keypad is in typing mode, the first switch

“dah” element, which is written as a “-.” Formally, a selection selects a group ofnine possible characters, and
“long switch closure” is three times longer than a short the second switch action selects a specific character. This
switch closure, a system that can be adjusted to the approach to typing is somewhat more efficient than
needs of the individual. Patterns of switch closures
produce the letters of the alphabet, number, and punc-
tuation. Pauses longer than five times the short switch *newAbilities System Inc., 470 San Antonio Rd., Suite G, Palo Alto,
closure indicate the end of a character. Two-switch CA 94306. http://members.aol.com/UCS1000/home.htm
270 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

Morse physically but does require the user to observe

the screen to know the current switch meaning.
A different approach to switch encoding is provided
by the T9 keyboard.* In this novel interface, each key of
the keyboard has several letters on it but the user types
as if only the desired character were present. The key-
board software determines from the user’s input what
word might have been intended. The “disambiguation
process” used in the T9 keyboard allows a high degree
of accuracy in determining which character the user in-
tended and also allows rapid learning of the keyboard.
This input technology is potentially compatible with ante|
the pointing systems described earlier in this chapter,
providing an excellent balance of target size and avail-
able options. Fig. 19-14 shows the T9 keyboard on a
Palm Pilot.

SPEECH INPUT. For many, speech input has a

magical allure. What could be more natural than to
speak to an EADL or computer and have one’s wishes
carried out? When first introduced by Dragon Systemst
in 1990, large vocabulary speech input systems were
enormously expensive and, for most, of limited utility.
Although highly dedicated users were able to type using
their voices in 1990, almost no one with the option of
the keyboard would choose to use voice for daily work.
These early systems required the user to pause between
each word so that the input system could recognize the
FIG. 19-14
units of speech. Ten years later, the technology has
T9 keyboard on a Palm Pilot. (From Tegic Communications.)
evolved to allow continuous speech, with recognition
accuracy greater than 90%. (The companies producing
speech products claim accuracy of greater than 95%.) ately to the presented cues, the training process will be
Although this advance in speech technology is remark- difficult. A few clinicians have reported success in train-
able, it does not mean that speech input is the control of ing students with learning disabilities or other cognitive
choice for people with disabilities, for a number of limitations to use speech input systems, but in general
reasons. the success rate is poor. Even after training, the user
Speech recognition requires consistent speech. Al- must watch carefully for misrecognized words and
though it is not necessary that the speech be absolutely correct them at the time the error is made. Modern
clear, the user must say words the same way each time speech recognition systems depend on context for their
for an input system to recognize them. Because of this, recognition. Each uncorrected error slightly changes the
the majority of people with speech impairments cannot context until the system can no longer recognize the
use a speech input system effectively; slurring and vari- words being spoken. Spell-checking a document will
ability of pronunciation will result in a low recognition not help the user find misrecognized words, since each
rate. word on the screen is a correctly spelled word—it just
A high degree of vigilance is needed during training may not be the word the user intended.
and use of speech input. Before current speech technol- Speech input is intrusive. One person in a shared
ogy devices can be used, they must be “trained” to un- office space talking to a computer will reduce the pro-
derstand the voice of the intended user. To do this, the ductivity of every other person in the office. If everyone ~
system presents text to the potential user, who must in the office were talking to their computers, the result-
read it into the microphone of the recognition system. If ing noise would be intolerable. Many offices have
the user lacks the cognitive skills to respond appropri- banned speech input for settings where data entry is
being performed because of the confusion and errors
produced by hearing numbers spoken while trying to
*Tegic Communications, 2001 Western Avenue, Suite 250, Seattle, WA
98121. http://www.tegic.com
focus on other numbers. Speech input is effective for a
‘Dragon Systems, Inc., 320 Nevada Street, Newton, MA 02460; person who works or lives alone but is not a good input
Phone: +1-617- 965-5200, Fax: + 1-617-965-2374. method for most office or classroom settings.
 Assistive Technology ves |

The type of speech system used depends on the In either application the process of composing thoughts
device being controlled. For EADL systems, discrete may require making hundreds or thousands of selec-
speech (e.g., “Lights—On”) provides an acceptable level tions in sequence. The cumulative effect of the pauses in
of control. The number of options is relatively small, row-column scanning slows productivity to the point
and there is seldom a need for split-second control. that functional communication is difficult and may be
Misrecognized words are unlikely to cause difficulty. impossible. Certainly, when productivity levels are
However, text generation for narrative description mandated, the communication rate available with scan-
places higher demands on the user for input speed and ning input will not be adequate.
transparency and may call for a continuous input
method. Other computer applications, however, may Rate Enhancement Options
work better with discrete than with continuous input For EADL systems, rate of control input is relatively
methods. Databases and spreadsheets typically have unimportant. As noted previously, the number of
many small input areas, with limited information in control options is relatively limited, and rarely are selec-
each. These applications are much better suited to dis- tions severely time constrained. However, the number
crete speech than continuous speech. of selections to be made in sequence is high with AAC
The “holy grail” of speech recognition is a system and computer control systems, and rate is frequently
that will recognize any speaker, with an accuracy better very important. Because a person with a disability typi-
than 99%. Developers of current speech systems say cally cannot make selections at the same rate as an able-
that, based on advances in processor speed and speech bodied person, rate enhancement technologies may be
technologies, this level of usability should be possible used to increase the information transmitted by each
within about 5 years. However, developers have been selection.
making the same prediction (within 5 years) for the past In general, language can be expressed in one of three
10 years! Modern speech recognition systems are vastly ways: letter-by-letter spelling, prediction, and compac-
better than those available 10 years ago and are also tion and expansion. Of these, the latter two options
available at just over 1% of the cost of the early systems. allow enhancement of language generation rates.
However, even with these improvements, they still are
not preferable to the conventional keyboard for most LETTER-BY-LETTER SPELLING. Typical typing uses
users. letter-by-letter representation and is relatively ineff-
cient. For each language and alphabet, there is a balance
Scanning Input Methods between the number of characters used to represent a
For the individual with limited cognition or motor language and the number of elements in a message.
control, a variant of row-column scanning is sometimes English, using the conventional alphabet, averages about
used. In scanning input, the system to be controlled se- six letters (selections) per word (including the spaces
quentially offers choices to the user and the user indi- between words). When represented in Morse code, the
cates assent when the correct choice is offered. Typically same text will require roughly 18 selections per word. By
such systems first offer groups of choices. When a group comparison, the basic Chinese vocabulary can be pro-
is selected, the system offers the items of the group se- duced using a single ideogram per word. However, thou-
quentially. Because early systems presented the items as sands of ideograms exist. In general, having a larger
part of a grid and offered the items a row at a time, such number of characters in an alphabet allows each charac-
systems are commonly referred to as “row-column” ter to convey more meaning but may make the selection
scanning even when no rows or columns are present. of each specific character more difficult.
Scanning input allows selection of specific choices Many AAC systems use an expanded set of “charac-
with limited physical effort. Generally, the majority of ters” in the form of pictograms or icons that represent
the user's time is spent waiting for the desired choice to entire words and may be selected by the user. Such “se-
be offered, so the energy expenditure is relatively small. mantic compaction” allows a large vocabulary to be
Unfortunately, the overall time expenditure is usually used within a device but requires a system of selection
relatively large. When the system has only a few choices that may add complexity to the device. For example, a
from which to select, as in most EADL systems, scan- device may require the user to select a word group (e.g.,
ning is a viable input method. The time spent waiting food) before selecting a specific word (e.g., hamburger)
while the system scans may be a minor annoyance, but from the group. Using subcategories, it is theoretically
the delay in turning on a light a few seconds from now possible to access a vocabulary of over 2 million words
rather than immediately is relatively acceptable. EADL on a 128-key keypad with just three selections.
systems are used intermittently throughout the day,
rather than continuously, so the delays over the course PREDICTION. Because messages in a language tend
of the day are acceptable in many cases. For AAC or to follow similar patterns, significant savings of effort
computer systems, however, the picture is very different. are possible by using prediction technology. Two types
272 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

of prediction are used in language: word completion tional effort of the user. Similarly, “TTFN” might be
and word or phrase prediction. used to store the social message, “Ta-ta for now.”
In word completion a communication system (AAC Effective abbreviations will be unique to the user,
or computer based) will present one or more options to rather than generally understood. An example of an ef-
the user after each keystroke, suggesting words that the fective form of abbreviation is the set of language short-
user might be typing. When the appropriate word is pre- cuts commonly used in note taking. These abbrevia-
sented by the prediction system, the user may select that tions form a shorthand unique to the individual,
word directly rather than continuing to spell out the allowing complex thoughts to be represented on the
word. Overall, this strategy may reduce the number of page quickly in the course of a lecture. A clinician
selections. However, it may not improve typing speed. should work carefully with the client to develop abbre-
Anson? demonstrated that when the user was typing viations that will be useful and easily remembered.
from copy using the keyboard, typing speed was reduced Another form of “abbreviation” that is less demand-
in direct proportion to the frequency of using word pre- ing to create involves correction of common spelling
diction. The burden of constantly scanning the predic- errors. For either students or adult writers who have cog-
tion list overwhelms the potential speed savings of word nitive deficits that influence spelling skills, expansions
completion systems under these conditions. However, can be created to automatically correct misspelled
when the user is typing using an on-screen keyboard or words. In these cases the “abbreviation” is the way that
scanning system, with which he or she must scan the the client generally misspells the word and the “expan-
input array in any case, word completion does appear to sion” is the correct spelling of the word. Once a library
increase typing speed as well as reduce the number of of misspelled words is created, the individual is relieved
selections made. of the need to worry about the correct spelling. Some
Because most language is similar in structure, it is maintain that this form of adaptation will discourage
also possible, in some cases, to predict the word that the individual from ever learning correct spelling. In
will be used following a specific word. For example, cases where the client is still developing spelling skills,
after a person types his or her first name, the surname this is probably a valid concern and the adaptation
will often follow. When this prediction is possible, the should not be used. But for the individual with a cogni-
next word may be generated with a single selection. tive deficit in which remediation is not possible, accom-
When combined with word completion, next-word pre- modation through compression and expansion tech-
diction has the potential to decrease the typing effort nology is a desirable choice.
substantially. However, in many cases this potential is None of the control technologies will allow a person
unrealized. Even when provided with next-word predic- with a disability to produce messages at the same rate as
tion, many users become so involved in spelling words an able-bodied person. However, individually and collec-
that they ignore the predictions even when the predic- tively, these technologies can make message generation
tions are accurate. The cognitive effort of switching significantly more efficient and accurate than it would be
between “typing mode” and “list scanning” mode may without them. The techniques are not mutually exclusive.
be greater than the physical benefit of not having to Icons can be predicted using “next word” techniques.
spell a word out. Abbreviations can be used in conjunction with word-
completion and word-prediction technologies.
COMPRESSION AND EXPANSION. Compression
and expansion strategies allow limited sets of com-
monly used words to be stored in unambiguous abbre-
Output Options
viations. When these abbreviations are selected, either As noted earlier, the control of assistive technologies in-
letter by letter or through word completion, the abbrevi- volves a cycle of both human output and human input,
ation is dynamically replaced by the expanded form of matched to technology input and technology output.
the word or phrase. Individuals who have sensory limitations may have dif-
Because the expansion can be many selections long, ficulty controlling assistive technologies (or common
this technology offers enormous potential to save technologies) because they are unable to perceive the
energy and time. However, the potential savings are re- messages that are being sent to them by the technology.
alized only when the person remembers to use the ab- Adaptations of the output of the technology may be
breviation rather than the expanded form of a word. needed for these individuals. These adaptations gener-
Because of this limitation, abbreviations must be care- ally depend on one of three sensory modalities: vision,
fully selected. Many abbreviations are already in hearing, or tactile sensation.
common use and can be stored conveniently. Most
people will refer to the television by the abbreviation Visual Output
“TV,” which requires just 20% of the selections to repre- The default output of many types of electronic technol-
sent. With an expansion system, each use of “TV” can ogy is visual. Computer screens are designed to resem-
automatically be converted to “television” with no addi- ble the printed page. AAC systems have input that
 Assistive Technology 273

“looks” like a keyboard, and the systems typically larger symbol to represent its meaning. However, as
provide a graphical message composition area. EADLs with keyboards for those with physical limitations, the
use display panels and lighted icons to show the current result is either fewer communication options or a more
status of controlled devices. The user must have visual complex interface for the user. Also, these accommoda-
acuity at nearly normal levels for perception of all of tions do not adapt the size of the message composition
these controls. When the client has some vision but that display, which may be inaccessible to the user with
vision is limited, some adaptations may be required. visual limitations.

COLORS AND CONTRAST. Many types of visual Speech Output

impairment affect the ability to separate foreground and It is important to keep the difference between voice input
background colors. In addition, bright background and voice output clearly in mind. In voice input, the user
colors can produce a visual glare that makes the fore- speaks and the spoken word is converted into com-
ground difficult to perceive. In accommodating visual mands within the assistive technology. In voice output,
deficits, the clinician should explore the colors that the the device communicates with the user by auditory
client easily perceives and those that the client has diffi- means, converting printed words or commands into
culty perceiving. For most people, background colors voice. Voice output technology has been in existence for
should be muted, soft colors that do not produce strong much longer than voice input and is a more mature
visual response. On the other hand, icons and letters technology—not perfect, but more mature.
may be represented in colors that provide visual con- The demands of voice output are varied, depending
trast with the background. Very bright or strident colors on the application and the intended listener. In general,
should be avoided with both background and icons or systems can be categorized as either those in which a
letters. The specific colors and contrast levels needed by second person is the listener or those in which the user
the user must be selected on an individual basis. is the listener.

IMAGE SIZE. Visual acuity deficits and display size SECOND PERSON AS _ LISTENER. Most voice
constraints present difficulty in output displays. Typi- output used in AAC applications is intended to be un-
cally, a person with 20/20 vision can easily read text pre- derstood by a person who may have little experience
sented in letters about 1/6 of an inch high. (This is equiv- with synthetic voices. For example, the AAC user at the
alent to a page printed in a 12-point font.) On a typical corner market buying 2 pounds of hamburger for
display, between 100 and 150 words of text, or a similar dinner will communicate with a butcher who will have
number of icons, may be presented for selection at one had very little experience with synthetic voice. When
time. If the user has lower visual acuity, the letter and asking for directions on the street corner, the AAC’s
icon size must be increased to accommodate that loss of voice will be competing with the sounds of trucks and
acuity. However, the display of larger icons necessitates busses while attempting to communicate with a listener
displaying either fewer letters at a time or increasing the who probably has little prior experience.
display size. For people with severe visual limitations, it To be understandable by novice listeners in real-
would be impractical to display all choices at once. world environments, a synthetic voice should be as clear
Screen enlargement programs typically overcome and as “human sounding” as possible. The voice will be
the limitation in display size by enlarging a portion of easily understood to the extent that it sounds like what
the full screen and moving this expanded portion to the the listener expects to hear. Ideally, the voice would
area most likely of interest to the user. The visual effect provide appropriate inflection in the spoken material
of this is similar to viewing the screen through a magni- and would be able to convey emotional content.
fying glass that the user moves over the display. Most Current AAC systems do not convey emotional content
programs can be configured to follow the text insertion well, but high-end voices do sound very much like
point, the mouse pointer, or other changes on the human speakers. Under adverse conditions, these
display. Navigation is a serious weakness with all such devices will remain less understandable than a human
programs. When the user can see only a small portion of speaker, because facial and lip movements (that provide
the screen at a time, the landmarks that are normally additional cues as to the sounds being produced) do
available to indicate the layout of the text on a page may not accompany synthetic voices.
be invisible because they are not in the field of view.
Any screen enlargement program must provide a means USER AS LISTENER. When synthetic voice is used
the client can use to orient to the location on the screen. for computer access or EADLs, the voice quality does
AAC systems can accommodate the needs of a person not need to be as “human sounding.” For either use, the
with low visual acuity by using precisely the same tech- user has the opportunity to learn to understand the
niques that are used for the person with limited fine voice in training. In EADL applications, relatively few
motor control. The keyboard of the device can be con- utterances need be produced, and these can be designed
figured with fewer, larger keys, each of which has a to sound as different from each other as possible so that
274 OCCUPATIONAL PERFORMANCE AND PERFORMANCE AREAS

there is little chance of confusion. General voice output reading for students at the National Institute for the
for an entire language is somewhat more difficult, Young Blind in Paris.* Over time, this original system
however, because many words sound similar and can be has been extended to allow communication of music,
easily confused. mathematics, and computer code to readers without
For general text reading, the primary issue is voicing vision. Basic Braille uses an array of six dots to repre-
speed. As noted earlier, humans generally talk at a rate sent letters and numbers. However, traditional Braille is
of between 150 and 175 words per minute. However, only usable for static text, such as printed books.
most humans also read between 300 and 400 words per Dynamic information cannot be represented by raised
minute. A person who depends on a human-sounding dots on a sheet of paper.
voice for reading printed material will be limited to Technology access requires the use of refreshable
reading at less than half the speed of able-bodied Braille. Refreshable Braille displays use a set of piezo-
readers. To be an effective text access method, synthetic electric pins to represent Braille letters. Changing electri-
voice must be understandable at speeds in excess of 400 cal signals to the display move the pins up and down,
words per minute. This requires significant training, allowing a single display to represent different portions
since untrained people without disabilities can’t under- of a longer document.
stand speech at such speeds. With training, however, Braille is not widely used among individuals who are
speech output is a useful way for a person to access blind. By some estimates, only 10% of the blind popu-
printed material. lation know and use Braille. It is not usable by those
Synthetic speech is a useful tool in two cases: when it who have limited tactile sensation in addition to blind-
replaces voice for a person with a disability and when ness. In spite of this, Braille is a skill that probably
the user is not able to use vision to access the technol- should be taught to a person who is blind. Most Braille
ogy. AAC devices using voice provide the most “normal” readers are employed; most people who are blind but
face-to-face communication available. In most con- do not read Braille are not employed. While Braille may
ditions, able-bodied people communicate by voice. not be an essential skill for employment, the ability to
People with disabilities generally want to communicate learn Braille certainly correlates with the ability to hold
in similar fashion. The other application of voice is a job.°
“eyes-free” control. In the mass market for able-bodied
consumers these applications include the presentation
of information over the telephone, while driving, or in
SUMMARY
other settings where a visual display might be difficult Assistive technologies provide a means for persons with
to use. All of these situations are important for people disabilities to perform tasks that would otherwise be
with disabilities as well. difficult or impossible for them to perform. The devel-
Persons with print impairments also may find value opment and increased availability of universal design
in assistive technologies using voice. Print impairments has improved access and ease of use for persons with
include conditions that result in very low vision and disabilities, as well as for the “temporarily able-bodied.”
blindness, as well as conditions that result in the inabil- This chapter has introduced several models for ap-
ity to translate visual stimuli to language and those that proaching assistive technology. The reader is asked to
make manipulation of printed materials difficult. consider the interface between a person, a technology,
Voice output technology may be a poor choice for an environment, and a task. Various technologies that
people who are developing language skills. Because are current state of the art have been described. These
English is an irregular language, with many letter com- cover the categories of electronic aids to daily living
binations making similar sounds, it is almost impossi- (EADL), augmentative and alternative communications
ble to learn spelling by listening to the sound of words. (AAC), and general computer applications and control
As such, children who are blind from birth may not be technologies.
good candidates for speech output as the primary lan- An occupational therapist should always keep in
guage access method because the structure of words is mind that although disability makes few things impos-
lost when the words are converted to speech. For these sible, it makes many things more difficult. Disability
children and for many others, tactile access is a better may make some tasks sufficiently hard that they are
tool. “not worth it.” The goal of rehabilitation is to make
those tasks possible. Assistive technology can make
Tactile Output many things easier for the person with a disability.
The oldest method for individuals with visual deficits When they are easier, many things that were previously
to access printed material is Braille. In 1829, Louis not worth the effort can become reasonable to attempt.
Braille developed the idea of adapting a military Assistive technology will never remove the functional
system that allowed aiming artillery in darkness and limitation. However, it can compensate for that func-
writing secret messages, to provide a method of tional limitation and enable ability.
 Assistive Technology 275

14. How would a therapist go about selecting colors

REVIEW QUESTIONS
and contrast for a visual output display? What
. Contrast rehabilitation technology with assistive factors are important?
technology. ile Braille is the oldest system of tactile input for
. Discuss the role of universal design in improving persons with vision loss, and yet the author advo-
technology options for persons with physical im- cates its continued use. Why?
pairments.
. Contrast the three models of HAAT, HETI, and HIA. REFERENCES
. Identify and describe at least three EADL that are ily Anson DK: Alternative computer access: a guide to selection, Philadel-
suitable for persons with physical impairments. phia, 1997, FA Davis.
. Indicate some of the technologies that can be used . Anson DK: The effect of word prediction on typing speed, Am J
Occup Ther 47(11):1039-1042, 1993.
for power switching.
. Canadian National Institute for the Blind: Braille Informa-
. Discuss the importance of feature control. Analyze tion Centre. Available online at “http://www.cnib.ca/braille_
the difficulties and solutions in providing feature information/louis_braille.htm.” May 1999, the Institute.
control to persons with physical impairments. . Center for Universal Design: Principles of universal design. Available
. Discuss several different augmentative and alterna- online at “http://www.design.ncsu.edu:8120/cud/univ_design/
princ_overview.htm.”
tive communication devices in terms of their bene-
. Cook AM, Hussey SM: Assistive technologies: principles and practice,
fits and their limitations. St Louis, 1995, Mosby.
Contrast message composition and message trans- . Smith RO: Technological approaches to performance enhance-
mission. Identify features that are important in ment. In Christiansen C, Baum C, editors: Occupational therapy:
each. overcoming human performance deficits, Thorofare, NJ, 1991, Slack
Publishers.
Contrast aural and graphical communications in
. Light J: Interaction involving individuals using augmentative and
terms of their demands on the user and on the tech- alternative communication systems: state of the art and future di-
nology. rections, Augmentative Altern Communication 4(2):66-82, 1988.
10. Give some examples of options for input devices. . Merzenich M, Jenkins W, Johnston P, et al: Temporal processing
Identify situations in which each would be appro- deficits of language-learning impaired children ameliorated by
training, Science 271(5245):77-81, 1996.
priate and situations in which each would be un-
. Miller GA: Language and speech, San Francisco, 1981, Freeman.
workable. 10. Morse 2000: Development specification: Morse code input system
i; How do prediction and compression and expan- for the Windows 2000 operating system, Available online at “http://
sion work? www.uwec.edu/academic/hss-or/Morse2000/MorseSpecification.
a2, The author suggests that prediction technologies doc.”
iW Tallal P, Miller S, Bedi G, et al: Language comprehension in lan-
may not save time in the way originally envisioned
guage-learning impaired children improved with acoustically
by their designers. What is the reason for this? modified speech, Science 271(5245):81-84, 1996.
i. List considerations that would apply in selecting
output options.
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cEy 1 -_ LEARNING OBJECTIVES

Functional motion assessment After reading this chapter the student or practitioner
Individual activity analysis will be able to do the following:
Objective activity analysis 1. Define functional motion assessment.
Clinical observation 2. Describe why it is desirable to assess motor
function through observation of activity
performance.
: 3. State two circumstances under which assessment of
‘ performance components is indicated.
r 4. Define individual activity analysis, or “dynamic
performance analysis.”
5. Describe why it is not possible to do an accurate
objective activity analysis.
6. List at least three questions that can guide the
clinical observation and clinical reasoning of the
occupational therapy practitioner while conducting
a functional motion assessment.
7. List factors other than range of motion (ROM),
strength, and motor control that can affect motor
performance.
8. Discuss how information gained from the
functional motion assessment differs from that
gained during assessment of performance
components.
9. State the minimum level of strength required
throughout the lower extremity for normal stance
and positioning.
10. Compare levels of muscle strength and associated
endurance in the upper extremities.
11. List activities that can be used to assess functional
motion in the upper extremities and in the lower
extremities.

BAF|
280 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

vation is to understand the patient's occupational per-

formance problems in the context of the interaction
any physical disabilities cause limitations in between the person, the task, and the environment.°
joint range of motion (ROM), muscle strength, or The therapist's scientific knowledge of the particular
motor control. These physical impairments result in dysfunction and an analysis of the ways in which activi-
movement limitations that can cause slight to substan- ties are generally performed influence the assessment of
tial deficits in occupational performance and prevent performance problems and aid in is development of
pursuit of self-care, work, leisure, and social activities. plans to remediate those problems.’
The functional motion assessment is a way of assessing The following are questions to guide the clinical ob-
ROM, strength, and motor control available for task per- servation and clinical reasoning processes:
formance by observing the patient during performance 1. Does the patient have adequate ROM to perform
of functional activities (activities of daily living [ADL], the task?
work, or leisure activities). a. Where are the joint limitations?
Since the primary responsibility of the occupational b. What are some possible causes of the limita-
therapist is to assess occupational performance, identify tions?
performance problems, and plan treatment strategies c. Are there true ROM limitations or are apparent
that will improve occupational performance, sensori- limitations actually caused by decreased muscle
motor limitations first should be assessed through ob- strength?
servation of functional activities. When improvement of 2. Does the patient have enough strength to perform
performance components is a goal of the intervention the task?
program, assessment of performance components may a. In which muscle groups is there apparent weak-
be indicated to make an objective assessment of physi- ness?
cal limitations and gains (Chapters 21 to 23). b. If strength appears inadequate to perform a task
Sensory, perceptual, cognitive, and psychosocial im- because the patient cannot complete the ROM,
pairments can also affect motor function. These compo- is there truly muscle weakness or is there actu-
nents must be considered in any performance evalua- ally limited ROM?
tion (Chapters 24 to 29). However, this chapter is 3. Does the patient have enough motor control to
limited to consideration of motor function (i.e., ROM, perform the task?
strength, and motor control) during the functional a. Is the movement smooth and rhythmic?
motion assessment. b. Is movement slow and difficult (e.g., as seen in
Except for a few diagnoses, comprehensive assess- spasticity and rigidity)?
ments of ROM, muscle strength,” and motor control are c. Are there extraneous movements when the pa-
seldom necessary. For example, performing a full ROM tient performs the task (e.g., tremors, athetoid,
assessment or manual muscle test is time consuming, can or choreiform movements)?
be tiring to the client, and may duplicate other services. The observing therapist must also consider the patient's
understanding of the instructions and perception of
task importance, as well as the possibility of sensory,
CLINICAL OBSERVATON
perceptual, and cognitive deficits. An analysis of the
In occupation-based practice, muscle strength, ROM, results of the functional motion assessment may indi-
and motor control can be observed during the perform- cate that formal assessment of performance compo-
ance of ordinary ADL.* For example, while assessing nents is needed. For example, this assessment may be
ADL, the therapist can observe for performance difficul- needed to differentiate muscle weakness from limited
ties and movement patterns that may signal limited ROM or to quantify (with a muscle ie muscle weak-
ROM, muscle weakness, muscle imbalance, poor en- ness in specific muscle groups.
durance, limited motor control, and compensatory Assessing ROM, strength, and motor conan by ob-
motions used for function. serving the patient perform functional activities can aid
Essentially, when observing a patient perform se- in selecting meaningful treatment goals relative to im-
lected tasks, the occupational therapist is doing an proving occupational performance. The therapist can
individual activity analysis or “dynamic performance ask the patient about his or her ability to perform the
analysis”’ to diagnose the occupational performance tasks of daily living but should also observe the patient
problems of that patient. Because people perform the performing such activities as dressing, walking, stand-
same task in a variety of ways and because there are so ing, and sitting to make an accurate assessment.~
many variables in task performance, it is not possible to Joint ROM, manual muscle testing, and motor
do an objective activity analysis, one that can be control assessments (Chapters 21, 22, and 23) will give
applied universally, and describe the sensorimotor re- the therapist specific information about the function of
quirements of the myriad of ADL. The purpose of obser- the musculoskeletal, neurophysiological, and sensori-
 Functional Motion Assessment 281

motor systems. Although the tests require minimum to Hip Complex

maximum active output by the client, the therapist will The hip joints support the body weight. Each joint acts
not be able to determine the client's ability to integrate as a fulcrum when a person is standing on one leg. Hip
these systems to perform specific goal-directed tasks movement makes it possible to move the body closer to
based on the results of these assessments. Rather, the or farther from the ground, bring the foot closer to the
therapist will have information about movements of a trunk, and position the lower limb in space.”
specific limb or a combination of limbs. Under carefully During functional activities, lumbar-pelvic move-
controlled conditions the therapist will know about ments accompany hip movement, which extends the
the flexibility of the components of the joint and the functional capabilities of the hip joint. The hip is
strength of muscles to create movements, such as flex- capable of flexion, extension, adduction, abduction,
ion, abduction, and external rotation. However, the and internal and external rotation.*
patient's motor performance capabilities are not meas-
ured by these assessments. For example, the manual FLEXION AND EXTENSION. Full flexion and exten-
muscle test cannot measure muscle endurance (number sion are required for many ADL. Standing requires full
of times the muscle can contract at its maximum level), hip extension. Squatting, bending to tie a shoelace with
motor control (smooth rhythmic interaction of muscle the foot on the ground, and toenail care done with the
function), and the patient's ability to use the muscles foot on the edge of the chair all require full or near full
for functional activities.’ While observing a patient per- hip flexion. Other activities that require moderate to full
forming functional activities, it would be most helpful if flexion and extension are donning panty hose or socks,
a therapist could also estimate the client's existing ROM, bathing the feet in a bathtub, ascending and descending
muscle strength, and motor control. stairs, and sitting and rising in a standard chair.”

ABDUCTION AND ADDUCTION. Most ordinary

FUNCTIONAL MOTION ASSESSMENT
ADL do not require full ranges of abduction and adduc-
The activities listed in the following sections for the tion. The main function of the hip abductors is to keep
functional motion assessment are suggested as a general the pelvis level when one foot is off the ground. For
starting place for the student or beginning practitioner. ADL, hip abduction may be used when stepping side-
Only upper and lower extremity activities are included. ways into a shower or bathtub, donning trousers when
Movements of the face, mouth, neck, and spine are sitting, squatting to pick up an object, or sitting with the
beyond the scope of this chapter. Many more activities foot across the opposite thigh.*
could be suggested in each category. The reader is re- Hip adduction brings the foot across the front of the
ferred to Musculoskeletal Assessment, second edition, by body. An individual uses this motion when kicking a
Hazel M. Clarkson’ for a comprehensive and detailed ball, moving an object on the floor with the foot, or
discussion of musculoskeletal assessment and its func- crossing one thigh over the other for donning or remov-
tional application. 7 ing shoes and socks.”

INTERNAL AND EXTERNAL ROTATION. Internal

Lower Extremity
rotation occurs when a person is pivoting medially on
Because of the somewhat stereotypical movements of the one foot. When a person is sitting, there is internal rota-
lower extremity, the arrangement of the large muscle tion when the person reaches to the lateral side of the
groups, and the nature of the overall functions of weight foot for washing or donning socks. Internal rotators are
bearing and ambulation, assumptions can be made active in walking.*
about muscle strength during functional activities. For External rotation with hip flexion and abduction
example, to assume a normal stance pattern, ambulate brings the foot across the opposite thigh for donning
without any compensatory gait patterns, or position the shoes or socks, or for foot hygiene.*
lower extremities (without the assistance of the upper ex-
tremities) during dressing, a minimum of F+ muscle Knee
strength is required in the musculature of the hips, knees, The knee joint supports the body weight. With the foot
ankles, and feet. If muscle strength in the lower extremi- fixed on the ground, knee flexion lowers the body
ties is only F throughout the lower extremity, ambulation toward the ground and knee extension raises the body.
without aids will not be possible. Good to normal If the foot is off the ground, as in sitting, the knee and
muscle strength is required for the endurance to perform hip are used to orient the foot in space.*
the small postural adjustments needed for maintained Daily living activities that require moderate to full
standing, repetitive movement patterns inherent in ranges of knee flexion and extension are standing and
walking, and the lifting, maneuvering, and balancing on walking, squatting to lift an object from the floor, cross-
the lower limbs that usually occur during dressing. ing the ankle of one foot over the thigh of the opposite
282 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

leg, sitting down and rising from a chair, and dressing adducted position. It would be inappropriate for the
the feet. therapist to instruct the client on how to don the shirt if
the therapist's goal was to attain some information re-
Ankle and Foot garding the client's level of independence in dressing
The foot is a flexible base of support when a person is and secondarily to make assumptions about ROM and
on rough terrain. It functions as a rigid lever during ter- muscle strength.
minal stance in the walking pattern. It absorbs shock The important thing to remember when observing a
when transmitting forces between the ground and the client perform functional motion tasks with the upper
leg. The foot and ankle function to elevate the body extremities is that even when it is not obvious or readily
from the ground when the foot is fixed. Dorsiflexion apparent, the muscles of the shoulder complex are con-
and plantar flexion occur at the ankle joint. Foot inver- tracting with varying degrees of tension. They may have
sion and eversion occur at the subtalar joint.* to contract with enough force to position the hand in
space and maintain it there, as when a person is
PLANTAR FLEXION. Full plantar flexion is used combing hair. At other times the humerus must be held
when a person is rising on the toes to reach upward to a close to the body to provide a stable base from which
high shelf. Some plantar flexion is used to depress the the forearm, wrist, and hand can maneuver, as when
accelerator in an automobile or control pedal on a hitting the keys on a keyboard, cutting food with a
sewing machine and when donning socks or shoes. knife, or writing. It would be an inaccurate assumption
that the extremity is just hanging passively at the side
DORSIFLEXION. Full range of dorsiflexion is when, in fact, the static contractions around the proxi-
needed to descend stairs. Dorsiflexion is used in such mal joints make it possible for the musculature of the
activities as positioning the foot to cut the toenails or distal extremity to work effectively. Conversely, the
tying shoe laces.” shoulder complex may have to be a moving unit, as
opposed to a positioning one, as when moving gro-
INVERSION AND EVERSION. Inversion and ever- ceries from a countertop to shelves in a kitchen cabinet.
sion function to provide flexibility when an individual General guidelines exist for assessing strength for
is walking on uneven ground. Inversion is used when function in the upper extremities. With good to normal
the foot is crossed over the opposite thigh and the sole endurance the patient with good (G) to normal (N)
is inspected.* muscle strength throughout the upper extremity will be
able to perform all ordinary ADL without undue
fatigue.° Ordinary ADL are considered here to be all
Upper Extremity
self-maintenance tasks, mobility, and vocational roles,
By simply observing a patient engaging in functional ac- except for strenuous labor. The patient with fair plus
tivities, the therapist cannot as easily make general as- (F+) muscle strength usually will have low endurance
sumptions about muscle strength in the upper extremi- and will fatigue more easily than a patient with G to N
ties as in the lower extremities. There are three reasons strength. The patient will be able to perform many ordi-
why this is the case: the variety of ways in which the nary ADL independently but may need frequent rest
upper extremity can be positioned to complete any periods. The patient with muscle grades of fair (F) will
given task (i.e., there is not one right way to do the task), be able to move parts against gravity and perform light
the complexity of motor patterns possible requiring tasks that require little or no resistance.”° Low en-
gross motor and fine motor skill, and the dependency of durance is a significant problem and will limit the
the distal joints and musculature on the more proximal amount of activity that can be done. The patient with
joints for positioning. low endurance probably will be able to eat finger foods
If several people are observed donning shirts, it will and perform light hygiene if given the time and rest
be apparent that different techniques are used by each. periods needed to reach the goals.° Poor’ (P) strength is
One person may lift the arm out to the side, increasing considered below functional range, but the patient with
shoulder abduction as the shirt is drawn onto the arm. poor strength will be able to perform some ADL with
Another person might prefer to dress with the arm more mechanical assistance and can maintain ROM inde-
in front of the body, thus positioning the humerus in pendently.° Patients with muscle grades of trace (T) and
flexion. A third person might hyperextend the humerus zero (0) will be completely dependent and unable to
as the shirt is pulled on. The difficulty, of course, is de- perform ADL without externally powered devices. Some
termining exactly how much ROM and muscle strength activities will be possible with special controls on
are minimally required at all of the joints involved when equipment, such as electric wheelchairs, electronic com-
so many options are available to perform one task. munication devices, and hand splints.°
In the first two examples of donning a shirt, the mus- Individuals use a variety of motor patterns when per-
culature of the shoulder complex would certainly have forming a functional task, and no one way is the right
to create more tension than if the humerus were in the way to perform the task. These facts make it impossible
 Functional Motion Assessment 283

for the therapist to predetermine the level of muscle sociated with supination when the elbow is extended, as
strength, amount of ROM, and degree of motor control when rotating a doorknob in a clockwise direction.”
needed in the upper extremity to perform any given Internal rotation is used when buttoning a shirt,
task. Individual styles of moving, numerous possibili- eating, and drinking from a cup. Full range of internal ro-
ties for compensatory movements when faced with loss tation with scapulothoracic motion is used to reach into
of joint flexibility, poor endurance, lack of motor a back pocket, fasten a bra, put a belt through the belt
control, impaired sensation, and pain are all factors that keepers on trousers, or do toilet hygiene. Internal rota-
may affect the client's ability to generate tension in a tion is often associated with forearm pronation, as when
muscle or muscle group and sustain muscle activity. putting a pillow behind the low back, turning a screw-
driver to unfasten a screw, rotating a doorknob in a coun-
Shoulder Complex terclockwise direction, and pouring water from a vessel.”
The shoulder complex is the most mobile joint complex
in the body. Its function is to move the arm in space and EXTENSION AND ADDUCTION. Extension and
position the hand for function. The shoulder complex is adduction are used to return the arm to the side of the
composed of the acromioclavicular, sternoclavicular, body from shoulder flexion and abduction, as after
scapulothoracic, and glenohumeral joints and the mus- reaching overhead. These motions are also used when
cles, ligaments, and other structures that move and sup- quick movement or force is required, as when an indi-
port these joints. In the performance of functional activ- vidual is closing a vertically oriented window, crutch
ities, scapular, clavicular, and trunk motions normally walking, or pushing off to rise from an armchair.”
accompany glenohumeral motion. These associated
movements increase the range of glenohumeral motion FLEXION AND ADDUCTION. Flexion and adduc-
for function. The shoulder complex functions in a coordi- tion are used in activities that require reaching the same
nated manner that is accomplished through scapulotho- side of the body, such as washing the cheek or ear and
racic and glenohumeral movement. This coordinated combing hair on the same side. Slight shoulder flexion
function is called scapulohumeral rhythm. Thus move- with adduction is used for hand-to-mouth activities and
ments at the shoulder are actually combinations of putting on an earring back.
several joint motions and are dependent on scapulo-
humeral rhythm in the performance of any given activity.” Elbow and Forearm
Elbow and forearm movements serve to place the hand
SHOULDER FLEXION AND ABDUCTION WITH for function. Elbow flexion moves the hand toward the
SCAPULA UPWARD ROTATION (OVERHEAD MOVE- body and elbow extension moves the hand away from
MENTS). Activities such as placing an object (eg., the body. Forearm pronation or supination usually ac-
book, box, or cup) on an overhead shelf or reaching companies elbow flexion and extension. Pronation and
overhead to pull on a light cord require these move- supination position the hand precisely for the require-
ments.* ments of the given activity. The elbow and forearm
support skilled and forceful movements of the hand
SHOULDER EXTENSION AND ADDUCTION that are used during performance of ADL and work
WITH SCAPULA DOWNWARD ROTATION. Activities activities.”
such as reaching back for toilet hygiene, swinging the Full or nearly full range of elbow flexion, usually
arm backward for throwing a ball, and reaching back- with some humeral flexion and forearm supination, is
ward to put an arm through the sleeve of a coat require used to bring food to the mouth, hold a telephone re-
these movements.* ceiver, place an earring on the ear, and reach the neck
level of a back zipper.
HORIZONTAL ADDUCTION AND ABDUCTION. Full range of elbow extension, usually with prona-
These movements allow the arm to be moved around tion, is used when an individual is reaching to the feet
the body. Reaching the opposite axilla or opposite ear to tie shoes, throwing a ball overhand, and using the
for hygiene activities, opening and closing a sliding arms to push off from a chair. Many other ADL require
door, combing the opposite side of the hair, and reach- less than full range of these movements.”
ing the upper back while bathing are some activities
that use horizontal adduction and abduction.” Wrist and Hand
The wrist controls the length-tension relations of the ex-
INTERNAL AND EXTERNAL ROTATION. Some trinsic muscles of the hand. It positions the hand rela-
degree of either internal or external rotation accompa- tive to the forearm for touch, grasp, or manipulation of
nies every glenohumeral motion. The ROM varies in objects. Wrist extension and ulnar deviation are most
various positions of the arm. Full range of external rota- important in performance of ADL.* It is possible to
tion is required for reaching the back of the head for perform some ADL when there is a loss of wrist ROM by
combing or washing hair. External rotation is often as- using compensatory movements of the proximal joints.
 284 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

The primary functions of the hand are to grasp and 3. What is meant by individual activity analysis?
manipulate objects and to discriminate sensory infor- 4. Why is it not possible to do an objective activity
mation about objects in the environment. The arches of analysis?
the hand make it possible to adapt the hand to the 5. List three major questions that can guide the clini-
shape of the object being manipulated. cal observation and clinical reasoning of the occu-
Power grip and precision grip are the bases of all pational therapy practitioner when doing a func-
hand activities. Power grip is used when force is re- tional motion assessment.
quired for grasping, such as holding a hammer handle, 6. Which factors, other than strength, ROM, and
a full glass, or the handle of a purse or suitcase. Preci- motor control, can affect the functional motion
sion grip is used when an object is pinched and when it assessment?
is being manipulated between the thumb and one or 7. How is the information gained from assessment of
more fingers. Precision grip is used for holding a pencil, performance components different from that
moving checkers or chess pieces, turning a key, thread- gained in a functional motion assessment?
ing a needle, and opening the cap of a medicine bottle. 8. What is the minimum level of strength required
(See Chapter 31, Section 1, for a full discussion of pre- throughout the lower extremity for normal stance
hension patterns).* and positioning?
9. List some activities that can be used to assess func-
SUMMARY tional motion in the lower extremities: hip, knee,
ankle, and foot.
Many physical disabilities cause deficitsinROM, strength, 10. Compare levels of muscle strength with endurance
and motor control that limit occupational performance. in the upper extremities.
The occupational therapist is primarily responsible for 11. List some activities that can be used to assess func-
assessing occupational performance, identifying per- tional motion in the upper extremities: shoulder
formance problems, and planning treatment that will complex, elbow and forearm, and wrist and hand.
improve the patient's occupational performance.
Because people perform the same activity in a variety REFERENCES
of ways, the level of ROM, strength, or motor control 1. Clarkson HM:Musculoskeletal assessment, ed 2, Philadelphia, 2000,
needed to do a task is variable. Assessment of physical Lippincott, Williams & Wilkins.
limitations can be made through observation of a 2. Cole JH, Furness AL, Twomey LT: Muscles in action, New York,
patient's performance of activities. Therefore, the thera- 1988, Churchill Livingstone.
3. Crepeau EB: Activity analysis: a way of thinking about occupational
pist must observe the patient performing selected tasks
: = ci ‘ 3 performance. In Neistadt ME, Crepeau EB: Willard and Spackman’s
in the person-task-environment interaction. occupational therapy, ed 9, Philadelphia, 1998, Lippincott.
While assessing the patient's ability to perform ADL, 4. Crepeau EB, editor: Willard & Spackman’s occupational therapy, ed 9,
work, or leisure activities, the therapist should observe Philadelphia, 1998, Lippincott.
for sensorimotor problems. An analysis of the results of 5. Daniels L, Worthingham C: Muscle testing, ed 5, Philadelphia,
1986, WB Saunders.
observation may indicate that an assessment of per-
6. Hislop H, Montgomery J: Daniels and Worthingham’s muscle testing,
formance components is needed. Questions to guide ed 6, Philadelphia, 1995, WB Saunders.
clinical observation and clinical reasoning and sug- 7. Killingsworth A: Basic physical disability procedures, San Jose, Calif,
gested activities to assess function of the upper and 1987, Maple Press.
lower extremities are outlined in this chapter. 8. Polatajko HJ, Mandich A, Martini R: Dynamic performance analy-
sis: a framework for understanding occupational performance, Am
J Occup Ther 54(1):65-72.
REVIEW QUESTIONS
1. Define functional motion assessment.
2. In occupation-based practice, how are sensorimotor
functions first assessed?
 LEARNING OBJECTIVES
Range of motion After studying this chapter the student or practitioner
Active range of motion will be able to do the following:
Passive range of motion 1. Define active, passive, and functional ROM.
End-feel 2. List the purposes of measuring ROM.
Joint measurement 3. Name two methods used to screen for ROM
Axis limitations.
Palpation 4. Name disabilities for which joint measurement is
Goniometer often an assessment tool.
Two-joint muscle 5. Describe how ROM measurements are used to
Stationary bar select treatment goals and methods.
Movable bar 6. Describe how to establish ROM norms for the
Functional range of motion patient with unilateral involvement.
7. Describe what the therapist should do before
actually measuring the joints with the goniometer.
8. Describe proper positioning of the therapist and
how to support limbs.
9. List precautions and contraindications for joint
measurement.
10. List and describe the steps in the joint
measurement procedure in correct order.
11. Describe how to record results of the joint
measurement.
12. Measure all the joints of a normal practice subject,
using the 180-degree method and correct
procedure.
13. Describe at least three treatment methods that can
be used to increase ROM.

oint range of motion (ROM) is the amount of move- slightly greater than AROM because of the slight elastic-
ment that is possible at a joint. It is the arc of motion ity of soft tissue.*” If PROM is significantly more than
_ through which a joint passes. When the joint is moved by AROM for the same joint motion, it is likely that there is
the muscles that act on the joint, it called active range of muscle weakness. '*
motion (AROM). When the joint is moved by an outside Decreased ROM can cause limited function and in-
force such as the therapist, it is called passive range of terfere with the performance of self-care, vocational,
motion (PROM).’ In normal individuals, PROM is leisure, and social activities. The functional motion test

285
286 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

(Chapter 20), screening tests, and measurement of joint in correct positioning and stabilization for measure-
ROM with a goniometer can all be used to assess ROM. ments, palpation, alignment and reading of the go-
The primary concern of the occupational therapist is niometer, and accurate recording of measurements.”
whether ROM is adequate to perform necessary and For the most reliable measurements, the same therapist
desired life activities. should assess and reassess the patient at the same time
Methods used to screen ROM limitations are observa- of day, using the same instrument and the same mea-
tion of AROM and PROM. For the former, the therapist surement protocol.’
asks the patient to perform all the active movements that
occur at the joint. For the latter, the therapist moves the
Visual Observation
joint passively through all of its motions. The purpose of
this is to estimate ROM, detect limitations, and observe The joint to be measured should be exposed, and the
quality of movement, end-feel, and the presence of therapist should observe the joint and adjacent areas.°
pain.* The therapist can then decide where precise ROM The therapist asks the patient to move the part through
measurement is indicated. the available ROM, if muscle strength is adequate, and
observes the movement.’ The therapist should look for
compensatory motions, posture, muscle contours, skin
JOINT MEASUREMENT
color and condition, and skin creases and compare the
Joint measurement is an assessment tool often used for joint with the noninjured part, if possible.* The thera-
physical disabilities that cause limited joint motion. pist should then move the part through its range to see
These include skin contracture caused by adhesions or and feel how the joint moves and to estimate ROM.
scar tissue; arthritis, fractures, burns, and hand trauma;
the displacement of fibrocartilage or the presence of
Palpation
other foreign bodies in the joint; bony obstruction or
destruction; and soft tissue contractures, such as Feeling the bony landmarks and soft tissue around the
tendon, muscle, or ligament shortening. Limited ROM joint is an essential skill, gained with practice and expe-
can also be secondary to spasticity, muscle weakness, rience. The pads of the index and middle fingers are
pain, and edema.*’’* used for palpation. The thumb is sometimes used. The
ROM measurements help the therapist select treat- therapist's fingernails should not make contact with the
ment goals, appropriate treatment modalities, position- patient's skin. Pressure is applied gently but firmly
ing techniques, and other strategies to reduce limita- enough to detect underlying muscle, tendons, or bony
tions. Specific purposes for measuring ROM are to structures. For joint measurement, the therapist must
determine limitations that interfere with function or palpate to locate bony landmarks for placement of the
may produce deformity, determine additional range goniometer.
needed to increase functional capacity or reduce defor-
mity, determine the need for splints and assistive
Positioning of Therapist and Support
devices, measure progress objectively, and record pro-
of Limbs
gression Or regression.
Normal ROM varies from one person to another. The The therapist's position varies, depending on the joints
therapist can establish norms for each individual by being measured. When fingers or wrist joints are being
measuring the analogous uninvolved part if possible.** measured, the therapist may sit next to or opposite the
Otherwise, the therapist uses average ranges listed in the patient. When the larger joints of the upper or lower ex-
literature as a guide.’ The therapist should check records tremity are being measured, the therapist may stand
and interview the patient for the presence of fused joints next to the patient on the side being measured. The
and other limitations caused by old injuries. Joints patient may be seated or lying down. The therapist
should not be forced when resistance is met on passive needs to employ good body mechanics in posture and
ROM. Pain may limit ROM, and crepitation may be in lifting and moving heavy limbs. The therapist should
heard on movement in some conditions. use a broad base of support and stand with the head
upright, keeping the back straight. The feet should be
PRINCIPLES AND PROCEDURES shoulder width apart with the knees slightly flexed. The
therapist's stance should be in line with the direction of
IN JOINT MEASUREMENT
movement. The limb should be supported at the level of
Before measuring ROM, the therapist should be familiar its center of gravity, approximately where the upper and
with average normal ROMs, joint structure and func- middle third of the segment meet. The therapist's hands
tion, normal end-feels, recommended positioning for should be in a relaxed grasp that conforms to the con-
self and patient, and bony landmarks related to each tours of the part. The therapist can provide additional
joint and joint axis.**”° The therapist should be skilled support by resting the part on his or her forearm.*
 Joint Range of Motion 287

Precautions and Contraindications

than normal anatomy.® Practice and experience are re-
In some instances, measuring joint ROM is contraindi- quired to detect end-feel accurately. Normal end-feel for
cated or should be undertaken with extreme caution. It each joint is noted with the directions for joint mea-
is contraindicated if there is a joint dislocation or un- surement that are listed in the following sections.
healed fracture, immediately following surgery of any
soft tissue structures surrounding joints, in the presence
Two-Joint Muscles
_of myositis ossificans, or if there might be ectopic ossi-
fiction.* When the ROM of a joint that is crossed by a two-joint
Joint measurement must always be done carefully. muscle is measured, the ROM of the joint being mea-
Extreme caution is needed in the following situations: sured may be affected by the position of the other joint
1. The patient has joint inflammation. because of passive insufficiency.* That is, joint motion is
2. The patient is taking either medication for pain or limited by the length of the muscle. A two-joint muscle
muscle relaxants. feels taut when it is at its full length over both joints it
Qo . The patient has osteoporosis, hypermobility, or sub- crosses and before it reaches the limits of the normal
luxation of a joint. ROM of both joints.’ For example, when the wrist is in
. The patient has hemophilia. full extension, passive finger extension is normally
. The patient has a hematoma. limited because of the passive insufficiency of the finger
. The patient has just had an injury to soft tissue. flexors that cross the wrist and finger joints. When the
. The patient has a newly united fracture. joints crossed by two-joint muscles are being measured,
ONAN?The patient has undergone prolonged immobiliza- it is necessary to place the joint not being measured in a
tion. neutral or relaxed position to place the two-joint muscle
9. Bony ankylosis is suspected.* on slack. For example, when finger extension is being
measured, the wrist should be placed in the neutral po-
sition to avoid full stretch of the finger flexors over all of
End-Feel
the joints they cross. Similarly, when hip flexion is being
Passive ROM is normally limited by the structure of the measured, the knee should also be flexed to place the
joint and surrounding soft tissues. Thus ligaments, the hamstrings in the slackened position.®
joint capsule, muscle and tendon tension, contact of
joint surfaces, and soft tissue approximation may limit METHODS OF JOINT MEASUREMENT
the end of a particular ROM. Each of these structures
The 180° System
has a different end-feel as the therapist moves the joint
passively through the ROM. End-feel is the normal re- In the 180° system of joint measurement, 0° is the start-
sistance to further joint motion because of stretching of ing position for all joint motions. For most motions the
soft tissue, stretching of ligaments and joint capsule, ap- anatomical position is the starting position. The body
proximation of soft tissue, and bone contacting bone. of the measuring instrument, the goniometer, is a half-
End-feel is normal when full ROM is achieved and the circle protractor with an axis and two arms. It is super-
motion is limited by normal anatomical structures. Ab- imposed on the body in the plane in which the motion
normal end-feel occurs when the ROM is increased or is to occur. The axis of the instrument is aligned with the
decreased or when ROM is normal but structures other axis of the joint. All joint motions begin at 0° and in-
than normal anatomy stop the ROM.® Practice and sen- crease toward 180°.*? The 180° system is used most
sitivity are required for the therapist to detect different often and is the one used later in this chapter to describe
end-feels and to distinguish the normal from the abnor- procedures for joint measurement.
mal?”
Normally, end-feel is hard, soft, or firm. An example
The 360° System
of hard end-feel is bone contacting bone when the
elbow is passively extended and the olecranon process The 360° system of joint measurement is used less fre-
contacts the olecranon fossa. Soft end-feel can be de- quently than the 180° system. The goniometer is a full-
tected on knee flexion when there is soft tissue apposi- circle, 360° protractor with two arms. Movements oc-
tion of the posterior aspects of the thigh and calf. A firm curring in the coronal and sagittal planes are related to
end-feel has a firm or springy sensation that has some the full circle. When the body is in the anatomical posi-
give, as when the ankle is dorsiflexed with the knee in tion, the circle is superimposed on it in the same plane
extension and the ROM is limited by tension in the gas- in which the motion is to occur, with the joint axis as
trocnemius muscle.’ the pivotal point. “The 0° (360°) position will be over-
In pathological states, end-feel is abnormal when head and the 180° position will be toward the feet.”°
passive ROM is increased or decreased or when PROM Thus, for example, shoulder flexion and abduction
is normal but movement is stopped by structures other are movements that proceed toward 0°, and shoulder
288 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

adduction and extension proceed toward 360°. The movable bar rotates around the protractor, the dial
average normal ROM for shoulder flexion is 170°. points to the number of degrees on the scale.
Therefore, in the 360° system, the movement would Two scales of figures are printed on the half circle.
start at 180° and progress toward 0° to 10°. The ROM Each starts at 0° and progresses toward 180°, but in op-
recorded would be 10°. On the other hand, shoulder ex- posite directions. Because the starting position in the
tension that has a normal ROM of 60° would begin at 180° system is always 0° and increases toward 180°,
180° and progress toward 360° to 240°, and 240° the outer row of figures is read if the bony segments
would be the ROM recorded.” The total-ROM of exten- being measured are end to end, as in elbow flexion. The
sion to flexion would be 240° to 10°—that is, 230°.°’° inner row of figures is read if the bony segments being
Some motions cannot be related to the full circle. In measured are alongside one another, as in shoulder
these instances, a 0° starting position is designated, and flexion.
the movements are measured as increases from 0°. Fig. 21-1 shows five styles of goniometers. The first
These motions occur in a horizontal plane around a ver- (Fig. 21-1, A) is a full-circle goniometer that has calibra-
tical axis. They are forearm pronation and supination, tions for both the 360° and the 180° systems printed
hip internal and external rotation, wrist radial and ulnar on its face. This goniometer has longer arms and is con-
deviation, and thumb palmar and radial abduction venient for use on the large joints of the body. Fig. 21-1,
(carpometacarpal flexion and extension).” B, shows a half-circle instrument used for the 180°
system. This goniometer is radiopaque and could be
used during radiographic examinations if necessary. Its
GONIOMETERS
dial is notched at two places for accurate motion
Goniometers are usually made of metal or plastic, come reading, regardless of whether the convexity of the half
in several sizes and types, and are available from medical circle is directed toward or away from the direction of
and rehabilitation equipment companies. ””’"' The word motion. Thus the evaluator does not have to reverse the
goniometer is derived from the Greek gonia, which goniometer, obscuring the scale. A special finger go-
means angle, and metron, which means measure.”’’* niometer is shown in Fig. 21-1, D. Its arms are short and
Thus, goniometer literally means “to measure angles.” flattened. It is designed to be used over the finger joint
The universal goniometer (Fig. 21-1) consists of a surfaces rather than on their lateral aspects, as is done in
body, a stationary (proximal) bar, and a movable most of the larger joint motions. Small plastic goniome-
(distal) bar.*” The stationary bar is attached to the body ters are shown in Fig. 21-1, C and E. These are inexpen-
of the goniometer. The body is a haif-circle or a full- sive and easy to carry. The longer one can be used with
circle protractor printed with a scale of degrees from 0° both large and small joints. The smaller is simply a
to 180° for the half-circle and 0° to 360° for the full- larger one that has been cut for use as a finger goniome-
circle goniometer.** The movable bar is attached at the ter. The dials of transparent goniometers are marked or
center, or axis, of the protractor and acts as a dial. As the notched in two places.

FIG. 21-1
Types of goniometers.

eB
n
ae
i
a
i
 Joint Range of Motion 289

One important feature of the goniometer is the as outlined. Range of glenohumeral joint motion is
fulcrum. The nut or rivet that acts as the fulcrum must highly dependent on scapula mobility, which gives the
move freely, yet must be tight enough to remain where shoulder its flexibility and wide ranges of motion. Al-
it was set when the goniometer is removed following though it is not possible to measure scapula movement
joint measurement.’ For easy, accurate readings, some with the goniometer, the evaluator should assess
goniometers have a locking nut that is tightened just scapula mobility by observation of active motion or by
before the goniometer is removed.” passive movement before proceeding with shoulder
Other types of goniometers are available. Some have joint measurements. Scapular ROM is noted as “full” or
a fluid indicator that provides the reading after the “restricted.”* If scapula motion is restricted, as when
motion is completed.° Others can be attached to a body musculature is in a state of spasticity or contracture, and
segment and have dials that register ROM. There are the shoulder joint is moved into extreme ranges of
special goniometers for cervical and spine ROM mea- motion (for example, above 90 degrees of flexion or ab-
surements and for forearm rotation." A tape measure or duction), glenohumeral joint damage can result.
metric scale may also be used on some joints by mea- When joint measurements may be performed in
suring the distance between two segments—for more than one position (e.g., as in shoulder internal
example, the distance between the chin and chest when and external rotation), the evaluator (E) should note on
measuring cervical flexion and extension, the distance the record in which position the measurement was
between the center of the tips of two fingers for finger taken. The “E” should also note any pain or discomfort
abduction, and the distance between the thumb tip and experienced by the subject (S), the appearance of pro-
little finger tip for opposition.* tective muscle spasm, whether active or passive ROM
was measured, and any deviations from recommended
testing procedures or positions.”
RECORDING MEASUREMENTS
When using the 180° system, the evaluator should RESULTS OF ASSESSMENT AS BASIS
record the number of degrees at the starting position
FOR TREATMENT PLANNING
and the number of degrees at the final position after the
joint has passed through the maximum possible arc of After joint measurement, the therapist should analyze the
motion.” Normal ROM always starts at 0° and increases results in relation to the patient's life role requirements.
toward 180°. When it is not possible to start the motion The therapist's first concern should be to correct ROM that
at 0° because of a limitation of motion, the ROM is is below functional limits. Many ordinary ADL do not
recorded by writing the number of degrees at the start- require full ROM. Functional ROM refers to the amount
ing position followed by the number of degrees at the of joint range necessary to perform essential ADL without
final position.* For example, elbow ROM limitations the use of special equipment. The first concern of treat-
can be noted as follows: <a
ment is trying to increase any ROM that is limiting per-
Normal: 0° to 140° formance of self-care and home-maintenance tasks to
Extension limitation: 15° to 140° functional levels.® For example, a severe limitation of
Flexion limitation: 0° to 110° elbow flexion affects eating and oral hygiene. Therefore it
Flexion and extension limitation: 15° to 110° is important to increase elbow flexion to nearly full ROM
Abnormal hyperextension of the elbow may be for function. Likewise, a severe limitation of forearm
recorded by indicating the number of degrees of hyper- pronation affects eating, washing the body, telephoning,
extension below the 0° starting position with a minus child care, and dressing. Because sitting comfortably re-
sign, followed by the 0° position and then the number quires hip ROM ofatleast 0° to 100°, a first goal might be
of degrees at the final position.” For example: to increase flexion to 100° if it is limited. Of course, if ad-
Normal: 0° to 140° ditional ROM can be gained, the therapist should plan the
Abnormal hyperextension: —20° to 0° to 140° progression of treatment to increase the ROM to the
There are alternative methods of recording ROM. The normal range.
evaluator is advised to learn and adopt the particular Some ROM limitations may be permanent. The role
method required by the health care facility. of the therapist in such cases is to work out methods to
A sample form for recording ROM measurements is compensate for the loss of ROM. Possibilities include
shown in Fig. 21-2. Average normal ROM for each joint assistive devices such as a long-handled comb, brush, or
motion is listed on the form and in Table 21-1. When shoe horn, a device to apply stockings, or adapted
measurements are being recorded, every space on the methods of performing a particular skill. See Chapter 13
form should be filled in. If the joint was not tested, for further suggestions of ADL techniques for those with
“NT” should be entered in the space.* limited ROM.
It should be noted that scapula movement accompa- In many diagnoses, such as burns and arthritis, the
nies movements of the shoulder (glenohumeral) joint loss of ROM can be anticipated. The goal oftreatment is
 JOINT RANGE MEASUREMENTS

Patient’siname 2. niet Lae ae a ele eee Chantino:

Date’ of: births eee
ee ee ee oe een eX
Diagnosis Date of onset
Disability
RIGHT
SPINE ne
Nga a
Cervical spine Rake
eae a
Extension 0-45
Lateral flexion 0-45
Rotation 0-60
Thoracic and lumbar spine
Flexion 0-80
Extension
Lateral flexion
Rotation
SHOULDER
Flexion 0 to 170
Extension 0 to 60
Abduction 0 to 170
Horizontal abduction 0-40
Horizontal adduction 0-130
| Internal rotation 0 to 70
External rotation 0 to 90
ELBOW AND FOREARM
Flexion 0 to 135-150
Supination 0 to 80-90
Pronation

| Flexion
he EM 0 to 80
Extension 0 to 70
Ulnar deviation 0 to 30
Radial deviation 0 to 20
THUMB
(r elas ft MP flexion 0 to 50
a IP flexion 0 to 80-90
Abduction 0 to 50
FINGERS
MP flexion 0 to 90
MP. hyperextension 0 to 15-45
PIP flexion 0 to 110
DIP flexion 0 to 80
Abduction 0 to 25
HIP
Flexion 0 to 120
_|__Extension 0 to 30
Abduction 0 to 40
= Adduction 0 to 35
Internal rotation 0 to 45
External rotation 0 to 45
KNEE
Flexion 0 to 135 “A,] ake eee ae
ANKLE AND FOOT
Plantar flexion 0 to 50
Dorsiflexion Oto 15
Inversion 0 to 35
| Eversion 0 to 20

FIG, 21-2
Form for recording joint ROM measurement.

290
 Joint Range of Motion ZOE

to prevent joint limitation with splints, positioning, ex- 5. Establish and palpate bony landmarks for the mea-
ercise, activity, and application of the principles of joint surement.
protection. 6. Stabilize joints proximal to the joint being mea-
Limited ROM, its causes, and the prognosis for in- sured.
creasing ROM will suggest treatment approaches. Some 7. Move the part passively through ROM to feel joint
of the specific methods used to increase ROM are dis- mobility and end-feel.
cussed elsewhere in this text (see Chapters 30 and 31). 8. Return the part to the starting position.
These include stretching exercise, resistive activity and 9. To measure the starting position, place the go-
exercise, strengthening of antagonistic muscle groups, niometer just over the surface of and lateral to the
activities that require active motion of the affected joint. Place the axis of the goniometer over the axis
joints through the full available ROM, splints, and posi- of the joint, using the designated bony prominence
tioning. To increase ROM, the physician may perform or anatomical landmark. Place the stationary bar on
surgery or may manipulate the part while the patient is or parallel to the longitudinal axis of the proximal
under anesthesia. The physical therapist may use joint or stationary bone and the movable bar on or paral-
mobilization techniques such as manual stretching with lel to the longitudinal axis of the distal or moving
heat and massage.® bone. To prevent the indicator on the movable bar
from going off the protractor dial, always face the
curved side away from the direction of motion,
PROCEDURE FOR MEASURING
unless the goniometer can be read after movement
PASSIVE ROM
in either direction.
Average normal ROM for each joint motion is listed in 10. Record the number of degrees at the starting posi-
Table 21-1, in Fig. 21-2, and before each of the following tion and remove the goniometer. Do not attempt to
procedures for measurement. The reader should keep in hold the goniometer in place while moving the
mind that these are averages and ROM may vary consid- joint through ROM.
erably from one individual to another. Normal ROM is 11. To measure PROM, hold the part securely above
affected by age, gender, and other factors such as lifestyle and below the joint being measured and gently
and occupation.” Therefore the subject (S) in the illustra- move the joint through ROM. Do not force the
tions may not always demonstrate the average ROM joints. Watch for signs of pain and discomfort.
listed for the particular motion. (Note: PROM may also be measured by asking S to
In the illustrations, the goniometer is shown in such a move actively through ROM and hold the position.
way that the reader can most easily see its positioning. Then E moves the joint through the final few
However, the evaluator (E) may not always be in the best degrees of PROM).
position for the particular measurement. For the pur- 12. Reposition the goniometer and record the number
poses of clear illustration, E is necessarily shown off to of degrees at the final position.
one side and may have one hand, rather than two, on the 13. Remove the goniometer and gently place the part in
instrument. Many of the motions require that E actually resting position.
be in front of S or that E’s hands obscure the goniometer. 14. Record the reading at final position and any nota-
How E holds the goniometer and supports the part being tions on the evaluation form.
measured is determined by factors such as the position of
S, amount of muscle weakness, presence or absence of
DIRECTIONS FOR JOINT
joint pain, and whether active or passive ROM is being
MEASUREMENT— 180° SYSTEM
measured. Both E and S should be positioned for the
greatest comfort, correct placement of the instrument,
and adequate stabilization of the part being tested to SPINE
effect the desired motion in the correct plane.
Cervical Spine
Measurements of neck movements are the least accu-
General Procedure—180° Method
rate, because there are few bony landmarks and much
of Measurement” soft tissue overlying bony segments.” A radiographic ex-
1. S should be comfortable and relaxed in the appro- amination is the best means to make an accurate meas-
priate position (described below) for the joint urement of the specific joints."” Measurements may be
measurement. taken with a tape measure to record the distance
2. Uncover the joint to be measured. between the chin and chest for flexion and extension,
3. Explain and demonstrate to S what you are going to chin and shoulder for neck rotation, and mastoid
do, why, and how you expect him or her to cooperate. process and shoulder for lateral flexion.?
4. Ifthereis unilateral involvement, assess the PROM on Approximate estimates of cervical flexion, extension,
the analogous limb to establish normal ROM forS. rotation, and lateral flexion may be made by using the
 Associated
Joint ROM Girdle Motion Joint ROM |
Cervical Spine Wrist Be
Flexion 0° to 45° Flexion 0° to 80°
Extension 0° to 45° Extension 0° to 70°
Lateral flexion 0° to 45° v* Ulnar deviation 0° to 30°
(adduction)
Rotation 0° to 60° Radial deviation 0% to: 20"
(abduction)

Thoracic and Thumb

Lumbar Spine
Flexion 0° to 80° DIP Flexion 0° to 80°-90°
Extension 0° to 30° MP flexion 0° to 50°
0°
Lateral flexion 0° to 40° Adduction, radial
and palmar
Rotation O25t6 450 Palmar abduction 0° to 50°
Radial abduction OF te 50°
Opposition Thumb pad to touch —
pad of little finger

Shoulder Fingers
Flexion 0° to 170° Abduction, lateral tilt, slight MP flexion 0° to 90°
elevation, slight upward
rotation
Extension O° to 60° Depression, adduction, MP hyperextension 0° to 15°-45°
upward tilt
Abduction 0° to 170° Upward rotation, elevation PIP flexion 0° to 110°
Adduction O? Depression, adduction, DIP flexion 0° to 80°
downward rotation
Horizontal abduction 0° to 40° Adduction, reduction of Abduction 0? to:25::
lateral tilt
Horizontal adduction 0? to 1302 Abduction, lateral tilt Hip
Internal rotation Abduction, lateral tilt Flexion 0° to 120°
(bent knee)
Arm in abduction 0° to 70° Extension 0* to: 30°
Arm in adduction 0° to 60° Abduction 0° to 40°
External rotation Adduction, reduction of Adduction O02 to-35°
lateral tilt
Arm in abduction OR10:902 Internal rotation “O81 452
Arm in adduction 0° to 80° External rotation 0" 40:45

Elbow Knee
Flexion O° to 135°-140° Flexion OF to: 130°
Oe
Extension

Ankle and Foot

Forearm Plantar flexion O° to 50°
Pronation 0° to 80°-90° Dorsiflexion OF 10-15
Supination 0° to 80°-90° Inversion Ge to-35"
Eversion O° to 20°
Data adapted from American Academy of Orthopaedic Surgeons: Joint motion: method of measuring and recording, Chicago, 1965, The Academy; Esch D, Lepley M:
Evaluation ofjoint motion: methods of measurement and recording, Minneapolis, 1974, University of Minnesota Press.
DIP, Distal interphalangeal; MP, metacarpophalangeal; PIP, proximal interphalangeal.

Das2
 Joint Range of Motion DASFe

goniometer or by estimating the number of degrees of motion may be estimated or the number of inches or
motion, using a fixed axis and estimating the arc of centimeters from the chin to the sternal notch may be
motion from that point (see Figs. 21-3 to 21-10).'* measured.’ Ifa goniometer is used, the axis is placed over
the angle of the jaw. E grasps the corner of the protractor,
Cervical Flexion which is now positioned with the arc downward, and
0° to 45° (Fig. 21-3). steadies his or her arm against S's shoulder. The movable
bar of the goniometer is moved upward to align with the
POSITION OF THE SUBJECT. Sitting or standing tongue depressor as the S extends the neck.*”
erect.
Lateral Flexion
MEASUREMENT. § is asked to flex the neck so that 0° to 45° (Fig. 21-5).
the chin moves toward the chest. The number of degrees
of motion may be estimated, or E may measure the POSITION OF THE SUBJECT. Sitting or standing
number of inches or centimeters from the chin to the erect.
sternal notch.'*”? If a goniometer is used, the axis is
placed over the angle of the jaw. E grasps the corner of MEASUREMENT. § is asked to flex the neck laterally
the protractor, which is positioned with the arc upward, without rotation, moving the ear toward the shoulder.
and steadies his or her arm by resting it against S's The number of degrees of motion may be estimated, or
shoulder. The arms of the goniometer are aligned with a E may measure the number of inches or centimeters
tongue depressor, which S is holding between the teeth. between the mastoid process and the acromion process
As S performs neck flexion, the movable bar of the go- of the shoulder.’” If a goniometer is used, the axis is
niometer is adjusted downward to align with the new placed over the spinous process of the seventh cervical
position of the tongue depressor.*” vertebra. The stationary bar may be over the shoulder
and parallel to the floor so that the motion begins at
Cervical Extension 90°, or it may be aligned with the thoracic vertebra for a
0° to 45° (Fig. 21-4). starting position of 0°. The movable bar is aligned with
the external occipital protuberance.'”
POSITION OF THE SUBJECT. Sitting or standing
erect. Cervical Rotation
0° to 60° (Fig. 21-6).
MEASUREMENT. S is asked to extend the neck as if to
look at the ceiling, so that the back of the head ap- POSITION OF THE SUBJECT. Lying supine or
proaches the thoracic spine. The number of degrees of seated.

MEASUREMENT. S is asked to rotate the head to

0° Neutral 0° Neutral right or left without rotating the trunk. The amount ofro-
tation may be estimated in degrees from the neutral posi-
tion,’ or a tape measure may be used to measure the dis-
tance from the tip of the chin to the acromion process of
the shoulder. The measure is taken first in the anatomical
position and then again after the neck has been rotated.”
In the lying position, if a goniometer is used, it is set at
90° and the axis is placed over the vertex ofthe head. The
stationary bar is held steady, parallel to the floor or to the
acromion process on the side being tested. The movable
bar is aligned with the tip of the nose.*”

Thoracic and Lumbar Spine

Flexion
0° to 80° and + 4 inches (Fig. 21-7).

POSITION OF THE SUBJECT. Standing erect.

MEASUREMENT. Four methods of estimating the

FIG. 21-3 range of spinal flexion are as follows: measuring trunk
Cervical flexion. A, Starting position. B, Final position. forward flexion in relation to the longitudinal axis of the
 FIG. 21-4
Cervical extension. A, Starting position. B, Final position.

A B

FIG. 21-5
Cervical lateral flexion. A, Starting position. B, Final position.

0° Neutral

B
FIG. 21-6
Cervical rotation. A, Starting position. B, Final position.

294
 Joint Range of Motion 295

FIG. 21-7
Spine flexion. A, Starting position. B, Final position.

0° Neutral 0° Neutral
40°

FIG. 21-8
Spine lateral flexion. A, Starting position. B, Final position.

body (E must hold the pelvis stable with the hands and bra when S is erect and again after S has flexed the spine
observe any change in S’s normal lordosis); recording the (Fig. 21-7).*° The fourth is probably the most accurate of
level of the fingertips along the front ofS’s leg; measuring these clinical methods.' In a normal adult, average in-
the number of inches or centimeters between S’s finger- crease in length in forward flexion ofthe spine is 4 inches
tips and the floor; and measuring the length of the spine (10 cm).° If S bends forward at the hips with a straight
from the seventh cervical vertebra to the first sacral verte- back, no difference in length will occur.
296 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

Lateral Flexion Extension

0° to 40° (Fig. 21-8). 0° to 30° (Fig. 21-9).

POSITION OF THE SUBJECT. Standing erect. POSITION OF THE SUBJECT. Standing erect or
lying prone.
MEASUREMENT. Several methods may be used to
estimate the range of lateral flexion of the trunk. The MEASUREMENT. S is asked to bend backward while
steel tape measure may be held in place during the maintaining stability of the pelvis. If necessary, E stabi-
motion and used to estimate the number of degrees lizes the pelvis from the anterior when the measure-
of lateral inclination of the trunk compared with the ment is taken in the standing position. The range of ex-
vertical position. Other methods include estimating tension is estimated in degrees from the vertical, using
the position of the spinous process of C7 in relation the superior iliac crest as the pivotal point in relation to
to the pelvis (Fig. 21-8); measuring the distance of the spinous process of C7. With S in the lying position,
the fingertips from the knee joint in lateral flexion; a pillow is placed under the abdomen and S's hands are
measuring the distance between the tip of the third placed at shoulder level on the treatment table. The
finger and the floor’; and using a long-arm goniome- pelvis is stabilized with a strap or by an assistant, and S
ter, placing the axis on S1, the stationary bar perpen- extends the elbows to raise the trunk from the table. A
dicular to the floor, and the movable bar aligned perpendicular measurement is taken of the distance
with C7."° between the suprasternal notch and the supporting
surface at the end of the ROM.*
0° Neutral
eae
Pg, 30° Rotation
0° to 45° (Fig. 21-10).

POSITION OF THE SUBJECT. Lying supine or

standing.

MEASUREMENT. S is asked to rotate the upper

trunk while maintaining neutral position of the pelvis.
E may fix the pelvis firmly to maintain the neutral posi-
tion. This step is especially important if S is in the stand-
ing position. This motion is recorded in degrees, using
the center of the crown of the head as a pivotal point
and the arc of motion made by the shoulder as it moves
upward or forward.

FIG. 21-9
Spine extension.

ee

Neutral

FIG. 21-10
Spine rotation. A, Starting position. B, Final position.
 Joint Range of Motion 297

A B

FIG. 21-11
Shoulder flexion. A, Starting position. B, Final position.

A B

FIG. 21-12
Shoulder extension. A, Starting position. B, Final position.

UPPER EXTREMITY! >?” POSITION OF GONIOMETER. The axis is in the

Shoulder center of the humeral head, just distal to the acromion
process on the lateral aspect of the humerus. The sta-
Flexion tionary bar is parallel to the trunk, and the movable bar
0° to 170° (Fig. 21-11). is parallel to the humerus. Note that when the shoulder
is flexed, the axis point moves upward and backward to
POSITION OF THE SUBJECT. Seated or supine the posterior surface of the shoulder. Thus, to take the
with the humerus in neutral rotation. measurement of the final position, E should place the
298 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

goniometer on the lateral surface of the shoulder, Internal Rotation

aligned with the imaginary axis through the center of 0° to 60° (Fig. 21-14).
the humeral head, which is just slightly superior to the
crease formed by the deltoid mass. POSITION OF THE SUBJECT (USED IF ABDUC-
TION CANNOT BE ACHIEVED). Seated with humerus
END-FEEL. Firm.* adducted against trunk, elbow at 90° and forearm at
midposition and perpendicular to body.’
Extension
0° to 60° (Fig. 21-12). POSITION OF GONIOMETER. The axis is on the
olecranon process of the elbow, and the stationary bar
POSITION OF THE SUBJECT. Seated or prone, with and movable bar are parallel to the forearm.
no obstruction behind the humerus and the humerus in
neutral rotation. Internal Rotation (Alternative Position)
0° to 70° (Fig. 21-15).
POSITION OF GONIOMETER. Same as for flexion,
but the axis point remains the same for starting and final POSITION OF THE SUBJECT (USED IF THERE IS
positions. Movement should be accompanied by a slight NO DANGER OF POSTERIOR DISLOCATION AND
upward tilt of the scapula. Excessive scapular motion ABDUCTION IS POSSIBLE). Prone or supine with
should be avoided. the humerus abducted to 90°, the elbow flexed to 90°,
and the forearm in pronation, perpendicular to the
END-FEEL. Firm.> floor.

Abduction POSITION OF GONIOMETER. The axis is on the

0° to 170° (Fig 21-13). olecranon process of the elbow, and the stationary bar
and movable bar are parallel to the forearm.
POSITION OF THE SUBJECT. Seated or lying
prone, with the humerus in adduction and external ro- END-FEEL. Firm.°
tation. Measure on the posterior surface.
External Rotation
POSITION OF GONIOMETER. The axis is on the 0° to 80° (Fig. 21-16).
acromion process on the posterior surface of the shoul-
der. The stationary bar is parallel to the trunk, and the POSITION OF THE SUBJECT (USED IF ABDUC-
movable bar is parallel to the humerus. TION IS NOT POSSIBLE). Seated, the humerus ad-
ducted, the elbow at 90°, and the forearm in midposi-
END-FEEL. Firm.> tion, perpendicular to the body.

FIG. 21-13
Shoulder abduction. A, Starting position. B, Final
position. A
 A B

FIG. 21-14
Shoulder internal rotation, shoulder adducted.
A, Starting position. B, Final position.

FIG. 21-15
Shoulder internal rotation, shoulder abducted (alternative position). A, Starting position. B, Final
position.

A B

FIG. 21-16
Shoulder external rotation, shoulder adducted. A, Starting position. B, Final position.

299
R100) EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

FIG. 21-17
Shoulder external rotation, shoulder abducted (alternative position). A, Starting po-
sition. B, Final position.

FIG. 21-18
Shoulder horizontal abduction. A, Starting position. B, Final position.

POSITION OF GONIOMETER. The axis is on the over the shoulder toward the neck, and the moy-
olecranon of the elbow. The stationary bar and movable able bar is parallel to the humerus on the superior
bar are parallel to the forearm.* aspect.

External Rotation (Alternative Position) END-FEEL. Firm.

0° to 90° (Fig. 21-17).
Horizontal Adduction
POSITION OF SUBJECT (USED IF THERE IS NO OS tons On (Fig. 21-19).
DANGER OF ANTERIOR DISLOCATION OF THE
HUMERUS).* Seated or supine with the humerus ab- POSITION OF SUBJECT AND GONIOMETER.
ducted to 90°, the elbow flexed to 90°, and the forearm Same as for horizontal abduction. -
pronated.
END-FEEL. Firm or soft.?
POSITION OF GONIOMETER. The axis is on the
olecranon process of the elbow, and the stationary bar
Elbow
and movable bar are parallel to forearm.
Extension to Flexion
END-FEEL. Firm.* OR TOMS 5glo Oe (Fig. 21-20).

Horizontal Abduction POSITION OF SUBJECT. Standing, sitting, or supine

0° to 40° (Fig. 21-18). with the humerus adducted and externally rotated and
the forearm supinated.
POSITION OF SUBJECT. Seated erect with the
shoulder to be tested abducted to 90°, the elbow ex- POSITION OF GONIOMETER. The axis is placed
tended, and the palm facing down. The therapist may over the lateral epicondyle of the humerus at the end of
support the arm in abduction.” the elbow crease. The stationary bar is parallel to the
midline of the humerus, and the movable bar is parallel
POSITION OF GONIOMETER. The axis is over to the radius. After the movement has been completed,
the acromion process. The stationary bar is parallel the position of the elbow crease changes in relation to
 Joint Range of Motion 301

FIG. 21-19
Shoulder horizontal adduction. A, Starting position. B, Final position.

sel ‘¥, = &

ai j

¥ i

FIG. 21-20
Elbow flexion. A, Starting position. B, Final position.

the lateral epicondyle because of the rise of the muscle POSITION OF THE SUBJECT. Seated or standing
bulk during the motion. The axis of the goniometer with the humerus adducted, the elbow at 90°, and the
should be repositioned so that it is over, although it will forearm in midposition.
not be directly on, the lateral epicondyle.
POSITION OF GONIOMETER. The axis is at the
END-FEEL. Soft, hard, and firm: flexion. Hard or ulnar border of the volar aspect of the wrist, just proxi-
firm: extension and hyperextension.* mal to the ulna styloid. The movable bar is resting
against the volar aspect of the wrist, and the stationary
bar is perpendicular to the floor. After the forearm is
Forearm
supinated, the goniometer should be repositioned so
Supination that the movable bar rests squarely across the center of
0° to 80° or 90° (Fig. 21-21). the distal forearm.
302 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

FIG. 21-21
Forearm supination. A, Starting position. B, Final position.

FIG. 21-22
Forearm supination (alternate method).A, Starting position. B, Final position.

Supination (Alternative Method) END-FEEL. Firm.*

0° to 80° or 90° (Fig. 21-22).
Pronation
POSITION OF THE SUBJECT. Seated or standing 0° to 80° or 90° (Fig. 21-23).
with the humerus adducted, the elbow at 90°, and the
forearm in midposition. Place a pencil in S’s hand so it POSITION OF THE SUBJECT. Seated or standing
is held perpendicular to the floor. with the humerus adducted, the elbow at 90°, and the
forearm in midposition.
POSITION OF GONIOMETER. The axis is over the
head of the third metacarpal, and the stationary bar is POSITION OF GONIOMETER. The axis is at the
perpendicular to the floor. The movable bar is parallel ulnar border of the dorsal aspect of the wrist, just proxi-
to the pencil. mal to the ulna styloid. The movable bar is resting
 Joint Range of Motion 303

FIG, 21-23
Forearm pronation. A, Starting position. B, Final position.

FIG. 21-24
Forearm pronation (alternate method). A, Starting position. B, Final position.

against the dorsal aspect of the wrist, and the stationary and the forearm in midposition. A pencil is placed
bar is perpendicular to the floor. After the forearm is in the hand so that it is held perpendicular to the
pronated, reposition the goniometer so that the movable floor.
bar rests squarely across the center of the dorsum of the
distal forearm. POSITION OF GONIOMETER. The axis is over the
head of the third metacarpal, the stationary bar is per-
Pronation (Alternative Method) pendicular to the floor, and the movable bar is parallel
0° to 80° or 90° (Fig. 21-24). to the pencil.

POSITION OF THE SUBJECT. Seated or stand- END-FEEL. Hard to firm.®

ing with the humerus adducted, the elbow at 90°,
304 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

Wrist
just beneath the ulna styloid, the movable bar is aligned
Flexion with the fifth metacarpal, and the stationary bar is
0° to 80° (Fig. 21-25). aligned with the ulna.’

POSITION OF THE SUBJECT. Seated with the END-FEEL. Firm.*

forearm in midposition and the hand and forearm
resting on a table on the ulnar border. The fingers are Extension
relaxed or extended. This measurement may also be 0° to 70° (Fig. 21-26).
taken with the forearm pronated and resting on a table.*
POSITION OF THE SUBJECT AND GONIOMETER.
POSITION OF GONIOMETER. If the wrist is meas- The same as for wrist flexion, except that the fingers
ured with the forearm in midposition, the axis is on the should be flexed.
lateral aspect of the wrist just distal to the radial styloid
in the anatomical snuffbox. The stationary bar is paral- END-FEEL. Firm or hard.?
lel to the radius, and the movable bar is parallel to the
metacarpal of the index finger. If this wrist is measured Ulnar Deviation
with the forearm pronated, the axis is placed at the wrist 0° to 30° (Fig. 21-27).

FIG. 21-25
Wrist flexion. A, Starting position. B, Final position.

FIG. 21-26
Wrist extension. A, Starting position. B, Final position.

FIG. 21-27
Wrist ulnar deviation. A, Starting position. B, Final position.
 Joint Range of Motion fo}Oe)

POSITION OF THE SUBJECT. Seated with the POSITION OF GONIOMETER. The axis is centered
forearm pronated, the wrist at neutral, the fingers on the dorsal aspect of the metacarpophalangeal (MP)
relaxed in extension, and the palm of the hand resting joint. The stationary bar is on top of the metacarpal,
flat on the table surface. and the movable bar is on top of the proximal
phalanx.
POSITION OF GONIOMETER. The axis is on the
dorsum of the wrist at the base of the third metacarpal, END-FEEL. Hard or firm.*
over the capitate bone. The movable bar is parallel to
the third metacarpal, and the stationary bar is over the Metacarpophalangeal Joint Hyperextension
midline of the dorsal forearm. 0° to 15°-45° (Fig. 21-30).
END-FEEL. Firm.® POSITION OF THE SUBJECT. Seated with the
forearm in midposition, the wrist at 0° neutral, the
Radial Deviation IP joints relaxed or in flexion, and the forearm and
0° to 20° (Fig. 21-28). hand supported on a firm surface on the ulnar
border.
POSITION OF THE SUBJECT AND GONIOMETER.
Same as for ulnar deviation. POSITION OF GONIOMETER. The axis is over
the lateral aspect of the MP joint of the index finger.
END-FEEL. Firm or hard.* The stationary bar is parallel to the metacarpal, and the
movable bar is parallel to the proximal phalanx. The
fifth finger MP joint may be measured similarly. ROM
Fingers
of the third and fourth fingers can be estimated by
Metacarpophalangeal Flexion comparison.
0° to 90° (Fig. 21-29). An alternative is to place the goniometer on the volar
aspect of the hand. With use of the edge of the go-
POSITION OF THE SUBJECT. Seated with the niometer, the axis is aligned over the MP joint being
elbow flexed, the forearm in midposition, the wrist at measured, the stationary bar is parallel to the meta-
0° neutral, and the forearm and hand supported on a carpal, and the movable bar is parallel to the proximal
firm surface on the ulnar border. phalanx.

FIG. 21-28
Wrist radial deviation. A, Starting position. B, Final position.

FIG. 21-29
Metacarpophalangeal flexion. A, Starting position. B, Final position.
1016) EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

END-FEEL. Firm.° END-FEEL. Firm.”

Metacarpophalangeal Abduction Proximal Interphalangeal Flexion
0° to 25° (Fig. 21-31). 0° to 110° (Fig. 21-32).
POSITION OF THE SUBJECT. Seated with the POSITION OF THE SUBJECT. Seated with the
forearm pronated, the wrist at 0° neutral deviation, the forearm in midposition, the wrist at 0° neutral, and
fingers straight, and the hand resting on a firm surface. the forearm and hand supported on a firm surface on the
ulnar border.
POSITION OF GONIOMETER. The axis is centered
over the MP joint being measured. The stationary bar is POSITION OF GONIOMETER. The axis is centered
over the corresponding metacarpal, and the movable on the dorsal surface of the proximal interphalangeal
bar is over the proximal phalanx. (PIP) joint being measured. The stationary bar is placed

FIG. 21-30
Metacarpophalangeal hyperextension.
A, Starting position. B, Final position.

FIG. 21-31
Metacarpophalangeal abduction. A, Starting position. B, Final position.

A B
FIG. 21-32
Proximal interphalangeal flexion.A, Starting position. B, Final position.
 Joint Range of Motion 307

over the proximal phalanx, and the movable bar is over END-FEEL. Firm.*
the distal phalanx.
Thumb
ALTERNATIVE METHOD. Measurement with a
tuler can also be taken. The IP and MP joints of the Metacarpophalangeal Flexion
fingers are flexed toward the palm. A ruler is used to 0° to 50° (Fig. 21-34).
measure from the pulp of the middle finger to the prox-
imal palmar crease.* POSITION OF THE SUBJECT. Seated with the
elbow flexed, the forearm in 45° of supination, the
END-FEEL. Usually hard; may be soft or firm.* wrist at 0° neutral, the MP and IP joints in extension,
and the hand and forearm supported on a firm surface.
Distal Interphalangeal (DIP) Flexion
0° to 80° (Fig. 21-33). POSITION OF GONIOMETER. The axis is on the
dorsal surface of the MP joint. The stationary bar is over
POSITION OF THE SUBJECT. Seated with the the thumb metacarpal, and the movable bar is over the
forearm in midposition, the wrist at 0° neutral, and the proximal phalanx.
forearm and hand supported on the ulnar border on a
firm surface. END-FEEL. Hard or firm.*

POSITION OF GONIOMETER. The axis is on the Interphalangeal Flexion

dorsal surface of the distal interphalangeal (DIP) joint. 0° to 80°-90° (Fig. 21-35).
The stationary bar is over the middle phalanx, and the
movable bar is over the distal phalanx. POSITION OF THE SUBJECT. Same as described
for PIP and DIP finger flexion.
ALTERNATIVE METHOD. With the MP joints in
0° extension, S flexes the IP and PIP joints toward POSITION OF GONIOMETER. The axis is on the
the palm. With a ruler, a measurement is taken from dorsal surface of the IP joint. The stationary bar is over
the pulp of the middle finger to the distal palmar the proximal phalanx, and the movable bar is over the
crease. distal phalanx.

B
FIG. 21-33
Distal interphalangeal flexion.A, Starting position. B, Final position.

FIG. 21-34
Thumb Metacarpophalangeal flexion. A, Starting position. B, Final position.
308 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

Radial Abduction (Carpometacarpal Extension) POSITION OF THE SUBJECT AND GONIOMETER.

0° to 50° (Fig. 21-36). S is positioned the same as described in the first
method. The axis is over the CMC joint at the base of
POSITION OF THE SUBJECT. Seated with the the thumb metacarpal. The stationary and movable bars
forearm pronated and the hand palm down, resting flat are together and parallel to the thumb and the first
on a firm surface. metacarpals. Neither will be directly over these bones.

POSITION OF GONIOMETER. The axis is over the END-FEEL. Firm.®

carpometacarpal (CMC) joint at the base of the thumb
metacarpal. The stationary bar is parallel to the radius, Palmar Abduction (Carpometacarpal Flexion)
and the movable bar is parallel to the thumb metacarpal. 0° to 50° (Fig. 21-38).

Radial Abduction (Alternative Method) POSITION OF THE SUBJECT. Seated with the fore-
0° to 50° (Fig. 21-37). arm at 0° midposition, the wrist at 0°, and the forearm

FIG. 21-35
Thumb interphalangeal flexion.A, Starting position. B, Final position.

FIG. 21-36
Thumb radial abduction. A, Starting position. B, Final position.

A B

FIG. 21-37
Thumb radial abduction (alternative method).A, Starting position. B, Final position.
 Joint Range of Motion 309

and hand resting on the ulnar border. The thumb is bars are lined up together, parallel to the thumb and the
rotated so that it is at right angles to the palm of the index finger metacarpals.
hand.
END-FEEL. Firm.*
POSITION OF GONIOMETER. The axis is at the
junction of the thumb and index finger metacarpals. Opposition
The stationary bar is over the radius, and the movable Deficits in opposition may be recorded by measuring the
bar is parallel to the thumb and _ index finger distance between the centers of the pads of the thumb
metacarpals. and the fifth finger with a centimeter ruler (Fig. 21-40).

Palmar Abduction (Alternative Method) END-FEEL. Soft or firm.*

0° to 50° (Fig. 21-39).
LOWER EXTREMITY*”’°”
POSITION OF THE SUBJECT AND GONIOMETER.
Hip
S is positioned the same as described in the first
method. The axis is at the junction of the thumb and Flexion
index finger metacarpals. The stationary and movable 0° to 120° (Fig. 21-41).

FIG. 21-38
Palmar abduction. A, Starting position. B, Final position.

FIG. 21-39
Palmar abduction (alternative method). A, Starting position. B, Final position.

FIG. 21-40
Thumb opposition to fifth finger.
310 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

FIG. 21-41
Hip flexion.A, Starting position. B, Final position.

POSITION OF THE SUBJECT. Supine, lying with POSITION OF GONIOMETER. The axis is placed on
the hip and knee in 0° neutral extension and rotation. the anterior superior iliac spine. The stationary bar is
placed on a line between two anterior superior iliac
POSITION OF GONIOMETER. The axis is on the spines, and the movable bar is parallel to the longitudi-
lateral aspect of the hip, over the greater trochanter of the nal axis of the femur over the anterior aspect of the thigh.
femur. The stationary bar is centered over the middle of Note that the starting position is at 90° for this measure-
the lateral aspect of the pelvis, and the movable bar is ment, and that the recording of the measurement should
parallel to the long axis of the femur on the lateral aspect be adjusted by subtracting 90° from the total number of
of the thigh. The knee is bent during the motion. degrees obtained in the arc of joint motion.

END-FEEL. Soft.* END-FEEL. Firm.*

Extension (Hyperextension) Adduction

0° to 30° (Fig. 21-42). 0° to 35° (Fig. 21-44).
POSITION OF THE SUBJECT. The subject is prone, POSITION OF THE SUBJECT AND GONIOMETER.
lying with the hip and knee at 0° neutral extension and The subject is supine, lying with the hip and knee of the
rotation and the feet over the end of the table. leg to be tested in extension and neutral rotation. The
leg not being tested should be abducted.. The goniome-
POSITION OF GONIOMETER. Same as for hip ter is positioned the same as for hip abduction.
flexion.
END-FEEL. Firm or soft.?
END-FEEL. Firm.*
Internal Rotation
Abduction 0° to 45° (Fig. 21-45).
0° to 40° (Fig. 21-43).
POSITION OF THE SUBJECT. The subject is seated
POSITION OF THE SUBJECT. The subject is with the hip in 0° neutral rotation and the hip and knee
supine, lying with the legs extended and the hip in 0° flexed to 90°. The knee is flexed over the end of the
neutral rotation. The pelvis is level. treatment table. A small roll or towel may be placed
 FIG. 21-42
Hip extension. A, Starting position. B, Final position.

FIG. 21-43
Hip abduction. A, Starting position. B, Final position.

FIG. 21-44
Hip adduction.
A, Starting position. B, Final position.

A B

FIG. 21-45
Hip internal rotation.A, Starting position. B, Final position.

311
312 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

under the distal end of the femur to maintain it in a

horizontal plane. The contralateral hip is abducted, and
the foot may be supported on a stool.

POSITION OF GONIOMETER. The axis is on the

center of the patella. The stationary and movable bars
are parallel to the longitudinal axis of the tibia on the
anterior aspect of the lower leg. The stationary bar
remains in this position, perpendicular to the floor,
while the movable bar follows the tibia as the hip is
rotated.

END-FEEL. Firm.*

External Rotation A B
0° to 45° (Fig. 21-46). FIG. 21-46
Hip external rotation. A, Starting position. B, Final position.
POSITION OF THE SUBJECT AND GONIOMETER.
The subject is seated with the hip in 0° neutral rotation
and the hip and knee of the leg to be tested flexed to 30°. The ankle is at 90° neutral position and the foot is
90°. The other leg should be (1) flexed at the knee so in 0° of inversion and eversion.
that the lower leg is back under the table or (2) flexed at
the hip and knee so that the foot is resting on the table. POSITION OF GONIOMETER. The axis is placed
These positions allow the motion to take place without below the medial malleolus.’ The stationary bar is paral-
obstruction. The trunk should remain erect during the lel to the longitudinal axis of the tibia and the movable
performance of the motion. The goniometer is posi- bar is parallel with the first metatarsal. (This measure-
tioned as for internal rotation. ment may also be taken on the lateral side of the foot).
Note that measurement begins at 90°, so 90° must be
END-FEEL. Firm.* subtracted when recording the joint measurement.

END-FEEL. Firm or hard.*

Knee
Extension-Flexion Plantar Flexion
0° to 135° (Fig. 21-47). 0° to 50° (Fig. 21-49).
POSITION OF THE SUBJECT. The subject should POSITION OF THE SUBJECT AND GONIOMETER.
be prone or supine, lying with the knees and hips ex- Same as for dorsiflexion.
tended and the hip in 0° neutral rotation.
END-FEEL. Firm or hard.?
POSITION OF GONIOMETER. With the subject in
the prone position, the axis is centered on the lateral Inversion
aspect of the knee joint at the lateral epicondyle of the 0° to 35° (Fig. 21-50).
femur. The stationary bar is on the lateral aspect of the
thigh, parallel to the longitudinal axis of the femur. The POSITION OF THE SUBJECT. The subject is supine
movable bar is parallel to the longitudinal axis of the with the knee and hip extended and in 0° neutral rota-
fibula, aligned with the lateral malleolus, on the lateral tion, the ankle in the 90° neutral position, and the foot
aspect of the leg. extended over the edge of the table. A small roll is
placed under the knee to maintain slight flexion. The al-
END-FEEL. Soft.’ ternative position is sitting with the knee flexed to 90°,
the leg over the edge of the supporting surface, and the
Ankle ankle in 90° neutral position.

Dorsiflexion POSITION OF GONIOMETER. The axis is placed at

0° to 15° (Fig. 21-48). the lateral border of the foot near the heel. The station-
ary bar is parallel to the longitudinal axis of the fibula
POSITION OF THE SUBJECT. The subject should on the lateral aspect of the leg. The movable bar is par-
be lying supine or seated with the knee flexed at least allel to the plantar surface of the heel.
 FIG. 21-47
Knee flexion. A, Starting position. B, Final position.

FIG. 21-48
Ankle dorsiflexion.A, Starting position. B, Final position.

FIG. 21-49
Ankle plantar flexion. A, Starting position. B, Final position.

FIG. 21-50
Ankle inversion. A, Starting position. B, Final position.

313
314 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

FIG. 21-51
Ankle eversion. A, Starting position. B, Final position.

END-FEEL. Firm.* REVIEW QUESTIONS

1. Describe general rules for positioning the goniome-
Eversion ter when measuring joint ROM.
0° to 20° (Fig. 21-51). 2. With which diagnoses is joint measurement likely
to be used?
POSITION OF THE SUBJECT. Sameas for inversion. 3. List and discuss four purposes of joint measure-
ment.
POSITION OF GONIOMETER. The axis is on the 4. Is formal joint measurement necessary for every
medial border of the foot, just proximal to the metatar- patient? If not, how may ROM be assessed?
sophalangeal joint. The stationary bar is parallel to the 5. What is meant by palpation? How is palpation done?
longitudinal aspect of the fibula on the medial aspect of 6. In observing joints and joint motions, what should
the lower leg. The movable bar is parallel to the plantar the therapist look for?
surface of the sole. Note that measurements for inver- 7. List at least five precautions or contraindications to
sion and eversion both begin at 90°. Therefore this joint measurement.
amount must be subtracted from the total when mea- 8. What is meant by end-feel?
surements are recorded. 9. When measuring a joint crossed by a two-joint
muscle, how should the OT practitioner position
the joint not being measured?
END-FEEL. Hard or firm.’
10. List the steps in the procedure for joint measure-
ment.
11. How is joint ROM measurement recorded on the
SUMMARY evaluation form?
Joint measurement is used to evaluate ROM in persons 12. List the average normal ROM for elbow flexion,
whose physical dysfunction affects joint mobility. Mea- shoulder flexion, finger MP flexion, hip flexion,
surements of ROM are used in setting treatment goals, knee flexion, and ankle dorsiflexion.
selecting treatment methods, and making objective as- 13. Describe how to read the goniometer when using
sessments of progress. the 180-degree system of joint measurement.
Before measuring ROM, the OT practitioner should 14. What is meant by functional range of motion?
know the principles of joint measurement. The proce- 15. List three treatment methods that could be used to
dure for measuring joint ROM involves correct position- increase ROM.
ing for patient and therapist, exposure of joints to be
measured, palpation, appropriate stabilization and
handling of parts, and correct placement of the go-
=, 4318)=)
niometer at the beginning and end of the ROM. 1. Measure all of the upper extremity joint motions of a
Directions and illustrations for measuring all of the normal subject. Record the findings on the form in
major joint motions in the neck, trunk, and upper and Figure 21-2.
lower extremities are included in this chapter. The 2. Repeat the first exercise, but S should play the role of
content is designed for the development of the funda- someone with several joint limitations.
mental techniques of joint measurement. The reader is 3. Observe joint motions used in ordinary ADL (eg.,
referred to the references for more comprehensive treat- self-care and home management). Estimate the func-
ment of the topic.*” tional ranges of motion for the following joint
 Joint Range of Motion io) bo)

motions: shoulder flexion, external rotation, internal . Hurt SP: Considerations of muscle function and their application
rotation, abduction, elbow flexion, wrist extension, to disability evaluation and treatment: joint measurement,
reprinted from Am J Occup Ther 1:69, 1947; 2:13, 1948.
hip flexion and extension, knee flexion, and ankle
. Kendall FP, McCreary EK: Muscles, testing and function, ed 3, Balti-
plantar flexion. more, 1983, Williams & Wilkins.
. Killingsworth A: Basic physical disability procedures, San Jose, Calif,
1987, Maple Press.
REFERENCES
. Norkin CC, White DJ: Measurement of joint motion: a guide to go-
1. American Academy of Orthopaedic Surgeons: Joint motion: method
niometry, Philadelphia, 1985, FA Davis.
of measuring and recording, Chicago, 1965, The Academy.
10. Rancho Los Amigos Hospital: How to measure range of motion of the
2. Baruch Center of Physical Medicine: The technique of goniometry
upper extremities (unpublished manuscript), Rancho Los Amigos,
(unpublished manuscript), Richmond, Va, Medical College of
Calif, the Hospital.
Virginia.
aie Sammons Preston Ability One: Rehabilitation Catalog 2000, Bol-
3. Clarkson HM: Musculoskeletal assessment, joint range of motion and
ingbrook, Ill.
manual muscle strength, ed 2, Philadelphia, 2000, Lippincott,
ips Smith HD: Assessment and evaluation: an overview. In Hopkins
:Williams & Wilkins.
HL, Smith HD, editors: Willard and Spackman’s occupational
4. Cole T: Measurement of musculoskeletal function: goniometry. In
therapy, ed 8, Philadelphia, 1993, JB Lippincott.
Kottke FJ, Stillwell GK, Lehmann JF, editors: Krusen’s handbook of
13; Thomas CL, editor: Taber's cyclopedic medical dictionary, ed 13,
physical medicine and rehabilitation, ed 3, Philadelphia, 1982, WB
Philadelphia, 1977, FA Davis.
Saunders.
5. Esch D, Lepley M: Evaluation of joint motion: methods of measure-
ment and recording, Minneapolis, 1974, University of Minnesota
Press.
KEY TERM 7 LEARNING OBJECTIVES
Screening test After studying this chapter the student or practitioner
Against gravity will be able to do the following:
Gravity-decreased 1. Describe screening tests for muscle strength
Resistance assessment.
Manual muscle test 2. Identify what is measured by the manual muscle test
Muscle grades (MMT).
Endurance 3. List diagnoses for which the MMT is appropriate
Available ROM and those for which it is not appropriate, with the
Muscle coordination rationale for each.
Palpate 4. List the steps of the manual muscle testing
Substitution procedure in correct order.
Sa a a ll fl la 5. Describe the limitations of the MMT.
6. Define muscle grades by name, letter, and number.
7. Administer a manual muscle test, using the
directions in this chapter, on a normal practice
subject.
8. Describe how the results of the muscle strength
assessment are used in treatment planning.

any physical disabilities cause muscle weak- at the level[s] of the lesion generally have a lower
ness. Slight to substantial limitations of occupational motor neuron paralysis), Guillain-Barré syndrome,
performance can result from loss of strength, depending and cranial nerve dysfunctions
on the degree of weakness and whether the weakness is 2. Primary muscle diseases, such as muscular dystrophy
permanent or temporary. If improvement is expected, and myasthenia gravis
the occupational therapist must assess the muscle weak- 3. Neurological diseases in which the lower motor
ness and plan treatment that will enable occupational neuron is affected, such as amyotrophic lateral scle-
performance and increase strength. rosis or multiple sclerosis
Disabilities in which a loss of muscle strength is
CAUSES OF MUSCLE WEAKNESS caused by disuse or immobilization rather than being a
direct effect of the disease process include burns, ampu-
A loss of muscle strength is a primary symptom of or tation, hand trauma (unless there is an accompanying
direct result of the following diseases or injuries: nerve injury), arthritis, fractures, and a variety of other
1. The lower motor neuron disorders, such as periph- orthopedic conditions.
eral neuropathies and peripheral nerve injuries, Muscle weakness can restrict or prevent the pursuit of
spinal cord injury (because those muscles innervated self-care, vocational, leisure, and social activities. These

i Ko)
 Muscle Strength 317

limitations are assessed by observation of performance nerve roots are involved and whether the involvement is
(see Chapter 20), screening tests, and manual muscle partial or complete. Careful evaluation can help deter-
_ testing, when indicated. mine the level(s) of spinal cord involvement." Along
with sensory evaluation, the MMT can therefore be an
important diagnostic aid in neuromuscular conditions.
SCREENING TESTS
The purposes for assessing muscle strength are to de-
Screening tests are useful for observing areas of termine the amount of muscle power available and thus
strength and weakness and for determining which areas establish a baseline for treatment, to discern how mus-
require specific manual muscle testing.°”''* The cle weakness is limiting performance of activities of
screening tests can help the therapist avoid unnecessary daily living (ADL), to prevent deformities that can result
testing or duplication of services.'° The tests are used by from imbalances of strength, to determine the need for
occupational therapists in some health care facilities assistive devices as compensatory measures, to aid in
where manual muscle testing is the responsibility of the the selection of activities within the patient's capabili-
physical therapy service. ties, and to evaluate the effectiveness of treatment.”
Screening may be accomplished by the following
means:
Methods of Assessment
1. Examination of the medical record for results of
previous muscle test and range of motion (ROM) Muscle strength can be assessed in several ways. The
assessments most precise method is a test of individual muscles. In
2. Observing the patient entering the clinic and moving this procedure the muscle is carefully isolated through
about proper positioning, stabilization, and control of the
3. Observing the patient perform functional activities movement pattern and its strength is graded. This type
such as removing an article of clothing and shaking of muscle testing is described by Kendall and Mc-
hands with the therapist®° Creary"' and Cole, Furness, and Twomey.® Another and
4. Performing a gross check of bilateral muscle groups” perhaps more common method of manual muscle
The last method can be performed while the subject testing is to assess the strength of groups of muscles that
is comfortably seated in a sturdy chair or wheelchair. perform specific motions at each joint. This type of
The subject is asked to perform the motions against testing was described by Daniels and Worthingham”
gravity (movements away from the floor), or in the and Hislop and Montgomery” and, for the most part, is
gravity-decreased plane (parallel to the floor) if moving the form that is presented later in this chapter.
against gravity is not possible. Active range of motion The functional motion assessment described in
(AROM) is observed and resistance (application of Chapter 20 and screening tests described above are also
force) can be given to the test motions to obtain a gross used to assess muscle strength. These tests are not as
estimate of strength. precise as the MMT, and their purpose is to make a
general evaluation of muscle strength and to determine
areas of weakness, performance limitations, and the
MANUAL MUSCLE TEST
need for more precise testing.
The manual muscle test (MMT) is a means of evaluat-
ing muscle strength. The MMT measures the maximal Results of Assessment as a Basis
contraction of a muscle or muscle group.° The criteria
for Treatment Planning
used to measure strength are evidence of muscle con-
traction, amount of ROM through which the joint When planning treatment for the maintenance or im-
passes when the muscle contracts, and amount of resist- provement of strength, the occupational therapist con-
ance against which the muscle can contract. Gravity is siders several factors in the clinical reasoning process
considered a form of resistance.*’”’” The MMT is used to before determining treatment priorities, goals, and
determine amount of muscle power and to record gains modalities. The results of the muscle strength assess-
and losses in strength. ment will suggest the progression of the treatment
program. What is the degree of weakness? Is it general-
ized or specific to one or more muscle groups? Are the
Purposes of Manual Muscle Testing muscle grades generally the same throughout, or is
The specific strength measurement of individual mus- there significant disparity in muscle grades? If there is
cles through manual muscle testing can be essential for disparity, is there an imbalance of strength between the
diagnosis of some neuromuscular conditions, such as agonist and antagonist muscles that necessitates protec-
peripheral nerve lesions and spinal cord injury. In pe- tion of the weaker muscles during treatment and ADL?
ripheral nerve or nerve root lesions the pattern of When there is substantial imbalance between an agonist
muscle weakness may help determine which nerve or and antagonist muscle, treatment goals may be directed
318 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

toward strengthening the weaker group while maintain- effect of exercise or activity on muscle function? Will
ing the strength of the stronger group. Muscle imbal- too much activity delay the progress of recovery? If
ance may also suggest the need for an orthosis to protect muscle power is expected to decrease, how rapid will the
the weaker muscles from overstretching while recovery progression be? Are there factors to be avoided, such as
is in progress. Examples of such orthoses are devices a vigorous activity or exercise program, that can acceler-
such as the bed footboard to prevent overstretching of ate the decrease in strength? If strength is declining, is
the weakened ankle dorsiflexors and the wrist cock- special equipment practical and necessary? How much
up splint to prevent overstretching of weakened wrist muscle power is needed to operate the equipment? How
extensors. long will the patient be able to operate a device before a
Muscle grades will suggest the level of therapeutic decrease in muscle power makes it impracticable?!”
activity or exercise that can help to maintain or im- The therapist should assess the effect of the muscle
prove strength. Is the weakness mild (G range), moderate weakness on the ability to perform ADL, which can be
(F to F+), or severe (P to 0)?'* Muscles graded F—, for observed during the ADL assessment. Which tasks are
example, could be strengthened by active assisted exer- most difficult to perform because of the muscle weak-
cise or light activity against gravity. Muscles graded P ness? How does the patient compensate for the weak-
likewise will require activity or exercise in the gravity- ness? Which tasks are most important for the patient to
decreased plane, with little or no resistance, to increase be able to perform? Is special equipment necessary or
strength. Further discussion of appropriate exercise and desirable for the performance of some ADL, such as the
activity for specific muscle grades appears in Chapter 30. mobile arm support (Chapter 31) for independence in
The endurance of the muscles (i.e., how many repeti- eating (Chapter 31)?
tions of the muscle contraction are possible before If the patient is involved in a total rehabilitation
fatigue sets in) is an important consideration in treat- program and receiving several other health care services,
ment planning. A frequent goal of the therapeutic activ- the activity and exercise programs must be synchronized
ity program is to increase endurance, as well as strength. and well balanced to meet the patient's needs rather than
Because the MMT does not measure endurance, the ther- the needs of the professionals, their schedules, and pos-
apist should assess endurance by engaging the patient in sibly their competition. The occupational therapist
periods of exercise or activity graded in length to deter- needs to be aware of the nature and extent of the pro-
mine the amount of time that the muscle group can be grams in which the patient is engaged in physical
used in sustained activity. There is usually a correlation therapy, recreation therapy, and any other services.
between strength and endurance. Weaker muscles will Ideally, the health care team should plan the exercise and
tend to have less endurance than stronger ones. When se- activity programs together to ensure that they comple-
lecting treatment modalities for increasing endurance, ment one another. The therapist must consider the fol-
the therapist may elect not to tax the muscle to its lowing questions: What is the patient doing in each of
maximal ability but rather to emphasize repetitive action the therapies? How long is each treatment session? Are
at less than the maximal contraction to increase en- the goals of all of the therapies similar and complemen-
durance and prevent fatigue. '* tary, or are they divergent and conflicting? Is the patient
Sensory loss, which often accompanies muscle weak- being overfatigued in the total program? Are the various
ness, complicates the ability of the patient to perform in treatment sessions in rapid succession, or are they well
an activity program. If there is little or no tactile or pro- spaced to meet the patient's need for rest periods?
prioceptive feedback from motion, the impulse to move On the basis of these considerations and others perti-
is decreased or lost, depending on the severity of the nent to the specific patient, the occupational therapist
sensory loss. Thus the movement may appear weak and can select enabling and purposeful activities designed to
ineffective even when strength is adequate for perform- maintain or increase strength, improve performance of
ance of a specific activity. With some diagnoses, a ADL, and enable the use of special equipment, while
sensory reeducation program (see Chapter 25) may be protecting weak muscles from overstretching and over-
indicated to increase the patient's sensory awareness fatigue.
and feedback from the part. In other instances the ther-
apist may elect to teach compensation techniques for
Relationship Between Joint Range
the sensory loss. These techniques include the use of
of Motion and Muscle Weakness
mirrors, video playback, and biofeedback, which can be
used as adjuncts to the strengthening program. One of the criteria used to grade muscle strength is the
Another important consideration in the therapist's joint range of motion (ROM) of the joint on which the
clinical reasoning is the diagnosis and expected course muscle acts—that is, did the muscle move the joint
of the disease. Is strength expected to increase, decrease, through complete, partial, or no ROM? Another crite-
or remain about the same? If strength is expected to in- rion is the amount of resistance that can be applied to
crease, what is the expected recovery period? What is the the part once the muscle has moved the joint through
 Muscle Strength 319

the partial or complete AROM. In this context, ROM is are influenced by primitive reflexes and the position of
not necessarily the full average normal ROM for the the head and body in space. Also, movements tend to
given joint; rather, it is the ROM available to the indi- occur in gross synergistic patterns that make perform-
vidual patient. When the therapist measures joint ance of isolated joint motion, required in the MMT, im-
motion (discussed in Chapter 21), it is the passive ROM possible.***”'> However, when administered during
(PROM) that is the measure of the range available to the the final recovery stage when spasticity and synergy pat-
patient. PROM, however, is not an indication of muscle terns have disappeared and the patient has achieved iso-
strength. lated control of voluntary muscle function, the MMT
When performing muscle testing, the occupational may reveal some residual weakness. In these instances,
therapist must know the patient's available ROM some assessment of strength can be of value in design-
(PROM) to assign muscle grades correctly. It is possible ing a treatment program. (See Chapter 23 for methods
that PROM would be limited or less than the average of evaluating motor function of patients with upper
for a joint motion but that the muscle strength would motor neuron disorders.)
be normal. Therefore it is necessary for the therapist
either to have measured joint ROM or to move joints
Contraindications and Precautions
passively to assess available ROM before administering
the muscle test. For example, the patient's PROM for Assessment of strength using the MMT is contraindi-
elbow flexion may be limited to 0° to 110° because of cated when the patient has inflammation or pain in the
an old fracture. If the patient can flex the elbow joint to region to be tested; a dislocation or unhealed fracture;
110° and hold against moderate resistance during the recent surgery, particularly of musculoskeletal struc-
muscle test, the muscle would be graded G(4). In such tures; or myositis ossificans.’
cases the examiner should record the limitation with Special precautions must be taken when resisted
the muscle grade—for example, 0° to 110°/G.? Con- movement could aggravate the patient’s condition, as
versely, if the patient's available ROM for elbow flexion might occur with osteoporosis; subluxation or hyper-
is 0° to 140°, and he or she can flex the elbow against mobility ofa joint; hemophilia or any type of cardiovas-
gravity through only 110°, the muscle would be graded cular risk or disease; abdominal surgery or an abdomi-
F— because the part moves through only partial ROM nal hernia; and fatigue that exacerbates the patient's
against gravity. When the therapist determines the condition.”
patient's available ROM before performing the muscle
test, he or she can grade muscle strength on that basis
rather than by using the average normal ROM as the
Knowledge and Skill of the Examiner
standard. The validity of the MMT depends on the examiner's
knowledge and skill in using the correct testing proce-
dure. Careful observation of movement, careful and ac-
Limitations of the Manual Muscle Test
curate palpation, correct positioning, consistency of
The limitations of the MMT are that it cannot measure procedure, and experience of the examiner are critical
muscle endurance (the number of times the muscle can factors in accurate testing.”
contract at its maximum level),° muscle coordination To be proficient in manual muscle testing, the exam-
(the smooth rhythmic interaction of muscle function), iner must have detailed knowledge about all aspects of
or motor performance capabilities of the patient (the muscle function. Joints and joint motions, muscle in-
use of the muscles for functional activities).® nervation, origin and insertion of muscles, action of
The MMT cannot be used accurately with patients muscles, direction of muscle fibers, angle of pull on the
who have spasticity caused by upper motor neuron dis- joints, and the role of muscles in fixation and substitu-
orders such as cerebrovascular accident (stroke) or tion are important considerations. The examiner must
cerebral palsy. In these disorders muscles are often hy- be able to locate and feel contraction of (palpate) the
pertonic. Muscle tone and ability to perform move- muscles, recognize whether the contour of the muscle
ments are influenced by primitive reflexes and the posi- is normal, atrophied, or hypertrophied, and detect ab-
tion of the head and body in space. Also, movements normal movements and positions. The examiner must
tend to occur in gross synergistic patterns that make it use consistent methods in the application of test pro-
impossible for the patient to isolate joint motions, cedures. Knowledge and experience are necessary to
which is demanded in the manual muscle testing proce- detect substitutions and to interpret strength grades
dures.2°?"%” 13
with accuracy."”"
The MMT is not appropriate for patients with upper It is necessary for the examiner to acquire skill and
motor neuron disorders such as CVA (stroke), cerebral experience in testing and grading muscles of normal
palsy, or head injury. In these disorders muscles are hy- persons of both genders and of all ages. Many factors
pertonic. Muscle tone and ability to perform movement affect muscle strength. The age, gender, and lifestyle of
 BPA) EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

the subject, the muscle size, and type and speed of con- lessened” may be more accurate terms. The term
traction, the effect of previous training for the testing “gravity-decreased” is used in this chapter.”
situation, the joint position during the muscle contrac- In many muscle tests the effect of gravity on the
tion, previous training effect, time of day, temperature, ability to perform the movement must be considered
and fatigue all can affect muscle strength.”’ Experience in grading muscle power. It is of lesser importance,
can help the examiner differentiate strength grades if however, in tests of the forearm, fingers, and toes
these factors are taken into account.’* because the weight of the part lifted against gravity is in-
significant compared with the muscle strength.””
GENERAL PRINCIPLES OF MANUAL Therefore the examiner may choose to do the tests for
MUSCLE TESTING F (3) to N (5) in the gravity-decreased plane. In other
tests, positioning for movements in the gravity-
Preparation for Testing decreased position or the against-gravity position may
If several tests are to be administered, they should be not be feasible. For example, in the test for scapula de-
organized to avoid frequent repositioning of the pression, positioning to perform the movement against
subject.'? The examiner should observe contour of the gravity would require the subject to assume an inverted
part, comparative symmetry of the muscle on both position. In individual cases, positioning for movement
sides, and any apparent hypertrophy or atrophy. During in the correct plane may not be possible because of con-
PROM the examiner can estimate muscle tone. Is there finement to bed, generalized weakness, trunk instabil-
lesser or greater than normal resistance to passive ity, immobilization devices, and medical precautions.
movement? During AROM, the examiner can observe In these instances the examiner must adapt the posi-
quality of movement, such as movement speed, smooth- tioning to the patient's needs and modify the grading
ness, rhythm, and any abnormal movements such as using clinical judgment. If tests of the forearm, fingers,
tremors.‘4 and toes are done against gravity rather than in the
Correct positioning of the subject and the body part gravity-decreased plane, the standard definitions of
is essential to effective and correct evaluation. The muscle grades can be modified when muscle grades are
subject should be positioned comfortably on a firm recorded. The partial ROM against gravity is graded P
surface. Clothing should be arranged or removed so that (2), and the full ROM against gravity is graded F (3).”
the examiner can see the muscle or muscles being Such modifications in positioning and grading should
tested. If the subject cannot be placed in the correct be noted by the examiner when results of the muscle
position for the test, the examiner must adapt the test test are recorded.
and use clinical judgment in approximating strength For consistency in procedure and grading, the
grades.'* In addition to correct positioning, test validity gravity-decreased positions and against-gravity posi-
depends on careful stabilization, palpation of the tions are used in the MMTs described later, except where
muscles, and observation of movement.” the positioning is not feasible or would be awkward or
uncomfortable for the subject. Modifications in posi-
tioning and grading have been cited with the individual
Gravity Influencing Muscle Function
tests.
Gravity is a form of resistance to muscle power. It is used
as a grading criterion in tests of the neck, trunk, and ex-
Muscle Grades
tremities. This means that the muscle grade is based on
whether a muscle can move the part against gravity.” Although the definitions of the muscle grades are stan-
“Movements against gravity are in a vertical plane (that™ dard, the assignment of muscle grades during the MMT
is, away from the floor or toward the ceiling) and are depends on the clinical judgment, knowledge, and ex-
used with grades F (3), G (4), and N (5). Movements perience of the examiner,” especially when determining
against gravity and resistance are performed in a vertic slight, moderate, or maximal resistance. Age, gender,
plane with added manual or mechanical resistance and body type, occupation, and leisure activities all influ-
are used with F+ (3+) to N (5) grades. Tests for thi ence the amount of resistance that a particular subject
weaker muscles (O, T [1], P [2], and P+ [2+] grades can take.””"” Normal strength for an 8-year-old girl will
often performed in a horizontal plane (that is, paralle' be considerably less than for a 25-year-old man, for
to the floor) to reduce the resistance of gravity on example. Additionally, strength tends to decline with
muscle power, This position has been referred to as age, and full resistance to the same muscle group will
the gravity-eliminated, gravity-decreased, or gravity- vary considerably from an 80-year-old man to a 25-
lessened test position.”’'’’* “Gravity eliminated” is the year-old man.”’" Therefore, the amount of resistance
common term to designate this position.'* Because that can be applied to grade a particular muscle group
the effect of gravity on muscle function cannot be as N (5) or G (4) varies from one individual to
eliminated completely, “gravity-decreased” or “gravity- another. ”’”
 Muscle Strength =a |

The amount of resistance that can be given also varies experienced examiner. Two examiners testing the same
from one muscle group to another. Muscle strength is individual may vary up to a half grade in their results,
relative to the cross-sectional size of the muscle. Larger but there should not be a whole grade difference.'*
muscles have greater strength.”” For example, the
flexors of the wrist are larger and therefore have more
Substitutions
power and can take much more resistance than the ab-
ductors of the fingers. The examiner must consider the The brain thinks in terms of movement and not in
size and relative power of the muscles and the leverage
<_< terms of contraction of individual muscles.? Thus a
used when giving resistance.'* The amount of resistance muscle or muscle group may attempt to compensate
applied should be modified accordingly. When only for the function of a weaker muscle to accomplish a
one side of the body is involved in the dysfunction movement. These movements are called trick move-
causing the muscle weakness, the examiner can estab- ments or substitutions.°”" Substitutions can occur
lish the standards for strength by testing the unaffected during the MMT. To test muscle strength accurately, it
side first. is
necessary for the therapist to give careful instruc?
Because weak muscles fatigue easily, the results of tions,to eliminate substitutionsinthe testing proce-
muscle testing may not be accurate if the subject is tired. durebycortect positioning, stabilization, and palpa?
There should be no more than three repetitions of the . of themuscle being tested, and to ensure carefu
test movement because fatigue can result in grading eareraameet of the test motion without ——
errors if the muscle becomes tired as a result of low en- movements. To prevent substitutions, the correct posi-"
durance.”’* Pain, swelling, or muscle spasm in the area “tion of the body should be maintained and movement
being tested may also interfere with the testing proce- of the part performed without shifting the body or
dure and accurate grading. Such problems should turning the part.°”"' The examiner must palpate~
be recorded on the evaluation form.'* Psychological —_ tissue — feo or ai to detect”
factors must be considered in interpreting muscle
strength grades. When interpreting strength, the exam- ony nis correct aie ae that the examiner can
iner must assess the motivation, cooperation, and effort be certain that the motion observed is not being per-
put forth by the subject.” formed by substitution.®°” Undetected trick movements
In the MMT, muscles are graded according to the cri- can mask the patient's problems and could result in in-
teria listed in Table 22-1.%''°° accurate treatment planning.°
The purpose of using “plus” or “minus” designations In the tests that follow, possible substitutions are de-
with the muscle grades is to “fine grade” muscle scribed at the end of the directions. The examiner
strength. These designations are likely to be used by the should be familiar with these substitutions to detect

Word/Letter Grade Definition

Zero (0) No muscle contraction can be seen or felt.

Trace (T) Contraction can be observed or felt, but there is no motion.

Poor minus (P—) Part moves through incomplete ROM with gravity decreased.

Poor (P) Part moves through complete ROM with gravity decreased.

Poor plus (P+) Part moves through less than 50% of available ROM against gravity or through
complete ROM with gravity decreased against slight resistance.”

Fair minus (F—) Part moves through more than 50% of available ROM against gravity.’

Fair (F) Part moves through complete ROM against gravity.

Fair plus (F+) Part moves through complete ROM against gravity and slight resistance.

Good (G) Part moves through complete ROM against gravity and moderate resistance.

Normal (N) Part moves through complete ROM against gravity and maximal resistance.
B22 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

them and correct the procedure. Detecting substitutions tests, as well as a comprehensive treatment of the topic
is a skill gained with time and experience. of manual muscle testing.® *"

Procedure for Manual Muscle Testing MANUAL MUSCLE TESTING

OF THE UPPER EXTREMITY
Testing should be performed according to a standard
Motion
procedure to ensure accuracy and consistency. The tests
that follow are each divided into these steps: (1) posi- Scapula elevation, neck rotation, and lateral flexion.
tion, (2) stabilize, (3) palpate, (4) observe, (5) resist,
Muscles? Innervation: nerve, nerve roots”’”
and (6) grade.
First the subject (S) should be positioned for the spe- Upper trapezius Accessory nerve (CN 11), C2-4
Levator scapula Dorsal scapular nerve, C3-5
cific muscle test. The examiner (E) should position
himself or herself in relation to S. Then E stabilizes the
part proximal to the part being tested to eliminate extra- Procedure for Testing Grades Normal (N or 5)
neous movements, isolate the muscle group, ensure to Fair (F or 3)”
the correct test motion, and eliminate substitutions. E 1. Position: S seated erect with arms resting at sides of
should then demonstrate or describe the test motion to body. E stands behind S toward the side to be tested.
S and ask S to perform the test motion and return to the 2. Stabilize: A chair back can offer stabilization to the
starting position. E makes a general observation of the trunk, if necessary.
form and quality of movement, looking for substitu- 3. Palpate: The upper trapezius parallel to the cervical
tions or difficulties that may require adjustments in po- vertebrae, near the shoulder-neck curve.”
sitioning and stabilization. E then places his or her 4. Observe: Elevation of the scapula as S shrugs the
fingers for palpation of one or more of the prime shoulder toward the ear and rotates and laterally
movers, or its tendinous insertion, in the muscle group flexes the neck toward the side being tested at the
being tested and asks S to repeat the test motion. E same time (Fig. 22-2, A)."
again observes the movement for possible substitution 5. Resist: With one hand on top of the shoulder toward
and the amount of range completed. When S has moved scapula depression and with the other hand on the
the part through the available ROM, E asks S to hold the side of the head toward derotation and lateral flexion
end position. E removes the palpating fingers and uses to the opposite side (Fig. 22-2, B).”
the free hand to resist in the direction opposite that of
the test movement. For example, when elbow flexion is Procedure for Testing Grades Poor (P or 2),
tested, E applies resistance in the direction of extension. ieee (T or 1), and Zero (0)?
E usually must maintain stabilization when resistance is . Position: S lying prone with head in midposition. E
given. Manual muscle tests use the “break test”; that is, stands opposite the side being tested.
the resistance is applied after S has reached the end of 2. Stabilize: The weight of the trunk on the supporting
the available ROM.”° surface is adequate stabilization.
S should be allowed to establish a maximal con- 3. Palpate: The upper trapezius, as described in the pre-
traction (set the muscles) before the resistance is vious procedure, while observing S elevate the shoul-
applied.”’'* In most tests E applies the resistance near der being tested. Because of the positioning, the neck
the distal segment to which the muscle is attached after rotation and lateral flexion components are omitted
preparing S by giving the command to hold. Resistance for these grades (Fig. 22-2, C).
should be applied gradually in a direction opposite to 4. Grade: According to standard definitions of muscle
the line of pull of the muscle or muscle group being grades.
tested.'° The break test should not evoke pain, and re- Substitutions: Rhomboids and levator scapula can
sistance should be released immediately if pain or dis- elevate the scapula if the upper trapezius is weak or
comfort occurs.” Finally, E grades the muscle strength absent. In the event of substitution, some downward ro-
according to the preceding standard definitions of tation of the acromion will be observed during the
muscle grades. This procedure is used for the tests of movement.*’!”’!°
strength of grades F+ (3+) and above. Resistance is not
applied for tests of muscles from F (3) to 0. Slight resist- Motion
ance is sometimes applied to a muscle that has com-
pleted the full ROM in the gravity-decreased plane to Scapula depression, adduction, and upward rotation.
determine if the grade is P+. Fig. 22-1 shows a sample Muscles! Innervation®’”
form for recording muscle grades. Lower trapezius Spinal accessory nerve, C3,4
The following directions do not include tests for the Middle trapezius
face, neck, and trunk. Refer to the references for these Serratus anterior Long thoracic nerve, C5-7
 MUSCLE EXAMINATION

Patient’s name Chart no.

Date of birth Neimeloninshittion mmeameenmstes Us RES ae 2 ee
Date of onset Attending) physician ;ememmeeneneeeee DD
Diagnosis:
LEFT RIGHT
Examiner’s initials

at
Meee op | NECK Flexors Sternocleidomastoid

met || TRUNK __Flexors Rectus abdominis

Lt. ext. ob.
Rotators Rt. int. obl

Extensors {Hste a dag

Biceps femoris
KNEE __Flexors {Sines hamstrings
Extensors Quadriceps
Fae ANKLE Plantar flexors {Gastrocnemius
en rs)

mie) | FOOT Invertors Peas anterior i

Tibialis posterior
Peroneus brevis ian
Ie Evertors
Peroneus longus
TOES __ MP flexors Lumbricales
al
Reseed: |
Lie?)
Jae MP extensors (Be doer ay
me
ee is HAWUX MP flexor Flex. hall. br.
(eg IP flexor Flex. hall. |. poe
re MP extensor Ext. hall. br. ee
pare IP extensor. Ext. hall. |. (eat femal
Measurements:

Cannot walk Date Speech

Stands Date Swallowing
Walks unaided Date Diaphragm
Walks with apparatus Date Intercostals
KEY

Normal Complete range of motion against gravity with full resistance.

Good* Complete range of motion against gravity with some resistance.
Fair* | Complete range of motion against gravity.
Poor* Complete range of motion with gravity eliminated.
Trace —_Evidence of slight contractility. No joint motion.
Om—-NWAMH
oe
Oot
recy Zero _ No evidence of contractility.
Sor SS Spasm or severe spasm.
CorCC Contracture or severe contracture.
*Muscle spasm or contracture may limit range of motion. A question mark
should be placed after the grading of a movement that is incomplete from
this cause.

Continued
FIG. 22-1
Muscle examination. (Adapted from March of Dimes Birth Defects Foundation.)

B22
 LEFT
Examiner’s initials
Date
SCAPULA Abductor Serratus anterior
Elevator {Upper trapezius
Depressor Lower trapezius
i trapezius
Adductors Piece
SHOULDER Flexor Anterior deltoid
Priors Lae dorsi
Teres major
| Abductor Middle deltoid
Horiz. abd. Posterior deltoid
Horiz. add. Pectoralis major
External rotator group
Internal rotator group
ELBOW Flexors
Extensor
{Biceps brachii
Brachioradialis
Triceps
FOREARM Supinator group
Pronator group
Flex. carpi rad.
WRIST Flexors Flex. carpi uln.
Ext. carpi rad.
Extensors . & br.
a carpi uln.
FINGERS MP flexors Lumbricales
i Flex. digit. sub.
IP flexors (second) Flex. digit. prof.
MP extensor Ext. digit. com.
Adductors Palmar interossei
Abductors Dorsal interossei
Abductor digiti quinti
Opponens digiti quinti
cde THUMB __ MP flexor Flex. poll. br.
IP flexor Flex. poll. |.
| MP extensor Ext. poll. br.
IP extensor Ext. poll. I.

Abductors {AP¢: Po pr
Adductor pollicis
Opponens pollicis
FACE

Eola
Additional data:

FIG, 22-1, cont’d

Muscle examination. (Adapted from March of Dimes Birth Defects Foundation.)

324
 Muscle Strength 325

ee
——wer

FIG. 22-2
Scapula elevation. A, Palpate and observe. B, Resist. C, Gravity-decreased position.

Procedure for Testing Grades N (5) to F (3) 2. Palpate and observe: Same as described for previous
1. Position: S lying prone with arm positioned over- test (Fig. 22-3, C).
head in 120° to 145° of abduction and resting on 3. Grade: Grade P if patient completes full scapular
the supporting surface. The forearm is in midposi- ROM without the weight of the arm.'®
tion with the thumb toward the ceiling.’° E stands Substitutions: Middle trapezius or rhomboids may
next to S on the opposite side” or on the same substitute.° Rotation of the inferior angle of the scapula
side." toward the spine is evidence of substitution.'°
2. Stabilize: The weight of the body is adequate stabi-
lization. This test is given in the gravity-decreased po-
Motion
sition, because it is not feasible to position S for the
against-gravity movement (head down). Scapula abduction and upward rotation.
If the deltoid is weak, the arm may be supported
and passively raised by E while S attempts the Muscles” " Innervation”’””
motion.” Serratus anterior Long thoracic nerve, C5-7
3. Palpate: The lower trapezius distal to the medial end
of the spine of the scapula and parallel to the tho- Procedure for Testing Grades N (5) to F (3)
racic vertebrae, approximately at the level of the infe- 1. Position: S lying supine with the shoulder flexed to 90°
rior angle of the scapula.’ and slightly abducted, elbow extended or fully flexed.
4. Observe: S lift the arm off the supporting surface to E stands next to S on the side being tested.°”"”""
ear level.’ During this movement, there is strong 2. Stabilize: The weight ofthe trunk or over the shoulder.°
downward fixation of the scapula by the lower 3. Palpate: The digitations of the origin of the serratus
trapezius (Fig. 22-3, A).° anterior on the ribs, along the midaxillary line and
5. Resist: At the lateral angle of the scapula, toward ele- just distal and anterior to the axillary border of the
vation and abduction (Fig. 22-3, B). Resistance may scapula.®” Note that muscle contraction may be dif-
be given on the humerus just above the elbow in a ficult to detect in women and overweight subjects.
downward direction if shoulder and elbow strength 4. Observe: S reach upward as if pushing the arm toward
are adequate." the ceiling, abducting the scapula (Fig. 22-4, A).°°
5. Resist: At the distal end of the humerus and push
Procedure for Testing Grades P (2), T (1), and 0 arm directly downward toward scapula adduction
1. Position and stabilize: As described for previous test. (Fig. 22-4, B).°”° If there is shoulder instability, E
No stabilization is required. E may support S's arm if should support the arm and not apply resistance. In
posterior deltoid and triceps are weak.'® this instance only a grade of F (3) can be tested.’
BPA0 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

B Cc

FIG. 22-3
Scapula depression. A, Palpate and observe. B, Resist. C, Test for grades P to O.

FIG. 22-4
Scapula abduction. A, Palpate and observe. B, Resist. C, Gravity-decreased position.

Procedure for Testing Grades P (2), T (1), and 0 5. Grade: According to standard definitions of muscle
1p Position: S seated with the arm supported by E in 90° grades.
of shoulder flexion and the elbow extended.°” Substitutions: The pectoralis major and minor may
. Stabilize: Over the shoulder to be tested. pull the scapula forward into abduction at its insertion
co Palpate: As described in the previous section. on the humerus; the upper and lower trapezius and con-
Observe: For abduction of the scapula as the arm tralateral trunk rotation may also substitute.° E observes
moves forward (Fig. 22-4, C).? Weakness of this for humeral horizontal adduction followed by scapula
muscle produces “winging” of the scapula.® abduction.”’'?
 Muscle Strength 327

Motion posture. Observe scapula adduction toward the verte-

bral column (Fig. 22-5, C).
Scapula adduction.
3. Grade: According to standard definitions of muscle
Muscles zat Innervation®” grades.
Middle trapezius Spinal accessory nerve, C3,4 Substitutions: The posterior deltoid can act on the
Rhomboids Dorsal scapular nerve, C4,5 humerus and produce scapula adduction.° Observe for
humeral extension being used to initiate scapula adduc-
Procedure for Testing Grades N (5) to F (3) tion. Rhomboids may substitute, but scapula will rotate
d bp ele
up Position: Lying prone with the shoulder abducted downwatr
to 90° and externally rotated and the elbow flexed to
90°, shoulder resting on the supporting surface. E
Motion
stands on the side being tested."
. Stabilize: The weight of the trunk on the supporting Scapula adduction and downward rotation.
surface is usually adequate stabilization, or over the Muscles’® Innervation®®
midthorax to prevent trunk rotation if necessary. Rhomboids major and minor Dorsal scapular nerve, C4,5
. Palpate: The middle trapezius between the spine of Levator scapula
the scapula and the adjacent vertebrae in alignment Middle trapezius Spinal accessory nerve, C3,4
with the abducted humerus.
. Observe: S lift the arm off the table. Observe move- Procedure for Testing Grades N (5) to F (3)
ment of the vertebral border of the scapula toward i Position: S lying prone with the head rotated to the
the thoracic vertebrae (Fig. 22-5, A). opposite side; the arm on the side being tested is
. Resist: At the vertebral border of the scapula toward placed in shoulder adduction and internal rotation,
°
abduction (Fig. 22-5, B).°7”"" with the elbow slightly flexed and the dorsum of
the hand resting over the lumbosacral area of the
Procedure for Testing Grades P (2), T (1), and 0 back.®'° E stands opposite the side being tested.””*”
dks Position and stabilize: As described for the previous . Stabilize: The weight of the trunk on the supporting
test, but E now supports the weight of the arm by surface offers adequate stabilization.””"
cradling under the humerus and forearm.'* S may . Palpate: Rhomboid muscles between the vertebral
also be positioned sitting erect, with arm resting on a border ofthe scapula and the 2nd to 5th thoracic ver-
high table and the shoulder midway between 90° tebrae.”’"' (They may be more easily discerned toward
flexion and abduction.” E stands behind S in this in- the lower half of the vertebral border of the
stance. scapula, because they lie under the trapezius muscle.)
. Palpate and observe: The middle trapezius. Ask E to . Observe: S raise the hand up off the back while
bring the shoulders together as if assuming an erect maintaining the position of the arm.”’"” During this

FIG, 22-5
Scapula adduction.
A, Palpate and observe. B, Resist. C, Test for grades P to O.
328 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

motion, the anterior aspect of the shoulder must lift Muscles” Innervation®”
from the table surface. Observe scapula adduction Anterior deltoid Axillary nerve, C5,6
and downward rotation while the shoulder joint is in Coracobrachialis Musculocutaneous nerve, C5-7

some extension (Fig. 22-6, A).”

Dé Resist: Over the scapula toward abduction and peace, for Testing Grades N (5) to F (3)
upward rotation® (Fig. 22-6, B). . Position: S seated, with the arm relaxed at the side of
the body and the hand facing backward."° A straight-
Procedure for Testing Grades P (2), T (1), and 0 backed chair may be used to offer trunk support.
L Position: S sitting erect with the arm positioned E stands on the side being tested and slightly
behind the back in the same manner described for behinds
the previous test. E stands behind §S, a little opposite . Stabilize: Over the shoulder being tested, but allow
the side being tested.” the normal abduction and upward rotation of the
. Stabilize: Trunk by placing one hand over the shoul- scapula that occurs with this movement.”’”®
der, opposite the one being tested, to prevent trunk . Palpate: The anterior deltoid just below the clavicle
flexion and rotation. on the anterior aspect of the humeral head.’
. Palpate: The rhomboids as described above. . Observe: S flex the shoulder joint to 90° of flexion
4. Observe: Scapula adduction and downward rotation (parallel to the floor) (Fig. 22-7, A).°”®
as S lifts the hand away from the back (Fig. 22-6, C). 5. Resist: At the distal end of the humerus downward
5. Grade: According to standard definitions of muscle toward shoulder extension (Fig. 22-7, B).°””*°
grades.
Substitutions: Middle trapezius, but the movement Procedure for Testing Grades P(2), T(1), and 0
will not be accompanied by downward rotation.'” The 1. Position: S in side-lying position. The side being
posterior deltoid acting to perform horizontal abduc- tested is superior. If S cannot maintain weight of the
tion or glenohumeral extension can produce scapula arm against gravity, E can support it.*'° If the side-
adduction through momentum. Scapula adduction lying position is not feasible, S may remain seated,
would be preceded by extension or abduction of the and the test procedure described above can be per-
humerus.'~'? The pectoralis minor could tip the formed with the grading modified.”
scapula forward.’ De Palpate and observe: The same as described for the pre-
vious test. The arm is moved toward the face to 90°
of shoulder flexion (Fig. 22-7, C).
Motion
3. Grade: According to standard definitions of muscle
Shoulder flexion. grades. If the seated position was used for the tests of

FIG. 22-6
Scapula adduction and downward rotation. A, Palpate and observe. B, Resist. C, Gravity-decreased
position.
 Muscle Strength 329

grades poor to zero, partial ROM against gravity Procedure for Testing Grades N (5) to F (3)
should be graded poor.”’® 1. Position: S lying prone, with the shoulder joint ad-
Substitutions: Clavicular fibers of the pectoralis major ducted and internally rotated so that the palm of the
can perform flexion through partial ROM while per- hand is facing up.°’””” E stands on the opposite side
forming horizontal adduction. The biceps brachii may or on the test side.
flex the shoulder, but the humerus will first be rotated 2. Stabilize: Over the scapula on the side being tested.
externally for the best mechanical advantage. The upper 3. Palpate: The teres major along the axillary border of
trapezius will assist flexion by elevating the scapula. the scapula. The latissimus dorsi may be palpated
Observe for flexion accompanied by horizontal adduc- slightly below this point or closer to its origins paral-
tion, external rotation, or scapula elevation. '”!*"” lel to the thoracic and lumbar vertebrae.” The pos-
Note: Arm elevation in the plane of the scapula, terior deltoid may be found over the posterior aspect
about halfway between shoulder flexion and abduc- of the humeral head (Fig. 22-8, A).
tion, is called scaption. This movement is more com- 4. Observe: S extending the shoulder joint.
monly used for function than either shoulder flexion 5. Resist: At the distal end of the humerus in a down-
or abduction. Scaption is performed by the deltoid and ward and outward direction, toward flexion and
supraspinatus muscles. It is tested similarly to shoulder slight abduction (Fig. 22-8, B).°7"
flexion, described earlier, except that the arm is ele-
vated in a position 30° to 45° anterior to the frontal Procedure for Testing Grades P (2), T (1), and 0
plane.®” 1. Position: S in the side-lying position; E stands be-
hind S.°
2. Stabilize: Over the scapula. If S cannot maintain the
Motion
weight of the part against gravity, E should support
Shoulder extension. S's arm.° If the side-lying position is not feasible, S
Muscles 4,9,11
Innervation®”
may remain in the prone lying position and the test
may be performed as described for the previous test
Latissimus dorsi Thoracodorsal nerve, C6-8
Teres major Lower subscapular nerve, C5-7 with modified grading.’
Posterior deltoid Axillary nerve, C5,6 3. Palpate: The teres major or latissimus dorsi as de-
scribed for the previous test.

FIG. 22-7
Shoulder flexion. A, Palpate and observe. B, Resist. C, Gravity-decreased position.

FIG. 22-8
Shoulder extension. A, Palpate and observe. B, Resist. C, Gravity-decreased position.
330 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

4. Observe: S extend the arm backward in a plane paral- 2. Stabilize: Over the shoulder to be tested.
lel to the floor (Fig. 22-8, C). 3. Palpate and observe: The sameas described for the previ-
5. Grade: According to standard definitions of muscle ous test. Easks S to bring the arm out and away from the
grades. If the test for grades poor to zero was done in body, abducting the shoulder to 90° (Fig. 22-9, C).
the prone-lying position, completion of partial ROM 4. Grade: According to standard definitions of muscle
should be graded poor.” grades.
Substitutions: Scapula adduction can substitute. Ob- Substitutions: The long head of the biceps may
serve for flexion of the shoulder or adduction of the attempt to substitute. Observe for elbow flexion and
scapula preceding extension of the humerus.’? external rotation accompanying the movement.” The
anterior and posterior deltoids can act together to
effect abduction. The upper trapezius may attempt to
Motion
assist. Observe for scapula elevation preceding the
Shoulder abduction to 90°. movement.”’'”’!°

Muscles a0 Innervation”
Motion
Middle deltoid Axillary nerve, C5,6
Supraspinatus Suprascapular nerve, C5 Shoulder external rotation.

Procedure for Testing Grades N (5) to F (3) Muscles

4,9,11
Innervation
4,9,11

1. Position: S seated, with arms relaxed at the sides of Infraspinatus Suprascapular nerve, C5,6
the body. The elbow on the side to be tested should Teres minor Axillary nerve, C5,6
be slightly flexed and the palms facing toward the
body. E stands behind S.°”’"° Procedure for Testing Grades N (5) to F (3)
2. Stabilize: Over the scapula on the side to be 1. Position: S lying prone, with the shoulder abducted to
tested." 90° and the humerus in neutral (0°) rotation, elbow
3. Palpate: The middle deltoid over the middle of the flexed to 90°. Forearm is in neutral rotation, hanging
shoulder joint from the acromion to the deltoid over the edge of the table, perpendicular to the
tuberosity.°”’’* The supraspinatus is too deep to floor.°*’’° E stands in front of the supporting surface,
palpate.® toward the side to be tested.””"
4. Observe: S abduct the shoulder to 90°. During the 2. Stabilize: At the distal end of the humerus by placing
movement, S’s palm should remain down and E a hand under the arm on the supporting surface to
should observe that there is no external rotation of the prevent shoulder abduction.”
shoulderorelevation ofthescapula.*”'*(Fig. 22-9,A). 3. Palpate: The infraspinatus muscle just below the spine
5. Resist: At the distal end of the humerus toward ad- of the scapula on the body of the scapula’ or the teres
duction (Fig. 22-9, B).'° minor along the axillary border of the scapula.’
4. Observe: S rotate the humerus so that the back of
Procedure for Testing Grades P (2), T (1), and 0 the hand is moving toward the ceiling (Fig. 22-10,
A) koe
1. Position: S in supine position, lying with the arm to be
tested resting at the side of the body, palm facing in 5. Resist: On the distal end of the forearm toward the
and the elbow slightly flexed. E stands in front of the floor in the direction of internal rotation (Fig. 22-10,
supporting surface toward the side to be tested.””"® B).°°" Apply resistance gently and slowly to prevent

Cc

FIG. 22-9
Shoulder abduction. A, Palpate and observe. B, Resist. C, Gravity-decreased position.
 Muscle Strength S34

Motion
injury to the glenohumeral joint, which is inherently
unstable. ’° Shoulder internal rotation.
Muscles” "7 Innervation*”””
Procedure for Testing Grades P (2), T (1), and 0
Subscapularis Subscapular nerve, C5,6
1. Position: S seated, with arm adducted and in neutral Pectoralis major Medial and lateral pectoral nerves, C5-T1
rotation at the shoulder. The elbow is flexed to 90° Latissimus dorsi Thoracodorsal nerve, C6-8
with the forearm in neutral rotation. E stands in Teres major Subscapular nerve, C5-7
front of S toward the side to be tested.”
2. Stabilize: Arm against the trunk at the distal end of Procedure for Testing Grades N (5) to F (3)
the humerus to prevent abduction and extension of 1. Position: S lying prone with the shoulder abducted to
the shoulder, and over the shoulder to be tested.”’”’'!® 90° and the humerus in neutral rotation, the elbow
The hand stabilizing over the shoulder can be used flexed to 90°. A rolled towel may be placed under the
to palpate the infraspinatus simultaneously. humerus. The forearm is perpendicular to the floor. E
3. Palpate: The infraspinatus and teres minor as de- stands on the side to be tested, just in front of S’s
arm.°=’ 10
scribed for previous test.
4. Observe: S move the forearm away from the body by 2. Stabilize: At the distal end of the humerus by placing
rotating the humerus while maintaining neutral ro- a hand under the arm and on the supporting surface,
tation of the forearm (Fig. 22-10, C).°'° as for external rotation.°”’”""
5. Grade: According to standard definitions of muscle 3. Palpate: The teres major and latissimus dorsi along the
grades. axillary border of the scapula toward the inferior angle.
Substitutions: If the elbow is extended and S sup- 4. Observe: S internally rotate the humerus, moving the
inates the forearm, the momentum could aid external palm of the hand upward toward the ceiling (Fig.
rotation of the humerus. Scapular adduction can pull SIT aA).
the humerus backward and into some external rota- 5. Resist: At the distal end of the volar surface of the
tion. E should observe for scapula adduction and initi- forearm anteriorly toward external rotation (Fig.
ation of movement with forearm supination.'*'” POETW969oe

FIG. 22-10
Shoulder external rotation.A, Palpate and observe. B, Resist. C, Gravity-decreased position.

FIG. 22-11
Shoulder internal rotation.A, Palpate and observe. B, Resist. C, Gravity-decreased position.
332 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

Procedure for Testing Grades P (2), T (1), and 0 ported on a high table or by E.*”° If a table is used,
1. Position: S seated, with the shoulder adducted and powder may be sprinkled on the surface to reduce
in neutral rotation, elbow flexed to 90° with the friction.
forearm in neutral rotation. E stands on the side to 2. Stabilize: Over the scapula.
be tested.*!° 3. Palpate: The posterior deltoid, as described for the
2. Stabilize: Arm at the distal end of the humerus previous test.
against the trunk to prevent abduction and extension 4. Observe: S pull arm backward into horizontal abduc-
of the shoulder. tion (Fig. 22-12, C).
3. Palpate: The teres major and latissimus dorsi, as de- 5. Grade: According to standard definitions of muscle
scribed for the previous test. grades.
4. Observe: S move the palm of the hand toward the Substitutions: Latissimus dorsi and teres major may
chest, internally rotating the humerus (Fig. 22-11, C). assist the movement if the posterior deltoid is very
Substitutions: If the trunk is rotated, gravity will act on weak. Movement will occur with more shoulder exten-
the humerus, rotating it internally.° E should observe for sion rather than at the horizontal level. Scapula adduc-
trunk rotation. When the elbow is in extension, prona- tion may produce slight horizontal abduction of the
tion of the forearm can substitute. '°!*'” humerus, but trunk rotation and shoulder retraction
would occur.*!*!° The long head of the triceps may
substitute. Maintain some flexion at the elbow to
Motion prevent this. '°
Shoulder horizontal abduction.

Muscles eee Innervation”© Motion

Posterior deltoid Axillary nerve, C5,6 Shoulder horizontal adduction.
Infraspinatus Suprascapular nerve, C5,6
Muscles*’!!2 Innervation*”’°
Pectoralis major Medial and lateral pectoral nerves, C5-T1
Procedure for Testing Grades N (5) to F (3) Anterior deltoid Axillary nerve, C5,6
1. Position: S prone, with the shoulder abducted to 90° Coracobrachialis Musculocutaneous nerve, C6,7
and in slight external rotation, elbow flexed to 90°,
and forearm perpendicular to the floor. E stands on Procedure for Testing Grades N (5) to F (3)
the side being tested.'""!* 1. Position: S supine, with the shoulder abducted to 90°,
2. Stabilize: Over the scapula.®° elbow flexed or extended. E stands next to S on the
3. Palpate: The posterior deltoid below the spine of the side being tested or behind S’s head.4’°"”"”’°
scapula and distally toward the deltoid tuberosity on 2. Stabilize: The trunk by placing one hand over the
the posterior aspect of the shoulder.’ shoulder on the side being tested to prevent trunk ro-
4. Observe: S horizontally abduct the humerus, lifting tation and scapula elevation.
the arm toward the ceiling (Fig. 22-12, A)."® 3. Palpate: Over the insertion of the pectoralis major at
5. Resist: Just proximal to the elbow obliquely down- the anterior aspect of the axilla.°
ward horizontal adduction (Fig. 22-12, B).° 1°" 4. Observe: § horizontally adduct the humerus, moving
the arm toward the opposite shoulder to a position
Procedure for Testing Grades P (2), T (1), and 0 of 90° of shoulder flexion.” If S cannot maintain
1. Position: S seated, with the arm in 90° abduction, the elbow extension, E may guide the forearm to prevent
elbow flexed to 90 degrees and the palm down, sup- the hand from hitting S’s face (Fig. 22-13, A).

FIG. 22-12
Shoulder horizontal abduction. A, Palpate and observe. B, Resist. C, Gravity-decreased position.
 Muscle Strength 333

5. Resist: At the distal end of the humerus, in an stands next to S on the side being tested or directly in
outward direction toward horizontal abduction (Fig. front of S.
22213,B).°"”° . Stabilize: The humerus in adduction.
. Palpate: The biceps brachii over the muscle belly, on
Procedure for Testing Grades P (2), T (1), and 0 the middle of the anterior aspect of the humerus. Its
1. Position: S seated next to a high table with the arm tendon may be palpated in the middle of the antecu-
supported in 90° of shoulder abduction and slight bital space.*’””” (Brachioradialis is palpated over the
flexion at the elbow.*'”'” Powder may be sprinkled upper third of the radius on the lateral aspect of the
on the supporting surface to reduce the effect of re- forearm, just below the elbow. The brachialis may be
sistance from friction during the movement, or E palpated lateral to the lower portion of the biceps
may support the arm.° brachii, if the elbow is flexed and in the pronated po-
. Stabilize: Over the shoulder on the side being tested, sition.'”)
using the stabilizing hand simultaneously to palpate . Observe: S flex elbow, hand toward the face. E should
the pectoralis major muscle.° observe for maintenance of forearm in supination
. Palpate: The pectoralis major, as described for the (when testing for biceps) and for relaxed or extended
previous test. wrist and fingers (Fig. 22-14, A).°1?
. Observe: S horizontally adduct the arm toward the . Resist: At the distal end of the volar aspect of the
opposite shoulder, in a plane parallel to the floor forearm, pulling downward toward elbow extension
(Fig. 22-13, C). (Fig. 22-14, B).’°™
Substitutions: Muscles may substitute for one another.
If the pectoralis major is not functioning, the other Procedure for Testing Grades P (2), T (1), and 0
muscles will perform the motion, which will be consid- A. Position: S supine, with the shoulder abducted to 90°
erably weakened.'* Contralateral trunk rotation, the and externally rotated, elbow extended, and forearm
coracobrachialis, or short head of the biceps may substi- supinated. E stands at the head of the table on the
tute.® side being tested. (S may also be seated, side being
tested resting on the treatment table, which is at axil-
lary height, humerus in 90° abduction, elbow ex-
Motion
tended, and forearm in neutral position.)’
Elbow flexion. . Stabilize: The humerus. The stabilizing hand can be
Muscles???" Innervation ’”"
used simultaneously for palpation here.
. Palpate: The biceps as described for the previous test.
Biceps brachii Musculocutaneous nerve C5,6
Brachialis
. Observe: S flex the elbow, the hand toward the
Brachioradialis Radial nerve C5,6 shoulder.’ Watch for maintenance of forearm supin-
ation and relaxation of the fingers and wrist (Fig.
Procedure for Testing Grades N (5) to F (3) Bela eC).2—
i. Position: S sitting, with the arm adducted at the . Grade: According to standard definitions of muscle
shoulder and extended at the elbow, held against the grades.
side of the trunk. The forearm is supinated to test for Substitutions: The brachioradialis will substitute for
the biceps, primarily (Forearm should be positioned the biceps, but the forearm will move to midposition
in pronation to test for the brachialis, primarily, and during flexion of the elbow. Wrist and finger flexors may
in midposition to test for brachioradialis).”’° E assist elbow flexion, which will be preceded by finger

A B

FIG. 22-13
Shoulder horizontal adduction. A, Palpate and observe. B, Resist. C, Gravity-decreased position.
 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

FIG. 22-14
Elbow flexion. A, Palpate and observe. B, Resist. C, Gravity-decreased position.

FIG. 22-15
Elbow extension. A, Palpate and observe. B, Resist. C, Gravity-decreased position.

and wrist flexion.”'”'? The pronator teres may assist. = Palpate: The triceps over the middle of the posterior
Forearm pronation during the movement may be evi- aspect of the humerus or the triceps tendon just
dence of this substitution.'” proximal to the olecranon process on the dorsal
surface of the arm.°”””’'?
Observe: S extend the elbow to just less than max-
Motion
imum range. The wrist and fingers remain relaxed
Elbow extension. (Fig. 22-15, A).
Muscles®”’?° Innervation?" . Resist: At the distal end of the forearm into elbow
Triceps Radial nerve, C6-8 flexion. Before resistance is given, be sure that the
Aconeus Radial nerve, C7,8 elbow is not locked. Resistance to a locked elbow can
cause joint injury (Fig. 22-15, B).°°
Procedure for Testing Grades N (5) to F (3)
1. Position: S prone, with the humerus abducted to 90°, Procedure for Testing Grades P (2), T (1), and 0
the elbow flexed to 90°, and the forearm in neutral Ae Position: S supine, with the humerus abducted to 90°
rotation and perpendicular to the floor. E stands next and in external rotation, the elbow fully flexed, and
to S, just behind the arm to be tested.” the forearm supinated. E is standing next to S, just
2. Stabilize: The humerus by placing one hand for behind the arm to be tested.” An alternate position is
support under it, between S's arm and the table.'"”" with S seated, shoulder abducted to 90° in neutral
 Muscle Strength 335

rotation, elbow flexed, and forearm in neutral posi- radius. The muscle can be best felt when the radial
tion, supported by E.””° . muscle group (extensor carpi radialis and brachiora-
2. Stabilize: The humerus by holding one hand over the dialis) are pushed up out of the way.* E may also
middle or distal end to prevent shoulder motion. palpate the biceps on the middle of the anterior
3. Palpate: The triceps as described for the previous test. surface of the humerus.*’”
4. Observe: S extend the elbow, moving the hand away 4. Observe: S supinate the forearm, turning the hand
from the head (Fig. 22-15, C). palm up. Because gravity assists the movement, after
5. Grade: According to standard definitions of muscle the 0° neutral position is passed, the therapist may
grades. apply slight resistance equal to the weight of the
Substitutions: Finger and wrist extensors may substi- forearm(Fig. 22-16, A).°”
tute for weak elbow extensors. Observe for finger and 5. Resist: By grasping around the dorsal aspect of the
wrist extension preceding elbow extension. When distal forearm with the fingers and heel of the hand,
Ce
7
bail
bel
att upright, gravity and eccentric contraction of the biceps turning the arm toward pronation(Fig. 22-16, B).°
will effect elbow extension from the flexed position,'”
scapula depression, and shoulder external rotation, Procedure for Testing Grades P (2), T (1), and 0
aided by gravity.° 1. Position: S seated, shoulder flexed to 90° and the
upper arm resting on the supporting surface, elbow
flexed to 90°, and the forearm in full pronation in a
Motion
position perpendicular to the floor.*”!° E stands
Forearm supination. next to S on the side to be tested.
i) . Stabilize: The humerus just proximal to the elbow.®

Muscles*”’”° Innervation®””"° 3. Palpate: The supinator or biceps as described for the

Biceps brachii Musculocutaneous nerve, C5,6 previous test.
Supinator Radial nerve, C5-7 4. Observe: S supinate the forearm, turning the palm of
the hand toward the face (Fig. 22-16, C).
Procedure for Testing Grades N (5) to F (3) 5. Grade: According to standard definitions of muscle
1. Position: S seated, with the humerus adducted, the grades.
elbow flexed to 90°, and the forearm pronated. E Substitutions: With the elbow flexed, external rotation
stands in front of S or next to S on the side to be and horizontal adduction of the humerus will effect
tested.” forearm supination. With the elbow extended, shoulder
N. Stabilize: The humerus just proximal to the elbow.°? external rotation will place the forearm in supination.
3. Palpate: Over the supinator muscle on the dorsal- The brachioradialis can bring the forearm from full
lateral aspect of the forearm, below the head of the pronation to midposition. Wrist and thumb extensors,

FIG. 22-16
Forearm supination. A, Palpate and observe. B, Resist. C, Gravity-decreased position.
336 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

assisted by gravity, can initiate supination. E should upper arm is resting on the supporting surface and
observe for external rotation of the humerus, supination the forearm is perpendicular to the floor.'? E stands
to midline only, and initiation of motion by wrist and next to S on the side to be tested.
thumb extension. '°'*! 2. Palpate: Palpate the pronator teres as described for
the previous test.
3. Observe: S pronate the forearm, turning the palm of
Motion
the hand away from the face (Fig. 22-17, C).
Forearm pronation. 4. Grade: According to standard definitions of muscle
Muscles
4,10,12
Innervation
10,11 grades.
Substitutions: With the elbow flexed, internal rotation
Pronator teres Median nerve, C6,7
Pronator quadratus Median nerve, C6-8 and abduction of the humerus will produce apparent
forearm pronation. With the elbow extended, internal
Procedure for Testing Grades N (5) to F (3) rotation can place the forearm in a pronated position.
1. Position: S seated, with the humerus adducted, the Brachioradialis can bring the fully supinated forearm to
elbow flexed to 90°, and the forearm in full supina- midposition. Wrist flexion, aided by gravity, can effect
pronation.©7 01215
tion. E stands beside S on the side to be tested.°°””"”
2. Stabilize: The humerus just proximal to the elbow to
prevent shoulder abduction.°”?""
Motion
3. Palpate: The pronator teres on the upper part of the
volar surface of the forearm, medial to the biceps Wrist extension with radial deviation.
tendon and diagonally from the medial condyle of Muscles?|! Innervation’ ©
the humerus to the lateral border of the radius.“””""’'*
Extensor carpi radialis longus (ECRL) Radial nerve, C5-7
4. Observe: S pronate the forearm, turning the hand Extensor carpi radialis brevis (ECRB) Radial nerve, C6-8
palm down (Fig. 22-17, A).’ Slight resistance may be Extensor carpi ulnaris (ECU)
applied after the arm has passed midposition to com-
pensate for the assistance of gravity after that point.° Procedure for Testing Grades N (5) to F (3)
5. Resist: By grasping over the dorsal aspect of the distal 1. Position: S seated or supine, with the forearm rest-
forearm using the fingers and heel of the hand and ing on the supporting surface in pronation, the
turn toward supination (Fig. 22-17, B). wrist at neutral, and the fingers and thumb relaxed.
E sits opposite S or next to S on the side to be
Procedure for Testing Grades P (2), T (1), and 0 tested.”
1. Position: S seated, shoulder flexed to 90°, elbow 2. Stabilize: Over the volar or dorsal aspect of the distal
flexed to 90°, and the forearm in full supination. The forearm, o's

FIG. 22-17
Forearm pronation. A, Palpate and observe. B, Resist. C, Gravity-decreased position.
 Muscle Strength 337

3. Palpate: The ECRL and ECRB tendons on the dorsal 3. Palpate: Radial wrist extensors as described for the
aspect of the wrist at the bases of the 2nd and 3rd previous test.
metacarpals, respectively.°”” The tendon of the 4. Observe: S extend the wrist, moving the hand away
ECU may be palpated at the base of the 5th from the body (Fig. 22-18, D).
metacarpal, just distal to the head of the ulna (Fig. 5. Grade: According to standard definitions of muscle
me 2-18,,A).*°??? grades.
4. Observe: S extend and radially deviate the wrist, lifting Substitutions: Wrist extensors can substitute for one
the hand from the supporting surface and simultane- another. In the absence of the extensor carpi radialis
ously moving it medially (to the radial side). The muscles, the extensor carpi ulnaris will extend the wrist,
movement should be performed without finger ex- but in an ulnar direction. The combined extension and
tension, which could substitute for the wrist motion radial deviation will not be possible. The extensor digi-
(Fig. 22-18, B).°!? torum communis muscle and the extensor pollicis
bhi
meted
5. Resist: Over the dorsum of the 2nd and 3rd meta- longus can initiate wrist extension, but finger or thumb
carpals, toward flexion and ulnar deviation (Fig. extension will precede wrist extension.°”’'°'!?'
Pete, cj)"

Procedure for Testing Grades P (2), T (1), and 0 moon

1. Position: As described for the previous test, except Wrist extension with ulnar deviation.
that the forearm is resting in midposition on its Muscles? linéwation! =
ulnar border. Extensor carpi ulnaris (ECU) Radial nerve, C6-8
2. Stabilize: At the ulnar border of t arm, sup- Extegsor carpi radialis brevis (ECRB)
ported slightly above the table s Extensor carpi radialis longus (ECRL) Radial nerve, C5-7

yae i
Left hand
af a () Dorsal view

“sy |e

£
Fr} —} pollicis longus
Extensor eer Pi:
Extensor t
| "
aa pollicis brevis ,
xtensor
Exter |
indicis \
"
Abductor
pollicis longus lV

My
i

q Extensor carpi
: aa radialis longus
Extensor
carpi ulnaris
2 i
a.
aie Extensor carpi
oa radialis brevis

Arrangement of Extensor Tendons

Cc D

FIG. 22-18
A,Arrangement of extensor tendons at wrist. B, Wrist extension with radial deviation. Palpate and
observe. C, Resist. D, Gravity-decreased position.
338 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

Procedure for Testing Grades N (5) to F (3) can be palpated at the ulnar side of the volar aspect
1. Position: S seated, forearm pronated, wrist neutral, of the wrist, at the base of the 5th metacarpal (Fig.
fingers and thumb relaxed, supported on a table. E 22-20, A).*
sits opposite or next to S on the side to be tested. 4. Observe: S flex and radially deviate the hand simulta-
2. Stabilize: Under the distal forearm.”" neously. E should observe that the fingers remain
3. Palpate: ECU tendon at the base of the 5th relaxed during the movement® (Fig. 22-20, B).
metacarpal, just distal to the ulna styloid,° and the 5. Resist: In the palm at the radial side of the hand, over
ECRL and ECRB tendons at the bases of the 2nd and the 2nd and 3rd metacarpals toward extension and
3rd metacarpals. ulnar deviation (Fig. 22-20, C).°
4. Observe: S extend the wrist and simultaneously move
it laterally (to the ulnar side). E should observe that Procedure for Testing Grades P (2), T (1), and 0
the movement is not preceded by thumb or finger ex- 1. Position: S seated with the forearm in midposition
tension (Fig. 22-19, A).° "0"? with the ulnar border of the hand resting on the sup-
5. Resist: Over the dorsal-lateral aspect of the 4th and porting surface.”’'° E sits next to S on the side to be
5th metacarpal toward flexion and radial deviation tested.
(Fig. 22°19; 'B)2° 2. Stabilize: Under the ulnar border of the forearm, sup-
porting the wrist slightly above the supporting
Procedure for Testing Grades P (2), T (1), and 0 surface.
1. Position: As described for the previous test, except 3. Palpate: Wrist flexor tendons as described for the pre-
that the forearm is in 45° of pronation and sup- vious test.
ported on a table. The wrist is flexed and radially de- 4. Observe: S flex and radially deviate the wrist. Move-
viated and the thumb and fingers are flexed.° ment should not be initiated with finger flexion (Fig.
2. Stabilize: Under the distal forearm, supporting it 29207).
slightly above the supporting surface.”" 5. Grade: According to standard definitions of muscle
Qo . Palpate: Extensor tendons as described above. grades.
4. Observe: S extend the wrist and move it ulnarly at the Substitutions: Wrist flexors can substitute for one
same time (Fig. 22-19, C). another. If flexor carpi radialis is weak or nonfunc-
5. Grade: According to standard definitions of muscle tioning in this test, flexor carpi ulnaris will produce
grades. wrist flexion, but in an ulnar direction, and the radial
Substitutions: In the absence of the ECU muscle, the deviation will not be possible. The finger flexors can
ECRL and ECRB muscles can extend the wrist but will assist wrist flexion, but finger flexion will occur be-
do so in a radial direction. The ulnar deviation compo- fore the wrist is flexed. The abductor pollicis longus,
nent of the test motion will not be possible. Long finger with the assistance of gravity, can initiate wrist
and thumb extensors can initiate wrist extension, but flexion.°”"!?
the movement will be preceded by finger or thumb
extension."
Motion
Wrist flexion with ulnar deviation.
Motion
9,10 5,9,10
Muscles Innervation
Wrist flexion with radial deviation.
Flexor carpi ulnaris (FCU) Ulnar nerve, C7-T1
Muscles 10,11
Innervation®?’*”
s ,O,
Palmaris longus Median nerve, C7-T1

Flexor carpi radialis (FCR) Flexor carpi radialis (FCR) Median nerve, C6-8
Median nerve, C6-8
Flexor carpi ulnaris (FCU) Ulnar nerve, C7-T1
Palmaris longus Median nerve, C7-T1 Procedure for Testing Grades N (5) to F (3)
1. Position: S seated or supine, with the forearm resting
Procedure for Testing Grades N (5) to F (3) in nearly full supination on the supporting surface,
1. Position: S seated or supine, with the forearm resting fingers and thumb relaxed. E is seated opposite or
in nearly full supination on the supporting surface, next to S on the side to be tested.”
fingers and thumb relaxed.”’'”’' E is seated next to S 2. Stabilize: Over the volar aspect of the middle of the
on the side to be tested. forearm."
2. Stabilize: Over the volar aspect of the midfore- 3. Palpate: Flexor tendons on the volar aspect of the
arm.°”” ll
wrist, the FCU at the base of the 5th metacarpal, the
3. Palpate: The FCR tendon can be palpated over the FCR at the base of the 2nd metacarpal, and the pal-
wrist at the base of the second metacarpal bone. The maris longus at the base of the 3rd metacarpal.*
palmaris longus tendon is at the center of the wrist at 4. Observe: S flex the wrist and simultaneously deviate it
the base of the 3rd metacarpal, and the FCU tendon ulnarly (Fig. 22-21, A).
 A B C

FIG. 22-19
Wrist extension with ulnar deviation. A, Palpate and observe. B, Resist. C, Gravity-decreased
position.

4 Left hand
- Palmar view
})
Flexor
4 digitorum
profundus
]
Flexor
digitorum
superficialis

Flexor carpi Flexor

radialis digitorum
superticialis

Palmaris Flexor carpi

longus ulnaris

‘ ‘eon ™

Cc D

FIG. 22-20
A, Arrangement of flexor tendons at wrist. B, Wrist flexion with
radial deviation. Palpate and observe. C, Resist. D, Gravity-
decreased position.

FIG. 22-21
Wrist flexion with ulnar deviation.A, Palpate and observe. B, Resist. C, Gravity-decreased position.

339
340 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

5. Resist: In the palm of the hand over the hypothenar The MP joints are extended and the IP joints are
eminence toward extension and radial deviation flexed.'"'° E sits next to S on the side being
(Fig, 22:21, Bye tested.
2. Stabilize: Over the metacarpals, proximal to the MP
Procedure for Testing Grades P (2), T (1), and 0 joints in the palm of the hand to prevent wrist
1. Position: S seated, with the forearm in neutral rota- motion.
tion and resting in 45° of supination on the ulnar 3. Palpate: The first dorsal interosseous muscle just
border of the arm and hand.” E sits opposite S or medial to the distal aspect of the 2nd metacarpal on
next to S on the side being tested. the dorsum of the hand. The remainder of these
. Stabilize: S's arm can be supported slightly above the muscles are not easily palpable because of their size
supporting surface and stabilized at the dorsal- and deep location in the hand.'”'°
medial aspect of the forearm to prevent elbow and 4. Observe: S flex the MP joints and extend the IP joints
forearm motion. simultaneously (Fig. 22-22, A).'°"
. Palpate: Wrist flexor tendons as described for the pre- 5. Resist: Each finger separately by grasping the distal
vious test. phalanx and pushing downward on the finger into
. Observe: S simultaneously flex and deviate the wrist the supporting surface toward MP extension and IP
toward ulnar side (Fig. 22-21, C). flexion, or apply pressure first against the dorsal
. Grade: According to standard definitions of muscle surface of the middle and distal phalanges toward
grades. flexion, followed by application of pressure to the
Substitutions: Wrist flexors can substitute for one volar surface of the proximal phalanges toward ex-
another. If FCU is weak or absent, FCR can produce tension (Fig. 22-22, B).”
wrist flexion in a radial direction and the ulnar devia-
tion will not be possible. The finger flexors can also Procedure for Testing Grades P (2), T (1), and 0
assist wrist flexion, but the motion will be preceded by 1. Position: S seated or supine, with the forearm and
flexion of the fingers.°'*!° wrist in midposition and resting on the ulnar border
on the supporting surface. MP joints are extended
‘ and IP joints are flexed.”’''° E sits next to S on the side
Motion bei
eing tested.
Metacarpophalangeal (MP) flexion with interphalangeal 2. Stabilize: The wrist and palm of the hand.
(IP) extension. Qo . Palpate: As described for the previous test.

Muscles!* Innervation
9,10 4. Observe: S flex the MP joints and extend the IP joints
Lumbricals 1 and 2 Median nerve, C8,T1
simultaneously (Fig. 22-22, C).
Lumbricals 3 and 4 Ulnar nerve, C8,T1 5. Grade: According to standard definitions of muscle
Dorsal interossei grades.
Palmar interossei Substitutions: Flexor digitorum profundus and su-
perficialis may substitute for weak or absent lum-
Procedure for Testing Grades N (5) to F (3) bricals.'° In this case, MP flexion will be preceded by
1. Position: S seated, with forearm in supination, flexion of the distal and proximal interphalangeal
wrist at neutral, resting on the supporting surface.® joints.’*”*°

FIG. 22-22
Metacarpophalangeal flexion with interphalangeal extension. A, Palpate and observe. B, Resist.
C, Gravity-decreased position.
 Muscle Strength 341

Motion flexion with tendon action can produce MP exten-

sion. 6,7,10,12,15
MP extension.

Muscles” !° Innervation”’”” Motion

Extensor digitorum communis (EDC) Radial nerve, C7,8
Extensor indicis PIP flexion, 2nd through 5th fingers.
Extensor digiti minimi (EDM)
9/11 °
Muscles Innervation®”’”
Procedure for Testing Grades N (5) to F (3) Flexor digitorum superficialis (FDS) Median nerve, C7,8,T1
1. Position: S seated, with the forearm pronated and the
wrist in the neutral position, MP and IP joints Procedure for Testing Grades N (5) to F (3)
relaxed in partial flexion.”””’'° E sits opposite or next 1. Position: S seated, with the forearm supinated, wrist
to S on the side to be tested. at neutral, fingers extended, and hand and forearm
. Stabilize: The wrist and metacarpals slightly above resting on the dorsal surface.°”’ E sits opposite or
the supporting surface?" next to S on the side being tested.
. Palpate: The EDC tendons where they course over the . Stabilize: The MP joint and proximal phalanx of the
dorsum of the hand.°’” In some individuals, the finger being tested. (Fig. 22-24, A)°”""' If it is diffi-
EDM tendon can be palpated or visualized just cult for S to isolate PIP flexion, hold all of the fingers
lateral to the EDC tendon to the 5th finger. The ex- not being tested in MP hyperextension and PIP ex-
tensor indicis tendon can be palpated or visualized tension. This maneuver inactivates the flexor digito-
just medial to the EDC tendon to the first finger.° rum profundus so that S cannot flex the distal joint
. Observe: S extend the MP joints, but maintaining the (Fig. 22-24, B).”°'°'° Most individuals cannot
IP joints in some flexion (Fig. 22-23, A).°® perform isolated action of the PIP joint of the 5th
. Resist: Each finger individually on the dorsum of finger, even with this assistance.'*
the Ppproximal phalanx toward MP flexion (Fig.
8 . Palpate: The FDS tendon on the volar surface of
=) 23,B).?™ the proximal phalanx.° A stabilizing finger may
be used to palpate in this instance.'* The tendon
Procedure for Testing Grades P (2), T (1), and 0 supplying the 4th finger may be palpated over
1 Position: The same as described for the previous test, the volar aspect of the wrist between the flexor
except that S’s forearm is in midposition and the hand carpi ulnaris and the palmaris longus tendons, if
and forearm are supported on the ulnar border.”’” desired.*”°
. Stabilize: The same as described for the previous test. . Observe: S flex the PIP joint while maintaining DIP
Qo . Palpate: The same as described for the previous test. extension (Fig. 22-24, A).
. Observe: S extend the MP joints while keeping the IP . Resist: With one finger at the volar aspect of the
joints somewhat flexed (Fig. 22-23, C). middle phalanx toward extension.®”’" If E uses the
. Grade: According to standard definitions of muscle index finger to apply resistance, the middle finger
grades. may be used to move the DIP joint to and fro to
Substitutions: With the wrist stabilized, no substitu- verify that the flexor digitorum profundus (FDP) is
tions are possible. When the wrist is not stabilized, wrist not substituting (Fig. 22-24, C).

Cc

FIG. 22-23
Metacarpophalangeal extension. A, Palpate and observe. B, Resist. C, Gravity-decreased position.
342 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

FIG. 22-24
Proximal interphalangeal flexion.A, Palpate and observe. B, Position to assist with isolation of prox-
imal interphalangeal joint flexion. C, Resist. Therapist checks for substitution by flexor digitorum
profundus. D, Gravity-decreased position.

Procedure for Testing Grades P (2), T (1), and 0 aos ainiyfor Testing Grades N (5) to F (3)
i; Position: S seated, with the forearm in midposition and . Position: S seated, with the forearm Sapien the
the wrist at neutral, resting on the ulnar border.'”’’” E wrist at neutral, and the fingers extended.’° E sits op-
sits opposite or next to S on the side to be tested. posite or next to S on the side being tested.”
. Stabilize: The MP joint and proximal phalanx of the . Stabilize: The wrist at neutral and the PIP joint and
finger.”" If stabilization during the motion is diffi- middle phalanx of the finger being tested.*'°
cult in this position, the forearm may be returned to . Palpate: Use the finger stabilizing the middle phalanx
full supination, because the effect of gravity on the to simultaneously palpate the FDP tendon over the
fingers is not significant. volar surface of the middle phalanx.®?’!?
. Palpate and observe: The same as described for the pre- . Observe: S flex the DIP joint (Fig. 22-25, A).
vious test, except that the movement is performed in . Resist: With one finger at the volar aspect of the distal
the gravity-decreased position (Fig. 22-24, D). phalanx toward extension (Fig. 22-25, B).°7"™
. Grade: According to standard definitions of muscle
grades. If the test for grades poor and below is done Procedure for Testing Grades P (2), T (1), and 0
with the forearm in full supination, partial ROM 1 Position: S seated, with the forearm in midposition
against gravity may be graded poor.” and with the wrist at neutral, resting on the ulnar
Substitutions: The FDP may substitute for the FDS. border.'”'° S may be positioned with the forearm
DIP flexion will precede PIP flexion.”'°'*!° Tendon supinated, if necessary.
action of the long finger flexors accompanies wrist ex- . Stabilize: The same as described for the previous test.
tension and can produce an apparent flexion of the . Palpate: The same as described for the previous test.
fingers through partial ROM.'?'*!? . Observe: S flex the DIP joint (Fig. 22-25, C).
B&B
MM
WN . Grade: According to standard definitions of muscle
grades, except that if the test for grades poor and below
Motion
was done with the forearm in full supination, move-
DIP flexion, 2nd through 5th fingers. ment through partial ROM may be graded poor.”
Muscles 9,10
Innervation?” Substitutions: None possible during the testing proce-
Flexor digitorum profundus Median and ulnar nerves, dure if the wrist is well stabilized because the FDP is the
(FDP) Corl only muscle that can act to flex the DIP joint when it
 Muscle Strength

FIG. 22-25
Distal interphalangeal flexion. A, Palpate and observe. B, Resist. C, Gravity-decreased position.

FIG. 22-26
Finger abduction. A, Palpate and observe. B, Resist.

is isolated. During normal hand function, however, 5. Resist: The first dorsal interosseus by applying pres-
wrist extension with tendon action of the finger flexors sure on the radial side of the proximal phalanx of
can produce partial flexion of the DIP joints. 10,327,135 the 2nd finger in an ulnar direction (Fig. 22-26, B);
the 2nd dorsal interosseus on the radial side of the
proximal phalanx of the middle finger in an ulnar
Motion
direction; the 3rd dorsal interosseus on the ulnar
Finger abduction. side of the proximal phalanx of the middle finger
Muscles”’° Innervation?” in a radial direction; the 4th dorsal interosseus on
Dorsal interossei Ulnar nerve, C8,T1 the ulnar side of the proximal phalanx of the ring
Abductor digiti minimi finger in a radial direction; the abductor digiti
minimi on the ulnar side of the proximal phalanx
Procedure for Testing Grades N (5) to F (3) of the little finger in a radial direction.*" An alter-
E. Position: S seated or supine, with the forearm native mode of resistance is to flick each finger
pronated, wrist at neutral, and fingers extended and toward adduction. If the finger rebounds, the grade
adducted. E is seated opposite or next to S on the is N (5).°
side to be tested.”’”°
. Stabilize: The wrist and metacarpals slightly above Procedure for Testing Grades P (2), T (1), and 0
the supporting surface. The tests for these muscle grades are the same as de-
. Palpate: The 1st dorsal interosseous muscle on the scribed for the previous test.
tadial side of the second metacarpal or of the ab- il Grade: Because the test motions were not performed
ductor digiti minimi on the ulnar border of the against gravity, some judgment of the examiner must
5th metacarpal. The remaining interossei are not be used in grading. For example, partial ROM in
palpable.°””” gravity-decreased position may be graded poor and
. Observe: S spread the fingers; abduction of the little full ROM graded fair.”’"°
finger, the ring finger toward the little finger, the Substitutions: EDC can assist weak or absent dorsal
middle finger toward the ring finger, and the index interossei, but abduction will be accompanied by MP
finger toward the thumb. (Fig. 22-26, A). '° extension.
6,12,15
344 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

Motion
Procedure for Testing Grades N (5) to F (3)
Finger adduction. 1; Position: S seated or supine, forearm in midposition,
wrist at neutral, and hand and forearm resting on the
Muscles eau Innervation””” ulnar border.*”'° The thumb is flexed into the palm
Palmar interossei, 1, 2, 3 Ulnar nerve, C8,T1 at the MP joint, and the IP joint is extended but
relaxed. E sits opposite or next to S on the side to be
Procedure for Testing Grades N (5) to F (3) tested.
15 Position: S seated, with forearm pronated, wrist in No . Stabilize: The wrist and the thumb metacarpal.°
neutral, and fingers extended and abducted.”’° . Palpate: The EPB tendon on the dorsoradial aspect of
2, Stabilize: The wrist and metacarpals slightly above the base of the 1st metacarpal. It lies just medial to
the supporting surface.° the abductor pollicis longus tendon on the radial
Uo . Palpate: Not palpable.® side of the anatomical snuffbox, which is the hollow
. Observe: S adduct the 1st, 4th, and 5th fingers toward space created between the EPL and EPB tendons
the middle finger (Fig. 22-27, A). when the thumb is fully extended and radially ab-
. Resist: The index finger at the proximal phalanx by ducted.*’°”
pulling it in a radial direction, the ring finger at the . Observe: S extend the MP joint. The IP joint remains
proximal phalanx in an ulnar direction, and the little relaxed (Fig. 22-28, A). It is difficult for many indi-
finger likewise (Fig. 22-27, B).°"" These muscles are viduals to isolate this motion.
very small, and resistance will have to be modified . Resist: On the dorsal surface of the proximal phalanx
to accommodate their comparatively limited power. toward MP flexion (Fig. 22-28, B).°?""
Fingers can also be grasped at the distal phalanx
and flicked in the direction of abduction. If the Procedure for Testing Grades (P), (T), and (0)
finger snaps back to the adducted position, the 1 Position and stabilize: Positioning and stabilizing are
grade is N (5).° the same as described for the previous test, except
that the forearm is fully pronated and resting on the
Procedure for Testing Grades P (2), T (1), and 0 volar surface.'” E may stabilize the 1st metacarpal,
The test for these muscle grades is the same as described holding the hand slightly above the supporting
for the previous test. The examiner's judgment must be surface. The test may also be performed in the same
used in determining the degree of weakness. Achieve- manner as for grades normal to fair, with modified
ment of full ROM may be graded fair and partial ROM grading.”
graded poor. 9,10 . Palpate and observe: The same as described for the pre-
Substitutions: FDP and FDS can substitute for weak vious test. MP extension is performed in a plane par-
palmar interossei, but IP flexion will occur with finger allel to the supporting surface (Fig. 22-28, C).
10,12,15
adduction. . Grade: According to standard definitions of muscle
grades. If midposition of the forearm was used,
partial ROM is graded poor and full ROM is
Motion
graded fair.”’'°
Thumb MP extension. Substitutions: Extensor pollicis longus may substitute
Muscles
9-11
Innervation”" for extensor pollicis brevis. IP extension will precede MP
6,77,10, 12,05
Extensor pollicis brevis (EPB) Radial nerve, C6-8 extension.

FIG. 22-27
Finger adduction. A, Therapist observes movement of fingers into adduction. Palpation of these
muscles is not possible. B, Resist.
 Muscle Strength 345

Motion
so that S‘s hand is held slightly above the supporting
Thumb IP extension. surface. The test may also be performed in the same
position as for grades normal to fair with modifica-
Muscles?" Innervation” " tion in grading.
Extensor pollicis longus (EPL) Radial nerve, C6-8 2. Palpate and observe: The same as described for the
previous test. IP extension is performed in the plane
Procedure for Testing Grades N (5) to F (3) of the palm, parallel to the supporting surface (Fig.
d: Position: S seated or supine, forearm in midposition, 9499,'G):
wrist at neutral, and hand and forearm resting on the 3. Grade: According to standard definitions of muscle
ulnarborder.°” ° The thumb is adducted, the MP joint grades. If the test was performed with the forearm in
is extended or slightly flexed, and the IP is flexed.° E midposition, partial ROM is graded P (2).°
sits opposite or next to S on the side being tested. Substitutions: A quick contraction of the flexor pollicis
. Stabilize: The wrist at neutral, 1st metacarpal, and the longus followed by rapid release will cause the IP joint
_awry
proximal phalanx of the thumb.° to rebound into extension.° IP flexion will precede IP
. Palpate: The EPL tendon on the dorsal surface of the extension.”'* The abductor pollicis brevis, flexor polli-
hand medial to the EPB tendon, between the head of cis brevis, the oblique fibers of the adductor pollicis,
the 1st metacarpal and the base of the 2nd on the and the Ist palmar interosseus can extend the IP joint
ulnar side of the anatomical snuff box.*°” because of their insertions into the extensor expansion
os Observe: § extend the IP joint (Fig. 22-29, A).
. of the thumb."""°
. Resist: On the dorsal surface of the distal phalanx,
, down toward IP flexion (Fig. 22-29, B).°"""
Motion
Procedure for Testing Grades P (2), T (1), and 0 Thumb MP flexion.
if Position and stabilize: Positioning and stabilizing are
9- - re ONT
the same as described for the previous test, except Muscles?” Innervation”
that the forearm is fully pronated.’” E may stabilize Flexor pollicis brevis (FPB) Median and ulnar nerves, C8, T1

FIG. 22-28
Thumb metacarpophalangeal extension. A, Palpate and observe. B, Resist. C, Gravity-decreased
position.

FIG. 22-29
Thumb IP extension.
A, Palpate and observe. B, Resist. C, Gravity-decreased position.
346 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

Procedure for Testing Grades N (5) to F (3) 2. Grade: Full ROM is graded fair; partial ROM is graded
1. Position: S seated or supine, the forearm supinated, poor. 9,10
the wrist in the neutral position, and the thumb in Substitutions: FPL can substitute for FPB. In this case,
extension and adduction.*” E is seated next to or isolated MP flexion will not be possible and MP flexion
opposite S$.” will be preceded by IP flexion.”""°!*"!°
2. Stabilize: The 1st metacarpal and the wrist."
3. Palpate: Over the middle of the palmar surface of the
Motion
thenar eminence just medial to the abductor pollicis
brevis muscle.®° The hand that is used to stabilize Thumb IP flexion.
may also be used for palpation.
Muscles 6,9,1
pete
.
Innervation”
:
4. Observe: S flex the MP joint while maintaining exten-
sion of the IP joint (Fig. 22-30, A).° It may not be Flexor pollicis longus (FPL) Median nerve, C7-T1

possible for some individuals to isolate flexion to the

MP joint. In this instance, both MP and IP flexion pala for Testing Grades N (5) to F (3)
may be tested together as a gross test for thumb . Position: S seated, with the forearm fully supinated,
flexion strength, and graded according to the exam- wrist in neutral position, and thumb extended and
iner’s judgment. adducted.”’”” E is seated next to or opposite S.
5. Resist! On the palmar surface of the first phalanx 2. Stabilize: The wrist, thumb metacarpal, and the prox-
toward MP extension (Fig. 22-30, B).°7""" imal phalanx of the thumb in extension.°7”""
3. Palpate: The FPL tendon on the palmar surface of the
Procedure for Testing Grades P (2), T (1), and (0) proximal phalanx.® In this instance the palpating
Positioning, stabilizing, and palpating are the same as finger may be the same one used for stabilizing the
described for the previous test. proximal phalanx.
1. Observe: S flex the MP joint so that the thumb moves 4. Observe: S flex the IP joint in the plane of the palm
over the palm of the hand. (Fig-322-31nA) ee)

FIG. 22-30
Thumb metacarpophalangeal flexion. A, Palpate and observe. B, Resist.

FIG. 22-31
Thumb interphalangeal flexion.A, Palpate and observe. B, Resist.
 Muscle Strength 347

5. Resist: On the palmar surface of the distal phalanx, 2. Stabilize: The wrist and metacarpals.
toward IP extension (Fig. 22-31, B).°?"" 3. Palpate: The APB muscle on the lateral aspect of the
thenar eminence.
Procedure for Testing Grades P (2), T (1), and 0 4. Observe: S move the thumb away from the palm in a
The test for these muscle grades is the same as described plane at right angles to the palm of the hand and
for the previous test. The examiner's judgment must be parallel to the supporting surface (Fig. 22-32, C).
used in determining the degree of weakness. Achieve- 5. Grade: According to standard definitions of muscle
ment of full ROM may be graded fair and partial ROM grades.
graded poor.” Substitutions: APL can substitute for APB. Abduction
Substitutions: A quick contraction and release of the will take place more in the plane of the palm, however,
EPL may cause an apparent flexion of the IP joint. E rather than perpendicular to it.'°'*'°
should observe for IP extension preceding IP
flexion.0771% 12/15
Motion
Thumb radial abduction.
Motion
Thumb palmar abduction. Muscles
10,11
Innervation
10,11

Abductor pollicis longus (APL) Radial nerve, C6-8

10,11 10,11
Muscles Innervation
Abductor pollicis brevis (APB) Median nerve, C8,T1 Procedure for Testing Grades N (5) to F (3)
1. Position: S seated or supine, forearm in neutral rota-
Procedure for Testing Grades Fair (F) tion, wrist at neutral, thumb adducted and slightly
to Normal (N) flexed across the palm. Hand and forearm are resting
1. Position: S seated or supine, forearm in supination, on the ulnar border." E sits opposite or next to S on
wrist at neutral, thumb extended and adducted, and the side being tested.
carpometacarpal (CMC) joint rotated so that the 2. Stabilize: The wrist and metacarpals of the fingers.”’””
thumb is resting in a plane perpendicular to the 3. Palpate: The APL tendon on the lateral aspect of the
palm. E sits opposite or next to S on the side to be base of the first metacarpal. It is the tendon immedi-
tested." ately lateral (radial) to the EPB tendon.*°?
2. Stabilize: The metacarpals and wrist. 4. Observe: S move the thumb out of the palm of the
3. Palpate: The APB muscle on the lateral aspect of the hand, abducting away from the index finger at an
thenar eminence, lateral to the flexor pollicis brevis angle of about 45° (Fig. 22-33, A). °
muscle.” 5. Resist: At the lateral aspect of the thumb metacarpal
4. Observe: S raise the thumb away from the palm in a toward adduction (Fig. 22-33, B).°”""
plane perpendicular to the palm (Fig. 22-32, A).°"
5. Resist: At the lateral aspect of the proximal phalanx, Procedure for Testing Grades P (2), T (1), and 0
downward toward adduction (Fig. 22-32, B).°"" 1. Position: As described for the previous test, except
that the forearm is in supination.”
Procedure for Testing Grades P (2), T (1), and 0 2. Stabilize: The wrist and palm of the hand.
1. Position: As described for the previous test, except Qo . Palpate: The same as described for the previous test.

that the forearm and hand are supported on the 4. Observe: S move the thumb out away from the palm
ulnar border.'”’” of the hand in the plane of the palm (Fig. 22-33, C).

FIG, 22-32
Thumb palmar abduction. A, Palpate and observe. B, Resist. C, Gravity-decreased position.
348 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS
rf

5. Grade: According to standard definitions of muscle 2. Stabilize: The wrist and metacarpals by grasping the
grades. hand around the ulnar side and supporting it slightly
Substitutions: APB can substitute for APL. Abduction above the resting surface.”’’°
will not take place in the plane of the palm, but rather 3. Palpate: AP on the palmar side of the thumb web
in a more ulnar direction.'*'” EPB can substitute for space:*??
APL. The movement will be more toward the dorsal 4. Observe: S adduct the thumb to touch the palm (Fig.
surface of the forearm."° 22-34, A).”’'° (The palm is turned up in the illustra-
tion to show the palpation point.)
5. Resist: By grasping the proximal phalanx of the
ae : thumb near the metacarpal head and pulling down-
Thumb adduction. ward, toward abduction (Fig. 22-34, B).”
Muscles”"" Innervation”"
Adductor pollicis (AP) Ulnar nerve, C8,T1 Procedure fe
or Testing Grades P (2) ,T (1) , and 0
1. Position: The same as described for the previous
Procedure for Testing Grades N (5) to F (3) test, except that the forearm is in midposition and
1. Position: S seated or supine, forearm pronated, wrist the forearm and hand are resting on the ulnar
at neutral, thumb is relaxed and in palmar abduc- border.!°
tion.” E is sitting opposite or next to S on the 2. Stabilize: Over the wrist and palm of the hand.
side to be tested. 3. Palpate: The same as described for the previous test.

A B Cc

FIG. 22-33
Radial abduction. A, Palpate and observe. B, Resist. C, Gravity-decreased position.

FIG. 22-34
Thumb adduction.
A, Palpate and observe. B, Resist. C, Gravity-decreased position.
 Muscle Strength 349

FIG. 22-35
Thumb opposition. A, Palpate and observe. B, Resist.

4. Observe: S adduct the thumb to touch the radial side Substitutions: APB will assist with opposition by
of the palm of the hand or the 2nd metacarpal (Fig. flexing and medially rotating the CMC joint, but the IP
BAC). joint will extend. The FPB will flex and medially rotate
5. Grade: According to standard definitions of muscle the CMC joint, but the thumb will not move away from
grades. the palm of the hand. The FPL will flex and slightly
Substitutions: FPL or EPL may assist weak or absent rotate the CMC joint, but the thumb will not move
AP. If one substitutes, adduction will be accompanied away from the palm and the IP joint will flex
by thumb flexion or extension preceding adduc- strongly.'*!° The DIP joints of the thumb and little
tion, 11215 finger may flex to meet, giving the appearance of full op-
position.”’”®

Motion
MANUAL MUSCLE TESTING OF THE
Opposition of the thumb to the 5th finger. LOWER EXTREMITY
9,10 9,10
Muscles Innervation
Motion
Opponens pollicis Median nerve, C8, T1
Opponens digiti minimi Ulnar nerve, C8, T1 Hip flexion

Procedure for Testing Grades N (5) to F (3) Muscles 4,7,9

Innervation*’*”
1. Position: S seated or supine, with forearm supinated, Psoas major Lumbar plexus, L1-3
wrist at neutral, thumb in palmar abduction, and 5th Iliacus Femoral nerve, L2,3
finger extended.®”’”’" E sits opposite or next to S on Rectus femoris Femoral nerve, L2-4
the side to be tested. Tensor fasciae latae Superior gluteal nerve, L4,5,S1
Sartorius Femoral nerve, L2-S1
2. Stabilize: The forearm and wrist.
Pectineus Femoral nerve, L2,3
3. Palpate: The opponens pollicis along the radial side
of the shaft of the first metacarpal, lateral to the APB;
the opponens digiti minimi on the shaft of the fifth Procedure for Testing Grades N (5) to F (3)
metacarpal.°””!? 1. Position: S seated, with knees flexed over the edge of
4. Observe: S oppose the thumb to touch the thumb pad the table and feet above the floor.'° E stands next to S
to the pad of the 5th finger, which flexes and rotates on the side being tested.’
toward the thumb (Fig. 22-35, A). °” 2. Stabilize: The pelvis at the iliac crest on the side being
5. Resist: At the distal ends of the 1st and 5th tested. S may hold onto the edge of the table or fold
metacarpals toward derotation of these bones and arms across chest.°”""!
flattening of the palm of the hand (Fig. 22-35, B).”’"° 3. Palpate: The psoas and iliacus are difficult to
palpate.°® The rectus femoris may be palpated on the
Procedure for Testing Grades P (2), T (1), and 0 middle anterior aspect of the thigh, just lateral to the
The procedure described for the previous test may be sartorius muscle.*’'*
used for these grades, if grading is modified to com- 4. Observe: S flex the hip so the femur rises above the
pensate for the movement of the parts against gravity. table surface (Fig. 22-36, A).
For example, movement through full ROM would be 5. Resist: Just proximal to the knee on the anterior
graded fair and through partial ROM would be graded surface of the thigh, down toward the table into hip
poor.” extension (Fig. 22-36, B).°”?""
350 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

FIG. 22-36
Hip flexion. A, Palpate and observe. B, Resist. C, Gravity-decreased position.

Muscles 6,10, 11
Innervation?”
Procedure for Testing Grades P (2), T (1), and 0
Gluteus maximus Inferior gluteal nerve, L5-S2
1. Position: S side-lying. E stands behind S, supporting Semitendinosus Sciatic nerve, L5-S2
the upper leg in neutral rotation and slight abduc- Semimembranosus
tion, with the knee extended.”’’° The lower leg (to be Biceps femoris (long head) Sciatic nerve, L5-S3
tested) is extended at the hip and knee.
2. Stabilize: The weight of the trunk may be adequate Procedure for Testing Grades N (5) to F (3)
stabilization, or E may stabilize the pelvis.” 1. Position: S lying prone, with the hip at neutral and
3. Palpate: The same as described for the previous test. the knee flexed to about 90°. This position is used to
4. Observe: S bring the lower leg up toward the trunk, isolate the gluteus maximus.*'? § may also be posi-
flexing the hip and knee (Fig. 22-36, C).’ tioned prone, with the knee extended.’ E stands
5. Grade: According to standard definitions of muscle next to S on the opposite side."’ Two pillows may be
grades. placed under the pelvis to flex the hips.°”
Substitutions: Observe for internal rotation, external 2. Stabilize: Over the iliac crest on the side being
rotation, and abduction accompanying the flexion as tested.”’”°
signs of substitution or muscle imbalance in this muscle 3. Palpate: The gluteus maximus on the middle poste-
group.””’'°" The hip flexors can substitute for one rior surface of the buttock.'*
another. If the iliacus and psoas major muscles are weak 4. Observe: S extend the hip while keeping the knee
or absent, hip flexion will be accompanied by other flexed to minimize action of the hamstring muscles
movements: abduction and external rotation (sarto- on the hip joint (Fig. 22-37, A).
rius), abduction and internal rotation (tensor fasciae 5. Resist: At the distal end of the posterior aspect of the
latae), and adduction (pectineus).”’'* If the anterior ab- thigh, downward, toward flexion (Fig. 22-37, B).>-"
dominal muscles do not stabilize the pelvis, it will flex
on the thighs; the hip flexors may hold against resist- Procedure for Testing Grades P (2), T (1), and 0
ance, but not at maximum ROM.” 1. Position: Side-lying. E stands in front of S, supporting
the upper leg in extension and slight abduction.” The
lower leg (to be tested) is flexed at the hip and knee.
Motion
2. Stabilize: The pelvis over the iliac crest.”
Hip extension. 3. Palpate: The same as described for the previous test.
~~

Muscle Strength 351

4. Observe: S extend the hip, bringing the lower leg 2. Stabilize: The pelvis over the iliac crest.?""
PE
Ge backward, while maintaining flexion of the knee 3. Palpate: The gluteus medius on the lateral aspect of
(Fig. 22-37, C). the ilium above the greater trochanter of the femur.*”
5. Grade: According to standard definitions of muscle 4. Observe: S abduct the hip, lifting the leg upward (Fig.
grades. 22-38, A).
Substitutions: Elevation of the pelvis and extension of 5. Resist: Just proximal to the knee in a downward di-
the lumbar spine can produce some hip extension. In rection, toward adduction (Fig. 22-38, B).°”"®
the supine position, gravity and eccentric contraction of
the hip flexors can return the flexed hip to extension.'* Procedure for Testing Grades P (2), T (1), and 0
Hip external rotation, abduction, or adduction may be 1. Position: S lying supine, with both legs extended and
used to substitute.’ in neutral rotation. E stands next to S on the opposite
side.’ E may use one hand to support at the ankle and
wry
slightly lift the test leg off the surface, being careful to
Motion offer no resistance or assistance to the movement.°
Hip abduction. 2. Stabilize: The pelvis at the iliac crest on the side to be
Muscles 6,9,10 Innervation?" tested and the opposite limb at the lateral aspect of
Gluteus medius Superior gluteal nerve, L4-S1 the calf.
Gluteus minimus 3. Palpate: Use the hand stabilizing over the pelvis to
palpate the gluteus medius muscle simultaneously
Procedure for Testing Grades N (5) to F (3) by adjusting the position of the hand so that the
1. Position: S side lying, upper leg (to be tested) has the fingers are touching the lateral aspect of the ilium,
knee extended and hip extended slightly beyond the above the greater trochanter, as described for the pre-
neutral position and slight forward rotation of the vious test.
pelvis’; the lower leg is flexed at the hip and knee to 4. Observe: S abduct the hip, moving the free leg side-
provide a wide base of support.’ E stands behind or ward, while maintaining neutral rotation during this
in front of $.°7°"" movement (Fig. 22-38, C).?

~~

FIG. 22-37
Hip extension. A, Palpate and observe. B, Resist. C, Gravity-decreased position.

FIG. 22-38
Hip abduction. A, Palpate and observe. B, Resist. C, Gravity-decreased position.
352 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

5. Grade: According to standard definitions of muscle Procedure for Testing Grades P (2), T (1), and 0
grades. i: Position: S supine; the limb to be tested is abducted to
Substitutions: Lateral muscles of the trunk may con- 45°. E stands next to S on the opposite side.
tract to bring the pelvis toward the thorax, effecting 2. Stabilize: Over the iliac crest on the side to be
partial abduction at the hip.? If the hip is extern- tested.”
ally rotated, the hip flexors may assist in abduc- 3. Palpate: The same as described for the previous test.
fiom 4. Observe: S adduct the leg toward midline (Fig.
22-39, C).
: 5. Grade: According to standard definitions of muscle
Motion padee
Hip adduction. Substitutions: Hip flexors may substitute for adduc-
4,9,10 4,9,10
tors. S will internally rotate the hip and tilt the pelvis
Muscles Innervation
backward. Hamstrings may be used to substitute for ad-
Adductor magnus Obturator L2-4
duction. S will externally rotate the hip and tip the
Adductor brevis
Adductor longus
pelvis forward. '”"'*
Gracilis
Pectineus Femoral L2-4
Motion
Procedure for Testing Grades N (5) to F (3) Hip external rotation.
1. Position: S side lying, with the test limb lowermost; E
supports the uppermost limb in 25° of abduction Muscles?” Innervation” °
and stands behind S.'° This test may also be done Quadratus femoris Sacral plexus, L5, $1
Piriformis Sacral plexus, $1,2
with S in the supine position.°°
Obturator internus Sacral plexus, L5-S2
. Stabilize: Support S’s upper leg in partial abduction Obturator externus Obturator nerve, L3,4
while S holds on to the supporting surface for sta- Gemellus superior Sacral plexus, L5-S2
bility?"
Gemellus inferior Sacral plexus, L4-S1
. Palpate: Any of the adductor muscles as follows: ad-
ductor magnus at the middle of the medial surface of Procedure for Testing Grades N (5) to F (3)
the thigh; adductor longus at the medial aspect of 1 Position: S seated, with knees flexed over the edge of
the groin; gracilis on the medial aspect of the poste- the table. A small pad or folded towel is placed under
rior surface of the knee, just anterior to the semi- the knee on the side to be tested. E stands in front of
tendinosus tendon.'* S toward the side to be tested.°?""
. Observe: S adduct the hip by raising the lower leg . Stabilize: On the lateral aspect of the knee on the side
from the table until it meets the upper leg. Observe
that there is no rotation, flexion, or extension of the
to be tested. § may grasp the edge of the table to sta-
bilize the trunk and pelvis.°”""
hip or pelvic tilting (Fig. 22-39, A).'°" . Palpate: These deep muscles are difficult or impossi-
. Resist: Over the medial aspect of the leg, just proximal ble to palpate.° Action of the external rotators may
to the knee, downward toward abduction or outward be detected by palpating deeply posterior to the
if tested in supine position (Fig. 22-39, B).°”"" greater trochanter of the femur.”

FIG. 22-39
Hip adduction. A, Palpate and observe. B, Resist. C, Gravity-decreased position.
 Muscle Strength
Motion
. Observe: S rotate the thigh outwardly, moving the
foot medially (Fig. 22-40, A). Hip internal rotation.
. Resist: At the medial aspect of the lower leg, just prox- Muscles 4,9,11 Innervation”’”
imal to the ankle in a lateral direction, toward inter- Gluteus minimus Superior gluteal nerve, L4-S1
nal rotation.”””"" .Resistance should be given care- Gluteus medius
fully and gradually, because the use of the long lever Tensor fasciae latae
arm can Cause joint injury if sudden forceful resist-
ance is given. Subjects with knee instability should Procedure for Testing Grades N (5) to F (3)
be tested in supine position (Fig. 22-40, B).”” . Position: S seated on a table, with the knees flexed
over the edge and with a small pad placed under the
oor for Testing Grades P (2), T (1), and 0 knee. E stands in front of or next to S on the side to
. Position: S lying supine, with hips and knees ex- be tested.®”° (E is shown on the opposite side in the
tended; the hip to be tested is internally rotated. E is illustration so that the palpation and stabilization
standing next to S on the opposite side.”” will be apparent.)
i) . Stabilize: The pelvis on the side to be tested. . Stabilize: At the medial aspect of the knee. S may
. Palpate: Action of the external rotators may be de- grasp the edge of the table to stabilize the pelvis and
trunk.°” ll
tected by palpating deeply posterior to the greater
trochanter of the femur. . Palpate: The gluteus medius between the iliac crest
. Observe: S externally rotate the thigh (roll laterally). and the greater trochanter.’
Gravity may assist this motion once S has passed the . Observe: S internally rotate the thigh, moving the foot
neutral position. E may use one hand to palpate and laterally. E should observe that S does not lift the
the other to offer slight resistance during the second pelvis on the side being tested (Fig. 22-41, A).°”®
half of the movement to compensate for the assis- . Resist: At the lateral aspect of the lower leg, pushing
tance of gravity. If the range can be completed with the leg medially and, therefore, the thigh toward ex-
slight resistance, a grade of poor can be given (Fig. ternal rotation. The resistance is stressful to the knee
22240;-C)° joint. Subjects with knee instability should be tested
. Grade: According to standard definitions of muscle in the supine position described for the next test (Fig.
grades for fair to normal muscles. Muscles are graded 22:41 Be oO
poor if ROM in the gravity-decreased position can be
achieved against slight resistance during the second Procedure for Testing Grades P (2), T (1), and 0
half of the ROM. A grade of trace can be assigned if ‘¥ Position: S supine, with hips and knees extended; the
contraction of external rotators can be detected by hip to be tested in external rotation. E stands on the
the deep palpation, described for the previous test, opposite side.”
- when the payanent is attempted in the gravity- . Stabilize: Over the iliac crest on the side to be tested.”
decreased position.” . Palpate: The same as described for the previous
Substitutions: Gluteus maximus may substitute for the test.
deep external rotators when the hip is in extension. Sar- . Observe: S rotate the thigh inwardly or medially. As in
torius may substitute, but external rotation will be ac- external rotation, gravity may assist the motion once
companied by hip flexion, abduction, and knee the neutral position is passed, but less than in the
flexion. 7, hid. test for external rotation (Fig. 22-41, C).

FIG. 22-40
Hip external rotation.A, Palpate and observe. B, Resist. C, Gravity-decreased position.
 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

FIG. 22-41
Hip internal rotation. A, Palpate and observe. B, Resist. C, Gravity-decreased position.

FIG. 22-42
Knee flexion. A, Palpate and observe. B, Resist. C, Gravity-decreased position.

5. Grade: According to standard definitions of muscle 4. Observe: § flex the knee to slightly less than 90° (Fig.
grades. 2249 Ayere
Substitutions: Hip adduction and knee flexion; trunk 5. Resist: Over the posterior aspect of the ankle down-
medial rotation may also cause some internal rotation ward toward knee extension.°”” Note that not as
of the hip.””!” much resistance can be applied to knee flexion in
this position as when tested in sitting position with
the hip flexed (Fig. 22-42, B)."
Motion
Knee flexion. Procedure for Testing Grades P (2), T (1), and 0
4,9,11 4,9,10 1. Position: S side lying, with knees and hips extended
Muscles Innervation
and in neutral rotation. E stands next to S and sup-
Biceps femoris Sciatic nerve, L5-S2
Semitendinosus
ports the upper leg in slight abduction to allow
Semimembranosus testing of the lower leg.”
(Hamstrings) 2. Stabilize: Over the medial aspect of the thigh.
3. Palpate: The semitendinosus as described for the pre-
Procedure for Testing Grades N (5) to F (3) vious test.
1. Position: S lying prone, with knees and hips in exten- 4. Observe: S flex the knee of the lower leg (Fig.
sion and neutral rotation with the foot in midline 20 AI PCK
and toes hanging over the end of the table.”’”?"" E 5. Grade: According to standard definitions of muscle
stands next to S on the opposite side, or the same grades.
side, toward the lower end of the supporting surface.” Substitutions: The sartorius may substitute or assist
2. Stabilize: Firmly over the posterior aspect of the thigh, the hamstrings, but hip flexion and external rotation
above the tendinous insertion ofthe knee flexors.°” will occur simultaneously.”'!? The gracilis may sub-
3. Palpate: For the biceps femoris tendon proximal to stitute, causing hip adduction with knee flexion."
the knee joint, on the lateral aspect of the popliteal The gastrocnemius may-assist or substitute if strong
fossa; or for the semitendinosus tendon proximal to plantar flexion of the ankle occurs during knee
the knee joint, medial to the popliteal fossa.*’°'? flexion.”’”°
 Muscle Strength 355

Motion
. Stabilize: The upper leg in slight abduction with one
Knee extension. hand, and with the other over the anterior aspect of
the thigh on the leg to be tested.”
Muscles’ Innervation”
. Palpate: Any of the muscles, as described for previous
The quadriceps group:
test, with the same hand used to stabilize S's thigh.
Rectus femoris Femoral nerve, L2-4
Vastus intermedius Then ask S to straighten the leg, extending the knee.
Vastus medialis Observe for hip movements as signs of substitution
Vastus lateralis (Fig. 22-43, C).
. Grade: According to standard definitions of muscle
peer? for Testing Grades N (5) to F (3) grades.
. Position: S sitting, with knees flexed over the edge of Substitutions: Tensor fasciae latae may substitute for
the table and feet suspended off the floor. S may lean or assist weak quadriceps. In this case hip internal rota-
backward slightly to release tension on the ham- tion will accompany knee extension. 6,9,11
strings and grasp the edge of the table for stabil-
ity.°’'° E stands next to S on the side to be tested.°”
Motion
. Stabilize: The thigh by holding hand firmly over it, or
place one hand under S's knee to cushion it from Ankle plantar flexion.
the edge of the table. S may grasp the edge of the Muscles ares Innervation”
table" Gastrocnemius Tibial nerve, $1,2
. Palpate: Any of the muscles in the quadriceps femoris Soleus Tibial nerve, L5-S2
group as follows: the rectus femoris on the anterior
aspect of the midthigh; the vastus medialis on the Procedure for Testing Grades N (5) to F (3)
medial aspect of the distal thigh; the vastus lateralis 1 Position: S lying prone, with the hips and knees ex-
on the lateral aspect of the midthigh. The vastus in- tended and the feet projecting beyond the edge of
termedius cannot be palpated.®'* the table. E stands at the lower end of the table,
. Observe: S extend the knee to slightly less than full facing S's feet.°7"1""
ROM. Observe for hip movements as evidence of Stabilize: The weight of the leg is usually adequate
substitutions (Fig. 22-43, A). stabilization. E may stabilize the leg proximal to the
. Resist: On the anterior surface of the leg, just above ankle.°
the ankle, with downward pressure toward knee . Palpate: The gastrocnemius on the posterior aspect of
flexion.°”"" § should not be allowed to lock the the calf of the leg, or the soleus, slightly lateral to and
knee joint at the end of the ROM when full exten- beneath the lateral head of the gastrocnemius.'*The
sion is achieved.””” Maintenance of a slight amount gastrocnemius tendon above the calcaneus may also
of knee flexion will prevent this condition. Resis- be palpated.”
tance to a locked knee can cause joint injury (Fig. . Observe: S plantar flex the ankle. Observe for flexion
22-43, B).° of the toes and forefoot before movement of the heel
as evidence of substitutions (Fig. 22-44, A).°""’'*
Procedure for Testing Grades P (2), T (1), and 0 . Resist: On the posterior aspect of the calcaneus as if
1. Position: S side lying on the side to be tested. The pulling downward and on the forefoot as if pushing
lower leg is positioned with the hip extended and the forward.'° If there is considerable weakness, pressure
knee flexed to 90°. E stands behind S. to the calcaneus may be sufficient (Fig. 22-44, B)."

FIG. 22-43
Knee extension. A, Palpate and observe. B, Resist. C, Gravity-decreased position.
 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

FIG. 22-44
Ankle plantar flexion. A, Palpate and observe. B, Resist. C, Gravity-decreased position.

Procedure for Testing Grades P(2), T (1), and 0 4. Observe: S dorsiflex and invert the foot, keeping the
1. Position: S lying on the side to be tested; hip and knee toes relaxed.'” Watch for extension of the great toe
of the lower limb are extended and the ankle is in preceding the ankle motion as a sign of muscle sub-
midposition. The upper limb may be flexed at the stitution (Fig. 22-45, A).?’°
knee to keep it out of the way. E stands at the lower 5. Resist: On the medial dorsal aspect of the foot, toward
end of the table.°” plantar flexion and eversion (Fig. 22-45, B).°”"
2. Stabilize: Over the posterior aspect of the calf.”
Uo . Palpate: As described for the previous test. Procedure for Testing Grades P (2), T (1), and 0
4. Observe: S pull the heel upward, pointing the toes The same position and procedure described for the pre-
down. Observe for toe flexion, inversion, or ever- vious test may be used, with modified grading. The test
sion of the foot as evidence of substitutions (Fig. may also be performed with S in side-lying or supine
22-44, C). position.”
5. Grade: According to standard definitions of muscle 1. Grade: If the against-gravity position is used in the pro-
grades. cedure for grades P to 0, clinical judgment of the exam-
Substitutions: The flexor digitorum longus and flexor iner must be used to determine muscle grades. Partial
hallucis longus can substitute for plantar flexors, pro- ROM against gravity can be graded poor.” If the test is
ducing toe flexion and flexion of the forefoot, with in- performed in the supine position for these grades,
complete movement of the calcaneus. Substitution by standard definitions of muscle grades may be used.”
the peroneus longus and brevis will cause foot eversion, Substitutions: The extensor hallucis longus and exten-
and substitution by the tibialis posterior will cause foot sor digitorum longus may assist or substitute. Move-
inversion. Substitution by all three will effect plantar ment will be preceded by extension of the great toe or
flexion of the forefoot, with limited movement of the by all of the toes.”!*
calcaneuss "+
Motion
Motion
Foot inversion.
Ankle dorsiflexion with inversion. Muscles?” Innervation’®
Tibialis posterior Tibial nerve, L5, S1
6,9,10 6,9,11
Muscles Innervation
Tibialis anterior Peroneal nerve, L4-S1 Procedure for Testing Grades N (5) to F (3)
1. Position: S lying on the side to be tested, with the hip
Procedure for Testing Grades N (5) to F (3) in neutral rotation, the knee slightly flexed, and the
1. Position: S seated, with the legs, flexed at the knees, foot and ankle in a neutral position.° The upper leg
over the edge of the table. E sits in front of S, slightly may be flexed at the knee to keep it out of the way. E
to the side to be tested.°? stands at the end of the table.
2. Stabilize: The leg just above the ankle. S’s heel can rest 2. Stabilize: The leg to be tested above the ankle joint on
in fsilapeos the dorsal surface of the calf, being careful not to put
3. Palpate: The tibialis anterior tendon on the anterior pressure on the tibialis posterior muscle.°”
medial aspect of the ankle joint.°”? Muscle fibers 3. Palpate: The tendon of the tibialis posterior muscle
may be palpated on the anterior surface of the leg, between the medial malleolus and navicular bone or
just lateral to the tibia.’ above and just posterior to the medial malleolus.°””
 Muscle Strength 357

FIG. 22-45
Ankle dorsiflexion with inversion. A, Palpate and observe. B, Resist.

FIG. 22-46
Foot inversion. A, Palpate and observe. B, Resist.

. Observe: S invert the foot, keeping the toes relaxed. rior. Movement will be accompanied by toe flexion, or
There normally will be some plantar flexion as well toes will flex when resistance is applied.”'*
(Fig. 22-46, A).”""
. Resist: On the medial border of the forefoot toward
" Motion
eversion (Fig. 22-46, B).°7"
Foot eversion.
Procedure for Testing Grades P (2), T (1), and 0 Muscles””” Innervation?”
1: Position: S lying supine, with the hip extended and in Peroneus longus Peroneal nerve, L4-S1
neutral rotation, the knee extended, and the ankle in Peroneus brevis
midposition.
N . Stabilize: The same as described for the previous test. Procedure for Testing Grades Normal (N)
. Palpate: The same as described for the previous and Fair (F)
test. H Position: S side lying, with the lower leg flexed at the
. Observe: S move the foot inward (medially), invert- knee to keep it out of the way. The upper test leg is in
ing it while keeping the toes relaxed. hip extension with neutral rotation, knee extension,
. Grade: According to standard definitions of muscle and ankle plantar flexion with foot inversion.°
grades. . Stabilize: Medially or laterally, above the ankle.°
Substitutions: The flexor hallucis longus and flexor . Palpate: The peroneus longus over the upper half of
digitorum longus can substitute for the tibialis poste- the lateral aspect of the calf, just distal to the head
 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

FIG. 22-47
Foot eversion. A, Palpate and observe. B, Resist. C, Gravity-decreased position.

of the fibula. Its tendon can be palpated on the and orthopedic conditions. It does not measure muscle
lateral aspect of the ankle, above and behind the endurance or coordination, and it cannot be used accu-
lateral malleolus. The peroneus brevis tendon may rately in upper motor neuron disorders when spasticity
be palpated on the lateral border of the foot, proxi- is present.
mal to the base of the 5th metatarsal.°”’!* Its muscle Accurate assessment of muscle strength depends on
fibers can be found on the lower half of the lateral the knowledge, skill, and experience of the examiner. Al-
surface of the leg, over the fibula.” though there are standard definitions of muscle grades,
4. Observe: S evert the foot. (Note that this movement is clinical judgment is important in accurate evaluation.
normally accompanied by some degree of plantar Muscle test results are used to plan treatment strate-
flexion."’'*) Observe for dorsiflexion or toe exten- gies to improve occupational performance, compensate
sion as evidence of substitutions (Fig. 22-47, A). for muscle weakness, and increase strength.
5. Resist: Against the lateral border and the plantar
surface of the foot toward inversion and dorsiflexion
REVIEW QUESTIONS
(Fige22-47,,B).°°7
1. List three general classifications of physical dysfunc-
Procedure for Testing Grades P (2), T (1), and 0 tion in which muscle weakness is a primary
1. Position: S lying supine, hip extended and in neutral symptom.
rotation.” The knee is extended, and the ankle is in 2. List at least three purposes for assessing muscle
midposition. strength.
. Stabilize: The leg under the calf. 3. Discuss five considerations and their implications
. Palpate: The same as described for the previous test. in treatment planning that are based on the results
. Observe: S evert the foot (Fig. 22-47, C). of the muscle strength assessment.
MW
Wh
& . Grade: Grade according to standard definitions of 4. Define endurance.
muscle grades. 5. How can muscle weakness be differentiated from
Substitutions: The peroneus tertius, while everting the joint limitation?
foot, also dorsiflexes it. If it is substituting for the per- 6. If there is joint limitation, can muscle strength be
oneus longus and peroneus brevis, dorsiflexion will ac- measured accurately? How is strength recorded
company eversion. The extensor digitorum longus can when available ROM is less than normal?
also substitute for the peroneals, and toe extension will 7. What does the MMT measure?
precede or accompany eversion.”’'* 8. What are the limitations of the MMT?
9. When is the MMT contraindicated?
10. What are the criteria for determining muscle
SUMMARY
grades?
Many diseases and injuries result in muscle weakness. 11. Inrelation to the floor as a horizontal plane, describe
Screening tests can be used to assess the general level or demonstrate what is meant by the terms “with
of strength available for ADL and to determine which gravity assisting,” “with gravity decreased,” “against
patients and which muscle groups might need the gravity,” and “against gravity and resistance.”
MMT. 12. List five factors that can influence the amount of re-
Manual muscle testing evaluates the level of strength sistance against which a muscle group can hold.
in a muscle or muscle group. It is used with patients 13. Define the muscle grades: N (5), F- (3-), F (3), P (2),
who have motor unit (lower motor neuron) disorders P- (2-), T (1), and zero (0).
 Muscle Strength 359

14. Explain what is meant by substitution. . . Clarkson HM: Musculoskeletal assessment, ed 2, Philadelphia, 2000,
¢
7
15. How are substitutions most likely to be ruled out in
—— Lippincott Williams & Wilkins.
. Clarkson HM, Gilewich GB: Musculoskeletal assessment, Baltimore,
the muscle testing procedure? 1989, Williams & Wilkins.
16. List the steps in the muscle testing procedure. . Cole JH, Furness AL, Twomey LT: Muscles in action, New York,
17. Is it always necessary to perform the MMT to deter- 1988, Churchill Livingstone.
_ mine level of strength? If not, what alternatives may . Daniels L, Worthingham C: Muscle testing, ed 5, Philadelphia,
be used to make a general assessment of strength? 1986, WB Saunders.
ee
10. Hislop HJ, Montgomery J: Daniels and Worthingham's muscle
18. List the purposes of screening tests.
testing, ed 6, Philadelphia, 1995, WB Saunders.
1 Kendall FP, McCreary EK: Muscles: testing and function, ed 2, Balti-
REFERENCES more, 1983, Williams & Wilkins.
1. Basmajian JF: Muscles alive, ed 4, Baltimore, 1978, Williams & 12 Killingsworth A: Basie physical disability procedures, San Jose, Calif,
Wilkins. 1987, Maple Press.
2. Bobath B: Adult hemiplegia: evaluation and treatment, ed 2, London, ile), Landen B, Amizich A: Functional muscle examination and gait
1978, William Heinemann Medical Books. analysis, JAm Phys Ther Assoc 43:39, 1963.
3. Brunnstrom S: Movement therapy in hemiplegia, New York, 1970, 14, Pact V, Sirotkin-Roses M, Beatus J: The muscle testing handbook,
Harper & Row. Boston, 1984, Little, Brown.
4. Brunnstrom S: Clinical kinesiology, Philadelphia, 1972, FA Davis. 15; Rancho Los Amigos Hospital, Department of Occupational
5. Chusid J: Correlative neuroanatomy and functional neurology, ed 19, Therapy: Guide for muscle testing of the upper extremity, Downey,
Los Altos, Calif, 1985, Lange Medical Publications. Calif, 1978, Professional Staff Association of the Rancho Los
Amigos Hospital.
KEY TER LEARNING OBJECTIVES
Motor control After studying this chapter the student or practitioner
Plasticity will be able to do the following:
Paresis 1: Differentiate between upper and lower motor
Flaccidity neuron pathological conditions.
Hypotonus ae List the components of motor control.
Hypertonus Differentiate between spasticity and hyperactive
Spinal Hypertonia tonic stretch reflexes.
Spasticity Recognize four types of rigidity.
Clonus Differentiate between spinal and cerebral
Hypertonic stretch reflexes hypertonus.
Rigidity Identify all categories of the Ashworth Scale.
Decerebrate rigidity List standardized assessments designed for
Decorticate rigidity evaluating function after cerebrovascular accident.
Intrathecal baclofen pump Describe normal muscle tone.
Postural mechanism List and describe at least four different abnormal
Coordination tone states.
Inhibitive casting 10; Describe how to assess muscle tone.
Serial casting LY List the components of the postural mechanism.
Nerve blocks 12% List and describe at least four types of cerebellar
disorders.
fe List and describe at least four extrapyramidal
I
disorders. ;
14. Describe how to assess coordination.
De Name several current medical and surgical
treatment options for management of hypertonia.
16. List at least three conservative occupational therapy
interventions for hypertonia.

Maureen (Mo) Johnson, OTR, BCN, and Jeffrey S. Hecht, MD,

FAAPMR, are gratefully acknowledged for reviewing and assisting with
this chapter.

360
 Motor Control 361

Observing for motor control dysfunction during

occupational performance is a way to assess motor
control. It is necessary to evaluate the specific compo-
nents that underlie motor control. These components
are muscle tone, postural tone and the postural mecha-
nism, reflexes, selective movement, and coordination. A
comprehensive assessment can help the patient and oc-
men rdination Connie: Mer ibaical sents cupational therapist plan appropriate treatment inter-
(i.e, the cerebral Sites basal ganglia, and cerebellum) vention.
collaborate to make motor control possible. A neuro- This chapter focuses on the functional effects of
logical insult such as cerebrovascular accident (stroke or lesions in the upper motor neuron system (UMNS). The
brain attack), brain injury, or a disease such as multiple UMNS includes any nerve cell body or nerve fiber in the
sclerosis or Parkinson's disease affects motor control. spinal cord (other than the anterior horn cells) and all
Functional recovery depends on the initial amount of superior structures. These structures include descending
neurological damage, prompt access to medical treat- nerve tracts and brain cells of both gray and white
ment that limits the extent of neurological damage,” matter that subserve motor function.
and therapeutic intervention that can facilitate motor The lower motor neuron system includes the anterior
recovery. horn cells of the spinal cord, the spinal nerves, the
nuclei and axons of cranial nerves III through X, and
the peripheral nerves. Lower motor neuron dysfunction
results in diminished or absent deep tendon reflexes
and muscle flaccidity. Figure 23-2 illustrates the influ-
®3 In some instances the central ence of the upper motor neuron system over the lower
nervous system (CNS) is able to reorganize and adapt to motor neuron system.°”
functional demands after injury.'° Motor relearning can
occur through the use of existing neural pathways (un-
masking) or through the development of new neural
PERFORMANCE ASSESSMENTS
connections (sprouting).°* In the case of unmasking, it The occupational therapist has the challenge of maxi-
is believed that seldom-used pathways become more mizing the patient's ability to return to purposeful and
active after the primary pathway has been injured. The meaningful occupation within his or her physical and
adjacent nerves take over the function of the damaged social environment.” Therefore, evaluating functional
nerves. In the case of sprouting, dendrites from one performance is primary in helping patients to actualize
nerve form a new attachment or synapse with another realistic goals. The Canadian Occupational Performance
(Fig. 23-1).7° It is also believed that new axonal processes Measure®® is an assessment tool that ensures client-
develop in sprouting.°® centered therapy. This tool helps prioritize the patient's

Injury causes
loss of nerves
Cc B and C.

New dendrite connections “sprout”

from nerve D to reestablish
contact with nerve A.

FIG. 23-1
Sprouting theory of nerve cell replacement. Injury causes loss of nerves B and C. New dendrite con-
nections “sprout” from nerve D to reestablish contact with nerve A. (From DeBoskey DS, Hecht JS,
Calub CJ: Educating families of the head injured, Rockville, Md, 1991, Aspen Publishers.)
362 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

Wy
The driver is like
The reins are like the the thinking brain.
upper motor neurons. a

The horses are like lower

motor neurons and muscles.

FIG. 23-2
Control of movement is comparable with a chariot driver with a team of horses. The upper motor
neuron system facilitates or inhibits the lower motor neuron system. The driver is like the brain, the
reins are like the descending nerve tracts, the horses are like lower motor neurons and muscles.
(From DeBoskey DS, Hecht, JS, Calub Cy): Educating families of the head injured, Rockville, Md, 1991,
Aspen Publishers).

functional activity goals in the areas of self-care, leisure, 10. What is the spontaneous, functional use of involved
and productivity.°° extremities?
The occupational therapist can observe the patient or Many ADL tests are available to assess occupational
client for motor control dysfunction during assessment performance and are also useful to observe motor
of basic activities of daily living (BADL) and instrumen- control. The Test d’Evaluation des Membres Superieurs
tal ADL (IADL), as well as of productive and leisure ac- de Personnes Agees (TEMPA) is an upper extremity
tivities. The therapist must observe how problems in functional activity performance test for geriatric pa-
motor control affect motor performance. The therapist tients. The test was developed to help therapists distin-
must also consider the patient's sensation, perception, guish between “normal and pathological aging in upper
cognition, and medical status. The following questions extremity performance.”** Some of the test items are
may be helpful to guide observation: picking up and moving a jar, ae on an envelope,
Le Is the patient having difficulty with sitting or stand- tying a scarf, and handling coins.”
ing balance? ‘Several assess
2. Is the patient having difficulty making appropriate
postural adjustments of the trunk and limbs to
achieve the best position and motions needed to femiplegic / aret oe
perform the activity? =xtrel § assesses the patient’ sability to use the in-
3. Is there adequate trunk control to perform the volved arm for purposeful tasks. This test provides ob-
activity? jective documentation of functional improvement.
4. Do changes in body and head position affect The test includes tasks ranging from those that involve
muscle tone? basic stabilization to more difficult tasks requiring
"5. Are primitive reflexes evoked during performance? fine manipulation and proximal stabilization. Exam-
6. Is hypertonicity limiting movement or speed of ples include holding a pouch, stabilizing a jar, wring-
movement? ing a rag, hooking and zipping a zipper, folding a
7. Is there weakness that prohibits antigravity activity? sheet, and putting in a light bulb overhead.**
8. Are tremors, athetoid, or choreiform movements 2. The Fugl-Myer’? is based on the natural progression
apparent? of neurological recovery after CVA. Low scores on the
9. Is there apparent incoordination (i.e., overshooting Fugl-Myer have been closely correlated with the pres-
or undershooting the target)? Are there extraneous ence of severe spasticity.’* Fugl-Meyer and associates
movements? developed a quantitative assessment of motor func-
 Motor Control 363

tion following stroke, by using Brunnstrom’s meth- degree of normal tone depends on such factors as age,
ods'* and by measuring such parameters as range of sex, and occupation. Normal muscle tone is character-_
motion (ROM), pain, sensation, and balance. The ized by the follo :
scores on the GES“Meyer assessment correlate with 1. Effective coactivation (stabilization) at axial and
ee
eee
eS ADL oe state proximal joints
> is a functional Ability to move against gravity and resistance
nction. Cutting Ability to maintain the position of the limb if it is
meat, making a sandwich, opening a jar, and putting placed passively by the examiner and then released'®
&
iBak
on a T-shirt are some of the tasks included in this Balanced tone between agonist and antagonistic
test. This test has high interrater reliability and test- muscles
Ease of ability to shift from stability to mobility and
is a valid and reliable test reverse as needed
of motor impairment that can be performed quickly. 6 pees tidto use muscles in groups or selectively, if nec-
The test assesses pinching a cube with the index essary”
finger and thumb, as well as elbow flexion, shoulder Resilience ey slight resistance in response to passive
abduction, ankle dorsiflexion, knee extension, and movement’°

is a standard Wa Ne eriececeecertomeescontcrie
skills in IADL. The test was created by occupational pee ‘Normalization of muscle tone
therapists. Although the test is not diagnosis specific, and amelioration of paresis (slight or incomplete paral-
it has been widely used with patients who have had a ysis) are desirable when striving for selective motor
CVA. Occupational therapy practitioners are eligible control. Some function can be achieved even though
to become certified in the use of this test, through a tone may not be normal.
five-day training course.°
After observing functional performance, the occupa-
ABNORMAL MUSCLE TONE
tional therapist usually will find it necessary to assess
the performance components that underlie motor Abnormal muscle tone is pela described with the fol-
control: muscle tone, the postural mechanism, reflexes, lowing terms: flaccidi ypotonusus, hypertonus, spasticity,
sensation, and coordination. and rigidity. To plan Peetaptns treatment interventions
the therapist must recognize the differences among
these tone states and identify them during the clinical
NORMAL MUSCLE TONE
assessment, to plan the appropriate intervention.

Flaccidity
pendent on the triers of peripheral and CNS Flaccidity
refers to the absence of tone. The patient will
mechanisms ane the properties of muscle. en have the absence of deep tendon reflexes. Active move-
ment is absent.***? Flaccidity can result from spinal or
cerebral shock immediately after a spinal or cerebral
insult. In traumatic upper motor neuron lesions of
The tension is fecanined partly by ra TRO ee cerebral or spinal origin, flaccidity is usually present
such as connective tissue and viscoelastic properties of initially and then changes to hypertonicity within a few
muscle, and partly by the degree of motor unit activity.” weeks.”
When passively stretched, the normal muscle offers a Flaccidity also can result from lower motor neuron
small amount of involuntary resistance. dysfunction, such as a peripheral nerve injury or a dis-
Normal muscle tone relies on normal function of the ruption ofthe reflex arc at the alpha motor neuron level.
cerebellum, motor cortex, basal ganglia, midbrain, The muscles feel soft and offer no resistance to passive
vestibular system, spinal cord functions, and neuromus- movement.** If the flaccid limb is moved passively, it
cular system (including the mechanical-elastic features will feel heavy. If moved to a given position and re-
of the muscle and connective tissues)”* and on a nor- leased, the limb will drop because the muscles are
mally functioning stretch reflex.'° The stretch reflex is unable to resist gravity.
mediated by the muscle spindle, a sophisticated sensory
receptor continuously reporting sensory information
Hypotonus
from muscles to the CNS.
Normal muscle tone varies from one individual to Hypotonus is considered by many to be a decrease of
another. Within the range that is considered normal, the normal muscle tone (i.e., low tone). Deep tendon
364 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

reflexes are diminished or absent.***” Van der Mech though hypertonic muscles appear to be able to take a
and Van der Gijn®® suggested that hypotonus could be lot of resistance, they do not function as normal, strong
an erroneous clinical concept. They performed elec- muscles do. Through the mechanism of reciprocal inhi-
tromyography (EMG) analysis on the quadriceps bition, hypertonic muscles inhibit activity of their an-
muscles in “hypotonic” patients (e.g. peripheral neu- tagonists and thus can mask potentially good or normal
ropathy, cerebral infarction, and other diagnoses) and function of antagonists.’*’*?
in relaxed normal subjects in a lower leg free-fall test.
They concluded in their study that if.a patient's limb Cerebral Hypertonia
feels hypotonic or flaccid, it is the result of weakness,
not long-latency stretch reflexes.*”

In multipl a stems from bo spinal

Hypertonus
and cerebral lesions.’* Tone fluctuates continuously in
Hypertonus is increased muscle tone. Hypertonicity can response to extrinsic and intrinsic factors. Cerebral hy-
occur when there is a lesion in the premotor cortex, the pertonia usually occurs in definite patterns of flexion or
basal ganglia, or descending pathways.'’ Damage to extension, causing the limb to draw in one direction
upper motor neuron systems increases stimulation of the (Fig. 23-3).'° Typically the patterns occur in the anti-
lower motor neurons, with a resultant increased alpha gravity muscles of the upper and lower extremities (e.g.,
motor activity.°’ Any neurological condition changing flexors of the upper extremities, extensors of the lower
the upper motor neuron pathways that directly or indi- extremities).
rectly facilitate alpha motor neuron activity may result in
hypertonicity.
Hypertonicity often occurs in a synergistic neuro-
muscular pattern. Synergies are defined as “a fixed set of
muscles contracting with a preset sequence of time and
contraction.”*” A typical synergy seen in the upper
extremity after CVA or traumatic brain injury is a flex-
ion synergy.'* For more details on synergies, refer to
Chapter 34.
There is considerable energy cost in moving against
hypertonicity. It takes a great deal of effort for patients
with moderate to severe hypertonicity to move against
this drawing force. Even patients with mild hypertonic-
ity report frustration during functional activities. This
frustration, coupled with the fatigue, decreased dexter-
ity, and paresis associated with upper motor neuron
syndrome, can influence therapy participation.’* Fur-
thermore, the architecture of hypertonic muscles
changes over time. The muscles lose their ability to
lengthen and shorten because of viscoelastic changes
that result from the hypertonia.'®°?
Hypertonicity can increase as a result of painful or
noxious stimuli. These stimuli can often be reduced
with good medical care. Stimuli that can increase tone
are pressure sores, ingrown toenails, tight elastic straps
on a urine collection leg bag, tight clothing, an ob-
structed catheter, urinary tract infections, constipation,
and fecal impaction.**°? Other triggering factors include
fear, anxiety, environmental temperature extremes, het-
erotopic ossification, and sensory overload.*”*’ These
factors are true for both cerebral and spinal hypertonic-
ity; however, they are more pronounced in spinal hyper-
tonia. Therapeutic intervention should be designed to
reduce, eliminate, or cope with these extrinsic factors. FIG. 23-3
Patients with hypertonicity often have difficulty initi- A patient with upper extremity hypertonicity after traumatic brain
ating movement, especially rapid movement.?* Al- injury.
 Motor Control 365

The reemergence of primitive reflexes and associated tually happens is that the initial high resistance of
reactions alters postural tone. When an individual is spasticity is suddenly inhibited.”
lying supine, muscle tone is less than when the individ- One of the main systems that has been affected when
ual is sitting or standing. The tone is at its highest spasticity is present is the pyramidal system, which con-
during ambulation. Thus attention to postural tone is sists of the corticospinal and corticobulbar tracts. The
important when positioning a patient for splinting or corticospinal tract controls goal-directed, voluntary
casting. A cast or splint fabricated on a patient in a movement.”'°
supine position may not fit when the patient is sitting
up, because of the influence of gravity and posture on
Clonus
muscle tone.’

Spinal Hypertonia often present in pallents Wich mowiewite to severe spas-

ticity. Clonus iiss characterized by passes
~ the spinal cord. In slow-onset spinal disease (e.g., spinal uuscles Et
mus j reenC
1 Tes

stenosis or tumor), there is no period of spinal shock. In Theresare recedebursts of IA cAciedt activity, aia
traumatic spinal cord injury, spinal shock occurs and is result in a cyclical oscillation of phasic stretch re-
characterized by flaccidity. (weeks or BaeEDs) flexes.’*”°? Clonus is most commonly seen in the finger
flexors and ankle plantar flexors.’” The occurrence of
develop flexor a init clonus can interfere with participation in purposeful ac-
tor tone. 91 Over time, extensor tone develops and tivity, transfers, and mobility. Therapists should educate
becomes predominant in the lower extremities. Spinal the patient about how to bear weight actively, because
hypertonia can lead to muscle spasms severe enough to this usually will stop the clonus. Therapists and physi-
cause an individual to fall out of a wheelchair, off a cians record clonus by counting the number of beats.°?
gurney, or out of bed. The degree of hypertonicity in in- A three-beat clonus can be rated as mild and is less
complete spinal lesions varies, depending on the degree likely to interfere with ADL than clonus that is 10-beat
and direction of remaining supraspinal influences.’’ or more. Clonus may be elicited during quick stretch
The tone tends to be more severe in incomplete spinal tone evaluation or may become apparent during assess-
cord lesions than in complete lesions.’” ment of occupation (e.g., grasping or ambulation). If
clonus greatly interferes with ADL, the patient may be a
candidate for a referral to a physiatrist or neurologist for
Spasticity oral medication, Botox* injection, or a Phenol motor
There has been much controversy in recent years about point block.’*
the difference between spasticity and hypertonia.
Lance’s’® definition of spasticity is still accepted by Hypertonic Stretch Reflex
many
physicians and therapists. He defined spasticity as
“a motor disorder characterized by a velocity-dependent Therapists often confuse hypertonic
stretch reflexes —
increase in tonic stretch reflexes (muscle tone) with ex- (HTSRs) with spasticity. These two conditions are
aggerated tendon jerks resulting from hyperexcitability ilar in two ways
of the stretch reflex as one component of the upper AL.HTSRsand spasticity both draw the limb into a uni-
motor neuron syndrome.””° lateral direction.
Little, and Massagli’®”” believe that pure spasticity is . HTSRs and spasticity are both types or subcategories
a subset of hypertonia. It is possible that Lance’s defini- of hypertonia.
tion does not adequately distinguish between the pres- TSRs are different from spasticity in four ways:
ence of phasic and tonic stretch reflexes, which present HTSRs are typically not velocity dependent; that is,
different clinical scenarios. This chapter attempts to they are not evoked by rapid movement; rather, they
pad the differences ees currentTe ae literature. are elicited by slow joint movement, and the hyper-
tonus persists as long as the muscle stretch is main-
Se eeactivity of the Psd needle s phasic stretch tained, because of the firing of group II muscle
ys how,
reflex with hyperactive firing of the IA afferent nerve spindle afferents
elocity dependence, meaning the stretch reflex is 2 HITRsoccur primarily in the flexor muscles in both
only elicited by the examiner's rapid passive upper and lower extremities, and often lead to con-
stretch?*? tractures.””
The “clasp-knife” phenomenon. This means that
when the examiner takes the extremity through a
quick passive stretch, a sudden catch or resistance is *Allergan Pharmaceuticals, Inc., 2525 Dupont Drive, P.O. Box 19534,
felt, followed by a release of the resistance. What ac- Irvine, CA 92713-9534
366 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

3. During passive movement, there is no catch felt with

HTSR, as there is with the clasp-knife phenomenon
MUSCLE TONE ASSESSMENT
of spasticity. Objective assessment of muscle tone in the patient with
4. Most of the resistance with HTSRs is felt at the end of cerebral spasticity is difficult because the tone fluctuates
the ROM, and is objectively measurable by EMG. continuously in response to extrinsic and _ intrinsic
factors. The postural reflex mechanism, the position of
Rigidity the body and head in space, the position of the head in
relation to the body, and stereotypical reflexes and asso-
Rigidity is an increase in muscle tone onist and ciated reactions all influence the degree and distribution
ant ist muscles simultaneously (i.e, muscles on of abnormal muscle tone.’”"
b ‘ sides of the joint). Both groups of muscles con-
tract steadily, leading to increased resistance to passive
movement in any direction and throughout the
Guidelines for Muscle Tone Assessment
ROM.*”’®? Rigidity signals involvement of the extra- The following steps describe the correct procedures for
pyramidal pathways in the circuitry of the basal assessing muscle tone.
ganglia, diencephalon, and brainstem. It occurs in iso- 1. Record the test position of the patient because body
lated forms in disorders such as Parkinson’s disease, and head position influence cerebral hypertonus.
traumatic brain injury, some degenerative diseases, en- The patient's upper extremity muscle tone is usually
cephalitis, tumors,*° and certain toxins and after carbon evaluated with the patient sitting on a mat table
monoxide poisoning. Rigidity is also seen in conjunc- when possible. Remember that the patient's posture
tion with spasticity in those with stroke and aan (e.g., the seated patient bearing weight symmetrically
pringaes ee is not 1 dependent.*? versus slumped or leaning to one side) will affect the
is evaluat ing muscle tone evaluation results of the tone evaluation.
mmonly seen: 2. Grasp the patient's limb proximal and distal to the
joint to be tested and move the joint slowly through
its range to determine the free and easy ROM avail-
able. Note the presence and location of pain.® If
there is no active movement and the limb feels
heavy, record that the limb is flaccid or “O” in
strength. If the limb has some active movement and
he a crawie
aver
is no evidence of increased tone, the affected muscle or
wly and vely in any direction. The rigidity;
feel muscle group may be labeled “paretic” instead of
similar:to thefing.of
eee ageora lead pipe, “hypotonic.” The paretic antagonist muscle can then
be graded in strength (usually the strength grade will
fall between 1 and 4—). Grading the paretic antago-
nist muscles provides more objective clinical infor-
wheel Tr may tee apenis eons on mation than merely labeling the muscles as hypo-
tremor, which results in the ratchety pattern.*® It is tonic. Strength grading antagonists can help the
crucial for the therapist to document the type of rigidity occupational therapist triage phenol block and
during initial assessment and how it affects the patient's Botox injection candidates who have potential to
performance. Deep tendon reflexes are normal or only improve function; for example, a patient with triceps
mildly increased in Parkinson’s rigidity. strength grade of 2— (in the presence of elbow flexor
Decerebrate and decorticate rigidity can occur after tone) would be a better block candidate than a
severe traumatic brain injury with diffuse cerebral patient with a triceps strength grade of 0.
damage or anoxia. These abnormal postures occur im- 3. Hold the limb on the lateral aspects to avoid giving
mediately after injury and can last a few days or weeks if tactile stimulation to the muscle belly of the muscle
recovery occurs, or persist indefinitely if there is little or being tested. Note also if the limb feels light or heavy.®
no recovery. 4. Clinical assessment of tone involves holding the
Decerebrate rigidity results from lesions in the bilat- patient's limb as just described and moving it rapidly
eral hemispheres of the diencephalon and midbrain. It through its full range while the patient is relaxed.
appears as rigid extension posturing of all limbs and the Label the tone “mild,” “moderate,” or “severe.” (Refer
neck. Bilateral cortical lesions can result in decorticate to tone rating scales defined in the next section.)
rigidity, which appears as flexion hypertonus in the 5. Clinical assessment of rigidity and hyperactive tonic
upper extremities and as extension tone in the lower ex- reflexes involves moving the limb slowly during the
tremities. Supine positioning increases the abnormal range, noting the location of first tone or resistance
tone, and with either type of rigidity it may be extremely to movement in degrees, and labeling it “mild,”
difficult to position patients in a sitting position.”” “moderate,” or “severe.” Some physicians find gonio-
 Motor Control 367

CRAIG HOSPITAL
TONE MANAGEMENT/ASSESSMENT FORM
OCCUPATIONAL/PHYSICAL THERAPY

Patient Name Date

BUR ie ee DX
Date of Injury
Primary Physician
Therapist

1. Brief history of patient per team members:

2. Patient/caregiver chief complaints/concerns:

Include results from Canadian Occupational Performance Measureo':

3. Functional areas effected by spasticity/hypertonus:

skin transfers
positioning (w/c, bed) ambulation
hygiene feeding
dressing other
mobility (w/c, bed)

4. Interventions tried and results:

Intervention Date Result
ROM program
Splinting/types:
Serial casting: lige
Medicine/types:
Blocks:
Surgeries:

1 The Canadian Occupational Performance Measure is copyrighted. Published by CAOT Publications ACE.

FIG. 23-4
Occupational and Physical Therapy Tone Evaluation, Craig Hospital. (From Lori Daane, OTR, Occu-
pational Therapy Department, Craig Hospital, Englewood, Colorado.) Continued

metric measuring of the location of the first tone Note how the patient moves in general. Is the head
helpful pre- and post long-acting nerve block. aligned or tilted to one side? Is one shoulder elevated?
6. Record findings for various muscle groups or move- Is the trunk rotated or elongated on one side and
ments (Fig. 23-4). shortened on the other? Such abnormalities will affect
It is important to note the patient's overall posture the patient's ability to move the limbs normally.
during the evaluation of muscle tone. Is the patient's Current intervention focuses heavily on quality of
posture symmetrical, with equal weight bearing on movement, achieving as normal movement as possible
both hips (if sitting) or on both feet (if standing)? during occupation.
368 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

5. Describe spasticity/hypertonus: Assess using Scale A or B (not both)

A. (Minimal = min., Moderate = mod., S = severe) (f = flexion or e = extension)
(c = clonus) (r = rigidity)
LUE: finger wrist elbow
shoulder scapula
RUE: _ finger wrist elbow
shoulder scapula
[LE toes: ankle knee hip
RLE: toes ankle knee hip
Neck: flexion extension
lateral flexion rotation
Note: Comment on flaccidity, paresis vs. paralysis.

B. Ashworth Score involved muscle groups:

Motion Date Date Date
Initial Follow-up Follow-up
L/R Oras L/R

C. Spontaneous spasms:
Date Date Date
Initial Follow-up Follow-up
Grade:

6. ROM measurements of involved joints:

Motion Date Date Date

Initial Follow-up Follow-up
a L/R L/R

FIG. 23-4 cont’d

Occupational and Physical Therapy Tone Evaluation, Craig Hospital. (From Lori Daane, OTR, Occu-
pational Therapy Department, Craig Hospital, Englewood, Colorado.)

Rating Scales for Spasticity

Tone fluctuates from hour to hour and day to day
and Hypertonicity
because of the intrinsic and extrinsic factors that influ-
Ashworth Scale ence it. This fluctuation makes accurate measurement
The Ashworth Scale? and the Modified Ashworth Scale” difficult, particularly for cerebral hypertonia. Rating
were not designed to differentiate between pure spastic- tone is still worthwhile, especially in the managed care
ity and hyperactive tonic stretch reflexes. These scales environment, in which objective measures of progress
are used to quantify the degree of the hypertonus. are needed to justify the continuation of therapy.
 Motor Control 1 obs)

7. Team/occupational/physical therapy goals of spasticity/hypertonus management:

8. Recommendations:

9. Procedures completed

A. Nerve/muscle Blocks

Medication Location Administration

and Dose
Local anesthesia
(specify medication)
Phenol

Botox®
(Botulinum toxin-type A)
Other
(specify medication)

Joint/Muscle Pretest Post-test | Follow-up Follow-up

Date Date Date Date
PROM SS Sa
AROM la ae
Astiwortisjeues eran 2078)
MMT
PROM |
AROM
PSiWwoiy eee ewes) eee 7
MMT
PROM bas
AROM =
Ashworth
MMT

| ae
FIG. 23-4 cont’d
Occupational and Physical Therapy Tone Evaluation, Craig Hospital. (From Lori Daane, OTR, Occu-
pational Therapy Department, Craig Hospital, Englewood, Colorado.) Continued

Bobath proposed that specific assessment of hypertonus dures. For example, part of the selection criteria for the
is not necessary. She believed that an assessment of the Synchromed* Intrathecal Baclofen Pump (ITB) im-
distribution of abnormal tone should be part of a com- plantation is based on the presence of a two-point re-
prehensive evaluation of the postural mechanism, in- duction on the Ashworth Scale after the test dose of
cluding selective movement.”’”°
Therapists familiar with the Ashworth Scale can help *Medtronic, Inc., Neurological Division, 800 53rd Ave, NE, Min-
physicians evaluate candidates for neurosurgical proce- neapolis, Minn, 55421.
BYAU EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

2).

Casting/splinting post block:

Functional changes: (spasticity, isolated mvmt., positioning, pain, other)

B. Intrathecal baclofen
Test dose protocol

Ashworth score
hte =
[ats
pL
|R | L Le
lliopsoas ae
Gluteals baa
ene
Pek
Ea
aa
a
Triceps a
Biceps ot
Wrist flexors et
Wrist extensors ie
Spontaneous spasms
Pre-test 1 hr. 2 hrs.

Grades A515 {01 2eecemeit s con

Muscle grading (MMT, PROM, AROM) Comments:

Pre-test:

2 hr.

4 hr.

FIG. 23-4 cont’d

Occupational and Physical Therapy Tone Evaluation, Craig Hospital. (From Lori Daane, OTR , Occu-
pational Therapy Department, Craig Hospital, Englewood, Colorado.)

medication is given.’* Ashworth described the resist- 3 = considerable increase in muscle tone
ance encountered during passive muscle stretching as = limb rigid in flexion or extension”
follows:
0 = normal muscle tone Mild-Moderate-Severe Spasticity Scale
1 = slight increase in muscle tone, “catch” when limb Some therapists and physicians find a mild-moderate-
moved severe scale easier to use. The following two scales are
2 = more marked increase in muscle tone, but limb suggested as a guide for estimating the degree of spastic-
easily flexed ity and hypertonicity:
 Motor Control 371

Comments: (positioning, function, pt. responses)

Pre-test:
2 hr.

4 hr.

Ashworth Scale
No increase in tone.
Slight increase in tone, giving a “catch” when
affected part(s) is moved in flexion or extension.
BS oe More marked increase in tone; passive movement
difficult.
Considerable increase in tone; passive movement
difficult.
Affected part(s) rigid in flexion or extension.

Spontaneous spasms
The number of spontaneous sustained flexor and extensor muscle spasms
per hour are to be recorded:
None.
No spontaneous spasms, vigorous sensory and
motor stimulation results in spasms.
Occasional spontaneous spasms and easily induced
spasms.
Greater than one, but less than 10 spontaneous
spasms per hour.
Greater than 10 spontaneous spasms per hour.

FIG. 23-4 cont’d

Occupational and Physical Therapy Tone Evaluation, Craig Hospital. (From Lori Daane, OTR , Occu-
pational Therapy Department, Craig Hospital, Englewood, Colorado.) Continued

Mild: The stretch reflex (palpable catch) occurs at the Preston's Three-Step Hypertonicity Scale
muscle’s end range (i.e., the muscle is in a lengthened 1 or Mild: First tone or resistance is felt when the muscle
position). is in a lengthened position.
Moderate: The stretch reflex (palpable catch) occurs in 2 or Moderate: First tone or resistance is felt in the mid
midrange. range of the muscle.
Severe: The stretch reflex (palpable catch) occurs when 3 or Severe: First tone or resistance occurs when the
the muscle is in a shortened range.*” muscle is in a shortened range.
372 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

Range of Motion Assessment

grade the strength of the antagonists to measure
in Tone Assessment
progress objectively.’*
Passive ROM (PROM) assessment supplements and Position change and labyrinthine and tonic neck re-
often correlates with tone assessment. For example, if a flexes influence muscle tone and motor control. Because
patient with acute CVA (1 month after onset) has a wrist the level and distribution of muscle tone changes as the
ROM measurement of 20° extension (normal is 70°) position of the head in space and of the head in relation
and orthopedic etiology (e.g., arthritis or fixed contrac- to the body change, tone cannot be assessed in isolation
ture) has been ruled out, the therapist should assess the from postural mechanisms, motor function, synergies
tone in the wrist flexors and extrinsic finger flexors. Hy- present, task specificity, and other factors related to
pertonicity of any of these muscles can prohibit full wrist motor control.”
extension. An assessment of PROM can reveal possible
signs of joint changes (e.g., subluxation, dislocation, or
Sensation
contracture) that have occurred from chronic hyper-
tonus, such as PIPs that measure —45° to 125° instead The following sensibility tests are recommended for pa-
of 0° to 100°. Some physicians find PROM measure- tients with damage to the CNS: static two-point discrim-
ments useful in documenting the location of the first ination, kinesthesia, proprioception, pain, and light
tone before and after nerve block and Botox injection. touch using the Semmes-Weinstein Monofilaments
test.’ The therapist can assess light touch more accu-
rately with the Semmes-Weinstein monofilaments
Other Considerations in Tone Assessment
because they have better pressure control than a cotton
Changes in bone or other peripheral structures can lead ball. Chapters 25 and 44 provide descriptions of
to ROM limitations. For example, the presence of hetero- sensory tests.
topic ossification can limit joint ROM. Heterotopic ossi-
fication is the formation of new bone in soft tissue or
Medical Assessment of Muscle Tone
joints, which can lead to joint anklyosis. Heterotopic os-
sification can occur in individuals with traumatic brain Physiatrists, orthopedic surgeons, and neurologists are
injury and spinal cord injury, along with severe spasticity, some of the physicians who may specialize in assess-
or in other types ofsevere injuries.'~”°'’*’ Conversely, the ment of muscle tone. They may use static or dynamic
presence of fixed contractures may be incorrectly labeled surface or percutaneous (needle) EMG. Multiple chan-
as hypertonus. Physiatrists or other physician specialists nels are used in dynamic EMG to evaluate the hyper-
can aid in the diagnosis of contractures with the use ofdi- tonicity of many contributing muscles.°® EMG helps the
agnostic short-term nerve blocks or EMG.”* physician determine abnormal, excessive electrical ac-
tivity in muscles. EMG can help physiatrists and neurol-
ogists plan and implement short- and long-acting nerve
Assessing Movement and Control
blocks to treat hypertonia. Patients who show local
Along with tone assessments previously described, the muscle wasting, flaccidity, numbness, or unexplained
occupational therapist performs an assessment of upper paresis should receive EMG assessment to rule out pe-
extremity movement and control. The therapist identi- ripheral neuropathy.®”
fies where and how much the patient’s motor control is
dominated by stereotypical patterns of movement, also
NORMAL POSTURAL MECHANISM
known as synergies (Chapter 34), and where some iso-
lated movement may be present. The degree to which Macgqnosea postural mechanism is composedof auto-
abnormal tone interferes with selective control is identi- mat oveme s that provide anappropriate level
fied. Also, determining in which direction of movement stability nobility.'’ These automatic reactions
hypertonicity occurs and how it affects function helps aeeing in He early years of life and allow for trunk
determine the need for intervention. control and mobility, head control, midline orientation
Manual muscle testing usually is not appropriate of self, weight bearing and weight shifting in all direc-
for patients who exhibit moderate to severe hyper- tions, dynamic balance, and controlled voluntary limb
tonicity or rigidity because the relative tone and movement. The components of the normal postural
strength of the muscles are not normal and movement mechanism include normal postural tone and control,
is not voluntary or selective. Tone and strength are in- integration of primitive reflexes and mass movement
fluenced by the position of the head and body in patterns, righting reactions, equilibrium and protective
space, abnormal contraction, deficits in tactile and reactions, and selective voluntary movement. '”’'”
proprioceptive sensation, and failures in reciprocal in- In patients who have suffered UMNS damage, the
nervation.'” However, if hypertonia is mild and selec- normal postural mechanism is disrupted. Abnormal
tive movements are possible, it may be helpful to tone and mass patterns of movement dominate the
 Motor Control Whe)

patient's movements, and these patients lack balance midline than necessary during functional activities,
and stability. Movements are slow and uncoordinated. such as lower extremity dressing.
Therapists must assess the extent of damage to the pos- Balance depends on normal equilibrium and protec-
tural mechanism in patients with CNS trauma or tive reactions. Balance is “the ability to maintain the
disease. center of gravity over the base of support, usually while
Normal postural tone is tonus that is present in the in an upright position.””* Balance involves a complex
postural muscles. It is high enough to resist gravity, yet interaction between many systems, including the ves-
low enough to allow movement.'” It allows automatic tibular, proprioceptive, visual, and motor modulation
and continuous adjustment to movement.’° Postural from the cerebellum, basal ganglia, and cerebral cortex.
control is the ability to control or regulate specific pos- Occupational and physical therapists must also observe
tural outputs.” This control provides the foundation for the patient's ankle, hip, and step strategies and note
voluntary selective movements because normal selective areas of breakdown in the kinetic chain.*°*?
movement cannot be superimposed on high degrees of When assessing a patient with CNS dysfunction, the
hypertonicity. therapist should assess the patient's static and dynamic
It is important to assess the following automatic reac- balance before leaving the patient unattended on a mat
tions, which are part of the postural mechanism, in pa- table, in a wheelchair, or during ambulatory ADL.
tients with CNS trauma or disease. Dynamic balance involves maintaining balance while
moving, and static balance involves maintaining equi-
librium while stationary.
Righting Reactions
The Physical Performance Test assesses physical func-
tion during activity. Seven of the nine tested items
involve static and dynamic balance.*° The test only
takes 10 minutes to complete.’* Fig. 23-5 shows the test
form and test protocol. Two other noteworthy balance
assessments are the Tinetti Balance Test of the Perfor-
mance-Oriented Assessment of Mobility Problems*®
and the Berg Balance Scale.”

Primitive Reflexes
The reemergence of primitive reflexes can interfere with
the patient's occupational performance. Difficulties that
all activities.’” 50 riieke reactions ensureSaaficient pos- may be encountered are described below. Observation
tural alignment when the body’s center of,pravaty is of these motor behaviors is a way of evaluating for the
altered by a change in the supporting surface.” Without presence of primitive reflexes.
equilibrium reactions, the patient will have difficulty
maintaining and recovering balance in all positions and CEE Level Sale
activities. ASYMN REFLEX. The
patient with Be amianical toniceke reflex may have dif-
ficulty maintaining the head in midline while moving the
Protective Reactions
eyes toward or past midline.” The patient may be unable
to (1) extend an arm without turning the head or (2) flex
the arm without turning the head the other way.”’?* The
patient may be unable to move either or both arms to
10,38> Without proreenve reactions midline, especially when in the supine position, because
the patient may fall or be reluctant to bear weight on the movement ofthe arms is dependent on head positioning.
affected side during normal bilateral activities. This positioning causes asymmetry in the arms. Thus
this reflex makes it difficult or impossible to bring an
Assessment of Righting, Equilibrium, Protective object to the mouth, hold an object in both hands, or
Reactions, and Balance grasp an object in front of the body while looking at it.
Formal testing of these reactions may be difficult
because of the cognitive and physical limitations of the NECK REFLEX. The
patient or time constraints of the therapist. The thera- mater with symmetrical tonic neck reflex will be
pist can evaluate righting reactions, however, during unable to support the body weight on hands and
transfers and ADL. Equilibrium and protective reactions knees, maintain balance in a quadruped position, or
can be observed when the patient shifts farther out of crawl normally without fixating the head.'° The patient
 PHYSICAL PERFORMANCE TEST SCORING SHEET
Physical Performance Test
Time* Scoring
Score

1. Write a sentence sec =10sec=4 Entin’s

(Whales live in the blue ocean.) 10.5-15 sec = 3
15.5-20 sec = 2
>20 sec = 1
unable = 0
2. Simulated eating sec =10sec=4 eereaYs
10.5-15 sec = 3
15.5-20 sec = 2
>20 sec = 1
unable = 0
3. Lift a book and put it sec =2 sec = 4 panes
on a shelf 2.5-4 sec = 3
4.5-6 sec = 2
>6 sec = 1
unable = 0
4. Putonand remove sec =10 sec = 4 Sere
a jacket 10.5-15 sec = 3
15.5-20 sec = 2
>20 sec = 1
unable = 0
5. Pick up penny from floor sec =2sec=4 —w
2.5-4 sec = 3
4.5-6 sec = 2
>6 sec = 1
unable = 0
6. Turn 360° discontinuous steps 0 (waa,
continuous steps 2
unsteady
(grabs, staggers) 0
steady 2
7. 50-foot walk test sec =15sec=4 :
15.5-20 sec = 3
20.5-25 sec = 2
>25 sec = 1
unable = 0
8. Climb one flight of stairs sec =5 sec =4 ————s
5.5-10 sec = 3
10.5-15 sec = 2
>15 sec = 1
unable = 0
9. Climb stairst Number of flights of stairs ____
up and down (maximum 4)
TOTAL SCORE (maximum 36 for nine-item, 28 for seven-item)
nine-item
seven-item
“For timed measurements, round to nearest 0.5 seconds.
tOmit for seven-item scoring.

FIG. 23-5
Physical performance test: scoring sheet and test protocol. (From Reuben DB, Siu AL: An objec-
tive measure of physical function of elderly outpatients—the physical performance test, |Am
Geriatr Soc 38[10]:1 111-1112, 1990.)

374
 Motor Control Whe)

PHYSICAL PERFORMANCE TEST PROTOCOL

Administer the Physical Performance Test as outlined below. Subjects are given up to two
chances to complete each item. Assistive devices are permitted for tasks 6 through 8.

1. Ask the subject, when given the command “go,” to write the sentence, “Whales live in
the blue ocean.” Time from the word “go” until the pen is lifted from the page at the end
of the sentence. All words must be included and legible. Period need not be included
for task to be considered completed.

2. Five kidney beans are placed in a bowl, 5 inches from the edge of the desk in front of
the patient. An empty coffee can is placed on the table at the patient’s nondominant
side. A teaspoon is placed in the patient’s dominant hand. Ask the subject, on the
command “go,” to pick up the beans, one at a time, and place each in the coffee can.
Time from the command “go” until the last bean is heard hitting the bottom of the can.

3. Place a Physician's Desk Reference or other heavy book on a table in front of the
patient. Ask the patient, when given the command “go,” to place the book on a shelf
above shoulder level. Time from the command “go” to the time the book is resting on
the shelf.

4. If the subject has a jacket or cardigan sweater, ask him or her to remove it. If not, give
the subject a lab coat. Ask the subject, on the command “go” to put the coat on
completely such that it is straight on his or her shoulders and then remove the garment
completely. Time from the command “go” until the garment has been completely
removed.

5. Place a penny approximately 1 foot from the patient's foot on the dominant side. Ask
the patient, on the command “go,” to pick up the penny from the floor and stand up.
Time from the command “go” until the subject is standing erect with penny in hand.

6. With subject in a corridor or in an open room, ask the subject to turn 360°. Evaluate
using scale on PPT scoring sheet.

7. Bring subject to start on 50-foot walk test course (25 feet out and 25 feet back) and ask
the subject, on the command “go,” to walk to 25-foot mark and back. Time from the
command “go” until the starting line is crossed on the way back.

8. Bring subject to foot of stairs (9 to 12 steps) and ask subject, on the command “go”
to begin climbing stairs until he or she feels tired and wishes to stop. Before beginning
this task, alert the subject to possibility of developing chest pain or shortness of breath
and inform the subject to tell you if any of these symptoms occur. Escort the subject up
the stairs. Time from the command “go” until the subject’s first foot reaches the top of
the first flight of stairs. Record the number of flights (maximum is four) climbed (up and
down in one flight).

a
FIG. 23-5 cont’d
Physical performance test: scoring sheet and test protocol. (From Reuben DB, Siu AL: An objec-
tive measure of physical function of elderly outpatients—the physical performance test, | Am
Geriatr Soc 38[10]:1 111-1112, 1990.)

will have difficulty moving from lying to sitting because as the arms and neck are extended to initiate the trans-
when the head is lifted to initiate the task, increased fer, one or both legs may show increased flexion, which
hip extension resists the movement. As the patient may cause the patient to slide under the bed or wheel-
struggles to sit up, increased leg extension can also in- chair. Additionally, the affected leg may actually lift off
terfere.?* The patient will have difficulty with transfers the floor, causing an inability to bear weight on that
from bed to wheelchair and wheelchair to bed because extremity.7*
BRYA EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

‘HINE REFLEX. The patient ex- . WIT WAL. The patient with flexor
hibiting poorly integrated tonic labyrinthine reflex will Pome recrey will enh wipseti? of the ankle, knee, and
be severely limited in the ability to move. A few exam- hip when the sole of the foot is touched (swiped heel to
ples of functional limitations are the inability to lift the ball of foot). This reflex clearly interferes with gait
head in the supine position, initiate flexion to sit up in- pattern and transfers.
dependently from the supine position, roll over, or sit in
a wheelchair for long periods.'”** In attempting to GRASP EX. The patient with a grasp reflex will
move from a supine to sitting position, extensor tone not aesae to eee objects pigcegpin the hand, even if
will dominate until the patient is halfway up, when active finger extension is present.** The reflexes just dis-
flexor tone begins to take over. Flexor tone continues cussed are rarely seen in isolation.
until full sitting is reached, causing the head to fall
forward, the spine to flex, and the patient to fall Automatic Adaptation of Muscles
forward.’ Sitting in a wheelchair for extended periods
to Changes in Posture
can lead to increased extensor tone as the patient hyper-
extends the head to view the environment. The knee is Normal muscles allow for smooth and well-controlled
extended, the foot is pushed forward off the wheelchair mobility against the force of gravity. A limb with normal
foot rest, and eventually the patient may slip or remain muscles can be placed; that is, it can be moved by the
in a half-lying asymmetrical position.** examiner and will feel light because it follows the move-
ment actively. '° Otherwise, the limb will feel heavy and
OSITIN PORTING REACTION. The positive flop down if released by the examiner. The limb may
cae reaction is caused by pressure on the ball of also feel resistant to movement, which indicates that it
the foot. This stimulus elicits extension and internal ro- does not have the ability to combat gravity appropri-
tation of the hip, knee extension, ankle plantar flexion, ately for function.
and foot inversion. The patient with a positive support- If reflexes or stereotypical patterns are not integrated
ing reaction will have difficulty placing the heel on the and righting, equilibrium, and protective reactions are
ground for standing, putting the heel down first in impaired, patients will have difficulty using their limbs
walking, and having normal body weight transference for function. These patients may not be able to place
in walking.'"”** The patient will have difficulty getting their limbs, stabilize an object, or manipulate an object.
up from a chair, sitting in a chair, or walking down They may not be able to use their limbs to prevent a fall
steps, because the leg remains in rigid extension and it is or maintain their balance.
not possible to move the joints while weight bearing.
The rigid leg can carry the patient's body weight but is
Trunk Control Assessment
unable to contribute to any balance reactions. All
balance reactions therefore are compensated for with Collin and Wade” designed a quick and easily adminis-
other parts of the body.’ tered test of trunk control that is valid and reliable in
patients with a diagnosis of CVA. It involves four timed
Spinal Level Reflexes tests: rolling to the weak side, rolling to the sound side,
Spinal reflexes can occur after an upper motor neuron moving from supine to sitting, and sitting on the side of
lesion. They appear because of a lack of inhibition from the bed with the feet off the floor for 30 seconds.”
higher centers. Some examples of exaggerated spinal re- To accurately assess trunk control, the therapist must
flexes are hyperactive deep tendon reflexes, the Babinski evaluate strength and control in the following muscle
sign, flexor withdrawal reflex, crossed extension, and groups: trunk flexors, extensors, lateral flexors, and rota-
grasp reflex.°* Three spinal reflexes are reviewed. tors. The patient should be sitting upright on a mat
table, with the feet supported for all tests. The patient
CROSSED EXTENSION REFLEX. The crossed ex- should not be left unattended on the mat table until
tension reflex causes increased extensor tone in one leg the therapist determines the patient has adequate trunk
when the other leg is flexed. Therefore, if the patient control and sitting balance. The procedures described
with hemiplegia who is influenced by this reflex flexes in the following sections are condensed from Gillen
the unaffected leg for walking, a strong extensor hyper- and Burkhardt’s Stroke Rehabilitation: A Function-Based
tonicity occurs in the affected leg and interferes with Approach.*°
the normal pattern of ambulation. By the same token
the patient can bridge (lift buttocks) in bed with the Trunk Flexors
weight supported by both legs. If the unaffected leg is The examiner asks the patient to sit upright, slowly
lifted (flexed), however, a total extension pattern move his or her shoulders behind the hips, (eccentric
occurs in the affected leg and the bridge cannot be control) and hold the end range posture (isometric
maintained.”’*# control) (Fig. 23-6, A). The patient is then asked to
 Motor Control av7

FIG. 23-6
Trunk flexor control. Dotted lines indicate trunk starting position, solid lines indicate trunk final po-
sition, arrows indicate movement direction, and plus symbols indicate muscle groups primarily re-
sponsible for control of pattern. (Skeletal muscle activity occurs on both sides of the trunk [recip-
rocal innervation].) (From Gillen G, Burkhardt A: Stroke rehabilitation: a function-based approach, St
Louis, 1998, Mosby.)

move anteriorly (concentric control) to resume the the lower trunk and pelvis. The end position is one of
initial upright posture (Fig. 23-6, B). trunk elongation on the weight-bearing side and short-
The examiner should observe for evidence of unilat- ening on the non-weight-bearing side, which involves
eral weakness, potential for falls, and symmetry of concentric contraction of the right side.
weight shift. A functional test for trunk flexor control is Lateral flexion is needed for fall prevention when a
to observe the patient move from supine to sitting. patient is reaching to the side (e.g., shutting a car door).

Trunk Extensors Trunk Rotation

TEST 1. The patient is sitting in a position of spinal The primary muscles responsible for rotation are the
flexion with a posterior pelvic tilt and moves into trunk obliques. When a person rotates the trunk to the left,
extension while simultaneously moving the pelvis into the right external and the left internal obliques are re-
neutral or into a slight anterior tilt. This test assesses cruited. Rotational control is a prerequisite for upper ex-
concentric trunk extensor control, which is a prerequi- tremity dressing and reaching across the midline. The
site for lower extremity dressing and forward reach (Fig. following three movement patterns are evaluated:
DS2ThA). 1. The patient sits upright, and the pelvis is in a
neutral, stable position. The patient reaches with his
TEST 2. The patient is seated in an upright posture. or her right arm, across the body, in the direction of
The examiner asks the patient to maintain an erect spine the floor. This motion helps assess concurrent
and lean forward. This test evaluates eccentric trunk ex- flexion and rotation. The motion tests concentric
tensor control (Fig. 23-7, B). For both trunk extensor control of the obliques and the back extensors (par-
tests the examiner should observe signs of unilateral ticularly the thoracic region). Both sides need to be
weakness and note end-range control. tested.
2. The second movement pattern involves trunk exten-
Lateral Flexors sion with rotation. The upper trunk remains stable,
The patient sits in an upright posture. The pelvis is and the lower trunk and pelvis move forward on one
stationary, and the upper trunk laterally flexes toward side (i.e. shifting forward). Again, both sides are
the mat table. Fig. 23-8, A, shows eccentric contraction tested.
of the left side and muscle shortening of the right 3. The patient is positioned supine for the third move-
side. The patient is then asked to return to the original ment. The patient initiates a “segmental roll by
test position (concentric control of the left side) (Fig. lifting the shoulders from the support surface and
23-8, B). toward the opposite side of the body. This pattern is
Fig. 23-8, C, shows assessment of trunk and pelvis controlled by a concentric contraction of the abdom-
lateral flexion, where the movement is initiated from inals (obliques).”*°
378 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

schema and body-to-space relationships is essential to

the production of coordinated movement.
For coordinated movement, all of the elements of the
neuromuscular mechanism must be intact. Coordinated
movement depends on the contraction of the correct
agonist muscles with simultaneous relaxation of the
correct antagonist muscles, together with the contraction
of the joint fixator and synergist muscles. In addition,
proprioception, body schema, and the ability to judge
space accurately and to direct body parts through space
with correct timing to the desired target must be intact.®

INCOORDINATION
Many types of lesions can produce disturbances in coor-
dination.® Disturbances of coordination often stem
FIG. 23-7
from cerebellar and extrapyramidal disorders. Noncere-
Trunk extensor control. Dotted lines indicate trunk starting posi-
bellar causes include diseases and injuries of muscles
tion, solid lines indicate trunk final position, arrows indicate move-
ment direction, and plus symbols indicate muscle groups primarily
and peripheral nerves, lesions of the posterior columns
responsible for control of pattern. (Skeletal muscle activity occurs of the spinal cord, and lesions of the frontal and post-
on both sides of the trunk [reciprocal innervation].) (From Gillen central cerebral cortex. Paralysis of the limbs caused by a
G, Burkhardt A: Stroke rehabilitation: a function-based approach, St peripheral nervous system lesion prevents carrying out
Louis, 1998, Mosby.) tests for coordination, even though CNS mechanisms
are intact.*°?

Cerebellar Disorders
Cerebellar dysfunction can cause incoordination that
can affect any body region and cause a variety of clinical
symptoms. For example, the patient may have postural
difficulties that include slouching or leaning positions
(caused by bilateral lesions) or spinal curvature (caused
by unilateral lesions) and wide-based standing. Eye
movements, both voluntary and reflexive, may be af-
fected, as well as the resting position of the eye. The fol-
lowing are common signs of cerebellar dysfunction that
the therapist may encounter.**
FIG, 23-8
Lateral flexor control. Dotted lines indicate trunk starting posi- Ataxia
tion, solid lines indicate trunk final position, arrows indicate move- Ataxia is manifested as delayed initiation of movement
ment direction, and plus symbols indicate muscle groups primarily responses, errors in range and force ofmovement, and
responsible for control of pattern. (Skeletal muscle activity occurs errors in the rate and regularity of movement. When a
on both sides of the trunk [reciprocal innervation].) (From Gillen patient with ataxia reaches for an object, it is apparent
G, BurkhardtA: Stroke rehabilitation: afunction-based approach, 1998, that the shortest distance between the patient and
St Louis, Mosby.) object is not a straight line. Ataxia results in incoordina-
tion and irregularity of movement. The patient with
ataxia has a staggering, wide-based gait with reduced or
no arm swing. Step length may be uneven, and the
COORDINATION
patient may have a tendency to fall to the side of the
Coordination is the ability to produce accurate, con- lesion. Ataxia will result in a lack of postural stability,
trolled movement. Characteristics of coordinated move- with patients tending to fixate to compensate for the
ment are smoothness, rhythm, appropriate speed, re- instability.7°°?’°?
finement to the minimum number of muscle groups
needed, and appropriate muscle tension, postural tone, Adiadochokinesis
and equilibrium. Coordination of muscle action is Adiadochokinesis is an inability to perform rapid alter-
under the control of the cerebellum and influenced by nating movements such as pronation
and supination or
the extrapyramidal system. Knowledge of the body elbow flexion and extension.”°
 Motor Control 379

Huntington’s disease. Tardive dyskinesia is a drug-

induced disorder, often associated with neuroleptic
drug use. Occupational therapists see tardive dyskinesia
evident when an Saereme touches the finger to the in psychiatric settings. Huntington’s disease is an inher-
nose or an object on a table, or when the individual ited, autosomal dominant disease. Patients with Hunt-
places limbs in voluntary movement.?° ington’s disease have an ataxic gait with choreoathetoid
movements. As the disease progresses, rigidity develops.
Dyssynergia Choreiform movements are faster than athetoid.*®
Literally, dyssynergia is a “decomposition of movement”
ee
ee
ee
—
in which voluntary movements are broken up into their Athetoid Movements
component parts and appear jerky. Dyssynergia can also
cause problems in articulation and phonation.”°

Rebound Phenomenon of Holmes thensame patterns wntines same subject and are not
The rebound phenomenon of Holmes is the lack of a present during sleep.*° Adult athetosis can occur after
“check reflex” —that is, the inability to stop a motion cerebral anoxia and Wilson's disease. Movement pat-
quickly to avoid striking something. For example, if the terns include alternating “extension and flexion of the
patient's arm is flexed against the resistance of the ex- arm, supination and pronation of the forearm, and
aminer and the resistance is released suddenly, the flexion and extension of the fingers.”** Athetosis that
patient's hand will hit the patient's face or body.?””° occurs with chorea is termed “choreoathetosis.”*°

pabicities
om
tonia result in persistent posturing of the extremi-—
aie feg., in fee ion or hyperflexion of the wrist
Itinterferes control and fine adjust- and fingers) with concurrent torsion of the spine and as-
ments required for balance. Nystagmus can occur as a sociated twisting of the trunk.’ Dystonic movements are
result of vestibular system, brainstem, or cerebellar writhing and often continuous and are often seen in
lesions.*° conjunction with spasticity.*° Dystonia can be primary
or secondary, the latter occurring with other CNS disor-
Dysarthria ders (e.g., hypoxic brain injury or tumor). Segmental
dystonia involves two or more adjacent body parts.
Generalized and multifocal dystonia also exist. Focal
speech may Fiso vary in
n pitch, seem nasal and tremu- dystonia involves only one limb, as seen in writer's
lous, or both.*°° cramp, musician’s cramp, and spasmodic torticollis.*’

Bal lism
Extrapyramidal Disorders
ptom that isproduced by continu- |
bnaaoeiits axial and proximal mus-
nes tkinesia. Parkinson’s disease is character-
ized by hypokinesia (bradykinesia), cogwheel and lead It occurs on aie side of the body
pipe rigidity, a decrease or loss of postural mechanisms, emiballism) and is caused by lesions of the opposite
and a resting, pill-rolling tremor.~” subthalamic nucleus.7”7°
“Parkinson's Plus” is the name given to a group of
movement disorders that have signs of Parkinson's ey
disease with concomitant neurological deficits. Progres-
sive supranuclear palsy is one such disease.** Affected
persons have “loss of vertical ocular gaze, rigidity of the occursarn Seine movement. It is aed
neck and trunk muscles, dementia, and parkinsonian at the termination of the movement and is often seen
signs,”*” usually in the absence of tremor. Life ex- in multiple sclerosis. The patient with intention
pectancy is shorter than in Parkinson's disease. Death tremor may have trouble performing tasks that
often occurs within 6 to 10 years.*’ require accuracy and precision of limb placement
(e.g., drinking from a cup or inserting a key in a
Chorea pes):
g tremor occurs at rest and subsides when vol-
untary movement is attempted. It occurs as a result
of disease of the basal ganglia and is seen in Parkin-
sleep.7° Two types of chorea are tardive dyskinesia and son’s disease.
 380 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

3 ial familial tremor is inherited as an autosomal the weights make the coordination worse. Some-
dominant trait. It is most visible when the patient is times the use of weights increases tremor.
carrying out a fine precision task.*” 5. Observe for tremor. Are the eyes and speech affected?
6. Does the patient's emotional status affect coordina-
ASSESSMENT OF COORDINATION tion?
How do the patient's ataxia or coordination prob-
Medical Assessment of Coordination
lems affect coordination?
Incoordination consists n rate, rhythm, range, 8. Perform an occupational history interview, asking
direction, and force of nent.’ Therefore observa- about the patient's roles, routines, goals, and envi-
tion is an important element of the clinical examina- ronment to determine which functions are impor-
tion. The neurological examination for incoordination tant for the patient.
may include the nose-finger-nose test, the finger-nose Several standardized tests of motor function and
test, the heel-knee test, the knee pat (pronation- manual dexterity are available and can be used to evalu-
supination) test, hand pat and foot pat tests, finger wig- ate coordination. Some of these tests are the Purdue
gling, and drawing a spiral.*°* Such tests can reveal Pegboard,’* the Minnesota Rate of Manipulation Test,°°
dysmetria, dyssynergia, adiadochokinesis, tremors, and the Lincoln-Oseretsky Motor Development Scale,” the
ataxia. Usually the neurologist or physiatrist performs Pennsylvania Bimanual Work Sample,”” the Crawford
these examinations. Magnetic resonance imaging and Small Parts Dexterity Test,** and the Jebsen-Taylor Hand
computerized tomography scans may also be ordered. Function Test.*? The standardized functional assess-
Tremors are frequency rated with EMG, which helps the ments for CVA and the TEMPA (geriatrics) mentioned
physician accurately diagnose tremor type.*” earlier may also be useful for the geriatric population.*®

Occupational Therapy Assessment of RESULTS OF ASSESSMENT AS A BASIS

Coordination FOR PLANNING INTERVENTION
Selected activities and specific performance tests can Although the therapist bases intervention on the results
reveal the effect of incoordination on function. The oc- of the patient's assessments, including cognition, vision,
cupational therapist can observe for coordination diffi- perception, sensation, psychological aspects, and occu-
culties during ADL assessment. The therapist can pational needs,°’ assessment of motor control suggests
prepare simulated tasks that require coordinated muscle some directions for treatment. Several approaches to
function, such as writing, opening containers, tossing motor control management are described in Chapters 9
and catching a bean-bag or ball, or playing a board and 32 to 36. The sensorimotor approaches are often
game.’® The therapist should observe for irregularity in used to enhance CNS integration and improve the pos-
the rate of movement and for sudden, corrective move- tural mechanism, muscle tone, and motor coordination
ments in an attempt to compensate for incoordination. and control.
Movement during the performance of various activities
may appear irregular and jerky and overreach the
Intervention for Hypertonicity
mark.®* The following general guidelines and questions
can be used when evaluating incoordination:
and Spasticity
1. Assess the muscle tone and joint mobility first. Hypertonicity is only one part of the UMNS. It is very
2. Observe the patient in the sitting position and locate important to treat other performance deficits of the
any overdeveloped muscle bulk. UMNS such as paresis, fatigue, and decreased dexter-
3. Observe for ataxia, proximal to distal, during func- ity. These deficits can impede function more than hy-
tional upper extremity movement. Are movements pertonia.'°
away from or toward the body more difficult for the Before treating hypertonus, the therapist and physi-
patient? Where, within the ROM, is ataxia most cian need to closely evaluate the function of the tone.
prevalent? Hypertonicity can have beneficial effects, such as aiding
4. Stabilize joints proximally to distally during the in standing and transfers, maintaining muscle bulk, and
functional task and note differences in patient per- preventing deep vein thrombosis, osteoporosis, and
formance, as compared with performance without edema. Intervention is necessary when spasticity inter-
stabilization. (Stabilization can be by splinting or feres with ADL, gait, sleep, or wheelchair positioning or
stabilizing the affected body part against a wall.) when it causes severe pain and limits hygiene (e.g., the
Weighted cuffs may be applied to the extremity patient is unable to wash hand or axilla) or leads to con-
during task performance to determine if weighting or tractures or decubitus ulcers. Hypertonicity or spasticity
resistance decreases the tremor (use caution). Note may be treated with conservative therapeutic interven-
the amount of resistance provided. Observe whether tions, pharmacological agents, or surgery.
 Motor Control 381

Conservative Treatment Approaches | upper arm portion of a long arm cast can be cut out to
For hypertonicity in the upper extremity, which is allow the triceps to be facilitated to extend the arm.
usually accompanied by synergy or patterned move- Serial casting should cease when desired position is
ment, treatment methods that use techniques of inhibi- achieved and tone is manageable with the last cast or
tion may be appropriate. This includes methods such as splint. If there is no evidence of increased passive ROM
the sensorimotor approaches described in Chapters 32 after two to three casts are removed, serial casting must
through 36. The appropriateness of these methods cease; however, the last cast should be kept, bivalved,
depends on the disability, severity, and distribution of and used as a splint to prevent further contracture.’*
the hypertonicity and on concomitant problems. The Many innovations have occurred in commercially avail-
goal of neurodevelopmental treatment is to balance the able spasticity reduction splints that are used to place
tone for more normal movement. Therefore interven- the wrist and hand in inhibitive postures. The patient
tion involving inhibition of the hypertonic muscles and and family need to be educated in continuing to incor-
facilitation of the antagonist muscles is implemented.’* porate the extremity in occupation, and to bear weight
Another OT objective is to have the patient manage on the extremity as much as possible to retain the ROM
muscle tone to accomplish essential daily living activi- gains achieved during casting.
ties. Positioning and movement in patterns opposite to Physical agent modalities such as cold, superficial
hypertonic or synergistic patterns are important in de- heat, ultrasound, and neuromuscular electrical stimula-
veloping quality movement that is as close to normal as tion can be used as preparation for or in conjunction
possible. At times it is appropriate to facilitate synergis- with purposeful activity and muscle reeducation, pro-
tic movements in the patient with chronic disease (or if vided the therapist has'the appropriate training and can
the patient does not recover beyond Brunnstrom’s'* prove competency. Ultrasound can help inhibit or
stage 3).°' The synergy patterns can be facilitated to reduce hypertonicity temporarily and increase tendon
improve lateral pinch or elbow flexion function. The and muscle extensibility. It is helpful to provide concur-
patient should be taught how to modulate the abnor- rent stretch during the ultrasound procedure.’* Neuro-
mal tone or how to instruct others to do so. The patient muscular electrical stimulation has been shown to
should also be taught how to incorporate the affected strengthen paretic muscles.'”’**
upper extremity as much as possible into all ADL.'***
ADL, crafts, games, and work activities can be used to Pharmacological Agents
teach incorporation of the extremities for a total ap- Pharmacological agents prescribed and administered by
proach to treatment.®” physicians include oral medication, short-term nerve
Even when motor control is adequate for some func- blocks, and long-term blocks.
tions, the sensory and perceptual abilities of the patient Patients with severe hypertonicity accompanied by
may affect the achievement of functional goals. Percep- severe pain may need evaluation ofthe cause ofthe pain.
tual dysfunction may alter the patient's abilities, requir- Drug therapy and other pain management techniques
ing the therapist to focus on perceptual training as well.° may be part of the treatment approach. The four drugs
In some cases unilateral hypertonicity is severe most commonly used for spasticity of UMN origin are
enough to necessitate serial inhibitive casting or splint- diazepam, baclofen, dantrolene sodium, and tizanidine.
ing (see Chapter 31). Casting in inhibitive postures has Dantrolene sodium acts at the skeletal muscle. Dantro-
been shown to be effective in tone reduction.2***°”” lene sodium is preferred in cerebral spasticity because it
The beneficial effect of casting on hypertonia and upper is less apt to cause sedation. Dantrolene can cause weak-
extremity contractures has also been well documented ness and liver damage.’* Diazepam’s side effects include
in the literature.'*'**° drowsiness, fatigue, and possible addiction. Baclofen is
Casting in inhibitive postures is effective because it more effective with spinal cord injuries than with cere-
provides neutral warmth, maintained pressure, and con- bral injuries. Its potential side effects are confusion,
stant joint positioning with static lengthening of drowsiness, and hallucinations. Neither diazepam nor
muscle.*° Serial casting is most successful when a con- baclofen can be discontinued suddenly because to do
tracture has been present for less than 6 months. The sO may cause seizures. Tizanidine HCl is labeled for
cast may be bivalved (cut in half) and worn as a splint. spasticity reduction in multiple sclerosis and spinal
This helps protect the skin and allows the therapist to cord injury. Its side effects may include hypotension, se-
work with the extremity out of the cast. However, many dation, and visual hallucinations. No matter which drug
clinicians believe that a nonbivalved cast is more effec- is used, it is crucial for the occupational therapist to
tive and actually causes less skin breakdown.’ A communicate to the medical staff any noted side effects
dropout cast, which can be used as part of the serial that interfere with the patient's overall function.’*
casting process, includes a cut-out area, allowing move- Nerve blocks are injections of a chemical agent
ment of the joint in the desired direction. For example, to diminish or obliterate tone. There are short and
for an elbow that has flexor hypertonicity, the dorsal long-term nerve blocks. Short-term nerve blocks are
382 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

injections of an anesthetic (e.g. bupivicaine) to tem- treatments and their relation to occupational therapy,
porarily reduce pain and muscle tone. These short-term the reader is referred to Preston and Hecht's Spasticity
blocks help the physician differentiate between hyper- Management: Rehabilitation Strategies.’*
tonus and contracture.”’ The short-term nerve blocks
last from 1 to 7 hours, depending on which anesthetic is
Treatment of Rigidity
used.
Long-term blocks, usually injections of phenol or Decerebrate and decorticate rigidity can wax and wane.
botulinum toxin-type A (Botox), generally last several When the rigidity is waning, it is recommended that the
months. Botox lasts for 3 to 5 months. Phenol blocks patient be transferred to a wheelchair or reclining chair
last from 2 to 8 months, depending on whether the because the rigidity decreases in sitting. The rigidity is
motor points (2 to 3 months) or the motor branch (8 worse during episodes of agitation.”” Parkinson’s rigid-
months) is injected. Phenol and Botox have different ity responds temporarily to heat, massage, stretching,
mechanisms of action. Botox exerts its effect via chemi- and ROM exercises. Rocking back and forth before
cal denervation, and phenol works via motor point or standing can aid in the transition. See Chapter 39 for
motor branch neurolysis. Both blocks can be used to di- additional treatment strategies for rigidity.°®
minish or obliterate hypertonicity in the agonist. The
blocks help to prevent contractures and render the hy-
Treatment of Flaccidity
pertonic muscle weak or flaccid.'?4”" The effect and
time interval of the long-term block provide therapists Flaccidity stemming from upper motor neuron dysfunc-
the opportunity to increase antagonistic strength and tion (e.g., recovering from spinal or cerebral shock re-
function. A combination of long-acting nerve blocks sulting from acute CNS insult) is treated with facilita-
and casting or splinting is often used to treat hyper- tion techniques such as weight bearing, high-frequency
tonicity. Long-term blocks in the upper extremities are vibration, tapping, quick stretch, bed positioning with
commonly used in the subscapularis, brachioradialis, weight on the flaccid side the majority of the time, and
and flexor digitorum sublimis. functional neuromuscular electrical stimulation. Splint-
ing the hand and wrist may be indicated for support.
Surgical Methods Therapists should closely supervise splinting, since con-
Surgery to control hypertonicity is also an option. tractures can result from excessive splint wear. Passive
Dynamic EMG can help orthopedic surgeons plan ROM exercises also are indicated.’*
surgery. Orthopedic surgical intervention can improve The arm can be positioned as normally as possible
function or release contractures. Examples of upper ex- during ADL tasks to provide sensory and proprioceptive
tremity functional surgery include lengthening of the feedback. Patient education in proper positioning and
biceps tendon to reduce elbow flexion and gain elbow joint protection is important to protect joint structures
extension, thumb-in-palm release, and transferral of the and prevent trauma.
flexor carpi ulnaris tendon to the extensor carpi radialis
longus or brevis tendons to decrease the deforming
Treatment of Incoordination
force of wrist flexion while simultaneously augmenting
wrist extension.’> An example of a contracture release Admittedly, treatment of incoordination is difficult.
procedure is the flexor digitorum superficialis to profun- Several approaches may be used. Incoordination arising
dus transfer to gain length in the extrinsic finger from lesions of the corticospinal system may be im-
flexors.*° proved using one of the sensorimotor approaches di-
A common neurosurgical procedure performed on rected to the normalization of muscle tone and the de-
adults with severe spasticity is intrathecal baclofen velopment of more normal movement patterns. Specific
pump (ITB) implantation. This enables baclofen to sensory input is used to change muscle tone and evoke
enter the body at the spinal level and avoids the cen- adaptive motor responses.
trally mediated side effects of oral baclofen.’* The ITB Activities graded on the basis of normal motor learn-
provides baclofen, a spasticity-reducing medication, di- ing and control may be helpful for attaining proximal
rectly into the intrathecal (subarachnoid) space via a stability and then mobility. Therapy directed toward the
catheter attached to a subcutaneous implantable pump modulation of reflexes and abnormal synergy patterns
in the abdomen. A patient must undergo a lumbar and the enhancement of postural control mechanisms,
puncture test dose of intrathecal baclofen to determine such as the righting and equilibrium reactions, can help
candidacy before pump implantation. to improve coordination. Weight bearing, joint approxi-
ITB has been shown to be very effective in the reduc- mation, placing and holding techniques, and fixed
tion of severe spinal spasticity and spasticity associated points of stability (tabletop) can be helpful.'’ The ther-
with multiple sclerosis and is also effective for cerebral apist should begin with small ranges of movement and
spasticity. For further details of medical and surgical gradually increase them as the patient progresses. Ini-
 Motor Control 383

tially, work is done in the plane and direction of move- surgical options in ameliorating motor control prob-
ment that are easiest for the patient, and the work pro- lems can play a triage role in suggesting referral to
gresses toward more difficult areas. Some of the invol- physician specialists.
untary movements of cerebellar or extrapyramidal
origin, particularly primary movement disorders, are
difficult to manage or change. Therapists have more in- REVIEW QUESTIONS
fluence over the movement disorders that are associated Define plasticity.
with traumatic brain injury and stroke. . When would a physician recommend a long-term
NOR
Methods and devices to compensate for incoordina- nerve block?
tion may be necessary to make ADL safer, more possi- 3. Describe the characteristics of rigidity.
ble, and more satisfying. A thorough occupational - Compare and contrast spasticity and HTSR.
history interview is necessary to make appropriate activ- 5. Why should the assessment of muscle tone be per-
ity and equipment choices and determine adaptive formed in conjunction with the patient's overall
strategies that the patient can carry over to the home en- motor function?
vironment. Some of these strategies are described in 6. List the procedure for an upper extremity muscle
Chapter 13. The physician may employ pharmacologi- tone evaluation.
cal agents or surgical intervention in an effort to control 7. What are the components of a normal postural
tremors or other involuntary movements. mechanism?
8. Describe equilibrium reactions and the functional
Surgical Intervention for Movement implications of their presence in motor control.
Disorders 9. Describe functional difficulties encountered when
the asymmetrical tonic neck reflex is present.
Neurosurgical intervention for movement disorders 10. Compare and contrast chorea and athetosis.
may include stereotactic thalatomy for ballismus, 11. Describe ataxia.
chorea (Huntington’s), Parkinson's disease, essential 12. Compare and contrast the following tremors: essen-
tremor, and athetosis. Surgical treatment for dystonia tial familial, resting, and intention.
may include rhizotomy, neurectomy, cryothalotomy, or
IBF implantation.*’ Deep brain stimulation has been ef- REFERENCES
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 1 nt of Visual Deficits

LEARNING OBJECTIVES
Visual perception After studying this chapter the student or practitioner
Visual perceptual hierarchy will be able to do the following:
Visual cognition 1. Understand the role vision plays in enabling the
Visual memory person to adapt to the environment.
Pattern recognition 2. Understand how visual input is processed within
Visual scanning the CNS to turn raw visual data into cognitive
Search concepts of space and form through the process of
Visual attention visual perception.
Oculomotor control 3. Understand the concept of the visual perceptual
Visual fields hierarchy as a framework for evaluation and
Visual acuity treatment of visual perceptual dysfunction.
Visual field deficit 4. Understand the purpose of evaluation completed by
Binocular vision occupational therapy (OT) practitioners.
Sensory fusion 5. Understand how visual acuity, visual field,
Diplopia oculomotor control, visual attention, and visual
Paralytic strabismus scanning change following brain injury.
Convergence insufficiency 6. Understand how visual acuity, visual field,
Hemi-inattention oculomotor control, visual attention, and visual
Visual neglect scanning affect functional performance.
7. Understand how to assess and treat deficits in visual
acuity, visual field, oculomotor control, visual
attention, and visual scanning.

n understanding of visual perceptual dysfunction whether the ability to process visual information has
after cerebrovascular accident (CVA) and traumatic brain been altered so that it prevents completion of a necessary
injury must be preceded by the realization that visual activity of daily living.
perception is a process used by the central nervous
system (CNS) to adapt to the environment. Visual per- ROLE OF VISION IN THE ADAPTATION
ception is not a series of discrete perceptual skills or the
PROCESS
function of a single sensory modality, but rather a
process that integrates vision with other sensory input According to Jean Ayres,* the overall function of the
for adaptation and survival.’*’*? The activities a person is brain is to filter, organize, and integrate sensory infor-
required to complete in a day will dictate the visual per- mation to make an adaptive response to the environ-
ceptual processing needed. Whether a patient has a ment. The brain or CNS receives a variety of sensory
visual perceptual deficit after brain injury will depend on information, including visual, proprioceptive, tactile,

386
 Evaluation and Treatment of Visual Deficits 387

vestibular, and auditory information. Vision is used speed of visual processing enables the rapid intake of
along with information from these other sensory large amounts of detailed information. The person can
systems to adapt to the environment—to act on it and instantly identify an object visually, whereas identifying
to manipulate, mold, and improve it. In adapting to the the object tactilely would take longer. For example, a
environment, the CNS combines the isolated bits of person groping for a bottle in the medicine cabinet late
sensory information it receives, integrating them to at night with the lights off knows that if a light is turned
form a picture of the environment. This picture, created on, the bottle will be found instantly.
by sensory input, becomes the context of a situation, The speed at which vision is able to supply informa-
and an individual uses this context to make decisions tion about the environment is critical to the ability to
and formulate plans to respond to various situations. negotiate dynamic environments safely. Dynamic envi-
Successful adaptation to the environment depends ronments are those in which objects and other persons
on the ability to anticipate information. The key to sur- are in motion independent of the individual in the en-
vival is to stay one step ahead of circumstances, whether vironment. To be able to move safely through such an
working with patients or navigating rush-hour traffic. environment without colliding with other objects re-
Anticipation enables an individual to plan for situa- quires rapid information processing, which can be sup-
tions, and planning allows manipulation of the envi- plied only by vision. For example, it is possible to send
ronment. If a person was unable to plan for situations a blindfolded person into an empty room to locate a
and able to react to them only once they occurred, the chair to sit upon without that person’s harshly colliding
person might be able to survive the challenges of the en- with other objects and possibly incurring injury. It will
vironment but not to act on or change the environment. take only a few minutes longer to complete this task
Anticipation and planning are driven by the sensory without vision than with vision. However, it is unlikely
context of a person’s circumstances: “It looks like rain. that the same person could be sent into a room full of
I'd better take an umbrella,” or “It’s dark in there. I'd people milling about and meet with the same success
better take a flashlight.” How sensory information is within the same time frame. The ADL most affected by
perceived determines the plan formulated to respond to visual impairment take place in dynamic, unpredictable
each situation. environments such as those found in the community
Given the importance of sensory context, what role and workplaces. Reintegrating a person with a visual im-
does vision, a basic sensory process, play in the adapta- pairment into the stable environment of the home is a
tion process? Vision is our most far-reaching sensory relatively easy process, but reintegrating a person into
system. It is the sensory system that takes us out into our community environments is much more difficult.
environment, that is the first to alert us to danger (e.g., Visual impairment can occur secondary to disease,
seeing a threatening storm approach), and that is the first trauma, and aging.”?***’* Often a combination of at
to alert us to pleasure (e.g., seeing your pet in the yard as least two of these causes is observed, especially in older
you drive up). Because of its far-reaching nature, visual patients. Visual impairment alters the quality and
input strongly dominates the construction of the envi- amount of visual input into the CNS or alters how the
ronmental picture we use to adapt. We rely on vision to CNS is able to process and use incoming visual input.
“size up” situations. We say to ourselves, “He looks Either way, the result is a decrease in the ability to use
harmless,” or “That looks delicious.” Our language is vision to adapt to the environment. The therapist will
peppered with phrases that reflect the importance of be able to observe a decrease in the speed with which a
vision in decision-making, such as, “I'll believe it when I patient can process information from the environment.
see it,” “I'll keep an eye out for it,” or “I can see what you This decrease in speed may prevent the patient from re-
mean.” Because visual input dominates the construction sponding safely in dynamic environments. Changes in
of sensory context, it plays a powerful role in the antici- decision making may be observed in which the patient
patory process, and therefore in our ability to adapt to makes errors because not enough visual information
the environment. How a person “sees” a situation trig- was received or because the information received was
gers the planning and decision-making processes. faulty. The patient may even be unable to make deci-
The decision-making process guided by vision is not sions. Visual impairment has the potential to change
limited to manipulation of objects in the environment. the patient's interaction with all aspects of the environ-
Vision plays an important role in social communica- ment and the persons and objects in it.
tion, enabling a person to “read” and respond to the
subtle gestural and facial expressions used to communi- AN OVERVIEW OF VISUAL PROCESSING
cate emotional content in conversations. Vision also
WITHIN THE CENTRAL NERVOUS SYSTEM
plays an important role in motor and postural accom-
modation by warning of upcoming challenges to pos- For vision to be used for adaptation, the raw mate-
tural control, such as the presence of a curb, stairs, a rial of vision (i.e., the pattern of light that falls on
ramp, a banana peel, or obstacles in the travel path. The the retina) must be transformed into images of the
 388 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

surrounding environment. Those images must then be each other. Visual information must be integrated with
conveyed to the prefrontal areas of the brain, where de- other sensory information to provide this orientation.
cision making takes place 54,64 , as Tactile, proprioceptive, kinesthetic, vestibular, and audi-
enters the eye & tory information is necessary, along with visual input,
for people to accurately assess the relationship between
them and the objects that surround them. The map
created by information synthesized in the parietal cir-
cuitry is body centered and dynamic, changing in shape
and content as the body moves through space.°”°*’?*
mation from The posterior parietal circuitry in each hemisphere
‘integrat es this i ~~ contains a map of the space on the contralateral side of
sion 3954 after synapsing in tiesLCN, Pail rare the body. Thus the right hemisphere contains a map of
ek avels over the geniculocalcarine tracts to the the left side of the body and surrounding space, and the
visual cortex (found within the occipital lobe). Fig. 24-1 left hemisphere contains a map of the right side of the
shows these pathways. The visual cortex sorts through body and surroundings.*° The map is not a detailed rep-
the incoming visual information, sharpening and fine- resentation of space but provides a general impression
tuning features such as orientation of line and color, of objects in space on that side of body. The CNS relies
then disperses this information for cortical process- on visual information from the peripheral areas of the
ing.””° From the visual cortex, visual information is retinal fields to create and maintain these maps. This
processed by cortical circuitry and eventually sent to area of the brain participates in directing general atten-
the prefrontal circuitry to be used in decision making. tion to and awareness of space.°”’°*
Before it can be used by the prefrontal areas, visual in- The final destination for visual information traveling
formation must be combined (integrated) with other through the posterior temporal and parietal circuitry is
incoming sensory information to establish images and the prefrontal area of the brain, where the information
relationships between the body and the environmental is used to make decisions and formulate plans. This
surround.”* area, along with the premotor circuitry and other areas,
is responsible for planning skilled body movements, in-
cluding eye movements.*”*”’** The frontal eye fields are
located in area eight of the prefrontal lobes and are re-
sponsible for voluntary visual search of the space on the
contralateral side of the body"”*°; that is, the frontal eye
fields in the right Beanenhiere direct visual search
a te eR Dessigs (Fig. toward the left visual space, and vice-versa. The frontal
24-2). eal Menai traveling the southern route eye fields conduct visual search based on an expectation
through the posterior temporal circuitry is processed for of where visual information will be found in the envi-
visual object information and recognition.?*°* The ronment; the fields then direct the eyes to move toward
purpose of this processing is to identify objects and clas- that area.°° For example, if you were looking for a light
sify them. Neural processes in the posterior temporal switch in a room, you would direct your visual search
lobe use precise visual input from the macular-foveal toward the walls, because that is where you expect to
area of the retina to tune into the visual details of find a light switch. You would not waste time searching
objects. Processing by posterior temporal circuitry is the floor or the ceiling. By directing visual search based
critical to the ability to distinguish discrete features of on the expected location of crucial visual information,
objects, such as the difference between the style of a can the CNS is able to process visual information quickly.
of diet Coke and regular Coke or particular facial fea- This arrangement enables us to engage successfully in
tures. This area of the CNS participates in directing at- activities that require rapid visual processing, such as
tention to visual detail. driving.
Visual information taking the northern route to the Not all visual information travels over the geniculo-
prefrontal circuitry travels through the posterior parietal calcarine tracts for cortical processing. Many neural
lobe. The parietal lobe is a synthesizer of sensory infor- pathways leave the optic nerve and tract and travel to
mation, receiving input from all of the sensory systems subcortical areas, including the hypothalamus and
and integrating the input to create internal sensory brainstem.*”*°°* The brainstem contains important
maps that are used to orient the body in space.°”?*?*’? neural structures involved in visual processing. The su-
Visual information traveling through the parietal cir- perior colliculi, located in the midbrain of the brain-
cuits is used to tune the CNS in to the presence of the stem, are primary brainstem processing centers. The su-
objects surrounding the body and to determine the perior colliculi are responsible for the detection of
spatial relationship of the objects to the body and to moving visual stimuli appearing in the peripheral visual
 PARALLEL-DISTRIBUTED PROCESSING OF THE VISUAL SYSTEM-I
Schematic inferior view of a horizontal slice of the brain

Major synaptic areas:

Retina:
Rods and cones >
Bipolar cells —>—
Ganglion cells (make
The eye and retina ——————— >| axons of optic nerve)

Optic nerve
From optic chiasm —>—
Hypothalamus
Optic chiasm

Optic tract From optic tract —>—

Midbrain reticular
formation
Cerebral peduncle

To lat. genic. nuc.

Geniculo-
calcarine trs. To midbrain sup.
colliculus (and istegia
nuc. above colliculus,
Lateral not shown)
geniculate nucleus

1° visual cortex and

. some to 2° visual
Hippocampal assoc. cortex
ormation and
temp. horn lat. ventricle

Not illust: to the

Calcarine fissure and 1° visual cortex “\; pulvinar of thalamus
‘ and accessory oculomotor
nuc. of midbrain
Longitudinal fissure between the hemispheres

The visual system is our mostimportant

sense in regard to:—
A. Learning, memory, and recall including our ability to see color and fine
details as well as the visual surround and global relationships.
B. Communication: use of symbolic language, speaking, and body language.
. Spatiotemporal orientation in concert with vestibular-proprioceptive systems.
. Early warning system to pleasure or danger, i.e., vision is our farthest
reaching distance receptor and movement detector par excellence.
ea E Visual-manual and visual-motor activities.
°, Primary.
2°, Secondary.
FIG. 24-1
Pathways from retina to LGN to visual cortex. (Courtesy of Josephine C. Moore, PhD, OTR.)

389
390 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

\LLEL-DISTRIBUTED PROCESSING OF THE VISUAL SYSTE

Two parallel routes carry visual information from the occipital lobe to the
prefrontal lobe and frontal eye field (FEF). Fibers from these two routes
istribute to many areas at each route (not illustrated) before terminating
in the prefrontal cortex and FEF as illustrated.

(N) = “Northern” or superior route via parietal and frontal lobes.

(S) = “Southern” or inferior route via temporal and frontal lobes.

Parietal association
cortex or visual-
spatial maps an
orientation including
movement detection
Prefrontal lobe
and FEF =
frontal eye field:
ecision-making,
planning ahea
and emotional tone

1° and association
visual cortex

Lateral view of the

eft hemisphere Posterior temporal
association cortex or
Superior visual object recognition
including color and form
Ant. Post.

Inferior
1° Primary.
FIG. 24-2
Visual input travels from the visual cortex through parietal and posterior temporal circuitry to the
prefrontal lobe to complete cortical visual processing. (Courtesy of Josephine C. Moore, PhD, OTR.)

fields.°°*°°°°° When motion is detected, the colliculi within and between hemispheres to ensure effective and
automatically initiate eye movement toward the direc- efficient visual processing. Like a car in which the fuel-
tion of the detected motion. In performing this func- injection system is as critical to performance as the
tion, the colliculi serve as an early warning system to spark plugs, the visual system will not run efficiently
prevent the CNS from being “caught off-guard” by unless all of its components are working together. When
events occurring in the environment.*”®* The brainstem brain injury or disease occurs, this communication
also contains centers for the control of horizontal- and system is disrupted and the organization of visual pro-
vertical-gaze eye movements. The nuclei of cranial cessing breaks down. Table 24-1 lists effects of various
nerves III, IV, and VI, which control the extraocular CNS lesions on different aspects of the visual system. In
muscles of the eyes, are also located in the brainstem, reviewing the table, remember that a patient will exhibit
along with basic visual functions such as the light a functional limitation only in those ADL that require
(pupillary) reflex and the accommodation reflex.*® the type of visual processing compromised by the
Various CNS areas are responsible for processing lesion. For example, a deficit in the ability to process
visual information, but all areas must work together for visual detail caused by a lesion in the left posterior tem-
a person to make sense of what is seen and thus use poral lobe would significantly affect the ability of a
visual information to adapt.°°°*”*°* Millions of long proofreader to return to work but might have little effect
and short neural fibers tie the various centers together on a piano tuner’s ability to return to work.
 Evaluation and Treatment of Visual Deficits

Summary of Cortical Hemispheric Functions for Visual Processing and Deficits Secondary
to Lesion Site
- Left Hemisphere
: Advantage Right Hemisphere Advantage
_ More detail-oriented in relation to persons, places, and things More global or holistic
__ Takes in minute details and compares and contrasts these details Takes a general view of the environment
_ Processes visual information sequentially in a systematic item-by- Processes multiple visual inputs simultaneously, grouping them into
_ item, serial search strategy meaningful categories
Attends only to right visual fields Attends globally to both left and right visual fields
Parietal Lesion Post. Temp. Lesion Parietal Lesion Post. Temp. Lesion
Biases attention to detail Biases attention to global Biases attention to detail Biases attention to global
“input input
Biases brain to right Biases brain to right Biases brain to left Biases brain to left
hemisphere advantages hemisphere advantages hemisphere advantages hemisphere advantages
May have right inferior May have right superior May have neglect or hemi- May have neglect or hemi-
quadrant visual field loss quadrant visual field loss inattention along with left inattention along with left
inferior quadrant visual field superior quadrant visual
loss field loss
Modified with permission of Josephine C. Moore.

FRAMEWORK FOR EVALUATION through vision is a result of the processes working in

AND TREATMENT OF VISUAL synergy. Although discrete perceptual processes can be
PERCEPTUAL DYSFUNCTION identified, they do not operate independent of one
A Hierarchical Model of Visual another. ;
The highest-order visual perceptual process in the hi-
Perceptual Processing
erarchy is visualpeepenion:

fliesSake ieeration ofvisionNeth ‘he CNS t to turn

the raw data supplied by the retina into cognitive con-
cepts of the perception of space and objects that be
ed and used for decision
oe ales com ples eda Uae. it serves as a foundation
for all academic endeavors, including reading, writing,
and mathematics, and many vocations, such as artist,
engineer, surgeon, architect, and scientist.
h eee Fig. 24- 3 aitereres nas set Visual cognition cannot occur eee the presence
chy. Within the (pleas each process is supported by
the one that precedes it and cannot properly function
without the integration of the lower-level UDIOcess, As
Fig. 24-3 Sat phe. vis e
* peaigon to bene ablesti to storeSarcoal images tem-
porarily in short-term memory, a person must also be
>/ able to store and retrieve images from long-term
O qd Dy memory. For example, to interpret the illustration in
Fig. 24-4, one must be able to access visual memories of
Sual felds, a 1a V Ud , the shape of both a goose and a hawk. Adults and older
The ability to use visual perception to adapt to the children can easily resolve this illusion, but most tod-
environment is the result of the interaction of all of the dlers cannot because they have not yet stored memories
processes in the hierarchy in a unified system. Each per- of the shapes of these birds.
ceptual process is discussed individually in this section. Before a visual image can be stored in memory, an in-
The reader should remember that the ability to adapt dividual must recognize the pattern making up the
04) Pd EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

Adaptation
Throug
Vision

Visuocognition

Visual Memory

Pattern Recognition

Scanning

Attention = Alert and Attending

Oculomotor Control Visual Fields Visual Acuity

FIG. 24-3
Hierarchy
of visual perce system. (Courtesy of Josephine C.
Moore, PhD, OTR. From ren M: A hierarchical ey for evaluation and treatment of visual per-
ceptual dysfunction in adult acquired brain injury, part |,AmJ Occup Ther 47[1]:55-66, 1993.)

scanning reflect the engagement of visual attention as it

is shifted from object to object. Visual search occurs on
feature is a feature thatrere onee object from two levels: an automatic or reflexive level largely con-
another. For example, the salient feature that differenti- trolled by the brainstem and a NONIIEON level driven by
ates an “E” from an “F” is the lower horizontal line on the cortical ps: of cognition.”
the “E.” Pattern recognition involves two abilities: the a ve
ability to identify the configural and holistic aspects of an
object—to see its general shape, contour, and features—
and the ability to identify specific features of an object,
such as details of color, shading, and texture.'® Both individual eee ‘inexpented intrusions in the environ-
aspects of recognition must occur for accurate identifi- ment. Voluntary visual search, directed by the cortex, is
cation.® completed for the explicit purpose of gathering infor-
Pattern recognition cannot be accomplished without mation. Visual search is purposefully and often con-
the next process in the hierarchy: organized and thor sciously driven by a desire to locate certain objects in
ough scanning of the visual scene. Visua r the environment, such as a misplaced set of keys, or
search is accomplished throu to obtain certain information, such as where an exit is
‘movements. A saccade is a located.??
an object of interest in the env it. The roe of
a saccade is to focus on the object with the fovea, the
area of the retina with the greatest ability to process object or ifonnanion determines if and how that visual
detail.*° In scanning a visual array, the eyes selectively input will be analyzed by the CNS, which becomes the
focus on the elements that are critical for accurately in- basis for decision making. People who do not attend to
terpreting the array.*~”°°’°* The most important details visual information do not initiate a search for visual in-
are reexamined several times through a series of cyclic formation, do not complete pattern recognition, do not
saccades to ensure that correct identification is made. lay down a visual memory, and cannot use this visual
Unessential elements in the scene are ignored.°*? input for decision making. Likewise, those who attend
 Evaluation and Treatment of Visual Deficits 393

FIG. 24-4
Is this a goose or a hawk? (From Warren M:A hierarchical model for evaluation and treatment of
visual perceptual dysfunction in adult acquired brain injury, part |, Am J Occup Ther 47[1]:55-66, 1993.)

to visual information in a random and incomplete way visual acuity. | > MOvE
—
often do not have sufficient or accurate information on curaa and
which to base a decision.
The type of visual attention engaged by the CNS
depends on the type of visual analysis needed. For
example, the type of attention needed for awareness
that a chair is in the room is different fromthe type these prerequisite maa functions, ; an1 inadequate iimage
needed to identify the style of the chair. The first in- is generated, preventing engagement of higher-level
stance requires a global awareness of the environment visual perceptual processing.
and the location of objects within it; the second requires Brain injury or disease can disrupt visual processing
selective visual attention to the details of the chair to at any level in the hierarchy. Because of the unity of the —
identify its features. Also, it is necessary to be able to _
hierarchy, if brain injury disturbs a lower-level process _
employ more than one type of visual attention at the inction, the processes above it will also be compro- |
same time. When crossing a crowded room to talk to a nis d. When this occurs, the patient may appear to
friend, a person must be aware of the movement of have a deficit in a higher-level process, even though the
people and the placement of obstacles in the room to deficit actually has occurred at a lower level in the hier-
avoid collision, while at the same time focusing on the archy. For example, a patient who is unable to com-
friend (or target). The CNS employs several types of plete an embedded figures test appears to have a deficit
visual attention simultaneously and shifts constantly in the visual cognitive process of figure-ground percep-
between types and levels of attention.°* A large amount tion. In fact, this patient may be experiencing inaccu-
of neural processing is devoted to directing visual atten- rate pattern recognition, caused by an asymmetrical
tion, causing visual attention to be disrupted easily by scanning pattern that results from visual inattention,
brain injury, but at the same time to be a highly resilient compounded by a visual field deficit. Treatment of the
visual perceptual process.°* higher-level process (figure-ground imperception) will
Engagement of visual attention and the other higher- not be successful unless the underlying deficits in visual
level processes in the hierarchy cannot occur unless the attention and visual field are addressed first. This effect
CNS is receiving clear, concise visual information from is similar to that observed in the motor system follow-
the environment. Visual input is provided through the ing brain injury. The high-level deficit observed is that
visual functions of oculomotor control, visual field, and the patient cannot use the hand to pick up an object.
394 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

The underlying deficits are reduced muscle tone and generally completes these first two steps. The two profes-
sensation and muscle weakness. Use of the hand for sions often collaborate with one another to complete
manipulation will not be possible until the deficits in this process and establish a diagnosis and prognosis of
muscle tone, strength, and sensation are addressed in the visual condition. Steps three and four of the process
treatment. Effective evaluation and treatment of visual consist of identifying the visual disability, which is the
perceptual dysfunction require an understanding of change in daily living performance that occurs as a result
how brain injury affects the integration of vision at each of the visual impairment, and the visual handicap, which
process level and how the levels interact to enable visual is the socioeconomic consequence of having the disabil-
perceptual processing. ity, such as an inability to be gainfully employed. Occu-
pational therapy (OT) practitioners and other rehabilita-
MEDICAL FRAMEWORK FOR EVALUATION tion professionals work collaboratively to complete
these two steps of the evaluation process. Comprehen-
AND TREATMENT OF VISUAL
sive medical management of the patient requires a team
IMPAIRMENT
approach that integrates several disciplines to ensure that
Rehabilitation of the patient with visual impairment is a each step of the process is completed.
multidisciplinary process. The World Health Organiza- The value of rehabilitation is that it can alter the
tion, in the International Classification of Diseases, Im- outcome in the last two categories of the process. Ac-
pairments, and Handicaps (ICDIH), established a four- cording to Colenbrander,’® rehabilitation is the art of
step process for the management of permanent visual influencing the links between the first and last cate-
impairment. This process serves as the medical model for gories of the process, “so that a given disorder results in
the rehabilitation of patients with visual impairment the least possible handicap.” Through treatment inter-
(Table 24-on erie The first step in the process is to vention it is possible to “optimize one’s abilities in the
presence of a given impairment.”'’ OT intervention can
facilitate this change because the relationship between
impairment and ability is not rigidly fixed.'” With treat-
ment, it is possible to exploit a patient's capabilities
while eliminating as many of the obstacles to success as
possible, and in so doing to achieve better functional
: An eye ccare performance. Accomplishing this is the essence of treat-
specialist, either an st NTRS a or an optometrist, ment intervention.

OCCUPATIONAL THERAPY EVALUATION

To provide treatment intervention, the OT practitioner
Organization Aspects of Vision must link visual disability and handicap to the presence
of a visual impairment. Establishing this relationship is
the purpose of the assessment of visual performance
Visual Visual Visual Visual
completed by an occupational therapist. This process
Disorder Impairment Disability Handicap
~<<—— The Organ ——> <<—The Person ———_>
also is known as establishing “medical necessity,” which
Anatomical Functional Skills and Social, Economic is the prerequisite to receiving reimbursement for OT
Changes Changes Abilities Consequences services. To achieve the link, the occupational therapist
Examples: must be able to identify the functional limitation in per-
Corneal Visual acuity Reading Need for extra formance of a daily activity and then connect it to the
opacity Skills effort presence of a visual impairment. This often requires that
the occupational therapist also complete assessments to
Cataract Visual field Writing Loss of
identify visual impairment. However, whereas an oph-
skills independence
thalmologist or optometrist evaluates visual impair- —
Retinal scar Color vision ADL skills Loss of earning ment for the purpose of diagnosing a visual disorder,
potential occupational therapists assess visual impairment to
Optic Night vision Mobility explain the presence of a functional limitation.
atrophy skills OT assessment has three purposes: to identify the
functional impairment, to link the functional impair-
Stroke Ocular Vocational
ment to the presence of a visual impairment, and to de-
motility skills
termine appropriate treatment intervention based on
From Colenbrander A, Fletcher DC: Basic concepts and terms for low vision the results of the assessment. In addressing evaluation
rehabilitation,
Am |Occup Ther 49(9):865-869, 1995. and treatment, it is important to remember that a
 Evaluation and Treatment of Visual Deficits Bb)

patient's visual performance is significant not in terms the alteration of the lower-level processes within the
of how it deviates from an established norm but in how perceptual hierarchy, including visual acuity, visual
it interferes with functional ability. A patient is consid- field, oculomotor control, and visual attention and
ered to have a visual impairment that requires treatment scanning. Deficits in these functions prevent the CNS
if the impairment interferes with performance of a nec- from accurately completing complex visual processing
essary ADL. and using vision for adaptation. Identification of defi-
Several tests are available to occupational therapists ciencies in these processes, followed by treatment to re-
to assess visual performance. Subtests from the Brain mediate the deficits, enables the CNS to process visual
Injury Visual Assessment Battery for Adults (biVABA)* input more efficiently and facilitates adaptation. This
developed by the author are used in this chapter to section focuses on assessment and treatment of these
describe assessment techniques.®* The biVABA was de- processes within the visual perceptual hierarchy and ex-
signed specifically as a tool to help occupational ther- amines how brain injury disrupts the functioning of
apists develop effective treatment plans and interven- each process, how the process is assessed, and how
tions for adults with visual impairment caused by treatment intervention is provided.
brain injury. The biVABA consists of 17 subtests de-
signed to measure visual processing ability. The assess-
Visual Acuity
ments include evaluation tools used by ophthalmolo-
gists and optometrists to measure basic visual function,
along with subtests designed specifically for occupa-
tional therapists.

OCCUPATIONAL THERAPY is ae dto |

ae The Bester the quality of the
INTERVENTION
visual input, the more precise the image created by CNS
The focus of OT intervention is to change the outcome in processing. The more precise the image, the faster and
the categories of visual disability and visual handicap. more accurate the ability of the CNS to recognize the
Three approaches are used in providing treatment. An object and discriminate it from other features in the en-
active approach may be used, in which treatment at- vironment. Good acuity therefore enables speed and ac-
tempts to change the patient's ability to complete visual curacy of information processing and decision making.
processing by improving aspects of visual performance, Acuity occurs through a multistep process that begins
such as increasing the efficiency of visual search or im- with the focusing of light onto the retina. Light rays enter
proving visual attention. A passive approach is also used, the eye through the pupil and are focused on the retina
in which the emphasis of treatment is on changing the by the anterior structures of the eye: the cornea, lens, and
environment or task to enable the patient to_use his or optic media (Fig. 24-5).°’ The retina, acting like film in a
her current level of visual processing. These two ap- camera, processes the light and records a “picture” that is
proaches may be used alone or together to improve func- relayed to the rest of the CNS by the optic nerve.®” Al-
tional performance. The third approach that is always though the concept is simple, the process is complex and
used in conjunction with the other two is education of the involves many factors. These factors include the ability
patient and family to increase their insight into how the to focus light precisely onto the retina, the ability to
patient's visual processing has changed and how it has af- maintain sharp focus over various focal distances, the
fected functional performance. Education is a critical ability to obtain sufficient illumination of the retina to
component of the treatment process because insight is capture a quality image, and the ability of the optic nerve
crucial to the ability to learn compensatory strategies. ' to transmit the image through the CNS for perceptual
processing.*” Any compromise of the structures in-
OCCUPATIONAL THERAPY ASSESSMENT volved in this process will result in degradation of the
image and reduced acuity.?”’”*
AND TREATMENT OF SPECIFIC VISUAL
Visual acuity is most commonly measured by having
IMPAIRMENTS the patient read progressively smaller optotypes on a
The concept of a visual perceptual hierarchy provides chart. The optotypes may be letters, numbers, or
the framework for the discussion of assessment and symbols. The most common acuity measurement unit
treatment. It is assumed that many changes in visual used in the United States is the Snellen fraction (20/20,
perceptual function after brain injury occur because of 20/50, etc.).'’ The numerator of this fraction is the dis-
tance (in feet) from which the person views the chart,
and the denominator is the distance at which a person
*Brain Injury Visual Assessment Battery for Adults, visAbilities Rehab
Services, Inc., 12008 W. 87th St., Suite 349, Lenexa, KS 66215; (888) with normal vision can identify a letter of a certain
752-4364. size.’* A measurement of “20/20” means that standing
396 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

CORNEA
SCHEMATIC ILLUSTRATION
OF WHE
BASIC STRUCTURES OF
THE RIGHT EYEBALL

\ \\ THREE LAYERS OF THE EYE:

a, 1. SCLERA
2. CHOROID
3. RETINA

AXIS
OPTICAL

OPTIC DISC OR THE FOVEA CENTRALIS OF THE MACULA

OPTIC PAPILLA, ALSO KNOWN AS LUTEA (SPOT + YELLOW). THE
THE BLIND SPOT AREA OF THE RETINA FOR FOVEAL
Ns (CENTRAL OR ACUTE) VISION: CONES,
xy
>
THE RODS, FOR NIGHT VISION & LACKING
COLOR VISION, ARE PERIPHERALLY
jes
LOCATED IN THE RETINA.
(@)

FIG. 24-5
Anterior structures of the eyeball. Light passes through these transparent structures to focus on the
receptor cells of the retina. (Courtesy of Josephine C. Moore, PhD, OTR.)

at a distance of 20 feet, the viewer can see the letter that walls, doors, door frames, and furniture also are often
a person with normal vision can see at 20 feet. Vision of monochromatic in design; without the ability to distin-
20/200 would indicate that a person standing at a dis- guish low-contrast features, it would not be possible
tance of 20 feet can see a letter that a person with to locate the door or avoid the chair jutting out into
normal vision could identify at 200 feet. the pathway in such environments. One of the most
Visual acuity typically is measured using a high- common low-contrast objects is the human face. Human
contrast, black-on-white test format. However, visual faces contain very little differentiation in contrast
acuity actually represents a continuum of visual function between the facial features. That is, the nose is the same
ranging from the ability to detect high-contrast features color as the forehead, cheeks, and chin, and eye and hair
on one end ofthe continuum to the ability to detect low- color are designed to blend with skin tones. To see
contrast features (such as beige on white) on the other the unique features of a human face requires very good
end.*° Low-contrast acuity, known as contrast sensitivity contrast sensitivity function. Although high- and low-
function (CSF), is the ability to detect the borders of contrast acuity represent opposite ends of a single con-
objects reliably as they decrease in contrast (rather than tinuum of visual acuity function, research has shown
size) from their backgrounds.*’ CSF makes it possible to that CSF can be impaired in patients even when their
distinguish and identify faint features of objects, such as high-contrast acuity is within normal limits.”’'~** There-
the curve of aconcrete curb or the protrusion ofthe nose fore both forms of acuity must be measured to obtain an
on the face.*” Because much of the environment is made accurate assessment of acuity function.
up of low-contrast features (gradations of colors between Besides high- and low-contrast acuity, two other mea-
objects rather than stark contrasts), CSF is a critical visual sures of visual acuity are used: distance acuity and reading
function for the ability to negotiate an environment (near) acuity. Distance acuity is the ability to see objects at
safely.”*? For example, curbs and steps are routinely the a distance. Near acuity is the ability to see objects clearly as
same color throughout; without CSF, it would not be they come closer to the eye. Near acuity is most accurately
possible to see the depth in the curb or step. Carpets, called “reading acuity” because reading is the primary
 Evaluation and Treatment of Visual Deficits

function enabled by near acuity. Usually this form of

acuity is measured by having the patient read sentences in
progressively smaller sizes of print.
Reading acuity is dependent on the brainstem neural of the CNS for processing.”* These Coeainnect may be
process of accommodation. Accommodation enables the direct result of a brain injury, a disease process, or a
the areto maintain clear focus on objects as they come change in the eye occurring incidental to the injury. It is
closer.*’ As an object approaches the eye, its point of not possible to describe all of the conditions that can
focus on the retina is pushed further back, eventually
aliieten
——
|
result in reduced acuity after brain injury, but the most
causing the image to go out of focus. The CNS adjusts common are described in the sections that follow.
for this situation through the three-step process of ac-
commodation. As the object comes closer, (1) the eyes TY TO FOCUS AN
converge (turn inward) to ensure that the light rays enter- . Sharp focusing of an image
ing the eye stay parallel and in focus, (2) the crystalline on the retina depends largely on the transparency of the
lens of the eye thickens to refract the light rays more intervening structures between the outside of the eye
strongly and shorten the focal distance, and (3) the and the retina and on the ability of these structures to
pupil constricts to reduce scattering of the light rays. focus the light rays entering the eye. Light entering the
These three steps enable objects to stay in focus in the eye passes through four transparent mediums: the
near vision range (distances between 3 and 16 inches cornea, aqueous humor, crystalline lens, and vitreous
from the eyes).*” humor. An opacity or irregularity in these structures will
prevent light from properly reaching the receptor cells in
Deficits in Visual Acuity the retina.*’ Conditions that can occur in conjunction
Until the fourth decade of life the accommodation with head trauma include corneal scarring, trauma-
process works efficiently to ensure equal acuity when an induced cataract, and vitreous hemorrhage.*° Corneal
individual is viewing objects both up close and at a dis- scarring may occur from direct trauma to the eye sus-
tance. As a person passes through the forties, the lens of tained during the assault to the head. The cornea is
the eye gradually becomes less flexible, reducing its damaged and scars as it heals, creating an irregular
ability to keep images in focus as they come closer. surface that refracts the light unevenly. The person expe-
The condition created by this change is known as riences blurred vision similar to that created by astigma-
presbyopia.’* Persons with this condition frequently tism. Trauma to the crystalline lens may cause displace-
complain of difficulty reading small print. Presbyopia is ment or result in the subsequent development of a
corrected either by using reading glasses to magnify cataract that clouds the lens and reduces acuity. Trauma
print or, if the person already wears eyeglasses, by to the eye also can result in bleeding into the vitreous
adding a magnifying lens or “reading ad” to the base of humor. Because blood is an opaque medium, light
the lenses to create a bifocal. cannot pass through it, and the patient experiences
In the normal eye, most deficiencies in visual acuity floaters, shadows, and episodes of darkness as the blood
are caused by defects in the optical system (the cornea or passes in front of the retina. Of these conditions, vitreal
lens or even the length of the eyeball), which cause hemorrhage is the only one that is temporary and that
images to be focused Day on the retina. os The three usually will resolve on its own without treatment.
Impairment of accommodation is another condition
that affects the focusing ability of the eye. This condition
is associated with brainstem injury, either from head
trauma or from stroke.'”*°*”’* A brainstem injury can
affect the functioning ofone or all of the components of
accommodation: convergence of the eyes, thickening of
the lens, and pupillary constriction. When accommoda-
tion is impaired, the patient has difficulty achieving and
sustaining focus during near-vision tasks. The most fre-
quent complaint voiced by the patient is difficulty with
maintaining focus during reading, which may cause the
nerect ae is cannedriya a corneaeee is notEeially print to blur and swirl on the page.'”
spherical but shaped more like a spoon. The defect
results in a blurring of the image because both meridians )F TH ATY OF THE RETINA
cannot be focused on the retina. Astigmatism is corrected PROCESS THE IMAGE. The health and integrity of
by saan a ene lens iin front of the eye. the retina also tafatence the quality of the image sent on
to the CNS. The receptor cells of the retina can be
damaged directly by injury or disease, preventing them
398 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

PARALLEL RAYS
EMMETROPIA
OR OF LIGHT
NORMAL VISION

LENS

NEARSI

SHORTSIGHTEDNESS)
j---|--4+--
ERROR IN REFRACTION OR DUE TO
AN ELONGATION OF THE EYE BALL,
----> HENCE RAYS OF LIGHT COME TO
CORRECTED WITH CONCAVE LENS FOCUS IN FRONT OF THE FOVEA.

(HYPERMETROPI,
FARSIGHT =DNESS :
LONGSIGHTEDNESS)
ERROR IN REFRACTION OR DUE TO
A SHORTENING OF THE EYE BALL,
CORRECTED WITH CONVEX LENS HENCE RAYS OF LIGHT COME TO
FOCUS BEHIND THE FOVEA.

FIG. 24-6
Normal, myopic, and hyperopic optical refraction of light coming into the eye and the type of lens
used to correct myopic and hyperopic optical refractive errors. (Courtesy of Josephine C. Moore,
PhD, OTR.)

from responding to light. Diseases that affect retinal strate reduced visual acuity secondary to eye disease.
function, such as macular degeneration and diabetic Too often the vision loss resulting from the disease is
retinopathy, are associated with age and significantly in- either overlooked or misdiagnosed as an attentional or
crease in incidence in the seventh and eighth decades of cognitive impairment associated with the CVA.
life.*? With damage to the retina (especially the macular
area), both high- and low-contrast visual acuity are di- DISRUPTION
OF THE ABILITY OF THE OPTIC
minished, making accurate identification of features NERVE TO SEND THE RETINAL IMAGE. The most
and objects difficult. It is estimated that approximately common cause of optic nerve damage in brain injury is
one in four persons over the age of 80 years has a visual trauma.°® An injury can occur from a direct penetrating
impairment that affects the retina significantly enough injury to the nerve, such as a missile wound to the head
to prevent the individual from reading standard print. It from a gunshot.*® Indirect trauma can also occur from an
is not uncommon for an older adult who has been re- optic canal fracture associated with facial or blunt fore-
ferred for treatment of a CVA (stroke) also to demon- head fractures. These fractures are most common in chil-
 Evaluation and Treatment of Visual Deficits 399

dren and young adults and usually result in unilateral in- Because brain injury can affect accommodative ability, it
juries.** Severe closed head injuries can cause stretching is important to measure both acuity distances.
or tearing of the optic nerve, resulting in significant and When measuring visual acuity, the therapist must be
usually bilateral damage to the nerves. Bilateral nerve sure that the chart is well illuminated and held at the
injury can also result from compression of the nerves sec- specified distance from the patient. Adequate illumina-
ondary to intracranial swelling or hematoma.*® tion is important because acuity shares a linear relation-
Other common conditions that can cause optic nerve ship with illumination; that is, as illumination de-
damage are glaucoma and multiple sclerosis. Glaucoma creases, so does acuity (no one can read a letter chart in
typically damages the optic nerve fibers carrying periph- the dark). Because acuity is depicted as a fraction of dis-
eral visual field input but can also affect the central tance over letter size (e.g., 20/20 or 20/200), the mea-
visual field, reducing visual acuity. Multiple sclerosis surement is not accurate unless the viewing distance is
can cause plaques to develop along the optic nerve, re- accurate. All test charts specify a distance at which they
sulting in optic neuritis, reduced visual field acuity, and are to be used, and this should not be altered.
sensitivity to light.” The patient's level of acuity is determined by the
smallest line of optotypes (letters) he or she can read on
the test chart. The patient is instructed to read the opto-
- Reduced visual eine can cause types on the chart out loud, beginning with the largest
limitations in a eeahicarit number of ADL. The sever- line and continuing to lower lines until the print is too
ity of the limitation depends on the extent of the small to see. Patients with brain injury may have deficits
acuity loss and whether there has been a loss of in cognition, language, and perception, which interfere
central acuity, peripheral acuity, or both. A loss of with the ability to provide an accurate and timely re-
central acuity results in an inability to discriminate sponse in a testing situation. Extra time may be needed
small visual details and to distinguish contrast and for this patient to locate the optotype on the chart,
color. Activities dependent on reading, writing, and process the image, and respond. Slowness in respond-
fine motor coordination (eg., reading recipes and ing therefore does not necessarily indicate that the
labels on foodstuffs, dialing a telephone, completing a patient lacks the acuity to identify the optotype. If the
check, paying a bill, applying makeup, shaving, identi- patient struggles with the identification of optotypes on
fying money, and shopping) will be affected. When each line but is accurate, the test should proceed until a
peripheral acuity is reduced, as occurs with visual field line is reached on which the patient can no longer iden-
deficit, mobility will be affected. The patient may be tify the majority of the optotypes.
unable to identify landmarks, see obstacles in the path The most useful chart for an occupational therapist is
of travel, or accurately detect motion, which may one that measures visual acuity as low as 20/1000 so
impair his or her ability to ambulate safely and main- that significant reductions in acuity can be measured.
tain orientation in the environment. This may reduce The standard charts used by doctors measure visual
independence in driving, shopping, and participation acuity only in the range that can be compensated for
in community activities. with eyeglasses, roughly to 20/100 Snellen acuity. When
acuity is below that level, magnification must be used
~
Assessment and the patient is referred to a low-vision specialist.
All evaluation begins with observation of the patient's Because some conditions such as optic nerve damage or
performance in daily activities. Patients with deficits in macular diseases can result in profound vision loss (less
visual acuity often complain of an inability to read print than 20/400 acuity), it is important for a therapist to be
and may state that the print is too small or too faint to able to measure acuity in the lower ranges so that ap-
read. Complaints that print appears distorted, that parts propriate referral and modifications can be made. The
of words are missing, or that words run together and swirl LeaNumbers Low Vision Test Chart* and the Warren
on the page are also common. Patients with CSF deficits Text card from the biVABA are examples of test charts
may complain ofan inability to see faces clearly. These pa- that measure visual acuity in the low vision ranges.
tients also may be unable to distinguish between colors of Contrast sensitivity function also is assessed by
similar hue, such as navy blue and black, or to detect low- viewing optotypes printed on a chart that is held at a
contrast substances such as water on the floor. specified distance from the patient. However, for this
If a decrease in visual acuity is suspected, a screening type of testing, the optotypes (which may be letters,
should be completed to determine how acuity has numbers, symbols, or sine wave gratings) remain the
changed. To obtain a complete picture of the patient's same size but diminish in contrast as one proceeds
visual acuity, both high- and low-contrast acuity are mea- down or across the chart. The patient is asked to identify
sured. High-contrast acuity testing generally is divided as many optotypes as possible. There are many forms of
into two additional measurements: far acuity, measured
with atest chart at a distance of 1 m orgreater, and reading *LeaNumbers and LeaSymbols Low Contrast Tests, Precision Vision,
acuity, measured using a text card at 40 cm (16 inches). 944 First St., LaSalle, IL 60301; (815)223-2022.
400 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

CSF tests on the market, from wall-mounted charts to REASING B/ KGRI JON In-

tests such as the Optec 2000, which uses slides installed creasing contrastoats ane ne ecbacerened color to
in vision testers. The least expensive and most portable contrast with an object can help the patient see objects
test charts are those designed by Dr. Lea Hyvarinen, more clearly. The application of this technique can be as
such as the LeaNumbers Low Contrast Screener in- simple as using a black cup for milk and a white cup for
cluded in the biVABA, the LeaSymbols Low Contrast coffee. In cases where background color cannot be
Screener, and the LeaNumbers and LeaSymbols Low changed readily, such as on carpeted steps, color can be
Contrast Tests available from Precision Vision.* When applied to provide a marker. For example, a line of bright
contrast sensitivity function is measured, the patient is fluorescent tape can be applied to the end of each step
asked to read down the chart as far as’possible until the riser on the carpeted stairs to distinguish between them.”"
optotype is too faint to be identified. As with high-con-
trast acuity testing, the test chart must be held at a spe- INCREASING ILLUMINATION. Increasing the in-
cific distance and must be well illuminated to obtain an tensity and amount of available light enables objects
accurate measurement. and environmental features to be seen more readily
In assessing visual acuity performance, the therapist and reduces the need for high contrast between objects.
does not have the job of diagnosing the cause of the For example, facial features can be identified more
deficiency, but rather linking the presence of the defi- easily if a person’s face is fully illuminated. The chal-
ciency to a functional limitation the patient has. This lenge in providing light is to increase illumination
is a subtle but important distinction that affects the as- without increasing glare. Halogen, fluorescent, and full-
sessment procedure. When a patient has reduced spectrum lights provide the best sources of high illumi-
visual acuity, the ophthalmologist or optometrist uses nation with minimum glare and are generally recom-
the results of the assessment to determine the cause of mended over standard incandescent lighting for both
the reduction (e.g., damage to the retina or cornea or room and task illumination. Lighting should be strate-
the presence of a refractive error). With this informa- gically placed to provide full, even illumination
tion the eye care specialist determines how to manage without areas of surface shadow. For example, if a 50-
the condition to restore optimum sight using optical watt halogen lamp is used for reading, it should be po-
devices (glasses or contact lenses), a surgical proce- sitioned behind the patient’s shoulder so that the page
dure, or the prescribing of medications. In contrast, of print is fully illuminated without the light’s shining
when a therapist determines that a patient has reduced directly in the patient's eyes.
visual acuity, he or she uses this information to
modify activities and the environment so that the
patient can compensate for the loss and achieve terned Backenseie have ite effect of camioutleee the
optimal performance in daily activities. For example, if objects lying on them. The detrimental effect of patterns
a patient cannot read the size of print on a medication on object identification can be minimized by using
label, the therapist determines whether the print can solid colors for background surfaces such as bedspreads,
be enlarged to a size that the patient can read or deter- place mats, dishes, countertops, rugs, towels, and furni-
mines another way for the patient to identify the med- ture coverings. Objects in the environment also create
ication bottle. background patterns. Cluttered environments with hap-
hazardly placed objects challenge even a person with
Treatment good acuity. If possible, the number of objects in the en-
If a significant reduction in visual acuity is noted, the vironment should be reduced and those remaining
patient should be referred to an ophthalmologist or op- arranged in an orderly fashion. Closets, drawers,
tometrist to determine the nature and cause of the shelves, and countertops should be reorganized and
vision loss and whether vision can be restored. Referring simplified, as should such areas as sewing baskets,
patients to specialists can take days, weeks, and even desks, refrigerators, and freezers.
months to complete. The patient's treatment program
cannot be placed on hold while the referral is being
processed; therefore the therapist uses the information | EN ifSecuBte niece should
obtained from the assessment to modify the environ- be enticed to Pate them more visible. Instructions can
ment and activities and enable the patient to use his or be reprinted in larger print, medications and other
her remaining visual acuity. Examples of specific tech- items relabeled, and calendars enlarged. The last line of
niques used in this passive treatment approach are de- print that is easily read on the reading acuity test card
scribed in the following paragraphs. indicates the minimum size to which to enlarge print
for the patient. Contrast should also be increased
*LeaNumbers and LeaSymbols Low Contrast Tests, Precision Vision, because it does little good to enlarge print if the print is
944 First St., LaSalle, IL 60301; (815)223-2022. faint. Black on white or white on black print is usually
 Evaluation and Treatment ofVisual Deficits 401

seen with greater ease than any other color combina- found in the resource section of the public library or by
tion. Many items now are manufactured with larger contacting an advocacy organization such as the Ameri-
print, including calculators, clocks, watches, telephones, can Foundation for the Blind or the Lighthouse Infor-
check registers, glucose monitors, scales, playing cards, mation and Resource Center. The following are some
games, and puzzles. These items can be purchased examples of available services:
through specialty catalogs. 1. The National Library Service for the Blind and Physi-
cally Handicapped, which offers books and maga-
ORGANIZATION. Once closets and shelves are re- zines on cassette tape through its Talking Books
arranged and simplified, every effort should be made to program
keep them organized. Putting items back where they 2. The Bible Alliance in Bradenton, Florida, which pro-
belong and maintaining organization reduces frustra- vides a free Bible on tape
tion and facilitates independence. Establishing routines 3. Local telephone companies, which may offer free di-
for activities such as filing nails and paying bills pre- rectory assistance to persons with disabilities
vents daily tasks from becoming overwhelming. Steps
that require visual monitoring should be eliminated as
Visual Field
much as possible. For example, the patient should be
advised to use prechopped and premeasured food in- The visual field is the visual surround that can be seen
gredients, wrinkle-free clothing, electronic funds trans- when a person looks straight ahead. It is analogous to the
fer, and voice-activated telephone dialing. dimensions of a picture imprinted on the film in a
camera (with the retina representing the film). The
ESS TO COMMUNITY SERVICES. A variety of normal visual field extends approximately 60° superi-
services areBecailable to assist persons with vision loss. orly, 75° inferiorly, 60° to the nasal side, and 100° to the
These services are generally free of charge and can be temporal side.*’”* As Fig. 24-7 shows, most of the visual

( )
VISUAL FIELD CHART AND DEGREES USED PERIPHERAL VISION = ALL AREAS
IN RELATION TO PERIMETER TESTING EXCEPT THE MACULA = CENTRAL 20°
I
l
|
|

LEFT. |RIGHT
|
|
I
|
|

me |
|
I
I
I
I
|
|
I
I
Pe I
I
I
I | | FOVEA = HIGHEST VISUAL ACUITY
I
I 'MACULA = NEXT HIGHEST AREA
I
A SINGLE EYE'S VISUAL FIELD HAS | PARACENTRAL AREA = VISUAL ACUITY FAIR*
\
A NORMAL RANGE OF 130° TO
‘ PERIPHERAL VISION = POOR VISUAL ACUITY BUT
145°. MOST STATE DRIVING LAWS
FIRST ALERTING SYSTEM FOR DETECTING MOVE-
REQUIRE AT LEAST 130° OF VISION,
MENT, FOR ORIENTING IN SPACE (BALANCE)
THUS A PERSON WITH ONE EYE
AND MOVING AROUND IN THE ENVIRONMENT.
CAN LEGALLY DRIVE.
*AKA: PARAMACULAR, PARAFOVEAL, OR THE
CENTRAL 30° OF VISION.

FIG. 24-7
Visual field chart illustrating the divisions of the visual field related to visual acuity. (Courtesy of
Josephine C. Moore, PhD, OTR.)
402 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

field is binocular and is seen by both eyes. A small and limits visual search to areas immediately adjacent
portion of the peripheral temporal field in each eye is to the seeing side of the body. The reason for this odd
monocular and can be seen only by one eye because the strategy is the influence of a visual process known as
bridge of the nose occludes vision in the other eye. At the “perceptual completion.”*°°*”"’? Perceptual comple-
very center of the retinal visual field is the fovea, an area tion is a process whereby the CNS fills in (or completes)
approximately 8° to 10° in diameter that records the absent visual information based on an expectation of
visual details for object identification. Surrounding the the visual information to be found in the visual scene.
fovea is the macular area of the field, also referred to as The perceptual outcome of this process is that the
the central visual field (Fig. 24-8). This area is approxi- viewer perceives that he or she is seeing a complete
mately 20° to 30° in diameter and is used for object visual scene, even though part of the visual information
identification.*”* The rest of the visual field is the pe- in the scene is absent. The best known example of the
ripheral field, which detects general shapes and move- effect of perceptual completion on the processing of
ment in the environment. On the border between the visual field input is the lack of awareness of one’s own
central and peripheral visual fields on the temporal side physiological blind spot. The blind spot creates a 5°
is the blind spot, so called because the optic disc pierces hole in the temporal visual field. Through perceptual
the retina here and there are no sensory receptor cells. completion, the CNS fills in the missing visual informa-
tion in the field, causing the person to be unaware of
Visual Field Deficits this gap in vision.”
Damage to the receptor cells in the retina or to the optic. Perceptual completion provides speed in informa-
pathway that re information to the CNS for tion processing by enabling an individual to infer a
processing results in a visual field deficit (VFD).*’”* Fig. whole visual scene based on partial visual input. As
24-1 illustrates this pathway as it changes from the optic such, it plays an important role in the person’s ability to
nerve to the optic tract to the geniculocalcarine tracts. adapt to fast-paced and dynamic environments.
The location and extent of the visual field deficit depend However, in the case of significant visual field loss, the
on where damage occurs on the pathway. Although any presence of perceptual completion makes it difficult for
type of visual field deficit is possible after brain injury, the patient to determine how his or her vision has
homonymous hemianopsia is the most common deficit changed.**" Because of perceptual completion, the
observed.”° Hemianopsia (hemi = half, anopsia - patient with a VFD is not immediately aware of the
blindness) means that there has been a loss of vision in absence of vision after onset of the deficit.**’”' He or she
one half of the visual field in the»eye. Homonymous perceives the presence of a complete visual field—there
means that the deficit is the same in both eyes. Th are no gaps or black holes in the visual scene. However,
patient may have either a left or a right hemianopsia, as the CNS cannot place objects in a visual scene that it
well. does not actually see. Therefore the patient may not be
aware of a chair, a plate of food, or other unanticipated
Functional Deficits Caused by Visual objects on the blind side. As a result, the patient may
Field Deficits run into a chair or other obstacles when navigating in
Although VED is often considered a mild impairment in the environment or may not be able to find items
comparison with the dramatic loss of use of the limbs, it placed within the blind field. Until the patient becomes
can create changes in visual processing that significantly aware of the VFD, he or she will have the odd percep-
limit daily performance. The most important change tion of a complete visual scene in which objects always
occurs in the search pattern used by an individual to seem to be appearing, disappearing, and reappearing,
compensate for the blind portion of the visual field. without warning, on the affected side. Uncertainty re-
Instead of spontaneously adopting a wider search strat- garding the accuracy of visual input on the affected side
egy, turning the head farther to see around the blind causes the patient to adopt a protective strategy, which
field, patients tend to narrow their scope of scan- is tuned into input from the intact visual field.°' This
ning.°’”°* The patient typically turns the head very little narrowed scope of scanning creates significant limita-
tions in activities, such as driving a car or traversing a
busy environment, that require monitoring of the full
FIG. 24-8
visual field.
Position of examiner and
patient for completion of
In addition to resulting in a narrow scope of scan-
perimetry testing using the ning, visual search into the blind field often is slow and
Damato 30-point Campime- delayed.**"’*! Again, the culprit is perceptual comple-
ter from the Brain Injury tion, which eliminates the presence of a marker to indi-
Visual Assessment Battery for cate the boundary between the seeing and nonseeing
Adults. (Courtesy of Precision fields. Unable to determine the actual border of the
Vision, LaSalle, III.) seeing field or where a target might be within the non-
 Evaluation and Treatment of Visual Deficits 403

seeing field, the patient naturally slows down when fected include mobility, reading, writing, and the ADL
scanning toward the blind field. The slow visual search dependent on these skills. These activities include
speed on the affected side increases the difficulties the grooming, medication management, financial manage-
patient has in moving and finding objects within the en- ment, meal preparation, clothing selection and care,
vironment and also reduces reading speed. meal preparation, home management, telephone usage,
If the VFD affects the macular portion of the visual and yard work. In general, the more dynamic the en-
field, especially the fovea, a patient may miss or vironment in which the ADL is completed and the
misidentify visual details when viewing objects because wider the field of view required to complete the task,
part of the object falls into the blind area of the field. the greater the limitation. Therefore only minor limita-
This can create significant challenges in reading.'°°”?’ tions are generally experienced in self-care activities,
Normal readers view words through a “window” or per- compared with significant limitations in shopping and
ceptual span that allows them to see approximately 18 driving.
characters (letters) with each fixation of the eye.°” The Persons with VFD commonly face significant emo-
reader typically moves from word to word using a series tional challenges in adapting to this considerable vision
of successive saccadic eye movements to cross the line of loss. For example, patients with VFD regularly report
print. Presence of a VFD can reduce the width of the per- feeling a sense of anxiety when moving in unfamiliar
ceptual window from 18 characters to as few as 3 to 4 environments. Sometimes the anxiety can be so severe
characters. This may cause the patient to view only part that the patient has an autonomic nervous system reac-
of a word during a fixation and even skip over small tion, becoming nauseated and short of breath and
words, often resulting in the transformation of words breaking out into a sweat in crowded environments.
and sentences. For example, a patient with a left VFD One individual with VFD described this sensation as
may read the sentence, “She should not shake the juice” “crowditis,” reporting that he became physically ill if he
s “He should make juice,” transforming “she” into had to go into a department store or other crowded en-
“he” and “shake” into “make” and leaving out “not” vironment.®*® This anxiety can become debilitating,
and “the.” Errors such as these cause the patient to have leading to a withdrawal from community activities and
to stop and reread sentences, reducing reading speed to social isolation. Other patients report a tremendous
and comprehension. Accuracy in reading numbers gen- loss of self-confidence because of the numerous mis-
erally creates more challenge for the patient than takes they make during the course of a day, and many
reading words. Whereas context alerts the patient to an express that they experience depression because of their
error when reading sentences (the sentence does not limitations, especially in the ability to drive a car and
make sense), numbers appear without precise context, read accurately.
causing mistakes to go unnoticed. For example, a bill for
$28.00 may be misread as $23.00 and the error missed ment
until a notice of insufficient payment is recéived. Pa- Taeubuocessohmeasuring the visual field is known as
tients making these kinds of errors quickly lose confi- perimetry.’ Several types of perimetry are available.
dence in their ability to pay bills and manage their These range from simple bedside assessments (such as
checkbook and turn over these important ADL to the confrontation test), which give a gross indication
someone else. of field loss, to the very precise imaging of a scanning
If the VFD has occurred on the same side as the laser ophthalmoscope (SLO).*’”* The perimetry test se-
dominant hand, the patient may have difficulty visu- lected depends on the availability and cost of the test
ally guiding the hand in fine motor activities. The and on the ability of the patient to participate in
most common functional change is a reduction of testing. For example, confrontation testing does not
writing legibility. The patient often cannot visually incur any expense and can be performed nearly any-
locate and maintain fixation on the tip of the writing where, whereas SLO imaging must be completed by a
instrument as the hand moves into the blind visual specially trained technician in a center that has pur-
field, causing handwriting to drift up and down on the chased the $120,000 instrument. In between these
line. Writing over something that was just written and two extremes are the tangent screen, campimeter,
improperly positioning handwriting on a form are also manual bowl perimeters (the Goldmann), and auto-
common mistakes. Quilting, hand sewing, pouring mated bowl perimeters (the Humphrey), ranging in
liquids, and other fine motor activities are also fre- cost from $100 to $20,000. In general, the more ex-
quently impaired. pensive the apparatus, the more precise the measure-
The behavioral changes described (narrow scope of ment provided.
scanning, slow scanning toward the blind side, missing All perimetry testing involves three parameters: fixa-
or misidentification of visual detail, and reduced visual tion on a central target by the patient while the testing is
monitoring of the hand) contribute to a variety of completed, presentation of a target of a specific size and
functional limitations. The primary functional skills af- luminosity in a designated area of the visual field, and
404 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

acknowledgment of the target by the patient.’ Testing is Testing using perimetry devices such as the Damato
done with either static or kinetic presentation of the 30-Point Multifixation Campimeter (biVABA) or a
target. In static presentation the target appears in a spec- tangent screen enables therapists to obtain a more accu-
ified area of the visual field without being shown rate measurement of central visual field function. The
moving to that location. In kinetic testing the target Damato campimeter shown in Fig. 24-8 is a portable
moves in from the periphery until it is identified.’ test card that provides a precise measurement of the
The most accurate perimetry test readily available central 30° of the visual field. The test grid consists of
clinically is computerized, automated perimetry.’ In 30 numbered targets that lead the patient's eye to move
automated perimetry the person being tested places his so as to place the test stimulus at known points in the
or her chin on a chin rest and fixates on a central target visual field. The test stimulus is a 6-mm black circle that
inside a bowl-shaped device. As the person fixates on is shown in the center part of the card. The patient is in-
the central target, lights are displayed inside the bowl structed to fixate on one of the numbered targets. The
in varying locations and intensities. The person is test stimulus is then shown in the central window, and
asked to respond by pushing a small button each time the patient indicates if and when he or she sees the
he or she sees a light. The test is very thorough, pre- circle. If the patient does not see the black circle, that
senting lights in over a hundred locations within the point in the visual field is recorded as a loss. The test
field and increasing the intensity of the light in a step proceeds with the patient successively viewing the num-
threshold sequence if the target is not appreciated the bered targets until the entire field is mapped out.
first time. The result is an accurate measurement of the The tangent screen consists of a black felt screen with
areas of absolute scotoma (total vision loss) and rela- a grid stitched into the felt in black thread so that the
tive scotoma (decreased retinal sensitivity) within the grid is visible only to the examiner.’ The patient sits di-
field. To obtain an automated perimetry test, the rectly in front of the screen at a distance of 1 meter. The
patient must be referred to either an ophthalmologist patient is instructed to fixate on the center of the screen
or an optometrist. as the examiner moves or places a white target attached
For OT practitioners who want to screen for visual to a black wand in a certain area of the screen. Without
field deficit, an indication of visual field loss can be breaking fixation on the center of the screen, the patient
achieved using simpler perimetry testing in combina- indicates if and when he or she sees the target. If the
tion with careful observation of patient performance on patient does not see the target when it is presented, that
ADL. Confrontation testing is a bedside examination point in the visual field is recorded as a loss. The exam-
that provides a crude indication of visual field loss.’”””* iner uses the grid to determine the location of the field
To complete a static confrontation test, the examiner sits deficit. Clinical observation of the patient's behavior is
in front of the patient and has the patient fixate on a especially important to confirm the presence of VFD
centrally placed target (often the examiner's eye or because of the limitations of perimetry testing.’* Pa-
nose). The examiner then holds up a target in each of tients with fluctuating or limited attention, language,
the four quadrants of the visual field (right upper, right and cognition may give unreliable perimetry results. It
lower, left upper, and left lower). The patient indicates also may be difficult to distinguish between VFD and a
whether he or she sees the target.*°’*’* For a kinetic deficit in visual attention. However, the patient's per-
test the examiner stands behind the patient and moves a formance of functional activities will strongly indicate
target (generally a penlight) in from the periphery while the presence of a VFD.
the patient fixates on a central target. The patient indi- The assessments previously described establish only
cates as soon as he or she notices the target. Standard- whether a VFD is present and the size and location of
ized versions of these tests are included in the biVABA. the deficit. To determine whether treatment interven-
Therapists using confrontation testing to quantify visual tion is needed, the therapist must determine whether
field deficit must be careful to correlate their findings the patient is able to compensate for the VFD in per-
with observations of patient performance because con- forming functional activities, as well as the quality and
frontation testing has been shown to be unreliable in consistency of that compensation. The presence of a
detecting all but gross defects.’® The presence of a visual VFD can cause significant limitations in ADL. The level |
field deficit may be indicated if any of the following are of impairment in daily living skills will depend on
observed: the patient changes head position when asked whether the VFD occurs alone or in conjunction with
to view objects placed in a certain plane; the patient visual inattention. An ADL assessment should be com-
consistently bumps into objects on one side; the patient pleted to evaluate patient performance in the primary
misplaces objects in one field; or the patient makes con- ADL areas, including dressing, bathing, grooming,
sistent errors in reading. If the confrontation test shows home management, and shopping. If the patient
no deficit but the clinical observations suggest that a demonstrates difficulty completing an activity, the
deficit is present, the clinical observations should carry visual requirements of the activity should be analyzed
the greater weight in deciding if a deficit exists. to determine if the VFD is interfering with performance.
 Evaluation and Treatment of Visual Deficits 405

For example, if the patient is unable to locate a tooth- ment of the patient's ability to execute these strategies
brush during grooming, is it because the toothbrush is can be made with a Dynavision 2000,* an apparatus in-
stored on the side of the patient's field deficit? creasingly used in rehabilitation to assess and train
Reading is another functional task that may be af- visual motor performance (Fig. 24-9).**** Therapists
fected by VFD. The Visual Skills for Reading Test (VSRT)* without access to a Dynavision can use a laser pointer to
provides an effective way to measure the interference of observe the patient's compensatory strategies. The beam
the VFD on reading performance. The VSRT is designed of light from the pointer is projected onto various areas
ers
|e
to assess the influence of a scotoma (or field loss) in the of a blank white wall, and the patient is instructed to
macula on the visual components of reading, including locate and touch the projected red dot. The strategy
visual word recognition and eye movement control.*” used by the patient to locate the dot and the efficiency
The patient is asked to read single letters and words of the strategy are noted. Integration of visual scanning
printed on a card. The words are not in context and are with ambulation is the final component of the assess-
designed so that they can be misread and still make ment in this area and must be completed to determine
sense (e.g., “shot” can be mistakenly read as “hot”). The whether the patient will be able to compensate for the
test measures reading accuracy and corrected reading deficit when moving in the environment. This is as-
rate and provides information on the prevalent types of sessed by using such tests as the ScanCourse from the
reading errors made by the patient. The patient's per- biVABA, to observe the patient search the environment
formance on the letter and reading charts used to while ambulating.
measure visual acuity also may indicate the influence of
a VFD on reading performance. Because of the wider Treatment—
visual field, a patient with a VFD may have more diffi- Identifying the presence of VFD is not in itself justifica-
culty reading the larger symbols and words on the chart tion for treatment unless the deficit affects the patient's
and may be able to read faster and more accurately as independence in completing ADL. Safety and accuracy
the optotypes (and field) decrease in size. Telephone are the two aspects of performance most affected by
Number Copy, part of the biVABA, provides information VFD. The emphasis in treatment is on teaching the
about the patient's accuracy in reading numbers. In this patient how to compensate for VFD in completion of
test, the patient is required to copy down telephone ADL such as meal preparation, shopping, and financial
numbers that include numbers easily misread by management. Patients will have the greatest limitations
persons with VFD, such as 6, 8, 9, and 3. in ADL that must be completed in dynamic environ-
To effectively compensate for the VFD, the patient ments, such as shopping, or activities that require
must execute an organized and thorough search of the monitoring of a wider visual field, such as meal prepa-
blind field, using the seeing portion of the visual field. ration or yard work. Resumption of driving may or
This means that a patient with a left visual field deficit may not be a goal, depending on the state’s driving
must use the right visual field to search both the left and statutes. Some states do not specify a minimum degree
right fields. Patients with VFD demonstrate difficulty of visual field for licensure. In these states a patient
searching both peripersonal space (the space immediately may be able to safely resume driving if given the
around the body) and extrapersonal space (the space ex- proper training. Reading and writing accurately may be
tending from the body into the environment). Deficien- addressed on the plan of care as specific goals but also
cies in searching peripersonal space affect performance may contribute to achievement of independent per-
of self-care activities such as grooming, dressing, formance in other goals such as financial management
reading, and writing, as well as activities completed and meal preparation.
within a restricted visual field, such as meal preparation The most important aspect of treatment is education
or leisure activities. Deficiencies in searching extraper- of the patient regarding the nature of his or her vision
sonal space have a pronounced impact on mobility and loss and the resulting functional limitations. Compen-
affect activities in outside and community environ- sation for VFD requires adopting a conscious, cognitive
ments, such as driving, shopping, and mowing the yard. strategy of using head movement to broaden the visual
For mobility in dynamic community environments, field. Because the CNS exercises perceptual completion,
the patient must use a wide scanning strategy that is ini- the patient often lacks insight into the extent and
tiated on the side of the deficit and executed quickly and boundaries of the field deficit. Successful compensation
efficiently. The patient also must be able to shift atten- requires the patient to believe firmly that the deficit
tion and visual search rapidly from the central visual exists and that the visual input from the blind side
field to the peripheral visual field. An objective assess- cannot be trusted. The patient who is able to develop

*Visual Skills for Reading Test, Mattingly International, Low Vision

Products, 938-K Andreasen Drive, Escondido, CA 92029; (800) 826- *Dynavision 2000, Performance Enterprises, 76 Major Buttons Drive,
4200. Markham, Ontario L3P3G7, Canada; (905) 472-9074.
406 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

FIG. 24-9
Example of a visual search task using the Dynavision 2000. The lights on the board are illuminated
one at a time in random patterns. The patient must locate the illuminated light and press it to turn
it off. As light is pressed, another light is illuminated.
The patient strikes as many lights as possible
within a specified time. The activity can be used to teach and reinforce efficient search patterns to
compensate for visual field deficits and visual inattention. (Dynavision 2000, manufactured by Per-
formance Enterprises, Ontario, Canada.)

this level of insight will be able to learn to effectively 5. Attention to and detection of visual detail on the
compensate for the deficit. Every effort must be made blind side
through activities and educational materials to make 6. Ability to quickly shift attention and search between
the patient aware of the location and extent of the the central visual field and the peripheral visual field
deficit. on the blind side
In providing treatment, the therapist uses a combina- The Dynavision 2000 apparatus has been shown to
tion of active and passive strategies. Active strategies be effective in teaching the components of effective
focus on increasing the speed and width of the search search patterns and is strongly recommended as a treat-
pattern. The patient must learn to turn the head quickl ment tool.** The following are other therapeutic activi-
to compensate for the restricted visual field. eae | ties that facilitate head turning to compensate for VFD:
pist teaches the following components
of an effective 1. Ball games in which balls are passed quickly from
tou al search oud oy? player to player
1. Initiation of a wide head turn towards the blind field 2. Balloon batting
2. An increase in the number of head and eye move- 3. Projection of light from a laser pointer onto various
ments toward the blind field locations on a white wall for the patient to search
3. Faster completion of head and eye movement toward and find
the blind field 4. Adhesive stick-on notes with numbers and letters
4. Execution of an organized and efficient search printed on them, widely scattered over a wall for the
pattern that begins on the blind side patient to search and find
 Evaluation and Treatment of Visual Deficits 407

Use of the search strategy can be reinforced through be used to help the patient monitor handwriting. The
the use of games such as concentration, solitaire, and simple addition of more light often increases reading
checkers and in ADL such as walking on a crowded speed and reduces errors. Reducing pattern in the envi-
street, finding clothes in a closet, or locating items ronment by reducing clutter and using solid-colored
needed for meal preparation. objects enhances the patient's ability to locate items.
For patients who have limitations in functional
mobility, practice in dynamic and in unfamiliar envi-
Oculomotor Function
—-
*
eee
P=
ronments is beneficial. The patient is taught to watch
out for features in the environment that could cause The purpose of oculomotor function is to achieve and
harm, such as steps, curb cuts, and other changes in maintain foveation of an object.?® That is, oculomotor
the support surface. The patient also is taught to be function ensures that the object the person wishes to
more observant of landmarks such as a picture on a view is focused on the fovea of both retinas (to ensure a
wall or a change in wall color to assist in maintaining clear image) and that focus is maintained as long as
orientation. needed to accomplish the desired goal. This is a daunt-
The patient's primary challenges in reading include ing task because human beings interact within dynamic,
locating and maintaining the correct line of print and moving environments. An image focused on the fovea is
accurately identifying words and numbers. Patients always in danger of slipping off as the head or object is
with left VFD often have difficulty accurately locating moved. Foveation is achieved and maintained by eye
the next line of print on the left margin of the reading movements that keep the target stabilized on the retina
material and lose their place. Drawing a bold red line during fixation, gaze shift, and head movement.?°*”"*°
down the left margin provides the patient with a _Another function of oculomotor controliis to
toprovide
visual cue to use as an “anchor” to find the left
margin.®® The same technique used on the right 10ugh the CN!I$i receiving two
margin helps the patient with right VFD who may be pesos sini N te each eye). The process
uncertain about the location of the end of the line of of pein two visual aa into one is RGSS
print. If the patient has difficulty staying on line or
moving from line to line, a ruler or card can be used
to underline the line of print and keep the patient's V e same ae Ifthe retinas aresie stimu-
place. Accuracy in reading numbers, letters, and words tated, and if ie images match in size and clarity, the
is reestablished through practice. Prereading and CNS is able to fuse the two images perceptually into
prewriting exercises such as those designed by one. If the eyes do not align with each other or if there is
Warren®°* or Wright and Watson,’* and commercially a significant difference between the eyes in acuity, a
available word and number searches’ can be used to double image (diplopia) may occur.*°*°*"
teach the patient to make the precise eye movements
needed to see words completely. Deficits in Oculomotor Function
Difficulty staying on line when writing is addressed Deficits in oculomotor control following brain injury
by teaching the patient to monitor the pen tip and generally result from either of two types of disruption:
maintain fixation as the hand moves across the page specific cranial nerve lesions causing paresis or paralysis
and into the side of field loss. Activities that require the of one or more of the extraocular muscles that control
Patient to trace lines towards the side of the VFD are ef- eye movements or disruption of central neural control
fective in reestablishing eye-hand coordination. Practice of the extraocular muscles affecting the coordination of
in completing blank checks, envelopes, and check regis- eye movements.”*!’*°*”’4 In the first case the message
ters is also helpful. to the extraocular muscles through the cranial nerve is
Reading, writing, and ADL performance can be en- blocked; in the second case the message comes through
hanced by modifying the visual environment of the but is scrambled. In both cases the functional result is
patient. Adding color and contrast to the key structures decreased speed, control, and coordination of eye
in the environment needed for orientation (e.g., door movements. Three pairs of cranial nerves (cn) control
frames and furniture) will help the patient locate these the extraocular muscles: the oculomotor nerve (cn III),
structures. Using black felt-tip pens can heighten the the trochlear nerve (cn IV), and the abducens nerve (cn
contrast in writing materials, and bold-lined paper can VI). Among them, these nerves are responsible for con-
trolling seven pairs of striated muscles that surround
and attach to the two eyeballs.
*Warren Prereading and Writing Exercises for Persons with Macular When a cranial nerve lesion occurs, the muscles con-
Scotomas, Mattingly International, Low Vision Products, 938-K An-
trolled by that cranial nerve are weakened or paralyzed,
dreasen Dr., Escondido, CA 92029; (800) 826-4200.
+Learn to Use Your Vision for Reading Workbook, Mattingly Interna- a condition known as paralytic strabismus.””*' As a
tional, Low Vision Products, Escondido, CA 92029. result, the eye is unable to move in the direction of the
408 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

etic muscles and may even be unable to maintain a three components of accommodation, the process that
apeottonin 2eye socket (i.e., it drifts in or out). keeps objects in focus as they come into close view.
ecause the eyes must always move in synergy and line When convergence insufficiency occurs, patients have
up evenly to maintain a single visual image, an individ- difficulty obtaining or sustaining adequate focus
ual sees a double image when the movement of one eye during near vision tasks (tasks within 20 inches of the
is impeded or when the eye’s position changes and does face). Patients with this condition often complain of
not match that of the other. This condition is known as fatigue, eye pain, or headache after a period of sus-
diplopia or double vision and is the primary functional tained viewing in near tasks such as reading. As the eye
disruption observed with cranial nerve lesions.””"” muscles fatigue from the exertion of sustaining conver-
gence during reading, patients may begin to complain
Functional Limitations Caused that the print is swirling and moving on the page. The
by Oculomotor Deficits condition often is overlooked in evaluation because
The presence of diplopia creates perceptual distortion, cranial nerve function usually is intact and patients’
which may significantly affect eye-hand coordination, complaints instead are attributed to inattention, lack
postural control, and binocular use of the eyes. The of effort, or dyslexia.'”*”
functional limitations this causes for the patient depend These disturbances in ocular motility can create a
on where the diplopia occurs within the focal range (the variety of functional deficits for the patient.?”’* The
range in which a person can keep objects in focus). speed and range of eye movement may be diminished.
Diplopia occurring within 20 inches of the face will This will reduce the speed at which the patient is able to
disrupt reading and activities requiring eye-hand coor- scan the environment and take in visual information,
dination, such as pouring liquids, writing, and groom- causing delays in responding to the environment. The
ing. Diplopia occurring at a distance (greater than 4 patient may have difficulty maintaining a clear image
feet) will affect walking, driving, television viewing, and and may experience doubling and blurring of visual
playing sports such as golf and tennis. images.'”?°’? There may be difficulty focusing at differ-
To eliminate the double image, the patient will often ent distances from the body. Depth perception may be
assume a head position that avoids the field of action of diminished. These conditions will create significant
the paretic muscle.”*””°* For example, a patient with a visual stress for the patient, reducing concentration and
left lateral rectus palsy (cn VI) will turn the head toward endurance for activities. The patient may respond to this
the left to avoid the need to abduct the eye. A patient increased stress by becoming agitated and uncoopera-
with paralysis of the right superior oblique muscle (cn tive in therapy sessions or complaining of headaches,
IV) will tilt the head to the right and downward to avoid eye strain, or neck strain.
the action of that muscle.” Unless oculomotor function Because a number of factors can disrupt the control
is carefully assessed, these alterations in head position of eye movements, much skill and expertise are needed
may be interpreted as resulting from changes in muscle to accurately diagnose the oculomotor deficit and
tone in the neck rather than as a functional adaptation design an appropriate treatment intervention. Thera-
purposely assumed to stabilize vision. pists who treat this type of dysfunction should do so
Often it is not the cranial nerves that are damaged with the guidance of an optometrist or ophthalmologist
during brain injury, but the neural centers that coordi- who specializes in visual impairment caused by neuro-
nate their actions. These structures are scattered logical conditions.7°*” .
throughout the brainstem and communicate exten-
sively with cortical, cerebellar, and subcortical areas of Assessment
the CNS and the spinal cord.”””* In cases of traumatic The purpose of an assessment completed by the OT prac-
brain injury, diffuse damage may take place throughout titioner is to determine whether the patient has func-
the brainstem, affecting these control centers. If the tional limitations from dysfunction within the oculomo-
centers are damaged, the person will have difficulty exe- tor system. It is not to determine whether the oculomotor
cuting eye movements even though the cranial nerves dysfunction is the result of cranial nerve lesion, brain-
are intact.“”’’* Disconjugate eye movements may occur, stem injury, or other conditions. Determining the etiol-
causing the patient to have difficulty using the eyes to- ogy of the dysfunction is the responsibility of the oph-
gether in a coordinated fashion. Dysmetric eye move- thalmologist or optometrist. However, the occupational
ment, in which the eye undershoots or overshoots a therapist is often one of the first members of the rehabil-
target, also may be observed.”* itation team to observe that the patient appears to have
Damage to the pretectal nuclei in the brainstem can an oculomotor impairment affecting functional per-
cause convergence insufficiency, a condition when the formance. This frequently places the occupational thera-
patient is unable to obtain or sustain convergence of pist in the position of requesting further evaluation by an
the eyes.'”*’ Convergence is the muscle action of eye care specialist. To make an appropriate referral, it is
moving the eyes inward in adduction. It is one of the necessary to complete a screening to identify patterns of
 Evaluation and Treatment of Visual Deficits 409

oculomotor dysfunction that may account for the func- pist concludes the interview by identifying activities the
tional limitations observed in the patient. patient has difficulty performing that could be caused
In assessing the patient, a “listen and look” ap- by oculomotor dysfunction. The therapist should look
proach is used, wherein the therapist listens to the com- for a pattern in the patient's response, such as difficulty
plaints being voiced by the patient or the rehabilitation with activities that require sustained focus in near space
staff working with the patient and looks for deviations (reading, writing, and quilting). The therapist should
in oculomotor control that may contribute to these pay attention to whether the patient's visual difficulty
complaints. This approach is described in the biVABA, seems to change with the focal length of the task and
and the following steps in evaluation are from that whether the patient's levels of fatigue and concentra-
assessment. tion appear to be related to activities requiring sus-
The first step in assessment is to obtain a visual tained focusing.
history from the patient. The history is necessary The next part of the assessment is observing the
because adults with childhood histories of oculomotor patient's eyes and eye movements for deficiencies. First,
dysfunction or reduced acuity often display oculomotor the eyes are observed for asymmetries in pupil size,
abnormalities that do not affect functional perform- eyelid function, and eye position as the patient focuses
ance. These individuals frequently wear eyeglasses to on a distant object. Asymmetries such as a dilated pupil
correct for the deficiencies; in this case the eyeglasses in one eye or a droopy eyelid may indicate cranial
must be worn during the assessment to obtain accurate nerve involvement. Next, movement of the eyes is ob-
results. Areas addressed in this part of the evaluation served by asking the patient to track a moving object
include whether the patient had good vision before (such as a penlight) through the nine cardinal direc-
brain injury, whether the patient wears eyeglasses, and tions of gaze plus convergence.’ This test can be
whether the patient has a history of conditions that may thought of as an active ROM test of the eyes because
affect oculomotor control, such as congenital strabis- the nine cardinal directions represent the directions
mus, lazy eye, or amblyopia. through which the eyes move. The test is used to deter-
Next, the patient is asked whether he or she is expe- mine if there are deviations in strength and function of
riencing diplopia. If the response is affirmative, the the extraocular muscles and is completed by observing
patient should be questioned about the characteristics the eyes move in a binocular test. During the test, the
of the diplopia. Does the diplopia disappear when one therapist observes the following: (1) the symmetry of
eye is closed? This indicates impairment of the extraoc- the eye movement; (2) whether the eyes move the same
ular muscles. Do objects double side to side or on top distance in each direction; (3) whether the eyes are able
of one another? Is the diplopia present at near distances to stay on target with a minimum of jerking move-
or at far distances? Is there any area within the range of ments; and (4) whether the patient is able to hold the
focus where the patient is able to achieve single vision? eyes in a deviated position at the end of the range for 2
The answers to these questions may suggest which to 3 seconds. Restriction of eye movement in a specific
cranial nerve has been injured (Table 24-3). The thera- direction or difficulty moving the eyes in a specific di-
rection may indicate impaired oculomotor function.”
Observing the eyes as they track an object moving
toward the bridge of the nose tests convergence. Most
adults can maintain focus and track an object to a dis-
Summary of Oculomotor Deficits Associated tance of approximately 3 inches from the bridge of the
nose. At that point one eye usually breaks fixation and
with Cranial Nerve Lesions
moves outward. The point at which convergence is
Oculomotor Trochlear Abducens broken is known as the near point of convergence.”
Nerve 3 Nerve 4 Nerve 6
Although the near point of convergence is 2 to 3
Impaired Impaired down- Impaired
inches from the bridge of the nose, few adults ever view
vertical eye ward and lateral lateral eye
objects that closely. Therefore limitations in conver-
movements eye movements movements
gence are generally not functionally significant unless the
Lateral diplopia Vertical diplopia Lateral diplopia patient is unable to converge the eyes and easily main-
for near vision for near vision for far vision tain convergence to a distance of 12 to 16 inches from
tasks tasks tasks
the bridge of the nose. An inability to converge the eyes
Dilation of pupil With bilateral to this distance and maintain convergence for several
and impaired lesion assumes seconds while focusing on an object may cause the
accommodation downward head patient to have difficulty performing tasks in near
tilt vision, especially those such as reading, which require a
Ptosis of eyelid sustained focus. Observation of convergence insuffi-
ciency on testing should be correlated with complaints
410 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

made by the patient regarding such tasks as reading, the difficulty the patient is having in maintaining con-
writing, quilting, or sewing. centration when reading. As another example, the ob-
The final component of the assessment is diplopia servation of downward movement of the left eye during
testing, which is completed only if the patient is com- the cover/uncover test may explain why the patient
plaining of diplopia.’* Diplopia testing is used to deter- complains of feeling off balance and unsure when de-
mine the severity of the diplopia and whether it is scending stairs. If oculomotor deficiencies are observed
caused by a tropia or a phoria. Tropia is the suffix that appear to limit function, referral should be made to
applied when there is a noticeable deviation of the posi- an ophthalmologist or optometrist for further evalua-
tion of one eye in relation to the other when the patient tion to determine the cause of the deficiency, the prog-
is viewing an object.’**' Phoria is the suffix used when nosis for improvement, and treatment options.
there is a deviation of the eye that is held in check by
fusion and is therefore not noticeable when the patient Treatment
is focusing on an object. These terms are used in con- With the exception of reading and tasks requiring fine
junction with a prefix describing the direction of the de- eye-hand coordination, the presence of oculomotor
viation. Four prefixes are used: eso-, meaning a turning dysfunction usually does not prevent completion of
in of the eye; exo-, a turning out of the eye; hypo-, a most ADL; however, it does make completion of all ADL
turning downward of the eye; and hyper-, a turning tedious and fatiguing. The patient may express reluc-
upward of the eye. Esotropia therefore describes an ob- tance to perform some activities, or even stop perform-
servable, inward deviation of the eye commonly de- ing them, because of the constant visual stress. Motor
scribed as “crossed eyes,” whereas esophoria indicates and postural control also may be compromised, reduc-
that the eye drifts inward when the patient is not focus- ing safety in navigation of the environment. For these
ing on an object but is held in check when the patient is reasons oculomotor dysfunction must be addressed in
focusing on an object.’* treatment, although it is not specifically identified as a
Diplopia testing is based on the principle that when treatment goal. That is, the goal for therapy remains a
an eye is required to fixate on an object, it will do so functional goal such as safe and accurate completion of
with the fovea. If an eye that is not fixating on a target is meal preparation, shopping, or bill paying, and man-
suddenly required to foveate, it will achieve foveation agement of the oculomotor dysfunction becomes one
by making a saccade toward the target. By requiring the of the methods used to achieve the goal.
patient to fixate with both eyes on a target and then cov- Treatment can be divided into four types of interven-
ering one of the patient's eyes during fixation, the exam- tion: occlusion, application of prism, eye exercises, and
iner can determine whether both eyes are aligned in fo- surgery.°’°*! The last three interventions are used to
cusing on the target and, if not, which eye is the deviant reestablish fusion and binocularity. Most oculomotor
(strabismic) eye.’”’*° Two tests are used: a cover/uncover dysfunction clears up without treatment intervention
test, which is completed when a tropia is suspected, and within 6 to 12 months after the brain injury.*' Because
a cross or alternate-cover test, which is completed when of this, ophthalmologists generally do not believe that it
a phoria is suspected.?”*®° If both eyes are aligned is necessary to provide any treatment other than to
equally and fixating on the target, no movement of eliminate the diplopia for the patient’s comfort during
either eye will be observed when one is covered. If the the recuperation period. If the diplopia persists and
eyes are not aligned, the deviating eye will move to take becomes chronic, surgery can be used to reestablish
up fixation when the nonaffected eye is covered. Pa- fusion. Optometrists often choose a more active ap-
tients with tropias generally complain of constant proach and prescribe eye exercises to reestablish binoc-
diplopia when viewing objects and will need to have ularity, in addition to using occlusion and prism.”* Brief
one eye occluded to eliminate the diplopia so that func- descriptions of these treatment interventions follow.
tional activities can be completed. Patients with phorias The treatinent option selected for a patient depends on
often complain of diplopia only intermittently, usually the prognosis for recovery, the patient's ability to partic-
when fatigued or stressed by sustained viewing of a ipate in therapy, family and financial resources, and the
target. Although the phoric patient may complete most eye specialist providing consultation.
activities without diplopia, he or she may experience
significant visual stress, which can manifest itself as OCCLUSION. The presence of diplopia causes per-
headaches, eye strain, or decreased concentration. ceptual distortion. This distortion creates confusion for
The information gathered from the assessment the patient and limits participation in therapy. There-
should be compared with the patient's visual com- fore diplopia must be eliminated if the patient is to
plaints and observations of his or her performance to benefit fully from rehabilitation. Diplopia is elimi-
determine if the oculomotor dysfunction is contributing nated by occluding the image presented to one eye. Oc-
to the patient's functional limitations. For example, the clusion can be achieved by assuming a head position
presence of convergence insufficiency may help explain or by covering one eye. Because assuming a deviant
 Evaluation and Treatment of Visual Deficits 411

head position often affects motor and postural control, tage is that peripheral vision is left intact and available
the preferred method is to cover one eye. Occlusion of for use in orientation to space and balance. The main
the eye can be achieved through either full or partial disadvantage of this type of occlusion is that the
occlusion.°777°°! patient must either wear prescription lenses or have
With full occlusion, vision is completely occluded in tape applied to a pair of frames with plain, nonrefrac-
one eye by application of a “pirate patch,” a clip-on oc- tive lenses. Either type of occlusion should be accom-
cluder, or opaque tape. The challenge with full occlu- panied by daily ROM exercises. The unaffected eye is
sion is that it eliminates peripheral visual input, dis- covered. The patient practices moving the strabismic
rupting normal CNS mechanisms for control of balance eye toward the direction of the paresis, then repeats the
and orientation to space. This often causes the patient to ROM exercises binocularly (using the eyes together) in
feel off balance and disoriented and reduces depth per- all directions of gaze to prevent contracture of the un-
ception. Another challenge is that the patient generally affected eye muscles.
cannot tolerate long periods of occlusion of an eye, es-
pecially of the dominant eye. Therefore, for the comfort MS. Ophthalmologists and optometrists may
of the patient, the period of occlusion is alternated use a prism to reestablish single vision in the primary
between the eyes every hour. Alternating occlusion directions of gaze: straight ahead and looking down.
between the eyes also reduces the likelihood of the de- Application of a prism displaces the image, causing the
velopment of secondary contracture of the muscles an- disparate images created by the strabismus to fuse into a
tagonistic to the paretic muscle. single image.*’’” The prism can be ground into the eye-
For partial occlusion, a strip of opaque material glass lenses worn by the patient or temporarily applied
(such as Transpore surgical tape) is applied to a to the lens of the glasses using a plastic Fresnel press-on
portion of the eyeglass lens to block visual stimulation prism. A prism is used only as long as it is needed to
in the central visual field, while the peripheral visual maintain fusion. If the paresis is resolving, the patient is
field is left unoccluded (Fig. 24-10). The patient is in- gradually weaned from the prism by reducing the
structed to view a target within the diplopic field. Tape dioptic strength of the prism over a period of time com-
is applied from the nasal rim toward the center of the mensurate with the rate of recovery.
lens until the patient reports that the diplopia is gone
when viewing the target. The tape is applied to the E EXERCISES. There has yet to be objective re-
nondominant eye for the greater comfort of the search unequivocally demonstrating that the use of eye
patient. The width of the tape is gradually reduced as exercises will restore binocular function following
the muscle paresis resolves. An advantage of partial oc- paretic strabismus. Eye exercises do not appear to ad-
clusion is that the patient is more comfortable and versely affect muscle function, however, and the use of
therefore that compliance is increased. Another advan- eye exercises can empower the patient by increasing his

FIG. 24-10
Example of partial occlusion to eliminate diplopia. Translucent tape is applied to the nasal portion of
the eyeglass lens on the side of the nondominant eye. (From Warren M: Brain Injury Visual Assessment
Battery for Adults Test Manual, Lenexa, Kan, 1998, visAbilities Rehab Services)
412 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

or her participation in the recovery process. If eye exer- must work together. The contribution of each is equally
cises are undertaken, they should be directed toward important to perceptual processing.
correcting the deficiencies observed in binocular func- In normal adults, visual search is completed using an
tion. Recommended exercises are those that increase organized, systematic, and efficient pattern.'**?°75**°
fusion and active ROM of the affected eye. An op- The type of search pattern used depends on the
tometrist often directs the use of eye exercises in this demands of the task. In reading English, for example, a
aspect of the rehabilitation program.’* left-to-right and top-to-bottom linear strategy is used. In
scanning an open array (such as a room), a circular, left-
SURGERY. Surgery is recommended when the to-right strategy generally is used, following either a
degree of strabismus is too large to be overcome consis- clockwise or a counterclockwise pattern.
tently and easily by fusional effort, or when there is a
significant strabismic condition that does not resolve in Deficits in Visual Attention and Scanning
12 to 18 months.” The general approach in surgery is to Studies have shown that disruption in the normal
make the action of one of the extraocular muscles either search strategy can occur after brain injury. The charac-
weaker or stronger by changing the position of its at- teristics of the disruption vary, depending on which
tachment on the eyeball. The position of the eye in the hemisphere was damaged. Visual search deficits associ-
socket is changed by the procedure, and the image is re- ated with right hemisphere injury are characterized by
aligned. Surgery is completed by an ophthalmologist avoidance i Sean heleferbalientiatinenay ual
space?” 24,31,,33,62,69 it is conc ni ; .
specially trained in strabismus surgery.
inattention. Instead of mane ees sore Tefete
right visual search pattern, patients with right hemi-
Visual Attention and Scanning
sphere injuries often begin and confine search to the
Visual attention is the ability to observe objects closely. right side of a visual array. This creates an asymmetrical
and carefully to discern information about their features — rather than a symmetrical search pattern. The patient
and their relationship to oneself and other objects in _ misses visual information on the left side and as a result
theenvironment. It requires being able to ignore irrele- may be deprived of information needed to make accu-
vant sensory input and random thought processes and rate identification and decisions.
to focus over a period of several seconds to several Hemi-inattention is associated with only right hemi-
minutes. Visual attention also entails being able to shift sphere injuries and occurs because of a difference in the
visual focus from object to object in an organized and way the hemispheres are programmed to direct visual
efficient manner. Engagement of visual attention is ac- attention.**’”° As illustrated in Fig. 24-11, the left hemi-
complished through visual scanning or search (these sphere directs attention toward the right half of the
two terms are used interchangeably). Although these visual space surrounding the body. In contrast, the right
two processes are separated within the visual perceptual hemisphere directs visual attention toward both the right
hierarchy to assist in understanding them, they cannot and left halves of the space surrounding the body. If a
be separated in function or in evaluation and treatment lesion occurs in the left hemisphere, visual attention
ofthe patient. Any change in visual attention will be ob- and search toward the right side are diminished, but
served in the patient as a change in the scanning pattern some attentional capability is still provided by the right
used for visual search. hemisphere. A similar lesion in the right hemisphere
Visual attention can be divided into two categories: may completely eliminate attentional capability toward
focal, or selective, visual attention and ambient, or pe-- the left because there is no other area directing attention
ripheral, visual attention.*”’°’ Focal attention is used for toward the left side.
object recognition and identification. Visual input from Hemi-inattention often is confused with the presence
the macular area of the retina is used to complete this of left VFD in the patient. Although both conditions
processing. Focal, or selective, attention enables an indi- may cause the patient to miss visual information on the
vidual to accurately distinguish visual details such as dif- left side, they are distinctly different conditions and do
ferences between letters, numbers, and faces. Ambient, or not have the same effect on performance. When left
peripheral, attention is concerned with the detection of VFD occurs, the patient attempts to compensate for the
events in the environment and their location in space loss of vision by engaging visual attention.*° The patient
and proximity to the person. It relies on input from the directs eye movements toward the blind left side in an
peripheral visual field. Peripheral attention ensures that attempt to gather visual information from that side.
a person is able to move safely through space and main- Because of the field deficit, however, the patient may not
tain orientation in space. Without peripheral attention, move the eyes far enough to acquire the needed visual
collisions with objects and disorientation when moving information from the left side and as a result may
would be the norm. To have a fully operational and effi- appear inattentive. In contrast, the patient with hemi-
cient visual system, these two modes of visual attention inattention has lost the attentional mechanisms in the
 Evaluation and Treatment of Visual Deficits 413

OR REFERRED TO AS:
HEMI-INATTENTION
THE NEGLECT SYNDROMES INATTENTION
HEMI-VISUAL INATTENTION
VISUAL NE
EX TRAPERSONAL
AND Sp ‘ACE ps
INTRAPERSONA L
spac
gieary SaAEMa

LEFT HEMISPHERE: > RIGHT HEMISPHERE:

KNOWLEDGEABLE OF AND 3 KNOWLEDGEABLE OF AND
ATTENDS TO RIGHT BODY (ieee yi) ATTENDS TO BOTH RIGHT
SCHEMA AND RIGHT EXTRA- t= pe AND LEFT BODY SCHEMA
PERSONAL SPACE AND EXTRAPERSONAL
SPACE

IN RELATION TO MOVEMENT AND SENSORY PERCEPTIONS SUCH AS VISION (VISUAL-SPATIAL

AND VISUAL-OBJECT AWARENESS AND RECOGNITION), AUDITORY AND SOMESTHETIC
(INCLUDING BODY IMAGE OR SCHEMA) COGNITION AND AWARENESS, IT APPEARS THAT THE
LEFT HEMISPHERE PRIMARILY ATTENDS TO THE RIGHT EXTRAPERSONAL SPACE AND/OR
BODY IMAGE PARAMETERS WHILE THE RIGHT HEMISPHERE ATTENDS TO BOTH RIGHT AND
LEFT EXTRAPERSONAL SPACE AND BODY IMAGE. THUS LEFT HEMISPHERE LESIONS
OF THE 1°, 2° OR 3° AREAS OF THE CEREBRAL CORTEX OR ASSOCIATED SUBCORTICAL
FIBER TRACTS CONCERNED WITH VISUAL, AUDITORY, SOMESTHETIC, OR MOTOR
FUNCTIONS RARELY RESULT IN A NEGLECT SYNDROME BECAUSE THE RIGHT HEMISPHERE
CAN ATTEND TO AND COMPENSATE FOR THE LEFT HEMISPHERE DEFICIT. HOWEVER
RIGHT HEMISPHERE LESIONS OF ONE OR MORE OF THESE FUNCTIONAL AREAS LEAVE
THE BRAIN UNABLE TO ATTEND TO OR BE AWARE OF THE LEFT EXTRAPERSONAL SPACE
AND BODY SCHEMA. VISUAL FIELD DEFICITS (ESPECIALLY LEFT HOMONYMOUS
HEMIANOPSIA) ALWAYS COMPOUND THE NEGLECT SYNDROME

FIG. 24-11
Difference between the right and left hemispheres in the direction of visual attention and the rela-
tionship of hemisphere lesions to hemi-inattention and neglect syndrome. (Courtesy of Josephine C.
Moore, PhD, OTR.)
414 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

CNS that drive the search for visual information on the complex visual arrays for specific targets, they have diffi-
left. No attempt will be made by the inattentive patient culty maintaining attention on the salient features of
to search for information on the left side of the visual the target and mistakenly select targets with similar fea-
space, and no eye movements or head turning will be tures.°”*? They also demonstrate an inability to super-
observed toward the left side.*° The most significant impose an organized, efficient structure for visual scan-
change in visual search happens when the two condi- ning when asked to search an array with randomly
tions occur together in the patient. In this case the displayed objects. For example, if asked to locate a
patient is not receiving visual input from the left side certain individual seated among others on rows of
because of VFD and does not compensate for the loss of benches (a structured visual array), the injured person
visual input by directing attention toward the left side. would be able to accomplish the task. However, if asked
The combination of hemi-inattention and left VFD to find the same individual standing in a jumbled
creates severe inattention, often called visual neglect. crowd of persons (a random visual array), the injured
Patients with this condition show exaggerated inatten- person would display a random approach to searching
tion toward the left half of the visual space surrounding the array and would likely miss the target.
the body and often do not move the eyes past midline
toward the left or turn the head toward the left side. Functional Deficits Caused by Visual Inattention
Visual neglect may be compounded by neglect of the Disruption of visual attention creates asymmetry and
limbs on the left side of the body or neglect of auditory gaps in the visual information gathered through visual
input from the left side.'”’*° The presence of neglect is search. The quality of an individual's adaptation to the
associated consistently with poor rehabilitation out- environment decreases because the CNS is not receiving
comes.'* complete visual information in an organized fashion
Another change in visual search associated with right and therefore is unable to effectively use this informa-
hemisphere lesions is a tendency to fixate first on the tion to make appropriate decisions. Reduction in visual
most peripheral visual stimuli occurring in the right attention will affect all aspects of the performance of
visual field.*° If two visual stimuli simultaneously ADL. However, the most affected activities will be those
appear in the right visual field, the patient will attend that require inspection and integration of significant
first to the most peripheral stimulus. The patient with amounts of visual detail and those completed in
this tendency makes frequent head turns to attend to dynamic environments. Driving and reading are two
events occurring in the right peripheral field, giving the diverse examples of tasks often significantly affected by
impression of being distractible. Yet another change in inattention.
visual search is a reluctance to rescan for additional in- Because visual attention is modulated through an ex-
formation once an area has been viewed, especially if tensive neural network involving the entire CNS, some
the area is on the left side.°°°* This may cause the capacity for visual attention generally is retained even in
patient to miss certain visual details when viewing cases of severe brain trauma.* On the other hand,
complex visual arrays. changes in visual attention occur even with mild in-
Although several distinct changes in visual search juries. Whether a change in visual attention affects func-
have been observed with right hemisphere lesions, only tional performance depends on the task to be com-
one has been observed following left hemisphere pleted. Tasks such as reading can require enormous
lesions. Patients with left hemisphere injury often show amounts of selective visual attention if an individual is
a symmetrical decrease in searching for detail when reading a highly technical textbook, and less selective
viewing a visual array.”’*'’”? These patients broadly scan attention if the individual is reading an advertisement.
the visual array for information but do not examine spe- The task of driving requires continuous global attention
cific aspects of the visual scene to gather additional in- to monitor the speed and position of other vehicles and
formation. Because of this, they may miss visual details objects, and sporadic selective attention to landmarks,
and often cannot accurately interpret or identify the street signs, and traffic lights. Whether a deficiency in
objects around them. This may be because of a disrup- visual attention manifests itself after brain injury
tion in the selective item-by-item search strategy medi- depends on the circumstances and requirements of the
ated by the left hemisphere.°*® Left hemisphere injury tasks the patient is required to complete.
does not result in hemi-inattention or neglect.
In general, patients with injuries to either hemi- Assessment
sphere are slower in scanning and show mote erratic fix- As a process found at the intermediate level of the visual
ation patterns, compared with persons without brain perceptual hierarchy, visual attention can be affected by
injury.*”’*? They also have greater difficulty engaging se- deficits in lower-level visual functions (visual acuity,
lective attention and executing an organized and effi- oculomotor function, and visual field). Therefore these
cient visual search strategy. Research has shown that functions should be assessed before visual attention is
when persons with brain injuries are asked to search measured. The presence of aphasia and motor impair-
 Evaluation and Treatment of Visual Deficits 415

ment can also affect performance on tests for visual at- result in decreased accuracy in identifying targets on a
tention. The criterion used in assessing visual search visual search task, the characteristics of the search defi-
and attention is how efficiently and completely a person ciencies are different.*° For example, a patient with a left
attends to and takes in visual information. That deter- hemianopsia may demonstrate a left-to-right linear
mines the ability to use the information for adaptation. search pattern that is abbreviated on the blind side. The
Therefore, the emphasis in assessment is on observing search pattern is organized but results in a number of
how a patient initiates and carries out visual scanning to errors on the left because the patient did not see
complete a task requiring visual search. During the as- that side of the array. In contrast, a patient with hemi-
sessment the therapist should answer the following inattention may demonstrate an asymmetrical pattern,
questions: Does the patient initiate an organized search initiating and confining visual search to the right side
strategy? Can the patient carry out the search strategy in using a disorganized and random search pattern. The
an organized and efficient manner? Does the patient pattern also results in a large number of errors on the
obtain complete visual information from visual search? left. Although accuracy on the search task may be
Is the patient able to identify visual detail correctly? similar for these two patients, the cause of the errors is
Does the patient's ability to search for information de- different. By observing the strategy used by the patient
crease as the visual complexity of the task increases? to complete the search task, it is possible to distinguish
Research has shown that persons with good visual at- between the two conditions. Table 24-4 compares the
tention demonstrate specific characteristics of search characteristics of search patterns used by persons with
patterns that make them effective in obtaining visual in- hemianopsia and persons with hemi-inattention. When
formation.'*’** These characteristics include strategies the two conditions occur together, it is important to de-
that are organized, symmetrical, thorough, resilient to termine the severity of the inattention because this will
challenge, and consistent. The use of these strategies determine whether the patient is able to learn the strate-
usually results in good accuracy and speed in comple- gies needed to compensate for the VFD.
tion of visual search tasks. In contrast, persons with The visual search tests that have been described are
severe VFD or inattention often demonstrate ineffective pencil-and-paper tasks presented in a restricted and
search strategies. These individuals demonstrate incom- well-defined personal space. Determining how the
plete or abbreviated patterns in which only a portion of patient applies a search strategy to broader extraper-
the visual array is searched, usually in a random, unpre- sonal space requires the use of a test such as the Scan-
Seaemiasiion. 27) *°*2°3°37/29,95.89 ‘The organiza- Board test described by Warren.** The test, part of the
tion and accuracy of the pattern often break down when biVABA, consists of a large (20 inches by 30 inches)
the person is challenged to search more complex visual board with a series of 10 numbers displayed in an un-
arrays. Fig. 24-12 provides examples of some of the inef- structured pattern. The board is placed at eye level and
fective search strategies used on the visual search sub- centered at the patient's midline. The patient is asked to
tests of the biVABA by persons with brain~injury. A scan the board and point out all of the numbers that he
patient who employs ineffective search strategies may or she sees. The examiner records the pattern the patient
not acquire sufficient visual information to complete follows in identifying the numbers. Research using this
perceptual processing accurately. He or she may acquire test has shown that adults with normal visual search
the information in such a way that it cannot be used to employ an organized, sequential search pattern, begin-
complete perceptual processing, or may not acquire the ning on the left side of the board and proceeding in
information rapidly enough to enable adaptation. The either a clockwise or counterclockwise fashion until all
subsequent disruption of perceptual processing may of the numbers are identified. In contrast, adults with
cause errors in decision making and adversely affect per- deficits in visual attention demonstrate disorganized,
formance of a variety of daily living activities. random, and often abbreviated search strategies, fre-
When measuring visual attention, the therapist must quently missing numbers on one side of the board.
be aware that visual search can be significantly affected Those with hemi-inattention often show an asymmetri-
by both the presence of a VFD and hemi-inattention. cal pattern, initiating and confining visual search to the
Because VFD and hemi-inattention are not the same right side of the board. Patients with VFD may miss
condition, it is necessary to distinguish between the two numbers on the blind side but demonstrate an organ-
conditions to establish an effective treatment plan. This ized search strategy.
can be difficult, both because similar errors are observed
with the two conditions on search tasks and because the Treatment
two can also occur together in the same patient. Information gathered from observing the patient com-
However, differentiation can be accomplished by ob- plete visual search tests should reveal specific deficien-
serving the strategies used by the patient to complete cies in the scanning pattern the patient uses to acquire
visual search tasks such as those on the biVABA (Fig. visual information during completion ofdaily tasks. For
24-12). Although both VFD and hemi-inattention can example, it may be observed that the patient does not
 NAMED a Rare te i eT ATE:

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UIPGONKJELSGHN®RKMVNGKWZX®RNOIM
TUEIOPTHVNCJERZMENRUIRVNOLKQTRNB
CVDEMGJBRQWIDKRKRGJKWKSKBNVRELKI

QWI®K BNGRCJKNVHEKWIEJDTIHRVNCNJK
UTRH©OBKVNPSLDKEIXKR¥GHBNKLGJKN
OPLNRIOWEKCNDKOMGNRRODRZXCKBMT

SINGLE LETTER SEARCH-CROWDED *° 1997, visABILITIES Rehab Services Inc.

NAKGte
Wr PCG Se Os SATE

RANDOM PLAIN CIRCLES-SAMPLE ©1997, visABILITIES Rehab Services Inc.

FIG. 24-12
Examples of ineffective search patterns used by patients to complete two visual search subtests of
the Brain Injury Visual Assessment Battery for Adults. A, An abbreviated search pattern used by a
patient with left hemianopsia when crossing out the letters P and F on the subtest; the patient exe-
cuted an organized left-to-right linear search pattern but failed to locate the beginning of the line on
the left side, and as a result failed to cross out targets on that side (the circled letters). B, An asym-
metrical and abbreviated search pattern executed by a patient with hemi-inattention and left hemi-
anopsia. The patient was asked to number the circles consecutively, choosing any pattern desired.
The patient began numbering the circles from the right rather than the left and failed to number
circles on the left side of the array.

416
 Evaluation and Treatment of Visual Deficits

Comparison of Search Patterns: Persons With Visual Field Deficit vs. Persons With Hemi-inattention
_ Visual Field Deficit Hemi-inattention
Search pattern is abbreviated toward blind field Search pattern is asymmetrical; initiated/confined to the right side

Attemytstodirect search toward blind side No attempt to direct search toward left side
sarch pattern is organized and generally efficient Search pattern is random and generally inefficient
Pete less ee
; Client rescans to check accuracy of performance Client does not rescan to check accuracy of performance

| Time spent on task is appropriate to level of difficulty Client completes task quickly; level of effort applied is not
a4 = consistent with difficulty of task

From Warren M: Brain Injury Visual Assessment Battery for Adults Test Manual, Lenexa, Kan, |998, visAbilities Rehab Services.

search toward the left side of visual arrays. If this defi- tification for therapy services. Likewise, if the patient's
ciency is significant, a similar performance should be performance does not improve, this helps to verify the
observed when the patient completes a daily activity. significance of the deficit and also may indicate reduced
This could be an inability to locate items placed to the rehabilitation potential.
left side of the sink in grooming or a tendency to begin The primary compensatory strategy taught to the
reading a recipe in the middle of the line of print patient with hemi-inattention is reorganizing the scan-
instead of at the left margin. ning pattern to begin visual search on the left side of a
Depending on the severity of the deficit, some pa- visual array and progress left to right.°* The use of this
tients with inattention are able to complete simple and pattern will counteract the patient's tendency to restrict
practiced daily activities and experience difficulty only all visual search to the right side and will increase the
on tasks that are unfamiliar or require search of a symmetry of the search pattern. Patients with left hemi-
complex visual array. Others, especially those with sphere injuries do not demonstrate asymmetry in visual
neglect, may have difficulty with such a simple task as search but often fail to notice details when searching
finding all the food on their plate. By combining infor- visual arrays. These patients should be taught to initiate
mation from visual search tests with that gained from careful item-by-item search of visual arrays. Two scan-
observation of ADL performance, it is possible to deter- ning strategies are taught with all patients: a left-to-right
mine if and how the patient's performance of daily ac- linear pattern for reading and inspection of small visual
tivities has been affected by impairment “of visual detail, and a left-to-right clockwise or counter-clockwise
search. The treatment goals on the plan of care should pattern for viewing unstructured and extrapersonal
be worded to reflect the specific daily activities com- visual arrays. Activities should be selected that encour-
promised by the inattention. For example, the plan age and reinforce the use of these patterns.
of care could include such treatments goals as, “The Compensatory strategies can be taught more effec-
patient will be able to complete grooming independ- tively if treatment activities are designed using the fol-
ently” or, “The patient will be able to prepare a simple ODE SUE aie
meal independently.”
The goals established for independent ADL perform-
ance are achieved by ensuring that the patient learns to require orientation to aceed visual space. To help
take in visual information in a consistent, systematic, the patient complete a wide visual search, the
and organized manner. Before a patient can learn to re- working field of the activity should be large enough
organize a visual search, he or she must understand how to require the patient either to turn the head or to
his or her visual search and attention have changed. To change body positions to accomplish the task. Many
facilitate the development of this insight, the examiner activities and games can be enlarged to require head
should carefully review the results of the patient's per- turning for scanning. For example, a deck of playing
formance on the visual search tests and show the cards can be laid out, facing up, in rows 2 to 3 feet
patient how his or her search pattern differed from the wide. The patient is given another deck of playing
norm and caused errors. If, after receiving this feedback, cards and instructed to match the cards in hand to
the patient wishes to retake one of the tests, he or she the cards on the table. The therapist ensures that the
should be allowed to do so. If the patient's performance patient initiates a left-to-right, top-to-bottom, organ-
improves on the retest, this is an indication of capability ized scanning pattern when searching for the match-
to benefit from therapy intervention and serves as a jus- ing cards to complete the task.
418 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

2. Treatment activities will be more effective if the patientis and the need to compensate is that their concept of
required to interact physically with the target once it is” their capabilities is based on premorbid experiences.
located. Research has shown that a stronger mental This causes these patients to overestimate their abilities
representation of a visual image is formed if what is after injury. Without a realistic understanding of his or
seen is verified by tactual exploration.* Whenever her limitations, the patient may be unwilling to use
possible, the treatment activity should be designed compensatory strategies. To increase insight, Abreu and
to be interactive. Games such as solitaire, dominoes, Toglia’ advocate teaching a patient to monitor and
ball games, or activities such as putting together large control his or her performance by learning to recognize
puzzles are examples of treatment activities with in- and correct for errors in performance. Giving the patient
teractive qualities. immediate feedback about the performance and point-
3. Treatment activities should emphasize conscious attention ing out deficiencies facilitate this process of error detec-
to visual detail and careful inspection and comparison of tion. The process can also be facilitated by teaching the
targets. Because complex visual processing is depend- patient to use self-monitoring techniques such as activ-
ent on initiation of the item-by-item search strategy ity prediction, in which the patient predicts how suc-
of selective visual attention, it is important to cessfully an activity will be performed and identifies the
include scanning activities that require discrimina- aspects of the activity in which errors are likely to occur.
tion of subtle details and matching. Patients should The patient then compares actual performance with pre-
be taught consciously to study objects for their rele- dicted performance. This technique helps the patient
vant features, with emphasis placed on attending to develop anticipatory skills and increase awareness of
detail in the impaired space. Many games such as how the deficit affects functional capabilities.
solitaire, double solitaire, concentration, Connect Some patients, because of the severity of their
Four, checkers, Scrabble, and dominoes have these deficits, lack the cognition to benefit from training in
qualities. Large 300- to 500-piece puzzles, word or compensatory strategies. Although treatment interven-
number searches, crossword puzzles, and needle- tion is limited, such patients may benefit from a passive
crafts such as latch hook also require these skills. approach to treatment that emphasizes modification of
Throughout performance of these tasks, patients the environment to help the patient use his or her
should be encouraged to recheck their work to make limited attentional capabilities. The environment can
sure that critical details are not missed. be made more “user friendly” by reducing factors that
4. Practice the search strategy within context to ensure carry- place stress on visual processing. Suggested environ-
over of application to daily living activities. Clinic activi- mental modifications include the following:
ties provide a starting placetobegin teaching the 1.Reduce background patternso that objects in the fore-
strategies needed for successful visual perceptual ground can be seen more Pay: The more dense the
processing. Research has shown, however, that pa- background pattern, the greater the amount of selec-
tients with brain injury often do not spontaneously tive attention needed to locate the desired object. Pa-
transfer skills from one learning situation to the next. tients with severe brain injuries may not be able to
Toglia’’ suggests that having the patient apply the sustain the effort needed to complete this level of
learned strategy in different contexts of daily living processing and may view their environments as filled
can facilitate transfer of learning. For example, the with “visual noise” rather than meaningful objects.
patient can be required to use a left-to-right search Backgrounds can be simplified by eliminating pat-
strategy when selecting clothes from a closet, search- terned designs and using solid colors on support sur-
ing for items in a refrigerator, or shopping for gro- faces such as rugs, carpets, place mats, and bed-
ceries. The more often the strategy is repeated under spreads. Eliminating superfluous objects such as
varied circumstances, the more the skill is general- knickknacks and old magazines and organizing fre-
ized and transferred to new situations. There is no quently used items on shelves and in containers also
substitute in therapy for the practice of real-life situa- simplify the background. As a general rule, environ-
tions to help the patient develop insight into abilities ments should be sparse and contain only the items
and compensation for limitations. Cafeterias, gift needed by the patient for completion of daily activi-
shops, and office areas within the hospital and fast ties. Items that contain a lot of pattern, such as
food restaurants and shops surrounding the hospital reading materials, can be enlarged to decrease the
can be used to expose the patient to more realistic density of the pattern.
and demanding visual environments. 2. Ensure that room and task illumination is adequate. Both
Insight on the part of the patient into the nature of too little and too much illumination can impair
the visual deficit and how it has affected functional per- visual processing. However, environments usually
formance is critical to learning compensation. Accord- contain too little rather than too much light. The
ing to Toglia,’’ one of the reasons patients with brain type of lighting used should provide bright, even il-
injury do not spontaneously recognize their limitations lumination without glare.
 Evaluation and Treatment of Visual Deficits 419

special note of how the patient's visual deficit affects his

or her ability to process the more complex visual infor-
aiaiiatineed tte noticed. For example, the ae of mation needed to complete the task. If the patient has
a white plate p aced on a black place mat is more difficulty successfully completing the task and the visual
visible than it would be if placed on a white place deficit appears to be the cause, the therapist should de-
mat, and milk in a black cup is more visible than in a termine if it is possible to improve the patient's perform-
white cup. The use of glass or clear plastic items ance with treatment of the visual deficit.
should be avoided because these items reduce con-
trast by absorbing whatever pattern or color is
around them.
SUMMARY
The CNS relies on visual information to anticipate and
plan adaptation to the environment. Brain injury or
Complex Visual Processing
disease disrupts the processing of visual information,
The processes of pattern recognition, visual memory, creating gaps in the visual input sent to the CNS. The
and visual cognition involve complex processing and in- quality of a person’s adaptation to the environment de-
tegration of vision with other sensory information, past creases, because the CNS does not have sufficient or ac-
experiences, and cognitive function. To complete this curate visual information to make decisions. Whether a
sophisticated level of processing requires not only or- person’s deficit in visual perceptual processing necessi-
ganized, high-quality sensory input, but also good cog- tates therapeutic intervention depends on the person’s
nitive ability such as the ability to categorize informa- lifestyle and whether the visual deficit prevents success-
tion and complete abstract reasoning. Complex visual ful completion of daily living activities. The framework
processing, like other cognitive functioning, is elicited for evaluation and treatment rests on the concept of a
by the demands of a particular event. It is a learned skill, hierarchy of visual perceptual processing levels that in-
established by one’s experiences in mastering the envi- teract with and subserve one another. Because of the
ronment. With few exceptions, complex visual process- unity of the hierarchy, a process cannot be disrupted at
ing always is applied within context—used to solve a one level without an adverse effect on all perceptual
problem, formulate a plan, or make a decision regard- processing. Evaluation must be directed at measuring
ing a specific situation. Because of the contextual nature function at all process levels, with particular emphasis
of complex visual processing, the best way to assess it is on the foundation of visual functions and visual atten-
not to ask the patient to complete some abstract, two-di- tion and scanning. Treatment focuses on increasing the
mensional visual task, but rather to observe the patient accuracy and organization of visual input into the
complete daily tasks requiring this level of processing. system through manipulation of the environment and
For example, if the patient is an architect planning to by providing the patient with strategies to compensate
return to work, his or her ability to design and execute for or minimize the effect of the deficit in ADL.
building plans or other aspects of the job should be as-
sessed, preferably at the patient's place of employment.
If the patient wants to return to driving, his or her ability
REVIEW QUESTIONS
to handle complex traffic situations should be assessed 1. What determines whether treatment intervention is
with a behind-the-wheel assessment. needed for a patient with a visual impairment?
Visual input that is of poor quality or is incomplete or 2. Describe the three purposes of the OT assessment.
inaccurate will affect the ability to complete complex 3. What is the normal search pattern executed by most
visual processing. Therefore visual acuity, visual field, adults when viewing an unstructured visual array? A
oculomotor control, and visual attention and search structured array?
should be assessed first to determine whether deficits 4. What is the primary compensatory strategy taught
exist that might contribute to deficiencies in complex to the patient with hemi-inattention?
processing. If deficits are identified, their effect on the 5. What is the most crucial lower-level visual process
patient’s performance of ADL that require complex contributing to the ability to complete visual cogni-
visual processing should be observed. For example, after tive processing?
having determined that a patient has left VFD and an in- 6. What changes occur in the visual search pattern fol-
complete search pattern indicative of hemi-inattention, lowing right hemisphere injury?
the therapist should observe the patient complete an 7. What prevents a patient from automatically com-
ADL requiring attending, planning, and decision pensating for VFD by turning the head farther to see
making. The activity may be preparing a meal, sorting around the blind field?
and completing laundry, shopping for groceries, mea- 8. What kind of protective behaviors do persons adopt
suring the oil level in the car, or completing a job-related following onset of visual field deficit? Why do they
task. In observing the patient, the therapist should make adopt these strategies?
EAU EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

Describe three of the treatment strategies for deficits 18. Delis DC, Robertson LC, Balliet R: The breakdown and rehabilita-
tion of visuospatial dysfunction in brain injured patients, Int
in visual acuity. Give an example of how each could
Rehabil Med 5:132-138, 1983.
be applied in an activity of daily living. ey. DeRenzi E: Disorders of space exploration and cognition, New York,
10. Describe the assessments completed by the occupa- 1982, John Wiley & Sons.
tional therapist to assess the functional perform- 20. DeRenzi E et al: Attentional shift towards the rightmost stimuli in
ance of the patient with VFD. patients with left visual neglect, Cortex 25:231-237, 1989.
11. Give an example of an active treatment strategy that 218 Dickman IR: Making life more livable, New York, 1985, American
Foundation for the Blind Press.
can be used to teach a patient to compensate for es Festinger L: Eye movements and perception. In Bach Y, Rita P,
VED: Collins CC, editors: The control of eye movements, New York, 1971,
12. Describe the assessment used to identify deficits in Academic Press.
visual search and scanning. DS: Fletcher D et al: Low vision rehabilitation: finding capable people
13. Discuss some treatment strategies for visual scan- behind damaged eyeballs, West JMed 154:554-556, 1991.
24. Gainotti G, Giustolisi L, Nocentini U: Contralateral and ipsilateral
ning and visual inattention. disorders of visual attention in patients with unilateral brain
14. When would partial occlusion be used with the damage, J Neurol Neurosurg Psychiatry 53:422-426, 1990.
patient? Describe the technique used to apply 29% Gianutsos R, Matheson P: The rehabilitation of visual perceptual
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15. How does convergence insufficiency affect func- Diller L, editors: Neuropsychological rehabilitation, New York, 1987,
Guilford Press.
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ices for survivors of acquired brain injury, Arch Phys Med Rehabil
69:573-578, 1988.
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 LEARNING OBJECTIVES
Somatosensory systems After studying this chapter the student or practitioner
Sensory feedback will be able to do the following:
Feedforward control L Define the keywords listed above.
Tactile (touch) sensation 2 Describe the normal function of sensation.
Two-point discrimination 3: Describe the role of sensation in motor
Sensation performance and the effects of sensory loss on
Sensibility motor performance.
Dermatome Define the role of feedback and feedforward
Pressure sensation systems in motor performance.
Light touch sensation Identify dysfunctions in which sensory assessment
Thermal sensation is indicated.
Superficial pain sensation Describe the sensory modalities included in this
Olfactory sensation chapter.
Hyposmia List the purposes of sensory assessment.
Anosmia List three methods of occluding vision during the
Parosmia sensory test.
Gustatory sensation Describe the variability of normal responses in
Proprioception sensory testing.
Kinesthesia 10. Administer a sensory assessment using procedures
Anesthesia described in this chapter.
Paresthesia Luh Differentiate central nervous system disorders from
Hypesthesia peripheral nervous system sensory disorders.
Hyperesthesia iE Describe compensatory and remedial. sensory
Analgesia reeducation programs.
Hypalgesia
Sensory reeducation
Compensatory treatment
Remedial treatment
Dysesthesia
Desensitization

422
 Evaluation of Sensation and Treatment of Sensory Dysfunction 423

descending command for motor performance is com-

pared with the incoming sensory information about the
his ad is concerned with opecryperes:r tad movements as they occur. When bathing, for example, if
the soap slips from the hand, the individual makes im-
mediate adjustments to grasp it tighter. Generally,
taste aad Pri. Vision is discussed in Chapter 24. sensory feedback is used during the performance of
Sensory systems allow us to enjoy life, warn us of goal-directed movements for guiding the direction,
danger, and cause discomfort in the form of pain. force, and accuracy of movement. Knowledge of the
Sensory information from the environment is received outcome of actions can also serve as feedback. For
by peripheral receptors and transmitted to the central example, if a wrong word or misspelling occurs when
nervous system (CNS) via the peripheral and spinal writing, visual feedback signals that an incorrect motor
nerves. Almost all sensory information reaching the response has been made. This sensory information is
cerebral cortex is processed through the thalamus. The then processed in the CNS, and a revision of the motor
exception is olfaction, in which information is transmit- response is planned and executed. Feedback can be in-
ted directly to the primitive cortex of the medial tempo- trinsic (i.e., sensations arising from the body during
tal lobe, then via the thalamus to the orbitofrontal movement) or extrinsic (e.g., information about effec-
cortex. Sensory information is used for sensory percep- tiveness or outcome of motor performance from a ther-
tion, cognitive processing, guidance of movement, and apist or teacher). Intrinsic feedback control is based on
maintenance of arousal. Although sensation is a con- information from peripheral sense organs and is used
scious experience, not all sensation is perceived (inter- primarily during postural adjustments and motor per-
preted) before the production of a motor response. For formance under sensory guidance because feedback
example, the withdrawal of the hand from a hot object processes operate relatively slowly.'”’7°
is driven by an automatic motor response before the
perception that the object is hot occurs.** Diverse Feedforward
sensory systems have in common their ability to extract
the same kinds of information from a sensory stimulus. is used for rapid or ballistic move-
That is, each system carries information about modality in advance. Because of their bal-—
(e.g., touch, pain, or taste) and the intensity, duration, annot be altered by
and location of the stimulus.** sensory feec k K ed. It is not that the move-
ment is rial atu any sensory input. The
movement was planned based on sensory information
SENSATION AND MOTOR PERFORMANCE obtained before the movement was initiated.'’ For
The external environment is represented internally example, skiing is initiated with feedforward control.
through sensation. From this internal representation of Anticipating the sensory experience is necessary to plan
the outside world, the information necessary to guide the motor act of descending the ski run. The slope of the
movement is derived (see Chapter 32).'’ Motor per- ski run, the rate of speed of descent, potential obstacles,
formance in purposeful activity is profoundly depend- and the path to be taken must be considered before the
ent on the continuous inflow of sensory informa- descent is initiated. This anticipation results in assum-
tion.’”*’ Sensory information is used to manage ing a specific posture, setting muscles, initiating the
effective movement and to correct errors in movement motion, making the appropriate balance responses, and
through feedback and feedforward mechanisms.'”’7° directing movement along a given path toward the des-
tination. As the motor act is being executed, the feed-
back system operates continuously to correct errors in
Feedback the intended movement. The feedforward system oper-
ates intermittently to anticipate or reevaluate the re-
quired action and to plan movement responses.'””*°
tions Penved from the ongoing movement are sent back
to the CNS, where a comparison is made between in- Effects of pac Loss on Movement
tended action and what is actually happening. Most
movements, such as dressing, eating, or bathing,
depend on feedback from muscle spindles, joint recep-
tors, and cutaneous receptors for sensory guidance. The Pe CseaTaODT of the sensory mrebetion a major pe-
ripheral nerves and dermatomes corresponding to
spinal segments is shown in Fig. 25-1. Patients with
Dr. A. Lee Dellon is gratefully acknowledged for reviewing this severe sensory loss as a result of peripheral neuropathies
chapter. have major motor performance deficits because of the
 PERIPHERAL DISTRIBUTION

Ophthalmic branch
SEGMENTAL OR RADICULAR
DISTRIBUTION
Trigeminal nerve Maxillary branch

Mandibular branch
Cervical cutaneous nerve

Supraclavicular nerves
Post,

Axillary nerve x

Medial brachial cutaneous i:

Intercostobrachial cutaneous 4~}

‘
iy
’
Posterior brachial cutaneous
(branch of radial nerve) AX¥

Medial antebrachial cutaneous

: ksp>
Lateral antebrachial cutaneous _-~&
(musculocutaneous)
bO>
Soli
Radial
eet iy Ulnar
Median by

Lateral femoral cutaneous

Obturator

Anterior femoral cutaneous (femoral)

xlliohypogastric

x llioinguinal

Common peroneal fLumboinguinal

Saphenous

Superficial peroneal

Deep peroneal

FIG. 25-1
A, Sensory distribution of major peripheral nerves and dermatomes corresponding to spinal cord _
egments, anterior view. (From Chusid JG: Correlative neuroanatomy and functional neurology, ed 19,
Los Altos, Calif, 1985, Lange Medical Publications.)
 PERIPHERAL DISTRIBUTION

joe > ee
SEGMENTAL OR RADICULAR i Great occipital nerve
DISTRIBUTION we
C-2 Small occipital nerve
Great auricular nerve

Cervical cutaneous nerve

Posterior rami of cervical nerves

Posterior supraclavicular nerve

Ss) Axillary nerve

KX
SoSeq
IRooy
‘ 1 Intercostobrachial cutaneous nerve

: Medial brachial cutaneous nerve

eo Posterior brachial cutaneous
iyf (branch of radial nerve)
<a rh
se Lh Medial antebrachial cutaneous nerve
\
|
\\ +
<7r\
\
Posterior antebrachial cutaneous nerve
wy
\ .
.ary‘R Lateral antebrachial cutaneous
es A(musculocutaneous) nerve
‘ [\
ha ‘

re, 4 i Superficial radial nerve

ne
Gea
torial
ATs
¢ 45
ALA Ulnar NY rN
py‘J eee ee : pbs .
Median nerve
a \Fd

/ Anterior femoral cutaneous nerve

Posterior femoral cutaneous nerve

Common peroneal nerve

bite
: ai ean
: ‘YT Superficial peroneal nerve
Flliohypogastric : iq h
(iliac branch) ' "| Saphenous nerve
1
1
* Obturator IX!

' Sural nerve

‘
‘

yp?
re
Lateral plantar nerve
Tibial nerve Medial plantar nerve

FIG. 25-1 cont’d

B, Sensory distribution, posterior view. /

425
426 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

absence of feedback control.?® Those with tactile and

proprioceptive dysfunction cannot sense the position
and motion of joints or sense contact with objects, re-
sulting in difficulties in the performance of the simplest
activities of daily living (ADL). When patients who have
sensory neuropathies with sensory loss but normal
muscle strength are asked to move their fingers with
their eyes closed, they can initially perform the move-
ment in a feedforward mode. With time, however, their
performance degrades because of the absence
of sensory guidance. Vision can compensate for the loss
of tactile and proprioceptive sensation, but the defects
in feedback and feedforward control limit even the
patient's ability to use vision effectively. The patient
cannot sense the resistance of the surface on which the
hand is moving or sense the tension in muscles and
tendons. As a result, jerky movements occur because --4 Forearm

visual feedback is slow and the errors in direction of

movement cannot be corrected in time.'”
Without sensation the conscious perception of pe- =" Index finger
ripheral sensory stimuli is lost and the affected part(s)
may be virtually paralyzed, even when there is ade- FIG. 25-2
Two-point discrimination on the body surface. (From Bear MS,
quate recovery of muscle function.” Patients with
Connors BW, Paradiso MA: Neuroscience, exploring the brain, Balti-
hemiplegia resulting from cerebrovascular accident
more, 1996,Williams & Wilkins.)
(CVA) tend not to use the affected hand unless propri-
oception is intact and two-point discrimination at the
fingertip is less than 1 cm apart, which is indicative of Occupational therapy (OT) practitioners frequently
good discriminative sensation. The minimum dis- assess sensation. It is important not only to assess the
tances for discrimination of two-point sensation vary patient's ability to recognize a touch or pinprick stimu-
from one part of the body to another (Fig. 25-2).* A lus, but also to determine whether sensation is adequate
test for two-point discrimination is described in for the performance of ADL.’ Any patient with CNS or
Chapter 44. Even slight sensory deficits limit function peripheral nervous system (PNS) dysfunction should be
of the affected hand because there are persistent prob- routinely evaluated for sensory loss. Patients with CNS
lems in performing fine motor activities. The highly dysfunction tend to show loss of many sensory modali-
motivated patient may use visual compensation to ties over generalized areas, whereas those with PNS dis-
engage the affected upper extremity in bilateral activi- orders tend to have loss of specific sensory modalities in
ties.°* Adaptive motor behavior frequently occurs in circumscribed areas.
response to external sensory stimuli, and adequate Sensory testing may also be indicated in (1) patients
sensation is essential for effective movement. Therefore with burns, in whom sensory receptors in the skin are
an understanding of the patient’s sensory status is nec- destroyed; (2) patients who have arthritis, in whom
essary to appreciate fully the causes of the apparent joint swelling may cause compression of a peripheral
motor dysfunction and to plan appropriate treatment nerve; (3) patients with traumatic hand and upper ex-
goals and methods. tremity injuries, in whom skin, muscles, tendons, liga-
ments, and nerves may be involved; and (4) elderly
individuals, who may show age-related changes in re-
PRINCIPLES OF SENSORY EVALUATION
sponse to sensory stimuli.'’1?””
The terms sensation and sensibility refer to the reception, Examples of other diagnoses that require sensory
transmission, and interpretation of sensory stimuli. testing are peripheral nerve injuries and diseases, spinal
These terms are sometimes used interchangeably, or cord injuries and diseases, brain injuries and diseases,
they may be differentiated.”""’*? Callahan’ defined sen- and fractures. With fractures, sensory testing may help
sation as the stimuli conveyed to the central interpretive. to determine if there is peripheral nerve involvement.
centers by the afferent nerves and sensibility as the
ability to perceive or interpret sensory stimuli.’ For the
purposes of this chapter, the term sensation will be used
Sensory Supply to Specific Areas
to refer to the ability to identify the sensory modality The sensory distribution of the major peripheral nerves
and its intensity and location. of the body and limbs is shown in Fig. 25-1. In assess-
 Evaluation of Sensation and Treatment of Sensory Dysfunction 427

ment of peripheral nerve dysfunction, it is important to can observe for spontaneous use of the affected part(s)
test the area supplied by the nerve or nerves that are af- in bilateral ADL.
fected. The sensory distribution of the dermatomes that
correspond to spinal cord segments is also shown in
Fig. 25-1. A dermatome is the area of the skin supplied
Occlusion of Vision During Testing
by one spinal dorsal root and its spinal nerve. Adjacent Almost all of the sensory tests described in this chapter
dermatomes overlap more for touch, pressure, and vi- require that the patient's vision be occluded so that the
bration than for pain and temperature. This means that test stimuli cannot be seen. The use of a blindfold and
assessment of pain and temperature will provide a keeping the eyes shut are the least desirable methods of
better determination of spinal nerve injury. Testing of occluding vision. A blindfold can be a source of sensory
patients with spinal cord injury or disease according to distraction and can provoke anxiety in patients with
this dermatomal distribution is important to determine sensory, perceptual, and balance disturbances.'* Addi-
the level or levels of spinal cord lesion and any sparing tionally, many individuals with CNS dysfunction have
of spinal cord function. difficulty maintaining eye closure because of apraxia
and motor impersistence.
There are several alternative methods for occluding
Purposes of Testing
vision. As shown later with actual tests, a small screen
By performing a sensory test, the therapist can carefully made by suspending a curtain between two posts is
outline areas of intact, impaired, or absent sensation. convenient and effective. If such a device cannot be
This information is sometimes of diagnostic or prog- constructed, something similar can be made by folding
nostic value to the physician and provides a baseline for in the sides of a corrugated box and draping a cloth
progress. The sensory assessment can also be used to de- over one side (Fig. 25-3, A), or a file folder can be held
termine the need to teach the patient how to protect over the area being tested (Fig. 25-3, B). Sensory
against injury, how to use compensatory techniques testing shields are also commercially available (Fig.
(such as visual guidance for movement during activi- 25:4)
..¢
ties), and whether a sensory or sensorimotor retraining
program is feasible. Sensory loss may affect the use of
TESTS FOR SENSATION
splints and braces because the patient may be unaware
of pressure points during wear. Sensory loss may also The following tests are based on evaluation tools of
affect controlled use of a dynamic splint, which requires clinical neurology and are designed to test gross sensa-
good sensory feedback for effective operation. Conse- tion in adults with CNS or PNS dysfunction.”’*” The
quently, the patient should be taught safety guidelines reference list includes additional sensory tests and
in the use of splints, particularly the need to check the tests of discrete sensation.”"'*° Tests of moving
insensitive body parts for early signs of injury» touch, constant touch, vibration sense, and two-point
Tests of sensory function do not always accurately discrimination are described in Chapter 44. Tests for
predict functional use of the hand. Moberg, cited by discriminative tactile perception are described in
Dellon,” studied patients with median nerve injury to Chapter 26.
determine whether a correlation existed between results
of clinical sensory tests and hand function. He used a
General Procedure
series of everyday activities that required several types of
grip and prehension and a test of picking up small Testing should take place in a quiet and nondistracting
objects and placing them in a container (Moberg environment. Extraneous noises from the examiner or
Picking Up Test) to evaluate hand function. Moberg testing instruments should be minimized. Tests should
concluded that tests of touch, pain, temperature, and vi- always be administered to the analogous limb on the
bration did not correlate with hand function. There was normal side if the patient has unilateral dysfunction, to
some correlation between two-point discrimination establish a standard of accuracy for the individual
and hand function.’ One of the reasons for the finding patient and to assure that directions for test administra-
may be that the test did not include a test of proprio- tion are understood. The parts to be tested should be
ceptive function. Nevertheless, Moberg’s work is impor- exposed and positioned comfortably. In some in-
tant to OT because it underscores a primary purpose stances, the examiner will have to support the part man-
and principle of OT practice: to evaluate function or ually or with therapy putty, sandbags, or other cushion-
performance. Thus it is important for the occupational ing material.’ It is important for the examiner (E) to
therapist not only to evaluate the sensory modalities, orient the subject (S) to the test procedures and to the
but also to evaluate function. The therapist can use one rationale for administering the tests. E should be sure
of several hand function tests to observe hand use under that S understands how to respond. S’s vision can be oc-
simulated conditions. More reliably still, the therapist cluded by shielding the parts being tested from view.
 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

FIG. 25-3
A, Device for occluding vision during sensory testing: box with cloth drape. B, File folder used to
occlude vision during sensory testing.

Light Touch and Pressure Sensation

MATERIALS. A screen or manila folder to occlude
Tactile sensitivity is critical to the performance of all vision; a cotton swab.
ADL. For example, knowing an object is in the hand or
feeling clothes on the body and knowing whether they CONDITIONS. A nondistracting environment in
are correctly adjusted is dependent on intact touch sensi- which S is seated at a narrow table. The test may also be
tivity. Pressure sensationis also important in ADL conducted at the bedside or in a wheelchair. The af-
because it is continuously received in activities such as fected hand and forearm should be supported comfort-
sitting, pushing drawers and doors, crossing the knees, ably on the table. E sits opposite S.
wearing belts and collars, and a host of other activities
that stimulate pressure receptors. It is possible for a METHOD. S's hand and forearm are hidden from S's
patient to have intact pressure sensation if touch is im- view by placing them under the screen or by E holding a
paired or absent because pressure receptors are in subcu- manila folder over them. The hand and forearm are
taneous and deeper tissue and touch receptors are in the touched lightly with a cotton swab at random locations,
superficial layers of the skin. Touch sensation is necessary covering the area supplied by each peripheral nerve and
for fine discriminative activities, and pressure is a protec- each dermatome. A few trial stimuli should be adminis-
tive sensation because it warns of deep pressure or repet- tered while S is watching, to be sure that S understands
itive pressure that can lead to injury.’ If touch sensation the procedure and how to respond. The test should be
is impaired, pressure sensation can aid in performance of administered on an uninvolved area first to establish a
ADLand substitute for touch feedback in some activities. standard. If spasticity is a problem, E may support the
Various tools have been used to apply stimuli for the hand on the dorsal surface and hold the thumb in radial
light touch and pressure tests. These include a cotton abduction and extension to secure relaxation of the
ball, cotton swab, fingertip, or pencil eraser. All of these fingers for palmar testing (Fig. 25-5, which also shows
objects can provide a gross or cursory evaluation of the screen mentioned earlier).
light touch sensation and pressure sensation. More
discrete and accurate testing of cutaneous pressure RESPONSES. After each stimulus, E asks S if S was
thresholds of light touch to deep pressure can be per- touched (recognition). S responds by nodding or saying
formed by using the Semmes-Weinstein Monofilaments yes or no. The screen is lifted or the folder is removed
described in Chapter 44"°° or the Pressure Specified after each stimulus, and S is asked to point to the place
Sensory Device.'* where S was touched, using the unaffected hand if pos-
sible. Localization responses are more accurate if S is
Test for Light Touch Sensation”’”’''*** allowed to use vision.’ If this cannot be done, S is asked
PURPOSE. To determine S's ability to recognize and to describe the location and E should select locations
localize light touch stimuli. that are easy to name (e.g., “knuckle of middle finger”).

LIMITATIONS. Patients with receptive aphasia SCORING. On the scoring chart E marks a “plus”
cannot be validly tested. (+) for the ability to recognize and localize touch
 Evaluation of Sensation and Treatment of Sensory Dysfunction

FIG. 25-5
Test for light touch and pressure sensation.

tial for the prevention of injury in many ADL, such as

bathing, cooking, and ironing. The ability to detect tem-
FIG. 25-4 perature also contributes to the enjoyment of food and
Sensory testing shield. (From Smith & Nephew, Germantown, Wis.) to the detection of uncomfortable environmental tem-
peratures. If the patient lacks accurate thermal discrimi-
nation, it will be necessary to teach precautions against
injury and to structure ADL to prevent burns. As in the
other sensory tests, the results can serve as a baseline for
stimuli, a “minus” (—) for the ability to recognize only, progress and changes in sensory status may be used to
and a “zero” (0) for an inability to recognize or localize measure recovery or degeneration, depending on the
a stimulus (Fig. 25-6). diagnosis.
Techniques such as touching the skin with test tubes
INTERPRETATION OF RESULTS Deviations of */s that are filled with hot and cold water, immersing the
to 1'/s inches (1.5 to 3 cm) from the point of applica- fingers or hand in hot or cold water, or touching small
tion of the stimulus are normal for localization of hot or cold compresses to the area being tested have
stimuli, depending on the area of the hand or,arm been used in tests for thermal sensation. Another
touched. Responses should be more accurate on the method is the Hot/Cold Discrimination Kit by Rolyan*
hand than on the forearm and more accurate on the (Fig. 25-7).°* This kit includes two metal temperature
forearm than on the upper arm. The ability to recog- probes with a thermometer at the head of each, two
nize and localize touch indicates intact sensation. The thermal cups, and a single-stem thermometer. One
ability to recognize but not localize touch stimuli indi- thermal cup is filled with ice and water, and the other is
cates sensory impairment, and an inability to recognize filled with hot tap water. The single thermometer is in-
or localize touch stimuli means touch sensation is serted into the thermal cup. When the desired tempera-
absent. ture is reached, the probe is inserted into the thermal cup
and allowed to reach the desired testing temperature.
Test for Pressure Sensation The metal probes, which look much like test tubes, are
Pressure sensitivity may be tested as described for light then put in contact with the skin surface to be tested.
touch, except that E should press hard enough with the This kit makes it possible to control temperatures more
cotton swab to dent and blanch the skin. If light touch precisely and to maintain constant temperature stimuli
sensitivity is severely impaired or absent, pressure sensi- for the duration of the test.°?
tivity may be intact and may provide important sensory
feedback, which can enhance function. Normally, pres- Test for Thermal Sensation””’'*'*
sure stimuli can be localized on the hand from 2.44 to PURPOSE. To determine S's ability to discriminate
2.83 mg of pressure (Fig. 25-5).°° between extremes of hot and cold and to detect varia-
tions in temperature at four levels.
Thermal Sensation
Thermal sensation is another of the protective sensory *Smith & Nephew, Inc., One Quality Drive, PO Box 1005, German-
modalities.° The ability to detect temperatures is essen- town, Wis.
 FORM FOR RECORDING SCORES ON
TESTS OF SENSATION
Department of Occupational Therapy

oe
Name Age Sex

Diagnosis Disability
Date

TEST FOR LIGHT

TOUCH SENSITIVITY LEFT RIGHT
Use a cotton swab Anterior Anterior
and touch random
locations on anterior
and posterior surfaces.
Indicate on diagram:
Intact: ar
Impaired: =—
Absent: 0

Posterior _ . Posterior

TEST FOR PRESSURE

SENSITIVITY LEFT RIGHT
Use a cotton swab Anterior Anterior
and press random
locations on anterior
and posterior surfaces.
Indicate on diagram: ‘
Intact: ae
Impaired: “
Absent: 0

Posterior Posterior

TEST FOR SUPERFICIAL PAIN LEFT RIGHT

Use a large safety pin and Anterior Anterior
touch random locations with
sharp and dull ends on
anterior and posterior ow
surfaces.
Indicate on diagram:
Sharp:
Correct response ao
Sharp reported dull D
No response =o
Dull:
Correct response +D
Dull reported sharp 5
No response —D Posterior Posterior
Remarks:

FIG. 25-6
Form for recording scores on tests of light touch, pressure, and superficial pain sensation.

430
ee
ie

ear
ay
ee

FIG. 25-8
Test for thermal sensation.

hand(s) in random order. If S is unable to hold the

FIG. 25-7 tubes, E may touch each one to S's palm and fingertips.
Hot/cold discrimination kit. (From Smith & Nephew, Germantown,
Wis.) RESPONSES
Sustest I. S responds “hot” or “cold” in response to
each stimulus. If S is aphasic, E should work out an al-
LIMITATIONS. Persons with receptive aphasia cannot ternative nonverbal response before beginning the tests.
be validly tested. It is difficult to control water tempera- Subtest II. S is asked to arrange the test tubes on a
ture very accurately, and the temperature may change table from the hottest to the coldest, in order from left
during the administration of the test. The results are to right. E checks the correctness of the order by color-
subjective and may only detect ability to discriminate coded stoppers and feeling tubes.
gross differences in temperature.
SCORING
MATERIALS. Four test tubes (?/4-inch or 2-em diam- Sustest I. (Fig. 25-9) E marks a “plus” (+) if the
eter) with stoppers; hot, warm, tepid, and cold water. temperature is correctly identified and marks a “zero”
(0) if S cannot distinguish hot from cold. Subtest II is
CONDITIONS. A nondistracting environment in not administered if S succeeds at subtest I (Fig. 25-9).
which §S is seated comfortably at a table with both the Sustest II. E marks the appropriate blanks on the
hand and forearm supported on a table, or alternative form with a check and the appropriate letter to indicate
positioning described for previous tests. S’s responses.

METHOD INTERPRETATION OF RESULTS. Adults in normal

Sustest I. Two test tubes are used, one filled with health should be able to complete all items on this test
cold water (45° F or 7° C) and one with hot water (110° successfully. The normal hand can detect temperatures
F or 43° C). Extreme temperatures should not be used, 1°16.5° G apart.
because they can stimulate the pain receptors. Stoppers
are placed in tubes. E touches the sides of the test tubes
Superficial Pain Sensation
to the skin surfaces to be tested in random order and at
random locations, being sure to cover the test area thor- Pain is one of the protective sensations that makes the
oughly (Fig. 25-8). detection of potentially harmful stimuli to the skin
Sustest II. Four test tubes are used, one filled with and subcutaneous tissue possible.’ The ability to
cold water, one with tepid water, one with warm water, detect painful stimuli is critical to avoiding injury
and one with hot water. E should color-code the stoppers during the performance of daily activities and the pre-
as follows: yellow for hot, green for warm, orange for vention of skin breakdown while wearing splints and
tepid, and red for cold. Place the stoppers in the tubes. E braces and using wheelchairs, crutches, and other
asks S to touch or hold test tubes with the affected adaptive devices. In normal circumstances pain sensa-
 FORM FOR RECORDING SCORES ON
TESTS OF THERMAL SENSITIVITY
Department of Occupational Therapy
Name Age Sex

Diagnosis/Disability
Date of Onset ; Date of Test

TEST FOR THERMAL SENSITIVITY

SUBTEST I.

Touch sides of hot and cold test tubes to skin surfaces in random order and at random
locations. Record scores on diagrams for tests of arms and hands or list site tested and
record scores in columns.

Test site (fill in location tested) Score (+, 0)

Dates

Use diagram to record scores on test of arms and hands

LEFT, RIGHT
Anterior Anterior

a
Posterior Posterior

SUBTEST Il. Date Date Date

Arrange test tubes in correct order.
Arrange test tubes in wrong order.

loess Suen of test tubes by fillingin spaces below with H for hot, W for warm,
T for tepid, and C for cold
Date:

FIG. 25-9
Form for recording scores on the test for thermal sensation.

432
 Evaluation of Sensation and Treatment of Sensory Dysfunction

tion warns the individual to move quickly, as when

withdrawing a finger from a hot surface. Pain sensa-
tion also signals the need to adjust the position of
clothing that binds or to remove an offending article
of apparel such as a shoe that is rubbing a blister on
the foot. The patient who lacks the ability to detect
such painful stimuli is more likely to be injured. If
pain sensation is absent or impaired, it is important to
teach sensory compensation and safety awareness in
the treatment program.
The following test uses a safety pin to apply light
_ pain stimuli. A new safety pin should be used for each
patient. The pin should be sterilized before testing and dis-
carded after the test. The examiner should be aware that
atrophic skin is particularly susceptible to injury and
that a pinprick stimulus, which would not break normal
skin, could produce a tiny break in atrophic skin. Skin
atrophy occurs after peripheral nerve injury. The inter-
ruption of nerve supply interferes with normal tissue
nutrition and causes the atrophy.’ If this possibility is a
FIG. 25-10
concern, the end of a straightened paper clip may be Test for superficial pain sensation.
used for the test.
}°:25-27
Test for Superficial Pain™
PURPOSE. To make a gross evaluation of superficial stands the test and knows how to respond. If spasticity
pain sensitivity. is a problem, E may support the hand on the dorsal
surface and hold the thumb in radial abduction and ex-
LIMITATIONS. Persons with receptive aphasia cannot tension to secure relaxation for palmar testing as shown
be validly tested. The pulp of the fingertips is relatively in Fig. 25-5.
insensitive to a pinprick. Callused or toughened areas
(e.g., the palms) are normally less sensitive to a pinprick RESPONSES. S should be asked to say “sharp” or
than other areas. If S is fearful of a safety pin, the “dull” in response to each stimulus. If S is aphasic or
straightened paper clip may be used. dysarthric, E should ask S to indicate a response by
pointing to the appropriate side of an open safety pin in
MATERIALS. The screen or a manila folder, to S's view.
occlude S’s vision; a large safety pin or straightened
paper clip. SCORING. Callahan’ recommended the following
coding system for responses: E marks a “plus S” (+S) at
CONDITIONS. A nondistracting environment in the stimulus point on the scoring chart for a correct re-
which S is seated at a narrow table. The affected hand sponse to a sharp stimulus, a “minus S” (—S) for no re-
and forearm should be supported comfortably on the sponse to a sharp stimulus, and a “D” if a sharp stimu-
table. E sits opposite S on the other side of the table. If S lus is reported as dull; a “plus D” (+D) for a correct
cannot be positioned in this manner, the test may be ad- response to a dull stimulus, a minus “D” (—D) for no
ministered while S is in bed or sitting in the wheelchair response to a dull stimulus, and an S if a dull stimulus is
with his or her arms resting on a lap board. reported as sharp.’ A form for recording the results of
the evaluation is shown in Fig. 25-6.
METHOD. The hand and forearm to be tested are
hidden from S's view by placing them under the screen INTERPRETATION OF RESULTS. Correct re-
or by E holding a manila folder over them. The affected sponses to both sharp and dull indicate that protective
hand and forearm are touched lightly at random loca- sensation is intact. Incorrect responses to both sharp
tions, using sharp and dull stimuli in random order and and dull are indicative of absent protective sensation.
at random speed. Each stimulus should be applied with If dull stimuli are reported as sharp, the patient has
the same degree of pressure (Fig. 25-10). It is important hyperesthesia; if sharp stimuli are reported as dull,
to apply stimuli to the area supplied by each peripheral that patient has pressure sensation.’ The computer-
nerve and each dermatome.’ A few trial stimuli should driven Automated Tactile Sensor may be used to record
be conducted with S watching, to be sure that S under- responses more accurately. '*
434 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

Olfactory Sensation (Smell) because they stimulate all receptors of the mucous
The sense of smell (olfactory sensation) is conveyed by membranes and tend to be irritating.’*’'° If S cannot
receptors that lie deep within the nasal cavity. Normal respond verbally, small cards with the word or a picture
individuals can detect thousands of odors at very low for each odor on them will be needed.
concentrations, making smell discrimination quite ex-
traordinary. The sense of smell is important for detec- CONDITIONS. A nondistracting environment in
tion of noxious and pleasant odors and is associated which no strong odors are present, with S seated or
with the pleasure of taste. Smell is also connected to semireclining.
neuronal circuits that influence emotional states, and
smell evokes certain memories. Olfactory acuity varies METHOD. S is asked to compress one nostril, or this
greatly among normal persons. Olfactory acuity nor- function may be provided by E. S is then asked to take a
mally declines with age.'* breath to demonstrate that the remaining nostril is
Hyposmia is a diminished sense of smell, whereas a open. If the substances can be recognized from their ap-
loss of the sense of smell is known as anosmia. Hyposmia_ pearance, vision is occluded. The cork of the bottle ora
refers to impaired sensation of a general nature. It may cotton swab moistened with an essence is held under
occur in patients with cystic fibrosis of the pancreas, the open nostril. In the case of solid substances, the
Parkinson’s disease, and untreated adrenal insufficiency. container may be held under S's nostril. S is asked to
Anosmia may be specific or general. Specific anosmia take two moderate sniffs. Each of the substances is tried,
refers to lowered sensitivity to a specific odorant whil with a short delay between them, and the nostrils are
perception of most other odors remains intact gene tested alternately using the same and different sub-
anosmia refers to absence of the sense of smell. Anosmia Stances. sue.
may result from local, chronic, or acute inflammatory
nasal disease or from intracranial lesions that may be the RESPONSES. E asks S if he or she can (1) detect an
result of CVA, head injury, tumors, and infections. In odor, (2) identify the odor, and (3) determine if the
some disturbances the sense of smell is distorted. There odors are the same or different to both nostrils.”~°
may be perception of odors that do not exist, or pleasant
odors may be distorted or perceived as noxious. This SCORING. E marks a “plus” (+) on the form if the
condition is known as parosmia.” odor is detected and correctly identified, a “minus” (—)
Anosmia interferes with function, as in the case of a if an odor is detected and incorrectly identified, and a
patient who has an occupation in which the sense of “zero” (0) if no odor is detected (Fig. 25-11). Whether
smell is critical to safety, or for the detection of house- the same odors are perceived as the same by both nos-
hold gas, chemicals, smoke, car exhaust, and noxious en- trils and whether S can differentiate between dissimilar
vironmental odors. The disturbance may interfere with odors presented to each nostril should be noted on the
the perception and enjoyment of food odors and taste form.
because a decreased sense of smell affects the ability to
taste. Therapists may also use olfactory stimulation in INTERPRETATION OF RESULTS. The ability to
the treatment of certain neurological disorders. '° detect and identify odors quickly, the ability to detect an
odor but not identify it, and the ability to detect and dif-
Test for Olfactory Sensation ferentiate odors without identification may all be re-
PURPOSE. To determine if the sense of smell is garded as normal responses. Distortion of the odor
intact, impaired, or lost and whether the loss is unilat- (parosmia) and inability to detect odors (anosmia) are
eral or bilateral.” regarded as dysfunctional. If test responses are vague
and variable, the results are unreliable and it is best to
LIMITATIONS. Persons with receptive aphasia postpone the test to a more favorable time.”
cannot be validly tested. Persons with expressive
aphasia who cannot communicate using symbols such
as pictures or words to indicate responses cannot be
Gustatory Sensation (Taste)
validly tested. The test is quite subjective, and E must Taste receptor cells, located in the taste buds of the
rely on S's report. tongue, palate, pharynx, epiglottis, and esophagus,
convey taste stimuli (gustatory sensation) to the brain
MATERIALS Five small opaque or dark-colored via the facial, glossopharyngeal, and vagus nerves (cranial
bottles containing essences, powders, or crystalline ma- nerves VII, IX, and X). Generally, four basic tastes can be
terial of familiar and natural odors; coffee, almond, detected: sweet, sour, salty, and bitter. Detection of more
chocolate, lemon oil, and peppermint are some that are complex taste sensations is thought to be a result of the
suitable.” Vinegar, ammonia, or other irritating chemi- activation of combinations of receptors for these four
cal odors should not be used in a test of olfaction basic tastes.‘
 Evaluation of Sensation and Treatment of Sensory Dysfunction 435

RECORDING SCORES OF OLFACTORY AND GUSTATORY SENSATION

Name:
Age: Diagnosis:
Date:
Key: + = Can detect and identify odor
— = Can detect odor, cannot identify odor
0 = Cannot detect or identify odor
S = Can detect same odors, both nostrils
D = Can detect different odors, both nostrils

OLFACTORY SENSATION Left nostril Right nostril © Comparisons

Coffee
Almond
Chocolate
Lemon
Peppermint

GUSTATORY SENSATION
Key: + = Identifies taste correctly
— = Cannot identify taste

FIG. 25-11
Form for recording scores on olfactory and gustatory sensation.

Disturbances of taste may be caused by PNS or CNS Test for Gustatory Sensation
lesions.*” Smokers may demonstrate a decreased sense PURPOSE. To determine if the sense of taste is
of taste with aging.'®° Taste is not only basic to the en- intact, impaired, or absent.
joyment of food, but also is one of the sensory stimuli
that trigger salivation and swallowing.” Like smell, taste LIMITATIONS. The same limitations as cited for the
is connected to neural circuits that control emotional test of olfaction apply here. The most accurate method
states and trigger specific memories.'* Taste sensation of administering the test requires that S keep the tongue
may be of concern to the occupational therapist as part extended.”**' Therefore S must respond by pointing to
of a comprehensive evaluation of oral-motor mecha- a word or picture. In instances where S has speech but
nisms and for planning feeding training programs cannot recognize words or pictures, a verbal response
(Chapter 40). should be allowed. If S is aphasic, E should observe for
436 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

aversive responses to the sour and bitter stimuli.’ The of the limbs, trunk, and head at any moment. Proprio-
appreciation of taste depends on an intact sense of ception, touch, and stereognosis make it possible to
smell.”''° write without looking at the pencil, type without
looking at the keys, and button clothes behind the back.
MATERIALS. A glass, pitcher of water, and small The awareness of motion and position is on a sub-
rinse basin; sugar or saccharin (sweet), salt or salt sub- cortical level and normally does not require conscious
stitute (salty), lemon or vinegar (sour), and quinine effort. To test position and motion sense, however, it is
(bitter) in small containers to test the four basic tastes’*; necessary to raise the sensation to a conscious level so
cotton swabs; response cards with the word for the taste that the patient can make the appropriate responses. A
or a picture symbol of the taste on each. partial or complete loss of position and motion sense
seriously impairs movement, even if muscle function is
CONDITIONS. A nondistracting environment in within normal limits. Therefore it is important for the
which §S is seated or semireclining. E should sit directly occupational therapist to know if the patient has the
in front of S. S’s vision should be occluded. The oral sensory loss, so that the motor dysfunction can be more
cavity should be clean and free of residual food tastes. fully understood. The assessment will help to plan treat-
ment by using compensatory methods or a sensory re-
METHOD. § is instructed to protrude the tongue, training program.
and a small amount of the test substance on the tip of a
wet cotton swab is applied to the appropriate place on Test of Position and Motion Sense”'”'*?°?777
the tongue: sweet on the front or tip of the tongue, salty PURPOSE. To evaluate S’s senses of motion and
on the anterior lateral margins of the tongue, sour on position.
the lateral middle margins of the tongue, and bitter on
the posterior tongue margin.”’’*’'® Tastes are presented LIMITATIONS. It is important that S comprehends
in that order because the bitter stimulus may evoke an instructions exactly. Thus patients with receptive
aversive response.'® If this technique is not effective, aphasia may not be validly tested. Movements must be
rubbing the substance along the side of the protruded made slowly and carefully enough to be detected.
tongue should be tried.”*° The tongue should be irri- Methods of responding must be well established and
gated with plain water between each stimulus.” '*"® understood before beginning the test. The patient's con-
centration on motion and position is essential.”
RESPONSES. S is instructed to point to a response
card before withdrawing the tongue and diffusing the MATERIALS. For testing hands and forearms, the
taste to all areas of the tongue.””” screen or a manila folder used to occlude vision; for
testing the elbow and shoulder, if space and equipment
SCORING. E should record a “plus” (+) if the taste permit, a screen high and wide enough to conceal S’s
is correctly identified and a “minus” (—) if the taste arm when held overhead or out in front when S is in a
cannot be identified (Fig. 25-11). seated position. The curtain screen should be full, con-
tinuous, and attached only at the top. If such a screen is
INTERPRETATION OF RESULTS. Normal adults not available, an assistant can shield S’s vision with a
should be able to identify all tastes accurately. manila folder. :

CONDITIONS. The test should be conducted in

Position and Motion Sense
privacy in a nondistracting environment. When the
Proprioception refers to the unconscious reception of fingers and wrist are being tested, S should be seated at
information about joint position and motion that arises a table with the screen in a position to accommodate
from receptors in the muscles, joints, ligaments, and the affected hand and forearm comfortably. E should sit
bones. The conscious sense of motion may be referred opposite S on the other side of the screen and support
to as kinesthesia. Equilibrium (balance) or vestibular S‘s hand for the test. When the elbow and shoulder are
sensation is part of proprioception.” These senses make being tested, S should be seated away from the table,
it possible to detect joint motion and position of the and the curtain screen should be draped over the af-
body or any of its parts. Sensation that is evoked by fected shoulder so that S is unable to see the arm. If this
movement is essential to being able to move effectively. position is not feasible, the test may be conducted with
Feedback and feedforward control mechanisms depend S seated or reclining in bed or seated in a wheelchair.
on proprioception.'’ These mechanisms provide infor-
mation about the motion and position of the body and RESPONSES. To determine appreciation of direc-
its parts. The mechanisms also help maintain erect tion of movement, S should be instructed to respond
posture, make postural adjustments, and localize action “up” (away from the floor) and “down” (toward the
 Evaluation of Sensation and Treatment of Sensory Dysfunction 437
7?

floor) or “out” (away from the body) and “in” (toward for all motions is with S's arm at the side, the shoulder
the body) as soon as he or she perceives direction of supported in 20° to 30° of abduction, the elbow sup-
movement. Aphasic subjects may respond by pointing ported at 90° of flexion, and the wrist stabilized at neutral.
in the appropriate direction. If there is an unaffected ex- Test positions are elbow extension, shoulder flexion,
tremity, as in hemiplegia, S should be asked to imitate shoulder internal rotation, and shoulder scaption
the motion and final position with the unaffected ex- (halfway between 90° of flexion and 90° of abduction).
tremity after E has ceased passive movement of the part Test positions should be presented in random order.
—
being tested, to evaluate appreciation of motion and Ranges should not be so extreme as to elicit a stretch reflex
position. or cause pain if there is joint tightness. S should be seated
away from the table. The curtain screen should be
METHOD arranged at S's test side. E should stand at S's test side and
Test OF FINGERS. Test positions are index finger guide the limb passively through the test positions. When
flexion, middle finger extension, thumb extension, and a right arm is being tested, E’s right hand should be placed
little finger flexion, which should be presented in along the ulnar border of S’s hand and wrist, stabilizing
random order. No range of motion should be so the wrist at neutral. E’s left hand should be placed on the
extreme as to elicit pain or a stretch reflex. S’s hand and dorsal surface of the upper arm, just proximal to the
forearm should be placed under the curtain, resting on elbow. The position is reversed when testing the left arm. E
the dorsal surface. When testing a right hand E should may carry out all test positions for the elbow and shoulder
support S's hand with the left palm and hold the thumb without changing the position of the hands (Fig. 25-13).
out of the way with the left thumb if necessary. This po-
sition should induce relaxation of the fingers if S has SCORING. Appreciation of the direction of move-
flexor spasticity. With the right hand E should grasp the ment: E records “plus” (+) if the direction is correctly
finger to be tested on each side at the distal phalanx to perceived or “zero” (0) if the direction is not perceived
avoid giving pressure cues with E’s thumb and index (Fig. 25-14).
finger. The finger being tested should be separated from APPRECIATION OF PosiTION. E records “plus” (+) if the
others and should be kept from touching the palm to correct response is given, “minus” (—) if the response is
avoid cues from contact. The position of E’s hands is re- delayed or nearly correct, and “zero” (0) if the response
versed when testing a left hand (Fig. 25-12). is obviously incorrect or if no response is given.
Test oF WRistT. Test positions are wrist flexion and REMARKS. On. the recording form, E comments on S's
extension. The ranges should not be so extreme as to reactions, unusual statements, observations, and indi-
elicit tendon action or a stretch reflex. E’s and S’s hands vidual variations in test procedure adapted for specific
are positioned as for testing the fingers. E makes a some- dysfunctions.
what firmer grasp at the sides of S’s hand, but reducing
contact between E’s palm and the back of S‘s ‘hand. INTERPRETATION OF RESULTS. Normal individ-
Test OF ELBOW AND SHOULDER. The starting position uals can detect movements of 1 or 2 mm ina joint.'® A
grade of “intact” was given by Kent if movement could
be detected in the first 15° of the range of motion. It is
possible for normal persons to duplicate the passive

FIG. 25-12 FIG. 25-13

Motion and position sense test of fingers. Motion and position sense test of elbow and shoulder.
438 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

FORM FOR RECORDING TESTS OF POSITION/MOTION SENSE

Department of Occupational Therapy
Name Age Sex Onset

Diagnosis/disability
Date

Directions:
Fingers and Wrist: Grasp part laterally.
Scoring: Direction of Movement
+ = Intact/correct response
0 = Absent/incorrect response or no response
Position Sense
+ = Intact/correct imitation of movement and position
— = Impaired /delayed response, minor to moderate errors in response
0 = Absent/significant errors or no response
Elbow/Shoulder: Starting position for all movements is:
Shoulder: 20° to 30° of abduction
Elbow: 90° flexion
Wrist: Stabilized at neutral
Scoring: Same as above for fingers and wrist

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Test of Motion/Position Sense UOSNpPgD-uOIxay
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Appreciation of direction of movement
Appreciation of position
Remarks:

FIG. 25-14
Form for recording the scores on tests of motion and position sense.

motion and position of the part being tested with the the dermatome supplied by the affected nerve root.
analogous uninvolved part quickly and with consider- Sensory dysfunction of CNS origin is more generalized
able accuracy. and affects the contralateral side of the body after
stroke or head injury, resulting in hemiplegia. Some of
the terms associated with sensory disturbances are
SENSORY DYSFUNCTION
anesthesia (complete loss of sensation), paresthesia
Sensory disturbances can result from CNS or PNS dys- (abnormal sensation such as tingling or crawling), hy-
function or from cranial nerve disorders. In peripheral pesthesia (decreased sensation), hyperesthesia (in-
and cranial nerve lesions the sensory disturbance is lo- creased tactile sensitivity), analgesia (complete loss of
calized to the area supplied by the affected nerve. pain sensation), and hypalgesia (diminished pain
Sensory disorders of nerve root origin are localized to sensation).®
 Evaluation of Sensation and Treatment of Sensory Dysfunction 439

Sensory loss may have a profound effect on the his or her sensory deficits. Safety factors during perform-
patient's ability to function in everyday activities. There- ance of everyday activities must be continuously
fore it is important to facilitate sensory recovery or reed- brought to the patient’s attention and reinforced. To
ucation to the extent possible or to teach compensatory compensate for sensory loss the patient can be trained
techniques and safety precautions. to check the position of the limbs by looking at them.
Patients must be evaluated for safety awareness and
trained to consider safety in hazardous activities. The
Treatment of Sensory Dysfunction
patient who wants to return to home management
Before treatment of sensory dysfunction can be initi- should demonstrate good judgment, safety awareness,
ated, a sensory assessment and an assessment of func- and ability to use visual compensation for sensory
tional use of the affected part should be completed. The loss.*? Frequent repetition of instructions and cuing by
therapist must have knowledge of the diagnosis, the the therapist are often necessary. Cognitive disturbances
cause of the sensory dysfunction, the prognosis for such as poor memory, perseveration, poor judgment,
return of sensation, and the current progression of and inability to see cause-and-effect relationships make
recovery. This information may help determine whether it difficult for some patients to learn and attend effec-
the treatment approach should be remedial, compensa- tively to compensatory techniques. In such instances,
tory, or both. The eames whorlis tosaa a— supervision is required.

Remedial Treatment.
Sensory bombardment involving as many of the senses
as possible has been found to be useful for sensory re-
training in some CVA patients. During regular therapeu-
tic activities and handling, the therapist can touch or
stroke the affected parts and encourage the patient to
Central Nervous System Dysfunction
observe the movement and touch stimulation. Weight
Effects of Sensory Loss bearing on the legs, arms, and trunk increases proprio-
Following CVA and other CNS disorders such as head ceptive feedback.**
injury, sensory loss can be a considerable problem. Eggers’ advocates integrating sensory retraining with
Sensory loss inhibits movement even when there is motor retraining, with the neurodevelopmental ap-
good motor return. The inclination to move is based on proach as the basis for treatment (see Chapter 36). She
sensory input and feedback. Persons with poor sensa- described a sensory retraining program that focuses pri-
tion have little urge to move. Attempted movement may marily on tactile and kinesthetic reeducation. A prereq-
be clumsy or uncoordinated. Sensory loss may con- uisite to sensory retraining is having the therapist nor-
tribute to, but is not the only cause of, the neglect of the malize the patient's muscle tone and find the optimal
affected extremity so often seen in patients with CVA. position for the sensory reeducation activities. The ther-
The possibility of injury is a serious concern, and the de- apist must find ways to stimulate sensation without in-
pendence on visual control negates carrying out many creasing spasticity. Sufficient time must be allowed for
activities such as reaching into a purse or pocket to re- the patient to make responses because many patients
trieve an item and fastening clothing at the side or exhibit delayed processing of sensory information.
back.'? Other deficits, such as hemianopsia, aphasia, and visual
perceptual deficits, must be considered when retraining
Compensatory Treatment for tactile-kinesthetic functions. Repetition and varia-
A first concern of treatment is safety and ensuring that tion of sensory stimuli are necessary with CNS patients
the patient is not injured by bumping, burning, or be- if they are to relearn sensation.'”
coming snagged in furniture or equipment during the Eggers'” describes a graded treatment program for
ee” of ADL. If the loss of sensation is perma- sensory deficits. Initially the patient is allowed to see
atory treatment will facilitate rehabilita- and hear an object as it is being felt, for the benefit of in-
tion. The fo owing aremecinales of compensation: tersensory facilitation. Then vision is occluded during
1. Using the less affected hand to perform such activi- the tactile exploration. Finally, a pad is placed on the
ties as cooking, eating, and ironing tabletop so that both auditory and visual clues are elim-
2. Using vision to observe the motion and location of inated and the patient relies on tactile-kinesthetic input
body parts; testing bath water with the less affected alone. The program for tactile-kinesthetic reeducation
hand or a bath thermometer begins with gross discrimination of objects that are very
3. Using adaptive devices such as the one-handed dissimilar—for example, smooth and rough textures or
cutting board to avoid cutting the affected hand*? round and square shapes. Next the patient is asked to
The patient with stroke (CVA) must be made aware of estimate quantities (such as the number of marbles in a
440 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

box) through touch. Then the patient must discriminate 4. Avoid tasks that require the use of one tool for long
between large and small objects hidden in sand, pro- periods, especially if the hand is unable to adapt by
gressing to discriminate between two- and _ three- changing the manner of grip.
dimensional objects. Finally the patient is required to 5. Change tools frequently at work to rest tissue areas.
pick a specific small object from among several objects. 6. Observe the skin for signs of stress (e.g., redness,
The reader is referred to the original source for a detailed edema, and warmth) and for excessive force or repet-
description of specific training activities.’” itive pressure, and rest the hand if these signs occur.
7. If blisters, lacerations, or other wounds occur, treat
them with the utmost care to avoid further injury to
Peripheral Nervous System Dysfunction
the skin and possible infection.
Treatment of Hypersensitivity 8. To keep skin soft and pliant, follow a daily routine of
Heightened, uncomfortable, or irritable responses to skin care, including soaking and oil massage to lock
nonnoxious stimuli often occur es aaa ies nerve in moisture.°
The patient with PNS dysfunction may be more
capable of learning and attending to the compensatory
sensory reeducation program, provided tha the patient techniques than the patient with CNS dysfunction. The
does not have open wounds or infection.*° Many pa- reason for this is that perceptual and cognitive skills are
tients with hypersensitivity tend to protect sensitive intact in patients with PNS dysfunction.
areas and avoid using the affected part in bilateral ADL.
The therapist must reassure the patient that eens Remedial Treatment
hypersensitive areas is beneficial.* Dese Z Following nerve injury repair and recovery, the neural
impulses received in the sensory cortex from sensory
stimulation of the injured hand are altered. The new
detailsofdesensitization programs <are pattern of neural impulses may be so different as to
beyond the scope of this chapter. oe is a preclude correct interpretation of the stimulus. Thus,
summary of those details discussed by Barber’ and although sensory information is received, it cannot be
Schutt and Opitz.*° interpreted correctly. The purpose of sensory reeduca-
Desensitization includes massage, tapping, or rolling tion is to help the patient reinterpret the sensory im-
with different textures over hypersensitive areas. Treat- pulses reaching his or her consciousness. The patient's
ment begins at the patient's level of tolerance, and then potential for functional recovery following nerve
textures are graded to coarser and rougher with increases repair will be enhanced by a sensory reeducation
in force, duration, and frequency of application. Vibra- program."
tion and immersion in materials such as_ soft Dellon" described a sensory reeducation program
Styrofoam balls, rice, beans, popcorn, buckshot, and that is divided into early and late phases. Progression of
plastic squares are also used. This method of treatment is the program is based on the recovery process. The nerve
based on increasing the pain threshold ofthe nerve.*’*° recovery is determined by giving specific sensory tests.
In the early phase of the program the focus is on reedu-
Compensatory Treatment cating moving touch, constant touch, pressure, and
A compensatory approach for patients with PNS dys- touch localization. For moving touch a pencil eraser or
function is similar to that described previously for pa- fingertip is moved up and down the area being treated.
tients with CNS dysfunction. The patient must be made First, the patient observes the stimulus. Next, vision is
aware of the specific sensory deficits and taught safety occluded as the patient concentrates on the stimulus
awareness for ADL. It may be necessary to avoid use of and then opens the eyes to verify what is happening.
the affected limb during bilateral activities that are po- The patient verbalizes what is being felt by saying, for
tentially hazardous. example, “I feel a soft object moving down the palm of
Callahan® proposed the following guidelines for pa- my hand.” A similar procedure is followed for constant
tients with PNS dysfunction who lack protective sensa- touch. A pencil eraser is used to press down on one
tion: place on the finger or palm in an area where constant
1. Avoid exposing the involved area to heat, cold, and touch is recovered. The patient is encouraged to practice
sharp objects. these reeducation techniques four times a day for at
2. When gripping a tool or object, be conscious of not least 5 minutes each but is directed not to stimulate one
applying more force than necessary. hand with the other, because this action would send
3. Be aware that the smaller the handle is, the less that two sets of sensory stimuli to the brain.®”
pressure is distributed over gripping surfaces. Avoid Late-phase sensory reeducation is initiated as soon as
small handles by building up the handle or using a moving and constant touch are perceived at the finger-
different tool whenever possible. tips and there is good localization, which is often 6 to 8
 Evaluation of Sensation and Treatment of Sensory Dysfunction 441

months after nerve repair at the wrist. The goal in this place specific forms, or identifying wooden letters for
phase is to facilitate the recovery of tactile gnosis. The spelling out words. Training is done in two to four 10-
exercises involve a series of tactile discrimination tasks, minute sessions a day. °°
which begin with the identification of large objects that Wynn Parry*° recommended the following procedure
are substantially different from one another and to train touch localization. Vision is occluded and the
progress to objects with more subtle differences. Famil- therapist touches several places on the volar surface of the
iar household objects are used at the outset. The process hand. The patient is asked to locate each stimulus with
is to grasp the object while looking at it, then to occlude the index finger of the unaffected hand. If the response is
the vision and concentrate on the perception, and, incorrect, the patient is directed to look at the place where
finally, to look again at the object for reinforcement. the hand was touched and to relate where the touch was
The next objects are those that differ in texture and then felt to where the stimulus was actually applied.*°
objects that are smaller and require more discrete dis- Reevaluation is done at 1 month, 3 months, and 6
crimination. Manipulation of the training objects also months after the initial examination to evaluate the ef-
contributes to motor recovery. Ultimately, the therapist fectiveness of training. The criteria used to evaluate
can incorporate activities that simulate those of the treatment effectiveness are time to recognize objects,
patient's occupational roles.*" time to recognize textures, and time for correct localiza-
Wynn Parry*® described a sensory retraining program tion. To avoid a training effect, the objects and some tex-
for patients with PNS injuries affecting the hand. The ra- tures used in testing are different from those used in the
tionale underlying the technique is that the patient can training program.*°
learn to “lay down a new code” in the CNS. It has been Turner’ described a sensory reeducation program
shown that in nerve regeneration following traumatic for patients with peripheral nerve lesions. Retraining is
lesions, there is a marked disturbance of cortical repre- initiated when there is return of protective sensation
sentation of sensory nerve fibers in the hand. The train- with that (deep pressure and pinprick) and touch per-
ing program works best with patients who are coopera- ception. The retraining activities consist of having the
tive and well motivated and need to use their sensation patient identify objects, shapes, and textures with the
for everyday activities.*° vision occluded. If the response is incorrect, the patient
Wynn Parry's training program begins when the is allowed to look at the object and compare its sensa-
patient has sensation in the fingers, about 6 to 8 months tion with that in the normal hand to allow the integra-
after a nerve suture at the wrist. The program begins tion of tactile sensation and vision. Activities that may
with the use of large wood blocks of different shapes. be helpful include using textured dominoes or checkers,
The patient's vision is occluded, and a block is placed in handling cut-out shapes, and finding large to small
the affected hand. The patient is asked to feel the block, common objects hidden in rice or lentils. Training with
describe its shape, and compare its weight with a block these objects is carried out three or four times a day for
placed in the unaffected hand. If an incorrect response 45 minutes. The training periods are alternated with
is given, the patient is allowed to look at the blocks and periods of general bilateral activity such as pottery,
repeat the manipulation, integrating visual and tactile bread-kneading, weaving, and macramé. The patient is
information. The patient then compares the sensory ex- encouraged to use the affected hand in bilateral activi-
perience in the affected hand with that of the normal ties and to compare the feelings of the tools and materi-
hand. The procedure continues until various shaped als in the affected hand with those in the unaffected
blocks have been mastered. Then blocks are used with hand.**
textures such as sandpaper or velvet on some surfaces. A program of sensory reeducation after nerve injury
The patient is asked to differentiate textured surfaces was described by La Croix and Helman.** The purpose
from wood surfaces.*° of the program is to help the patient correctly interpret
In the next phase of training, the patient is asked to different sensory impulses. A series of graded stimuli is
identify several textures such as sheepskin, leather, silk, used in treatment, such as constant pressure, move-
canvas, rubber, plastic, wool, carpet, and sandpaper, all ment, light touch, and vibration. The least stressful
presented with the vision occluded. Finally, common stimuli are presented first. The patient does the training
objects are used in training, and the patient is asked to exercises several times a day for short periods. The exer-
identify them without the aid of vision. If there are in- cises are done on the unaffected side and then on the af-
correct responses for texture and object identification, fected side, first with the aid of vision and then with
the patient is allowed to perform the manipulations vision occluded. Areas of hypersensitivity are noted.
while looking at the training objects and to relate what Sensory stimulation such as stroking, deep pressure,
is felt to what is seen. Objects are graded from large to rubbing, and maintained touch with different textures
small. Training sessions may be varied by burying and shapes is used to reduce hypersensitivity.~*
objects in a bowl of sand and asking the patient to re- Sensory reeducation for PNS disorders focuses on ap-
trieve a specific object, using a form board in which to plying graded stimuli according to the progression of
442 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

nerve recovery. Sensory stimuli such as touch localiza- 10. Why is it important to grasp the fingers and wrist
tion, moving touch, and constant touch are followed laterally during the test for position sense?
by exercises for tactile discrimination of shape, size, 11. Describe two methods for testing thermal sensa-
texture, and object identification. Intermodal reinforce- tion.
ment through visual, auditory, and tactile senses is an 12. How are olfactory and gustatory sensations related?
important part of the reeducation program. 13. Discuss two approaches to the treatment of sensory
dysfunction and the purposes of each.
14. Describe the general principles for treatment of hy-
SUMMARY
persensitivity.
Exteroceptive receptors convey sensory information 15. With which disabilities is desensitization most
from the environment to the brain by way of peripheral likely to be used?
and spinal nerves and the spinal cord. Almost all 16. What is the neurophysiological principle on which
sensory stimuli are processed through the thalamus sensory education for PNS dysfunction is based?
before reaching the cerebral cortex. Sensation presents
the external environment to the brain and provides in-
formation necessary to guide purposeful and effective REFERENCES
movement responses. Motor performance is dependent 1. Adams RD, Victor M: Principles of neurology, ed 5, New York, 1993,
McGraw-Hill.
on sensory input, and significant motor deficits can
2. Ayres AJ: Sensory integration and learning disorders, Los Angeles,
result from dysfunction of sensory systems. Movement 1972, Western Psychological Services.
is guided by sensory feedback and feedforward control 3. Barber LM: Desensitization of the traumatized hand. In Hunter
systems. Defects in sensation disrupt these systems. JM et al, editors: Rehabilitation of the hand, St Louis, 1990, Mosby.
Sensory testing should be part of the comprehen- 4. Bear MS, Connors BW, Paradiso MA: Neuroscience, exploring the
brain, Baltimore, 1996, Williams & Wilkins.
sive OT evaluation of patients with upper and lower
5. Bickerstaff ER, Spillane JA: Neurological examination in clinical prac-
motor neuron disorders. Testing helps the therapist tice, ed 5, London, 1989, Blackwell Scientific Publications.
understand the complexity of the patient's motor dys- 6. Callahan AD: Methods of compensation and reeducation for
function. Paralyzed muscles are not the sole cause of sensory dysfunction. In Hunter JM et al, editors: Rehabilitation of
faulty or absent use of affected limbs. Rather, a the hand, ed 3, St Louis, 1990, Mosby.
7. Callahan AD: Sensibility testing: clinical methods. In Hunter JM
sensory disturbance can be the primary or comple-
et al, editors: Rehabilitation of the hand, ed 3, St Louis, 1990,
mentary cause of motor paralysis and movement Mosby.
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This chapter presents clinical screening tests for the Los Altos, Calif, 1985, Lange Medical Publications.
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ton & Lange.
sensation, proprioception, smell, and taste. It pro-
10. De Jong R: The neurologic examination, New York, 1958, Paul B
vides information on setting up, administering, Hoeber.
scoring, and interpreting results of these tests. Pro- 11. Dellon AL: Evaluation of sensibility and re-education of sensation in
grams for the treatment of sensory dysfunction are the hand, Baltimore, 1981, Williams & Wilkins.
reviewed. 12. Dellon AL: Somatosensory testing and rehabilitation, Bethesda, Md,
1997, American Occupational Therapy Association.
13. De Myer W: Technique of the neurologic examination: a programmed
REVIEW QUESTIONS text, ed 2, New York, 1974, McGraw-Hill.
14. Dodd J, Castellucci VF: Smell and taste: the chemical senses. In
1. What is the role of normal sensation in movement? Kandel ER, Schwartz JH, Jessel TM, editors: Principles of neural
2. What is the effect of sensory loss on motor perform- science, New York, 1991, Elsevier Science Publishing.
15. Eggers O: Occupational therapy in the treatment ofadult hemiplegia,
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Rockville, Md, 1984, Aspen Systems.
3. Why is sensory evaluation necessary and important 16. Farber SD: Neurorehabilitation, a multisensory Pee Philadel-
to occupational therapy? phia, 1982, WB Saunders.
4. What types of disabilities should be routinely given 17. Ghez C: The control of movement. In Kandel ER, Schwartz JH,
sensory evaluation? Jessel TM, editors: Principles of neural science, New York, 1991, Else-
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5. What are the differences between sensory loss from
18. Gilroy J, Meyer JS: Medical neurology, London, 1969, Macmillan.
CNS disorders and PNS disorders? 19. Goldman J, Cote L: Aging of the brain: dementia of the
6. Do normal individuals all respond with the same Alzheimer’s type. In Kandel ER, Schwartz JH, Jessel TM, editors:
accuracy on sensory tests? Principles of neural science, ed 3, New York, 1991, Elsevier.
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21. Jackson O: Brain function, aging, and dementia. In Umphred DA,
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23. La Croix E, Helman J: Upper extremity orthopedics. In Logigian 30. Schutt AH, Opitz JL: Hand rehabilitation. In Goodgold J, editor:
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CHAPT

treatment of Perceptual
(o)to}u DYasta@lts
CAROL J. 1

KEY TERMS LEARNING OBJECTIVES

Perception After studying this chapter the student or practitioner
Adaptive approaches will be able to do the following:
Remedial approaches 1. Define perceptual motor function.
Stereognosis 2. Identify the value of perceptual testing and
Graphesthesia functional assessment of perceptual motor skills.
Body scheme 3. Differentiate the two major approaches to treatment
Finger agnosia of perceptual motor dysfunction.
Right/left discrimination 4. Define each of the perceptual motor skills cited.
Prosopagnosia nn . Cite standardized assessment tools for each of the

Agnosia primary skill areas of perceptual motor function.

Gestalt 6. Describe specific treatment activities for targeted
Form constancy perceptual motor deficits.
Position in space
Visual closure
Figure-ground discrimination
Spatial relations
Visuoconstructional skills
Praxis
Ideomotor apraxia
Ideational apraxia
Conceptual apraxia
Dressing apraxia

Perception is the gateway to cognition’*

grocery store, a person may observe the array of brightly
Perception is the mechanism by which the brain inter- wrapped candy lining the aisle, may remember the
prets sensory information received from the environ- sweet taste of the chocolate, may remember a recent res-
ment. The perceived information is then further olution to lose weight, and may choose to resist adding
processed by the various cognitive functions (described any candy bars to the grocery cart. The person may look
in Chapter 27), and the individual may choose either to over to the next aisle, recognize a neighbor, and begin a
respond by a verbal expression or motor act, or to conversation. In a few minutes, the person may notice
simply perceive and think about the observed stimuli. that another register has a shorter line and may choose
For example, when waiting in a check-out line in a to move over to that line to be able to complete grocery

444
 Evaluation and Treatment of Perceptual and Perceptual Motor Deficits 445

shopping in a shorter amount of time. Perception of the Arnadottir> recommends the use of ADL to assess
environment provides the information to enable these neurobehavioral dysfunctions and their effect on the
response options. performance of tasks essential to functional independ-
In early development, tactile, proprioceptive, vestibu- ence. She maintains that it is preferable for occupational
lar, and visual perception provide an internalized sense therapists to assess neurobehavioral deficits directly
of the body scheme, which is basic to all motor func- from the ADL evaluation. She developed the Arnadottir
tion.°°”** Highly developed spatial skills ate critical to OT-ADL Neurobehavioral Evaluation (A-ONE), which
an artist, architect, plumber, or ees provides information on neurobehavioral impairments
and deficits in functional performance by assessing ADL
denced by blind individuals
i who, are Bentis restored skills.* The reader is referred to the original source for
later in life, have difficulty making sense of what they more information on this perspective and a detailed de-
see.’° scription of the A-ONE instrument.??>4
Acquired perceptual deficits are noted in persons
with cerebrovascular accident (CVA), traumatic brain
APPROACHES TO TREATMENT
injury (TBI), and later stages of degenerative disorders,
such as multiple sclerosis and Parkinson’s disease.?*”° An underlying assumption about perceptual-motor
Spatial disorders and apraxia of a progressive nature are function is that perceptual deficits will adversely affect
also seen in Alzheimer’s disease.”’'* functional performance. Further, it is assumed that re-
Severe perceptual deficits, frequently combined with mediation of or compensation for perceptual deficits
cognitive impairments, can affect every aspect of activi- will improve functional performance.°? In her critical
ties of daily living (ADL) and can present serious safety analysis of approaches to treatment for perceptual
concerns. For example, the individual who cannot judge deficits, Neistadt®° described two general pepe
distance and the spatial relationship of his foot to the ofapp roaches: ibe adaptive and the remedial. Adaptiv
top step of his stairwell may be in danger of a serious appro ovide training
in daily living aiaviod to
fall. Another person who cannot judge the position of 1to the environment for maximal
the dial on the stove whenpreparing a meal may cause ndividual. In_ contrast, the remedial
cause some change in central
Ss system (( )functions.”~ The effectiveness of
mervarious approac 1es to the remediation of perceptual
deficits has not been well documented and requires sci-
entific investigation.7°°"”*
Thisee MF ines higher-level tactile discrimina- A therapist may use one approach or a combination
tive sensation, body scheme, spatial processing, praxis, of approaches in the treatment of perceptual deficits.
and the deficits that result from impairment’ to these The remedial and adaptive approaches can be used in a
areas. Suggestions for standardized and functional continuum, beginning with attempts to improve the
testing are provided. General approaches to treatment basic skills and gradually incorporating compensatory
are reviewed, and suggestions for specific treatment techniques as the deficits persist.** The occupational
tasks are presented. therapy (OT) literature suggests many specific activities
for treatment of perceptual deficits, but protocols for the
use of such activities are lacking.** For measuring effec-
GENERAL PRINCIPLES OF EVALUATION
tiveness of treatment, criteria are needed for successful
The optimal battery of standardized tests includes as- performance, task grading, objective methods of evalu-
sessment tools that require a verbal response (e.g., ating performance, and guidelines for task modifica-
naming a picture) or motor response (e.g., drawing) or tion.’ In the absence of such objective criteria, the oc-
have flexible response requirements of either mode cupational therapist relies on empirical methods to
(multiple choice indicated by verbalizing the number or measure and report improvement. The relationship
letter or by pointing to the chosen item). With a variety between perceptual deficits and functional performance
of such tests, the therapist can gather information to has been demonstrated in several studies.”*”7””""
discriminate between a deficit in the reception of infor-
mation and a deficit in the verbal or motor output. This,
Remedial Approach
in turn, influences the treatment approach. Observa-
tions of performance and analysis of the perceptual- he remedial, or transfer of training, approach as-
motor demands of functional activities further comple- that practice in a particular perceptual task
ment standardized assessment tools and enable the ies over to eine. of similar tasks or func-
determination of underlying causes of deficits in func- artanneaaties requiring the same perceptual skills.°°
tional performance. For example, practice in reproducing pegboard designs
 8) EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

for spatial relations training could carry over to dress- formance of hand activities without the need to concen-
ing skills that require spatial judgment (such as match- trate visually on the implements being used. Examples
ing blouse to body and discriminating between right are knitting while watching television, reaching into a kemr
al

and left shoes). The capacity for persons to improve pocket for house keys, and using a fork to eat while
their performance on perceptual tests following percep- engaged in conversation. A deficit in stereognosis is
tual training has been documented.*” However, reports called astereognosis. Persons who have astereognosis
conflict as to the effectiveness of such remediation in but retain much of their motor function must visually
improving functional performance, and further re- monitor their hands’ activities. Thus they must be very
search is needed to determine the benefits.**’** slow and purposeful in their movements and tend to be
generally less active.
Adaptive Approach Test for Stereognosis''*)"")”°°
e
e
e
a

The adaptive, or functional PURPOSE. To evaluate a person’s ability to identify

b ‘the repetitive p actice of p common objects and perceive their tactile properties.
“person become more independent in the pe ance
of ADL.® This approach is frequently used in clinics
en,
«LS
MATERIALS. A means to occlude the person’s vision
because current reimbursement for therapy services is is needed, such as a curtain or folder as described in
based on functional outcome.’ The therapist does not Chapter 25. Typical objects that could be used for iden-
retrain specific perceptual skills. Rather, the person is tification include a pencil, fountain pen, pair of sun-
made aware of the problem and taught methods of glasses, key, nail, safety pin, paper clip, metal teaspoon,
adapting to or compensating for the deficit during func- quarter, nickel, button, and small leather coin purse.
tional activities. For example, if the individual has diff- Any common objects may be used, but it is important to
culty with dressing because of a body scheme deficit, the consider the person's social and ethnic background to
therapist may set up a regular dressing routine and ensure that he or she has had previous experience with
provide cues with repetitive practice. With these adapta- the objects. Three-dimensional geometric shapes (e.g.,
tions, the person may learn to dress. Adaptation of envi- square, sphere, and pyramid) can also be used to test
ronment or materials is another way to compensate for shape and form perception.
a perceptual deficit. If an individual has difficulty dis-
criminating a white shirt against the white sheets of the CONDITIONS. The test should be conducted in
bed, the therapist may encourage the person to select a privacy in an environment with minimal distractions.
patterned shirt or may lay the white shirt on a colored The person should be seated at a table in a position that
towel or bedspread to provide a contrasting back- accommodates the affected hand and forearm comfort-
ground. ably. The therapist should sit opposite the person being
tested. If the individual is unable to manipulate test
ASSESSMENT AND TREATMENT objects because of motor weakness, the therapist should
OF SPECIFIC DEFICITS assist him or her to manipulate them in as near normal
a manner as possible.
Stereognosis
Stereognosis and graphesthesia are tactile discrimina- METHOD. The person’s vision is occluded, with the
tive skills of the parietal lobes. These skills require a dorsal surface of the hand resting on the table. Objects
higher level of synthesis than the basic tactile sensory are presented in random order. Manipulation of objects
functions of light touch and pressure described in is allowed and encouraged. The therapist assists with
Chapter 25. the manipulation of items if the person’s hand function
Stereognosis, also known as tactile gnosis, isthe is impaired.
perceptual skill that enables an individual
to identify —
common objects and geometric shapes through tactile RESPONSES. The person should be asked to name
perception without the aid of vision.It results from the the object, or, if he or she is unable to name the object,
integration of the senses of touch, pressure, position, to describe its properties. Aphasic individuals may view
motion, texture, weight, and temperature and is de- a duplicate set of test objects after each trial and point to
pendent on intact parietal cortical function.*’ a choice.
Stereognosis is essential to daily living because the
ability to “see with the hands” is critical to many daily SCORING. The person’s response to each of the
activities. It is the skill that makes it possible to reach items presented is scored. The therapist notes if the
into a handbag and find a pen and to find the light object is identified quickly and correctly, if there is a
switch in a dark room. Along with proprioception, long delay before the identification of the object, or if
stereognosis enables the use of all hand tools and per- the individual can describe only properties (e.g., size,
 Evaluation and Treatment of Perceptual and Perceptual Motor Deficits 447

texture, material, and shape) of the object. The therapist Perceptual Processing
also notes if the person cannot identify the object or de-
scribe its properties. Body Scheme
Following a CVA or TBI, a person’s sense of his or her
Test for Graphesthesia body’s shape, position, and capacity frequently is dis-
An additional test of discriminative sensation that torted. This is known as a disorder of body scheme, or
measures parietal lobe function is the test for graphes- autotopagnosia.® This can be noted in attempts to draw
thesia, the ability to recognize numbers, letters, or a human figure (Fig. 26-1) or in a person’s unrealistic
forms written on the skin.'”°”’® The loss of this ability expectations of performance abilities.°* For example, an
is called agraphesthesia. To test graphesthesia, the exam- individual with left hemiplegia after a traumatic brain
iner occludes the examiner's vision and traces letters, injury expressed his intention to return to his previous
numbers, or geometric forms on the fingertips or palm manual labor job of installing garage doors. The disor-
with a dull-pointed pencil or similar instrument. The der can affect egocentric perception of one’s own body
person tells the therapist which symbol was written.® If or allocentric orientation of another person’s body.°”°?
the person is aphasic, pictures of the symbols may be A person may neglect one side of the body or demon-
provided for the individual to indicate a response after strate generally distorted impressions of the body’s con-
each test stimulus. figuration. The person may confuse his or her body with
that of another, such as the person who thought that her
Treatment of Astereognosis wedding ring had been stolen by the therapist, not real-
A graded treatment program for sensory deficits is de- izing that the hand she was viewing was her own. Finger
scribed by Eggers.*” Initially, the person is allowed to agnosia, or the inability to discriminate the fingers of
see and hear an object while feeling it for the benefit of the hand, can also be part of the disorder.® An individ-
intersensory facilitation; then vision is occluded during ual may confuse the right and left side of his or her
the tactile exploration. Finally, a pad is placed on the body, which is a deficit in right-left discrimination. An
tabletop so that both auditory and visual clues are elim- impaired body scheme will also affect self-care, since
inated and the person relies on tactile-kinesthetic input the individual may have difficulty with feeding, dress-
alone. The program for tactile-kinesthetic reeducation ing, hygiene activities, or mobility.”°
begins with gross discrimination of objects that are very
ASSESSMENT OF BODY SCHEME. Body scheme
dissimilar—for example, smooth and rough textures or
round and square shapes. Next, the person is asked to disorders can be assessed by asking the individual to
estimate quantities (such as number of marbles in a draw a human figure (Fig. 26-1) or point to body parts
box) through touch. Then the individual must discrimi- on command. Finger agnosia is evaluated by occluding
the person’s vision and asking the person to name each
nate between large and small objects hidden in sand
and progress to discriminating between two- and three-
finger as it is touched by the therapist. Assessment of
dimensional objects. Finally, the person is required to right-left discrimination can be included in body part
identification or finger agnosia testing.
pick a specific small object from among several objects.
The reader is referred to the original source for a de-
tailed description of specific training activities.”
Farber described a treatment approach to retrain
stereognosis for adults and children with CNS dysfunc-
tion.”' First, the person is allowed to examine the train-
ing object visually as it is rotated by the therapist. The
person is then allowed to handle the object in the less
affected hand while observing the hand. In the next
step, the person is allowed to manipulate the object
with both hands while looking. Then the object is
placed in the affected hand and the person manipulates
the object while looking at it. The individual may place
the hand in a mirror-lined, three-sided box to increase
visual input during these manipulations. This sequence
is then repeated with the vision occluded. Once several
objects can be identified consistently, two of the objects
may be hidden in a tub of sand or rice. The person is FIG. 26-1
then asked to reach into the tub and retrieve a specific Example of impaired body scheme. Drawing on left is the person's
object. If the sensation of the sand or rice is overstimu- first attempt to draw a face. Therapist asked the person to try
lating or disturbing, the objects can be placed in a bag.” again. Second effort is drawing on right.
448 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

Facial Perception Spatial Functions

Prosopagnosia refers to an inability to recognize Spatial abilities refers to the capacity to appreciate the
faces.'°’*>’’* The affected individual may have difficulty spatial arrangement of one’s body, objects in relation-
recognizing his or her own face, as well as the faces of ship to oneself, and relationships between objects in
family members and friends, or of famous individuals. space. Various efforts have been made to subdivide
When attempting to identify family members and ac- spatial skills into components such as form recognition,
quaintances, the person tends to compensate by relying figure-ground discrimination, and others, but recent
on auditory cues such as the sound of the family writers acknowledge that spatial skills cannot be iso-
member's voice or a distinctive feature such as long, lated easily from one another.’® It is generally acknowl-
blond hair. edged that the right hemisphere, which controls spatial
Brain damage can also impair the ability to interpret abilities, tends to function in the gestalt (whole),
facial expressions, which can have significant social whereas the left hemisphere, which is responsible
consequences.
'’’*° For example, one individual tended for linguistic operations, tends to focus on discrete
to be very suspicious of others. He was observed to details.°*
have difficulty describing the expressions of various Perception often occurs instantaneously, and it is
persons depicted in photographs. Because he had emi- because of this rapid processing of information that,
grated to the United States from another country, it when operating a motor vehicle, it is possible to react
was considered that his difficulty could be a result of quickly to another driver's actions and so avoid a colli-
cultural differences. He was asked to bring in a news- sion. An individual with mild perceptual impairment
paper that he regularly received from his native may need additional time to perform a task, but
country. The captions of the photographs were oc- processes the information correctly, possibly by com-
cluded, and he was asked to describe the emotional ex- pensating with verbal analysis of the perceptual compo-
pressions of the persons shown. He was then asked to nents. Severe impairment may result in the incorrect re-
translate the photo captions and became aware that he sponse despite additional time used in attempting to
was unable to discriminate the emotions apparent on solve the problem.
the faces. Spatial skills are not limited to the visual domain.”*
Sounds can be localized in space, and the mobility and
ASSESSMENT OF FACIAL PERCEPTION. A stan- daily functions of blind individuals are heavily depend-
dardized Test of Facial Recognition’? is available, which ent on the tactile appreciation of the spatial arrange-
presents a multiple-choice matching of faces presented ments of objects.°° For example, a blind person’s ability
in front view and side view and under various lighting to navigate through a familiar room requires awareness
conditions. A formal test of facial expression discrimi- of the layout of each piece of furniture in the area, and
nation is not available,’* but an informal assessment is continual shifting of the individual's “cognitive map”
possible using pictures and photographs. while changing position in the room.
Spatial abilities are subdivided into the following
Agnosia skill areas’:
Visual object recognitionrefers to the ability to identify
objects via visual input. Adeficit in this area is called|
agnosia. 4554 The individual with agnosia demonstrates
normal visual abilities, as indicated by the person’s the eerieon a desk, in various sizes or in various posi-
ability to ambulate around furniture through a room; tions in the pencil holder.
further, the inability to name objects is not caused by a
language deficit in naming the object, as noted in
aphasic disorders. Rather, the person is unable to know
an item using only visual means. If the person holds the
object, he or she can identify it via tactile input, or by ol-
factory means if the object has a distinguishable odor,
such as a flower.”*
Testing is performed by informal means of asking the
individual to identify various common objects by
sight. Case studies describe compensatory methods of Ricvecene discrim
minati ‘ lows 1 ivid
keeping frequently used objects, such as a hairbrush, in toA striymemeane chiany from ‘he hee in the
consistent locations, and teaching the individual to rely ing the targeted object
more heavily on stereognosis to seek and find desired
items.*° Efforts to retrain object recognition have met
with limited success.*°
 Evaluation and Treatment of Perceptual and Perceptual Motor Deficits

FIG. 26-2
Spatial functions in real life. Note that all components of spatial functions can be found in this scene.

relative orientation of the pencil to the table surface as cal impairment or with significant limitations in com-
the pencil nears the edge and is about to fall to the floor. munication ability. It is critical that an assessment of
Fig. 26-2 illustrates many of these spatial functions. basic visual skills (see Chapter 24) be performed before
visual perceptual assessment. For example, a deficit in
VISUOCONSTRUCTIONAL SKILLS. Many func- visual acuity could be the underlying cause of poor per-
tional activities depend on visuoconstructional skills, formance on a test of visual perceptual function. The
or the ability to organize visual information into mean- normal aging process also results in a decline in visual
ingful spatial representations. Constructional deficits efficiency.’ It is also possible that performance on
refer to the inability to organize or assemble parts into a visual perceptual tests may be affected by deficits in cog-
whole, as in putting together block designs (three- nitive areas, such as attention, memory, or executive
dimensional) or drawings (two-dimensional). Con- function (see Chapter 27). For example, an individual
structional deficits can result in significant dysfunction with severely limited attention and concentration is un-
in activities that require constructional ability, such as likely to perform well on any test, regardless of the
dressing, following instructions for assembling a toy, modality or nature of the task.
and stacking a dishwasher.°”’”” Fig. 26-3, which shows Tsurumi and Todd*® analyze the cognitive skills in-
evidence of left neglect, also demonstrates construc- volved in the commonly used tests of visual perceptual
tional deficits. An individual acts on his or her environ- functions and warn that individuals’ performance using
ment based on the information he or she perceives. two-dimensional representations of visual stimuli may
Therefore, deficits in perception become more apparent not be predictive of the person’s performance in a
when a person interacts with the environment in mal- three-dimensional world.®? Tests that require three-
adaptive ways. dimensional object manipulation are available. (See the
Tests of Constructional Functions section later in this
ASSESSMENT OF PERCEPTUAL PROCESSING. chapter. )
Visual perceptual tests require either a verbal or simple The Loewenstein Occupational Therapy Cognitive
motor (pointing) response to a multiple-choice selec- Assessment (LOTCA)*’ and Rivermead Perceptual As-
tion or require a skilled motor response such as drawing sessment Battery’”’*’ provide a comprehensive profile
or construction. This enables the therapist to assess of visual perceptual and motor skills and involve both
visual perceptual function in a client with severe physi- motor-free and constructional functions.
450 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

FIG. 26-3
Example of two-dimensional constructional disorder and left-sided inattention in a drawing of a
house by a retired architect who had had a cerebrovascular accident (CVA) on the right side.

Non/Low-MoTor TESTING OF PERCEPTUAL SKILLS. A structing matchstick designs, assembling block designs,
variety of assessment tools require either a verbal or a or building a structure to match a model.*’ In daily
simple pointing response. The Motor-Free Visual Per- living, tasks such as dressing or setting the table require
ceptual Test—Revised (MVPT-R)7° assesses basic visual constructional skills. To perform such tasks successfully,
perceptual abilities. An alternative version of the test an individual must have integrated visual perception,
presents the multiple choices in a vertical format motor planning, and motor execution./03977:F7==
(MVPT-V) to reduce the interference of hemianopsia or Several studies have gathered data on the constructional
inattention.’® The Test of Visual Perceptual Skills— skills of unimpaired subjects for use as a normative ref-
Upper Level (TVPS-UL)*? also provides a multiple- erence for persons with CVA and TBI.*”°? In a study
choice format and has been normed for adults. Test of constructional abilities in the well elderly, Fall*°
items require a higher level of visual analysis compared demonstrated that results are influenced by the type of
with the MVPT, and the test is untimed. The Hooper test administration. Subjects tended to score higher on
Visual Organization Test** requires that the individual tests that used three-dimensional models as guides for
mentally assemble fragmented drawings of common construction than on those that used photographs or
objects. The Minnesota Paper Form Board Test?” is a drawings. The implications of this finding for occupa-
high-level assessment of visual organization, requiring tional therapists are that (1) the type of test administra-
mental rotation of fragmented geometric shapes. tion affects scores, and (2) in teaching persons with
TESTS OF CONSTRUCTIONAL SKILLS. Traditional tests of constructional disorders, models or demonstrations of
constructional abilities in a two-dimensional mode are desired performance are likely to produce better results
the Test of Visual-Motor Skills,** the copy administra- than would photographs or drawings.*°
tion of the Benton Visual Retention Test,’° and the Rey TREATMENT OF PERCEPTUAL AND CONSTRUCTIONAL
Complex Figure.’* The latter two tests also are used to Dericits. The remedial approach involves the use of
evaluate visual memory skills. Use of the Rey Complex perceptual tasks such as paper and pencil activities and
Figure has been suggested for a quick screening of visual puzzles to improve basic perceptual skills. The adaptive
perceptual functions.°® The Three-Dimensional Block approach would include training for functional ADL
Construction” involves the use of various blocks to tasks and developing compensatory approaches to the
copy a design from a three-dimensional model. Non- functional performance deficits. Many functional activi-
standardized tests that may be used are drawing, con- ties are suitable for perceptual motor treatment; folding
 Evaluation and Treatment of Perceptual and Perceptual Motor Deficits 451

towels, setting the dinner table, and weeding the garden Ideational Apraxia
are but a few examples. This is discussed further in the Ideational apraxia (IA) is a conceptual deficit, seen as
Approaches to Treatment section earlier in this chapter. an inability to use real objects appropriately.***°*°
the use of the term con-
Praxis c praxia.**’°* The individual also may have dif-
ficulty sequencing acts in the proper order,** such as
Praxis is the ability to plan and perfor with folding a sheet of paper and inserting it into an
a Apraxia has Been classically Aetned as a envelope. The individual may use the wrong tool for
eficit in “the execution of learned movement which the task or may associate the wrong tool with the
cannot be accounted for by either weakness, incoordi- object to be acted on, such as by attempting to write
nation, or sensory loss, or by incomprehension of or with a spoon.** This deficit has significant functional
inattention to commands.”*° The disorder can result implications.
from damage to either side of the brain or to the corpus Another category seeen in the literature is dressing
callosum*”’®” but is more frequently noted with left apraxia. The c lressing impairment as a
hemisphere damage.** Apraxia is often seen in persons “SRE CL
f apraxia
eelaaahaiebes
has been questioned in recent years
with aphasia; however, not all aphasic persons are because the difficulties in functional self-care are con-
apraxic, nor are all apraxic persons aphasic.*°*? This sidered to be caused by perceptual or cognitive dysfunc-
type of dysfunction may occur after CVA or TBI. Progres- tion'®*"®® (if apraxia is not noted in other activities), or
sive apraxia is often noted with degenerative disorders are seen as an extension of an ideational or ideomotor
such as Alzheimer's disease.**°* See also Chapters apraxic disorder.
37 to 39 in this text. The term constructional disorder is now favored over
Apraxia has been strongly correlated with depend- the previously used term of constructional apraxia since
ence in ADL.’”*' For example, in a severe case of the deficit does not clearly fall within the definition
apraxia, an individual initially required full assistance of apraxia.”'°°* (See the Visuoconstructional Skills
with self-care. The individual was fully cognizant of section of this chapter for further discussion.)
ongoing events but could not even direct her arm and
leg movements in a way that would assist the nursing General Principles in the Assessment
staff during dressing. When asked to pick up a pencil, and Treatment of Apraxia
the individual walked around all four sides of the table ASSESSMENT. It is important that assessments of
in an attempt to position her hand correctly to grasp the sensory function, muscle strength, and dexterity are
object. She could describe the desired action in words completed before the test of praxis because deficits in
(“I want to pick up the pencil between my thumb and these areas would complicate any assessment of
index finger, with the lead point of the pencil close to apraxia. If a person has a hemiplegia, the unaffected
the tips of my fingers”) but reported after returning to hand is used for testing. Input from the speech-lan-
her seat that her hand never “looked like it was in the guage pathologist is important for establishing an in-
right position” to take hold of the pencil. dividual’s capacity for basic comprehension via words
The categories of apraxia are difficult to differentiate, or gestures. Because of the frequent association of
and authors differ in their use of terms.’*® The principal apraxia with aphasia and left hemisphere brain
types are ideomotor apraxia and ideational apraxia. damage, an apraxia screening is included as a part of
Because the distinction between ideational and ideo- many aphasia batteries’® used by speech-language
motor apraxia is often perplexing, some authors recom- pathologists.
mend simply using the term apraxia.”’”* The literature’® offers several apraxia assessments used
in research, such as the Florida Apraxia Screening Test
Ideomotor Apraxia (FAST), the Movement Imitation Test,***” and the Use
_ Ideomotor apraxia (IMA) is an inability to carry out a of Objects Test.** The Loewenstein Occupational Therapy
motor act on verbal command or imitation. However, Cognitive Assessment (LOTCA)*’ includes a praxis sub-
the person with ideomotor apraxia is able to perform section, as does the Rivermead Perceptual Assessment
the act correctly when asked to use the actual object.*” *” Battery,** both of which serve as screening tools for the
For example, a person is unable to mime the action of disorder. The Santa Clara Valley Medical Center Praxis Test
brushing his teeth on request but is observed using a and the Solet Test for Apraxia are two additional evalua-
toothbrush correctly when he is performing grooming tion tools developed by occupational therapists.°”
activities. Observation of the person in activity perform- A thorough assessment includes items presented,
ance is critical to the identification of this deficit. The such as those shown in Table 26-1,47 and involves both
deficit is demonstrated only in the testing environment transitive movements (action involving both tool and
and appears to have little functional impact, as com- use, such as writing with an imaginary pen), and intran-
pared with, ideational apraxia.’® sitive movements (movements for communication,
 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

nsive Apraxia Assessment

Test Condition Example
Gesture to command “Show me how you would take off your hat.’ (transitive)
“Show me how you would throw a kiss.” (intransitive)

Gesture to imitation “Copy what | do.”

Therapist shrugs shoulders. (intransitive)
Therapist flips an imaginary coin. (transitive)

Gesture in response to seeing the tool “Show me how you would use this object.”
Therapist provides screwdriver for display.

Gesture in response to seeing the object upon which the “Show me how you would use this object.” Therapist provides
tool works screwdriver and block of wood with screw partially inserted.

Actual tool use “Show me how you would use this object.’ Therapist provides
screwdriver for use.
Imitation of the examiner using the tool “Copy what | do.” Therapist makes stirring motion, using a spoon.

Discrimination between correct and incorrect pantomimed “Is this the correct way to blow out a match?" Therapist
movements pantomimes holding match in unsafe manner (e.g., match held
upside down, with head of match near palm of hand).

Gesture comprehension “What object am | using?” Therapist pantomimes shaving face with
qd razor.
Serial acts “Show me how you would open an imaginary can of soda, pour
it into a glass, and take a drink.”

From Heilman KM, Rothi LJG: Apraxia. In Heilman KM,Valenstein E, editors: Clinical neuropsychology, New York, 1993, Oxford University Press.

such as waving farewell). Lists of gestures used in assess- smaller units and verbally guiding (conducting) the se-
ment are noted in several studies.'%?7°8 084 quence.°’ The individual improved on targeted tasks,
but minimal generalization was noted in everyday activ-
TREATMENT. The severely impaired individual who ities (see also the Generalization and Transfer section of
was described in the second paragraph of this section Chapter 27).
on praxis was treated first by practicing basic motor The treatment of dressing impairment involves teach-
movements, then following a developmental sequence ing a set pattern for dressing and giving cues that help
to more advanced functional motor activities. For the person distinguish right from left or front from
example, following repetition of basic movement pat- back. A helpful method is to have the individual posi-
terns, the person with apraxia progressed to coloring tion the garment the same way each time—for example,
geometric shapes (felt-tip markers were initially placed positioning a shirt with the buttons face-up and pants
in a vertical stand for easy grasp) and gradually to with the zipper face-up. Labels, small buttons, or
writing exercises. Independent telephone use was im- ribbons can be used as cues to differentiate the front
portant to the individual, so a large calculator was used from the back of the garment.°”’*®
for keystroke practice. The individual gradually pro-
gressed to a disconnected telephone and then to a func-
BEHAVIORAL ASPECTS OF PERCEPTUAL
tional telephone. By the termination of the treatment
MOTOR DYSFUNCTION
program, the individual was independent in all aspects
of self-care, although additional time was needed for Some degree of accurate self-awareness and recognition
each activity. of the effect of the disability on one’s functioning is
The clinical reasoning process was used in planning needed if the person is to invest energy in the therapy
the treatment for an individual with apraxia, beginning process.°*
with spoken instruction for each sequence in the task, An individual who is unaware of perceptual deficits
written or pictorial instructions, and visual monitoring may be a serious safety risk and may attempt activities
of her limbs throughout each aspect of the task.’® that are well beyond present physical abilities. Denial is
Another case study of apraxia treatment involved con- often noted in early stages of recovery from CVA or TBI
ductive education—that is, breaking the task into and may serve as a protective coping mechanism that
 Evaluation and Treatment of Perceptual and Perceptual Motor Deficits 453

allow the individual to gradually absorb the effect of the 8. Describe the two approaches to treatment of percep-
injury on his or her functioning. A person’s innate trust tual deficits and give one example of a treatment ac-
of the accuracy of perceptions often is a basis for unreal- tivity for each.
istic self-confidence; demonstrating to the individual
that his or her perceptions are now distorted and no REFERENCES
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CHAT
ent of Cognitive

CARO

KEY LEARNING OBJECTIVES

Cognition After studying this chapter the student or practitioner
Metacognition will be able to do the following:
Ecological validity 1. Define cognition.
Orientation 2. Explain the value of a team approach to cognitive
Simultaneous multiple attention rehabilitation.
Vigilance 3. Summarize the effects of environmental factors on a
Working memory person's cognitive process.
Declarative memory 4. Describe the effects of the aging process on cognitive
Implicit memory skills.
Explicit memory 5. Differentiate the major cognitive treatment
Procedural memory approaches in the field of occupational therapy.
Everyday memory 6. Provide examples of the use of assistive technology
Prospective memory to compensate for cognitive dysfunction.
Confabulation 7. Cite standardized assessment tools for each of the
Learning style primary skill areas of cognition.
Errorless learning 8. Describe specific treatment efforts for targeted
Domain-specific learning cognitive deficits.
Dyscalculia
Executive function
Anosognosia
Disinhibition
Stimulus-bound behavior
Perseveration

ognitive impairment can lead to profound func- Cognition is a series of complex thought processes
tional limitations. Cognitive impairment often followsa by which we come to know and act on our environ-
cerebrovascular accident (CVA), traumatic brain injury ment, to benefit from past experiences, and to generate
(TBI), or acquired disease that results in brain damage, new ideas to advance our existence. Cognitive process-
such as multiple sclerosis or Alzheimer’s dementia. This ing spans a wide range of activity and input. It can
chapter aims to increase the therapist's understanding of involve multiple sensory input from the external envi-
cognitive processes and to describe the principles of cog- ronment or can be carried on with only intrinsic mate-
nitive assessment and treatment. rial. For example, when driving a vehicle, an individual
 Evaluation and Treatment of Cognitive Dysfunction 457

needs to process a continuous stream of information include the physician, therapeutic recreation specialist,
from the environment—the response of the automo- and other disciplines, depending on the goals and re-
bile, the conditions of the road, traffic signs, and the sources of the facility.
movement of other vehicles or pedestrians in relation-
ship to the vehicle being driven. In contrast, when a
person is writing a term paper, much of the cognitive ac-
Optimal Test Battery
tivity is internal, employing memories of information The optimal test battery involves several tests, standard-
previously read, reasoning, analysis, and organization. ized and normed for the population, and a variety of
Metacognition, described as “knowing about know- functional activities that are relevant to the individual.
ing,””' is the ability to know and monitor the individual Therapists need standardized tests to provide objective,
characteristics of cognitive skills. It is considered the quantifiable data, to measure the extent of the deficit
bridge that links together all the various aspects of cog- compared to an established norm, to document progress,
nition and enables a person to choose memory strate- and to enable discharge planning. In addition, the
gies, problem-solving approaches, and _ reasoning common terminology, concepts, and testing conditions
methods that are uniquely beneficial to the completion of standardized tests facilitate communication between
of a cognitive activity.** practitioners. The ecological validity of a standardized
The assessment and remediation of cognitive deficits test refers to the test's ability to predict functional
can be challenging and complex. Cognitive functions performance based on test results—in other words, the
are discussed and evaluated in discrete subsections, but extent to which a test predicts ability to function in im-
in practical reality, cognitive skills are employed to- portant life tasks.'7’?’
gether in every task to varying degrees. These functions Functional activities provide opportunities to ob-
include attention, memory, initiation, planning and or- serve the practical implications of deficits identified by
ganization, mental flexibility, abstraction, insight, rea- standardized tests. Further, functional activities per-
soning, problem-solving, and judgment. formed in the OT clinic allow the therapist to better
predict an individual's functioning in the home envi-
PRINCIPLES OF COGNITIVE ASSESSMENT ronment.
The assessment process is similar to solving a puzzle
Team Approach to Evaluation
in which a variety of tests and functional tasks are used
Many health care professionals from a variety of disci- to deduce the areas of strengths and weaknesses, to
plines work together in the assessment and treatment of explain the person's behavior, and to identify potential
persons with cognitive dysfunction. Discussion of occu- treatment approaches.
pational therapy (OT) evaluation results with other Several test batteries are available that screen a range
members of the team increases the therapist's under- of cognitive skills, including the following: the Cogni-
standing of the person’s capacity and the relationship of tive Assessment of Minnesota,’* The Loewenstein Occu-
the deficits assessed to dysfunction in other skill areas. pational Therapy Cognitive Assessment (LOTCA),”? and
The OT approach to cognitive skills tends to emphasize the Neurobehavioral Cognitive Status Screening Exami-
the processing of visual, tactile, and spatial information, nation (COGNISTAT).” The Arnadottir OT-ADL Neu-
which is largely mediated by the right hemisphere of the robehavioral Evaluation (A-ONE) provides an analysis
brain. Consultation with the speech pathologist con- of functional activities to determine cognitive skill
cerning the person’s auditory, language, and linguistic deficit areas.* The Cognitive Rehabilitation Workbook
and cognitive abilities is essential because these skills provides a pretest and posttest, as well as treatment ex-
are processed mostly by the left brain hemisphere. Phys- ercises, for community living skills such as constructing
ical therapists can provide observations about the a schedule and reading a map.””
person's visual perceptual functioning during gross
motor and ambulation tasks. The psychologist or neu- Environmental Effects on Performance
ropsychologist can provide information regarding the Human performance is variable by nature. The testing
individual's intellectual range with an overview of the environment can exert influence—sometimes strong,
relative strengths and weakness of the various skills. In sometimes subtle—on the results of the cognitive assess-
addition, the individual's family can provide the team ment. The concept of environment includes not only the
with a description of the individual's functioning before physical features and time ofday, but also the amount of
the onset of the disability. Without prior knowledge of structure and feedback provided by the examiner. For
all these areas, interpretation of the OT cognitive assess- example, the person’s ability to attend to tasks may be
ment may be inaccurate. The therapist should always very different early in the morning while lying in bed
look at the total picture when interpreting an individ- compared with taking a structured test, with cueing pro-
ual’s behavior. Frequently the conclusions are the result vided by the examiner, while seated in a wheelchair. The
of much team discussion.*”°? The team may also person’s behavior in the foreign environment of the
458 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

hospital or rehabilitation facility may be quite different through the items. After completion of the test, the ther-
from performance in the familiar home setting. Health apist could return to earlier items, repeating the instruc-
team members often disagree about the person's cogni- tions for each item. A sharp improvement in perform-
tive status when, in fact, discrepancies are merely the ance may suggest a memory deficit rather than a
result of environmental differences in the administra- perceptual deficit. Some of the newer testing instru-
tion and nature of testing. Instead of being alarmed by ments provide for the intervention of various cueing
these differences in test results, the more constructive strategies, allowing for assessment of the effectiveness of
approach is to analyze and use the information in de- the strategy, as well as of the skill area itself. An example
signing the most effective plan for remediation and is the Contextual Memory Test,°° in which the therapist
compensation of deficits. records the strategies used (e.g., imagery) and docu-
ments the effect of the strategy on the memory task. Fre-
Therapist’s Approach quently the therapist develops a repertoire of manage-
When introducing a cognitive test to a person, the ther- ment strategies to support the optimum functioning of
apist should avoid a condescending attitude or a the person, but unless the strategies are documented,
manner that is too bright or artificially positive. No they will have to be rediscovered (or sometimes not) by
matter what the level of functioning, the person must be other therapists who are working with that individual.
approached in an age-appropriate manner.
It is important to avoid offering choices when there Relationship of Cognitive Deficits to
actually are none. Instead, choices should be offered,
Other Performance Components
such as: “Would you prefer to perform coordination
tests or cognitive tests first?” This suggests that all of the As cognitive processes interrelate, the therapist must
tests must be completed eventually. The therapist assess a broad spectrum of skill areas, from basic
should not ask for cooperation as a personal favor (“I sensory functions to complex processing, and compare
would like you to. . .,") or imply that the test is a joint findings with those of other members of the team. A
effort (“Let's do some testing today!”). Instead, recog- poor score on a test of complex cognitive function may
nize each person’s responsibility, by such phrases as “I be caused or complicated by a deficiency in a more basic
willbe. . ., and yourjobisto... .”** skill. For example, a person with a left visual field loss
Avoid power struggles at all costs. Forcing a person to may select a lightweight garment on a cold day, simply
cooperate is not likely to produce valid assessment because he or she failed to scan the full contents of the
results. closet to see the sweater hanging to the left. In addition,
It is also important that the therapist not provide the individual who does not remember the selection of
cues to right or wrong responses; as an alternative, ran- clothing brought to the rehabilitation facility will not
domly reward the person’s effort throughout the test by search for the sweater among his or her belongings.
such comments as, “Good job” or “You put a lot of
effort into that test.”** Intellectual Capacity Before Injury
For a highly distractible individual, the therapist may The individual's family should be interviewed and exist-
model the desired behavior. The therapist who is gazing ing records reviewed to determine the individual's level
around the room during the test may serve as a distract- of functioning before the injury or CVA. For example,
ing stimulus. In contrast, a therapist who is steadily persons who were below average in intellectual level
gazing at the test items may cue the person to follow before injury cannot be expected to perform at a higher
suit. level on tests administered after the injury. Similarly, ifa
person has a previous learning disability affecting the
Test Administration ability to read and write, the therapist should recognize
The therapist must adhere to the instructions that ac- that the quality of the person’s written responses on a
company standardized tests, or the results of the tests given test may be the result of factors other than the
will be invalid. Later, when the test is repeated by a dif- CVA. Another example is the individual who functioned
ferent therapist or different facility, variability in re- at a very high level before brain injury and who now
sponse may be difficult to explain. However, it is possi- scores in the average range. Although the person’s func-
ble and sometimes clinically useful to test beyond the tioning may be sufficient for daily activities, this is still a
limits of a standardized assessment tool by following significant drop from previous capacity. The individual
the rules as given until the assessment is completed and may need to learn new ways to cope with this change in
then exploring various modifications. It is important to functional level.
document the adaptations and results.** For example, a
person may perform poorly on a perceptual test because Impact of Substance Abuse
he has difficulty keeping the directions in working An individual with cognitive impairments caused by
memory (see the Memory section) as he progresses head trauma, CVA, or other causes may also have a
 Evaluation and Treatment of Cognitive Dysfunction 459

history of substance abuse.° The long-term effects of use blending treatment models based on the response of
and abuse of illegal substances are widely recognized, the person.
but studies have been hindered by related factors of The remedial and adaptive approaches were once
ongoing abuse, medical complications, and poor educa- viewed as incompatible but are now recognized as parts
tion.** It is important to know if a person has a history of a continuum. Acute care centers frequently find reme-
of alcoholism because prolonged use can lead to Kor- dial intervention to be effective. Adaptive compensatory
sakoff's syndrome, with significant loss of new learning approaches are used in rehabilitation facilities as the
capacity.'” period of rapid recovery diminishes.*°
A treatment task can be analyzed and modified in
Cognition and Aging several ways to improve performance.°® This process is
In the normal aging process, decline is noted in working commonly known as providing structure. A treatment
memory, face recognition, speed of information pro- activity can be graded by changing the task parameters,
cessing, and spatial recall,”’ complicated by the decline which include the environment, familiarity with the
in visual and auditory skills. This can have implications task, directions for completing the task, number of
for everyday functioning, such as remembering a route, items, spatial arrangement of items, number of re-
keeping to medication schedules, and facial recall of sponse options, and response rate required.
new acquaintances. An older adult’s performance is rel- Examples of task grading are the treatment of an inat-
atively higher for familiar tasks in familiar settings than tentive individual in a quiet, uncluttered environment
for unfamiliar tasks in unfamiliar settings.7° Because the and the treatment of the person with poor memory in
speed of information processing is slower for older the same environment every day. Various environmen-
persons, the therapist must match the pacing of the ac- tal cues can be established in the person's work area to
tivity to the individual and allow for multiple repeti- stimulate recall.
tions and a longer response time.*”””* Cues are provided via systematic interpersonal inter-
Some assessment tools, such as the Benton Visual Re- action with the therapist or others and modified accord-
tention Test,”® adjust the interpretation of scores based ing to the client's response. Cues can direct attention to
on age. The Mini-Mental State Examination frequently a particular aspect ofa task, guide problem solving, and
is used as a screening tool to assess the cognitive skills of facilitate recall. Examples of cues are repetition (“Try
the older population.**”*? again”), analysis (“What do these objects have in
An area of growing concern to geriatric therapists is common?”), and direction of attention (“Look here on
that of the person with Alzheimer’s dementia.** This your left”).°° The client should be involved in the devel-
disorder leads to progressive decline in behavior, atten- opment of the cueing system whenever possible because
tion, memory, visual perception, praxis, language, and the client will select the cues that are most meaningful.
executive functioning.**’*’ The goal of therapeutic inter- The therapist's task is to identify the conditions that
vention is to maximize the person’s functional level, in- elicit the best performance from the client (e.g., styles of
crease safety, minimize confusion, develop behavioral interaction with the client, cues to stimulate memory, or
management strategies, and serve as a resource to fami- controls to elicit socially acceptable behavior). To chal-
lies.” '??° Rather than attempting to improve recall with lenge the client to expand his or her abilities, the thera-
drills or internal mnemonic strategies, the therapist pist must achieve a delicate balance in presenting activi-
makes changes to the environment to stimulate ties that are near, yet just beyond, the client's current
memory and orientation. Alzheimer’s units in skilled capacity. One client described the OT program as “a
nursing facilities may be designed to minimize resi- moving target.” Several resources offer a variety of treat-
dents’ confusion. An example is placing a small display ment tasks and ideas.'**°°’*4
case next to a person’s doorway, in which to store arti-
cles that have a strong personal meaning and thereby
Technology in Cognitive Retraining
aid the person in recognizing which room is his or her
own.!7!°
Recent advances in technology have provided addi-
tional options for remediation and compensation of
APPROACHES TO TREATMENT cognitive deficits. Computers can be useful for rehabili-
tation, as a means by which to practice cognitive skills
Models of Treatment or strategies taught by the therapist.7° In work-oriented
Table 27-1 summarizes various treatment approaches tasks, the computer can be programmed to monitor,
proposed in OT literature. The reader can consult the cue, and organize an individual's output.*’
references for more in-depth discussions of each treat- Miniaturization and the increased power of micro-
ment approach. processors have permitted the development of a
Therapists may choose to follow a certain treatment number of electronic devices that can be used in com-
philosophy or may adopt a more eclectic approach, pensation for cognitive and memory impairments.***”
 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

Model Definition ite

Remedial, transfer of training approach Uses practice with activities designed to target the deficit areas. Typically, tabletop pencil-and-
paper tasks are used, involving skills that have been found by formal testing to be deficient.**

Adaptive approach Focuses on the skills that are relatively intact, to develop compensatory methods for deficit
areas, Treatment activities are functional, real-life tasks. 7147

Dynamic interactional approach Resists labeling individual deficits (e.g., attention and memory). Instead, focuses on the
processes used by the person as he or she performs various cognitive tasks; therapist teaches
strategies to improve performance across the cognitive spectrum. The approach uses factors
external to the patient (environmental context, nature of the task, and criteria of learning), as
well as internal factors (metacognition, processing strategies, and the characteristics of the
learner).A particular strategy is targeted and practiced in multiple environments to increase
the likelihood of transfer, with a variety of tasks and movement demands.°°

Quadraphonic approach Integrates four theoretical approaches: information processing, learning theory, biomechanical,
and neurodevelopmental, and emphasizes the need for the therapist to continuously adapt
the treatment to the patient's changing status and the changing environment. Treatment
guides the patient through the sequence of problem detection, discrimination and analysis,
and hypothesis generation while performing therapeutic activities.

Neurofunctional approach Metacognitive training is combined with applied behavioral analysis to retrain for functional
skills, using the behavioral approaches of shaping, fading, and reinforcement“?

Cognitive disabilities approach Developed initially for chronic mental illness, this approach uses the Allen Cognitive Levels to
determine a match between the patient's functioning and the environmental demands of the
task, and to provide guidelines for caregivers.’

These include alarm watches; pocket-sized, computer- ented to his or her surroundings. A TBI can result in a
ized data storage units; electronic pillboxes; and tele- period of coma, the length of which is indicative of the
phones with phone number memory features. The ther- severity of injury. Chapters 37 and 38 provide further
apist’s role is to determine which device meets the discussion on cerebrovascular accidents and traumatic
client's need, to aid in the initial programming of the head injury.
device, and to train the client and family to integrate the An unimpaired person is oriented to person (“Who
device into the client's daily routine. am I?”), place (“Where am I?”), and time (“What year,
month, day, or time of day is it?”). Orientation involves
ASSESSMENT AND TREATMENT an individual’s memory capacity, because a person must
be able to remember past occurrences in order to place
OF SPECIFIC DEFICIT AREAS
current events in their proper perspective. After a severe
Although cognitive processing relies on the complex in- TBI or CVA, persons initially may be confused regarding
tegration of functions, isolation of various skills for their identity, indicating a disorientation to person. This
close analysis is helpful. The therapist may find it useful deficit is more global than an inability to speak one’s
to assess the client according to the following hierarchy name, which may occur in the case of aphasia (difficulty
of skills. with the verbal expression of any message). Some people
may also confuse the identities of other individuals, such
as by thinking that the therapist is a family member. Ori-
Orientation and Attention
entation to place refers to an individual's knowledge of
Orientation refers to an individual’s ongoing awareness the fact that he or she is in a hospital, for example, or the
of the situation, the environment, and the passage of name of the immediate town, city, and state. Difficulty
time. From the point ofa traumatic injury that results in monitoring the passage of time can result in time disori-
cognitive impairment, an individual must develop an entation. Persons often have difficulty beyond simply re-
awareness of the events that preceded the accident and membering the date; they may confuse the sequence of
those occurring since that time. Frequently after a CVA events in time. For example, a person may report that a
the individual is initially disoriented. As the mental certain family member visited the previous day, when
state clears, the individual becomes increasingly ori- the family member actually may have visited a week
 Evaluation and Treatment of Cognitive Dysfunction 461

earlier. As with all aspects of cognition, discussion with general awareness of events occurring around them. A
other team members is critical to ensure a comprehen- family member once described his brother as tending
sive understanding of the individual's deficit. to “get sucked into the computer,” and a closer exami-
Topographical orientation describes an individual's nation of the person’s activity revealed that the person
awareness of his or her position in relation to the envi- was not performing any useful work, only rearranging
ronment (e.g., the room, building, or town). Functional his computer files day after day. See the sections on ex-
examples of this disorder are noted when an individual ecutive function and behavior later in this chapter.
becomes confused while attempting to leave a room, Either extreme is undesirable. Normal functioning
locate another therapy department, or travel to the cafe- requires that a person be able to focus, sustain a low
teria. Such individuals frequently perform better in the level of awareness of peripheral events, and disengage,
familiar environment of the home and community, but then reengage concentration as needed.
deficits may still be apparent, particularly when there is
a need to travel to a new environment. Assessment of Orientation and Attention
Attention requires a fluid, ever-changing focus on rel- Orientation to person, time, and place can be assessed
evant internal and environmental information. Atten- informally by asking the person basic questions about
tion involves the simultaneous engagement of alertness, his or her identity, the date, time of day, and season of
selectivity, sustained effort, flexibility, and mental track- the year, and the name of the hospital, city, and state.
ing.°* An individual must be alert and awake and able Because levels of orientation can vary, it is best to ask
to select a relevant focus of interest. The individual must these questions several times to determine the consis-
be able to maintain focus for as long as needed, yet be tency of the person’s awareness. Topographical orienta-
able to shift focus if another event of interest or impor- tion can be assessed informally by observing a person
tance occurs. In addition, the individual must ignore in- traveling from one site to another or by asking the
formation if it is not relevant and must be able to track person to draw a floor plan of his or her room, therapy
multiple sequences of information simultaneously. area, or home, verifying the latter with the family. The
Because these skills underlie all aspects of cognitive therapist must also consider the influence of possible vi-
functioning, they are frequently affected by TBI or CVA, suospatial deficits on this task. Orientation questions
and deficits may hinder all higher skill levels. For and route finding are also included as part of the River-
example, a person who is unable to attend to a task for mead Behavioural Memory Test.’®
more than a few seconds cannot take in all the necessary Examples of standardized tests of attention include
information to perform a higher-level reasoning task. the Knox Cube Test®* and, for divided attention, the
Information processing can occur via well-estab- Trail Making Test.* Additional information on these and
lished habits, referred to as automatic processing, or on a other standardized tests of attention is given in sources
more conscious, controlled processing level.*’ A person referenced at the end of this chapter.°*°* The oc-
undergoing rehabilitation often needs to use controlled cupational therapist's assessment of attention should
processing to perform basic tasks that were handled au- include structured clinical observation and _ activity
tomatically before the injury. A person who has diffi- analysis during functional tasks.
culty with divided attention, or simultaneous multiple
attention, may not be able to handle more than one Treatment of Deficits in Orientation
task at a time. The person typically responds by revert- and Attention
ing to focused attention. For example, during a physical ORIENTATION. All staff and family members who
therapy session, the person with hemiplegia who is come into contact with the person should make efforts
asked a question while ambulating may stop walking in to reestablish orientation as frequently as possible. Ex-
order to engage in conversation. ternal aids such as calendars, bulletin boards, and “ori-
Concentration requires sustained attention, also re- entation boards” with pertinent information (e.g., the
ferred to as vigilance. Persons may be highly distractible name of the facility, the date, season, and current
or very sensitive to events in the immediate environ- events) are often used in rehabilitation centers. An ori-
ment, which pulls their focus away from the task at entation group can be scheduled to meet at the start of
hand. It is important to note which types of stimuli each day to review the day's upcoming events and previ-
(e.g., visual, auditory, tactile, or gustatory) distract the ous day’s happenings.
*°’*?
person easily. A low-stimulus environment or “quiet
room” may be beneficial. Such a room is designed for ATTENTION. The initial goal of treatment is to de-
minimal visual stimuli and for insulation from nearby termine the optimal activities or environment that
noise and activity. enables the person to focus for the longest time. As at-
Some individuals have the opposite problem. That tention and concentration improve, the therapist can
is, they can become very deeply focused on a given increase the duration, as well as the complexity, of
stimulus or activity and have difficulty maintaining a the activity. Finally, the person should gradually be
462 3 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

weaned from the low-stimulus environment as toler- Another distinction in memory function concerns the
ance increases. Formalized attention-training models memory of the source of the information. Many
are available.°4*°° memory-impaired individuals may recall the informa-
tion but not the details of when, where, and from whom
they learned it. This is labeled implicit memory.” In
MEMORY
contrast, memory of the source of the information in
Memory is the process by which all information is addition to the information itself is called explicit
stored and retrieved in the cognitive-system. It is a memory. The difference can be seen in the example of a
dynamic continuation of the attentional process that in- person who is informed by his nurse that there will be a
cludes the factor of time. As an individual is able to cancellation for an appointment that day, because his
maintain focus on a task, information becomes stored therapist is not available. Later, another staff member ob-
in the memory process. The memory process is summa- serves the person in the recreation room during his regu-
rized in Fig. 27-1. larly scheduled therapy time and admonishes the person
The memory process can break down at any level. Ifa for missing therapy. The person cannot explain the
person is unable to maintain attention, the information reason he is not in therapy because he lacks the explicit
may never enter the system. Some persons are able to recall of the conversation with his nurse earlier that day.
process information in short-term or working memory Nonetheless, he has acted on correct implicit memory
but never encode the material into long-term storage. for the change in schedule.
Others can store the information but have a deficit in Some individuals have a considerable deficit in de-
the retrieval process. Strategic testing, comparing tests clarative memory, but less impaired procedural
requiring free recall (open-ended questions) with recog- memory, memory for a skill or series of actions.*° For
nition (multiple-choice responses), may help the thera- example, a person may be unable to tell a therapist the
pist determine the breakdown in the memory process, steps in making a sandwich and a cup of coffee but may
which can then guide the treatment approach. be able to perform the activity correctly. The process of
People with memory deficits, who need to expend obtaining a driver's license requires a written law test (de-
additional effort to learn new material, may also have clarative recall) followed by a behind-the-wheel test
difficulty forgetting information when it is no longer (procedural recall). It is procedural learning that enables
needed. It is critical that the therapist be well prepared a person to learn new self-care techniques despite severe
when planning to teach new information to a person, to memory deficits on standardized memory tests. This
avoid teaching incorrectly anything that the person will phenomenon underscores the need for integration
later need to unlearn. between test performance and observations made during
The ability to recite or reproduce information is gen- functional activities.
erally taken as an indication of recall and is referred to Everyday memory refers to a person’s ability to re-
as declarative memory. Tests often require a person to member information pertinent to daily life (eg.,
repeat a word list or draw a set of geometric designs, or learning the names and faces of the doctors, nurses, and
a therapist may quiz a person about events occurring therapy staff who work regularly with the person in the
earlier in the day. Declarative memory is divided into hospital or rehabilitation facility). Learning a schedule
two categories. Episodic memory refers to an individual's of appointments or the locations of various depart-
recall of his or her personal history and lifetime of expe- ments may be difficult and further. complicated by fre-
riences. The general fund of knowledge shared by quent changes. The hospital escort staff often assumes
groups of people is called semantic memory and includes this responsibility for the person, which masks the
such information as language and rules of social behav- deficit. Everyday memory also includes the ability to
ior. Semantic memory is generally less affected than is keep track of daily events in their proper sequence.
episodic recall after an injury.7° Prospective memory refers to the ability to remember
events that are set to occur at some future time, such as
an appointment scheduled for later in the day.”
A person with memory deficits may tend toward
eeRETRIEVAL confabulation,* or filling in the gaps in memory with
imaginary material. This person is not aware of adding
SENSORY INPUT —3= WORKING MEMORY — LONG-TERM
erroneous information to the factual data and so can
| ] MEMORY become confused regarding past events or may insist on
im | the accuracy of his memory, to the confusion of others
Selective Temporary Encoding and around him. Some persons with memory deficits try to
attention storage consolidation
“fake it” to cover their embarrassment at the extent of
FIG. 27-1 their memory loss, but this practice is not considered
Memory process. confabulation.
 Evaluation and Treatment of Cognitive Dysfunction 463

Families frequently report that the individual recalls characteristics of optimal teaching methods become ap-
events from his or her life before the accident with great parent, this information can be communicated to the
detail and accuracy but has very poor memory for team, the person’s family, and the person, who can
events occurring in the immediate past. This phenome- learn to request that new information be provided in
non is called Ribot'’s Law.”° the most effective manner.
Just as is true for any individual, activities or topics of The concept of errorless learning has been explored
interest or of personal relevance tend to elicit the best with memory-deficient individuals in recent years, with
performance. As a result, the family may minimize the positive results in teaching everyday information and
deficit: “He can remember if he wants to.” It is impor- skills.’°’” New information is taught to individuals in
tant to reinforce to the family that although the impair- small increments, with many cues, feedback, and correct
ment may be less with certain types of material, the answers provided, so that the chance of failure is mini-
deficit remains. mized. Over many learning trials, cues are gradually
reduced. In contrast, the more common trial-and-error
Assessment of Memory Functions approach encourages the person to guess, sometimes
One standardized test for the assessment of visual resulting in incorrect responses. The person then must
memory is the Benton Visual Retention Test, *® which re- differentiate right from wrong responses in memory,
quires free recall of geometric figures and can also indi- which requires accurate explicit recall. The errorless
cate an inattention deficit. Selected subtests of the Test technique maximizes the recall of the correct informa-
of Visual Perceptual Skills assess recognition memory.~” tion and uses the implicit memory capacity of the
The Rey Complex Figure Test** provides a measure of person. ’” |
incidental learning, since the test initially is presented A practical example of an errorful learning experience
to the person as a drawing task, with recall requested is the process of learning a new procedure on the com-
immediately after drawing a figure and then again 20 to puter. By attempting a variety of commands, the com-
30 minutes later. The Learning Efficiency Test” provides puter user eventually succeeds in performing the func-
a comparison of auditory versus visual recall. The River- tion, but may not recall the correct sequence when
mead Behavioural Memory Test’® is an evaluation of attempting to execute the function again. Errorless
everyday memory skills and can immediately provide learning will occur when an experienced computer user
relevant information about the person’s capacity to teaches each step in sequence and observes the new user
function safely in the home environment. The Contex- until he or she has learned all of the steps correctly.
tual Memory Test®° provides information on the aware- Memory strategies can be divided into two groups:
ness of the deficits, as well as the use and relative value internal, referring to techniques carried out via mental
of various strategies, thus offering important informa- effort by the person, and external, referring to methods
tion to guide treatment. used by the therapist or cues in the environment to
A number of standardized memory questionnaires trigger an individual's recall. Examples of external cues
are available.** These can be filled out by both the are oral reminders from the therapist, signs, cue cards,
person and a family member to determine the person's notebooks, written instructions, and electronic memory
level of awareness of his or her memory deficits and aids such as alarm watches and computer data storage
the effect of the deficit on the person’s everyday units.**”’° Internal mnemonic strategies include re-
functioning. hearsal, chunking, association, and imagery.**’”° Table
27-2 lists some memory strategies.
Treatment of Memory Deficits Memory treatment techniques use several known
In concert with the psychologist, speech-language characteristics of memory and cognitive functioning.
pathologist, and other team members, the occupational Often the deficit is one of retrieval rather than recall, so
therapist can explore the person’s optimal learning many of the mnemonic techniques are designed to
style.**’* Because flexibility in adapting to various cue the memory system to elicit the information. An
teaching approaches is often lost or diminished in indi- example is first-letter cueing for a list of words. It is also
viduals with cognitive deficits, it becomes the responsi- known that deeper processing of the information
bility of the therapist to present new information in the creates more retrieval possibilities, so mnemonic tech-
most efficient way for the person. If the deficit is one of niques can be a means to facilitate more complex exam-
retrieval, the team can explore the types of cues that ination of the information to be learned. Using associa-
most effectively facilitate the individual’s recall. The tion to remember a person's name requires that the
therapist can identify a person's learning style by ob- individual generate an association between the name
serving the response to instructions (oral, written, and the person; one client learned the author's name by
demonstrated, and diagrammatic) for standardized visualizing a person singing holiday songs while stand-
tests and functional activities, as well as by analyzing ing in a wheat field. The use of environmental cues cap-
the data obtained from standardized memory tests. As italizes on a person’s tendency to be stimulus bound
 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS
-

to the ability to apply knowledge and skills learned to a

variety of similar but novel situations.** A person who
can generalize could perform clothes cleaning tasks in
any laundry setting. Individuals with cognitive deficits
Functional Task Internal Strategy External Strategy frequently have difficulty with transfer of learning and
Names Word mnemonic for — List of names with may be unable to generalize skills to novel situations.
association: photographs in Transfer of new skills must be built into treatment plan-
Notice the person memory notebook
ning, because the person may not be able to transfer
Ask the person to
skills independently.
spell or pronounce
his or her name
The principle of domain-specific learning is based
Mention the name in on the assumption that generalization is not likely to be
conversation achieved by severely memory-impaired individuals.
Exaggerate some However, a person may be able to learn specific skills
facial feature relative to a particular situation and to continue to
apply these skills in that specific environment.** Teach-
Schedule Develop rhyme: Alarm watch or hand-
Breakfast pills are held computer data
ing one-handed cooking skills in the OT department
pink, two to help storage unit kitchen may be ineffective if the person is unable to gen-
me think eralize those skills to the kitchen at home. This person
may be better served if the instruction is provided in the
Route Develop series of Map or building floor
home environment by the home health therapist.°° Job
landmarks to plan
coaching, a type of supported employment, also is
guide route
based on this premise. The skills needed for the job are
Parente R, Herrmann D: Retraining cognition: techniques and applications, taught on the job site rather than being taught in
Gaithersburg, Md, 1996, Aspen. advance in a setting other than the job site.”

REASONING AND PROBLEM-SOLVING

(see the section on executive functions). One example
SKILLS
of this is a brightly colored key rack located just inside
the front door for the individual to store house keys. Abstract thinking enables a person to see relationships
The selection of mnemonic strategies depends on the between objects, events, or ideas, to discriminate rele-
characteristics of the learner. For example, an individual vant from irrelevant detail, and to recognize absurdi-
with relatively high spatial skills may profit from a visu- ties.** Cognitive deficits in this area and resultant be-
alization strategy, and a person who has limited atten- haviors create difficulty in transfer of knowledge to new
tion and concentration may not be able to use internal situations and in problem solving.** Persons with
mnemonics but may benefit from strategically placed frontal lobe damage commonly lose abstract thinking
environmental cues. If it has been determined that the ability and think only in the most concrete, literal
individual has a deficit in storage of information but manner. This literal thinking is often paired with mental
demonstrates good procedural recall, perhaps an elec- inflexibility.
tronic notebook would be useful. The therapist can The following is an example of: concrete thinking. A
assist the individual and family to set up the notebook, person is asked the interview question, “What brought
determine the critical information to be recorded, you to this hospital?” The person responds, “My parent's
program the storage, and teach the individual to retrieve car.” The person is interpreting the question literally,
the information. The goal of therapy is to progress from rather than understanding it as a reference to the acci-
the use of external cues designed by the therapist to in- dent that resulted in brain injury.
ternal and external cues established and maintained by Problem solving is a complex process involving many
the individual independently. A group approach, em- cognitive skills. Problem solving can take the form of
powering individuals to guide the treatment process, convergent thinking, which enables a person to:arrive at a
has also been shown to be effective.*° central idea, and divergent thinking, which is aimed at
The concepts of generalization and transfer are also generating alternatives.** The process of grocery shop-
critical to the learning of new skills. Transfer of learning ping provides an example of both types of thinking. An
refers to the application of information learned in one individual knows that milk, eggs, and butter are needed
situation to another, similar situation. An example is and by convergent thinking identifies them as dairy
the use of a clothes washer and dryer in the OT depart- products. Divergent thinking is used to arrive at a list of
ment to teach laundry skills; this training method re- stores that carry these items.
quires that individuals transfer skills learned in the Various types of reasoning can be used in the
clinic laundry room to their homes. Generalization refers problem-solving process. Deductive reasoning refers to
 Evaluation and Treatment of Cognitive Dysfunction eTye)

the ability to arrive at conclusions. For example, a groupings from one category to another.°’ Assessment
person notices that items grasped in the affected right of reasoning skills during functional task performance
hand tend to drop to the floor and concludes that the can provide predictions of a person's safety and readi-
hand is not reliable for grasping and holding. Inductive ness to return home from the rehabilitation facility.
reasoning enables a person to draw generalizations from An assessment of calculation abilities should include
specific experiences. For example, after a period of per- number recognition and simple to complex mathemati-
sistent right-hand incoordination, the person realizes cal problems, as well as functionally oriented items
that the ability to return to a previous occupation in- such as calculating change, recognizing coins, and bud-
volving bilateral manual skills (such as assembly-line geting. The Cognitive Rehabilitation Workbook~° in-
work) is now questionable.”’** cludes everyday calculation tasks, providing pretest and
Reasoning deficits can be noted in a person’s inabil- posttest measures and training exercises.
ity to recognize the long-term consequences of an
action and focus instead on the immediate effect. Treatment of Reasoning and Problem-Solving
Persons with deficits in reasoning may have difficulty es- Deficits
tablishing priorities when faced with a number of tasks The steps that comprise the problem-solving process have
to be accomplished. been organized into the acronym SOLVE”? for easy recall:
Dyscalculia is a deficit in the reasoning ability used
to perform simple calculations. This deficit can have im- Specify the problem Frequently, persons have
difficulty defining the
portant implications for an individual’s independent
problem and so tend to
functioning in the community. Various types of calcula- generate misdirected
tion disorders have been identified.*” A person may solutions
have difficulty reading (alexia) or writing (agraphia) Options For those who focus
numbers, and consultation should be sought with narrowly on one
solution, developing
the speech-language pathologist or psychologist on the several possible solutions
team. increases the likelihood
Spatial dyscalculia refers to a deficit in the spatial of success
arrangement of numbers (Fig. 27-2). Anarithmetria is an Listen to other's advice This encourages the person
inability to perform calculations in someone who has to fully explore the
problem to avoid missing
no deficits in reading and writing numbers or spatially some critical element.
arranging the numbers in the calculation and who had a Vary the solution This encourages expanded
satisfactory educational background and academic skills mental flexibility.
before the injury.*’ Evaluate Individuals are encouraged
to assess what worked
and what did not and use
Assessment of Reasoning and Problem Solving the new information for
Abstract conceptual thinking can be assessed in a future situations.
number of ways. The Test of Nonverbal Intelligence
(TONI)," the Space Visualization subtest of the Em- This sequence can be taught to the individual, with
ployee Aptitude Series,°” and the Minnesota Paper Form instructions to use the steps when a problem is encoun-
Board Test*” all assess complex spatial reasoning skills. tered in therapy or in functional tasks.”’°* The therapist
The Toglia Category Assessment can test a person’s assists the individual in transferring this technique to a
ability to organize and group objects and to change variety of functional situations.”

Executive Functions
X24? Ween Deficits in executive skills are generally the result of
a) er damage to the frontal lobes of the brain. The dysexecu-
sy ae ie7. tive syndrome’* is composed of deficits in the following

ng ae
Smee areas: goal formation and follow-through, memory,
disinhibition, and behavior and personality changes.
Memory and behavior are discussed in separate sections
ee
Sse
of this chapter.

GOAL FORMATION AND FOLLOW THROUGH.

An example of a deficit in goal formation is the person
FIG. 27-2 who does not generate an idea for activity, but who re-
Examples of spatial dyscalculia. sponds well to an established routine. The structured
466 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

schedule of a hospital or rehabilitation facility may edge or tends to devalue the deficit, may require super-
mask deficits in this area. These deficits become appar- vision by another individual. A family member or sig-
ent once the person is discharged to his or her home, nificant other may be trained to set up a daily routine,
where the routine is less formalized. Some persons are provide the verbal prompts needed, and maintain the
able to verbalize an intended goal and plan a course of system of environmental cues established.
action but are unable to carry it out. The problem may
be one of initiation of the activity or of sequencing the
BEHAVIORAL DEFICITS
steps of the plan in a profitable manner. Individuals
with this deficit often seem far more capable than their A variety of behavioral deficits can be the result of cog-
behavior demonstrates. Effective performance requires nitive dysfunction or may also develop in response to
that the individual continually monitor and adjust per- the frustration and outrage at the disability and the pro-
formance throughout the execution of a task. Some found changes in a person’s life and sense of self.
people demonstrate an inability to perceive errors,
while others may recognize an error but make no effort IMPAIRED AWARENESS. In the immediate postin-
to correct it. jury stage, persons frequently attempt activities that are
When trying to carry out the plan, a person may beyond their physical or mental capacity, demonstrat-
demonstrate poor mental flexibility or may have diffi- ing a deficit in the awareness of their limitations. People
culty changing mental set. For example, a person is at- may be operating on old intrinsic knowledge of their ca-
tempting to solve a problem using a selected solution. pacities and may not have incorporated their limita-
The solution proves ineffective, but the person contin- tions into their sense of self since the injury.** Years
ues the effort unabated. The therapist may guide the later, an individual may tell stories of gradual realiza-
person’s awareness to acknowledge the lack of success, tion of deficits: “I didn’t realize that my left side was par-
but the person may persist in trying the same solution. alyzed until I tried to get out of bed.” With individuals
whose awareness is impaired, the rehabilitation effort
Assessment of Executive Functions may become a power struggle, since the person may see
Family members are frequently the best source of infor- no reason to have therapy.*® A person's insight fre-
mation about the person’s executive functioning. The quently increases as the body scheme is modified in re-
Dysexecutive Questionnaire’’ is designed to be com- sponse to changes imposed by the disability—a long
pleted by both the person and the family, thus provid- and complex process.
ing a comparison with which to determine the person’s Memory deficits may also complicate a person’s
insight into his or her own deficits. awareness of the frequency with which a problem occurs.
Standardized assessments include the Behavioural For example, the person who acknowledges difficulty re-
Assessment of the Dysexecutive Syndrome,*° as well as calling a nurse’s name only two or three times a day may
formal assessments of everyday tasks such as route consider the memory problem minimal, although the
finding” and errand planning.”® The therapist should incidence is actually closer to 12 to 15 times a day and
also assess these skills through close clinical observa- extends to the entire staff. Sometimes the use of a fre-
tion. A homemaking assessment that includes planning quency check sheet, recorded by the person under the su-
and simultaneous preparation of a variety of dishes fora pervision of the therapist, may help the person more
meal may be useful. Perseverative or stimulus-bound be- fully understand the extent of the problem.
havior should be noted, as related to both a specific en-
vironment and particular tasks. The therapist must re- ANOSOGNOSIA. Anosognosia is a total inability,
member that similar behaviors may be related to other exceeding common denial, to recognize deficits.*” Use
clinical deficits such as poor comprehension or apraxia of the normal coping strategy of denial implies that the
or may be a sign of depression. Ongoing close observa- individual appreciates the problem on some level; the
tion, assessment, and consultation with other team anosognosic person is completely unable to acknowl-
members increase the likelihood of correct interpreta- edge the impaired function. A team approach is needed
tion and management of behavior. to distinguish between neurological and psychological
types of awareness deficits.’ An example is a person
Treatment of Deficits in Executive Functions (with intact basic perceptual and language abilities)
An individual’s level of awareness of the executive who cannot recognize her own handwriting on a task
deficits will determine the treatment approach.” A performed earlier in the day and accuses the therapist of
person with relatively good metacognitive skills, one falsifying the work.
who can recognize, comprehend, and appreciate the
implications of inactivity, may be responsive to self- INAPPROPRIATE EMOTIONAL RESPONSE. A
monitoring strategies or environmental cues. A more person may laugh, cry, or express other emotions that
severely impaired individual, one who cannot acknowl- have no relation to the actual emotional context of a
 Evaluation and Treatment of Cognitive Dysfunction 467

situation. Other individuals may respond with the Assessment of Behavioral Deficits
correct category of emotion, such as laughing at a hu- Assessment of these behavioral deficits is made by be-
morous situation, but the extent and forcefulness of havioral observation and interviews with the family.
their laughter may be inappropriately exaggerated. Subjective questionnaires'* can be completed by both
People cope with this trait in various ways. Some avoid the person and a family member, and the results can be
social contact, and others learn to mask this trait or even compared and discussed with both parties. The behav-
use it to their advantage. One person developed a reper- ior must be considered in relation to the social and cul-
toire of jokes to tell; another person realized that people tural background of the person and his or her personal-
enjoyed socializing with him, since he smiled all the ity characteristics before the onset of the disability.
time and appeared to have a lighthearted approach to
life. In more serious relationships, this person would Treatment of Behavioral Deficits
explain the deficit to his friends so they could learn to Awareness can be further addressed in treatment using
read his emotions more accurately. several approaches.°” Self-estimation can be encouraged
by asking questions requiring an individual to predict
DISINHIBITION. Some people with executive dys- performance on a certain task. Role reversal can be used
function demonstrate disinhibition, or impulsive be- between the therapist and the individual. Self-questioning
havior.'* These people may continuously generate ideas during an activity and self-evaluation after completion
for activity but cannot delay or resist the need to act on of the task can also be important tools for increasing
the thought immediately. A person may greet a new- awareness.”
comer and announce his first impression: “You have a Behavioral managementstrategies can be developed to
stain on your shirt.” Other people are able to recognize impose restrictions on an individual's behavior. Specific,
and discuss their inappropriate behavior but may still direct feedback regarding the inappropriateness of a be-
be unable to control it. An individual may demonstrate havior should be given to the person. If the person’s level
stimulus-bound behavior as he or she impulsively of insight and control warrants, internal strategies can be
begins the task before being instructed or cannot draw taught, such as “time out,” in which the person voluntar-
attention away from a task when necessary. One person, ily leaves the situation. Ifthis approach fails, external con-
when presented with the first item of a multiple-choice trols may be used and astaff person may escort the person
visual closure test (the Motor-Free Visual Perception to a quiet area until behavioral control is reestablished. It
Test), immediately began drawing on the test booklet is critical that the staff person remain calm because a
to complete the partially drawn items. Perseveration, strong emotional response from staff can further exacer-
which refers to the rapid continuation or repetition of bate the situation.**
an action beyond its purpose, can be seen in motor acts, A group approach can also be useful for providing
verbalizations, or thought processes. Fig. 27-3 provides feedback from peers.**’° Videotaping can provide a
an illustration of writing perseveration. visual record of behavior that can be discussed with the
person.
PERSONALITY AND EMOTIONAL FACTORS. The
person may demonstrate apathy, indifference, or de-
creased spontaneity. The person may also exhibit a
slowness of response or absence of initiative unless As a reader, you have been using your own metacogni-
specifically instructed to perform the task. Other indi- tive skills in processing the preceding material. This
viduals may be inappropriately happy or euphoric and chapter has provided a description of basic cognitive
in conversation may minimize the effect that their processing, the principles of cognitive assessment, and
deficits have had on their lives and families.*” An addi- suggested methods of remediation and compensation.
tional factor is the person’s emotional response to the The field of cognitive neuroscience is ever changing, as
effects of the disability on his or her life; a person with new mechanisms are developed to explore, image, and
cognitive deficits will still pass through the stages of understand the complexity of the brain. Students and
emotional adjustment to disability that can be expected therapists are encouraged to continue to stay abreast of
of anyone undergoing the rehabilitation process. new developments to provide the optimal benefit to pa-
tients and clients.

gcd Sons fo REVIEW QUESTIONS

1. Discuss the difference between cognition and
metacognition.
FIG. 27-3 2. List the areas of cognition that the occupational
Example of writing perseveration. therapist should assess.
468 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

What are the related factors of performance that the 14. Burgess PW, Shallice T: Confabulation and the control of recollec-
therapist should consider when evaluating cogni- tion, Memory 4:359, 1996.
15). Calkins MP: Designing special care units: a systematic approach,
tive function?
Am J Alzheimer's Care Res March/April:16, 1987.
Describe and compare the various theoretical ap- 16. Calkins MP: Designing special care units: a systematic approach.
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. What is environmental feedback, or cueing? es Cermack LS: Models of memory loss in Korsakoff and alcoholic
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18. Craine JE. Gudeman HE: The rehabilitation of brain functions: princi-
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N. Describe the various types of memory functioning. 1981, Charles C Thomas.
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 LEARNING OBJECTIVES
Values After studying this chapter the student or practitioner
Spread will be able to do the following:
Stigma 1. Compare and contrast the values of occupational
Liminality therapy with those of traditional medicine, showing
Stereotypy how these translate into complementary goals for
People with disabilities the two professions.
Patient-agent 2. Discuss several implications of the use of the term
Americans with Disabilities Act patient-agent for the recipient of occupational
Equality of capability therapy services.
Occupation as therapy 3. Visualize new models of practice employing
Adaptation with disability occupation as therapy.
Mutual cooperation 4. Name three positive outcomes of the patient-agent’s
Comanagement engagement in occupation.
Independent living movement 5. Discuss a new, alternative view of health that
includes rather than excludes people with disabilities.
6. Identify two provisions of the Americans With
Disabilities Act.
7. Discuss how practicing occupational therapists
might use people’s experiences of having disabilities
to improve service.
8. List three characteristics of a constructive parent-
professional relationship.

I was quite literally separated from the earth, for while I spent
Many years ago I met “Jeff,” a patient undergoing reha-
my time in an iron lung, in a bed, or in a wheelchair, my feet
almost never touched the ground. bilitation at a large hospital in which I worked as an
But more important, I believe, was being separated from so occupational therapist. My encounter with Jeff created a
many of the elemental routines that occupy people. I felt no turning point in my thinking about people with disabil-
longer connected with the familiar roles I had known in family, ities and influenced the direction of my entire subse-
work, sports. My place in the culture was gone. quent career.

470
 The Social and Psychological Experience of Having a Disability 471
One day Jeff wheeled into my office. I could see that
QUESTIONS
he was very excited about something. “Betty, if you have This chapter explores several questions that are central
a minute, I want to show you something,” he exclaimed, to occupational therapists who work with people with
his eyes bright with anticipation. disabilities. These queries permeate our practice regard-
“Sure, Jeff,” | replied. “What is it?” He handed me a less of the technology we employ, the theories that
ad
4
manuscript. As I examined it, I realized that it was a guide us, or the particular type of disability with which
eee
he scholarly paper. It was titled something like this: “The the patient must live. The four major themes of this
Social Status of People with Disabilities as a Maligned chapter are as follows:
Minority Group.” Because it was the early 1960s, Jeff's 1. Through what “pair of glasses” do occupational ther-
Paper conveyed a new idea to me. apists view the recipients of their services?
“I've written it for a sociology class I’m taking at 2. What is it like to have a disability?°
UCLA. I thought you might like to read it.” His tone of 3. What, if anything, does our society need to do for
voice conveyed both a question and a hope. people with disabilities?
“I'd love to read it,” I replied, full of curiosity by now. 4. (The bottom-line question) How can occupational
“Could I borrow it for a few days?” He nodded, left his therapists help improve life opportunities for people
paper, and told me he would return by the end of the with disabilities?
week.
I took Jeff's paper home that night and read it with THE “PAIR OF GLASSES” THROUGH
increasing interest. He proposed and supported, with
WHICH OCCUPATIONAL THERAPISTS
many references, the idea that people with disabilities
VIEW THEIR PATIENTS
were treated as second-class citizens in American society
and were the recipients of pervasive prejudice that Before we examine these important questions, let me
limited their life opportunities. | saw images in my identify some of my assumptions. The first assump-
mind of events that had occurred at our rehabilitation tion is that all professionals, including occupational
center, events that had bothered me. For example, I re- therapists, wear a particular “pair of glasses” through
membered patients being talked about as though they which we view the people who receive our services.
were invisible in conferences at which they were These glasses are constructed of the beliefs, values, and
present. I saw patients segregated from professional staff traditions of the profession and are transmitted via
members into separate eating areas and rest rooms education, including clinical socialization.*° I assume
clearly labeled “patients” versus “staff.” References to that the lenses worn by occupational therapists are
some patients were in such terms as “uncooperative” or different from those worn by physicians and other
“has not accepted his or her disability.” Such labels were medical personnel, even though occupational thera-
the kiss of death, since these patients were discharged as pists often practice within a medical or rehabilitation
soon as possible, often in an atmosphere of Contempt milieu.”
and hostility. Table 28-1 summarizes key values and beliefs of
With these pictures racing through my mind and the occupational therapists, derived from our history and
increasing conviction that Jeff was onto something im- literature. Occupational therapists’ values seem to
portant, I showed his paper to a colleague the next day. center on a humanistic concern for the individual who
“Take a look at this,” I exclaimed. My coworker may have a chronic, severe, and lifelong disability and
quickly scanned Jeff's paper. Then she turned to me with who will never be cured.” The occupational thera-
a slight smile and in a tone of incredulity, as though I pists’ lenses see the essential humanity of each person,
had been taken in, said, “Betty, remember this. Jeff has including the need to maximize his or her capacity or
brain damage!” capability. Rather than eradicating disease, occupa-
Both Jeffs paper and the rejection of his experiences tional therapists identify and strengthen the healthy
by this professional colleague created a new impetus for aspects or potential of the person. Self-directedness
me to explore what it is like to have a disability. I hoped and self-responsibility of the person are emphasized
that such a quest would enable me to do a better job as rather than compliance or adherence to orders. A gen-
an occupational therapist. eralist, integrated view of the person as one who inter-
acts with his or her environment guides occupational
therapy (OT) practice, rather than a specialist, reduc-
tive perspective. This integration is required by our
1 am indebted to Carol Stein, MA, OTR, for helpful suggestions that emphasis on patients’ daily life activities and their
strengthened this work, to the Occupational Therapy Department at
the University of Southern California for their support in preparing
engagement in the occupations expected by their
the manuscript, and to Marian Karsjens who processed the words so culture. In OT, therapeutic relationships are based
competently. upon a model of mutual cooperation’’ with the
 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

Finally, the occupational therapist seeks to understand

the patient's experience and point of view instead of
Fison ofTraditional Values Supporting relying solely on observation as the only credible source
e of Occupational Therapy With Those of information. The patient's view is essential to our un-
derstanding of people’s motivation to engage in the ac-
tivities of daily life.
Occupational Therapy Medicine By way of contrast, in their classic work, Siegler and
Essential humanity of patient- Freedom from threat of Osmond”® identified important values supporting the
agent; obligation to seek life death; responsibility limited traditional practice of medicine. These values constitute
satisfaction for people with to illness —
the glasses through which physicians have historically
severe disability
viewed their patients. The values are based on Aescu-
Maintain and enhance health; Eradicate disease, lapian authority, conferred by society, which defines
support healthy aspects of pathological conditions; the physician-patient relationship. The physician has
patient-agent confer the sick role the power to confer the sick role upon the patient. This
Self-directedness and Patient compliance to role requires that the patient admit to being ill, submit
responsibility of patient-agent orders; moral authority to treatment, and curtail his or her usual activities
while being exempted from normal responsibilities.
Generalist, integrated view of Specialist, reductionistic
The patient's job is to get well by complying with
patient-agent emphasis on organ systems
orders.
Therapeutic relationship of Therapeutic relationship of A physician's authority ends when the illness ends. It
mutual cooperation with activity of physician, passivity does not deal with the state of impairment that results
patient-agent; shared of patient; Aesculapian and when the person recovers from the illness but still has a
authority sapient authority of physician
disability.
Patient-agent acts on Patient as determined by The values supporting the traditional practice and
environment rather than being environment and “‘body science of medicine include freeing the patient from the
determined by it machine” threat of death; eradicating disease while conferring the
Faith in patient-agent’s Faith in science and healer's sick role; expecting patient compliance; employing a
potential competence and charismatic specialist approach in order to possess superior, precise
authority knowledge; promoting a physician-patient relationship
in which the physician is active and the patient is passive;
Patient-agent productivity Patient.relieved of all
perceiving the patient as more or less of a body machine
and participation responsibilities except getting
well determined by physical laws; placing faith in natural
science and the competence of the physician-healer; re-
Play, leisure activities as Recovery from illness, lieving the patient of everyday responsibilities; focusing
essential components of freedom from disease as on recovery from illness rather than engagement in daily
balanced life major concern
activities; and relying on an objective, observable assess-
Understanding of subjective Emphasis on objectivity, ment of the patient’s symptoms to produce a diagnosis
perspectives of patient- analysis, observation, and and to indicate a course of treatment, which usually
agent diagnosis employs technology such as drugs or surgery.
Throughout this chapter I will assume that occupa-
Modified from Yerxa EJ: Audacious values: the energy source for occupational
therapy practice. In Kielhofner G, editor: Health through occupation, Philadel-
tional therapists focus on improving life opportunities
phia, 1983, FA Davis. for people who often do not recover but must live with
the impact of having a chronic condition. According to
the American Occupational Therapy Association, the
patient rather than a model of an active therapist and majority of occupational therapists work with people
passive patient. The patient is viewed as an agent or who have chronic and often severe disabling condi-
actor with goals, interests, and motives and not as one tions.’ Thus, although occupational therapists may .
whose behavior is determined by physical laws.**? The provide services in a medical milieu, we view the
occupational therapist seems to possess faith in the patient in a way different from the traditional medical
patient's potential ability, which is actualized by en- perspective of diagnosis, cure, and recovery, and we
gagement in activity. follow a different thought process. I also assume that
Therapeutic intervention emphasizes the recipient's our concern for people's capacity to engage in their
productivity and participation rather than relief from re- rounds of daily life activities means that our scope of
sponsibility. Occupational therapists seek to facilitate practice includes not only the hospital, but also the
a balance among work, rest, play, and sleep in the patient's home and community. Thus occupational
patient's daily life rather than only recovery from illness. therapists practice both within and outside of the
 The Social and Psychological Experience of Having a Disability 473

medical milieu, often helping patients to become Table 28-2 presents the WHO classification as three
agents. In this sense OT practice bridges the sometimes models of disability. To include some important impli-
alien world of acute medical care with the familiar cations of the separate perspectives, I have expanded
world of home, family, and culture. these to include the columns labeled “Problem” and
“Power.” Each of the three classifications—impairment,
disability, and handicap—represents a different view of
WHAT IS IT LIKE TO HAVE A DISABILITY?
what it is like to have a disability.° Because impairment
Bickenbach,° a philosopher, suggested that society has emphasizes pathological structures, it reflects the tradi-
not yet answered in a satisfactory manner the “straight- tional biomedical model of disability. In this view the
forward” and “childishly simple” query, “What does it problem of having a disability resides in the body,
mean to have a disability?” As with the contrasting which needs to be cured or modified in some way (for
glasses worn by physicians and occupational therapists, example, through surgery or technology). The power to
the answer depends on one’s perception or point of view. accomplish a solution to the problem therefore rests in
the medical profession by virtue of its superior knowl-
edge and authority.
World Health Organization Classification
A disability presents a contrasting economic model.
In 1980 the World Health Organization (WHO),°’ to The problem resides in those who are unable to con-
assess the effectiveness of health care systems, adopted a tribute to society by fulfilling an occupational or social
classification of the outcomes of the physical event of a role as a result of their limitations. The beginning of the
disability (“Definition” column of Table 28-2). This rehabilitation movement in the United States was
classification system is used internationally to provide marked by efforts to restore people with disabilities to
consistent terminology, formulate research questions, gainful employment so that they would contribute to
and influence public policy. the economic well-being of the country rather than
Impairment means an abnormality of a physiological deplete its resources.° The power in this model rests in
structure or deviation from a biomedical norm.° For the marketplace or state, which assesses the value of the
example, a fracture-dislocation of the cervical vertebra at individual according to his or her capacity to be a pro-
the level of C5,6 is an impairment. ductive contributor to society. The state may intervene
A disability is a limitation resulting from the impair- by providing vocational rehabilitation services to in-
ment. It may be an inability to perform any activity con- crease productivity.
sidered normal or required for some recognized social The handicap model adopts a sociopolitical pair of
role or occupation.® For example, an inability to dress glasses. In this view, the problem does not reside in the
oneself because of the loss of hand function caused by body or in the individual’s ability to contribute to
the impairment of the cervical fracture with resultant society's productivity; rather, it resides in the social envi-
spinal cord injury constitutes a disability. ronment in which the person with a disability goes
A handicap is any disability-related social disadvan- about daily life. Thus, to have a handicap means to ex-
tage for an individual that limits the fulfillment of a perience a social disadvantage or injustice because of
normal role or occupation.° For example, for a person social stigma, prejudice, or other environmental con-
with quadriplegia, the lack of accessibility to a job site straints.° Therefore, the power and solution rest in self-
caused by architectural or social barriers constitutes a advocacy, in which people with disability work to bring
handicap. about social change to achieve equality of opportunity
and justice. An example of such self-advocacy is the po-
litical organization by and for people with disability to
influence legislation designed to remove barriers to
their full participation in society.”*
Each of these models represents a different percep-
Three Models of Disability
tion of what it means to have a disability. According to
Definition Model Problem Power Bickenbach,® none is complete or integrated; rather,
Impairment Biomedical Body Medicine each model represents only a partial and selective view-
Disability Economic Individuals Marketplace/ point. He urges society to develop an integrated, com-
contribution state prehensive model of disability rather than focusing on
to economy these partial and conflicting views.
Perhaps in recognition of these significant issues,*°
Handicap Sociopolitical Social Self-advocacy
the WHO is currently considering revising its classifica-
Environment
tion of people’s health status.°° The three proposed
Modified from Bickenbach JE: Physical disability and social policy, Toronto, |993, dimensions of function are body level, person level,
University of Toronto Press. and society level. The categories are named “(B) Body
474 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

functions and structures,” “(A) Activities,” and “(P) Par- Because of OT’s values and its emphasis on what
ticipation.” All dimensions interact in an environmen- people want and need to do in daily life, many of our
tal context. I see three implications of this proposed re- theorists seek to integrate and address all of these levels,
vision. It refers to “all people,” integrating those with as well as the environments in which people actually
disabilities into the mainstream. It avoids such pejora- live. Although different levels present valid perspectives,
tive terms as disability and handicap by emphasizing these perspectives must be integrated to provide a com-
ability to function. It reflects a dynamic, interactive plete picture, supplemented by the insider's experiences
systems view (biopsychosocial) of human beings. All of daily life (i.e., experiences of the person with the dis-
occupational therapists will want to be alert to whether ability) and the characteristics of the environment.
this new classification is adopted, because it appears The scientists and practitioners of OT need to
more integrated and congruent with our perspectives. develop new approaches to augment the strengths and
potential of people beyond current models and inte-
grating perspectives. The remainder of this chapter de-
Need for an Integrated Model scribes a systems view of what it is like to have a disabil-
The biomedical and economic models necessarily em- ity, emphasizing the complexity and uniqueness of
phasize what is wrong with the person who has disability interactions between the individual and the environ-
as seen by an outside observer (the physician or potential ment.
employer). In contrast, the sociopolitical model empha-
sizes what is wrong with the social environmentas seen by
Social Attitudes Toward People
the person who has the disability, and in this sense pro-
With Disabilities
vides an insider's view. Occupational therapists working
with individuals who have lifelong disability need an in- OT students at Boston University participated in a class
tegrating model of what it means to have a disability, a designed to provide a first-person experience of archi-
model that reflects our ethical values and seeks to under- tectural barriers. Students spent most of the day in
stand both the outsider’s and insider's view of disability. wheelchairs going about their daily routines as students,
Although we often provide our services in a medically ori- visiting classrooms, libraries, and cafeterias. At the end
ented environment, we know that OT cannot be limited of the day they returned to the classroom for discussion.
to concern with the body. It must also focus on people’s Although the students discovered architectural barri-
ability to connect with the daily routines oftheir culture® ers, Many were much more impressed with the behav-
in their own physical and social environments. iors of able-bodied people they encountered. Students
One of the insights of the occupational behavior were the recipients of stares, averted eye contact,
frame of reference,”’ the model of human occupation,~’ obvious social discomfort, and conversations directed
and of the newly emerging discipline of occupational to their wheelchair pushers rather than to them. (Most
science’’ is the recognition of the complexity of the people didn’t know these students were able bodied.)
people served by occupational therapists. In these con- One student put it this way: “I couldn’t wait until 4:00
ceptual frameworks a person is viewed as a multilevel, PM when I could get out of that damned wheelchair.
open system interacting with his or her environment. What must it be like for people who really have a dis-
Thus all people, with or without disabilities, have bio- ability and cannot walk away?”
logical, psychological, sociocultural, and spiritual or
transcendental levels of existence, open to a multitude Outsiders’ Views
of inputs from the outside world. How society views people with disability, an outsider’s
In the sciences each level also represents a pair of view, is sometimes categorized as social attitude.
glasses through which outsiders may perceive a human Wright,°’ a social psychologist, has studied society's re-
being. Many respected and powerful academic disci- actions to people with disability for many years. She
plines tend to focus on only one level, ignoring the used the term spread to describe how the presence of
others or reducing them to lower levels. For example, disability or an atypical physique serves as a stimulus to
medical knowledge, emanating from the natural sci- inferences, assumptions, or expectations about the
ences, may focus primarily on the microbiological level, person who has disability. For example, a person who is
emphasizing the integrity of body structures. Sociolo- blind may be shouted at, as though lack of vision indi-
gists may focus on the level of society and culture. Al- cates impaired hearing as well, or a person with cerebral
though these are legitimate disciplines, their partial palsy may be assumed to be mentally retarded.
views may fail to address significant aspects of human One extreme manifestation of spread is the belief
life and their tools for helping people may be limited or that an individual's life must be a tragedy because of
even distorting. In the realm of people with disability, having a disability. This attitude may be expressed in
medicine emphasizes impairment, whereas sociology such statements as, “I would rather be dead than have
emphasizes handicap. multiple sclerosis.” The assumption of a life sentence to
 The Social and Psychological Experience of Having a Disability

a tragic existence denies that satisfaction and happiness are likely to attribute their own failures to environmen-
may ever be obtained in the presence of a disabling con- tal conditions but other people’s failures to personality
dition. This attitude is of particular ethical concern factors. This observation seems to describe how society
today, when genetic counseling and euthanasia may views people with disability, except that failures are
provide a socially acceptable means of exterminating blamed on the disability.
people with disability.” If life is seen as tragic or not Attitudes are often reflected in research approaches.
worth living, it is a fairly easy step to argue that it would Twenty-five years ago I conducted a small study compar-
be better for everyone if people with disability ceased to ing the self-esteem of children with and without disabil-
exist.*® ity. I expected to find lower self-esteem in the children
Goffman’s classic work”* used the term stigma to de- with disability, but I did not. I know now that my ex-
scribe the social discrediting process that reduces the life pectation was based on the erroneous assumption that
chances of people with disability or other differences. to have disability meant to have a more negative self-
An obvious impairment is translated into “something concept. My previous view was recently echoed by
bad about the moral status of the signifier.”** The indi- another researcher's perspective.” Having found that
vidual with stigma is seen as not quite human. Society the self-esteem of college students with disability was
tends to impute a wide range of imperfections on the similar to that of nondisabled students, the authors
basis of the original stimulus (impairment) and at the asked, “Why then do people with disabilities have posi-
same time project some positive (but undesired) attrib- tive self-images?” This question reflects an unstated as-
utes such as heroism or a sixth sense. sumption that such people should have negative self-
Stigma often is a societal reaction to fear of the images. This study also was based on the unstated
unknown. Despite mainstreaming in education and the assumption that disability is such a powerful, salient
removal of many environmental barriers, the general stimulus that it overrides every other aspect of the
public has little social contact with people who have person and his or her environment—a questionable as-
disability and does not know what to expect of them in sumption, to say the least. When reading research about
daily life. As a result, people with disability are often people with disability, it is useful to determine what as-
categorized as different from other people. This treat- sumptions are embedded in the study and what sort of
ment may be complicated by the just-world hypothe- attitudes they reflect.
sis.°* If the world is just and having a disability is a Siller,°? a social psychologist, has studied attitudes
tragedy, then the person or the family must have done toward people with disability for over 30 years. In a
something morally reprehensible to be the recipients of wide-ranging review of the extant research he con-
such a fate. Such thinking leads easily to stigmatization cluded, “Any inclination to consider disability outside
and social distancing. Liachowitz** argued that, histori- of the larger social context and as something that
cally, people who were physically different were often resides only in the disabled person is destructively
the recipients of philanthropy that inadvertently rein- wrong” (p. 280).
forced negative beliefs of helplessness and dependency
by society at large. One current example is the approach Cultural Influences
used in telethons or other fund-raising ventures, in Edgerton,'® an anthropologist, discussed social reac-
which people with disabilities may be portrayed as tions to disability within the context of the social rules
victims, reinforcing negative attitudes and stigmas. In of culture. “Rules are a shared understanding of how
contrast, some network television programs and com- people ought to behave and what should be done if
mercials include people with disabilities as regular par- someone behaves in a way that conflicts with that un-
ticipants in daily life, as workers or family members. derstanding” (p. 24).
Echoing the WHO classification of handicap, Cultural rules influence the treatment of people with
Wright®’ posited that outside observers may attribute disability. Societies differ in the extent to which they
the behavior of people with disability to the disability relieve their sick members of responsibilities. Often, the
rather than the environmental situation, which is often rules are different when someone is sick. For example,
the real culprit. For example, a child’s inattentiveness the Chinese in Taiwan are more willing than those in
may be accounted for in terms of presumed hyperactiv- America to exempt sick people from their responsibili-
ity or mental retardation, disregarding possible environ- ties. In some societies, people with severe mental retar-
mental contributions to the observed behavior. People dation may receive almost total exemption from re-
with disabilities may be blamed for being unemployed, sponsibility to follow the rules, whereas in other
when in fact environmental factors such as employer at- societies (e.g., that of the Northern Salteaux Indians),
titudes, transportation and architectural barriers, com- such people could be burned alive as children. Some so-
munity unemployment levels, or family obstacles are cieties do not indulge their ill members. For example, it
the cause, rather than personal attributes. Dawes,'” a re- is inexcusable for married females to be sick among the
search psychologist, pointed out that in general people Sarakatsani shepherds of Greece, and anyone too ill to
476 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

travel was left to die in the Siriond culture of the tropical What sorts of attitudes are displayed by OT students?
forests of Bolivia. Lyons”” studied the attitudes of Australian students. He
Many impairments are culturally recognized as brief found that the attitudes of first-year OT students did not
periods during which the temporarily ill person is ex- differ significantly from those of business majors. The
pected to behave in ways that normally would be pro- OT students’ attitudes did not vary with the years of un-
hibited. Culture also dictates great differences in a dergraduate education completed. However, those stu-
person's responses to pain. For example, Jews and Ital- dents who had valued social role contact with people
ians are encouraged to respond to pain as an expression with disability (e.g., a friend, family, or coworker, rather
of their feelings and emotions, whereas other cultures than a patient) had significantly more positive attitudes
disapprove of such expression.'® Culture and its rules than those without such contact. He recommended that
create profound differences in both the expectations educational programs in OT facilitate such valued social
and opportunities for people with disability. role contact. In another study of social distance, Lyons*°
found that undergraduate OT students most preferred
Attitudes of Rehabilitation Workers to work with people who had less visible types of dis-
Many people with disability encounter the health care abilities and least preferred to work with those who had
system, but what is known about the attitudes of those disorders of the mind—namely, people with cerebral
providing services? Siller’? described an array of studies palsy, mental retardation, mental illness, or alcoholism
about rehabilitation personnel. First, he observed that or those with a criminal record.
certain conditions have less appeal to medical students Other studies of occupational therapists**° yielded
than do others. Patients who are elderly, have mental re- conflicting results, some finding more positive atti-
tardation, are dying, or have a chronic disability seem to tudes than those reported by Lyons. Westbrook and
have less appeal than patients who are seen as most like Adamson™ concluded that “occupational therapy stu-
the medical students or are perceived as more capable of dents tend to underestimate the normalcy of lives that
being helped. handicapped people are managing to live in a relatively
The expectations of the teacher influence the per- prejudiced society.”
formance of students. This is referred to as the “Pyg- Vash,°* a psychologist who also has disability, re-
malion effect.” For example, higher expectations are cor- counted a rehabilitation conference held in 1974. A psy-
related with better school performance. Several studies chiatrist addressed the audience, alternately standing up
in rehabilitation settings support this theory for profes- and sitting in a wheelchair, all the while challenging ob-
sionals (who have higher status) and their patients servers to deny that their perceptions of his competence
(who have lower status). For example, a correlation was fluctuated as he stood and sat, over and over. Vash re-
found between the expectations of house parents and ported that much discussion followed and that virtually
the performance of institutionalized adolescents. Siller”” all in attendance acknowledged that their views of his
concluded that such findings about expectations proba- competence had changed; the psychiatrist appeared
bly can be generalized to all disability conditions and all more credible and more worthy of attention when he
rehabilitation professions. Lower expectations may lead stood. The experience was emotionally draining for
to lower performance, and higher expectations produce many because it forced them to confront the prejudice
better performance. they had denied or ignored previously. A wheelchair can
Having relatives with a particular type of disability be a powerful social symbol, conveying devaluation of
and knowing more about a certain disability are corre- the person in it.
lated with a professional's preference to work in that Vash°? introduced her work on the psychology of dis-
area.’ In another study, counselors who rated people ability with this bit of wisdom: some dangers inhere in
with disability similarly to people without disability even acknowledging the validity of the concept “the psy-
were judged by their superiors as more effective than chology of disability,” since in the past’it has led to
counselors who rated the two groups differently.”” unhelpful exaggerations of the perceived differences
Siller’’ observed that medical personnel, particularly between people with disabilities and those without. The
physicians, may see themselves as healers. They have fact is, human beings are more alike than different, re-
often been trained within an acute medical care frame gardless of variances in their physical bodies, sensory ca-
of reference in which passivity on the part of the patient pacities, or intellectual abilities.
is encouraged or insisted upon. Some rehabilitation
professionals may need to emphasize the negative How Different Are People With Disabilities?
aspects of disability to reassure themselves of the im- What is actually known about the similarities and differ-
portance oftheir services. Siller concluded, “One cannot ences between people with and people without disabil-
overly stress the crucial importance for those with ity? Siller’? reported mixed results. He inferred that, “As
chronic disabling conditions to be self-sufficient and soon as one departs from the direct fact of disability, evi-
active in their own behalf.””? dence can be provided to demonstrate that persons with
 The Social and Psychological Experience of Having a Disability

disabilities do or do not have different developmental pairment or disability, we cannot assume anything
tracks, social skills and precepts, defensive orientations, about his or her social or psychological status.
empathetic potential, etc. The data suggest that if the dis-
abled* do present themselves as ‘different’ this is often a
secondary consequence of the social climate rather than
Insider’s Views of Having a Disability
_ inherent disability-specific phenomena” (p. 142). How do people with disabilities perceive themselves? A
Weinberg®* reported that a group of people with dis- growing body of literature provides us with the insiders’
ability showed no differences in life satisfaction, frustra- viewpoint of what it is like to have disability.
tion, or happiness, compared with a group without dis- Zola,’* a sociologist who has disability, observed
ability. The only difference found was on ratings of the that, at its worst, society denigrates, stigmatizes, and dis-
difficulty of life. People with disability judged their lives tances itself from people with chronic conditions. He
to be more difficult and more likely to remain so. She experienced little encouragement to integrate his “dis-
reported another study in which people with chronic, abled self into the rest of his life” because this integra-
but not fatal, health problems not only seemed to be tion would be interpreted as “giving up the struggle to
quite happy, but also derived some happiness from be normal.” In letting his disability surface as a real and
their ability to cope with their difficulty. She concluded not necessarily bad part of himself, he was able to shed
that, “we need to question the assumption that physical his super strong, “I can do it myself” attitudes and be
limitations are directly related to happiness. Instead, it more demanding for what he needed. Only later did he
may be that many people with disabilities find happi- come to believe that, he had the right to ask for or
ness despite their disabilities, even though the able- demand certain accommodations. He began to refuse
bodied public would not always expect this.”°* invitations for speaking engagements unless they were
Studies in Sweden showed that among community- held in a fully accessible facility (not only for him as the
based people who had had strokes, life satisfaction was speaker, but also for the audience).
not correlated with the degree of physical impairment. Vash°* reported that at the age of 19, about 3 years
Rather, it was related to people's ability to achieve their after the onset of poliomyelitis, she was rejected for
own valued goals.” service by the state-funded vocational rehabilitation
Another longitudinal study found that although ado- program. The reason given was that she refused to
lescent girls with cerebral palsy scored significantly abandon her “unrealistic” goal of becoming a psycholo-
lower on physical, social, and personal self-esteem, as gist for the practical goal of becoming a secretary. She
adults they no longer scored significantly differently has subsequently had a productive career as a psycholo-
from other able-bodied groups.*® The authors specu- gist, professor, and writer who still cannot type.
lated that factors in their subjects’ changed self-esteem In one of her books, Vash°* described the impact of
might have been a greater choice of environments in disability from her unique insider-outsider perspective
which to interact, better social relationships;or a wider as a person with disability and as a psychologist. She
range of experiences in education, work, and commerce. observed that an individual's reactions to having dis-
A study of adolescents with disability (e.g., cerebral ability are influenced not only by the type of disability,
palsy, orofacial clefts, and spina bifida) found that the but also by its severity and stability, as well as the
subjects’ self-evaluations of global self-worth did not person's gender, inner resources, temperament, self-
differ from those of an able-bodied comparison group. image, family support, income, technology, and even
Speaking to occupational therapists, the authors of this government funding trends.
study concluded that, “clinicians should not assume The stage of life at which disability occurs influences
that adolescents with physical disabilities will have a person’s reaction because it affects the way the person
problems in self-esteem.””* is perceived and the developmental tasks that might be
Social attitudes toward people with disability are interrupted. The person who is born with disability or
often stigmatizing and devaluing, increasing the degree acquires disability in infancy or childhood may experi-
of handicap and decreasing life opportunities. Such atti- ence isolation or separation from the mainstream in
tudes may be found among professional rehabilitation family life, play, and education. A person who acquires
workers, including occupational therapists. Positive atti- disability later in life may face different issues, such as
tudes are associated with valued social role contact as the need to change vocations, find a marital partner, or
friends, family, or coworkers. Much research supports remain a part of his or her culture via the routines of
the finding that people with disability are more like daily life.*’°
their nondisabled peers than they are different from In terms of functions impaired, Vash®* believed that
them in life satisfaction, happiness, and self-esteem. Ap- different disabilities (such as blindness or paralysis)
parently, when we know only that a person has an im- generate different reactions because each creates differ-
ent problems or challenges. She observed, however, that
*"The disabled” is Siller’s terminology. the insider-outsider perspective also applies to people
478 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

with disability. Thus the person with disability may feel and women’s reactions differently. For example, the
that his or her condition is not as difficult as that of need for women to be “physically perfect specimens”°*
others; for example, a person who is blind may feel that or to carry the major responsibility for managing the
it would be worse to be deaf. Reactions are also tem- home and caring for children may create a different
pered by the impact of the disability on the valued skills impact for women.
and capacities the person has lost. For example, a Vash°* gave great importance to the activities affected
person who loves music more than the visual arts may by disablement. In fact, she stated that, “The impact of
have a stronger reaction to loss of hearing than a visual disablement is largely contingent on the extent to which
person with the opposite pattern. (Note the use of the it interferes with what you are doing.” It is not only
word “may” throughout this paragraph, indicating that actual activities that influence a person’s reactions, but
reactions are individualized and unpredictable.) also the potential activities that are held as goals for the
The severity of disability does not have a direct, one- future.
to-one relationship with the person’s reaction to it. Interests, values, and goals influence a person’s reac-
Vash°* stated, “One person can assimilate total paralysis tion to disablement. The individual with a limited range
with fair equanimity, while another is devastated by the of interests may react more negatively to a disability that
loss of a finger.” prevents their expression, whereas an individual with a
The visibility or invisibility of impairment may influ- wide range of interests and goals may adapt more
ence a person's response to his or her disability because readily. Vash°* observed that people may not be aware
of social reactions.°* For example, invisible disabilities of their interests, values, and goals and therefore may
such as pain may create difficulties because other people not be conscious of those that have the potential to lead
expect the person to perform in impossible ways. One to satisfaction after acquiring a disability. She empha-
woman with arthritis indicated that it was easier for her sized the importance of interests: “The more varied this
to go grocery shopping when she wore her hand splints potential, the more protected is the individual from
because then her disability was visible and people would frustration and dejection over being disabled.”*
carry her packages for her without her having to ask. Vash°* proposed that the resources the individual
The stability of the disability or the extent to which it possesses for coping with and enjoying life are assets
changes over time may influence reactions.°* In some that may counterbalance the devastation of loss of func-
progressive disabilities the individual faces uncertainty tion. Some of these, such as social skills and persistence,
as to the degree oflimitations, as well as (in some cases) may be developed to a level enabling paid employment,
a hastened death. Reactions to such disabilities are whereas others, such as artistic talent or leisure skills,
shaped by these realities and by what the affected may contribute to a more satisfying life.
people tell themselves about their projected futures. Vash°? is one of the few authors who emphasized the
When hope for neither containment nor cure is sub- importance of spiritual and philosophical beliefs to a
stantiated, the person may experience a new round of person’s reactions to disablement. She separated spiritu-
disappointment, fear, or anger. ality from religiosity, with the observation that people
Pain tends to usurp consciousness whenever it is who acknowledge a spiritual dimension of life and who
present. As Vash°* observed, “It is hard to be jolly, cre- have a philosophy of life into which disablement can be
ative or maybe even civil when you hurt—but some integrated in a meaningful, nondestructive way may be
[people] can learn to do so.” Reactions to pain are better able to deal with having a disability. Specific reli-
highly individualized and influenced by culture.'* gious beliefs may or may not be helpful. The person
In discussing reactions to disability, Vash°* observed who views having a disability as punishment for past
that they depend not only on the disability, but also on sins will respond differently from one who views the
the people who become disabled. She observed that we disability as a test or opportunity for spiritual develop-
need to ask, “What remaining resources do they have ment. ,
for developing effective and gratifying lifestyles?” This Finally, Vash°* acknowledged the importance of the
question seems particularly important for occupational person’s environment in influencing his or her reactions
therapists because of our concern for what people can to having disability. Immediate environmenta! qualities
do and how their own occupations influence their such as family support and acceptance, income, com-
health and quality of life. Vash raised other questions munity resources, and loyal friends are powerful con-
relevant to occupational therapists: “What activities and tributors. The institutional environment if one is hospi-
behavior patterns are interrupted by disablement, and talized also has a profound effect, especially the
how central are these to their happiness? What is the attitudes and behaviors of the staff members. The
spiritual or philosophical base of their lives?” culture and its support (or lack thereof) for resolving
Gender influences a person's reactions. Certain socie-
tal expectations that people fulfill their social and sexual
roles and live up to social ideals may influence men’s *”Being disabled” is Vash’s term.
 The Social and Psychological Experience of Having a Disability

functional problems or protecting the civil rights of one of them came to a ward of patients, the room
people with disability is another significant influence. brightened and the patients’ fears and tensions lessened
Vash®* provided a broad and complex picture of considerably.
people's reactions to having a disability. In her portrayal Beisser’ discussed his reactions to acquiring disabil-
of the impact of impairment and disability on the bio- ity. First he had to give up the “old and obsolete, prepar-
logical, psychological, social, and spiritual levels of the ing the ground for something new.” Then he had to find
human, she recognized the need to discover resources at something positive, available for a new commitment.
all of these levels and stressed the importance of the The first step in giving up the old was a grieving process,
person’s interaction with his or her environment, espe- which involved a gradual reduction in the energy in-
cially in being able to do something, to act. Vash’s work vested in what had been lost. He described passing
supported both OT’s values and its open-systems view through stages of denial (he had not really lost anything
of human beings. of value), blaming (whose fault is this?), and bargaining
A growing body of literature provides insight into the (with physicians, God, and the universe) that if he did
experiences of having disability.7°"'”?77**"*?? These X, he would get back what he had lost. When he dis-
works provide occupational therapists with a much covered that there was no one to blame or bargain with
needed insider's view. or rage against, despair and depression appeared. Al-
Beisser’ had just completed medical school at age 23 though this stage is supposed to lead to acceptance,
when he acquired poliomyelitis, which left him totally Beisser’ asked, “Acceptance of what?” Why would a
paralyzed and unable to breathe without a respirator. person accept the loss of something valued unless there
He spent a year in the hospital, occupying the same was something new of value to take its place? There had
room. Later, he was able to articulate his experiences to be a positive replacement. In his case he had to find a
with a clarity and sensitivity that enable us, almost, to new way of being, involving his old enthusiasms. The
share them. Some of his experiences in the hospital are first was sports, then people in his life, and finally work,
noteworthy. but these discoveries took a long time.
Beisser frequently felt that those who attended to his Although he couldn't become a surgeon, he did
body were more the owners of it than he was. Although become a psychiatrist; although he could no longer play
he was often cold because his paralysis prevented his tennis, he could become an enthusiastic sports fan (he
muscles from generating heat, the nurse doubted his later wrote a book about sports). The stages of accept-
judgment. She would feel his leg and say, “Oh, it’s all ance, which needed to occur simultaneously with grief,
tight, you're not cold.” These experiences happened were the following: “Rejection of unfamiliar options;
over and over. Beisser’ observed, “They thought they looking for something new; a grudging acceptance of
knew how | felt better than I did. I was not even ac- something new; behaving ‘as if you accept it; discover-
knowledged as a separate person.” Although enraged by ing some of the same satisfaction in the new that you
his imposed powerlessness, he learned that yow “cannot had with the obsolete.”
get mad in hospitals” because “angry patients come Another insider's view of disability is provided by
last” (i.e, have their needs attended to last). He com- Robert Murphy,** a professor of anthropology who de-
pared his experience of hospitalization to being a pris- veloped a progressive spinal cord tumor that moved
oner of war, except that, although he depended upon from “a little muscle spasm in 1972 to quadriplegia in
his captor’s feelings and behaviors for his self-esteem, 1986,” the year he wrote his book.
he could never become one of them no matter how Murphy” described his initial reaction to having dis-
hard he tried to be a good patient. ability: “But what depressed me above all else was the
Depersonalization was common. Some of the em- realization that I had lost my freedom, that I was to be
ployees on whom Beisser depended made it clear that it an occasional prisoner of hospitals for some time to
was just a job to them. In one hospital the first hour of come, that my future was under the control of the
the nurses’ shift was spent deciding about coffee breaks. medical establishment.” This feeling was like falling
Patient needs were secondary. Sometimes workers even into a vast web, a trap from which he might never
left him in midair in a lift to go on a coffee break. “One escape.
of the worst times was at ‘change of shift’ because then Murphy’s view of hospitalization was similar to
there was absolutely no chance of getting anyone to Beisser’s.° He described the key rules for a sick person as
help even if the problem was urgent.” Beisser® observed, (1) don’t complain, and (2) maintain a cheery exterior.
“To me, what they did or did not do was not ‘just a job’ Doctors and nurses appreciate patients who can follow
but a matter of survival, of both my physical body and these rules.
my sense of myself as a person.” The hospital patient must conform to the routine
Fortunately, he sometimes had other sorts of helpers imposed by the establishment. For example, Murphy
who helped willingly with interest and compassion, spent 5 weeks on one ward where he was bathed at 5:30
whose primary goal was the comfort of patients. When every morning because the day shift nurses were too
480 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

busy to do it. The chain of authority from physicians on and death. Life has a liturgy which must be constantly
down creates a bureaucratic structure that breeds and celebrated and renewed; it is a feast whose sacra-
feeds on impersonality.** The totality (social isolation) ment is consummated in the paralytic’s breaking out
of such institutions is greater in long-term care facilities, from his prison of flesh and bone, and in his quest
such as mental hospitals and rehabilitation centers. A for autonomy.”
closed-off, total institution generally attempts to erase Williams’ autobiography®’ provides a glimpse into
prior identity and make the person assume a new one, the experiences of a woman with diagnosed autism. The
imposed by authority. The hospital requires that the book provides a rich portrait of one person’s experience
inmates think of themselves primarily as patients, a of growing up in an alien world. When she was a child,
condition of “conformity and subservience.” her mother and brother often joined together to put her
In relation to his social world, Murphy*” experienced down. “To them, I was a nut, a retard, a spastic. I threw
an increase in social isolation because some of his mentals and couldn’t act normal.” She sought safety in
friends avoided him. He often encountered physical hanging on to an insular little world in which com-
barriers in his environment. He was surprised to dis- munication via objects was comfortable but any physi-
cover that in attending meetings of organizations of cal contact with people was anxiety ridden. “I felt that
people with disability, often more attention was paid to all touching was pain, and I was frightened” (at the
the opinions of outside experts who were able bodied prospect of hugging or being hugged).
than to his views (in spite of his having disability and Fortunately, Williams’ father was sensitive to her
being a professor of anthropology). He observed that needs. “He simply sat within my presence, letting me
people with disability fit into a mold of liminality (in- show him how] felt in the only way I could—via objects.
visibility); as their bodies are impaired, so is their social I eventually had the courage to show him some of the
standing. “Their persons are regarded as contaminated; secret pictures I'd drawn and the poems I'd written.”°”
eyes are averted and people take care not to approach Williams’ existence became one of her own construc-
wheelchairs too closely.”** One of his colleagues viewed tion as she tried to resist intrusion from the outside
wheelchairs as portable seclusion huts or isolation world of fragments and incoherence. For example, al-
chambers. Even so, Murphy** expressed a sense of though she could read novels fluently, she was unable to
wonder that so many people with disability manage to understand what books were about. The meaning got
break out into the world. lost in “the jumble of trivial words.”°° Concentration
A great deal of Murphy's book*” recounts his struggle was difficult, especially for imposed tasks. Unless the ac-
for autonomy. Because of changes in his physical condi- tivity was one she had chosen, she would drift off, no
tion, he decided to have his wife, Yolanda, do the matter how hard she tried. “Anything I tried to learn,
driving. Later he realized that this change was a mistake unless it was something I sought and taught myself,
because it resulted in the loss of his sense of mastery closed me out and became hard to comprehend, just
and power. Driving an automobile meant not only mo- like any other intrusion from ‘the world!”
bility, but also spontaneity and free will. Having to rely At the end of her odyssey, often similar to that of
on other people and the planning necessary to go any- being on a strange planet, Williams®” recounted those
where because of his increasing paralysis “invaded my experiences that had been helpful:
entire assessment of time.” He observed that not only
he, but all people with paraplegia and quadriplegia, Allowing me my privacy and space was the most beneficial
have problems of planning activities and often have to thing I ever got. As much as many of the things I did were dan-
gerous and as much as people could sense my isolation, this
conform to the timetables of family members, aides,
isolation was not from being left to my own devices. It
and service providers.
stemmed from the isolation of my inner world, and only the
A major contributor to Murphy’s sense of mastery unthreatening nature of privacy and space would inspire the
was his work as a professor, which he continued as courage to explore the world and get out of my world under
long as possible. But even with his status as an interna- glass step by step.
tionally recognized anthropologist and researcher, hos-
pital personnel often saw him as an anomaly. A social Williams’ book conveys the experiential basis of her .
worker asked him, “What was your occupation?” even behavior, which often might otherwise appear bizarre
though he was working full time and doing research in and incomprehensible to an outside observer. The book
areas related to medical expertise. With their mindset, also offers support for the importance of choices, a safe
hospital workers seemed unable to place him in the space for exploration, and intrinsic motivation for en-
mainstream of society. Murphy** concluded that people gagement in activities.
with disability must make extra efforts to establish Dubus,’ an accomplished novelist, acquired a severe
themselves as autonomous, worthy individuals. His disability when he was hit by an automobile after he
book ended with this observation: “But the essence of had stopped to help a couple whose car had broken
the well-lived life is the defiance of negativity, inertia down on a busy highway. He was suddenly transformed
 The Social and Psychological Experience of Having a Disability

into a “disabled man” with one leg amputated and the Osborn’s story is an honest portrait of a woman
other so badly shattered that he needed to use a wheel- struggling to survive, contribute, find something worth
chair as a permanent mode of transportation. He gradu- doing, and forge a new identity. As I read it, I was struck
ally moved from initial despair toward surrender and with her unmet needs for (1) engagement in occupation
acceptance. Along the way he told of changes in how he and (2) the discovery, via occupations, of her nascent
perceived his environment: capabilities.
These articulate people help us understand the expe-
The world is a different place when seen from a wheelchair. It’s rience of having disability from an insider's point of
a landscape made up of obstacles and traps. How to get a glass
view. An increasing amount of literature provides new
of water the nurse has put out of reach? How to get in and out
insights into experiences such as encounters with social
of a car? How to shave, how to shower? How to reach the dials
on the stove? What do you do if your car breaks down? How stigma, reactions to the medical system, and the need to
do you ask for things without making every request a state- have a supportive environment. Of particular relevance
ment of disability? to occupational therapists are these insiders’ quests for
autonomy and a sense of mastery over their daily lives,
Dubus’ solution to the last question in his list was, “I their needs to discover substitute interests for those lost,
say things like ‘I wonder if there’s any cheese?’ or ‘Does and the essential strength of their unique resources and
anyone want hot chocolate?’”’” their embeddedness in the mainstream of humanity.
Like Murphy*” and Beisser,*’ Dubus’” had a profound Reading these and other”?***?”*?*? original sources
change in his sense of time. Everything took him three may provide occupational therapists with new under-
times as long to do as it had previously. As a result, time standing of how to make their services better fit the
seemed to move “three times as fast as the action that needs of people—needs identified by the people them-
once used a third of it.” Dubus’ experiences underline selves. These sources cast light on how people adapt to
his need to develop extraordinary new skills to manage the challenges of their environments in the presence of
his space, time, and social relationships as a person with a disabling condition by discovering, enhancing, and
disability. using their strengths and resources. This process can be
Osborn* is a physician who received a traumatic profoundly affected by OT.
head injury as a result of a bicycle-automobile accident.
Her book is one of the few memoirs written by WHAT, IF ANYTHING, DOES SOCIETY
someone who is both a physician and a person who
NEED TO DO FOR PEOPLE WITH
needed to learn how to live with the effects of a brain
DISABILITIES?
injury. Although she completed two 5-month stints of
cognitive rehabilitation at an internationally recognized This section explores the social context of having a dis-
center, little or no help was available to enable her to ability. The first issue is current trends in terminology,
function in her daily routines in her own environments. followed by changes in health care affecting life oppor-
She reported that while living alone in New York City tunities for people with disability. Finally, some current
(so that she could attend the rehabilitation program), social policies regarding the civil rights of people with
she had extreme problems in performing daily occupa- disability and attempts to reduce social handicapping®
tions such as organizing her time and space, using are presented.
public transportation, and completing the tasks of daily
living. For example, she often went to bed hungry
Terminology
because she forgot to shop or because she botched
shopping: “I couldn't decide what to put on my list. I The language used to communicate ideas about people
didn’t know where to go or what to buy.” with disability is important because it conveys images
As she engaged in the lengthy process of recovery and about the people that may or may not diminish their
adaptation to her changed status, Osborn discovered status as human beings. For example, in the jargon ofthe
the joys of painting and writing. “If I could not speak medical environment people may be called “quads,”
what I felt, I would draw and write it.” She began to “paras,” “CPs” or “that stroke down the hall.” This cate-
value the fledgling part of the new individual she was gorization easily leads to viewing individuals as cate-
becoming, while recognizing the loss of the old. “I gories (stereotypy), and also as being “engulfed”° by
would love to be that woman again, but she died in their impairments. Additionally, referring to such people
1988. While I shall always miss her, I do not idealize as “the disabled” or “a disabled person” seems to make
her. She wasn’t much fun. She steeped herself in her the disability swallow up their entire identity, leaving
work and was often unavailable to her friends and them outside the mainstream of humanity. How, then,
family; she was so attentive to her patients’ needs that might one talk about them in a spirit ofdignity?
there was not much left for herself. She could not paint Many years ago, Vash°? edited a chapter I had written
and she wrote nothing that was not medical.” for one ofher books. In the margin she wrote, “Why not
482 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

refer to ‘people with disabilities’ rather than ‘the dis- the patient’s active and involved commitment to the
abled’?” This was her way of emphasizing that each in- process of rehabilitation, to achieve a good quality of
dividual was a person first, with all of the uniqueness life, and to restore viable social functioning.
and the similarity to everyone else that personhood Because rehabilitation is often based on a model of
conveys. I have used that terminology throughout this acute medical care, Robinson recommended that the
chapter with the intention that disability be defined in traditional goals of short-term, acute medical care be
the broadest sense to include any condition (internal or radically changed to goals appropriate to the rehabilita-
external) that may interfere with the accomplishment of tion of people with long-term disability. The aim of re-
goals and intentions. People with disabilities is in- habilitation would thus change from cure to alleviation,
creasingly being used by other writers in this field.°°*"°? its focus from impairment to handicap,° and its style
Another issue is that of what to call the recipient of OT: from technique centered to patient centered. He recom-
“patient,” “client,” or even “patient-client.” In a medical mended that the physician's role change from controller
setting, “patient” may convey both a sense of ethical re- to coordinator and that therapists change from medical
sponsibility’* toward, and a state of passivity and de- agents (carrying out medical orders) to autonomous
pendence’? of, people receiving care. “Client,” on the contractors (who can deal with the long-term complex
other hand, conveys an economic relationship,”° as does relationships among impairment, disability, and handi-
“consumer.” What these latter terms may gain in auton- cap).’ The patient's role would change from that of
omy, they seem to lose in beneficence. Most people do passive complier with preset goals to active definer of re-
not choose to need health care and are especially vul- habilitation goals. The site of service provision would
nerable to professional practices because of the trau- change from the hospital to the community.°*
matic nature of illness and disability. Therefore I suggest Interestingly, Robinson”? observed that of the health
that the term patient-agent be used in a medical setting, professionals involved in rehabilitation, occupational
to convey both the ethical responsibility of care givers therapists were most likely to adapt to these needed
and the goal of enabling patients to become agents (an changes because of their traditional involvement with
agent is one who acts, has power, and is capable of pro- long-term impairments and “the very adaptability and
ducing an effect). diversity of occupational therapy, centered around ideas
In a community or nonmedical setting it may be ap- of occupation and activity.” As more and more people
propriate to use such terms as “students” (in an educa- live with disability in an increasingly complex environ-
tional program) or the more generic “service recipient.” ment,’* such changes in rehabilitation will be urgently
I prefer the latter term because it conveys the important needed to improve the life opportunities of people with
point that OT is a service and not’a commodity to be disability and to ensure that they can achieve their goals
consumed. Service conveys benefits, help, and useful- and purposes in real-life environments.
ness rather than a business (client) relationship in
which the buyer may need to beware that the goal of the
Legislation
provider is to maximize his or her profits.
The WHO terminology of “impairment,” “disability,” Legislation is another way for society to improve life by
and “handicap”®’ also may be useful in separating the decreasing the handicap of people with disability. After
biomedical, economic, and social perspectives of dis- decades of work by people with disability and their ad-
ability. The terminology is used widely in the interna- vocates, the Rehabilitation Act of 1973 was passed as a
tional community. Whatever terminology is selected first step toward full recognition of the rights of such
needs to be chosen with care and thoughtfulness to people. It prohibited discrimination on the basis of dis-
ensure that it conveys respect, dignity, and a sense of ability in all federally funded programs and activities
ethical responsibility toward those who receive OT. and required that federal contractors use affirmative
action in hiring and promoting qualified people with
disability.°
Changes in Health Care
In 1990, the Americans With Disabilities Act®° was
Changes in the health care system are resulting from the passed, reflecting further progress in achieving civil
increased population of people with chronic conditions rights. At the time the act was passed, 67% of the esti-
and the increased knowledge and activism of those re- mated 43 million people with disability residing in the
ceiving care, especially long-term care such as rehabilita- USA were unemployed. The act consists of 5 sections
tion. These changes will certainly affect the way society (called titles) designed to prevent employers and busi-
provides opportunities for people with disability. nesses from discriminating on the basis of physical or
Robinson,”” a British social scientist who has written mental disability. It broadens the scope of the Rehabili-
about the experience of having multiple sclerosis, urged tation Act of 1973 to prohibit discrimination by all
that major changes be made in the organization of re- businesses (not just federally funded businesses). The
habilitative care. Such changes are needed to support act prohibits discrimination on the basis of physical or
 The Social and Psychological Experience of Having a Disability 483

mental disability. Disability is defined as an impair- as central to OT practice. In Bickenbach’s°® view, capabil-
ment that substantially limits a major life activity such ity is a “set of functionings, over which a person has a
as caring for oneself, performing manual tasks, walk- choice, so that the set of a person's capabilities consti-
ing, learning, and working.°° Major provisions include tute his or her actual freedom of choice over alternative
prohibition of discrimination in employment of those lives he or she can lead.” The value of this freedom is in
with disability who are qualified to perform the job, its positivity, range of options, and functionings (things
with or without accommodations at the work site; ac- people can do or become or have a realistic choice
cessibility to all state and local government services about). For example, equality of capability for a man
without discrimination against individuals with dis- with blindness might mean a world in which he could
ability; and accessibility to public goods and services rise in the morning, help get the children off to school,
(e.g., restaurants and inns, hospitals, universities, zoos, bid his wife good-bye, and proceed along the street to
amusement parks, and homeless shelters). Such acces- his daily work without dog, cane, or guide (if he so
sibility may be achieved through removal of architec- desired), proceeding with assurance and knowing that
tural barriers and by changes in company policies and he is a member of the public for whom the streets are
practices. Telephone systems must make public accom- maintained with the help of his taxes and that he shares
modations more accessible to hearing-impaired and a world in which he also has a right to live.° Equality of
speech-impaired persons. Finally, the act prohibits re- capability respects people as agents and emphasizes not
taliation or coercion against people who seek the rights what they do choose but what they can and might
granted by the act. (See also Chapter 17.) choose.
Any legislation is only as effective as its enforcement. In answer to the question of society's responsibilities
According to public television,*’ complying with the act to people with disability, several directions are now ap-
has not resulted in the huge expenditure predicted by parent. The words used to refer to people with disability
many business owners. But although progress is being need to be chosen carefully so that they convey dignity
made, many medium-sized and smaller businesses are and reflect individual personhood rather than stereo-
still not in compliance, as is true of many universities. typy. Changes are needed in the health care system so
As a result, more people with disability are filing law- that the current paradigm of acute medical care is re-
suits to achieve their rights by bringing about needed placed with a model of long-term commitment to im-
changes in their social and physical environments. Oc- proving life opportunities for people with disability,
cupational therapists may help achieve the goals of the leading to more autonomy for both patient-agents and
act by serving as both advocates and sources of informa- the occupational therapists who serve them. Legislation
tion for people with disability about their rights. to protect the civil rights of people with disability needs
to be passed, widely publicized, and enforced so that
handicap is no longer a social barrier. People with dis-
Public Policy ability need to know about their rights to participate
A final point about society's responsibility to people fully in life. Finally, society needs to understand and
with disability concerns public policy. Bickenbach’s support the goal of equality of capability so that people
entire book® deals with the issue of how the decisions with disability can enjoy their agency and have full par-
made by social entities such as governments affect the ticipation in the routines of their culture, to the degree
lives of individuals with disability. He pointed out that that they so desire.
such policies ultimately affect almost everyone because
those without disability are really TABs (temporarily
able bodied), whose status may change because of HOW MAY OCCUPATIONAL THERAPISTS
aging, acute conditions such as fractures, or pregnancy. HELP IMPROVE THE LIFE
Bickenbach® concluded that policies should promote OPPORTUNITIES OF PEOPLE
the goals of respect for, social participation of, and ac- WITH DISABILITIES?
commodation for people with disability. He viewed dis-
Mind-Body Split
ablement as a condition of social, structural inequality.
He then raised the question of what equality might Several years ago, a patient in a large rehabilitation
mean, asking “Equality of what?” For example, it might center attempted suicide. The administrators tried to
be defined as equality of respect, antidiscrimination, transfer him to a psychiatric facility. However, that hos-
opportunity, or equality of result (such as political and pital would not accept him because he had a spinal
economic power). After exploring each of these ideas, cord injury. This incident emphasizes the mind-body
he concluded that equality of capability is the most just split'**" in categorization that forces whole people into
and encompassing goal. medically defined, diagnostic boxes. It is often assumed
Equality of capability seems relevant to OT and is that a person with physical disability has a physical im-
reminiscent of Reilly's goal”’ of reduction of incapacity pairment that can be fixed via technology and therapy.
484 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

If such a person displays so-called psychosocial prob- achieve mastery, efficacy, and autonomy is identified by
lems, these are viewed as adjustment or behavioral many authors with disability as an important contribu-
deficits requiring counseling or psychotherapy. Because tor to the quality of their lives and their sense of well-
occupational therapists are educated to provide services being.*?”**4749-° Humans possess an innate need to
for people with diagnoses of both physical and psychi- exercise control over their environment, a need that
atric disability, therapists might similarly dichotomize rarely seems to be recognized in the traditional medical
their patients and approach those with physical impair- milieu and therefore compounds the impact of the dis-
ments by providing technical solutions, including ability. Instead of learned helplessness,” in which
devices and physical modalities. If these patients display people see themselves as the victims of overwhelming
emotional reactions such as depression, the occupa- forces in their environment, the ability to do°? some-
tional therapists might supplement their techniques thing the person really wants to do contributes to a sense
with counseling or talk therapy. But note that the of efficacy. Dawes‘? wrote that self-esteem frequently
patient-agent is fragmented and the approach is one of results from achievement and effort rather than being
“doing to” a patient by a professional. The majority of their precursor. He also cited research supporting the
people seen by occupational therapists have lifelong idea that mild depression is often alleviated by simply
conditions that cannot be cured,’ so the fixing is only encouraging and enabling people to engage in the activi-
partially successful and the cost of what is neglected ties they enjoy. Engagement in occupation may con-
may be high in terms of loss of the patient-agent’s au- tribute to self-esteem and mitigate depressive emotions.
tonomy and future quality of life. Occupation as therapy enables people to learn those
skills they need to fulfill their social roles.’ For
example, Beisser’ needed to learn how to pursue his in-
Occupation as Therapy
terest in sports in a new way (by writing a book) and
In contrast to the previously described approach, the oc- how to work as a physician (as a psychiatrist rather than
cupational therapist might employ occupation as ther- a surgeon). These are examples of how occupations
apy, engaging the recipient of services in self-initiated, enabled him to be reconnected with his culture and to
self-directed, purposeful (to the patient-agent) activity. find his place in society.
Here I do not mean only self-care, but rather the whole The use of occupation as therapy demands a systems
gamut of playful, creative, and productive human activ- perspective of the recipient, rather than a perspective
ity that is recognized as meaningful by both the indi- limited to impairment, disability, or handicap alone.
vidual and his or her culture. Such occupation helps to Occupation involves all levels of the human system (bi-
put the patient-agent back together again because it is ological, psychological, sociocultural, and spiritual) in
not exclusively physical or mental but, as Reilly’® said, interaction with that person’s real environment. The ac-
is energized by mind and will. The use of occupation tivity is the integrator of these levels, producing an
performed by the recipient of OT services has several output such as competence or skill.
implications relevant to the social and psychological ex- The occupational therapist has a significant, com-
perience of having disability. First, it enables the expres- plex, and sensitive part to play in the use of occupation
sion of the unique pattern of interests each individual as therapy. He or she creates an environment in which
possesses. Pursuing old interests and developing new the patient-agent can make an adaptive response. This
ones are vital ingredients in enabling people to adapt to role requires setting the stage at the right level of chal-
their environments in the presence of disabling condi- lenge—neither too difficult nor too easy—for each indi-
tions.*°?**°*°° The activation of interests through oc- vidual. It also requires suggesting activities that are con-
cupation also is a way of tapping into the intrinsic moti- sonant with the individual’s interests and that may need
vation’? that will energize the person—not only for to be adapted so that the individual can perform them.
the short term, but also for life in the real world of One of my colleagues had a serious traumatic head
home and community. injury when her children were still young. Her occupa-
Engagement in occupation involves the whole tional therapist helped her learn how to resume her re-
human being in the development of skill, which he or sponsibilities as a mother by performing a task analysis
she will possess as a resource. Occupation requires of subroutines. The therapist broke these occupations
such subroutines as planning, problem solving, appli- into small, achievable units. When accomplished, these
cation of work habits, knowing and following rules, units were synthesized to enable my colleague to achieve
and identifying and correcting mistakes, all of which the global skills of child care. The ability to resume her
contribute to the ability of the eye, hand, and mind’ to role of mother was a powerful contributor to her sense of
function cooperatively in producing an effect on the competence and the reuniting of her family.
environment. Using occupation as therapy requires discovering the
Because occupation enables the actor to produce an resources each individual possesses. This process is
effect, it contributes to a sense of mastery. The need to grounded in an optimistic view of human nature’ in
 The Social and Psychological Experience of Having a Disability 485

which all persons are seen as having resources that can experiences of having a disability mentioned problems
be reclaimed,*' regardless of the degree of impairment. and frustrations with time, space, and daily rou-
Much of the literature®°”’°*”° supports the validity of tines.177244743-49 Such organization is becoming
viewing people with disability not according to what is more overwhelming as society increases in technologi-
wrong with them but according to what is right about cal complexity. Some patient-agents never may have
them. For example, psychologists Wright and Fletcher”? learned how to plan and might need help in determin-
claimed that a professional preoccupation with the neg- ing their goals. This possibility is especially likely if,
ative leads rehabilitation workers to underestimate instead, they have learned helplessness. Occupational
people's abilities. They recommended that more atten- therapists with a knowledge of organization can help
tion be given in assessment procedures to the environ- patient-agents organize their lives for maximum satis-
ments in which the patient-agent will live (e.g., school, faction and participation, contributing to their equality
workplace, community). They also urged that evaluators of capability.°
Pay as much attention to describing the strengths and
resources of the individual (and his or her environ-
Mourning and Value Changes
ments) as to exposing deficiencies and problems.
A study by Burnett and Yerxa”® of the self-identified Wright®’ discussed the common experience of people
needs of community-based people with disabilities who acquire disability as feelings of shame and inferior-
demonstrated many unmet needs. Our subjects re- ity along with avoidance of being identified as a person
ported lower confidence levels than a sample of people with disability. She urged that caregivers conceptualize
without disabilities in performing problem-solving, acceptance of disability in a new way. Rather than resig-
social, recreational, school, vocational, and home skills, nation or preference of one’s state over another, she rec-
as well as in community mobility. Basic activities of ommended the goal of acceptance of one’s disability as
daily living was the only area of similar confidence. nondevaluing. The disability may still be seen as incon-
Many of these people had received previous hospital- venient and limiting, requiring work to improve certain
based rehabilitation services including OT, yet perva- facets of life, but the person will not feel debased or
sive needs for the skills required to live in the com- need to hide in shame. Almost all of the people whose
munity persisted. As a result, a new program was experiences were described earlier talked at length about
established by the authors at a community college. It is the devaluation they experienced.7777/7447/499709/74
directed by Burnett,’ an occupational therapist. The The crisis of suddenly having disability may produce
program includes not only skill development for inde- a gamut of emotions and thoughts, including disbelief
pendent living in the community, but also training in and denial, anger, panic, self-devaluation, and guilt,
self-advocacy (to reduce or eliminate handicap). fluctuating with hope and encouragement, feelings of
The use of occupation as therapy reveals the occupa- being comforted, relief, and exaltation. These rapidly
tional therapist's role as coach (a term suggested by occurring cycles are highly individual and may become
Mary Reilly). Rather than doing to or for the patient, the less acute as the person begins to acknowledge reality.°”
occupational therapist has the role of fostering the How might health care workers help people
patient-agent’s adaptive response, often by making it through such crises toward nondevaluing acceptance
possible for the patient to use existing strengths and ca- of loss? Wright®’ suggested that changes are needed in
pabilities or to develop new ones. This approach takes people’s value systems. These changes include “(1) en-
sensitivity, skill, and an understanding of intrinsic moti- larging the scope of values, (2) subordinating phy-
vation’ far beyond that required for the “laying on of sique relative to other values, (3) containing disability
hands.” Just as an athlete needs coaching to achieve the effects, and (4) transforming comparative-status values
highest level of performance, the recipients of our serv- into asset values.” Note that these changes apply both
ices need coaching from occupational therapists to to the person with disability and to outsiders such as
reach a level of competence that enables them to occupational therapists and the patient-agent’s family
achieve their goals in their own environments. This is members. The value changes are discussed in the para-
the process by which patients may be transmuted to graphs that follow.
agents. We need to study and learn much more about In enlarging the scope of values, the person with dis-
this process, a process that is consonant with needed ability may initially be preoccupied with loss, going
changes in the health care system.”* through a period of mourning. Wright®’ viewed this
Finally, the use of occupation as therapy requires that process as unique to the individual in length and depth.
patient-agents learn to organize their lives to reduce the She observed that caregivers who are outsiders may
interference of the disability. This aspect requires a overestimate the degree of depression, whereas the
knowledge of how people may organize their time, insider, because his or her life depends on it, may have a
space, resources, and daily routines to achieve their strong need to cope and to discover and hold onto hope
goals. Almost all of the people who wrote about their and positive aspects of the situation. Some forces that
486 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

may keep the person in a mourning state are a need to that physique is less important than what one can do
hold on to the preferred state that was, the need for time and be°’ and so that new possibilities are discovered as
to absorb the changes, and perceptual emphasis on the asset values.
difference of disability, rather than on commonalities Although psychologists such as Wright®’ and Siller””
and continuity with the past. In contrast, the scope of emphasize adjustment to disability, | prefer the broader
values may be enlarged by the comparison of one’s state concept of adaptation with disability.*° This goal sug-
with other states (e.g., death or having other disabili- gests that the disability or handicap constitutes only ee
wo

ties); arousal of dominant values such as awakened one class of challenges among many others with which
pride or the need to deal with the problems at hand; the all human beings must deal to achieve a good fit with
satiation factor, whereby the emotions devoted to their environment. Adaptation places the person with
mourning are worn out and the person feels wrung out disability within the mainstream of humanity and ac-
and becomes ready for something new; and, finally, in- knowledges his or her resources gained by evolution. It
volvement in the necessities of daily living. places proper attention on the social barriers of handi-
Mourning may not always be protracted or intense, cap, rather than putting the entire responsibility on the
but it needs to be recognized as a healing period during person with disability.
which the wound is first anesthetized and then closed
gradually with some scarring. Wright®” observed that as Relationship Between Occupational
depression lifts, the sheer necessities of living contribute
Therapist and Patient-Agent
to needed changes in values. Bodily needs prod the
person with paraplegia; for example, trying to move or Occupational therapists are said to value a model of
sit up represents a “here and now” challenge. Mastering mutual cooperation’’’” as the ideal relationship with
the activities of daily living (ADL) helps enlarge the the patient-agent. This collaborative relationship is dif-
scope of values, although as Wright observed, “Master- ferent in style and substance from the traditional
ing ADL is surely not sufficient for enjoying a new lease physician-patient relationship in which the professional
on life.” Seeing films of other patient-agents who can is active and the patient is passive. What are some char-
manage the ordinary affairs of daily life may also acteristics of the occupational therapist/patient-agent
provide valuable support for the person who has re- relationship?
cently acquired disability.°? The occupational therapist's Peloquin** urged that occupational therapists be not
regulated optimism regarding the patient-agent’s poten- only competent but also caring. She observed that the
tial may contribute to a sense of the possible. profit-driven nature of health care provision often leads
As mourning subsides after sufficient time has to treatment of patients as mere customers and results
elapsed for its expression and the opportunity to engage in a budgeting of caring actions. Many patients com-
in activity, physique may still hold a potent value. Value plain about the impersonality and overreliance on tech-
changes may eventually override this potency through a nical methods they experience in the hospital or clinic.
shift in emphasis from appearance to personality or ca- The system values competence over caring because of
pability, reducing the effects of spread. three social trends: “(1) emphasis on rational fixing of
Containing disability effects involves understanding health care problems, (2) overreliance on methods and
that although a physical impairment is a fact that may protocols, and (3) a health care system driven by busi-
affect aspects of life, it does not affect all of life, and its ness, efficiency, and profits.” Peloquin challenged occu-
effects are not necessarily negative. Instead, “It involves pational therapists to recognize the extent to which
certain limitations in certain situations. The source of such social forces shape the manner in which they relate
limitation is due to barriers imposed by society and not to patients.
only to personal incapacity.”°” Despite the influence of the profit-driven nature of
Finally, transforming comparative-status values into health care provision, Peloquin** observed that occupa-
asset values is an important shift. Status values or judg- tional therapists can be both competent and caring.
ments of the worthiness of a person can be replaced by This goal may be accomplished by getting to know each
asset values. Asset values are attributes that, rather than patient as a person, gaining more power in the system
being competitive or judgmental, are seen as useful or (in order to change it), tempering that power with care,
intrinsically worthwhile. For example, being able to get seeking to understand patients’ feelings about their
around in one’s community while using a wheelchair illness, and, rather than acting as an authoritarian
may constitute an asset value without comparison with parent or technician, providing patients with opportu-
how other people do it or even how the person with dis- nities for control over their own lives. These recommen-
ability used to do it. Occupational therapists who dations seem congruent with valuing mutual coopera-
enable people to achieve their personal goals by discov- tion in planning and implementing OT. For example, if
ering and using their strengths and resources may help the occupational therapist wishes to elicit the patient's
people with disability to enlarge their scope of values so interests and goals, he or she must get to know each
 The Social and Psychological Experience of Having a Disability 487

patient as an individual. Providing opportunities for to the solution” to prod constructive thinking. For
control and self-direction is congruent with the ultimate example, why not employ more people with disability
goal of independent living in the community, whereas to work in OT departments, to pave the way for real par-
expecting compliance with professional orders may ticipation on the part of patient-agents?
seem more efficient but may subvert the learning of Some other suggestions for comanagement are that
habits of independence and self-sufficiency. patient-agents be given more active roles and responsi-
Schlaff,°* an occupational therapist, proposed that bilities in the day-to-day activities of the hospital, such
occupational therapists help redefine disability. This re- as administrative problem solving that planning the re-
definition would include working for changes in social habilitation program be a joint effort of patient-agents
attitudes and practices so that society would recognize and staff; that patient-agents be encouraged to make de-
the dignity and worth of people with disability, granting cisions and evaluate options (at every stage of the thera-
their rights to self-definition and self-direction. The oc- peutic process); and that professionals be given training
cupational therapist would strive to work in an inde- in encouraging participants to become comanagers.°” I
pendent living paradigm as a consultant, helper, and would add that patient-agents, too, may need training
advocate, rather than as a diagnostician or a prescriber in how to be comanagers and that OT, with its emphasis
and manager of treatment. “The consumer is or on self-directed occupations, is a likely learning labora-
becomes self-directed, and both the consumer and oc- tory for the development of such skills.
cupational therapist work to remove community barri- Wright®” cited research that supported the findings
ers and disincentives” for economic independence. '*’”* about long-term effects of comanagement. A group of
Wright's perspective®’ of the client as comanager in 100 patients with severe disability underwent rehabilita-
rehabilitation echoes the valuing of mutual cooperation tion in a hospital that encouraged their maximum in-
by OT. She observed that if the goal of rehabilitation is volvement and participation. One year after discharge,
independence and self-directedness, these must be nur- their status was compared with that of a control group
tured during rehabilitation. She proposed that coman- who had completed a conventional rehabilitation
agement could result in increased self-esteem, intrinsic program at the same hospital. The experimental group
motivation, and better potential for learning because showed a greater degree of sustained improvement in
the patient-agent is actively involved. Besides, health self-care and ambulation and a lower mortality rate.°”
care professionals need the knowledge that only the Wright®’ concluded with the conviction that when-
patient-agent can provide to recommend the best ever feasible, comanagement on the part of the client
course of action. Vash®* obviously knew herself better should be promoted. The therapist should support this
than her vocational counselor did when she decided to belief by showing that he or she likes the patient-agent,
become a psychologist rather than a secretary. If mutual by being friendly and caring, and by showing concern
cooperation is actualized by comanagement, what about the patient-agent’s welfare. Basic civilities such as
might impede this cooperation? ~ introducing oneself and addressing the recipient of
Wright®’ observed that the helping relationship itself services by name are also important. The professional
might get in the way because it conveys subservience person needs “to question at all times whether the client
and less power for the person being helped, reinforcing is at the helm” or whether the person is being “paternal-
the view that the expert has (or should have) the istically directed.”°” This last test is especially important
answers. The patient-agent might expect and want the for occupational therapists who may work in an envi-
professional to take complete charge. In some circum- ronment in which professional authoritarianism is the
stances, such as acute illness, this approach is necessary norm.
and commendable. However, the shifting of responsi- The therapeutic relationship of mutual cooperation
bility to the therapist can interfere substantially with the and comanagement extends to the interaction between
goals of rehabilitation and OT, especially those of even- the occupational therapist and parent when providing
tual unsupervised and independent living. Wright®” services to a child with disability. Parents need to learn
therefore asserted that “It is essential that the client be the skills of relating to a wide range of professionals to
brought into a directorship role as soon as feasible.” obtain needed services, often in an atmosphere that
Wright™ also acknowledged that helpers may have fosters an uneven distribution of power. Parents deal
needs that interfere with comanagement. They might with the diagnosis of a lifelong disability in highly indi-
need to assert themselves, display their knowledge, gain vidual ways, attempting a resolution between profes-
power, or achieve satisfaction in an authoritative role. sionally provided definitions and their everyday experi-
Wright also cited the increasing pressure for efficiency ences ofliving with a child who is not a clinical category
and cost containment in the system as a stumbling but a real person with both resources and problems.°°
block because comanagement may require more time Wright®’ viewed the parent as a key participant in the
and effort than would professional prescriptions. Her rehabilitation process. Parents offer knowledge about
advice was, “Don’t get stuck with the problem; move on their children, and their cooperation is essential. They
488 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

also may need help and support in accepting the child’s A study of mothers of children with cerebral palsy”
disability as nondevaluing and in learning to cope with uncovered frustration at the fact that their input was
the challenges awaiting them. sometimes disregarded by professionals and at the high
Wright cited three characteristics of a constructive rate of turnover of therapists and resulting lack of conti-
professional-parent relationship: parents need to feel nuity in the care of their children. These mothers viewed
that the professional is not working against them and occupational therapists as agents of change, sources of
that together they are seeking solutions; they need to information, and sources of support. Recommendations
believe that the professional likes their child and sees for occupational therapists working with such children
him or her as a special individual; and they need to included the following: developing active, respectful lis-
feel that the professional appreciates their struggle to tening skills; establishing a priority of therapist continu-
do the best they can for their child and that although ity; increasing mothers’ trust and confidence; providing
they may have shortcomings, they also have strengths expressions of optimism; and enabling children to
and ideas.°” receive as much therapy as possible.
Wright® proposed that rather than an exaggerated The relationship between the patient-agent and the oc-
valuing of independence, the goal of balancing inde- cupational therapist is both complex and sensitive. It em-
pendence, dependence, and interdependence is more phasizes the model of mutual cooperation and the full
helpful. Finding this balance is a necessity in all human participation of the service recipient in identifying goals.
relationships, and it is likely to ensure the proper em- It provides a safe space for growth and the learning of
phasis on warmth, love, and caring, which every child skills, as well as the discovery and nurturing of the patient-
needs. Independence often means making choices and agent's resources for adaptation and competence.
calling the shots while still depending on others for
some things. For example, a person might be independ-
New Models of Practice
ent in hiring or firing an attendant for some personal
care but dependent in needing a person to perform such The literature provides several examples of new models
services. of OT practice with patient-agents who have physical
There are many ways to achieve the balance among disability. These examples have been selected because
independence, dependence, and interdependence. For they appear congruent with both the values of the pro-
example, the balance might be enhanced by opportuni- fession and the experiences of people with disability;
ties for parents to observe other children with the same they foster positive attitudes and emphasize the
disability as that of their own child; parent discussion strengths and resources of the individual (such as adap-
groups, including brainstorming for problem solving; tive capacities) and employ occupation as therapy.
special techniques that make life easier at home; cre- Montgomery” described the OT hospital-based
ation of opportunities for specific experiences such as clinic as a resource reclamation center. The occupational
play and leisure activities; the judicious use of reading therapist discovers and augments the patient's potential
material to impart factual information and constructive strengths, which have developed over the three time
attitudes; and opportunity for the child to assume in- spans of evolution, development, and learning. As these
creasing responsibility for his or her own self-help be- resources are enhanced through activity, the patient-
havior and activities involving other people®’ (such as agent is helped to resume daily living in the real world
doing chores at home). of home and community—not as a disabled person, but
Occupational therapists can contribute to achieving as a person who is part of the mainstream of humanity
balance by working in partnership with the families of with the same needs and resources as anyone else.
children who have disability.'? For example, therapists In a classic article, Burke® explored the complex
can assist family members in setting aside space and issue of intrinsic motivation that cuts across all di-
time for play, leisure, and social activities in the home, mensions of OT practice. Her paper provides occupa-
as well as personal time and space for the primary care- tional therapists with useful information on coaching
giver, who is often the mother.'? (Housework, child patient-agents to engage in occupations and become
care, lack of financial resources, and fatigue often make self-directed originators rather than pawns. It ad-
such time out essential.) Other ways occupational ther- dresses creation of a just-right challenge from the en-
apists can help are by reducing environmental barriers vironment so that patient-agents may make their own
to the child’s participation in daily life; determining the adaptive response.
child’s strengths and resources (reducing negative Several models of OT practice are devoted to the de-
spread); enlarging the child’s scope of activities by pro- velopment of independent living skills for community
viding the necessary time, patience, and opportunity for living. Pendleton*’ found that occupational therapists
learning; and helping the family organize its time and working in rehabilitation centers frequently place much
resources to avoid frustrations and fatigue and to ensure more emphasis on technical goals (such as range of
participation in satisfying family activities. motion and muscle strengthening) than on the skills
 The Social and Psychological Experience of Having a Disability

needed for independent living. She urged occupational Burnett (now Burnett-Beaulieu)’ developed a nontra-
therapists to devote more time and energy to preparing ditional OT program for community college students
patient-agents for the capacity to function in their own with disability. The goals of the program are similar to
communities. those described by Cole,'* with a primary emphasis
The independent living movement’® arose to in- upon enabling students with disability to function suc-
crease the self-direction and ensure the civil rights of cessfully in their roles as college students. She reported
people with disability. The movement is based on the that this program often serves as a bridge between
idea that people with disability are the best judges of medical rehabilitation and life in the mainstream. It in-
their own needs. It emphasizes the goals not only of cludes three levels of skills: self-care, home management,
self-care, but also of mobility, employment, accessible and community mobility; social-recreational, cognitive,
living arrangements, out-of-home activity (to enlarge and classroom skills; and consumer rights skills. Burnett-
the environment), and consumer assertiveness. This Beaulieu’ posited that these skills can be grouped into a
movement appears compatible with the goals and hierarchy, with the first level basic to the achievement of
values of OT in its pursuit of equality of capability, en- the other two levels.
abling people to manage their own environments, in- Another OT program was developed by Jackson*° and
cluding their time, space, and energy. In some respects it colleagues. It was designed for adolescents with develop-
addresses the shortcomings of the medical and rehabili- mental disability. This Options program is provided at a
tation system, which may foster paternalistic depend- nonmainstreamed high school campus. The goal of the
ence on professionals. For example, one of the move- program is to enable students to make a successful tran-
ment'’s goals is to enable people with disability to take sition from school to community living through explor-
risks. “Without the possibility of failure, the disabled ing and broadening their choices about employment,
person* lacks true independence and the ultimate mark living arrangements, and social activities. It focuses not
of humanity, the right to choose for good or evil.”'° only on the skills and resources of the students, but also
Some models of OT practice reflect an emphasis on on the characteristics of their environments. Parents and
autonomy, choice, and the skills needed to increase family members are included as advocates. An important
people’s capacity for daily living. Several models are feature of the program is the learning of employment
based in community settings such as schools and in- skills in a supported work environment.
dependent living centers rather than in hospitals. The programs described in the preceding paragraphs
Community-based OT practice is likely to become more may stimulate occupational therapists to think about
common in the 21st century because of the high cost of and develop new models of community-based practice
hospital care and the need for long-term services for as a needed alternative to traditional hospital-based
those with chronic conditions. practice. This alternative is made more urgent by revolu-
Cole (now Cole-Spencer),'* an anthropologist and tionary changes in the health care system,” the needs
occupational therapist, described a program for teach- and experiences of people with disability,*~°~’”* and the
ing independent living skills. She observed that such values and traditions of OT.” We need many more such
skills must include planning and management and the models to achieve our potential contribution as a pro-
skills for self-direction rather than task-oriented behav- fession, to improve life opportunities for people with
ioral capabilities (such as basic self-care). Some skills disability, and to influence public attitudes toward
her program emphasized were communicating effec- people with disability in a positive way by emphasizing
tively to have one’s needs met; identifying and using the skills of such people and their similarities rather
resources; identifying and comparing choices; making than their differences as human beings.
decisions and setting priorities; committing oneself to
long-term goals and persisting until they are attained;
SUMMARY
developing sequential plans so that efforts produce a
cumulative effect and outcome; assessing risks and de- This chapter explores important questions about the
veloping judgment about risk taking; managing crises social and psychological experiences of having disability
such as medical or financial emergencies; and solving and what implications these experiences hold for OT
problems. These skills are needed by every human practice. I have suggested that the experiences of people
being and are not limited to people with disability. with disability are important resources for occupational
(They are even useful for students studying OT!) Such therapists in enabling us to broaden our vision and po-
skills are developed through engagement in self-directed tential contribution to the quality of life of the recipi-
activity rather than doing to or for the recipients of ents of our services. In widening our scope, we need to
service. take a systems view of each individual as one who inter-
acts with a unique environment by engaging in a
unique pattern of occupations, dictated by both culture
*”The disabled person” is De Jong’s terminology. and unique interests.
 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

4. Define stigma as described by Goffman.

5. Why is it essential for occupational therapists and
odel of Occupational Therapy other health professionals to consider the environ-
Definition Model Problem Power mentand social context of the person with disability?
6. To what extent is it valid to predict that a person
Capability Occupational Discover/ Human with disability will have low self-esteem? ee
Ca
a
a

therapy nurture system

7. How do a person’s interests, values, and goals influ-
potential acting on the
ence his or her reactions to acquiring disability?
for agency environment
: with a
8. Which aspects of Murphy’s daily life contributed to
repertoire his sense of autonomy and which diminished it?
of skills 9. What needs that could be met by occupational
therapy were revealed in the autobiographies of
people with disabilities?
10. What unmet needs for community living skills were
identified in Burnett and Yerxa’s study?
11. Differentiate between the terms “adjustment to dis-
When Reilly*? proposed her great hypothesis that ability” and “adaptation with disability.”
humans could influence the state of their own health 12. Discuss a new view of health as it applies to people
through the use of hands, mind, and will, she was con- with chronic conditions.
veying not only the essence of OT, but also perhaps a
much needed new view of health. Occupational thera- > 45 (eh) 3
pists work primarily with people having chronic condi-
tions who will never get well. Therefore we need to help 1. Please read the following description: “James, an ado-
society redefine health, not as the absence of impair- lescent of fourteen, has spastic cerebral palsy, fre-
ment or disease, but as the possession of a repertoire of quently relates to his siblings and peers aggressively, is
skills*” that enable a person to achieve his or her valued 2 years below grade level in reading and arithmetic,
goals. Thus people with irremediable impairments can and has parents who are rarely present at home.”””
still look forward to a healthy life. Stop here. What is your impression of James?
Returning to Bickenbach’s® three models of disability 2. Now add this: “James does an outstanding job on his
(Table 28-2), we can now add a fourth model, that of paper route, likes to write poetry and fantasy stories,
OT (Table 28-3). In this model the problem is the need has a close relationship with his uncle and aunt who
to discover and nurture the individual’s potential for live nearby, and is making steady progress in physical
agency. The definition is human capability, which em- therapy.” What is your impression of James?
phasizes people’s abilities to do what they want and 3. Relate this exercise to how occupational therapists
need to do and their opportunities to make choices. Al- assess or evaluate their patient-agents.
though it may be threatened or diminished by impair-
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Bile The MacNeil/Lehrer NewsHour, Public Broadcasting System, April 67. World Health Organization: International classification of impair-
4, 1994. ments, disabilities and handicaps: a manual of classification relating to
38. Magill-Evans JE, Restall G: Self-esteem of persons with cerebral the consequences of disease, Geneva, 1980, The Organization.
palsy: from adolescence to adulthood, Am J Occup Ther 45(9):819- 68. World Health Organization: I C I DH-2, Beta 2 Draft, Introduc-
pls), USE tion, Geneva, April 1999, The Organization.
59. Matsutsuyu JS: The interest checklist, Am J Occup Ther 23(4):323- 69. Wright B: Physical disability: a psychosocial approach, ed 2, New York,
2257 1969, 1983, Harper & Row.
492 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

70. Wright B, Fletcher BL: Uncovering hidden resources: a challenge 73. Yerxa EJ et al: An introduction to occupational science, a founda-
in assessment, Prof Psychol 13:229, 1982. tion for occupational therapy in the 21st century, Occup Ther
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Philadelphia, 1983, FA Davis. phia, 1982, Temple University Press.
72. Yerxa EJ: Dreams, dilemmas and decisions for occupational
therapy practice in a new millenium: an American perspective, Am
J Occup Ther 48:586, 1994.

a
Pain eVivteaentantt

LEARNING OBJECTIVES
Acute pain After studying this chapter the student or practitioner
Chronic pain will be able to do the following:
Gate control theory 1. Discuss the differences between acute and chronic
Pain behavior pain.
Pain assessment 2. Explain the gate control theory of pain
Pain intervention transmission.
3. Identify two pain syndromes.
> . Summarize two approaches to pain assessment.

5. Describe three approaches to pain intervention.

espite advances in medicine, rehabilitation, and a well-defined pain onset. It is associated with sympa-
technology, pain often affects an individual’s occupa- thetic nervous system arousal (e.g., increases in muscle
tional performance and quality of life. Pain may.coexist tone). Acute pain serves a biological purpose, directing
with a medical condition (e.g., arthritis) or rehabilita- attention to injury, irritation, or disease and signaling
tion procedure (e.g., stretching) or be the primary com- the need for immobilization and protection of a body
plaint (e.g., low back pain). Occupational therapists part.*° Fortunately, acute pain usually responds to med-
may suspect that pain is impeding the patient's progress ication, management, and treatment of the underlying
but feel unsure about how to approach evaluation and cause of pain.'®
intervention. This chapter defines pain, discusses pain In contrast, chronic pain may begin as acute pain or
transmission, describes common pain syndromes, out- may be more insidious and endure beyond the point at
lines evaluation procedures, and proposes intervention which an underlying pathological condition can be
strategies. identified. Increased sympathetic nervous system activ-
ity does not continue. Chronic pain does not appear to
serve a biological purpose. Chronic pain often produces
DEFINITION OF PAIN
significant changes in personality, lifestyle, and func-
Pain is an unpleasant sensory and emotional experience tional ability.'°
associated with actual or potential tissue damage or de-
scribed in terms of such damage.'® This definition
PAIN TRANSMISSION
conveys that pain is a subjective experience and multidi-
mensional. Individual variables such as mood, atten- Multiple theories of pain transmission have been pro-
tion, prior pain experiences, and culture are known to posed. To date, the gate control theory”° represents the
affect one’s experience of pain.”” single most important theoretical contribution to our
Most investigators agree in differentiating acute from understanding of pain. Melzack and Wall*® offered a
chronic pain, which is critical for selecting appropriate variation of the previously accepted specificity and
assessment and intervention strategies.*° Acute pain has pattern theories to explain pain transmission. They

493
494 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

suggested that pain is modulated by a “gating” mecha- aches do not seek treatment because they perceive the
nism in the spinal cord that can increase or decrease the problem as too trivial, have concerns about medica-
flow of nerve impulses to the brain. Sensory impulses tion side effects, and believe no adequate treatment is
travel to the dorsal horn along large- and small-diame- available.**
ter nerves associated with pain impulses. At the dorsal Migraines affect 17.6% of women and 5.7% of men.**
horn, these impulses encounter a gate believed to be A strong genetic predisposition exists for migraines.
composed of substantia gelatinosa cells. This gate, These headaches are characterized by recurrent pain
which may be presynaptic, postsynaptic, or a combina- episodes varying in frequency, duration, and intensity.
tion of both, can be closed, partially open, or open. If The pain is typically unilateral and pulsatile and may be
the gate is closed, pain impulses cannot proceed. If the accompanied by anorexia, nausea, vomiting, neurologi-
gate is at least partially open, pain impulses stimulate cal symptoms (e.g., photosensitivity and photophobia),
transmission or trigger cells in the dorsal horn which and mood changes (e.g., irritability).7*
then ascend the spinal cord to the brain and result in Tension-type headaches are the most common head-
pain perception. Once the pain impulses are perceived, ache disorder. Approximately 73% of adult Americans
higher central nervous system structures (brain stem, experience one or more headaches in a year.’ These
thalamus, cerebral cortex) can modify pain by influenc- headaches are typically of mild to moderate intensity.
ing T-cell activity. These structures can alter such factors The pain is bilateral and of a pressing character and does
as attention, memory, and affect, contributing to an in- not have associated symptoms. Precipitating headache
dividual’s unique pain perception. Pain management factors include situational stress, missed meals, sleep
therefore focuses on “closing the gate” through a combi- deprivation, and noxious stimuli (e.g., heat exposure).7*
nation of interventions.’”*”
Fordyce’* proposed a different perspective of pain
Low Back Pain
transmission based on learning theory. Pain behaviors
communicate to others that pain is being experienced. Low back pain (LBP) is the second most common pain
According to Fordyce, pain behavior can be classified as complaint among the adult population. Eighty percent
respondent if its onset was caused by antecedent tissue ir- of workers with LBP are absent from their jobs as a
ritation or damage. Respondent pain may be reduced by result of the pain.*° The incidence of LBP is influenced
medication, avoidance of specific activities, and certain by occupation; individuals employed in jobs that
body postures. As individuals in the patient's environ- involve heavy physical work and lifting are more suscep-
ment respond to these pain behaviors (e.g., moaning, tible to LBP than others.'°
grimacing, limping, and taking medications), the be- The most common causes of LBP are injury and
haviors may be reinforced. This contingent relationship stress, resulting in musculoskeletal and neurological
may continue after initial tissue irritation or damage has disorders (e.g., muscle spasm and sciatica). Back pain
subsided and may result in operant pain, with the also may result from infections, degenerative diseases
patient taking on a “sick role.” Intervention for operant (e.g., osteoarthritis), rheumatoid arthritis, spinal steno-
pain requires that reinforcement of operant pain behavy- sis, tumors, and congenital disorders.*° Once significant
iors be removed, so as to increase the occurrence of back pain has lasted for 6 months, the chance of return
healthy behaviors (e.g., functional activity). to work is only 50%.’
The above theories help to explain the variation in
pain perception and expression. These theories guide
Arthritis
the occupational therapist in multidimensional pain as-
sessment and intervention. Bonica* estimated that 24 million Americans experience
painful arthritis and 11.5 million are at least partially
disabled. Osteoarthritis is characterized by a progres-
PAIN SYNDROMES
sive, dull ache and swelling, typically affecting the
Pain is a primary reason for seeking health care. The fingers, elbows, hips, knees, and ankles. Osteoarthritis
evaluation and treatment of pain resulting from trauma, may be exacerbated by movement. Degeneration of the
disease, or unknown etiology are a significant health articular cartilage and swelling occur, typically affecting
care concerns. The following sections provide descrip- weight-bearing joints.**
tions of common pain syndromes. Rheumatoid arthritis usually has a slow insidious on-
set, characterized by aches, pains, swelling, and stiffness.
Any joint may be involved, but usually there is a sym-
Headache Pain
metrical pattern affecting the fingers, wrists, knees,
Recurrent headaches are one of the most common pain ankles, and cervical spine.'® This systemic disease in-
problems, affecting over 40% of the U.S. population. volves remissions and exacerbations of destructive in-
Over half of the population of persons with head- flammation of connective tissue, especially in the syn-
 Pain Management 495

ovial joints.** See Chapter 43 for more information on activities. Factors that may contribute to pain percep-
arthritis. tion and decreased functional performance should be
identified.
The occupational therapist performs a pain assess-
Reflex Sympathetic Dystrophy Pain
ment, viewing pain as a complex phenomenon in-
Reflex sympathetic dystrophy (RSD) pain is continuous volving psychological arousal, sensations of noxious
burning pain that results from trauma, postsurgical in- stimulation, tissue damage or irritation, behavioral
- flammation, infection, or laceration to an extremity, avoidance, and complaints of subjective distress. Pain is
causing a cycle of vasospasm and vasodilatation. Pain, conceptualized as an interacting cluster of overt and
edema, shiny skin, and coolness of the hand occur. An covert behaviors. Overt behaviors, or observable pain
individual experiencing RSD pain may also have exces- behaviors, are commonly targeted in evaluation. Such
_ sive sweating or dryness. Exacerbating pain factors pain behaviors include guarded movement, bracing,
include movement, cutaneous stimulation, and stress.'” posturing, limping, rubbing, and facial grimacing, all of
which suggest discomfort.’ The University of Alabama
Myofascial Pain Pain Behavior Scale”? is an example of a standardized
rating scale that is reliable, valid, and an easy method
Myofascial pain is a common pain syndrome defined by for documenting overt behaviors. Analysis of the
the presence of “trigger points” (localized areas of deep patient's overt behaviors before, during, and after inter-
muscle tenderness). Pressure on the trigger point elicits vention can provide valuable information about the
pain to a well-defined distal area. Myofascial pain may role of situational and learned factors in the individual's
result from sustained muscle contraction or from pain perception, as well as responses to treatment pro-
trauma to the head, neck, shoulder, or lower back cedures. Merskey~’ cautions practitioners not to provide
regions.'” treatment for reducing pain behaviors in lieu of at-
tempts at alleviating the pain. Evaluation that focuses
solely on pain behavior may lead to the inaccurate con-
Cancer Pain
clusion that pain behavior suggests malingering, lack of
Patients with cancer often have multiple pain problems motivation, or hypochondriasis.
that are frequently undertreated. Cancer pain is often Covert behaviors or self-reports of pain are also as-
chronic. In the initial and intermediate stages 30% to sessed because pain is considered to be primarily a sub-
45% of patients experience moderate to severe pain. jective phenomenon. The clinical interview focuses on
About 75% of patients with advanced cancer have pain. the patient's identification of pain location, frequency,
Cancer pain may result from tumor progression, inter- duration, intensity, onset, exacerbating and relieving
ventions (e.g., surgery, chemotherapy, and radiation), pain factors, past and present pain treatments, affect,
infection, or muscle aches when patients decrease their and functional performance. The single most reliable
activity.*” indicator of the existence and intensity of pain, and any
resultant affective discomfort, is the patient's self-
report.’ A Simple Descriptive Pain Intensity Scale, 0-10
Referred Pain
Numeric Pain Intensity Scale, or Visual Analog Scale
Referred pain is a common feature of low back and (Box 29-1) may be used in assessing self-reports of pain
myofascial pain. Referred pain is experienced within the intensity.’’ These instruments are easy to use and can be
same dermatome as the tissue damage, in a distant area adapted to the patient's vocabulary.
supplied by the same nerve, or in areas with no anatom- Activity performance is the primary focus ofthe occu-
ical correlation.'” pational therapist. The patient may complete daily ac-
tivity diaries as an assessment technique and outcome
measure. With this technique, hourly entries of time
EVALUATION spent in sitting, standing, reclining, and other produc-
A referral for occupational therapy (OT) evaluation is tive activities are recorded by the patient and may be
made when pain interferes with the patient's perform- corroborated by trained staff.'° The Brief Pain Inven-
ance of activities of daily living (ADL), work and other tory® is a reliable and valid instrument that may also be
productive activities, or leisure. Occupational therapists used to measure pain interference. Patients rate on an
focus evaluation on psychosocial and environmental ordinal scale how much their pain has interfered with
factors that contribute to the patient's pain perception general activity, mood, mobility, work, interpersonal re-
and on the effects of pain on functional performance. lationships, sleep, enjoyment oflife, self-care, and recre-
Before interventions are implemented, objective mea- ation (Box 29-2). This information may be helpful in
sures of occupational performance should be obtained determining baseline tolerance levels for specific func-
to assess the status of the patient and the value of those tional tasks that may be addressed in treatment.
 Simple descriptive pain intensity scale” 5 eee

No Mild Moderate —-Severe Very Worst pain

“= 0-10 Numerical pain intensity scale"

No Moderate Worst pain

pain pain possible

Visual analog scale (VAS)*

No Pain as bad
pain as it could
possibly be

From US Department of Health and Human Services, Acute Pain Management Guideline Panel: Acute pain management in adults: operative procedures. Quick refer-
ence guide for clinicians, AHCPR Pub No. 92-0019, Rockville, Md, 1995, US Government Printing Office.
*If used as a graphic rating scale, a |0-cm baseline is recommended.
TA 10-cm baseline is recommended for VAS scales.

A. In the past week, how much has pain interfered with your daily activities?
0-10 Numerical pain intensity scale

0 2 Ee see 6 To 8 9 0 = 4
No Unable to carry out -
interference any activities .

B. In the past week, how much has pain interfered with your ability to take part in recreational, social, and family activities?
0-10 Numerical pain intensity scale

0 | LOAD SAVARESE SS 6 7S Bo iy |
No Unable to carry out ~ 2
interference any activities ;

C. In the past week, how much has pain interfered with your ability to work (including housework)?

0-10 Numerical pain intensity scale

0 | 2 3 4 5 6 3 8 9 10
No Unable to carry out
interference any activities

From National Institutes of Health, National Institute of Child Health and Human Development, National Institute of Neurological Disorders and Stroke: Ongoing
research, (Grant No. | PO! HD/NS33988).
 Pain Management 497

INTERVENTION
tion is needed to ensure that the practitioner is compe-
The obligation to manage pain and relieve a patient's tent in the use of these modalities.** Both heat and ice
suffering is fundamental. Occupational therapy inter- are useful in reducing pain and muscle spasm of muscu-
ventions focus on increasing physical capacities, pro- loskeletal and neurological pathologies. Superficial heat
ductive and satisfying performance of life tasks and includes hot packs, heating pads, paraffin wax, flu-
roles, mastery of self and environment through activi- idotherapy, hydrotherapy, Hubbard tank, whirlpool,
ties, and education.'’ As the causes of pain are multifac- and heat lamps. The application of heat results in an in-
torial, so are the approaches to treatment. Typical pain crease in local metabolism and circulation. Vasocon-
interventions may include the following. striction occurs initially, followed by vasodilatation re-
sulting in muscle relaxation. The use of heat is indicated
in the treatment of subacute and chronic traumatic and
Medication
inflammatory conditions such as muscle spasms, arthri-
Medications are generally the treatment of choice for in- tis of the small joints of the hands and feet,'’?? ten-
dividuals experiencing acute pain. Occupational thera- donitis, and bursitis.
pists need to observe patients for possible drug reac- The use of heat is contraindicated in several in-
tions. To reduce possible discomfort from rehabilitative stances. Heat is not to be used for patients who have
procedures, practitioners should check that patients are acute inflammatory conditions, cardiac insufficiency,
adequately medicated. Aspirin and acetaminophen are malignancies, or peripheral vascular disease. Preexisting
frequently used in the treatment of mild pain (eg., edema may be aggravated. Heat may cause malignancies
headache) because of their high level of effectiveness, to spread. Paraffin therapy produces increased skin
low level of toxicity, and limited abuse potential. Non- tissue temperature while decreasing the temperature of
steroidal antiinflammatory agents have been used in the subcutaneous tissue.
treatment of arthritis and inflammation of a muscu- Cold can improve pain control by elevating the pain
loskeletal origin. Codeine is often used for moderate- threshold (i.e., the minimal level of noxious stimulation
intensity pain that has not responded adequately to at which the patient first reports pain). Local vasocon-
aspirin or acetaminophen. Morphine is the standard striction occurs in direct response to cold therapy
medication used in the relief of severe pain. The use (cryotherapy). When the area is subsequently exposed to
of opioid analgesics (a newer term for narcotics) in air, vasodilatation occurs. Cold applications also result
chronic nonmalignant pain has been controversial in decreased local metabolism, slowing of nerve con-
because of concerns about addiction.'° duction velocity, diminished muscle spasm secondary to
joint or skeletal pathological conditions and spasticity,
decreased edema, and lessened tissue damage. Cold can
Activity Tolerance be applied via packs, sprays, or a massage stick.77
Although a few days of rest may be indicated for acute There are several contraindications in the use of
pain, therapeutic activity is important for the treatment cryotherapy. Patients who are extremely sensitive may
of any underlying impairment. Activity levels are in- not be able to tolerate cold. If a patient has a history of
creased on a gradual basis, with the patient working to frostbite in the area to be treated, another modality must
“tolerance” (gradual increase in task demands such as be used. If a patient has Raynaud's disease, severe pain
duration, mobility, strength, and endurance), as op- may occur in the treated area. Cryotherapy is contraindi-
posed to “pain,” before a scheduled rest period. The cated in the very young and elderly because their ther-
patient should not initiate rest at the time of the pain moregulatory responses may not function sufficiently."
onset or exacerbation because this may reinforce pain
behaviors.'* A gradual increase in activity also lessens Transcutaneous Electrical
the likelihood of an exacerbation of pain. Fordyce'*
Nerve Stimulation
provides guidelines for the use of quota programs for
patients with chronic pain. Modalities (e.g., heat or Transcutaneous electrical nerve stimulation (TENS) is a
cold) may be applied before activity as a means of en- noninvasive pain relief measure that uses cutaneous
hancing functional performance. Patients are also most stimulation. A TENS unit consists of a battery-powered
likely to adhere to functional tasks that they find inter- generator that sends a mild electrical current through
esting”? electrodes placed on the skin at or near the pain site,
stimulating A fibers. Some success has been demon-
strated with using TENS to relieve acute and chronic
Therapeutic Modalities painful conditions caused by disease or injury of
Physical agent modalities (PAM) may be used by occu- nervous system structures or the skeleton, muscle pain
pational therapists as adjuncts to or preparation for pur- of ischemic origin in the extremities, and angina pec-
poseful activities. Appropriate postprofessional educa- toris.*
498 EVALUATION AND INTERVENTION: THE PERFORMANCE COMPONENTS

Body Mechanics and Posture Training tensed muscles feel, and release of the muscles and
Instruction in and rehearsal of proper body mechanics passive focusing on the sensations of relaxation. As the
and postures that will not increase the risk of low back patient learns to recognize muscle tension, he or she
injury or strain are essential for patients experiencing can direct attention to inducing relaxation.
both acute and chronic LBP.”* Practice in using the body Autogenic training is another means to inducing re-
safely and to maximum performance during routine laxation. This approach involves the silent repetition of
tasks in natural (i.e., home, work, or leisure) environ- self-directed formulas that describe the psychophysio-
ment is particularly important.*° The patient should be logical aspects of relaxation (e.g., “My arms and legs are
taught to avoid tasks or positions that do not allow warm”). The patient passively concentrates on these
balanced posture. For detailed guidelines on proper phrases while assuming a relaxed body posture, with
posture and body mechanic principles, please refer to eyes closed, in a quiet setting. Relaxation training has
Chapter 46. For patients in wheelchairs, the informa- been used successfully to modify a variety of chronic
tion on positioning in Chapter 14 is also important. pain complaints, including headache, LBP, myofascial
pain, arthritis, and cancer pain.'*
a

Energy Conservation, Pacing,

and Joint Protection Biofeedback
Instruction in energy conservation, pacing, and joint pro- Biofeedback is the use of instrumentation to provide
tection may be beneficial for achieving recommended visual or auditory signals that indicate some change in
amounts of rest during task completion, time spent phys- a biological process, such as skin temperature, as it
ically active, and balance between rest and physical activ- occurs. The signals are used to increase the patient's
ity. Patients, especially those with rheumatoid arthritis, awareness of these changes so that the changes may
are taught to use these strategies before they experience come under voluntary control. Biofeedback is based on
pain and fatigue so that occupational performance can the assumption that a maladaptive psychophysiological
continue as longas possible without pain and fatigue.'* response results in chronic pain. Despite the question-
able validity of this assumption, data do exist to support
the use of biofeedback for the treatment of headache
Splinting
disorders, LBP, arthritis, myofascial pain, and RSD."*
Splinting of the upper extremity may be necessary if con-
tractures or muscle imbalances occur. In RSD static
SUMMARY
resting splints may provide pain relief. Splint use is alter-
nated with tasks that require joints to be taken through Pain is a complex phenomenon. Occupational thera-
range of motion, since total immobilization could lead pists bring their understanding of anatomy, physiology,
to increased pain and dysfunction. Static resting splints kinesiology, psychology, and function to the compre-
maintain joint alignment, reducing inflammation and hensive evaluation and treatment of the patient with
pain during flare-ups of rheumatoid arthritis. Splints pain. Interventions focus on relieving pain, improving
that support the wrist in a functional position through- functional levels, and developing coping strategies. Data
out the day and night may be necessary for 4 to 6 weeks.* are needed to support the use of the OT interventions
People with compromised proximal joint mobility described in this chapter.
should use caution because orthoses may add to the
stress on proximal joints when the wrist is confined.*

Adaptive Equipment
Patients with acute LBP may use a back support for sta- Gating Mechanism:A neural mechanism in the spinal cord
bilization of the lumbar area and increased abdominal that acts like a gate to facilitate or inhibit the flow of nerve
pressure to improve postural alignment. This can result impulses from peripheral fibers to the central nervous
in decreased muscle spasm, reduced pain, and im- system.
proved ability to engage in occupations.**° Operant Pain: Pain behaviors that occur as responses to
cues in the environment.
Pain: An unpleasant sensory and emotional experience
Relaxation associated with actual or potential tissue damage.
Pain Behavior: Observable and measurable behaviors used
Relaxation training can be used to decrease muscle by the patient to communicate the experience of pain to
tension, which is believed to precipitate or exacerbate others. -
pain. Progressive muscle relaxation involves the system- Pain Contingent Rest: Breaks taken when the patient
atic tensing of major musculoskeletal groups for several experiences an aversive task.
seconds, passive focusing of attention on how the
 Pain Management

Case Stupy—C.A.
CA, a 34-year-old woman, was injured 5 months ago when strated poor body mechanics, poor posture, and mild shortness
catching a heavy weight while employed as an electrician. She of breath. C.A. offered numerous verbal complaints of pain and
sustained a lumbar strain. C.A. was initially treated at an emer- expressed fear that the pain would never go away.
gency room, where narcotics, muscle relaxants, heat application, Physical retraining and cognitive behavioral techniques were
~ and bed rest were prescribed. After persistent pain complaints, emphasized in intervention. C.A. participated in generalized mo-
she was given pelvic traction and TENS. C.A. has not returned to bility, strengthening, and cardiovascular endurance exercises as a
work since her injury and described her current lifestyle as means of increasing her occupational performance, minimizing
sedentary. She described her pain as severe (a‘'9” or “10” on an fatigue, and increasing feelings of well-being. Functional tasks were
10-point numerical scale, with ‘'0" = “no pain” and “10" = “pain incorporated into treatment. C.A. was instructed in how to
as bad as could be’) and almost constant. She identified pro- monitor her daily routine (e.g., balance of rest, relaxation, and ac-
longed sitting, standing, and ambulation as exacerbating pain tivity) and modify faulty thinking (e.g, catastrophizing, such as
factors. C.A. described occasional mild pain relief with ibuprofen thinking there is nothing that can stop the pain). Her daily routine
use and bed rest. Her self-report on the Brief Pain Inventory re- included progressive relaxation rehearsal.
vealed moderate to high pain interference with IADL and recre- C.A. made fair progress in her 4-week treatment program.
ational, social, and work activities. C.A. described using pain- She demonstrated normal mobility, strength, and endurance.
contingent rest and asking for assistance as the means of coping Bed rest during the day was eliminated. C.A. was taught proper
with her pain. posture and body mechanics and was observed to use them in
During evaluation, C.A. was found to have decreased active her routine activities. Her verbal complaints of pain remained un-
right shoulder range of motion and strength, decreased left lower changed, but she stated that she no longer felt the pain was con-
extremity strength, and muscle spasms throughout the left trolling her. C.A. was now ready to progress to a work-hardening
lumbar paraspinal muscles and into the left buttocks. She demon- program.

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25. Melzack R: The puzzle of pain, New York, 1973, BasicBooks. adults. In Neistadt ME, Crepeau EB, editors: Willard & Spackman’s
26. Melzack R, Wall PD: Pain mechanisms: a new theory, Science occupational therapy, ed 9, Philadelphia, 1998, Lippincott.
150(699):971-979, 1965. 305 Strong J: Chronic pain: the occupational therapist's perspective, New
PTE Merskey H: Limitations of pain behavior, APS 1:101-104, 1992. York, 1996, Churchill Livingstone.
28. Pedretti LW, Wade IE: Therapeutic modalities, In Pedretti LW, 36. Tyson R, Strong J: Adaptive equipment: its effectiveness for
editor: Occupational therapy: practice skills for physical dysfunction, ed people with chronic lower back pain, Occup Ther J Res 10:111,
4, St Louis, 1996, Mosby. 1990.
pXS). Richards JS et al: Assessing pain behavior: the UAB Pain Behavior B7e U.S. Department of Health and Human Services: Management of
Scale, Pain 14:393, 1982. cancer pain, Rockville, Md, 1994, AHCPR.
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 LEARNING OBJECTIVES
Active occupation After studying this chapter the student or practitioner
Egocentric realm will be able to do the following:
— Exocentric realm 1. Recognize the organizing concepts of occupational
Consensual realm genesis as they relate to active occupation.
Occupational genesis 2. Discuss the role of activity analysis in the selection
Physical agent modalities of therapeutic activity.
Purposeful occupation and activity 3. Understand the similarities and distinctions
Grading activity between therapeutic activity and therapeutic
Resistive exercise exercise.
Simulated or enabling activity 4. Identify the role of physical agent modalities in
Adjunctive modalities occupational therapy (OT) practice.
Isotonic exercise 5. Describe how grading activity heightens functional
Isometric exercise performance.
~~
Active exercise 6. Differentiate between the various types of
Passive exercise therapeutic exercise.
7. Describe how and why simulated and enabling
activities are used in practice.
8. Describe how and why adjunctive modalities are
used in OT practice.
9. Identify the requirements established by the
American Occupational Therapy Association for
the use of adjunctive modalities in OT practice.
10. Perform an activity analysis appropriate for
physical dysfunction.

ACTIVE OCCUPATION
When physical disability strikes and the ability to
Active occupations are the foundation of occupational perform occupational roles and activities becomes im-
therapy (OT) practice. Active occupations are those activ- paired, the occupational therapist helps patients regain
ities in which people engage as part of their life’s roles. their skills using active occupations as therapeutic tools
These include personal care, the constructional tasks that to stimulate performance.
involve the use of hand and mechanical tools, technolog- Active occupation is the primary therapeutic modal-
ical activities involving such tools as calculators, comput- ity of OT, designed both to stimulate function and to
ers, and electronics, games of various sorts, and voca- lead to improved function.
tional skills. They function together in a complex process, Engagement in activity enhances performance
stimulating growth and health throughout the life span. beyond the given task. Learning to perform one activity

to)Os
 504 OCCUPATIONAL THERAPY INTERVENTIONS

skillfully leads to skillful performance in other activi- modern.' Their competence is derived from entry-level
ties. Therefore active occupations are both the objectives through graduate education, specialty certification, con-
and the tools of practice. Activities are the means and tinuing education, and work experience. The scope of
the end to heightened performance. Whether related to practice is broad and addresses the continuum of treat-
personal care, work, or leisure, active occupations con- ment from acute care through advanced rehabilitation.
stitute an effective and substantial portion of any OT Therefore OT offers comprehensive services and chal-
program. lenges the OT practitioner to keep pace with new devel-
The needs and interests of patients guide the selec- opments in society and in practice.
tion of occupations used for therapy. These needs are
governed by the roles patients play in their worlds. As
PHILOSOPHICAL FOUNDATIONS
members of society, patients represent the societies in
which they perform activities, and the activities in
which they engage reflect their worlds. Patients’ needs
and interests are tied to the societies in which they live.
Patients must assume their personal and social obli-
gations to become effective members of society. To
assume these responsibilities, patients must acquire the e
ee
skills needed to perform their occupational roles. The
ae people assume _Teflect their odio For
These med stem fo theNort erjah Deweyss and
auiiingilalscarstaarn te perform i the other American philosophers of pragmatism whose
Therefore
the occupational ———— be ened work influenced the mental hygiene movement, which
with
a broad knowledge of activities and techniq in turn influenced the founders of the profession.'”
that may then
be used as tools of therapy
in a patient- Dewey's use of the terms purposive activity and active oc-
centered approach, Occupational therapists must un- cupation, along with his renowned concept of learning
derstand the roles and activities in which people engage through doing, are found in his text Democracy and Edu-
to perform their life’s tasks. As a consequence, occupa- cation,'* published in 1916 in Chicago, a year before the
tional therapists must be prepared to meet the chal- establishment of the National Society for the Promo-
lenges that ordinarily occur as people and societies tion of Occupational Therapy.
evolve and change.
Just as society changes and adapts with the invention
of new objects and methods, so do the activities pa-
Egocentric Realm —
tients use in their lives. Nowhere is this more readily ob- Intensive training in the motor, neurological, and per-
served than by examining the OT treatment environ- ceptual-cognitive components of performance prepares
ment. Just as the nature of activity has changed over the occupational therapist with a refined knowledge of
time as societies have evolved and adapted, the scope of what contributes to a patient's performance in all
OT’s treatment methods and modalities has changed aspects of the mind and body. Mind and body are seen
and broadened considerably over the years. as interactive and together govern performance.
When the field of OT became formalized in the early
1900s, the nature of human occupation was limited to
the scope of activities that had been developed up to Exocentric Realm,
that time. Consequently, the use of handicrafts and Occupational therapists have an equally refined under-
early industrial tasks guided activity at the outset of the standing of the material world in which people live, act,
profession. Although commonly described as crafts, and react. Textures, weights, direction, location, time,
these activities can be viewed from an anthropological and other objective means regulate performance in the
perspective, representing the times in which they were world. A person functions within a real world filled with
developed and in which they met people's personal and objects and environments that must be manipulated in
social needs. But times changed, and along with these one manner or another. Occupational therapists are
changes society developed new and different occupa- expert in adapting the tangible and durable elements of
tions, requiring occupational therapists to expand their the world to enhance function.
skills to incorporate activities and techniques of the
modern era.
Today's occupational therapists are qualified and Consensual Realm,
competent in the use of a wide variety of therapeutic Occupational therapists also bring their knowledge of
occupations and modalities, both traditional and the effect of society on individual and group perform-
 Therapeutic Occupations and Modalities io)Ue)

ance. This knowledge is used to enhance patients’ func- therapists use various modalities to integrate these three
tion by effectuating the roles they play in their social realms, thus enhancing patient performance and en-
worlds. Recognizing and valuing the sociocultural abling patients to meet life needs.
aspects of occupation and their implications for patient
performance contribute to the occupational therapist's
EVOLVING PRACTICE
knowledge base.
Just as society and its occupations have evolved and
continue to evolve, occupational therapy practice has
Relationships Among Realms
evolved. New media and modalities have emerged to
enable patients to become skilled in functional per-
formance. In addition to therapeutic exercise and activ-
ity and the facilitation and inhibition techniques associ-
ated with the sensorimotor approaches to treatment,
therapists have added adjunctive therapies to their
pists use one or more of these realms to influence or repertoires, all designed to enhance patients’ perform-
heighten performance in impaired aspects (Fig. 30-1). ance in purposeful occupation.
For example, a splint (exocentric) can be used to stabi- Although use of adjunctive therapies such as physi-
lize a wrist to reduce pain (egocentric), enabling the cal agent modalities is not considered to be an entry
patient to prepare a meal for the family (consensual). A level skill,** some therapists have become increasingly
walker can be adapted so a patient can carry her knitting skilled in the application of these therapies. These
(exocentric), allowing her to prepare gifts for her grand- modalities traditionally belonged to the field of physi-
child (consensual) and heighten her feelings of efficacy cal therapy but have since entered the realm of OT prac-
(egocentric). tice. They are used by trained occupational therapists to
enhance the development of the individual's ability to
perform purposeful occupation, the primary objective
Development and Evolution
of OT. Their use by occupational therapists should be
The interaction among these three realms represents a limited to the role of an adjunct to purposeful active
developmental continuum. They influence one another occupation.
throughout the life span in a process defined as occu-
pational genesis.'° Interactions among physical and
mental capacities, the tangible world, and the roles
people play in their worlds are reflected and governed
by the activities in which people engage bene
their lives.
Intensive preparation in these three realms and their (eityoy-ta(e)ar-lis Mat-var-l>)Van (oleh Talons
interaction constitute the education and preparation of
the OT practitioner and guide the therapist in treatment.
Modality: The employment of, or method of employment of, a
With this comprehensive foundation, occupational therapeutic agent (Webster's New World College Dictionary,
edition 2).' Traditionally, the modalities of occupational
therapy were its crafts. The term has grown to be
understood more broadly and defines active occupation as
the primary therapeutic modality of occupational therapy.
The term “modality” also includes both media and
methods." Media are the means by which therapeutic
effects are transmitted. For example, media can include a
variety of objects such as an article of clothing, a vestibular
ball, or an adapted tool. Methods are the steps, sequence, or
approaches used to activate the therapeutic effect of a
medium, such as the movements required in the creation of
a macramé plant hanger to heighten shoulder flexion or
reduce edema, or the movements used with the vestibular
FIG. 30-1 ball to effect the desired motor responses. The modalities,
The egocentric (E), exocentric (X), and consensual (C) realms of media, and methods of occupational therapy are variable in
occupational therapy’s knowledge base are related. (From Breines their application and require considerable expertise to
EB: Occupational therapy from clay to computers: theory & practice, select, modify, adapt, and apply to elicit therapeutic effects.
Philadelphia, 1995, FA Davis.) a a ae a
1016) OCCUPATIONAL THERAPY INTERVENTIONS

PURPOSEFUL OCCUPATION
to psychosocial, physical, and developmental dysfunc-
AND ACTIVITY tion, as well as to health maintenance.*
One of the first principles of OT, stated by Dunton in Purposeful activity has both inherent and therapeutic
1918, is that there must be some useful end to occupa- goals. For example, sawing wood (Fig. 30-2) may have the
tion for it to be effective in the treatment of mental and inherent goal of securing parts for construction of a book-
physical disability.** This principle implies that occupa- shelf, whereas the therapeutic objectives may be to
tion has a purpose and that purposeful activity has an au- strengthen shoulder and elbow musculature. The con-
tonomous or inherent goal beyond the motor function scious effort of the patient is focused on the ultimate
required to perform the task.® An individual engaged in outcome of the project and not on the movement itself.®
purposeful activity focuses attention on the goal rather The patient directs and is in control of the movement, yet
than the processes required to reach the goal.” that control is ordinarily outside of conscious awareness
Conversely, nonpurposeful activity has been defined as the patient focuses on the goal aspects of performance.
as activity that has no inherent goal other than the motor In fact, performance outside of conscious awareness dis-
function used to perform the activity.** The person per- tinguishes OT’s therapeutic effectiveness. Performance
forming a nonpurposeful activity is likely to be focused that is deliberate is not effective in producing enhanced
on the activity process or movements rather than a func- levels of skill. To enhance skill building, performance
tional or meaningful goal. Therapeutic exercise and en- must become automatic.'? Automatic performance
abling activities such as moving cones and stacking serves as a subskill for more advanced performance. For
blocks cannot be considered purposeful activity when example, Huss~’ suggested that the child who must attend
they have no purpose for the patient. This statement does to sitting is unable to focus on the task performance that
not imply that such media have no place in the treatment automatic sitting would ordinarily enable. Consequently,
continuum. Yet treatment must consider the inherent oc- the child cannot engage in active occupations essential to
cupational objectives of the patient as both tools of treat- growth and the development of social roles.
ment and skills to be acquired, for these are more readily The importance of purposeful activity is readily ob-
tied to purpose, meaning, and therapeutic value and con- served in goal-directed performance. As the patient
stitute the occupational nature of therapy. becomes absorbed in the performance of any given ac-
Purposeful activity is the cornerstone of OT, and is its tivity, affected parts are used more naturally and with
primary treatment modality.**° In a position paper on less fatigue.*’ Concentration on motion has a detrimen-
purposeful activity, the American Occupational Therapy tal effect on that motion, and muscles controlled by
Association (AOTA) defined the term as “goal-directed conscious attention and focused effort fatigue rapidly.
behaviors or tasks that comprise occupations. An activ- The value of goal-oriented effort in purposeful tasks is
ity is purposeful if the individual is an active, voluntary clear. It is of greater therapeutic value to focus attention
participant and if the activity is directed toward a goal on an activity of interest to the patient and its inherent
that the individual considers meaningful.”” The unique- goal than on the muscles or motions being used to ac-
ness of OT lies in its emphasis on the extensive use of complish the activity.®
purposeful or meaningful activity. This emphasis gives A number of studies have shown the efficacy of pur-
OT the theoretical foundation for its broad application poseful activity.*® Steinbeck** demonstrated that patients
performing purposeful activity perform for a longer
period than when they are performing nonpurposeful ac-
tivity. A study of motivation for product-oriented versus
non-product-oriented activity by Thibodeaux and Lud-
wig’” indicated the need to determine the patient's level
of interest in the process and the product and to incorpo-
rate his or her image of the activity in treatment planning.
Rocker and Nelson** found that not being allowed to
keep an activity product can elicit hostile feelings in
normal subjects, demonstrating the importance of tangi-
ble productivity for sustaining people’s interest. Yoder,
Nelson, and Smith’ studied the effects of added-purpose
versus rote exercise in female nursing home residents. The
added-purpose exercise resulted in significantly more
movement repetitions than did rote exercise.°* These
studies suggest that goal-directed, purposeful activity in-
creases motivation for paiticipation in sustained activity
FIG. 30-2 and can therefore be assumed to heighten the willingness
Sawing wood to strengthen shoulder and elbow musculature. of patients to engage in therapeutic activity.
 Occupations and Modalities 507

When a treatment plan is being developed, the inher- taxes tor granted until some dysfunction disrupts their
ent goals of the activity, the patient's level of interest in performance. It is the role of the occupational therapist
the activity, and the meaning of the activity and its to adapt activity so that patients can resume their ability
product are important considerations in the ultimate ef- to perform life’s tasks. OT is founded on the notion
fectiveness of the media and methods selected for treat- that dysfunction can be modified, altered, or reversed
-ment. Purposeful activities are used, or adapted for use, toward function through engagement in activities of
to meet one or more of the following therapeutic objec- real life. Cynkin and Robinson'® make several assump-
tives: to develop or maintain strength, endurance, work tions about activities that are summarized as follows:
tolerance, range of motion (ROM), and coordination; 1. A wide variety of activities are important to the indi-
to practice and use voluntary, automatic movement in vidual. Activities fulfill many of a person’s needs and
goal-directed tasks; to provide for purposeful use of and wants, and they are essential to physical and psy-
general exercise to affected parts; to explore vocational chosocial growth and development and the attain-
potential or train in work skills; to improve sensation, ment of mastery and competence.
perception, and cognition; to improve socialization 2. Activities are socioculturally regulated by the values
skills and enhance emotional growth and development; and beliefs of the culture that defines acceptable be-
and to increase independence in occupational role per- havior for groups of people in the culture. Whether a
formance. It is recognized that some of these objectives society is rigid or flexible in its interpretation of ac-
alone might not be considered purposeful unless they ceptable behaviors for various groups, at some point
relate to function. Arts, crafts, games, sports, leisure, self- deviations in behavior or activity patterns are deemed
care, home management, purposive mobility, and work- unacceptable.
related activities are considered purposeful activities. 3. Activity-related behavior can change from dysfunc-
tional toward more functional. Persons can change
and desire change.
OCCUPATION AND HEALTH 4. Changes in activity-related behavior take place
OT was founded on the concept that human beings through motor, cognitive, and social learning.'°
have an occupational nature. That is, it is natural for
humans to be engaged in activity, and the process of
Assessment of Occupational
being occupied contributes to the health and well-being
Role Performance
of the organism.*'”’'°* Activity is valuable for the
maintenance of health in the healthy person and for the The therapist should establish the patient's occupa-
restoration of health after illness and disability. When tional goals and needs, as described in Chapter 12. A
the patient engages in relevant, meaningful, and pur- top-down, client-centered approach is recommended.
poseful activity, change is possible and dysfunction is Identifying appropriate and meaningful therapeutic ac-
reversible.'® The occupational therapist acts as facili- tivities should begin with obtaining and analyzing the
tator of the change process.'” Therefore physical dys- patient's occupational history and interests.”°
function can be ameliorated when the patient partici- The Canadian Occupational Performance Measure~’
pates in goal-directed (purposeful) and thus therapeutic and the Activity Configuration'” are two examples of
activity.® occupational performance assessments. See Chapter 12
The value of purposeful activity lies in the patient's for more information about assessing occupational per-
simultaneous mental and physical involvement. Activity formance.
provides the exercise needed to help develop the use of
affected parts and also provides an opportunity to meet
ACTIVITY ANALYSIS
emotional, social, and personal gratification needs.*’*’
Cynkin and Robinson’® pointed out that, for the attain- Careful activity analysis is essential to the selection of ap-
ment of optimal function and health, the human being propriate treatment activities. It should yield informa-
must be consciously involved in problem-solving and tion about various activities as intervention strategies for
creative activity, processes that are linked with the use of physical dysfunction and health maintenance. Activities
the hands.'° should be analyzed from three perspectives: the contri-
Virtually all occupational performance involves the butions of the person or actor, the effects of the physical
hands or requires the substitution of methods that sim- environment, and the implications ofthe social environ-
ulate the use of hands. One example of an activity ordi- ment. The therapist should recognize that these three el-
narily performed by the hands is the use of a computer- ements are inextricable and form the context for treat-
driven environmental control unit operated by a puff- ment. The importance of context in treatment is widely
and-sip mechanism. recognized throughout the profession.°
The activities that form the pattern of a person’s life, Comprehensive guides to activity analysis have been
that are performed routinely and automatically, are developed by a number of theorists"’°°” and can serve
jo)Os) OCCUPATIONAL THERAPY INTERVENTIONS

as useful resources. A guide to activity analysis specifi- (PNF) approach, it is important to incorporate PNF pat-
cally relevant to practice in physical dysfunction follows terns in the activity or to select activities that use these
on page 526. patterns naturally. For the neurodevelopmental (Bobath)
approach, postures and movements that inhibit abnor-
mal reflexes, reactions, and tone are important. These
Principles of Activity Analysis
and other sensorimotor approaches and their applica-
Activities selected for therapeutic purposes should be tions to activity are discussed in Chapters 32 through 36.
goal directed; have some meaning to the patient to meet Analysis of the perceptual and cognitive require-
individual needs in relation to social roles; require the ments of the activity is particularly important for pa-
mental or physical participation of the patient; be de- tients with upper motor neuron disorders because these
signed to prevent or reverse dysfunction; develop skills functions are often disturbed. It is important for the
to enhance performance in life roles; relate to the therapist to select activities that not only meet the re-
patient's interests; be adaptable, gradable, and age ap- quirements for motor performance but also can be per-
propriate; and be selected through knowledge and pro- formed with some success.
fessional judgment of the occupational therapist in Regardless of diagnosis or therapeutic approach, ac-
concert with the patient.7? A comprehensive activity tivity analysis should include the contextual aspects of
analysis includes all aspects of performance that are po- performance. The tangible environment and the social
tentially elicited by specific activities and serves to reveal environment dictate occupational performance to the
their potential for therapeutic application. same extent that physical and mental capacities do, and
they must be considered in developing a treatment
plan.
THERAPEUTIC APPROACHES
A variety of therapeutic approaches are available to ADAPTING AND GRADING ACTIVITY
occupational therapists. Although these approaches
Adaptation of Activity
differ in their emphasis, all are consistent with an occu-
pational approach to treatment. Aspects of activity It may be necessary to adapt activities to suit the
analysis relevant to various therapeutic approaches are special needs of the patient or the environment. An
listed below. activity may need to be performed in a special way to
accommodate the patient's residual abilities—for
example, eating using a special splint with a utensil
Biomechanical Approach
holder fitted to the hand (Fig. 30-3). An activity may
The biomechanical approach to treatment is likely to be need to be adapted to the positioning of the patient or
used in the treatment of lower motor neuron and ortho- to the environment—for instance, by setting up a
pedic dysfunctions. Improvements in strength, ROM, special reading stand and providing prism glasses to
and muscle endurance are the goals of OT for such dys- enable a patient to read while supine in bed. The
functions. Thus the emphasis of activity analysis is on
muscles, joints, and motor patterns required to perform
the activity. Steps of the activity must be identified and
broken down into the motions required to perform
each step. ROM, degree of muscle strength, and type of
muscle contraction to perform each step should be
identified. The activity analysis format at the end of this
chapter is based on the biomechanical approach.

Sensorimotor Approach
Sensorimotor approaches to treatment are likely to be
used for upper motor neuron disorders such as cerebral
palsy, stroke, and head injury. Activity analysis for these
dysfunctions should focus on the sensory perception of
the patient and the movement patterns required in the
particular treatment approach. The therapist must also
consider the effect of the activity on balance, posture,
muscle tone, and the facilitation or inhibition of abnor- FIG. 30-3
mal reflexes and movements. For example, ifthe therapist Eating using a special splint with a utensil holder fitted to the
is using the proprioceptive neuromuscular facilitation hand.
 Therapeutic Occupations and Modalities

problem-solving ability, creativity, and ingenuity of oc-

cupational therapists in making adaptations are some
of their unique skills.
The therapist should remember that for adaptations
to be effective, the patient must be able to use them in a
comfortable position. The patient must understand the
need and purpose of the activity and the adaptations
and be willing to perform the activity with the simple
modifications. Peculiar and complicated adaptations
that require frequent adjustment and modification
should be avoided.*"’4”

Grading of Activity
Grading an activity means pacing it appropriately and
modifying it for the patient's maximal performance. If
movement patterns or degree of resistance cannot be
attained when the activity is performed in the usual
manner, simple modifications may be made. The pa-
tient usually accepts changes if they are not complex
and do not require strained and unnatural motions.
The novice is cautioned that the value of the activity
may be diminished if it is designed to be performed
with artificial movements or excessive resistance. Such
methods discourage participation and interfere with
the development of coordination.*°*’ They also re-
quire that the patient focus on movements rather than
on the goal of the activity, which reduces satisfaction
FIG. 30-4
and defeats the primary purpose of purposeful activity
Weight attached to the wrist increases resistance during needle-
as described earlier. The skilled occupational therapist work or leatherwork.
adapts and grades activities so that they are easily ac-
cepted by the patient and provide the “just right” de-
mand upon performance.
Activities may be graded in many ways’ to suit the
patient's needs and the treatment objectives. Activities fasten the hand to a tool or equipment handle to assist
can be graded for increasing strength, ROM, endurance grip strength and allow arm motion.
and tolerance, coordination, and perceptual, cognitive,
and social skills. Range of Motion
Activities for increasing or maintaining joint ROM may
Strength be graded by positioning materials and equipment to
Strength may be graded by increasing resistance. demand greater reach or excursion of joints or by adapt-
Methods include changing the plane of movement from ing equipment with lengthened handles to facilitate
gravity eliminated to against-gravity, by adding weights active stretching.
to the equipment or to the patient, using tools of in- An example of a simple adaptation is positioning a
creasing weights, grading the texture of the materials weaving project in a vertical position to achieve the
from soft to hard or fine to rough, or changing to desired range of shoulder flexion while working. As the
another more or less resistive activity. work progresses, the activity itself establishes increased
For example, a weight attached to the wrist by a strap demands on active range. Positioning objects, such as
increases resistance to arm movements during needle or tiles used in a mosaic tile project, at increasing or de-
leatherwork (Figure 30-4). A pulley-and-weight system creasing distances from the patient changes the range
can be attached to an inclined plane sanding board to needed to reach the materials (Fig. 30-5). Tool handles
increase resistance to the biceps when the sanding block such as those used in woodworking may be increased in
is pulled downward, as the patient sands a cutting board size by using a larger dowel or by padding the handle
for use in one-handed cutting. Springs may be used to with foam rubber to accommodate limited ROM or
increase resistance on a block printing press. When to facilitate grasp (Fig. 30-6). Reducing the amount of
grasp strength is inadequate, grasp mitts may be used to padding as range increases can effect grading.
 OCCUPATIONAL THERAPY INTERVENTIONS

Endurance and Tolerance

Endurance may be graded by moving from light to
heavy work and increasing the duration of the work
period. For example, an initial household task of
folding paper napkins can be graded to sorting heavier
and heavier objects, such as the task of sitting to sort
kitchen utensils, and then grading to a standing posi-
tion to organize tools on a pegboard. Standing and
walking tolerance may be graded by increasing the time
spent standing to work, perhaps at first at a stand-up
table (Fig. 30-7), and increasing the time and distance
spent in activities requiring walking, perhaps including
home management and workshop activities.
Conditions that are progressively degenerative, such
as muscular dystrophy, multiple sclerosis, or Parkin-
son’s disease, may require grading endurance in a nega-
Fig. 30-5 tive direction to accommodate a diminishing physical
Placing objects at alternate distances changes the range needed to condition. In such cases it is advisable to change the ac-
reach materials. tivity to one that requires less effort rather than reducing
the demand of an existing project. The latter can have a
negative psychological effect if the patient readily recog-
nizes the reduction in performance capacity.

FIG. 30-6 FIG. 30-7

The size of tool handles may be increased by padding the handle Stand-up table with sliding door, padded knee supports, and back-
with foam rubber. rest.
 Therapeutic Occupations and Modalities 511

Coordination 3. Activities should allow for one or more kind of

Coordination and muscle control may be graded by de- grading, such as for resistance, range, coordination,
creasing the gross resistive movements and increasing endurance, or complexity.7'"*”
the fine controlled movements required. An example is The type of exercise that is needed must be consid-
progressing from sawing wood with a crosscut saw to ered when choosing an activity. Active and resistive ex-
using a coping saw to using a jeweler’s saw. Dexterity ercises are most often used in the performance of pur-
and speed of movement may be graded by practice at in- poseful activity.*” Requirements for passive and active
creasing speeds once movement patterns have been assisted exercise are harder (although not impossible)
mastered through coordination training and neuromus- to apply to purposeful activities, for example, bilateral
cular education. sanding or bilateral sponge wiping. Other important
considerations in the selection of activity are the objects
Perceptual, Cognitive, and Social Skills and environment required to perform the activity; safety
In grading cognitive skills, the therapist can begin the factors; preparation and completion time; complexity,
treatment program with simple one- or two-step activi- type of instruction, and supervision required; structure
ties that require little judgment, decision making, or and controls in the activity; learning requirements;
problem solving, and progress to activities with several independence, decision making, and problem solving
steps that require some judgment or problem-solving required; social interaction potential and communica-
processes. A patient in a lunch preparation group may tion skills required; and potential gratification to the
butter bread that has already been lined up on the work person.
surface. This task could be graded to lining up the bread, If an activity is selected in which the patient has an
then buttering it and placing a slice of lunch meat on it, interest, the patient is more likely to experience suffi-
and, ultimately, to making sandwiches. cient satisfaction to sustain performance. The therapist's
For grading social interaction, the same treatment job is to guide the patient to suitable therapeutic activi-
may begin with an activity that demands interaction ties at just the right level of challenge so that the patient
only with the therapist. The patient can progress to will achieve satisfaction by engaging in the activity. This
activities requiring dyadic interaction with another satisfaction is an important characteristic of intrinsic
patient and, ultimately, to small group activities. The motivation. Thus purposeful activities both meet the re-
therapist can facilitate the patient's progression from quirements for motor performance and can be per-
the role of observer to that of participant and then to formed with success.
leader. Concomitantly, the therapist decreases his or her
supervision, guidance, and assistance to facilitate more
SIMULATED OR ENABLING ACTIVITY
independent functioning in the patient.
The clinical environment may not be fully equipped to
meet the exact occupational needs of all patients. When
SELECTION OF ACTIVITY this is the case, it may be necessary to simulate appro-
In the treatment of physical dysfunction, activities are priate active occupation by adapting the environment
usually selected for their potential to improve both sen- or activity to meet the patient's needs and retain his or
sorimotor and psychosocial components in order to her interest.
ensure that patients’ motivation to engage in activity is Occupational therapists have developed a variety of
sustained. Activities selected for the improvement of methods to simulate active occupation. A number of
physical performance should provide desired exercise or these activities were devised initially from equipment
purposeful use of affected parts. They should enable the and found materials used in other activities. For
patient to transfer the motion, strength, and coordina- example, a common item found in every OT clinic in its
tion gained in adjunctive and enabling modalities to earliest days was empty cones that had held the thread
useful, normal daily activities. If activities are to be used that was used to warp looms. Because of their availabil-
for physical restoration, they should have certain char- ity, these cones were adapted for many uses in the clinic.
acteristics, as follows: Some activities that were devised are moving a series of
1. Activities should provide action rather than merely cones from one side of a tabletop to the other, or stack-
the position of involved joints and muscles; that is, ing them, to increase ROM in the shoulder along with
they should allow alternate contraction and relax- grasp. Cones can also be used to train gross coordina-
ation of the muscles being exercised and allow pa- tion and a combined (out of synergy) movement
tients to course through their available ROM. pattern in the Brunnstrom approach, discussed in
2. Activities should provide repetition of motion. That Chapter 34.
is, activities should allow for a considerable number Another devised activity is the simulated inclined
of repetitions of movement patterns sufficient to be sanding board (Fig. 30-8). The sanding board was de-
of benefit to the patient. signed to incline wood while the wood was being
 OCCUPATIONAL THERAPY INTERVENTIONS

FIG. 30-8
Inclined sanding board used to sand wood.

sanded. Therapists began using the board, without the Fig. 30-9
wood, to exercise muscles of the elbow and shoulder. Puzzles and other perceptual and cognitive training media are used
Without the wood there is no end product and thus no on the tabletop. (Courtesy of North Coast Medical, Morgan Hill,
inherent purposefulness. However, incorporating wood Calif.)
for a project can turn this activity from a simulated to a
meaningful one.
Puzzles and other perceptual and cognitive training
media are used to train patients in visual perceptual
functions, motor planning skills, memory, sequencing,
and problem solving, among other skills (Fig. 30-9).
Clothing fastener boards and household hardware
boards may provide practice in the manipulation of
everyday objects before the patient is confronted with
the real task (Fig. 30-10). At a higher level of technolog-
ical sophistication, commercial work simulators (see
Chapter 16) and computer programs are used to train
patients in physical and cognitive skills.
Although many of these items are readily available in
clinics, the nature and purpose of occupational therapy
are best met when the patient can be engaged in an ac-
tivity in which he or she finds purpose and meaning.
The therapist should take into consideration the needs
and interests of the patient in selecting activities, rather
than relying on available objects that meet only physical
needs.
Enabling activities are considered nonpurposeful
and generally do not have an inherent goal, but they
may engage the mental and physical participation of
the patient. The purposes of engaging in enabling ac-
tivities are to practice specific motor patterns, to train
in perceptual and cognitive skills, and to practice sen-
sorimotor skills necessary for function in the home FIG. 30-10
and community. Indeed, many enabling modalities Boards built with household fasteners are simulations used for
used in OT practice facilitate perceptual, cognitive, and practicing manipulation and management of common household
motor learning. Such activities may be appropriate for hardware. (Reprinted with permission, S & S Worldwide, adapt-
the skill acquisition stage of learning, when the patient Ability, 1995.)
 Therapeutic Occupations and Modalities 513

is getting the idea of the movement and _practicing ally exclusive, yet the principles of exercise had been
problem solving. Practice should be daily or frequent applied to purposeful activity from early in the history
and feedback given often so that errors are decreased of OT. Exercise and activity are complementary in the
and skills refined to prepare for performance of real- treatment continuum, and both may be used in a single
life purposeful activity. These activities should be used treatment plan. However, if only pure exercise is used,
judiciously, and their place in the sequence of treat- the patient has not received OT.*°
ment and motor learning should be well planned. When used by occupational therapists, therapeutic
They may be used along with adjunctive modalities exercise should be used to remediate sensory and
and purposeful activities as part of a comprehensive motor dysfunction, augment purposeful activity, and
treatment program. prepare the patient for performing a functional occu-
pation.
A comprehensive understanding of the principles of
ADJUNCTIVE MODALITIES
exercise is basic to the application of therapeutic activ-
Adjunctive modalities may be used as a preliminary to ity. Therapeutic exercise is defined as any body move-
purposeful activity. When used by the occupational ment or muscle contraction to prevent or correct a
therapist they are meant to prepare the patient for occu- physical impairment, improve musculoskeletal func-
pational performance. Examples of adjunctive modali- tion, and maintain a state of well-being.'**’ A wide
ties are exercise, orthotics, sensory stimulation, and variety of exercise options are available; each should be
physical agent modalities.*”? Therapeutic exercise and tailored to meet the goals of treatment and the specific
physical agent modalities are described below. Many of capacities and precautions relative to the patient's
the principles of therapeutic exercise are readily and physical condition.
customarily incorporated into therapeutic activity and Exercise can be used to increase ROM and flexibility,
consequently are inherent aspects of OT practice. strength, coordination, endurance, and cardiovascular
fitness.*’ Specific exercise protocols may be used to
achieve specific goals. However, exercise without activity
THERAPEUTIC EXERCISE AND ACTIVITY
is apt to place the exercise in the realm of deliberate
From the earliest history of OT it was recognized that rather than automatic performance, therefore violating
the mind and body are inextricably united in perform- essential principles of OT discussed earlier. Although ju-
ance. Both the psychological and physical effects of dicious application of therapeutic exercise may have a
purposeful activity were recognized in the treatment limited place in the therapeutic program, the occupa-
of individuals with mental conditions, as well as in tional therapist should structure treatment so that
the treatment of persons with physical dysfunc- the patient is primarily engaged in activity to take advan-
tion.”'*!?*4 Because it was recognized that physical tage of the automaticity generated by purposeful
benefits accrued from the performance of~activity, ki- goal-directed therapeutic activity.
nesiological considerations were applied in the selec-
tion of appropriate therapeutic activities. To apply ki-
Purposes
nesiologic considerations to purposeful activity, it was
necessary to understand the principles of therapeutic The general purposes of therapeutic exercise, as with
exercise. therapeutic activity, are as follows:
As treatment methods evolved, occupational thera- 1. To develop awareness of normal movement patterns
pists began to use therapeutic exercise alone to prepare and improve voluntary, automatic movement re-
patients for purposeful activity and to expedite treat- sponses
ment in a health care system constrained by budget and 2. To develop strength and endurance in patterns of
time. The treatment of patients in acute stages of illness movement that are acceptable and necessary and do
and disability imposed new demands and role responsi- not produce deformity
bilities on occupational therapists. Short treatment ses- 3. To improve coordination, regardless of strength
sions in acute care settings, the extent of the patient's 4. To increase the power of specific isolated muscles or
physical incapacities, and shortened length of stay in muscle groups
hospital and rehabilitation facilities caused occupa- 5. To aid in overcoming ROM deficits
tional therapists to expand the range of modalities used 6. To increase the strength of muscles that will power
in treatment. hand splints, mobile arm supports, and other devices
The use of therapeutic exercise as an isolated mod- 7. To increase work tolerance and physical endurance
ality raised considerable controversy.*° It was feared through increased strength
that if occupational therapists used exercise or other 8. To prevent or eliminate contractures developing as a
preparatory modalities, purpose would be forgotten. Ex- result of imbalanced muscle power by strengthening
ercise and activity tended to be seen by some as mutu- the antagonistic muscles”
 OCCUPATIONAL THERAPY INTERVENTIONS
Indications for Use
disuse, muscle strength decreases. When strength is inad-
Therapeutic exercise is most effective in the treatment of equate, substitution patterns or “trick” movements are
orthopedic disorders (such as contractures and arthritis) likely to develop.”’ A substitution is the attempt to
and lower motor neuron disorders that produce weak- achieve a functional goal by using muscle groups and pat-
ness and flaccidity. Examples of the latter are peripheral terns of motion not ordinarily used. Substitution is used
nerve injuries and diseases, poliomyelitis, Guillain- when there is loss or weakness of the muscles normally
Barré syndrome, infectious neuronitis, and spinal cord used to perform the movements or restrictions in ROM
injuries and diseases. because of structural dysfunction. An example is using
The candidate for therapeutic exercise must be med- shoulder abduction to achieve a hand-to-mouth move-
ically able to participate in the exercise regimen, able to ment if elbow flexors cannot perform against gravity
understand the directions and purposes, and interested (Fig. 30-11). When muscle loss is permanent, some sub-
and motivated to perform. The patient must have avail- stitution patterns may be desirable as a compensatory
able motor pathways and the potential for recovery or measure to improve performance of functional activities,
improvement of strength, ROM, coordination, or move- such as the use of tenodesis to permit grasp that will
ment patterns, as applicable. It is important that some enable self-feeding. Many substitute movements are not
sensory feedback be available to the patient; that is, sen- desirable, however, and it is often the aim of therapeutic
sation must be at least partially intact so the patient can exercise to prevent or correct substitution patterns.”*
perceive motion and the position of the exercised part A muscle must contract at or near its maximal capac-
and sense superficial and deep pain. Muscles and ity and for enough repetitions and time to increase
tendons must be intact, stable, and free to move. Joints strength. Strengthening programs generally are based
must be able to move through an effective ROM for those on having the muscle contract against a large resistance
types of exercise that use joint motion. The patient for a few repetitions. Strengthening exercises are not ef-
should be relatively free of pain during motion and fective if the contraction is insufficient.'*7° Excess
should be able to perform isolated, coordinated move- strengthening, however, may result in muscle fatigue,
ment. If the patient has any dyskinetic movement, he or pain, and temporary reduction of strength. If a muscle is
she should be able to control it so that the procedure can overworked, it becomes fatigued and is unable to con-
be performed as prescribed.*? The type of exercise se- tract. The type of exercise must suit the muscle grade
lected depends on muscle grade, muscle endurance, joint and the patient's fatigue tolerance level. Fatigue level
mobility, diagnosis and physical condition, treatment varies from individual to individual, and the threshold
goals, position of the patient, and desirable plane of for muscle fatigue decreases in pathological states.7®
movement. Each of these requirements is also applicable Many patients may not be sensitive to fatigue or may
to the use of exercise-focused therapeutic activity, and push themselves beyond tolerance in the belief that this
should underlie its selection as a therapeutic tool. approach hastens recovery. Therefore the therapist must
carefully assess the patient’s muscle power and capacity
for performance. The therapist must also supervise the
Contraindications
Therapeutic exercise and exercise-focused therapeutic
activity are contraindicated for patients who have poor
general health or inflamed joints or who have had
recent surgery.*° They may not be useful where joint
ROM is severely limited as the result of well-established,
permanent contractures. As defined and described here,
they cannot be used effectively for those who have spas-
ticity and lack voluntary control of isolated motion or
those who cannot control dyskinetic movement. The
latter conditions are likely to occur in upper motor
neuron disorders, which are more amenable to exercise
regimens of the sensorimotor approaches to treatment
(see Chapters 32 to 36).

Exercise Programs
Muscle Strengthening
Active-assisted, active, and resistive isotonic and isomet- FIG. 30-11
ric exercises are used to increase strength. After partial or Using shoulder abduction as compensation to achieve hand-to-
complete denervation of muscle and during inactivity or mouth movement.
 Therapeutic Occupations and Modalities 515

patient closely and observe for signs of fatigue. These muscles. The use of thermal agents or neuromuscular fa-
signs may be slowed performance, distraction, perspira- cilitation techniques may enhance static stretching. '*
tion, increase in rate of respiration, performance of ex-
ercise pattern through a decreased ROM, and inability Coordination and Neuromuscular Control
to complete the prescribed number of repetitions. Coordination is the combined activity of many muscles
into smooth patterns and sequences of motion. Coordi-
Increasing Muscle Endurance nation is an automatic response monitored primarily
Endurance is the ability of the muscle to work for pro- through proprioceptive sensory feedback. Kottke’® dif-
longed periods and resist fatigue. Although a high-load, ferentiated between neuromuscular control and coordi-
low-repetition regimen is effective for muscle strength- nation. He defined control as “the conscious activation
ening, a low-load and high-repetition exercise program of an individual muscle or the conscious initiation of a
is more effective for building endurance.'*’'’ Having de- pre-programmed engram.” Control involves conscious
termined the patient's maximum capacity for a strength- attention to and guidance of an activity. Conscious at-
ening program, the therapist can reduce the maximum tention to activity may limit the achievement of further
resistance load and increase the number of repetitions skill.
to build endurance in specific muscles or muscle A preprogrammed pattern of muscular activity repre-
groups. The strength versus endurance training may be sented in the central nervous system (CNS) has been de-
seen as a continuum. Resistance and the number of rep- scribed as an engram. An engram is formed only if there
etitions can be modulated so that gains in strength and are many repetitions of a specific motion or activity. With
endurance accrue.'* repetition, conscious effort of the patient is decreased
and the motion becomes more and more automatic. Ul-
Physical Conditioning and Cardiovascular timately the motion can be carried out with little con-
Fitness scious attention. It has been hypothesized that when an
Improving general physical endurance and cardiovascu- engram is excited, the same pattern of movement is
lar fitness requires the use of large muscle groups in sus- produced automatically. Neuromuscular education or
tained, rhythmic aerobic exercise or activity. Examples control training involves teaching the patient to control
are swimming, walking, bicycling, jogging, and some individual muscles or motions through conscious atten-
games and sports. This type of activity is often used in tion. Coordination training is used to develop prepro-
cardiac rehabilitation programs in which the parameters grammed multimuscular patterns or engrams.~°
of the patient's physical capacities and tolerance for ex-
ercise should be well defined and medically supervised.
Types of Muscle Contraction
To improve cardiovascular fitness, exercise should be
done 3 to 5 days per week at 60% to 90% of maximum Isometric or Static Contraction
heart rate or 50% to 85% of maximum oxygen uptake. During an isometric contraction no joint motion
Fifteen to 60 minutes of exercise or rhythmic activities occurs, and the muscle length remains the same. The
using large muscle groups is desirable.‘ limb is set or held taut as agonist and antagonist
muscles are contracted at a point in the ROM to stabi-
Range of Motion and Joint Flexibility lize a joint. This action may be without resistance or
Active and passive ROM are used to maintain joint against some outside resistance, such as the therapist's
motion and flexibility. Active exercise is that performed hand ora fixed object. An example of isometric exercise
solely by the performer. An outside force such as the of the triceps against resistance is pressing down against
therapist or a device can be used for performing passive a tabletop with the ulnar border of the forearm while
exercise. The continuous passive motion machine, a the elbow remains at 90° flexion. An example of an ac-
device that can be preset to provide continuous passive tivity that requires isometric contraction is stabilizing
motion throughout the joint range, is an example. Ap- the arm in a locked position when carrying a shopping
plication of any mechanical device requires caution and bag slung over the forearm.?~”*
careful monitoring to prevent mishaps and possible
deleterious effects.'* Isotonic or Concentric Contraction
Stretching or forced exercise may be necessary to in- During an isotonic contraction there is joint motion
crease ROM. Some type of force is applied to the part and the muscle shortens. This contraction may be done
when soft tissue (muscles, tendons, and ligaments) is at with or without resistance. Isotonic contractions may be
or near its available length. The use of a low-resistance performed in positions with gravity decreased or against
stretch of sustained duration is preferred to high resist- gravity, according to the patient's muscle grade and the
ance and repetitive, quick, bouncing movements. The goal of the exercise or activity. An isotonic contraction
former method is less likely to produce tissue tearing, of the biceps is used to lift a fork to the mouth for
trauma, and activation of stretch reflexes in hypertonic eating.?7”7®
516 OCCUPATIONAL THERAPY INTERVENTIONS

Eccentric Contraction repetitions at 75% of maximal resistance; third set, 10

When muscles contract eccentrically, the tension in the repetitions at maximal resistance.'*’'”*° The load must
muscle increases or remains constant, while the muscle be sufficient so that the patient can perform 10 repeti-
lengthens. This contraction may be performed with or tions. As strength improves, resistance is increased so
without resistance. An example of an eccentric contrac- that 10 repetitions can always be performed.’ The
tion performed without resistance is the lowering of the patient is instructed to inhale during the shortening
arm to the table when placing a napkin next to a plate. contraction and exhale during the relaxation or eccen-
The biceps contracts eccentrically in this instance. An tric contraction. '”"*°
example of eccentric contraction against resistance is the An example of a PRE is a triceps, capable of 12
controlled return of a pail of sand lifted from the pounds maximal resistance, extending the elbow, first
ground. In this example the biceps is contracting eccen- against 6 pounds, then against 9 pounds, and the final
trically to control the rate and coordination of the 10 repetitions against 12 pounds. Maximal resistance,
elbow extension in setting the pail on the ground.?7”** the amount of resistance the muscle can lift through the
ROM 10 times, is determined by contracting the muscle
and moving the part through the full ROM against pro-
Exercise and Activity Classifications
gressively increasing loads for sets of 10 repetitions,
Isotonic Resistive Exercise until the maximal load that can be lifted 10 times is
Resistive exercise uses isotonic muscle contraction reached.
against a specific amount of weight to move the load At the beginning of the treatment program it is
through a certain ROM.'*~”* It is also possible to use often difficult for the therapist to determine the
eccentric contraction against resistance. Resistive exercise patient’s maximal resistance. Reasons may be that the
is used primarily for increasing the strength of fair plus to patient may not know how to exert maximal effort,
normal muscles but may also be helpful for producing may be reluctant to exercise strenuously for fear of
relaxation of the antagonists to the contracting muscles. pain or reinjury, may be unwilling or unable to endure
This latter purpose can be useful if increased range is discomfort, and may have difficulty with the timing of
desired for stretching or relaxing hypertonic antagonists. exercises.
The patient performs muscle contraction against re- The experience of the therapist and trial and error
sistance and moves the part through the available ROM. aid in determining maximal resistance. The therapist
The resistance applied should be the maximum against should estimate the amount of resistance the patient
which the muscle is capable of contracting. Resistance can take based on the muscle test results, and add or
may be applied manually or by weights, springs, elastic subtract resistance (weight or tension) until the patient
bands, sandbags, or special devices. The source of resist- can perform the sets of repetitions adequately.
ance depends on the activity, and resistance is graded The exercises should be performed once daily, four or
progressively with an increasing amount of resist- five times a week, and rest periods of 2 to 4 minutes
ance. '“’***® The number of possible repetitions depends should be allowed between each set of 10 repetitions.
on the patient's general physical endurance and the en- The exercise procedure may be modified to suit individ-
durance ofthe specific muscle. ual needs. Some possibilities are 10 repetitions at 25%
There are many types of strength training programs, of maximal resistance, 10 repetitions at 50%, 10 repeti-
most based on the principle that to increase strength, tions at 75%, and 10 repetitions at maximal resistance.
the muscle must contract against its maximal resistance. Another possibility is five repetitions at 50% and 10 rep-
The number of repetitions, rest intervals, frequency of etitions at maximal resistance. Still another possibility is
training, and speed of movement vary with the particu- to omit the second set of exercises. Adjustments in the
lar approach and with the patient's ability to accommo- first two sets of exercises may be made to suit the capac-
date to the exercise or activity regimen.’ One specialized ity of the individual.'”
type of resistive exercise is the DeLorme method of pro- Another approach is the Oxford technique, essen-
gressive resistive exercise (PRE).'”*° PRE is based on the tially a reverse of the DeLorme method. The exercise se-
overload principle: muscles perform more efficiently if quence begins with 100% resistance and decreases to
given a warmup period and must be taxed beyond usual 75%, and then to 50% on subsequent sets of 10 repeti-
daily activity to improve in performance and strength.'’ tions each.'’*° The greatest gains may be made in the
During the exercise procedure small loads are used ini- early weeks of the treatment program, with smaller in-
tially and increased gradually after each set of 10 repeti- creases occurring at a slower pace in the subsequent
tions. The muscle is thus warmed up to prepare to exert weeks or months. During performance of the exercise,
its maximal power for the final 10 repetitions. The exer- the therapist should be aware of joint alignment of the
cise procedure consists of three sets of 10 repetitions exercise device; proper fit and adjustment of the device;
each, with resistance applied as follows: first set, 10 rep- ruling out of substitute movements; and clear instruc-
etitions at 50% of maximal resistance; second set, 10 tion of speed, ROM, and proper breathing.’”””!
 Therapeutic Occupations and Modalities

APPLICATION TO ACTIVITY. Many purposeful ac-

tivities lend themselves well to resistive exercise. For in-
stance, leather lacing can offer slight resistance to the an-
terior deltoid if the lace is pushed in an upward direction.
Sanding wood with a weighted sand block can offer sub-
_ stantial resistance to the anterior deltoid and triceps if
done on an inclined plane. Activities such as sawing and
hammering offer resistance to upper extremity muscula-
ture. Kneading dough and forming clay objects offer re-
sistance to muscles of the hands and arms.

Isotonic Active Exercise

Isotonic muscle contraction is used in active exercise.
Eccentric contraction may also be used. Active exercise is
performed when the patient moves the joint through its
available ROM against no outside resistance. Active
motion through the complete ROM with gravity de- Fig. 30-12
creased or against gravity may be used for poor to fair Latch hooking to provide active resistive exercise to the wrist
muscles to improve strength, with the added benefit of extensors.
maintaining ROM. It may be used with higher muscle
grades for the maintenance of strength and ROM when structured so that assistance can be offered by the thera-
resistance is contraindicated. Active exercise is not used pist, the patient's other arm or leg, or a mechanical
to increase ROM because this purpose requires added device. Various bilateral activities lend themselves well
force not present in active exercise. to active-assisted exercise. Bilateral sanding, bilateral
In active exercise the patient moves the part through sponge wiping, using a sweeper, and sawing are some
the complete ROM independently. If the exercise is examples. In bilateral activities the unaffected arm or
performed in a gravity-decreased plane, a powdered leg can perform a major share of the work, and the af-
surface, skateboard, deltoid aid, or free-moving suspen- fected arm or leg can assist to the extent possible.
sion sling may be used to reduce the resistance pro-
duced by friction. The exercise is graded by a change to Passive Exercise
resistive exercise as strength improves.?”7* In passive exercise there is no muscle contraction. There-
fore passive exercise is not used to increase strength
APPLICATION TO ACTIVITY. Activities that offer because no force is applied. The purpose of passive exer-
little or no resistance can be used as active exercise. A cise is to maintain ROM, thereby preventing contrac-
needlework activity performed in the gravity-decreased tures, adhesions, and deformity. To achieve this goal,
plane provides active exercise to the wrist extensors. the person should perform exercise for at least three
When a grade of fair or 3 is reached, the activity can be repetitions, twice daily.7’ It is used when absent or
repositioned to move against gravity, as in latch minimal muscle strength (grades 0 to 1) precludes the
hooking (Fig. 30-12). active motion or when active exercise is contraindicated
because of the patient's physical condition. During the
Active-Assisted Exercise exercise procedure the joint or joints to be exercised are
Isotonic muscle contraction is used in active-assisted ex- moved through their normal ranges manually by the
ercise. The patient moves the joint through partial ROM, therapist or patient, or mechanically by an external
and the therapist or a mechanical device completes the device such as a pulley or counterbalance sling. The
range. Slings, pulleys, weights, springs, or elastic bands joint proximal to the joint being exercised should be
may be used to provide mechanical assistance.*° The stabilized during the exercise procedure (Fig. 30-13).?7
goal of active-assisted exercise is to increase strength of
trace, poor minus, and fair minus muscles while main- APPLICATION TO ACTIVITY. It is often possible to
taining ROM. In the case of trace muscles the patient include a passive limb in a bilateral activity if the con-
may contract the muscle, and the therapist completes tralateral limb is unaffected. Several of the activities de-
the entire ROM. This exercise is graded by decreasing scribed previously for active-assisted exercise can also be
the amount of assistance until the patient can perform used for passive exercise.
active exercises.?~7*
Passive Stretch
APPLICATION TO ACTIVITY. If assistance is re- For passive stretching, the therapist moves the joint
quired to complete the movement, an activity must be through the available ROM and holds momentarily,
 OCCUPATIONAL THERAPY INTERVENTIONS

and motivation of the patient. For example, forceful

contraction of the triceps to stretch the biceps muscle
can be performed. Because the exercise may produce
discomfort, there is a natural tendency for the patient to
avoid the stretching component of the movement.
Therefore supervision and frequent evaluation of its ef-
fectiveness are necessary.

APPLICATION TO ACTIVITY. Many activities can

be used to incorporate active stretching. For example,
slowly sawing wood requires a forceful contraction of
the triceps with a concomitant stretch of the biceps.

Isometric Exercise Without Resistance

Isometric exercise uses isometric contractions of a spe-
FIG. 30-13 cific muscle or muscle group. In isometric exercises a
Passive exercise of the wrist with stabilization of the joint prox- muscle or group of muscles is actively contracted and
imal to the one being exercised. relaxed without producing motion of the joint that it
ordinarily mobilizes. The purpose of isometric exercise
applying a gentle but firm force or stretch at the end of without resistance is to maintain muscle strength when
the ROM. There should be no residual pain when the active motion is not possible or is contraindicated. It
stretching is discontinued. Passive stretch or forced exer- may be used with any muscle grade above trace. It is es-
cise is meant to increase ROM. It is used when there is a pecially useful for patients in casts, after surgery, and
loss of joint ROM and stretching is not contraindicated. with arthritis or burns.'*
If muscle grades are adequate, the patient can move the The patient is taught to set or contract the muscles
part actively through the available ROM and the thera- voluntarily and to hold the contraction for 5 or 6
pist can take it a little farther, thus forcing or stretching seconds. Without offering resistance, the therapist's
the soft-tissue structures around the joint. fingers provide a kinesthetic image of resistance and
Passive stretching requires a good understanding of help the patient learn to set the muscle. If needed, the
joint anatomy and muscle function. It should be carried therapist's fingers may be placed distal to the joint on
out cautiously under good medical supervision and which the muscles act. If passive motion is allowed, the
with medical approval. Muscles to be stretched should therapist may move the joint to the desired point in the
be in a relaxed state.*® The therapist should never force ROM and ask the patient to hold the position.
muscles when pain is present, unless ordered by the Isometric exercise affects the cardiovascular system,
physician to work through pain. Gentle, firm stretching which may be a contraindication for some patients. It
held for a few seconds is more effective and less haz- may cause a rapid and sudden increase in blood pres-
ardous than quick, short stretching. The parts around sure, depending on the age of the patient, the intensity
the area being stretched should be stabilized, and com- of contraction, and muscle mass being contracted.
pensatory movements should be prevented. Incorrect Therefore it should be used with caution.'*
stretching procedures can produce muscle tearing, joint
fracture, and inflammatory edema.’ Isometric Exercise With Resistance
Isometric exercise with applied resistance uses isometric
APPLICATION TO ACTIVITY. Passive stretching muscle contraction performed against some outside re-
may be incorporated into an activity if an unaffected sistance. Its purpose is to increase muscle strength in
part guides the movement of the affected part and forces muscles graded fairt+ or 3+ to normal or 5. The patient
it slightly beyond the available ROM. One example is sets the muscle or muscle group while resistance is
the passive stretch of wrist flexors during a block print- applied, and holds the contraction for 5 or 6 seconds.
ing activity if the block is pressed down to stabilize the Isometric exercises should be performed for one exer-
block with an open hand while the patient is standing. cise session per day, 5 days a week. In addition to
manual resistance, the patient may hold a weight or
Active Stretch resist against a solid surface, depending on the muscle
The purpose of active stretch is the same as for passive group being exercised. A small weight held in the hand
stretch: to increase joint ROM. In active stretching, the while the wrist is stabilized at neutral requires isometric
patient uses the force of the agonist muscle to increase contractions of the wrist flexors and extensors.
the length of the antagonist. This requires good to Exercise is graded by increasing the amount of resist-
normal strength of the antagonist, good coordination, ance or the degree of force the patient holds against. A
 Therapeutic Occupations and Modalities 519

tension gauge should be used to monitor accurately the part. The skin over the muscle belly and tendon inser-
amount of resistance applied. Isometric exercises are ef- tion may be stimulated to enhance the effect of the
fective for increasing strength, but isotonic exercise is stretch reflex. Stroking and tapping over the muscle
the method of choice. Isometric exercise has several spe- belly may be used to facilitate muscle action.*°
cific applications, as in arthritis, when joint motion may The therapist should explain the location and func-
be contraindicated but muscle strength must be in- tion of the muscle, its origin and insertion, line of pull,
creased or maintained.***' The cardiovascular precau- and action on the joint. The therapist should then
tions stated previously are particularly important with demonstrate the motion and instruct the patient to
isometric resistive exercise. think of the pull of the muscle from insertion to origin.
The skin over muscle insertion can be stroked in the di-
APPLICATION TO ACTIVITY. Any activity that re- rection of pull while the patient concentrates on the
quires holding or static posture incorporates isomet- sensation of the motion during the passive movement
ric exercise. Holding tool handles and holding the performed by the therapist.
arm in elevation while painting are examples. This The exercise sequence begins with instructions to
type of exercise, if contraction is sustained, can be the patient to think about the motion, while the thera-
very fatiguing. pist carries it out passively and strokes the skin over
the insertion in the direction of the motion. The
Neuromuscular Control and Coordination patient is then instructed to assist by contracting the
Procedures for the development of neuromuscular muscle while the therapist performs passive motion
control and neuromuscular coordination are briefly and stimulates the skin as before. Next the patient
outlined in the following paragraphs. The reader is re- moves the part through ROM with assistance and cuta-
ferred to original sources for a full discussion of the neous stimulation, while the therapist emphasizes con-
neurophysiological mechanisms underlying these exer- traction of the prime mover only. Finally the patient
cises. Neuromuscular education or control training in- carries out the movement independently, using the
volves teaching the patient to control individual prime mover.
muscles or motions through conscious attention. Coor- The exercises must be initiated against minimal re-
dination training is used to develop preprogrammed sistance if activity is to be isolated to prime movers. If
multimuscular patterns or engrams. the muscle is very weak (trace to poor), the procedure
may be carried out entirely in an active-assisted manner
NEUROMUSCULAR CONTROL. It may be desir- so that the muscle contracts against no resistance and
able to teach control of individual muscles when they can function without activating synergists. Progression
are so weak that they cannot be used normally. The from one step to the next depends on successful per-
purpose is to improve muscle strength and muscle coor- formance of the steps without substitutions. Each step is
dination to new patterns. To achieve these ends, the carried out three to five times per session for each
person must learn precise control of the muscle, an es- muscle, depending on the patient's tolerance.
sential step in the development of optimal coordination
for persons with neuromuscular disease. COORDINATION TRAINING. The goal of coordi-
To participate successfully the patient must be able to nation training is to develop the ability to perform mul-
learn and follow instructions, cooperate, and concen- timuscular motor patterns that are faster, more precise,
trate on the muscular retraining. Before beginning, the and stronger than those performed when control of in-
patient should be comfortable and securely supported. dividual muscles is used. The development of coordina-
The exercises should be carried out in a nondistracting tion depends on repetition. Initially in training, the
environment. The patient must be alert, calm, and movement must be simple and slow so that the patient
rested. He or she should have an adequate pain-free arc can be consciously aware of the activity and its compo-
of motion of the joint on which the muscle acts, as well nents. Good coordination does not develop until re-
as good proprioception. Visual and tactile sensory feed- peated practice results in a well-developed activity
back may be used to compensate or substitute for pattern that no longer requires conscious effort and
limited proprioception, but the coordination achieved attention.
will never be as great as when proprioception is intact.*° Training should take place in an environment in
The patient’s awareness of the desired motion and which the patient can concentrate. The exercise is
the muscles that effect it is first increased by passive divided into components that the patient can perform
motion to stimulate the proprioceptive stretch reflex. correctly. Kottke calls this approach desynthesis.*° The
This passive movement may be repeated several times. level of effort required should be kept low, by reduc-
The patient’s awareness may be enhanced if the thera- ing speed and resistance, to prevent the spread of excita-
pist also demonstrates the desired movement and if the tion to muscles that are not part of the desired move-
movement is performed by the analogous unaffected ment pattern. Other theorists offer contrary advice,
520 OCCUPATIONAL THERAPY INTERVENTIONS

PHYSICAL AGENT MODALITIES*

emphasizing the integration of movements that cus-
tomarily occurs during activity. The therapist's experi- The introduction of physical agent modalities (PAMs)
ence and judgment are important in determining which into OT practice generated considerable contro-
method to use. versy.*”°? The use of such modalities was initiated by
When the motor pattern is divided into units that the occupational therapists specializing in hand rehabilita-
patient can perform successfully, each unit is trained by tion in which inclusion of physical agents in a compre-
practice under voluntary control, as described previ- hensive treatment program became expedient.***° After
ously for training of control. The therapist instructs the much study and discussion, the AOTA published a posi-
patient in the desired movement and uses sensory stim- tion paper on physical agent modalities.** In this offi-
ulation and passive movement. The patient must cial document, physical agents were defined and their
observe and voluntarily modify the motion. Slow prac- use as adjuncts to or preparation for purposeful activity
tice is imperative to make this monitoring possible. The was specified. “The exclusive
use of physical agent
therapist offers enough assistance to ensure precise modalities as a treatment method during a treatment’
movement while allowing the patient to concentrate on session without application to a functional outcome is?
the sensations produced by the movements. When the not considered occupational therapy.”* Further, the tise
patient concentrates on movement, fatigue occurs of PAMs is not considered entry-level practice: rather,’
rapidly and the patient should be given frequent, short appropriate postprofessional education is required
rests. As the patient masters the components of the ensure Snipes of the OT practitioners using these
pattern and performs them precisely and independ- nodalities!* The AOTA stipulated that the practitioner
ently, the sequence is graded to subtasks or several com- must have documented evidence of the theoretical
ponents that are practiced repetitively. As the subtasks background and technical skills to apply the modality
are perfected, they are linked progressively until the and integrate it into an OT intervention plan.** Gener-
movement pattern can be performed. ating from these notions, several states have required in
The protocol can be graded for speed, force, or com- their licensure laws that occupational therapists have
plexity, but the therapist must be aware that the in- advanced training in order to use PAMs in treatment.
creased effort put forth by the patient may result in in- Physical agent modalities are used before or during
coordinated movement. Therefore the grading must functional activities to enhance the effects of treatment.
remain within the patient's capacity to perform the This section introduces the reader to basic techniques
precise movement pattern. The motor pattern must be and when and why they might be applied. Examples of
performed correctly to prevent the development of the treatment of upper extremity injuries are presented
faulty patterns. because modalities are most commonly used by occu-
If CNS impulses irradiate pase to muscles that pational therapists for treatment of hand injuries and
should not be involved in the movement pattern, inco- diseases. The use of the techniques described is not
ordinated motion results. Constant repetition of an in- limited to the treatment of hands, however.
coordinated pattern reinforces the pattern, resulting in a
persistent incoordination. Factors that increase incoor-
Thermal Modalities
dination are fear, poor balance, too much resistance,
pain, fatigue, strong emotions, prolonged inactivity,*° In a
clinical setting heatisused to increase motion, de-
and excessively prolonged activity. crease joint stiffness, relieve muscle spasms, inctease
blood flow, decrease pain, and aidin the reabsorption
APPLICATION TO ACTIVITY. OT can be used to of exudates and edema in a chronic condition: Colla-
develop coordination, strength, and endurance. Active gen fibers have an elastic component and when
occupations have the advantage of engaging the stretched will return to their original length. Applying
patient's attention and interest. Activities should be heat before a prolonged stretch, as in dynamic splinting,
structured to enable the patient to use the precise move- allows the permanent elongation of these fibers. The
ment pattern and to work at speeds consistent with the blood flow maintains a person’s core temperature at
maintenance of precision. 98.6° E To obtain maximum benefits from heat, tissue
Therapists may initiate coordination training with temperature must be raised to 105° to 113° EF Precau-
neuromuscular education and progress to repetitious tions must be taken with temperatures above this range
activities requiring desired coordinated movement pat- to prevent tissue destruction.
terns. Placing small blocks, marbles, cones, paper cups, Contraindications to the use of heat include acute
or pegs is an enabling activity that demands repetitious conditions, sensory losses, impaired vascular structures,
patterns of nonresistive movement. Purposeful activities
such as leather lacing, mosaic tile work, needlecrafts,
and household tasks such as wiping, sweeping, and *Ingrid E. Wade, OTR, is gratefully acknowledged for her contribution
dusting also provide such repetitious movements. of this topic in the fourth edition of this book.
 Therapeutic Occupations and Modalities Pas!

malignancies, and application to the very young or very ature is thermostatically maintained, with the therapeu-
old. The use of heat may substantially enhance the tic range extending to 125° F, Studies have shown this
effects of splinting and therapeutic activities that technique to be excellent for raising tissue temperature
attempt to increase range of motion and functional in the hands and feet.’* An additional benefit is its
abilities. effect on desensitization. The agitator can be adjusted to
decrease or increase the flow of the corn particles, thus
enon controlling the amount of stimulation to the skin.
Because an extremity can be heated generally, this tech-
nique is effective as a warmup before exercises, dexterity
en paratantiseR in a tub. tasks, functional activities, and work simulation tasks.
that maintains a temperature between 125° and 130° E
The client repeatedly dips his or her hand into the tub dba
until a thick, insulating layer of paraffin is applied to the Ot when heat is generated internally by
extremity. The hand is then wrapped in a plastic bag and Giniiiniadg ERT peanaRNEENTCen The?
towel for 10 to 20 minutes.*' This technique provides an sound
waves penetrate the tissues, causing vibration of |
excellent conforming characteristic, so it is ideal for use the
molecules, and the resulting friction generates heat.
in hands and digits. Partial hand coverage is possible. The energy of sound waves is thus converted to heat
The paraffin transfers its heat to the hand, and the bag energy. The sound waves are applied with a transducer,
and towel act as an insulator against dissipation of heat which glides across the skin in slow, continuous
to the air. motions. Gel is used to improve thetransmission of the”
Care must be taken to protect insensate parts from ‘sound to the tissues. Ultrasound is considered a deep’
burns. To prevent excessive vasodilation, paraffin should heating agent. At 1 MHz (1 million cycles per second), it
not be applied when moderate to severe edema is can heat tissues to a depth of 5 cm. The previous
present. It cannot be used if open wounds are present. methods produce heating to 1 cm.*’ Many therapeutic
Paraffin can be used in the clinic or incorporated into a ultrasound machines provide a 3-MHz option for treat-
home program. The tubs are small, and the technique is ment of more superficial structures, with the correspon-
safe and easy to use in the home. It is an excellent ding heating depth reduced to 3 cm. Ultrasound at fre-
adjunct to home programs that include dynamic splint- quencies higher than recommended standards can
ing, exercises, or general ADL. It may be used in the clinic destroy tissue. In addition, precautions must be taken to
before therapeutic exercises and functional activities. avoid growth plates in the bones of children, an unpro-
Hot packs contain either a silicate gel or a bentonite tected spinal cord, and freshly repaired structures such
clay wrapped in a cotton bag and submerged in a hy- as tendons and nerves. Because of its ability to heat
drocollator, a water tank that maintains the temperature deeper tissues, ultrasound is excellent for treating prob-
of the packs at 160° to 175° F.*' Because tisstte damage lems associated with joint contractures, scarring with its
may occur at these temperatures, the packs are separated associated adhesions, and muscle spasms. When apply-
from the skin by layers of towels. As with paraffin, pre- ing the ultrasound, the therapist should apply a stretch
cautions should be taken when applying hot packs to to the tissues while they are being heated, followed by
insensate tissue that has sustained vascular damage. Hot activities, exercises, and splints to maintain the stretch.
packs are commonly used for myofascial pain, before Ultrasound may also be used in a nonthermal appli-
soft-tissue mobilization, and before any activities aimed cation in which the ultrasound waves are used to drive
at elongating contracted tissue.'* For a client with a antiinflammatory medications into tissues. This process
hand injury the packs may be applied to the extrinsic is called phonophoresis. Ultrasound is thought to increase
musculature to decrease muscle tone caused by guard- membrane permeability for greater symptom relief, and
ing, without also heating the hand. Unless contraindi- may also be used after corticosteroid injections.
cated, hot packs can be used (with precautions) when Cryotherapy, the use of cold in therapy, is often used
open wounds are present. in the treatment of edema, pain, and inflammation. The
cold produces a vasoconstriction, which decreases the
Convection amount of blood flow into the injured tissue. Cold de-
Sennen ne piiesaiventatmatineai ssues by |fluid mo- creases muscle spasms by decreasing the amount of
nd the tissues. Examples of convection. are firing from the afferent muscle spindles. Cryotherapy is
la uidotherapy.f Whirlpool is used more contraindicated for clients with cold intolerance or vas-
commonly for wound management than for heat appli- cular repairs. The use of cryotherapy may be incorpo-
cation. Fluidotherapy involves a machine that agitates rated into clinical treatment; however, it is particularly
finely ground cornhusk particles by blowing warm air useful in a home program.
through them. This device is similar to the whirlpool, Cold packs can be applied in a number of ways.
but corn particles are used instead of water. The temper- There are many commercial packs, ranging in size and
Sp up OCCUPATIONAL THERAPY INTERVENTIONS

cost. An alternative to purchasing a cold pack is to use a joint dysfunction occurs. ** These reactions magnify and
bag of frozen vegetables or to combine crushed ice and compound the problems associated with the initial pain
alcohol in a plastic bag to make a reusable slush bag. Ice response. The therapist's goal after an acute injury is to
packs should be covered with a moist towel to prevent prevent this cycle. In the case of chronic pain the goal is
tissue injury. The benefit of commercial packs is that to stop the cycle that has been established. TENS is an
they are easy to use, especially if the client must use effective technique for controlling pain without the side
them frequently during the day. When clients are effects of medications. Pain medications are frequently
working, it is recommended that they keep cold packs at used in conjunction with TENS, which often reduces the
home and at work, to increase the ease of use. The duration of their use. TENS is safe to use, and clients can
optimum temperature for storing a cold pack is 45° FE. be educated in independent home use.
Other forms of cryotherapy include ice massage and TENS provides constant electrical stimulation with a
cooling machines. Ice massage is used when the area to modulated current and is directed to the peripheral
be cooled is small and very specific—for example, in- nerves through electrode placement. The therapist can
flammation of a tendon specifically at its insertion or control several attributes of the modulation waveform
origin. The procedure entails using a large piece of ice such as the frequency, amplitude, and the pulse width.
(water frozen in a paper cup) and massaging the area When TENS is applied at a low-fire setting, endogenous
with circular motions until the skin is numb, usually for opiates are released. Endorphins, naturally occurring
4 to 5 minutes. Cooling devices, which circulate cold substances, reduce the sensation of pain. The effects of
water through tubes in a pack, are available through high-frequency TENS are based on the gate control
vendors. These devices maintain their cold temperatures theory originally proposed by Melzack and Wall in
for a long time, but they are expensive to rent or pur- 1965. This theory describes how the electrical current
chase. They are effective in reducing edema immediately from TENS, applied to the peripheral nerves, blocks the
after surgery or injury, during the inflammatory phase of perception of pain in the brain. Nociceptors (pain re-
wound healing. ceptors) transmit information to the CNS through the
Contrast baths combine the use of heat and cold. The A, delta, and C fibers. A fibers transmit information
physical response is alternating vasoconstriction and va- about pressure and touch. It is thought that TENS stim-
sodilation of the blood vessels. The client is asked to ulates the A fibers, effectively saturating the gate to pain
submerge the arm, for example, alternating between two perception, and the transmission of pain signals via the
tubs of water. One contains cold water (59° to 68°F), A, delta, and C fibers are blocked at the level of the
and the other contains warm water (96° to 105°F). The spinal cord.** TENS can be applied for acute or chronic
purpose is to increase collateral circulation, which effec- pain. TENS is frequently used postsurgically, when it is
tively reduces pain and edema. As with the use of cold mandatory that motion be initiated within 72 hours
packs, contrast baths are a beneficial addition to a such as in tenolysis and capsulotomy surgeries or when
home therapy program. This technique is contraindi- is important to maintain tendon gliding through the
cated for clients with vascular disorders or injuries. injured area after fractures. TENS can be especially
helpful with clients who have a low threshold to pain,
making exercising easier. TENS is also useful in treating
Electrical Modalities
clients with reflex sympathetic dystrophy because con-
Electrical modalities are used to decrease pain, decrease tinued active motion is crucial.
edema, increase motion, and reeducate muscles. As with TENS can be used to decrease pain from an inflam-
all PAMs, occupational therapists use these modalities matory condition such as tendonitis or a nerve impinge-
to increase a client's functional abilities. Many tech- ment; however, it is mandatory that the client be edu-
niques are available; those most commonly used are cated in tendon and nerve protection and rest, with a
presented here. Electrical modalities should not be used proper home program of symptom management, posi-
with clients with pacemakers or cardiac conditions. tioning, and ADL and work modification. Without the
sensation of pain, it is possible for the client to overdo
Transcutaneous Electrical Nerve Stimulation and stress the tissues. It is recommended that other
(TENS) techniques be tried first to decrease pain for these
TENS employs electrical current to decrease pain. Pain is clients. TENS is also used for treating trigger points, with
classified in three categories: physical, physiological, direct electrode application to the trigger point to de-
and psychological. When trauma occurs, an individual crease its irritability.°°
responds to the initial pain by guarding the painful
body part. This guarding may result in muscle spasms Neuromuscular Electrical Stimulation
and fatigue of the muscle fibers, especially after pro- Neuromuscular electrical stimulation (NMES) provides
longed guarding. The supply of blood and oxygen to the a continuous interrupted current. It is applied through
affected area decreases, and resultant soft-tissue and an electrode to the motor point of innervated muscles
 Therapeutic Occupations and Modalities io2s

to provide a muscle contraction. The current is inter- tional therapist applies a positioning splint to a patient
rupted to enable the muscle to relax between contrac- immediately after hand surgery, considering how the
tions, and the durations of the on and off times can be hand will be used later in treatment and in real life. It
adjusted by the therapist. Adjustments can also be made means the therapist may use sensory stimulation on
to control the rate of the increase in current (ramp) and the comatose patient because arousal and a return to
intensity of the contraction. interacting with persons and objects in the environ-
NMES is used to increase ROM, facilitate muscle con- ment will make performance of purposeful activity
tractions, and strengthen muscles.*” It may be used possible in the future. It means the therapist may apply
postsurgically to provide a stronger contraction for re- paraffin to decrease joint stiffness and increase mobil-
leased tendon gliding—for example, after a tenolysis. It ity of finger joints before performance of a macrame
also may be used later in the tendon repair protocol, project. It also may mean preparing the patient and
once the tendon has healed sufficiently to tolerate family to plan for the future, when life skills may need
stress, usually at a minimum of 6 weeks. NMES may be to be performed in ways new to them, such as modi-
used to lengthen a muscle that has become weakened fied sexual positioning for arthritic or spinal cord pa-
because of disuse. During the reinnervation phase after tients or learning self-care of the colostomy. The
a nerve injury, this technique may be used to help stim- unique perspective of the occupational therapist is
ulate and strengthen a newly innervated muscle. Care seeing the potential for performance and using modal-
must be taken not to overfatigue the muscle. NMES can ities that lead incrementally to performance relevant to
be applied during a dexterity or functional activity, the lives patients wish to lead.
which allows the muscle to be retrained in the purpose
of its contraction. As with TENS, NMES may be incorpo-
rated into a home program with proper client education
and follow-through. Active occupation is the primary tool and objective of
Other techniques that use an electrical current OT practice. Occupational therapists use purposeful ac-
include high-voltage galvanic stimulation (HVGS) and tivity, activity analysis, adaptation, grading of activities,
inferential electrical stimulation. These techniques are therapeutic exercise, simulated or enabling activities,
applied to treat pain and edema.°’ Electrical stimula- and adjunctive modalities in the continuum of treat-
tion may be applied in conjunction with ultrasound ment, and they may use these methods simultaneously
through a single transducer to provide heat simultane- toward these ends. Through this breadth of practice
ously with current. This approach is beneficial in treat- skills, based on the patient's personal and social needs,
ing trigger points and myofascial pain. lontophoresis the occupational therapist helps the patient apply newly
uses a current to drive ionized medication into inflamed gained strength, ROM, and coordination during the per-
tissue and scar tissue. The technique uses an electrode formance of purposeful activity, preparing the patient to
filled with the medication of choice. The medicine is assume or reassume life roles. Appropriate therapeutic
transferred by applying an electric field that repels the activity is individualized and designed to be meaningful
ions into the tissues. and interesting to the patient, while meeting therapeu-
tic objectives.
Therapeutic activity may be adapted to meet special
SELECTION OF APPROPRIATE
needs of the patient or the environment. It may be
MODALITIES IN THE CONTINUUM
graded for physical, perceptual, cognitive, and social
OF CARE purposes to keep the patient functioning at maximal
Many years ago treatment roles and responsibilities potential at any point in the treatment program. The
were more specifically delineated. Occupational thera- uniqueness of OT lies in its extensive use of goal-
pists treated patients only after the patients were directed purposeful activities as treatment modalities,
capable, at least to some degree, of performing purpose- making use of the mind-body continuum within the
ful activity.~° Evolution of treatment methods, trends in tangible and social context. Purposeful activity is the
health care (Chapter 2), and medical technology have core of OT practice.
significantly altered the role of the respective therapists In practice, therapists’ roles may not be sharply
and expanded the repertoire of treatment modalities defined because they are subject to variations in expec-
that therapists are competent to practice. tations that stem from regional differences, health care
Patients are now referred to OT long before they are developments, legislation, institutional philosophy, and
capable of performing purposeful activity. Therapists the roles and responsibilities assigned by the treatment
are treating patients in the very acute stages of illness facility. In all instances, therapists must be well trained
and disability. Treatment is directed toward preparing and well qualified to deliver all aspects of practice. They
the patient for the time when purposeful activity is should not hesitate to refer patients to experts for treat-
possible. This approach may mean that the occupa- ment whenever appropriate.
524 OCCUPATIONAL THERAPY INTERVENTIONS

T2s Breines EB: Origins and adaptations: a philosophy of practice,

REVIEW QUESTIONS Lebanon, NJ, 1986, Geri-Rehab.
13; Cannon NM, Mullins PT: Manual on management of specific hand
. Identify the three realms of occupational genesis problems, Pittsburgh, 1984, American Rehabilitation Educational
and their relation to the concept of development. Network.
. Define modality. . Ciccone CD, Alexander J: Physiology and therapeutics of exercise.
. What is required for an activity to be considered In Goodgold J, editor: Rehabilitation medicine, St Louis, 1988,
Mosby.
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. Cynkin S: Occupational therapy: toward health through activities,
. Name two reasons that activity is valuable. Boston, 1979, Little, Brown.
. List the six elements of an activity configuration. . Cynkin C, Robinson AM: Occupational therapy: toward health
. Name a client-centered tool used to identify pa- through activities, Boston, 1990, Little, Brown.
tients’ goals, objectives, and lifestyles. . DeLateur BJ, Lehmann J: Therapeutic exercise to develop strength
and endurance. In Kottke FJ, Stillwell GK, Lehmann JE, editors:
. Name the three perspectives of activity analysis.
Krusen's handbook of physical medicine and rehabilitation, ed 4,
. What term bests describes how activities and envi- Philadelphia, 1990, WB Saunders.
ronments are modified to meet the individualized . Dewey J: Democracy and education: an introduction to the philosophy
needs of patients? of education, Toronto, 1916, Collier-Macmillan.
. What is used to create the “just right” challenge in . Dunton WR: Prescribing occupational therapy, Springfield, Ill, 1928,
Charles C Thomas.
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20. Dutton R: Guidelines for using both activity and exercise, Am J
10. What is the term that refers to activities that are con- Occup Ther 43(9):573-580, 1989.
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11. When are adjunctive modalities appropriately used therapy, ed 7, Philadelphia, 1988, JB Lippincott.
20) Huddleston OL: Therapeutic exercises, Philadelphia, 1961, FA
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12: For which types of disabilities would therapeutic ex- 23. Huss AJ: From kinesiology to adaptation, Am J Occup Ther
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lie. List and define three types of muscle contraction. 24, Kielhofner G: A heritage of activity: development of theory, Am J
14. Identify an activity that can be used to provide resis- Occup Ther 36(11):723-730, 1982.
2s Killingsworth A: Activity module for OCTH 120, functional kinesiol-
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ogy, 1989, San Jose State University, San Jose, California (unpub-
153 List four general categories of physical agent modal- lished).
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16. What kinds of symptoms are treated with cryo- nation. In Kottke FJ, Stillwell GK, Lehmann JF, editors: Krusen’s
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27. Kottke FJ: Therapeutic exercise to maintain mobility. In Kottke FJ,
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keeping an activity product, Am J Occup Ther 41(3):152-157. 53: Wynn-Parry CB: Vicarious motions. In Basmajian JV, editor: Ther-
45. Rose H: Physical agent modalities: OT’s contribution, OT Week apeutic exercise, ed 3, Baltimore, 1982, Williams & Wilkins.
8(37):16-17, Bethesda, Md, 1994, American Occupational Ther- 54. Yoder RM, Nelson DL, Smith DA: Added-purpose versus rote exer-
apy Association. cise in female nursing home residents, Am J Occup Ther 43(9):581-
46. Schram DA: Resistance exercise. In Basmajian JV, editor: Therapeu- 586, 1989.
tic exercise, ed 4, Baltimore, 1984, Williams & Wilkins.
47. Spackman CS: Occupational therapy for the restoration of physi-
cal function. In Willard HS, and Spackman CS, editors: Occupa-
tional therapy, ed 4, Philadelphia, 1974, JB Lippincott.
526 OCCUPATIONAL THERAPY INTERVENTIONS

APPENDIX
4. Equipment and supplies necessary
Activity Analysis Model a. Ball of soft ceramic clay
The activity analysis offers the reader one systematic ap- b. Wooden table 30 to 32 inches high or a
proach for looking at the therapeutic potential of activi- wooden work surface fastened to a table with
ties. This model includes some factors that must be C clamps
considered about the performer, the environmental c. Chair at the work table
context, and the activity in the selection of purposeful, d. Sponge and bowl of water
therapeutic activity. In the model, just two steps of a e. Ceramic smoothing tool
multistep activity are analyzed for the sake of space and . Environmental context'”’°: Occupational ther-
simplicity. The reader is encouraged to complete the apy workshop or craft activity room. A sink and
motor analysis by considering movements of the shoul- damp storage area should be available in the
der, forearm, and wrist that accompany the pinch and work area. There should be ample room around
release pattern analyzed. the work table so that the performer is not
I. Preliminary information crowded and can move freely between the table
il Name of activity: Pinch pottery and the sink and damp storage closet. Lighting
a Components of the task should be adequate for clear visualization of
a. Roll some clay into a ball, 3 to 4 inches in di- clay object and work area.
ameter. . Position of the performer in relation to the work
b. Place the ball centered on the work table in surface and equipment: The performer is seated
front of the performer. in the chair at the table, at a comfortable distance
c. Make a hole in the center of the ball with the for reaching and manipulating the clay and tools.
right or left thumb (Fig. 30-14). The clay is centered in front of the performer, and
d. With the thumb and first two fingers of both the tool, sponge, and water bowl are to the right
hands, pinch around and around the hole and near the top of the work area.
from base to top of the ball. . Starting position of the performer: Sitting erect
i. Pinch by pressing thumb against index with feet flat on the floor; shoulders are slightly
and middle fingers. abducted and in slight internal rotation, bringing
ii. Release pinch by extending thumb and both hands to the center work surface; elbows are
index and middle fingers slightly. flexed to about 90°; forearms are pronated about
e. Continue pinching in this way, gradually 45°; wrists are slightly extended and in ulnar
spreading the walls ofthe clay until a small deviation, thumbs are opposed to index and
bowl of the desired size is formed. middle fingers, ready to pinch the posterior
Steps of activity being analyzed surface of the opened clay ball.
a. Pinch . Movement pattern used to perform the steps
b. Release under analysis: Flexion of the MP and IP joints
of index and middle fingers; opposition and
flexion of the thumb (pinch) followed by exten-
sion of the MP and IP joints index and middle
fingers and extension and palmar abduction of
the thumb (release). Repeat the pattern around
ball of clay until a small bowl of desired size and
thickness is formed.
II]. Motor analysis*”
1. Joint and Muscle activity: List the joint motions
for all movements used during performance of
the activity. For each, indicate amount of ROM
used (minimal, moderate, or full), muscle group
used to perform the motion, strength required
(minimal [P+ to F], moderate [F+ to G], and
full [G+ to N]), and type of muscle contraction
(isotonic, isometric, eccentric) (Table 30-1).
. Grading: Grade this activity for one or more of
FIG. 30-14 the following factors:
Opening pinch pot with thumb. (From Breines EB: Occupational a. ROM: Cannot be graded for ROM.
therapy from clay to computers: theory & practice, Philadelphia, 1995, b. Strength: Grade for strength by increasing the
FA Davis.) consistency of the clay.
 Therapeutic Occupations and Modalities

haKolatelate we)a edlaleta}

Type of Muscle
Range of Motion Muscle Group Strength Contraction

Minimal FDP. FDS lumbricales Moderate Isotonic

Minimal FDP FDS Moderate lsotonic

Minimal FDP Moderate Isotonic

Maximal Palmar interossei ; Moderate Isometric

Full Opponens pollicis, FPI, FPB Moderate lsotonic

: Motions for Release Index and Middle Fingers

:MP extension ue Minimal EDC, EIP Minimal lsotonic
PP and DIP extension Minimal EDC EIR © Minimal lsotonic
:Finger adduction Maximal Palmar interossei Moderate Isometric

_Thumb
Radial abduction Moderate APL, APB Minimal lsotonic
MP IP extension Full EPL, EPB Minimal Isotonic
Adapted from Killingsworth A: OT! 20 activity module, San Jose, Calif, 1989, San Jose State University.
APB, Abductor pollicis brevis; APL, abductor pollicis longus; DIP, distal interphalangeal; EDC, extensor digitorum communis; EIP, extensor indicis proprius; EPB, exten-
sor pollicis brevis; EPL, extensor pollicis longus; FDP, flexor digitorum profundus; FDS, flexor digitorum superficialis; FPB, flexor pollicis brevis; FPL, flexor pollicis
. longus; IP, interphalangeal; MP, metacarpophalangeal; PIP, proximal interphalangeal.

c. Endurance: Grade for sitting tolerance by in-

| creasing the length of activity sessions. , Sensory Modality How Received
! d. Grade for sitting balance by decreasing sitting Tactile x Touching clay and tools
support. vite es
e. Coordination: Requires fine coordination as se eae Z ee er
performed; grade coordination by adding sense) during pinch/release
scored or painted designs to surface; grade to =
sculpture of small clay figures. Vestibular (balance, x Maintaining posture in
3. Criteria for activity as exercise pee Ot body ee bericemne
a. Action of joints: Movement localized to pees moun) ree
flexion and extension of MP and IP joints of Visual x Seeing clay object,
index and middle fingers; CMC, MP, and IP environment
joint of thumb. Olfactory (smell) x Smelling a slight odor of
b. Repetition of motion: The pinch and release damp clay
sequence is repeated until the bowl has
reached the desired height and thickness. Fol a
c. Gradable: The activity is gradable for strength Thermal (temperature) x Hands sensing coldness of
and endurance. clay
Ill. Sensory analysis**** Pressure Xx Fingertips and thumb tips
1. Check the sensory stimuli received by the person pressing against walls of
performing the activity. Include any sensory ex- clay bowl
perience obtained from position, motion, mate-
tials, or equipment. Describe how sensation is a) :
received (Table 30-2). Other
O, Sensory stimuli not received;X, sensory stimuli received.
 OCCUPATIONAL THERAPY INTERVENTIONS

Adequate supervision should be provided to

ensure appropriate use of clay and tool, and the
task should be performed from a wheelchair with
Cognitive Skill Justification
supports if sitting balance is impaired.
Memory x Re ernibeis metiction VI. Interpersonal aspects of activity
1. Solitary activity: May be done alone.
Sequencing (steps in ‘Performs steps inorder 2. Potential for dyadic interaction: May be done
ooo) in parallel with one other person but does not
Problem-solving skills Knows what to do if clay is require interaction.
too wet or too dry, if walls of 3. Potential for group interaction: May be done in
bowl are too thin or too thick a group but does not require interaction.
VII. Psychological and psychosocial factors
Following Instructions 1. Symbolism in performer's culture’: May be
seen as more feminine than masculine in
Spoken x Is able to comprehend and
mainstream American culture; may be associ-
follow spoken instructions
ated with the artistic, liberal, naturalist groups
Demonstrated x Is able to comprehend and of people in American society.
follow demonstrated 2. Symbolic meaning of activity to performer:
instructions May be seen as leisure skill rather than work:
Written O may be regarded as child’s play by some
persons.
Concentration and x Moderate: focuses on bowl 3. Feelings or reactions evoked in performer
attention required and knows when its walls are 3 as
4 thin enough and high enough
during performance of activity’*: The soft,
moist, pliable, and plastic properties of the clay
O, Cognitive skill note used; X, cognitive skill required in activity. may evoke soothing feelings in many persons.
Others may regard it as messy or dirty. Poten-
tial for personal gratification is good because
attractive end product is easy to achieve; activ-
IV. Cognitive analysis**: Check all that apply and ity is creative, individualistic, and useful.
justify your answer (Table 30-3). VIII. Therapeutic use of activity
V. Safety factors: What are the’ potential hazards of 1. List the autonomous goal of the activity: To
this activity? Describe safety precautions necessary make a small clay bowl.
for this activity. There are few hazards in this activ- 2. List possible therapeutic objective(s) for the
ity. Ingesting clay or using the smoothing tool in- activity
appropriately is possible. Also, sitting balance a. To increase pinch strength
must be adequate to maintain upright posture to b. To improve coordination of opposition
perform the activity. Precautions must be taken: c. To increase sitting tolerance
@}utevojare:

LEARNING OBJECTIVES
SECTION 1 After studying Section 1 the student or practitioner will
Hand Splinting: Principles, Practice, and Decision be able to do the following:
Making 1. Identify basic hand anatomy.
Tenodesis 2. Describe the difference between single-axis and
Dynamic splint multiaxis joints, and explain how they relate to
Grasp splinting.
Prehension 3. Define torque, and describe how a splint produces
Force torque.
Axis of motion 4. Discuss the relationship of angle of approach to
Friction dynamic splinting.
Torque 5. Describe the three major purposes of splints.
Translational force 6. Demonstrate an understanding of the principles of
Serial static making a splint pattern.
Static progressive 7. Identify three characteristics of low-temperature
Static splint thermoplastic material.
Low-temperature thermoplastic 8. Discuss two ways in which splints may apply force.
Orthosis 9. Demonstrate how to determine the proper length of
a forearm-based splint.
SECTION 2
After studying Section 2 the student or practitioner will
Suspension Arm Devices and Mobile Arm Supports
be able to do the following:
Suspension arm device
1. List the purposes of suspension arm devices.
Mobile arm support
2. List physical disabilities with which suspension
Suspension rod
arm devices are used.
Overhead rod
3. List the elements of adjustment and the training
Suspension sling
program for suspension arm devices.
Suspension arm support
4. Briefly describe the evolution of the mobile arm
Sling bracket
support (MAS) and name its parts.
Rocker trough
5. List the benefits of the MAS to persons with severe
Vertical motion
upper extremity weakness.
Proximal arm
6. List the criteria for use of the MAS and describe
Distal arm
how it works.
Horizontal motion
Pa List two special parts of the MAS.
Outside rocker assembly
8. Name the flexible, low-profile device that facilitates
Elevating proximal arm
passage through doorways.
Multilink articulated arm

529
oye) OCCUPATIONAL THERAPY INTERVENTIONS

According to Mosby's Medical, Nursing, & Allied Health cluded is testament to the sensibility of the hand. That
Dictionary,’ orthotics is “the design and use of external we can wield a hammer to drive a nail is testament to the
appliances to support a paralyzed muscle, promote a integrity of the skin and the strength of the muscles that
specific motion, or correct musculoskeletal deformi- power the hand. That we can speak volumes with a sweep
ties;” an orthosis is “a force system designed to control, of our hands or a caressing touch is testament to the aes-
correct, or compensate for a bone deformity, deforming thetics of the hand. It is a remarkable instrument indeed.
forces, or forces absent from the body. . . [and] often Occupational therapists deal with the human being
involves the use of special braces;” and’a splint is “an or- as a whole, not as just a hand, a toe, or a shoulder. With
thopedic device for immobilization, restraint, or the human hand, even the smallest impairment may
support of any part of the body.” Both splints and sus- affect function. Loss of placement of the hand may
pension arm devices can be considered orthoses. Occu- mean an inability to achieve a hand-to-mouth pattern,
pational therapists often design and contruct splints. An making independent feeding impossible. Pain and fear
orthotist usually designs and constructs suspension arm can and do accompany injury, and when independence
devices, and occupational therapists adjust them and or livelihood is threatened by hand dysfunction, the
train patients to use them. In practice, the term orthosis outcomes are often dramatic. The hand is perhaps most
is more frequently used to refer to suspension arm valued only when it ceases to function and we must pay
devices than splints. Hand splinting is the topic of it attention.
Section 1 of this chapter and suspension arm devices are A splint is one of the most important tools therapists
described in Section 2. use to minimize or correct impairment and to restore or
augment function. Little else so readily calls attention to
SS ee ees eae eae the hand as a splint. An individual may not receive com-
SECTION 1 ments on a new ring or a recent manicure, but put a
splint on the hand and all will take notice. The decision
Hand Splinting; Principles, Practice, to provide or fabricate a splint requires an in-depth un-
and Decision Making derstanding of the pathological condition to be affected
and of the many splinting choices available.
JULIE BELKIN
Section 1 of this chapter serves as an introduction to
the anatomical and biomechanical principles necessary
The human hand is the brain’s most important instru- to the understanding of the basic concepts and models
ment with which to explore and master the world. It is of splinting. This section briefly reviews the anatomy of
the only body part that can substitute for other senses. the hand and its relationship to principles of splinting,
We read with our hands if we suffer a loss of vision; we introduces the biomechanical principles involved in
communicate with our hands in the absence of speech splint design and fabrication, and introduces a five-step
or hearing. Our hands give us expression and console us. splint fabrication process. This process involves instruc-
We first explore our hands and explore with our hands tion in pattern making, material choices, types of trac-
as infants. The wonder of the human hand is the preci- tion, and techniques of fabrication.
sion with which it functions and the extremes of abuse it
tolerates. We can and do take our hands for granted
ROLE OF THE OCCUPATIONAL
because they seem to function effortlessly— that is, until
THERAPIST
we experience some level of impairment or dysfunction.
The hand does not function independent of the The education an occupational therapist receives in the
whole human organism. It is connected to the brain via analysis of activity and the assessment of human occu-
a complex tangle of nerves and is dependent on precise pation and function leads naturally to the use of splint-
synaptic connections. The hand does not function inde- ing as one therapeutic tool in the treatment regimen.
pendent of the upper extremity (UE); stability and Occupational therapists most commonly fabricate
control of the shoulder, elbow, and wrist are needed to splints for the hand and UE, but they also may be called
position the hand in space. Dysfunction anywhere from on to design and fabricate splints for the lower extrem-
the brain to the fingertips may cause impaired function ity (LE) and even for the back or spine. The basic princi-
of the hand. ples of splinting apply regardless of which part is being
Humans achieve mastery and independence over splinted.
their environment because of the superiority of the Involvement of the occupational therapist in all
human brain and the dexterity of the hand. Tying a knot, phases of splint fabrication is recommended from the
opening a necklace clasp, wielding a hammer, and initial assessment of need, through the design phase,
throwing a ball are all abilities unique to the human the fabrication, and the training and follow-up neces-
hand. That we can close a necklace with our vision oc- sary to ensure proper use and fit of the splint. This in-
 Orthotics 531

volvement requires an understanding of the anatomy flexion, extension, and deviation, with excessive mo-
and biomechanics of the normal, unimpaired hand tion checked by the carpal ligaments.
and of the pathology of the impaired hand. Many ex- Placement of the hand for functional tasks is reliant
cellent texts describe both hand anatomy and biome- on the stability, mobility, and precision of placement
chanics in extensive detail and should be included in permitted by the wrist complex. Any mechanism of
the library of any occupational therapist treating the injury or disease that alters this complex system trans-
hand. This chapter briefly reviews the anatomy and lates into some level of dysfunction. Even the simplest
biomechanics of the hand most pertinent to splinting. splint that crosses the wrist will in some way alter the
The lists of references and suggested readings at the functional abilities of the hand. Splint designs that
end of this chapter provide several excellent selections attempt to augment or substitute for wrist motion are
for further study. likely to limit component motions or be too complex to
One reference of note that should be included in fabricate or wear.
every therapist's library is Clinical Mechanics of the When static positioning of the wrist is required, the
Hand,’ third edition, by Paul W. Brand and Anne Hol- optimal degree of flexion or extension and ulnar or
lister. This text is an excellent source for a straightfor- radial deviation will vary with the task and with the
ward explanation of the mechanics of muscles, joints, patient's preference.
and skeletal structures and how they contribute to the
remarkable dexterity and strength of the hand. Brand Wrist Tenodesis
and Hollister also discuss clinical approaches and how Tenodesis is the reciprocal motion of the wrist and
they affect the natural biomechanics of the hand. fingers that occurs during active or passive wrist flexion
and extension. Tenodesis is the action of wrist extension
ANATOMICAL STRUCTURES producing finger flexion and wrist flexion producing
OF THE HAND finger extension. It is caused by the lack of change in
length of the long finger muscles during wrist flexion
Wrist
or extension (Fig. 31-2). The extrinsic finger muscle
The hand and wrist are composed of an arrangement of tendon units have a fixed resting length, and because
27 bones that contribute to mobility and adaptability. they cross multiple joints before inserting onto the
The wrist is a complex consisting of the distal ulna and phalanges, they can affect the position of several joints
radius and the eight carpal bones arranged in two rows. without any contraction or length change required of
The carpal bones form the concave transverse arch and, the muscles. This concept is crucial to understanding
with the configuration of the distal radius, contribute
substantially to the conformability of the hand.* The
distal ulna does not articulate with any carpal bone and
its contribution to wrist stability is through the attach-
ments of the ulnar collateral ligament, which places a
check on radial deviation (Fig. 31-1).
The wrist complex allows a greater arc of motion
than any other joint complex except the ankle. This
mobility is a result of a unique skeletal configuration
Trapezium Capitate
and an involved ligamentous system. All motion at the Hamate
Trapezoid
wrist is Component motion occurring in more than one Triquetral
anatomical plane; there are no pure or isolated Scaphoid Pisiform
motions. This concept is key in any treatment directed Lunate

at the wrist. Extension occurs with a degree of radial

deviation and supination. Wrist flexion includes both
ulnar deviation and pronation. The wrist is contiguous
and continuous with the hand. The distal carpal row
(the trapezium, trapezoid, capitate, and hamate) articu-
lates firmly with the metacarpals. Motion is produced
across these articulations by muscles that cross the
carpals and attach to the metacarpals. The proximal
carpal row (the scaphoid, lunate, and triquetrum) artic-
ulates distally with the distal carpal row and proxi-
mally with the radius and the triangular cartilage. ane ae, FZ
Gliding motions occur between the carpal rows during Skeletal structures of the wrist, dorsal view.
532 OCCUPATIONAL THERAPY INTERVENTIONS

how passive positioning of the wrist affects the resting

position of the digits. In the nerve-injured hand, ten-
odesis is often harnessed by splints to provide function.
The patient with spinal cord injury with sparing of a
wrist extensor (C6, 7 level) gains considerable function
from a tenodesis splint. In a dynamic splint, the effect
that tenodesis has on tendon length will in part dictate
the wrist position that will optimize forces directed at
the digits.

Metacarpal Joints
The metacarpals articulate with the carpal bones proxi-
mally and with the phalanges distally. The first meta-
carpal, the thumb, articulates with the saddle-shaped
trapezium and is considered separately. The second
metacarpal fits into the central ridge of the trapezoid,
and the third articulates firmly with the facets of the
B capitate. These articulations form the immobile central
segment of the hand around which the other
metacarpals rotate. The fourth and fifth metacarpals ar-
FIG. 31-2
Tenodesis. A, Active wrist extension results in passive finger
ticulate with the concave distal surface of the hamate.
flexion. B, Active wrist flexion results in passive finger extension. The shorter length of the ulnar two metacarpals and
their greater mobility form the flexible arches of the
hand, allowing it to conform and fold around objects of
various shapes.
The distal transverse arch of the hand lies obliquely
across the metacarpal heads. This obliquity is critical to
the hand’s ability to adapt its shape to objects. The

FIG. 31-3
A, Trim lines of splint extend distal to metacarpophalangeal creases and limit finger flexion. B,
Splint’s distal trim lines fall proximal to metacarpophalangeal creases and permit full finger flexion.
 Orthotics

FIG. 31-4
A, Fourth and fifth digits are prevented from full flexion. B, Full finger flexion is possible with proper
trim lines.

hand does not form a cylinder as it closes but instead Distal trim lines that fall proximal to the MP creases
assumes the position of a cone. In making a fist, the will allow for full MP flexion (Fig. 31-4, B).
ulnar two digits of the hand contact the palm first, and
the radial two digits follow. This cascade of the fingers
Thumb
is a direct result of the oblique angle formed at the
metacarpal heads. This concept is most important in The base of the first metacarpal articulates with the tra-
splinting in determining the distal trim lines for a wrist pezium to form a highly mobile joint that is often
support when full metacarpophalangeal (MP) flexion compared to the shape of a saddle. The base of the first
is desired. The splint in Fig. 31-3, A, is improperly metacarpal is concave in the anteroposterior plane and
trimmed distal to the MP creases. Distal trim lines convex in the lateral plane. This surface is met by recip-
should be established proximal to the MP creases, as in rocal surfaces on the trapezium. This configuration
Fig. 31-3, B. allows for a wide arc of motion, with the thumb able
to rotate not only for pad-to-pad opposition but also
for full extension and abduction to move away from
Metacarpophalangeal Joints
the palm.® Both motions are important to function.
The distal heads of the metacarpals articulate with the That is, a thumb posted in permanent opposition may
proximal phalanges to form the MP joints. Active. make grasp possible but release of objects impossible.
motion is possible along an axis of flexion and exten- This concept is crucial to the understanding of splints
sion and along an axis of abduction and adduction. that augment the tenodesis action of the hand by
Additionally, a small degree of rotation is present at the posting the thumb in opposition to the index and long
MP joints. These axes of motion allow for expansion or fingers. With such splints the therapist must carefully
spreading of the hand and contribute to the ability of consider the degree of abduction and opposition in
the hand to conform to different shapes and sizes of which the thumb is posted, to maximize both grasp
objects. An attempt to hold a softball without abduct- and release.
ing the fingers shows the importance of this motion. A
splint with trim lines along the ulnar border of the
Interphalangeal Joints
hand that extend too far distally limits both flexion
and abduction of the fourth and fifth digits. As a result, The proximal interphalangeal (PIP) and distal interpha-
the hand will have a limited ability to grasp large langeal (DIP) joints are true hinge joints, with motion
objects, and function will be restricted (Fig. 31-4, A). in only one plane. This limitation of motion ensures
534 OCCUPATIONAL THERAPY INTERVENTIONS

FIG. 31-6
The shape of the forearm is altered as it moves from supination to
pronation. Forearm-based splints must be repositioned to accom-
modate this if the forearm is rotated during the fabrication
process. (From Wilton JC: Hand splinting, principles of design and fab-
rication, Philadelphia, 1997, WB Saunders.)
FIG. 31-5
The axis of motion for supination and pronation extends the
length of the forearm and is centered through the radial head and
capitulum and the distal ulnar styloid. (From Colello-Abraham K:
Rehabilitation of the hand, ed 3, St Louis, 1990, Mosby).
midline along the supinated forearm shift dramatically
greater stability in these joints, which contributes to upon pronation. Splints are generally used for function
their ability to resist palmar and lateral stresses and so with the forearm in pronation, but they are easier to
impart strength and precision to functional tasks. fabricate with the forearm in supination. If the forearm
is not pronated before the splint material is set, the trim
lines will be high on the radial border and low on the
Forearm Rotation
ulnar border.
Close consideration of forearm rotation (i.e., supina- One final active demonstration highlights the impor-
tion and pronation) is necessary because of the impor- tance of forearm position on hand function. Place a
tance of these motions to function and to the fitting of coin of any size on a tabletop, and, holding the forearm
splints. Forearm rotation occurs at the elbow and at in neutral (thumb straight up), attempt to pick up the
the distal forearm, with axes of rotation through the coin. It becomes rapidly apparent that the ability to po-
center of the radial head and capitulum and along a sition the hand for function relies in great part on the
line extending through the base of the ulnar styloid more proximal joints of the forearm.
(Fig. 31-5). During pronation the ulnar styloid moves
laterally as the radial styloid travels medially. During
Ligaments of Wrist and Hand
supination the opposite occurs, with the ulnar styloid
moving medially. This movement results in a displace- The ligamentous structures of the hand act as checkreins
ment of the styloids, which in turn alters the architec- for the hand and wrist, limiting extremes of motion and
ture of the forearm in supination as compared with providing stability. The complex motions of the wrist
pronation. are dependent in large part on the ligaments that re-
The way in which this change in dimensions affects strain them, rather than on the contact surfaces between
splint trim lines is shown in Fig. 31-6. Lines drawn at the carpals and metacarpals. Three groups of ligaments
 Orthotics

are discussed briefly to highlight their contribution to

wrist stability and mobility.
The palmar ligaments include the radioscapho-
os
capitate ligament, which contributes support to the
scaphoid; the radiolunate, which supports the lunate;
and the radioscapholunate ligament, which connects
the scapholunate articulation with the palmar surface of
6S the distal radius.
— The stability and mobility of the
thumb and radial carpus depend on the integrity of
these ligaments. Disruption of the ligaments results not
only in instability and pain at the wrist, but also in sig-
nificant dysfunction of the thumb. Splinting is fre-
quently the treatment of choice to supply stability for
pain reduction.
The radial and ulnar collateral ligaments provide
FIG. 31-7
dorsal stability. These capsular ligaments, along with
Oblique angle of transverse arch at metacarpophalangeal joints
the radiocarpal and dorsal carpal ligaments, provide
must be accommodated to ensure maintenance of more mobile
carpal stability and permit range of motion (ROM). Dis- fourth and fifth digits.
ruption of any of these ligaments may result in pain,
loss of strength, and functional impairment.
The triangular fibrocartilage complex (TFCC) in- fifth digits are positioned in the splint to accommodate
cludes the ligaments and the cartilaginous structures their additional degree of mobility by allowing some-
that suspend the distal radius from the distal ulna and what greater flexion at their MP joints (Fig. 31-7).
the proximal carpus. Tears or strains in this complex are
evidenced by pain and weakness with resultant loss of Proximal Interphalangeal Joints
function in resistive tasks. The advent of new imaging The PIP joint capsule and ligaments provide stability
techniques has made the diagnosis of TFCC tears more and allow mobility in one plane only. Collateral liga-
common, and splinting is often ordered for support and ments on each side of the joint run in a dorsal-to-
pain relief. palmar direction, inserting into the fibrocartilage plate
of the PIP. These ligaments and plate are lax with the
Metacarpophalangeal Joints PIP joint in flexion and taut with it in extension. The
The soft-tissue structures that surround the MP joints seemingly simple joint is made more complex by the
include the joint capsule, collateral ligaments, and an inclusion of the extensor mechanism passing through
anterior fibrocartilage or volar plate. The capsule covers the capsule dorsally and contributing slips to the
the head of the metacarpal and is reinforced by the col- system of ligaments affecting this joint. The potential
lateral ligaments. The collateral ligaments are config- for disruption of the extensor mechanism is high.
ured to allow side-to-side motion when the MP is in ex- Many of the most commonly fabricated finger splints
tension and to tighten as the MP is flexed. The volar are used to correct the PIP boutonniere (Fig. 31-8, A),
plate is attached to the base of the proximal phalanx and swan neck (Fig. 31-8, B) deformities.
and loosely attached to the base of the neck of the
metacarpal through the joint capsule. This configura- Distal Interphalangeal Joints
tion allows for sliding of the plate proximally during The DIP joint capsule and ligaments are similar to the
MP flexion. The plate returns to its lengthened state PIP joint, but with less structural strength to the termi-
with the MP in extension and acts as a checkrein to volar nal insertions of its palmar plate and collateral liga-
displacement of the MP joint when it is extended. ments. As the structures become smaller, they lose in-
When the MPs are immobilized in extension, there is tegrity and strength. It is no wonder that one of the
a strong tendency for secondary shortening of the lax most frequent injuries to the digits is the disruption of
collateral ligaments, as well as contraction and adher- the terminal end of the extensor tendon, resulting in a
ence of the volar plate, resulting in limited MP flexion mallet or “baseball” finger (Fig. 31-8, C).
and loss of functional grasp patterns. The commonly
accepted resting position splint, which places the wrist
Muscles and Tendons of Forearm,
in 25° to 35° of extension, the MP joints at 60° to 70°
Wrist, and Hand
of flexion, and the PIP and DIP at 10° to 35° of flexion,
is designed to prevent shortening and maintain the Balance in the hand must be considered when the hand
joints in midrange for optimal function. An important is assessed for a splint. Two groups of muscles act on the
consideration is to ensure that the mobile fourth and wrist and hand: the extrinsic muscles that arise from the
536 OCCUPATIONAL THERAPY INTERVENTIONS

A Boutonniére

B Swan Neck

CAN
C Mallet ° EG yA <=40
FIG. 31-8
A, Boutonniere deformity characterized by proximal interpha-
langeal joint flexion and distal interphalangeal joint hyperexten-
sion. B, Swan neck deformity with proximal interphalangeal joint
hyperextension and distal interphalangeal joint flexion. C, Mallet
deformity with distal interphalangeal joint flexion and loss of active E —»>VU<E
extension.
FIG. 31-9
Potential sites for nerve compression from improperly fitted
splints. A, Radial nerve. B, Ulnar nerve. C, Radial digital nerve in
elbow and the proximal half of the’midforearm, and the
anatomical snuffbox. D, Ulnar nerve in Guyon’s canal. E, Digital
intrinsic muscles with origins and insertions entirely in nerves.
the hand. The extrinsic muscles include both a flexor
and extensor group acting on the wrist and on the digits.
The intrinsics include the lumbricals, the dorsal and
palmar interossei, and the thenar and hypothenar where the nerves are superficial and prone to com-
groups. Smooth, coordinated motions of the hand pression. These sites include the ulnar nerve at the
depend on a well-integrated balance between and elbow and in the Guyon canal in the palm, the radial
within these two muscle groups. Many of the contrac- nerve at the elbow and in the thenar snuffbox, and
tures occupational therapists are called on to correct the digital nerves along the medial and lateral borders
with splinting are caused by neurological dysfunction of the digits (Fig. 31-9).
(central or peripheral), which results in imbalance of Three peripheral nerves supply the motor and
muscle tone or innervation. sensory function to the hand (Fig. 31-10). The radial
nerve is the primary motor supplier to the extensor and
supinator muscles. The sensory fibers of the radial nerve
Nerve Supply
supply the dorsum and radial border of the hand. The
In a discussion of the nerve supply to the hand it is median nerve provides motor supply to the flexor- .
important to mention the continuity of the brachial pronator group, including most of the long flexors and
plexus from its origins in the spinal cord to its termi- the muscles of the thenar eminence. The sensory distri-
nal innervations in the hand. Injuries or compressions bution of the median nerve is functionally the most im-
occurring anywhere along this continuum may result portant because it includes the palmar surface of the
in motor or sensory dysfunction. When splinting the thumb, index, and long fingers and the radial half of the
UE, the therapist must give attention to the pathways ring finger. The ulnar nerve supplies most of the intrin-
of the nerves supplying the UE and to the potential sic muscles, the hypothenar muscles, the ulnarmost pro-
sites for entrapment. In the fabrication of splints, care fundi, and the adductor pollicis brevis. The sensory
must be taken to avoid applying pressure over sites supply of the ulnar nerve includes the palmar surface of
 Orthotics 537

are more likely to be concerned with the superficial

venous system because it lies superficially in the dorsum
of the hand. Disruption of this superficial system may
result in extensive fluid edema in the dorsum of the
hand, that requires the therapist's intervention.
© Uinar
_. Radial Skin
Median
The mobility of the hand is directly related to the type
and condition of the skin. Anyone who has put on a
ring that is slightly too small, only to be unable to
remove it, has experienced the redundancy of the skin
on the dorsum of the hand. The skin on the dorsum of
FIG. 31-10
Sensory distribution in hand. Median nerve distribution includes the hand is loosely anchored to underlying structures
most of the prehensile surface of the palm. and moves easily to allow flexion and extension of the
digits. The ring “problem” occurs because of a greater
degree of elasticity in the dorsal skin when it is pulled
distally, as opposed to when it is pulled proximally. This
the ulnar half of the ring finger, the little finger, and the fact should be considered when the use of finger splints
ulnar half of the palm. is contemplated.
Nerve dysfunction presents a challenge to the splint The palmar skin, by contrast, is thicker and relatively
maker. Muscle imbalance leads to dysfunctional pos- inelastic. It is firmly connected to the underlying palmar
turing of the hand and muscle atrophy that reduces aponeurosis for stability and protection during prehen-
the natural padding of the hand. Abrasions or ulcera- sion activities. Furthermore, the underlying fascia of the
tions may occur in persons who do not remove their palmar skin is thicker and protects the nerve endings,
splints because they do not feel pain caused by shear- while acting to supply adequate moisture and oils to the
ing forces or pressure areas inside the splint. Finally, skin surface.
skin with marked sensory impairment lacks natural
oils and perspiration, leading to dry skin that abrades
Superficial Anatomy and Landmarks
easily. These factors must be assessed and considered
carefully when splints are being fitted on persons with When fabricating a splint, therapists must consider
sensory impairment. where to apply force without causing further trauma.
Splinting the neurologically impaired hand is di- Despite its deftness and power, the hand’s lack of pro-
rected at prevention of joint and soft-tissue contractures tective fascia means that it tolerates external pressures
and at restoration of functional positioning. Splinting poorly and shearing stresses not at all. The prominent
cannot restore sensibility, and care must be taken to ulnar styloid, the distal head of the radius at the ulnar
prevent damage to sensory-impaired skin and to limit snuffbox, and the thumb carpometacarpal joint are
further reduction of sensory feedback by covering common sites for pressure. A truism that will always
sensate surfaces. hold in splinting is that padding adds pressure. The
softest padding added to a too-tight splint will only add
pressure. Pressure is relieved by creation of a reliefin the
Blood Supply splint or by application of padding and material
Blood supply to the hand is carried by the radial and molded over the pad to make it an integral part of the
ulnar arteries. The ulnar artery lies just lateral to the splint (Fig. 31-11). Added padding to relieve pressure
flexor carpi ulnaris tendon, where it divides into a large after the splint is formed, should be avoided.
branch that forms the superficial arterial arch and a
small branch that forms the lesser part of the deep
PREHENSION AND GRASP PATTERNS
palmar arch. The ulnar artery is vulnerable to trauma
where it passes between the pisiform and the hamate The ability of the human hand to assume myriad posi-
(the canal of Guyon). The radial artery divides at the tions and to apply only the precise amount of pressure
proximal wrist crease into a small, superficial branch necessary to hold an object is a result of the mobility
and a larger, deep radial branch. The superficial arterial and stability supplied by the skeleton, the power of the
arch further divides into common digital branches and muscles, and the remarkable degree of sensory feedback
then into proper digital branches. from the nerves. This sensory feedback is used to assess
Venous drainage of the hand is accomplished by two the size, shape, texture, and weight of an object. The
sets of veins: a superficial and a deep group. Therapists brain then determines which type of prehension to use.
 OCCUPATIONAL THERAPY INTERVENTIONS

Lateral Prehension
In lateral prehension the pad of the thumb is positioned
to contact the radial side of either the middle or distal
phalanx of the index finger (Fig. 31-12). Most com-
monly this pattern of prehension is used in holding a
pen or eating utensil and in holding and turning a key.
The short or long opponens splint is used to stabilize
the thumb to achieve this prehension pattern.

Palmar Prehension
Palmar prehension is also called three-jaw chuck pinch.
The thumb is positioned in opposition to the index and
long fingers (Fig. 31-13). The important component of
motion in this pattern is thumb rotation, which allows
FIG. 31-11
for pad-to-pad opposition. This prehension pattern is
Relief “bubbled” over the ulnar styloid accomplished by molding
plastic over a pad placed on the styloid.
used in lifting objects from a flat surface, in holding

The feedback used in the grasping and lifting of an

object is dependent both on the brain’s interpreting cor-
rectly what is seen and on the hand's responding appro-
priately. Once an object is in the hand, further adap-
tation in prehension will occur if the initial visual
assessment was faulty.
Splints can maximize functional prehension. In
achieving this goal the therapist must be aware of what
a splint can and cannot do; a splint can stabilize an
unstable part, position a thumb in opposition, and
even assist or substitute for lost motion. The splint
maker must be aware that a splint may also limit mo-
FIG. 31-12
bility at uninvolved joints, reduce sensory feedback,
Lateral prehension or key pinch in short opponens splint that po-
add bulk to the hand, and transfer stresses to un- sitions thumb in lateral opposition to index finger.
splinted joints proximal or distal to the part being
splinted.
The prehension patterns the hand is able to achieve
are as exhaustive as the objects that are available to
grasp or pinch. Several authors have contributed to clas-
sifications of normal prehension, and the presentation
by Flatt? is recommended for further study of the
subject. It is possible to reduce the many patterns to two
basic classifications, prehension and grasp, from which
other patterns may be derived. Prehension is defined as
a position of the hand that allows finger and thumb
contact and facilitates manipulation of objects. Grasp is
defined as a position of the hand that facilitates contact
of an object against the palm and the palmar surface of
the partially flexed digits.
The thumb is involved in all but one type of grip, that
of hook grasp. Carpometacarpal and MP rotation is
Bie gre
crucial to prehension and cannot be overstressed in its
importance in splinting to achieve function. This rota- FIG. 31-13
tion allows for full contact of the thumb in pad-to-pad Palmar prehension or three-jaw chuck pinch in short opponens
prehension. that positions thumb in opposition to index and long fingers.
 Orthotics

small objects, and in tying a shoe or bow. The short and extension block is useful to limit IP hyperextension and
a
SS long opponens splints may also be fabricated to posi- to facilitate the IP flexion required for tip prehension.
tion the thumb in palmar prehension.
Cylindrical Grasp
Tip Prehension
.
Cylindrical grasp, the most common static grasp
In tip prehension the IP joint of the thumb and the DIP pattern, is used to stabilize objects against the palm and
and PIP joints of the finger are flexed to facilitate tip-to- the fingers, with the thumb acting as an opposing force
tip prehension (Fig. 31-14). These motions are neces- (Fig. 31-15). This pattern is assumed for grasping a
sary to pick up a pin or a coin. It is difficult to substitute hammer, pot handle, drinking glass, or the handhold
for tip prehension because it is rarely a static holding
ees
EE
on a walker or crutch. Splinting offers little to restore
posture. Once a pin is in the hand, tip prehension will this grasp directly, although positioning the wrist in ex-
convert to palmar prehension to provide more skin tension offers greater stability to the hand as it assumes
surface area to retain a small object. A thumb IP hyper- this grasp pattern. A dorsal wrist stabilizer offers stabil-
ity while minimizing palm coverage.

Spherical Grasp
Also called ball grasp, this pattern is assumed for
holding a round object such as a ball or apple. It
differs from cylindrical grasp primarily in the position-
ing of the fourth and fifth digits. In cylindrical grasp
the two ulnar metacarpals are held in greater flexion.
In spherical grasp the two ulnar digits are supported in
greater extension to allow a more open hand posture
(Fig. 31-16). In splinting, to facilitate or support this
pattern of grasp, the wrist-stabilizing splint must be
proximal to the distal palmar crease and contoured to
allow for the obliquity at the fourth and fifth
metacarpal heads.

FIG. 31-14
Tip prehension with thumb and index finger in interphalangeal
blocker that secures interphalangeal joint in slight flexion tovassist
tip prehension.

FIG. 31-16
FIG. 31-15 Spherical grasp in dorsal splint. Splint stabilizes wrist to increase
Cylindrical grasp in dorsal splint that stabilizes wrist to increase grip force and permits metacarpal mobility required for spherical
grip force and minimizes palm covering. grasp.
 OCCUPATIONAL THERAPY INTERVENTIONS

FIG. 31-18
Figure-eight splint substitutes for loss of intrinsic function with
median and ulnar neuropathy.
FIG. 31-17
Hook grasp does not involve thumb. Grasp pattern is seen in
median and ulnar neuropathy; splinting is aimed at correcting
rather than augmenting grasp. functions through the application of a splint is complex
and relies on an understanding of the biomechanics of
the hand and the mechanics involved in splinting. It is
beyond the scope of this chapter to present this topic in
Hook Grasp depth. Presented here is an introduction to those tenets
Hook grasp is the only prehension pattern that does not of clinical mechanics deemed necessary for the begin-
include the thumb to supply opposition. The MPs are ning splint maker.
held in extension, and the DIP and PIP joints are held Mechanics deals with the application of force, and
in flexion (Fig. 31-17). This is the attitude the hand biomechanics may be viewed as the body’s response to
assumes when holding the handle of a shopping bag, a those forces. In the hand the force required for produc-
pail, or a briefcase. In the nerve-injured hand, splinting ing motion is supplied by muscles. The force is then
is more commonly directed at correcting this posture transmitted by the tendons to the bones and joints,
than at facilitating it. with control supplied by the skin and pulp of the
fingers and palm.° How the application of a splint
affects the transmission of force to produce motion
Intrinsic Plus Grasp
depends on the relationship between the axis of rota-
Intrinsic plus grasp is characterized by the positioning tion of joints and anatomical planes and the forces
of all the MPs of the fingers in flexion, the DIP and PIP imposed on the hand.
joints in full extension, and the thumb in opposition to
the third and fourth fingers (Fig. 31-18). This pattern is
Axis of Motion
used in grasping and holding large, flat objects such as
books or plates. Intrinsic plus grasp is often lost in the Hollister and Giurintano® define axis of motion as a
presence of median or ulnar nerve dysfunction, and a stable line that does not move when the bones of a joint
figure-eight or dynamic MP flexion splint is used for move in relation to each other (Fig. 31-19). This stable
substitution. line is illustrated by Fig. 31-19, B, which shows a tire
perfectly balanced around its axis of motion. When a
tire is perfectly balanced, it does not wobble; it has pure
MECHANICS OF THE HAND
motion around a single point.
AND PRINCIPLES OF SPLINTING
In a single-axis joint, motion occurs in only one
McCollough and Sarrafian’ stated that the three basic plane. The PIP joint is an example of a single-axis joint
motor functions of the upper limb are “prehension and in alignment with an anatomical plane. It moves only in
release, transfer of objects in space, and manipulation of the plane of flexion and extension.
objects within the grasp.” These functions depend on Joints that have more than one axis of motion may
the structural integrity of the skeleton, the muscles that move in more than one plane at a time. For example,
provide power, and feedback to which the brain re- the wrist complex has two axes of motion: flexion-ex-
sponds when enabling the limb to meet functional tension and radial-ulnar deviation. A joint with multi-
demands. The task of restoring any one of these basic ple axes has conjoint motions that occur in addition to
 Orthotics 541

the primary motions described by the joint. Wrist happens as forces are applied within the body by
flexion occurs with a moment of ulnar deviation and muscles and externally by splints.
with a small degree of pronation. Wrist extension occurs
with radial deviation and slight supination. These con- Definitions
junct motions are what make circumduction of the wrist The use of the term force, as it relates to splinting, de-
possible. They are also what makes splinting the wrist scribes the effect materials and dynamic components
with hinged joints a challenge. have on bone and tissue. Force is a measure of stress,
A splint with a movable hinge or coil has a single friction, or torque. Stress is resistance to any force that
axis. When used to splint a single-axis joint such as a PIP strains or deforms tissue. Shear stress occurs when force
joint, a hinge can and should be properly aligned to is applied to tissues at an angle or in opposing direc-
avoid binding that will limit motion. If a single-axis tions. Pinching skin between the surface of a splint and
hinge or coil is used to reproduce motion in a multiaxis the underlying bony structures causes shear stress.
joint, there will always be some binding or friction, no Friction occurs when one surface impedes or prevents
matter how well aligned, because the hinge or coil does gliding of a surface on another. Friction is produced in
not allow for, or reproduce, the conjunct motions avail- the stiff or contracted joint when soft-tissue restriction
able in the unsplinted joint. prevents gliding of the bones. Splints may contribute to
friction if they are misaligned in relation to a joint axis.
For example, a hinged splint that is not properly aligned
Force
with the axis of rotation will limit motion by producing
It is crucial to understand basic principles of force and friction as the joint attempts to move.
apply them correctly in splinting. An understanding of Torque is a measure of the force that results in rota-
the forces applied by levers and the stresses that occur tion of a lever around an axis. The torque created when
between opposing surfaces can help explain what a lever rotates depends on the force used and the length
of the lever employed. In the body, muscles are the
levers that create torque when they act to move a joint.
Externally, splints may act as levers to apply the force
A
necessary to move a bone around its axis. The measure
of torque is given by the formula:
Torque = (amount of) Force X (length of) Lever arm

Internally, the length of the lever arm is measured as

Not aligned
with axis
the perpendicular distance from the axis of the joint to
of rotation the tendon. Externally, the length of the lever arm is
measured as the estimated distance from the joint axis
to the attachment of force. In splinting, the attachment
point of the force is usually a soft or molded cuff. If the
splint includes an outrigger with a finger cuff, as shown
in Fig. 31-20, the lever arm is the distance from the axis
of the joint to the finger cuff, as indicated in line M.
It can be seen in the illustration in Fig. 31-20 that the
angle of approach of the force to the finger also affects
B the length of the lever arm and ultimately the torque
applied. The angle of approach is the angle that the line
of traction makes as it meets the part being splinted.
When the angle of approach is at a right angle (90°) to
the long axis of the phalanx, the lever arm is M. When
Aligned with the cuff is at less than 90° to the long axis of the
axis of rotation phalanx, the lever arm is shortened to M1. This shorter
lever arm will produce less torque and therefore less
rotation unless greater force is applied.
Given an equal amount of resistance or load, a 2-foot
lever will require half as much force to create motion
FIG. 31-19
A, If a tire is not balanced around its axis, it wobbles. If a splint around an axis as will a 1-foot lever. The important
hinge is not aligned with joint axis, wobble is seen as binding of principle for splint makers is that the greater the dis-
joint. B, Proper alignment of a tire or of a hinge with anatomical tance between the attachment of the cuff or strap to the
joint results in smooth, unimpeded motion. joint axis, the less the force required to achieve motion.
542 OCCUPATIONAL THERAPY INTERVENTIONS

M Line |

FIG. 31-20
Tension F on the phalanx has a moment arm of M acting on the
joint. Tension F! has a smaller moment arm, M1], (with less result-
ing torque) when the angle of approach is not 90°. (From Brand
PW, Hollister A: Clinical mechanics of the hand, ed 2, St Louis, 1993,
Mosby).

FIG. 31-22
As dynamic traction acts on range of motion at the proximal in-
terphalangeal joint, splint must be adjusted to maintain 90° angle of
approach.

joint compression or distraction may lead to mere dis-

comfort or to actual joint damage. Translational force
also is undesirable because it undermines the effective-
ness of the splint by shortening the lever arm.°
The challenge in splinting with an outrigger is to posi-
FIG. 31-21 tion the splint so there is a 90° angle of approach. In the
A, Angle of approach is 90° to middle phalanx, ensuring force outrigger in Fig. 31-22, as long as the finger does not
pulling proximal interphalangeal joint in to extension is not dissi-
move, the 90° angle will remain. As soon as the finger
pated. B,Angle of approach less than 90° to middle phalanx causes
moves, however, the 90° angle changes. Since few outrig-
joint compression. C,Angle of approach greater than 90° distracts
joint. gers allow for this automatic readjustment in position, it
is important to adjust the outrigger as the contracture
lessens in order to maintain the 90° angle of approach.

Translational Forces
SPLINT CLASSIFICATIONS
In addition to the angle of approach affecting the length
of the lever arm, an approach of less than or greater Splints may be described in a number of ways. Termi-
than 90° results in translational forces. The outrigger nology varies, and it is useful to understand some of the
splint in Fig. 31-21, A, shows a 90° angle of approach ways splints may be described. For purposes of clarity,
between the nylon line and the phalanx, producing splint classifications are described here according to
only rotation around the axis of the joint. type, purpose, and design.
When force is applied at any angle other than 90°, One reference to be considered when discussing clas-
translational forces are created. This alteration of the sification is the Splint Classification System (SCS)' pub-
angle of approach translates some of the rotational lished by The American Society of Hand Therapists
force away from producing joint extension and directs (ASHT). The SCS describes splint nomenclature based
the force into joint compression or joint distraction on the functional requirement of a splint, as well as on
(Fig. 31-21, B and C). The greater the deviation from the anatomy affected. This nomenclature is quite inclu-
90°, the greater the translational force. Depending on sive of the broad variety of UE splints fabricated by oc-
the type of splint and the condition of the joint, the cupational therapists and is suggested for study.
 Orthotics

FIG. 31-23
Forearm-based four-digit outrigger with dynamic extension assist
supplied by springs. FIG. 31-25
A series of cylindrical plaster casts is made to reduce flexion con-
tracture at proximal interphalangeal joint.

FIG. 31-24
Single-surface static resting splint positions hand in 20° to 30°
wrist extension, 45° to 60° metacarpophalangeal flexion, and 15°
to 30° proximal interphalangeal and distal interphalangeal flexion.

Splints Classified by Type

FIG. 31-26
Dynamic splints include one or more resilient compo- Static progressive web strap adjusts with hook closure. Patient is
nents (elastics, rubber bands, or springs) that produce taught to adjust strap as tolerance permits.
motion. The force applied from the resilient component
is constant even when tissues have reached end range.
Dynamic splints are designed to increase passive ment repositions the part at the end of the available
motion, to augment active motion by assisting a joint range to progressively gain passive motion. A cylindrical
through its range, or to substitute for lost motion. cast designed to reduce a PIP joint flexion contracture
Dynamic splints generally include a static base on which through frequent removal and recasting is a classic
to attach the movable, resilient components (Fig. 31-23). example of a serial static splint (Fig. 31-25).
A static splint has no movable components and im- Static progressive splints include a static mechanism
mobilizes a joint or part. Static splints are fabricated to that adjusts the amount or angle of traction acting on a
rest or protect, to reduce pain, or to prevent muscle part. This mechanism may be a turnbuckle, cloth strap,
shortening or contracture. An example of a static splint nylon line, or buckle. The static progressive splint is dis-
is a resting pan splint that maintains the hand in a func- tinguished from the dynamic splint by its lack of a re-
tional or resting position (Fig. 31-24). silient force. It is distinguished from a serial static splint
A serial static splint achieves a slow, progressive in- in having a built-in adjustment mechanism so that the
crease in ROM by repeated remolding of the splint or part can be repositioned at end range without the need
cast. The serial static splint has no movable or resilient to remold the splint. Generally the static progressive
components, but rather is a static splint whose design mechanism can be adjusted by the patient as prescribed
and material allow repeated remoldings. Each adjust- or as tolerated (Fig. 31-26).
 OCCUPATIONAL THERAPY INTERVENTIONS

FIG. 31-27
Oval-8 ring splints. A, Ring splint restricts proximal interphalangeal joint hyperextension. B, Ring
splint allows full flexion.

Splints Classified by Purpose

Though nomenclatures may vary, the categories pre-
sented in the splint classification system (SCS) describe
splints in functional rather than in design terms.’ The
SCS describes three overriding purposes of splints: re-
striction, immobilization, and mobilization. The publi-
cation also lists many functions of splints, each of which
is placed in one of three categories. Splints may fulfill
more than one function or purpose, depending on the
method of fabrication and the problems they address.
FIG. 31-28
Restrictive Splints Spring coil splint substitutes for absent wrist extension in radial
nerve injury.
Restrictive splints limit joint ROM but do not com-
pletely stop joint motion. One example is the splint in
Fig. 31-27 that blocks PIP joint hyperextension while al- lost because of nerve injury or muscle dysfunction (Fig.
lowing unlimited PIP joint flexion. Semiflexible splints 31-28). The splint may attempt to balance the pull of
are available that limit motion at the extremes of range unopposed spastic muscles to prevent deformity, as well
but allow motion in the middle of range. Although the as to assist function. A splint may resist a weak muscle
splint may be restrictive, the goal or function of the to improve its strength or to facilitate tendon gliding
splint may vary. after tendon surgery. Frequently, a mobilizing splint is
used to increase the ROM of a contracted joint.
Immobilizing Splints
Immobilizing splints may be fit for protection to prevent
Splints Classified by Design
injury, for rest to reduce inflammation or pain, or for po-
sitioning to facilitate proper healing after surgery. The After the purpose of the splint has been determined, the
classic example is the resting pan splint (see Fig. 31-24) next decision relates to its design. Each of the types of
that serves two of the three functions. A resting splint fit splints described earlier (static, dynamic, serial static,
for a patient after a cerebrovascular accident (CVA) posi- and static progressive) may be fabricated as a single
tions the wrist and digits to prevent contractures and can surface design, a circumferential design, or a three-point
protect the desensate hand against damage. design. A final category, the loop design, is generally
limited to acting on finger IP joints by providing a loop
Mobilizing Splints of material that wraps around the joints to restore the
Mobilizing splints are designed to increase limited final degrees of joint flexion.
ROM or to restore or augment function. A mobilizing All splints are designed to provide some degree of
splint may assist a weak muscle or substitute for motion force. That force may be distributed as a continuous
 Orthotics

FIG. 31-30
Three-point pressure splint with spring wire reduces proximal in-
terphalangeal joint flexion contractures of 35° or less.

FIG. 31-29
Final flexion strap designed to restore full interphalangeal joint FIG. 31-31
flexion provides equal force on all surfaces of the digit. Single-surface splint requires properly placed straps to create
three-point pressure systems to secure splint and ensure distribu-
tion of pressure.
loop, with equal and opposing forces wrapping around
two or more joints (Fig. 31-29). More commonly the
force is applied through three points of pressure (Fig. The dynamic finger-based three-point splint just de-
31-30). Although the loop design is generally used only scribed is a unique design that does not adhere to the 90°
on finger IP joints, some variation of the three-point rule. That is, when the splint is applied to a joint with a
pressure design is used in all other splints. flexion contracture, the angle of approach of the line of
Three-point finger splints that incorporate springs, traction is never 90°. The more severe the contracture,
spring wire, or elastics are often used to correct DIP and the more translational force is present; therefore it is less
PIP joint flexion contractures. A flexion contracture exists effective than a properly contoured outrigger splint that
when a joint will not move passively out of aclosed posi- adheres to the 90° rule. This design should be fitted only
tion into extension. These designs include two points of in the presence of IP joint flexion contractures of 35° or
pressure, one proximal to the joint and one distal, and less. For finger contractures in excess of 35° a hand- or
the third or central opposing force acting directly over or forearm-based outrigger splint is recommended because
close to the joint, as in Fig. 31-30. In a three-point finger it can be positioned to apply force at a 90° angle of
splint the force of the central point is equal to the sum of attack. Alternatively, a conforming, serial static splint can
the two forces of the correcting points. This fact is clini- be used, as described in the section on traction.
cally important because tissue tolerance under this
central point may be insufficient and may react with pain Single-Surface or Circumferential Design
and inflammation. This problem is seen frequently at the If amolded splint is to be fabricated, the next decision is
PIP joint where there is limited surface area over which whether to use a circumferential or single-surface
to distribute pressure. It is important to distribute pres- design. Single-surface splints are fabricated to cover
sure with contoured surfaces that are as broad as possible only one surface, either the palmar or dorsal surface of a
and to adjust the spring or elastic force and the wearing limb or the ulnar or radial half of the hand or forearm.
time to tolerance. Proper padding incorporated into the Straps are added to create the three points of pressure
splint can also aid in distributing pressure. necessary to secure the splint (Fig. 31-31).
546 OCCUPATIONAL THERAPY INTERVENTIONS

WHEN TO SPLINT AND WHEN

Circumferential splints wrap around a part, covering
NOT TO SPLINT
all surfaces with equal amounts of pressure (Fig. 31-32).
Straps are used solely to close the splint or to create an A first step in deciding which splint style and design to
overlap. Thinner materials can be employed in molding choose is determining if the patient is a good candidate
a circumferential splint, since the increased contours in for wearing a splint. Several issues should be examined
the material add to the splint’s rigidity. That contours in this regard.
add strength to materials is clearly seen when corruga-
tions that create contours are added to paper to increase
Compliance Issues
strength. Circumferential splints then can be made
lighter and out of highly perforated materials for air cir- First, the therapist must consider whether the patient is
culation without a sacrifice of control. likely to comply with the splinting program. The splint
may have a negative effect on the patient's ability to be
Indications for Single-Surface Splinting independent in self-care or to function at work. Some
Single-surface splinting is effective for supporting joints patients are extremely sensitive about their appearance
surrounded by weak or flaccid muscles, such as follow- and refuse to wear a splint if it offends their aesthetic
ing a CVA or peripheral nerve injury. Because little or no sense. Compliance with a splinting program may be
active motion is available, the extra control given by cir- poor if the patient’s general level of motivation to get
cumferential splinting is not needed, and donning and better is low. On the other hand, some patients are so
doffing the splint will be easier. A single-surface splint is highly motivated that they will overdo the splinting
also effective as the base for attaching outriggers in program and cause themselves damage. Finally, the
dynamic splinting and for postoperative splints in patient's cognitive and perceptual ability to follow a
which the fabrication of a circumferential splint may splinting program should be considered, especially if
damage repaired structures. there is no responsible caretaker.

Indications for Circumferential Splinting

Ability to Don and Doff a Splint
Circumferential splinting is effective for immobilizing
painful joints or for protecting soft tissue (Fig. 31-32). Even if compliance is not an issue, there may be prob-
Because the circumferential design gives comfortable, lems with the patient's donning and doffing (putting
complete control, it is particularly helpful when the on and removing) the splint. For example, the patient
patient has active motion and will be wearing the splint may have no one at home to assist in donning and
during activity, when shear forces can be a problem. doffing a difficult splint. The hospitalized patient may
This comfortable, complete control also makes a cir- not have adequate staff for help with following the
cumferential design useful for serial static splints used wearing schedule or applying the splint correctly.
to reduce contractures. The control a circumferential
design supplies also makes it a good design for stabiliz-
Skin Tolerance and Hypersensitivity
ing proximal joints when outriggers are applied to act
on more distal joints. The therapist must assess the skin condition of the
patient before deciding to fit a splint. If the patient
suffers from brain or spinal cord damage, he or she may
be diaphoretic and produce excessive perspiration, that
can lead to rapid skin maceration. Some patients are in-

A ds
tolerant of any pressure because of extremely thin and
fragile skin. Patients with sensory dysfunction may be
hypersensitive and unable to tolerate many hard or even
soft splints. If any of these issues exist and cannot be
ameliorated, safe alternative therapeutic interventions
must be substituted for the splint.

Wearing Schedule
If none of the preceding issues prevents the patient from
being a candidate for splinting, the therapist must decide
FIG. 31-32 a V on the best wearing schedule for the splint. Nighttime
Circumferential splints create multiple three-point pressure may be the optimal time for the patient to wear a static
systems to secure splint for immobilization. splint designed to change ROM. It is also the time when
 Orthotics

patients need resting splints to prevent them from sleep- the splint is being made, and how and where that splint
ing in positions that damage the hand. During the is going to fit. Ultimately a properly fitted pattern will
daytime the patient may wear a dynamic splint or a make the entire fabrication process easier and faster and
splint designed to assist function. It is often best to min- will increase the chance of success.
imize splinting during the day if possible, so that the The process of making a pattern involves an under-
' patient can use his or her hand as normally as possible. standing of the geometry of the hand and the materials
to be used, as well as a bit of old-fashioned dressmak-
SPLINT FABRICATION PROCESS ing. Understanding how positional changes alter length
and how depth and width relate to the pattern is para-
Step One—Creating A Pattern
mount to success.
Once the decision has been reached to fabricate a splint, ’ The common technique of making a pattern starts
arguably the most important step in the fabrication with a tracing or outline of the hand. This is generally
process is deciding on and creating a pattern. Although taken with the hand lying flat when possible, or by
it may seem elementary even to the novice splint maker, tracing the uninvolved hand if necessary. An amount is
this step can determine the success of the splint in terms added to this outline to approximate the width and
of both fit and function. Allowing the time to make a length needed for the splint. A common error in this
well-thought-out and properly fitted pattern gives the technique is not taking into account the position in
splint maker the chance to deal with such issues as what which the hand (or other body part) will ultimately be
he or she is trying to accomplish with the splint, why held in the splint.
Fig. 31-33, A and B, shows a pattern taken with the
hand lying flat, without adding any length to the
pattern. In Fig. 31-34, when the pattern is fit on the
volar surface of the hand with the hand in functional
position (the wrist in 35° of extension, the MP joints
at 70° of flexion, and the IP joints in 10° to 20° of
flexion), the pattern extends beyond the fingertips and
is in fact too long. The same pattern on the dorsum of
the hand (Fig. 31-35) with the wrist now in flexion il-
lustrates that the pattern is now too short. Going from
the volar surface of the hand to the dorsal surface is
akin to driving around the inside of a curve as opposed
to the outside of a curve. As any race car driver knows,
the inside of a curve is the shorter distance. Altering
the position of the hand and altering the surface to
which the splint will be fit alters the length of the
pattern. The splint maker must accommodate for this

FIG. 31-33 FIG. 31-34

A, Tracing with pencil perpendicular to arm creates a true size Pattern is too long when fit on the volar surface with hand in
pattern. B, Pattern is full length with hand flat. resting position.
 OCCUPATIONAL THERAPY INTERVENTIONS

FIG. 31-36
Forearm trim lines. A, Trim lines are too high, extending above
forearm. Straps will bridge arm and be ineffective. B, Trim lines too
low. Straps cannot substitute for too-low trim lines without apply-
ing excessive pressure. C, Midline trim lines ensure straps properly
secure splint on arm and hand.
FIG. 31-35 E
Pattern is too short when fit on dorsum of hand with wrist and
fingers in flexion.

FIG. 31-37
A, Narrowing the proximal pattern will cause trim lines to drop below midline. B, Flaring the prox-
imal border of the splint maintains trim lines at midline.
 Orthotics 549

by checking the splint pattern on the hand in the posi-

tion in which the hand will be splinted.
Depth is the second dimension that needs to be
considered when a pattern is made. The ideal trim
lines of a single-surface splint will fall at midline
along the arm, hand, leg, or foot. A splint trimmed at
midline will provide optimal support and will allow
for proper strapping to help secure the splint in place
(Fig. 31-36).
To determine how much to add to the outline to
achieve midline trim lines, the maker must observe the
width and depth of the arm or hand. The forearm is a
cone shape, not a straight cylinder, and it graduates in
depth over the forearm muscle. Even the thinnest
forearm graduates in width and depth proximally.
Persons with significant muscle bulk may have gradua-
tion at quite an acute angle from the wrist to the proxi-
mal forearm. Determination of how much to add to a
forearm trough must consider how much the splint
must come out, around, and up the forearm to reach
midline. The depth of the hand, particularly the depth
of the hypothenar eminence, must be known to create
the proper trimlines for a hand platform. FIG. 31-38
It is important in the fit of any forearm-based splint Length of forearm-based splint is checked by flexing elbow and
that the proximal trimlines take advantage of the soft noting where biceps meets forearm. Splint is trimmed 4 to 4 inch
muscle bellies that protect the radius and ulna. The distal to point of contact.
proximal borders of the splint should be flared so that
the trimline remains at midline to help secure the splint
in place on the arm (Fig. 31-37).
A forearm-based splint should extend approxi- have certain characteristics that can be defined accord-
mately two thirds of the length of the forearm, as ing to how a material reacts or handles when warm and
measured from the wrist proximally. A good rule to re- how it reacts once molded.
member is to bend the patient's elbow fully and mark Choosing the optimal material for a given splint ap-
where the forearm and the biceps muscle~meet. The plication can make the difference between a quick and
splint should be trimmed '/; inch below this point to easy splint-making process or one that requires exten-
avoid limiting elbow flexion and to prevent the splint sive adjustments and reheating. It behooves every splint
from being pushed distally when the elbow is flexed maker, novice to advanced, to sample a variety of mate-
(Fig. 31-38). rials and test for the handling characteristics so no sur-
Most low-temperature thermoplastics used to make prises occur when a material is heated and ready to be
splints will stretch to conform around angles and con- cut and fitted to a patient.
tours. When a pattern is created that will go around an
acute angle, such as a 90° angle around a flexed elbow Characteristics of Splint Materials
or wrist, the pattern should include a dart where the Each LTT has some handling characteristics that apply
material can be overlapped without causing undue bulk when the materials are warm and pliable and some that
(Fig. 31-39). The pattern may also be angled where nec- apply when they are cold or molded. The following is a
essary to accommodate acute angles. A well-fit and list of the most common characteristics and how they
thought out pattern translates to less material wasted, contribute to the choice of a material for a specific ap-
less expense, and shorter fabrication time. plication.

RESISTANCE TO STRETCH. Resistance to stretch

Step Two—Choosing Appropriate Material
describes the extent to which a material resists pulling
The materials commonly used for custom fabricated or stretching. The greater the resistance, the greater the
splints are those in a family of plastic polymers that degree of control the splint maker will have over the
become pliable at a temperature low enough for the material. Materials that resist stretch tend to hold their
material to be molded directly on the skin. The low- shape and thickness while warm and can be handled
temperature thermoplastics (LITs) available today more aggressively without thinning. The more resistive
550 OCCUPATIONAL THERAPY INTERVENTIONS

FIG. 31-39
Drawing darts in elbow pattern allows material to be overlapped and contoured without excess
material.

materials are recommended for large splints and for overstretching and fingerprints in the material. Materi-
splints made for persons who are unable to cooperate in als with a high degree of drape are not recommended
the fabrication process. In contrast, the less resistance to for large splints or for uncooperative patients. They are
stretch a material has, the more the material is likely to ideal, however, for splinting postoperative patients
thin during the fabrication process and the more deli- when minimal pressure is desired and for dynamic
cately it must be handled. The advantage of stretch is splint bases where conformability secures the splint
seen in the greater degree of conformability obtained against migration (movement distally) when compo-
with less effort on the splint maker's part. nents are attached. Materials with a low degree of
drape must be handled continuously until the materi-
CONFORMABILITY OR DRAPE. Resistance to als are fully cooled to achieve a contoured fit and
stretch and conformability or drape describe nearly the often will not conform intimately around small parts
same characteristic; that is, if a material stretches such as the fingers.
easily, it will have better drape and conformability. The
great advantage of materials with a high degree of MEMORY. Memory is the ability of a material,
drape or conformability is that with a light, controlled when reheated, to return to its original, flat shape after
touch or simply the pull of gravity, they readily it has been stretched and molded. The advantage of
conform around a part for a precise fit, with minimal high memory in a material is that the splint can be re-
effort on the splint maker's part. The disadvantage of molded repeatedly without the material thinning and
materials with a high degree of drape (and generally losing strength. Materials with memory require han-
also low resistance to stretch) is that they tolerate only dling throughout the splint-making process because
minimal handling, and care must be taken to prevent until they are fully cooled and molded, they tend to
 Orthotics yon |

return to a flat shape. This and the slightly longer SOFT SPLINT MATERIALS. Soft, flexible materials
cooling time of materials with high memory can be such as cotton duck, neoprene, knit elastics, and plastic-
used to advantage with patients who require more ag- impregnated materials may be used alone or in combina-
gressive handling to achieve the desired position. Dis- tion with metal or plastic stays to fabricate semiflexible
advantages of materials with excellent memory are their splints. These materials allow fabrication of splints that
‘tendency to return to a flat sheet state when an area is permit partial motion around a joint, yet still limit or
spot heated for adjustment and their need for longer protect the part. Semiflexible splints are sometimes used
handling to ensure that they maintain their molded during sporting activities and to assist patients with
shape until fully cooled. chronic pain in returning to functional activity. Semiflex-
ible splints are also used for geriatric patients and patients
RIGIDITY VERSUS FLEXIBILITY. Rigidity and flex- with arthritis who often cannot tolerate rigid splints.
ibility in cold splint material are terms describing the Neoprene splints can be fabricated with use of a
amount of resistance a material gives when force is sealing glue or iron-on tapes. Careful attention must be
applied to it. A highly rigid material is very resistive to given to the patterns for soft splints because the
applied force and may, with enough force, break. A support they offer relies primarily on achieving a
highly flexible material bends easily when even small secure fit without gapping or excess material. Most
force is applied to it, and it is not apt to break under other soft materials require sewing, and the fully
high stress. Materials are available that fall all along this equipped OT department should include a sewing
continuum. machine. A sewing machine is useful for adapting and
Generally, the thicker a thermoplastic and the more adjusting prefabricated soft splints to ensure that each
plastic its formula contains, the more rigid the material splint that leaves the clinic is indeed custom fit, if not
will be. Thermoplastics come in thicknesses from '/s custom fabricated.
inch (3.2 mm) to as thin as is inch (1.6 mm). The
thinner materials and the thermoplastics that contain Choosing the Best Category of Material
tubberlike polymers in their formula tend to have for the Splint
greater flexibility in their molded state. Flexibility in a Although an experienced splint maker can make many
material allows for easier donning and doffing of cir- types of splints from the same material, it is better to
cumferential splints and may be desirable for patients choose a material with the appropriate handling char-
unable to tolerate the more unforgiving rigid materials. acteristics for the type of splint being made. The fol-
Rigidity is also a factor of the number and depth of the lowing list can be used as a guideline from which to
contours included in the design. A material may yield a start choosing materials for different applications. The
semiflexible splint when used to make a single-surface availability of materials and the experience level of the
splint with shallow contours, and rigid when used to therapist will further determine the most appropriate
make a tightly fit circumferential splint. . material.

BONDING. Bonding is the ability of a material to FOREARM- AND HAND-BASED SPLINTS. Splints
adhere to itself when warmed and pressed together. need close conformability around a part when they
Many materials are coated to resist accidental bonding serve as a base for a dynamic splint, stabilize a part of
and require solvents or surface scraping to remove the body, reduce contractures, remodel scar tissue, or
the coating in order to bond. Uncoated materials, immobilize to facilitate healing of an acute condition.
which require no solvents or scraping, have very strong Such splints should be made from a material with a
bonding properties when two warm pieces are pressed high degree of conformability to achieve a conforming
together. Self-bonding is helpful when outriggers or fit. When conformability is not crucial, the splint can be
overlapping corners are applied to form acute angles made from a material with high resistance to stretch
but can be a problem if two pieces adhere accidentally. and low to moderate drape. Splints fabricated for burns
and other acute trauma do not require as conforming a
SELF-SEALING EDGES. Self-sealing edges are fit and can be made from low-drape materials. Materials
edges that round and seal themselves when heated that resist stretch and tolerate aggressive handling are
material is cut. This characteristic produces smooth also recommended for positioning of a spastic body
edges that require no additional finishing, which adds part, since such a material will not stretch and thin
time to the fabrication process. Materials with little or during the splint-making process.
no memory and high conformability generally
produce smooth, sealed edges when cut while warm. LARGE UPPER AND LOWER EXTREMITY
Materials with memory, or those that have a high re- SPLINTS. Long splints fabricated for the elbow, shoul-
sistance to stretch, resist sealing and require additional der, knee, or ankle should generally be made of materi-
finishing. als that have high resistance to stretch to provide the
552 OCCUPATIONAL THERAPY INTERVENTIONS

control necessary for dealing with large pieces of mate-

rial. Such splints generally do not need to be highly
conforming because they are molded over broad ex-
panses of soft tissue. Care must be taken to provide
relief for bony prominences or to provide padding to
distribute pressure.

CIRCUMFERENTIAL SPLINTS. A splint designed to

wrap all the way around the part should be fabricated
from materials that have a high degree of memory and
that tolerate stretching without forming thin spots. The
materials should be highly perforated, thin, or able to
be stretched evenly. After being stretched, these materi-
als will cinch in around the body part but still allow suf-
ficient flexibility for easy donning and doffing. These
materials work very well for fracture bracing and for cir- FIG. 31-40
cumferential splints that are used for contracture reduc- Easily adjustable Phoenix outrigger with slotted pulleys allows fre-
tion and for stabilizing or immobilizing joints. Another quent changes in angle of approach.
choice for making less restrictive circumferential splints
is the use of semiflexible materials, which facilitate easy
donning and doffing and allow limited motion within
the available arc of motion. Spring coils are best suited to assist weak muscles or
substitute for paralyzed muscles (Fig. 31-28). Patients
SERIAL SPLINTS. Serial splints that require fre- with weak or paralyzed muscles will likely require the
quent remolding to accommodate increases in joint splint for a long time and will wear it while working or
range of motion should be made from a material that performing their ADL. The low-profile, lightweight con-
has considerable memory or is highly resistant to struction of a coil splint is recommended because it is
stretch to avoid thinning with repeated remolding. The less likely to interfere with hand function. Spring coils
chosen material should have moderate to high rigidity retain their force and alignment over time, rarely require
when molded to resist forces from contracted joints or adjustment, and are ideal for long-term conditions.
from spastic muscle tone. Splints with outriggers are the optimal choice for
splinting postoperative patients (Fig. 31-40). These
splints allow frequent adjustments to maintain correct
Step Three—Choosing the Type
positioning and to accommodate changes in bandage
of Traction
thickness and edema as the healing and rehabilitation
All splints provide some form of traction to move or progresses. The postoperative patient will likely use the
stabilize a joint or joints. The traction mechanism may splint for only a short time, generally 4 to 6 weeks. Such
be dynamic, using a spring, hinge, or elastic. Traction a patient will not be returning to normal functional ac-
may also be static, employing straps or turnbuckles or tivities with the affected hand during that time. Thus the
involving remolding of the splint base itself. If the bulkiness and limitation of function with an outrigger
mechanism moves or is resilient, the splint is called a splint are relatively unimportant.
dynamic splint, and if it does not move, the splint is Splints with outriggers are also used for contracture
called a static splint. The following section describes the reduction. For this purpose they are generally most effec-
various options for applying traction and discusses the tive when used during the early stages of healing when
appropriate uses of each option. the contracture feels soft and is easy to reduce.* Fre-
quently patients at this stage still have pain and inflam-
Dynamic Traction mation. They cannot tolerate a rigid, static splint, but
The purpose of dynamic splints is the mobilization of a they will tolerate a light force provided by an outrigger.
joint through the use of a resilient force attached to an
outrigger or through the use of a spring coil. Each mech- Static Traction
anism of force has advantages and disadvantages that The overall purpose of static splints is to apply traction
make it suited for some uses and ill suited to others. The to immobilize or restrict motion. When static splints
construction techniques differ substantially when immobilize, they are protecting, resting, or positioning.
spring coils are used, versus outriggers with elastic com- When they restrict, they are blocking motion, aligning
ponents. Thus the indications for each style of splint joints, or limiting motion. When static splints are used
vary. to mobilize, they are used in either a serial static or static
 Orthotics 553

progressive fashion to reduce contractures and remodel strapping or contouring may actually apply pressure in
scar. areas that the splint was designed to relieve.

Serial Static Traction AMOUNT OF FORCE TO APPLY. How much force

A serial static splint is fabricated by repeated adjust- can be applied safely? There are no absolute rules about
_ ments that position a joint at its end range of motion the amount of force that can be applied for immobiliza-
each time to achieve slow, progressive increases in ROM. tion or to a restricted joint to produce motion. The
For example, a cylindrical cast made for gaining PIP ex- splint maker must apply sufficient force to create
tension must be remade after a time (usually 1 to 3 motion, but not so much as to cause ischemia. Much
days) to reposition the joint at the end of its range of depends on the degree of the contracture, how long the
motion (Fig. 31-25). restriction has existed, the age of the patient, and the lo-
cation of the restriction. This leaves the therapist with
Static Progressive Traction several options when choosing which force and how
A static progressive splint requires a built-in mechanism much force to apply.
for adjusting the traction. Choosing which mechanism For example, external force in dynamic splints is
to use, be it a turnbuckle, Velcro strap, or buckle, generally applied through the addition of rubber
depends on availability, the therapist's experience, and bands, elastic, or springs. Neither option is ideal, and
the patient's ability to manage the mechanism. A good both require careful selection and frequent adjustment.
tule to follow is to choose the simplest component that The amount of force supplied by rubber bands and
will achieve the desired goal. springs depends on both their thickness and _ their
Serial static splints and static progressive splints each length. The thickness of the band or spring determines
have certain advantages and disadvantages. Serial static its potential force, whereas the length of the band or
splints are useful for difficult patients who have high spring (or the number of coils in the spring) deter-
muscle tone or who are cognitively impaired and would mines the ROM through which the force can be
have problems with the adjustment mechanisms. Also, applied. When either bands or springs are used, it is de-
the therapist has the control necessary for patients who sirable to use the optimal force (i.e., the greatest tolera-
are noncompliant or who would be overly zealous and ble force over the longest wearing time) that does not
apply too much force. The disadvantages are that the produce ischemia. To accomplish this, the midrange of
splint requires more therapist time because it must be the bands or springs should be used, rather than their
remolded many times and that if the patient does not end ranges, which are either too slack or too strong. A
remove it for several days, some ROM may be lost in the gauge is available for measuring the applied force of
direction opposite to that in which the splint is apply- elastic, which should generally be between 100 and 300
ing force. grams.
The advantages of a static progressive splint are that Techniques are available for avoiding pressure areas
the therapist has to make only one splint and that reli- and shear forces in a dynamic splint, particularly where
able patients with normal muscle tone may make traction is applied to mobilize a finger joint. First, it is
more rapid progress because they can tailor the adjust- important to stabilize the joint(s) proximal to the finger
ment to their own pace and tolerance. The disadvan- joint being splinted. For instance, to mobilize a PIP
tage of a static progressive splint is that it cannot be joint with an outrigger and cuff, the MP joint must be
used on the patient who has abnormal tone or who is held securely so that no movement occurs to cause the
unreliable. splint to produce pressure points elsewhere on the hand
or digits. Care must be taken in the contouring of the
IMPLICATIONS OF APPLICATION OF FORCE. All splint around the proximal phalanx to distribute pres-
splints, whether static or dynamic, apply force and to sure and prevent motion that could cause shearing over
some degree stress on the structures they contact. The the dorsum of the finger. In this case, padding may be
unimpaired hand tolerates a wide range of stresses by necessary to help distribute pressure over the small and
adaptation when possible and by avoidance when not. thinly padded phalanx (Fig. 31-41).
The patient with sensory or cognitive impairment may
lack the protective responses necessary to reposition the DURATION OF TRACTION. Basic to answering the
hand away from the stresses applied by splints. question, “How long should traction be applied?” is an
Pressure causes ischemia (localized anemia caused understanding of theories of tissue stretching versus
by obstruction of blood supply to tissues), and pressure tissue growth. Three key concepts aid in the under-
increases when splints are contoured too sharply, when standing of these two different tissue responses. First,
they do not conform uniformly, or when they do not all materials, including human tissue, respond to
cover a broad enough area of soft tissue. Splints that applied stress. If stress is applied over time and then
migrate or move on the hand because of insufficient relaxed, the tissue will no longer return to its original
 OCCUPATIONAL THERAPY INTERVENTIONS

The difference in these two approaches is one of time

and of being able to judge the elastic limits of tissue.
The first approach relies on principles of stress relax-
ation, which theorizes that tissues reach their elastic
limit over a shorter period with frequent repositioning
and will retain this newly set limit over time.? The
second and more commonly used approach relies on
the application of a low load over a long time to allow
tissue growth to occur. Both approaches have merit, and
it is up to the therapist and prescribing physician to de-
termine the appropriate approach in each instance.

Step Four—Choosing a Splint Design

for a Given Purpose
FIG. 31-41
Felt padding distributes pressure over bony proximal phalanx. Mobilizing Splints to Remodel Scar Tissue
and Reduce Contractures
Scar tissue is one of the major contributors to deformity.
Anytime there is an insult to tissue, as occurs after an
shape but will adapt to the new shape. This stretching open injury or after surgery, scar tissue is produced by
phenomenon in skin is a result of its plastic behavior the body to heal the wound. The scar may be subcuta-
and is known as creep. The lengthening that occurs with neous, superficial, or both. When it is subcutaneous, it
creep is found to be the result of “a slippage of short often results in loss of motion because it acts like glue,
collagen fibers on one another within the tissue. Some keeping tissue planes from gliding. Scar also contracts,
fibers may rupture while others just slide on each and when that contracture occurs over a joint, loss of
other.”* joint motion results. To restore motion, scar tissue must
The second concept is that of the elastic limit of be remodeled; that is, it must be softened and length-
tissue. Think of pulling on a rubber band. As the band is ened. If the contracture is caused by shortened soft
pulled, tension increases until the elastic limit is tissue that is not scar, that soft tissue must also be
reached. If pulled beyond its elastic limit, the rubber lengthened. The process is the same for scar or soft
band will break. In clinical terms the end of the elastic tissue.
limit is the point of tissue elongation at which pain will The effectiveness of splinting for remodeling scar and
be felt and tissue damage may occur. Stretching tissue reducing contractures can be increased greatly by apply-
beyond its elastic limit does not lead to permanent ing a deep heat modality, such as paraffin or moist heat,
lengthening, but instead to unwanted tearing and prob- before applying the splint. When tissue is unheated it is
able further tissue contracture.* less elastic, meaning it has a great deal of tension and is
For creep to occur in living tissue, traction must hold difficult to elongate. With the application of heat, tissue
the skin with sufficient force to exceed the skin's elastic becomes temporarily more elastic, meaning that the
limit. This may cause tearing of small fibers and possi- tension in the tissue is reduced and the tissue is much
ble hemorrhaging, leading to inflammation and addi- easier to elongate.
tional scarring caused by fibrogen deposits. There are many approaches to splinting for remodel-
The third concept is tissue growth. True growth ing scar and reducing contractures. Three-point splints
occurs when “living cells will sense strain and collagen can be used for flexion contractures, loop splints for IP
fibers will be actively and progressively absorbed and joint extension contractures, and outriggers for MCP ex-
laid down again with modified bonding patterns with tension contractures. Dynamic outriggers can be used
no creep and no inflammation.”* This is the aim of for reducing early, soft contractures, particularly when
splinting when the goal is contracture reduction or the patient cannot tolerate a static splint. Static progres-
lengthening of restricted soft tissue. sive splints or static splints can be used in a serial
There are two approaches to the application of trac- fashion.
tion to lengthen soft tissue and reduce contractures.
One approach is to position the tissue at the end range Immobilizing and Restrictive Splints
of its elastic limits and hold it statically for short for Pain Reduction
periods, and then to relax and reposition it frequently. Of the many uses of splints, perhaps the most common
This approach is termed stress relaxation.? The second is to limit or reduce pain by providing rest and
approach is to apply force within the elastic limits of the support. The most common splint prescriptions are
tissue, hold it for a long period, and then reposition it. written for splints to reduce the pain caused by the in-
 Orthotics (355

flammatory processes of tendinitis or following sprain impede motion elsewhere. If the purpose of the splint is
or strain injuries. to rest the tendons at the wrist to reduce inflammation,
Several questions help determine which splint will the splint must not limit CMC or MP joint motion if
best serve the patient's need. First, if the injury is caused these structures are not symptomatic. If used during the
by an acute sprain, the choice may be for an immobiliz- performance of ADL, splints that fully immobilize a
ing splint until pain and edema have subsided. If the joint may transfer stress to joints proximal or distal to
pain is chronic in nature and caused by the performance the immobilized joint. For this reason semiflexible
of a particular activity, a semiflexible splint may serve splints that restrict only end ranges of motion may be
best. A semiflexible restrictive splint may sufficiently indicated during activity, whereas an immobilizing
reduce pain by limiting ROM, yet still allow function splint may be indicated for total rest at night.
without increasing stress on unaffected joints or tissue
(Fig. 31-42). Immobilizing Splints For Positioning
A second question concerns the need for full-time One of the splints most frequently fabricated by occu-
splinting versus intermittent wear. In the presence of an pational therapists is the resting pan (also known as the
acute injury with orthopedic involvement or tissue resting hand or functional position splint), used to
damage, the splint may not only need to immobilize, maintain the hand in a functional position (Fig. 31-24).
but also to protect the part from further damage. Here, The purpose of this positioning splint is to keep the soft
patient tolerance and compliance will in part determine tissues of the hand in midrange in order to maintain
material and design choice. The therapist may also need optimal mobility and prevent shortening of the soft
to consider the integrity of tissue and the need to ac- tissue structures around the joints. Occasionally, posi-
commodate bandages and bandage changes. If the tioning splints are prescribed to position joints at end
splint is indicated only for intermittent wear, the design range to prevent contractures in the presence of severe
choice may depend more on the patient's ability to tissue damage. Resting splints fitted on persons with
readily don and doff the splint. The choice of materials burns are the prime example of this splint because the
may be dictated by the functional needs of the patient. MP joints are positioned in full available flexion. The
For intermittent splints used for vocational activities, important decision in this case is determination of the
lightweight, well-aerated materials may be indicated. optimal position for the most functional outcome.
For intermittent splints used for positioning, such as a Positioning splints may be fabricated for temporary
resting splint designed to maintain functional position use after surgery and may require frequent adjustment
between exercise sessions, stronger materials may be in- to accommodate changes in edema and bandages. The
dicated and perforations may not be necessary. materials chosen for these splints should have
A third important question in deciding on a splint memory to allow for remolding while keeping its
design is, “What structures need to be immobilized or thickness and strength. Resting splints fabricated for
supported, and which should be left free?” When pro- patients after a CVA will likely require only minimal
tective or pain-reducing splints are provided, care must adjustment, so more conforming plastic materials with
be taken to splint only the involved structures and not little or no memory can be used. Further choices of a
dorsal- versus a volar-based splint and a single-surface
versus a circumferential splint will depend on surgical
and wound sites, need for ease of donning and
doffing, and therapist and physician preference and
experience.

Step Five—Fabrication
The fabrication processes for single-surface and circum-
ferential splints differ significantly. They do have a start-
ing point in common: the pattern from which the splint
will be made. Starting with a paper pattern is recom-
mended, particularly for the novice splint maker. One
very basic rule of splinting is to get the pattern right
before beginning to work with plastic. It is far less ex-
pensive to discard a few pieces of paper than even a
small piece of LTT. Pattern making is discussed in detail
FIG. 31-42 earlier in this chapter and should be reviewed before
Flexible thumb splint provides support yet allows midrange move- creating the pattern as step one in the fabrication
ment. process.
 OCCUPATIONAL THERAPY INTERVENTIONS

FIG. 31-43 FIG. 31-45

Pattern for single-surface cock-up splint on left requires precision Fold edges of material and gently press flat to create thin, smooth
for a proper fit. Pattern on right for circumferential splint does not edges that distribute pressure better.
need precise fit because material stretches and overlaps to achieve
proper size.

single-surface splints require thicker materials to

provide sufficient support.
. Etch the pattern onto the cold thermoplastic mate-
rial with a scratch awl or wax pencil before placing
the material in a hot water bath. The water temper-
ature for most materials to soften properly is ap-
proximately 160° F. Temperature and time will
vary, depending on the material and its thickness.
Most materials heat to the pliable stage in 2 to 3
minutes.
. Carefully remove the material from the hot water
bath and lay it flat on the table to cut. To prevent
stretching, avoid holding material unsupported
while cutting (Fig. 31-44).
. Starting in the neck of the scissors, cut with long,
FIG. 31-44 even strokes to prevent jagged edges.
Support material on table to prevent stretching and cut with long . Reheat the material if it has cooled too much to be
strokes of scissors. formed. Place the material on the forearm and hand
with the forearm in supination so that gravity can
assist the initial molding. Check that the trim lines
Fabrication Techniques for Single-Surface fall at midline. If they do not, mark where excess
Splinting material needs to be removed. Trim the material
Single-surface splints cover the volar surface, the dorsal before it cools. Note areas that will need to be
surface, the ulnar half, or the radial half of the arm and folded for clearance and to create smooth edges.
hand. Generally, single-surface splints have gentle con- Fold and secure the edges firmly in place (Fig.
tours and cover as broad an area of tissue as is feasible 31-45).
to distribute pressure. The following steps should be . Reposition the splint on the forearm. Maintaining
used as a guideline in the process of creating a single- control on the wrist and forearm sections, carefully
surface splint. For the sake of demonstration, the pronate the forearm. Maintain the wrist in exten-
single-surface and the circumferential splints described sion at all times. The tendency for the wrist to drop
and pictured are wrist extension (cock-up) splints (Fig. into flexion when the forearm is pronated is univer-
31-43). sal. Controlling the wrist will ensure that the
1. Except for the fingers, ‘s-inch-thick material is rec- desired wrist position is maintained at all times
ommended to obtain sufficient rigidity to hold the (Fig. 31-46). If necessary, rotate the forearm section
joint firmly in position. The broad contours of to ensure that the trim lines are at midline. Refer to
 Orthotics 557

Cc
AW

A B

FIG. 31-47
Forearm is cone shaped, gradually widening from wrist to elbow.
FIG. 31-46 A, Strap laced straight across broader proximal forearm contacts
Gently support the wrist at all times to achieve proper fit. skin only at point A and does not secure splint. B, Strap placed at
angl e applies even pressure along line BC to secure splint.

Fig. 31-6 to review the importance of the changing Fabrication Techniques for Circumferential
shape of the forearm from a supinated to a Splints
pronated position. i: Use a thin or highly perforated elastic material or
7. Allow the splint to cool until it holds its shape. It flexible rubber material that has some memory. For
does not have to be held in place until completely hand and forearm-based splints, thin elastic materi-
cold. Remove the splint. Heat and smooth any als (‘he-, ‘i2-, Or 42-inch) provide sufficient strength
rough edges as needed and apply the straps. because of the rigidity provided by the curves of the
. Strapping is critical to secure the splinted part in the splint. For splints covering larger areas, a highly per-
splint and diminish both shear forces and the possi- forated ‘4-inch material is recommended. Materials
bility of pressure areas developing. The splint may for circumferential splints should be coated to
require several straps, and wide or crossed straps are prevent permanent adherence when warm or should
suggested to obtain the necessary control. Because be able to be pulled apart once cooled.
the forearm is cone shaped, straps placed straight . Etch the pattern onto the material. Because the
across the forearm will contact the skin effectively materials for circumferential splints are generally
only on their proximal surface (Fig. 31-47). To have stretched to contour around the arm, the pattern
the forearm straps apply effective and well-distrib- does not need to be as precise-as for a single-surface
uted pressure, place them at an angle. splint. It is important to know how much the mate-
. Single-surface splints rely on strapping to hold rial will be pulled and if it will be overlapped or fin-
them in place and create one or more three-point ished edge to edge so that a piece of sufficient size is
pressure systems to securely hold the joint or joints cut (Fig. 31-48).
being splinted (Fig. 31-30). To ensure that straps oF Wrap the material all the way around the part being
function properly, trim lines must fall midline splinted. Two techniques can be used in creating a
along the arm and hand. Ifthe trim lines are left too closure for a circumferential splint. The first is to pull
high, making the trough too deep for the part, the the material around the part and pinch the remain-
straps will bridge the part and sit up on the edge of ing material together to create a seam. Gently tug on
the splint, where they are ineffective. The most ef- the seam to conform the material. When the material
fective way to secure a splint in place on the forearm is cool, open the seam and trim the splint. The
is to apply pressure through the splint onto the soft second technique is to overlap the two ends to form
tissue of the forearm muscle bellies. If the forearm a flap (Fig. 31-49). To prevent the flap from adhering
trim lines angle below the muscle bellies, the splint (this may happen when the coating is thinned as the
will no longer be secured on the muscle bellies. material is stretched), wait until it has cooled slightly
10. Instruct the wearer in the wearing schedule and in before overlapping.
the proper care of the splint. To prevent ischemia . Smooth edges as necessary. The circumferential
and shear forces, check the fit of the splint regularly. splint creates multiple three-point pressure systems
 OCCUPATIONAL THERAPY INTERVENTIONS

FIG. 31-48
Circumferential splint trimmed to close edge to edge.

by virtue of its design, and strapping is used only to

hold the splint firmly closed.

Fabrication and Fitting of Semiflexible Splints

and Prefabricated Splints
Materials used in the fabrication of semiflexible splints
include neoprene, cotton duck, woven elastics, and ther-
FIG. 31-49
moplastic-impregnated materials. Neoprene splints are
Circumferential splint made from flexible material with overlap for
generally fabricated using a special glue that adheres
easy donning and doffing.
pieces together at the edges. The patterns for neoprene
splints must be very precise to achieve a conforming fit.
Cotton duck and other woven materials require sewing fabrication of a splint. The anatomy and biomechanics
and considerable skill in pattern creation and the addi- of the hand and types of grasp and prehension are re-
tion of darts to assure a good fit. Very thin thermoplastic viewed. Splint classification and the purposes of splint-
materials can be used to create semiflexible splints, and ing are described. The section presents a variety of splint-
certain patterns can be adapted to allow for partial ing materials and their appropriate uses for different
range of motion within a splint. types of splints. Principles of safe and effective splinting
Many of the commercially prefabricated splints are and basic fabrication techniques are also described.
made from woven materials, because they present the The occupational therapist must bring to the splint-
broadest range of size adjustability and are less likely to ing process a knowledge of anatomy and biomechanics,
require custom fabrication. It is highly recommended skills in assessing function, and the ability to determine
that even a prefabricated splint be custom fit by a thera- the optimal intervention for each patient, whether it in-
pist to ensure proper fit and adherence to an appropri- cludes a splint or not.
ate wearing schedule. A well-supplied splint department
should include a sewing machine to custom fit all Ea
splints. Remember when fitting prefabricated supports SECTION 2
that if a patient comes to see a therapist with a prescrip-
tion for a splint, it is the therapist's responsibility to take
Suspension Arm Devices
the time and develop the skills to be certain that even and Mobile Arm Supports
prefabricated splints fit as if they were custom made.
LYNN YASUDA
RS ESR ee aaa (ee oe &
Sl IMMARY
SUMMA ae <a s
SUMMA AE: i. 8|
Suspension arm devices.and mobile arm supports are
Section 1 of this chapter introduces the basic concepts of commonly used and can fulfill several treatment objec-
splint design and problem solving that must precede the tives for the person with severe physical disability. These
 Orthotics 559

devices can support the shoulder and forearm, encour-

age motion of weakened proximal musculature, prevent
loss of ROM, provide pain relief, provide proximal
support for distal function, and enable occupational
performance.

SUSPENSION ARM DEVICES

Suspension arm devices are suspended from above the
head, generally on an overhead suspension rod that is
most often attached to a wheelchair. They can also be at-
tached to regular chairs, a child’s highchair, a body
jacket, and even an overhead track used for walking
patients.’ Without the overhead rod, they are also at-
tached to over-bed frames to allow the patient to use the
device while in bed. These suspension arm devices were
found in OT clinics as early as the 1940s. The ease of
management, low cost, and ability to support proximal
weakness of the upper limb contributed to their early
popularity,° and they continue to be used for selected
purposes.

Purposes
Suspension arm devices may be used to meet some of
the following objectives: FIG. 31-50
# To position the shoulder girdle musculature to allow Suspension sling. (Modified with permission from Occupational
distal muscles to engage in functional activities Therapy Department, Rancho Los Amigos Hospital, Downey,
@ To assist and support below fair-grade (F or 3) shoul- Calif.)
der girdle musculature
@ To allow gravity-eliminated exercise for weak shoul-
der girdle musculature
@ To encourage use of increased ROM through repeti- Suspension Sling
tive activities® The suspension sling (Fig. 31-50) has a single strap (A)
= To prepare patients to use the mobile arm supports suspended from the overhead bar (B). A horizontal bar
(MAS) by encouraging weak proximal musculature to (adjustable balance bar, JAECO”) with holes for adjust-
move ment of the fulcrum (C), supports the two vertical straps
@ To support a painful shoulder (D). These straps provide support for the wrist and
# To position an edematous hand away from a depend- elbow separately.
ent position
@ To prevent loss of shoulder ROM Suspension Arm Support
Suspension arm devices are generally more effective The suspension arm support (offset suspension arm
for positioning and exercise than for function because positioner, JAECO”) (Fig. 31-51) has a forearm trough
of the mechanical principles on which they operate. The that is the same as that used in the mobile arm
upper limb swings as a pendulum from straps attached support. It is suspended from a single point on the
to the suspension rod, thus making it difficult for fine overhead bar. This device can be used as an initial step
adjustments in movement.° for the patient who can benefit from a MAS and is
easily applied to the wheelchair. It can be easily at-
tached and adjusted to over-bed frames to allow pa-
Variations in Suspension Arm Devices
tients who are confined to bed to perform tabletop ac-
There are several variations of suspension arm devices. tivities, as well as hand-to-face activities with this
The overhead rod may be the same, but the attach- device (Fig. 31-52). However, it does not have the fine
ments to the rod identify the variation. The variations adjustment capabilities of the MAS, which extremely
listed here are commercially available and are in weak patients need. With a special bracket (Fig. 31-53),
current use. the suspension arm support is easily adaptable to the
560 OCCUPATIONAL THERAPY INTERVENTIONS

and causes the upper limb to move uphill at each

extreme of the arc. Lowering the overhead rod can thus
add undesirable resistance to a group of muscles during
functional performance.

ROTATION. The shoulder can be placed in horizon-

tal abduction and external rotation as the suspension
rod is rotated outward, or in horizontal adduction and
internal rotation if the suspension rod is rotated inward.
This gives mechanical advantage to those muscles that
are held in shortened range and offers resistance to the
opposing muscles.”’°

SPRINGS. Springs of various tensions may be in-

serted in the straps supporting the upper limb. In early
muscle reeducation, these springs allow the very weak
patient to produce and visualize some slight bouncing
movement while upright by contracting available
muscles, a motion not as easily possible with straps
alone.

HORIZONTAL BAR. Moving the strap on the holes

on the horizontal bar (also called adjustable balance
bar, made by JAECO”) will position the elbow in greater
or lesser degrees of flexion. The bar is often positioned
for the comfort of the patient, or, if edema is present,
FIG, 31-51 the hand is held higher than the elbow.
Suspension arm support.
ROCKER TROUGH. The rocker trough (also called
forearm trough, made by JAECO”) is the same one used
in the MAS. However, this trough has a vertical metal
rod attached to the rocker arm. The rocker arm can be
moved on the trough, permitting greater directional as-
reclining wheelchair. This feature makes it useful sistance for vertical motion, up or down, depending on
during the rehabilitation of patients who cannot yet sit the patient's specific weakness in shoulder rotator or
upright. elbow musculature.

FULLY RECLINING SLING BRACKET. For all sus-

Adjustment of Suspension Arm Devices
pension devices, the overhead rod may be supported by
Straps a reclining bracket that permits the suspension to be
The strap that connects the overhead rod to the limb di- perpendicular to the floor when the patient is reclined
rectly or by the horizontal bar or forearm trough rocker in the wheelchair.
attachment may be adjusted for length. This provides el-
evation control for the entire limb or for the wrist and Training in the Use of Suspension Arm Devices
elbow separately when separate supports are provided. Suspension arm supports can be used as training for or
Adjustments for height relative to the work surface or to as an interim device before using the MAS. Training can
the face are similar to those discussed in the later section include exercises for the shoulder and elbow, including
on mobile arm supports. scapular protraction and adduction, shoulder flexion
and extension, elbow flexion and extension, and shoul-
Overhead Rod der internal and external rotation (especially with the
HEIGHT. The overhead rod can be adjusted on the use of the forearm trough and rocker arm). Because the
wheelchair sling bracket. The higher the overhead rod, forearm trough is easily attached to over-bed frames,
the flatter the arc of pendulum swing when the arm is in functional activities can be practiced using a table
motion. Usually the bar is kept as high as is possible surface and any distal orthoses and adapted equipment
while still allowing the wheelchair to pass through that are needed® before the patient is able to be upright
doorways. Lowering the bar shortens the pendulum arc in a wheelchair.
 Orthotics

FIG. 31-52
Suspension arm support attached to bed. (From ARHP Arthritis Teaching Slide Collection, American
College of Rheumatology.)

MOBILE ARM SUPPORTS

Mobile arm supports are mechanical devices that
support the weight of the arm and provide assistance to
shoulder and elbow motions through a linkage of ball-
bearing joints. They are used for persons with weakness
of the shoulder and elbow that affects their ability to
position the hand. Mobile arm supports are or have
been known by other names. Among these are MASs,
ball-bearing feeder, ball-bearing arm support, balanced
forearm orthosis (BFO), and arm positioner.
The MAS in current use (Fig. 31-54) has not changed
significantly in design since 1952.' Earlier prototypes
were reported as long ago as 1936, when a patient at the
Georgia Warm Springs Foundation was given a Barker
feeder, a device that was bolted to the lap board of a
wheelchair and that required shoulder depression to
bring the hands toward the head. Several other models
FIG. 31-53 were subsequently reported in the literature, until the
Reclining suspension arm support bracket. (Courtesy of Paul design of the 1952 segmented arm feeder, which has
Weinreich, Rancho Los Amigos National Rehabilitation Center.) close similarities to that seen today.'’"°
 OCCUPATIONAL THERAPY INTERVENTIONS

Adequate Motor Control

The person must be able to contract and relax funcea
ing muscles. People with such conditions as cerebral
palsy or significant elbow flexor tone are not usually
good candidates for the mobile arm supports.

Sufficient Range of Motion

The preferred ROM for joints to use the MAS well is
shoulder flexion and abduction (90°), shoulder exter-
nal rotation (30°), shoulder internal rotation (normal),
FIG. 31-54
Patient in standard mobile arm support set up on a wheelchair.
elbow flexion (normal), forearm pronation (80°), and
(Courtesy of Paul Weinreich, Rancho Los Amigos National Reha- hip flexion (100°).
bilitation Center.)
Stable Trunk Positioning
An upright sitting posture is ideal. Good head and neck
positioning is important.

Mobile arm supports have increased UE function for Patient Motivation

persons with severe arm paralysis caused by such dis- The patient must want to use the device and have suffi-
abilities as cervical spinal cord injury, muscular dystro- cient motivation for training to use it proficiently.
phy, Guillain-Barré syndrome, amyotrophic lateral scle-
rosis, poliomyelitis, and polymyositis.” The MAS has Supportive Environment
also been used for pain relief in the upper arm during Generally, people who use this device cannot put it on
function for patients with arthritis and other painful themselves and will need support to help with the use
conditions. of the device.®

How Mobile Arm Supports Work Adjustment of Mobile Arm Supports

Mobile arm supports compensate for proximal weak- The adjustment of mobile arm supports generally re-
ness in the UE in three ways. They provide arm quires postgraduate practical training. However, having
motion, which allows for active ROM in the shoulder some knowledge of adjustment will give the reader a
and elbow, they allow weak muscles that are below greater appreciation for the need to have additional
functional level to be used for movement; and they training to learn how to make fine adjustments. One
enable hand placement for activity in a variety of study has shown that even when the MAS is not ad-
positions. justed correctly, a person with sufficient muscle power
The purposes of mobile arm supports can be func- can overcome the lack of fine adjustment.'* This does
tional (i.e., allowing the weak arm to perform tabletop not negate the need for therapists to be trained to
and hand-to-face activities, which otherwise are impos- ensure the best possible adjustment and mechanical ad-
sible or difficult) and therapeutic (i.e., improving ROM, vantage possible for the patient using the MAS.
strength, and endurance). The devices can be temporary Even with practical training, there are additional
or permanent.® parts beyond the basic pieces that enhance the effective-
The mechanical principles of mobile arm supports are ness of the device. The training needed to use these ad-
threefold. The MAS uses gravity to assist weak muscles, ditional parts comes with practice, experience, and con-
supports a weak arm to reduce the load of weak muscles, sultation with therapists familiar with the use of special
and reduces friction by using ball-bearing joints.® parts.

Adjustment of Basic Parts

Criteria for Use
(Fig. 31-55)
Functional Need
The person must have a need to perform specific activi- FOREARM TROUGH. (Fig. 31-55, D). The forearm
ties that cannot otherwise be accomplished because of trough is initially fitted by bending the dial to accom-
weak shoulder and elbow musculature. modate the left or right elbow.

Adequate Source of Power ROCKER ARM. The rocker arm is attached to the
The source of power can be the muscles of the neck, trough. The standard rocker arm is attached to the first
trunk, shoulder, shoulder girdle, and elbow. and third holes closest to the elbow.
~
os

Orthotics 563

CHECKING FIT DURING OCCUPATIONAL PER-

FORMANCE. Further adjustments may be needed with
the weight of objects in the hand.®

Training
Training proceeds using all activities that interest the
patient and that need to be performed. Any of these ac-
tivities may require various adjustments until the final
OT
———
—————— settings are achieved. If strength or ROM increases
during the training period, further adjustments may be
needed. Adapted equipment can be used in conjunction
.
—_——"
with the MAS. A wrist-hand orthosis may be required or
adjusted for use with the MAS.®
Follow-up with patients is indicated, especially for a
FIG. 31-55 growing child. Mobile arm supports can come out of
Parts of standard mobile arm support. A, Distal arms, right and left;
adjustment over time. The questions in Box 31-1 are
B, proximal arms; C, semireclining brackets, right and left; D,
from a mobile arm support appraisal form that was
forearm troughs.

SEMIRECLINING BRACKET, PROXIMAL ARM,

DISTAL ARM, AND FOREARM TROUGH. The bracket bile Arm Support Appraisal
(Fig. 31-55, C) is attached to the wheelchair, the proxi-
mal arm (Fig. 31-55, B) is placed in the bracket, the
distal arm (Fig. 31-55, A) is placed in the proximal arm, . Are the patient's hips set back in the chair?
. Is the spine in good vertical alignment?
and the forearm trough is placed in the distal arm.
. Is there good lateral trunk stability?
. Is the chair seat and back adequate for comfort and stability?
BALANCING THE MOBILE ARM SUPPORT AT . Is the patient able to sit upright?
NEUTRAL. The bracket is adjusted so that the ball bear- . lf the patient wears hand splints, are they on?
ings are parallel to the floor. . Does the patient have adequate passive range of motion?
BS
Rs
SOM
CO . Is the bracket tight on the wheelchair and positioned per-
Sites
OO

CHECKING THE BRACKET HEIGHT. The patient is pendicular to the floor?

placed in the MAS, and the therapist passively moves Xo. Is the bracket at the proper height, so that the shoulders

the hand to the mouth. If the shoulder is elevated or de- are not forced into elevation?
_ pressed, the height of the bracket should be adjusted. 10. Is the proximal arm all the way down in the bracket?
||. Does the elbow dial clear the lap surface when the trough
is in the “up” position?
ASSESSING TROUGH FOR FIT AND ADAPTA-
12. When the trough is in the “up” position, is the patient's
TIONS. The trough is observed for forearm comfort hand as close to the mouth as possible?
and allowance of wrist flexion (if patient has active 13. Can the patient obtain maximal active reach?
motion). Measurements are taken to have the trough 14. Is the trough the correct length? Does the distal end of the
cut if necessary to prevent discomfort and nonconfor- trough stop at the wrist joint?
mity to the size and shape of the forearm. 15. Are the trough edges rolled so that they do not contact the
forearm?
ADJUSTING FOR HORIZONTAL MOTION. The 16. Is the elbow secure and comfortable in the elbow support?
bracket is rolled to assist horizontal abduction or ad- 17. Is the trough balanced correctly?
duction. The pitch of the bracket or the distal bearing is 18. In vertical motion, is the dial free of the distal arm?
19, Can the patient control motion of the proximal arm from
adjusted to achieve maximum horizontal motion in
either extreme?
front of the patient. 20. Can the patient control motion of the distal arm from
either extreme?
ADJUSTING FOR VERTICAL MOTION. The rocker 2 Can the patient control vertical motion of the trough from
arm is moved on the trough if up or down motion is dif- either extreme?
ficult. 22. Have stops been applied to limit range, if necessary?
23. Can the patient lift a sufficient amount of weight to
READJUSTING FOR FINE BALANCE. The therapist perform appropriate functional tasks?
reviews all the adjustments to ensure maximum motion. SN RS ELIE SE LIT BRITE PTET UN ESET ESE ET ERS ee EE
564 OCCUPATIONAL THERAPY INTERVENTIONS

developed at Rancho Los Amigos National Rehabilita- 2).° The patient initiates the elevating motion, and
tion Center in the polio era.’ It can be a useful tool to rubber band assists allow the patient to flex and abduct
check the adequacy of the fit of the MAS when the the humerus to a higher level.
patient returns to the clinic for follow-up visits. Many other useful, but not commonly used, special
parts are commercially available for patients with special
problems. Understanding the use and adjustment of
Special Parts of the Mobile Arm Support
these special parts generally requires training.* With the
Some commonly used special parts include the outside advent of new designs for wheelchairs, it is sometimes
rocker assembly (also known as an offset swivel) and necessary to adapt the MAS bracket to attach to the newer
the elevating proximal arm (Fig. 31-56). The outside wheelchairs. Some wheelchair manufacturers can assist
rocker assembly has a ball-bearing joint that allows with providing solutions to these problems, and some
greater freedom in vertical motion. The elevating proxi- centers have developed common solutions.®
mal arm is useful for the person who has deltoid
muscles that are between fair (F or 3) and poor (P or
FUTURE RESEARCH
Problems with the standard MAS have included diffi-
culty mounting to wheelchairs, difficulty with learn-
ing adjustment strategies, and difficulty going through
common doorways. As a part of a research grant funded
by the National Institute on Disability and Rehabilita-
tion Research (NIDRR), U.S. Department of Education
for Rehabilitation Engineering Research Center on Tech-
nology for Children, a multilink articulated arm for
the MAS that shows promise was developed at Rancho
Los Amigos National Rehabilitation Center (Fig. 31-57).

Rancho Mobile Arm Support—In Development

Wheelchair Mount

” Trough Coll

Bubble Stem ial

Level Screw
i i - Standard Stem
a

Long Stem
Multi Link Arm
B

FIG. 31-56
A, Offset swivel with up and down stops and humeral rotation FIG. 31-57
assist (outside rocker arm with rocker band assist). B, Elevating New multilinked mobile arm support. (From Rancho Los Amigos
proximal arm. (Courtesy of JAECO Orthopedic Specialities, Hot National Rehabilitation Center, Rehabilitation Engineering Center,
Springs, Ark.) Downey, Calif.)
 Orthotics 565

The multilink articulated arm for the MAS is low 12. How does the amount of drape in a low-tempera-
profile and flexible to facilitate passage through door- ture thermoplastic material affect the making of a
ways. Children who tested the arm were pleased with splint?
the appearance and operation of the multilink design. It 13. What is the recommended type of material for
is not intended to replace the current MAS design but small finger splints? Why?
may offer a simpler option for users who do not have 14. What is the recommended type of material for large
complex fitting problems.” At the time of this writing, elbow and lower extremity splints? Why?
the research is in its pilot phase of trial use with patients 15. What is the importance of straps on a single-surface
throughout the United States. splint?

ae
SUMMARY
SECTION 2
Suspension arm devices and mobile arm supports can 1. What are the purposes of suspension arm devices?
support the shoulder and forearm and afford increased 2. Where are suspension arm devices attached?
occupational performance for persons with severe UE 3. What are the limitations of suspension arm devices?
weakness. The MAS has been used for over 40 years. 4. What is the difference between a suspension arm
Adjustment of the device and training patients in its sling and a suspension arm support?
use require postgraduate training and experience. On . Which types of patients are good candidates for sus-
Patients have been known to have the device origi- pension arm devices? Which are not good candi-
nally ordered for at least 10 years, and probably dates?
beyond this. When fitted correctly the MAS enhances 6. How are suspension arm devices adjusted?
increased occupational performance and can facilitate 7. When were mobile arm supports first used?
remediation of performance components. For some 8. Name the parts of the MAS.
patients the device is useful for life. For other patients 9. What are the benefits of the MAS?
the mobile support is a temporary device that allows 10. How does the MAS work?
function and enables exercise until musculature is 11. What are the criteria necessary to use the MAS?
strong enough to perform purposeful activities without 12. How is the MAS adjusted for each patient?
them. 13. What is the multilink articulated arm?

REFERENCES
REVIEW QUESTIONS 1. Anderson KN, Anderson LE, Glanze WD, editors: Mosby’s medical,
nursing, and allied health dictionary, ed 4, St Louis, 1994, Mosby.
a
SECTION 1 tia re ee
1. Describe the role of the occupational therapist in SECTION 1
the splint-making process. 1. American Society of Hand Therapists: Splint classification system,
2. What is wrist tenodesis, and how can it be used Chicago, 1992, The Society.
2. Bonutti PM, Windau JE, Ables BA, et al: Static progressive stretch
functionally?
to reestablish elbow range of motion, Clin Orthop June(303):128-
3. Describe the axis of motion of forearm rotation, 134, 1994.
and discuss how it affects the fit of a splint. 3. Brand PW, Hollister A: Clinical mechanics of the hand, ed.3, St
4. Name the three major nerves supplying the hand, Louis, 1999, Mosby.
and describe their sensory innervation patterns. 4. Colditz J: Dynamic splinting ofthe stiff hand. In Hunter J, Schnei-
5. Why is tip prehension considered to be a dynamic der L, Mackin E, et al: Rehabilitation of the hand: surgery and therapy,
ed 3, St Louis, 1990, Mosby.
prehension pattern rather than static? 5. Flatt AE: Care of the arthritic hand, St Louis, 1983, Mosby.
6. What is the one grasp pattern that does not include 6. Hollister A, Giurintano D: How joints move. In Brand PW, Hollis-
the thumb? ter A: Clinical mechanics of the hand, ed 3, St Louis, 1999, Mosby.
7. Define the terms “friction,” “torque,” and “stress.”
Nu
7. McCollough N, Sarrafian S: Biomechanical analysis system. In
Atlas of orthotics, biomechanical principles and application, St
8. How is shear stress created, and how can it best be
Louis, 1975, Mosby.
avoided? 8. Strickland JW: Anatomy and kinesiology of the hand. In Fess E,
9. Why do translational forces minimize the effective- Philips C: Hand splinting: principles and methods, St Louis, 1987,
ness of a splint? Mosby.
10. Describe the difference between a dynamic and a
static splint. ee
11. How might a splint pattern vary if it is to be fitted SECTION 2
on the dorsum of the hand, as compared with the 1. Bennett RL: The evolution of the Georgia Warm Springs Founda-
volar surface? tion Feeder, Artif Limb 10(1):5-9, 1966.
566 OCCUPATIONAL THERAPY INTERVENTIONS

. Bennett RL: Orthotics for function. I. Prescription, Phys Ther Rev 5. Rehabilitation Engineering Program: Annual report, 1997, RERC on
36(11):1-25, 1956. Technology for Children, Downey, Calif, 1997, Rancho Los Amigos
. Bennett RL, Stephens HR: Care of severely paralyzed upper ex- Medical Center Research and Education Institute.
tremities, JAMA 149(2):105-109, 1952. 10. Snelson R, Conry J: Recent advancements in functional arm
. Haworth R, Dunscombe §S, Nichols PJR: Mobile arm supports: an bracing correlated with orthopedic surgery for the severely para-
evaluation, Rheumatol Rehabil 17(4):240-244, 1978. lyzed upper extremity, Orthop Prosthet Appliance J, 41-49, 1958.
. JAECO Orthopedic Specialties catalog, Hot Springs, Ark (undated). Le Wilson DJ, McKenzie MW, Barber LM: Spinal cord injury: a treat-
. Long C: Upper limb bracing. In Licth S, editor: Orthotics etcetera, ment guide for occupational therapists, rev ed, Thorofare, NJ, 1984,
Baltimore, 1966, Waverly Press. Slack.
. Rancho Los Amigos Medical Center, Occupational Therapy De- 12 Yasuda, YL, Bowman K, Hsu JD: Mobile arm supports: criteria for
partment: Mobile arm support appraisal, Downey, Calif, 1969, the successful use in muscle disease patients, Arch Phys Med Rehabil
Center (unpublished). 67(4):253-256, 1986.
. Rancho Los Amigos National Rehabilitation Center, Occupa-
tional Therapy Department: Mobile arm support workshop manual,
Downey, Calif, 1998, the Center.
 eda Approaches

1. 0
+ radian Sensorimotor Approaches
to Treatment: An @hiaaulans

LEARNING OBJECTIVES
Lower motor neurons After studying this chapter the student or practitioner
Upper motor neurons will be able to do the following:
Information flow [: Name the structures that constitute the upper
Motivational urge motor neurons.
Ideation Pap Describe the four general processes of information
Movement strategy flow related to control of movement.
Motor program . Define motivational urge, and name the locus of this
Execution level function in the brain.
Sensorimotor system . Describe where in the brain motivational urge is
Reflex and hierarchical models transformed to ideas for purposeful movement.
~~,
Top-down orientation . Trace the flow of information in the central and
Sensory stimulation peripheral nervous systems that leads to purposeful
Evolution in reverse movement.
Mass movement patterns . Define sensorimotor system and give its locus in the
brain.
. Describe where movement planning takes place in
the brain.
List the structures that constitute the higher,
middle, and lower levels of the central nervous
system components for movement.
Name the four traditional sensorimotor
approaches to treatment and the theorist
responsible for each.
10. Name the two models of motor control that form
the basis for the sensorimotor approaches to
treatment.
phe Briefly describe each of the four traditional
sensorimotor approaches to treatment; compare
and contrast their similarities and their differences.

567
568 OCCUPATIONAL THERAPY INTERVENTIONS

that is still unknown, both animal and human research

suggest that there are four general processes related to
ccupational therapists working with patients the control of movement. The four general processes of
who have sustained damage to the central nervous information flow are motivation, ideation, program-
system (CNS) are concerned with enhancing functional ming, and execution.””* A schematic diagram indicating
movement and promoting independence in occupa- the main direction of information flow and connecting
tional performance. To achieve this objective, a variety of the various motor centers appears in Fig. 32-1.
treatment approaches are available from which the ther- The motivation or emotive component of the move-
apist may choose. This chapter reviews the neurological ment is a function of the limbic system.”’* The moti-
considerations for these approaches and presents a brief vational urge or impulse to act of the limbic system is
description of each. More detailed explanations of the transformed to ideas by the cortical association areas.
approaches can be found in Chapters 33 to 36. The association areas of the frontal, parietal, temporal,
and occipital lobes are concerned with ideation, or the
NEUROLOGICAL CONSIDERATIONS FOR goal of the movement, and the programming or move-
ment strategy (plan) that best achieves the goal. Pro-
THE TRADITIONAL SENSORIMOTOR
gramming also involves the premotor areas, the basal
APPROACHES TO TREATMENT
ganglia, and the cerebellum. The motor program is
Occupation presupposes voluntary movement that is the procedure or the spatiotemporal order of muscle
controlled and monitored by the nervous system. This activation that is needed for smooth and accurate
control is precise and all encompassing, whether the motor performance. The execution level, represented
movement is to maintain a posture, carry a load, or play by the motor cortex, the cerebellum, and the spinal
the piano. The nervous system determines both the cord, is concerned with the activation of the spinal
muscles to be activated and the extent of their activa- motor neurons and interneurons that generate the
tion. If a movement is poorly performed, learning goal-directed movement and the necessary postural
occurs through feedback and the commands to the adjustments.
muscles are updated so that accuracy of movement is To appreciate the flow of information leading to pur-
achieved. This requires the coordinated activity of many poseful movement, consider the actions of a person
brain regions. Knowledge of the intricate working of the who is thirsty and who is reaching out for a glass of
nervous system is of special importance to the occupa- water (Fig. 32-2). The limbic system, which connects
tional therapist concerned with refining and improving with the areas of the midbrain and brainstem that
the motor performance of patients with neurological control vital functions such as hunger and thirst, has
conditions. A brief overview of the flow of information registered the need for water.° This need for drinking
associated with the control of movement is described in water has been conveyed to the cortical association
the following sections. areas, which have information based on vision, audi-
tion, somatic sensation, and proprioception about pre-
cisely where the body is in space and where the glass of
Brain Control of Movement
water is relative to the body. This sensory information is
The firing of motor neurons located in the spinal cord needed before the movement is initiated. Strategies or
produces all movements.'’ These neurons directly in- motor plans are formulated to move the arm and hand
nervate the skeletal muscles. The activity of the spinal or from their immediate location in space to one in which
lower motor neurons can be modulated by local seg- the glass of water is picked up and moved to the mouth.
mental spinal circuitry and by the descending drive Motor programs are generated by the association cortex
from the motor neurons located in the motor cortex in conjunction with the basal ganglia, lateral cerebel-
and brainstem. Two other structures, the basal ganglia lum, and premotor cortex. Once strategy is determined,
and the cerebellum, and their associated pathways are the motor cortex is activated. The motor cortex, in turn,
intimately involved with motor control. Thus there are conveys the action plan to reach and lift the glass in a
three structures or upper motor neurons involved in particular manner to the brainstem and spinal cord. Ac-
movement production. Lesions of each of these struc- tivation of the cervical spinal neurons generates a coor-
tures are associated with characteristic weaknesses. The dinated and precise movement of the shoulder, elbow,
unmodified term upper motor neuron can be confusing wrist, and fingers. Input from the brainstem ensures that
and inappropriate, since the upper motor neuron is the necessary postural adjustments are made by the
composed of three structures. axial musculature. Sensory information during the
Movement production does not begin and end with movement is necessary not only to ensure the smooth
the motor system. Many CNS structures contribute to performance of the ongoing movement, but also to im-
the development ofthe signals that activate muscles. Al- prove subsequent similar movements. Since the motor
though there is much about the control of movement areas rely so heavily on sensory information, provided
 Traditional Sensorimotor Approaches to Treatment: Overview 569

NEURAL
LEVEL STRUCTURE FUNCTION

Limbic System Motivational Urge

HIGHER
!
Cortical Association Areas Select Goals

Programming
MIDDLE

Premotor Determine Motor

Areas Plan

Motor Execution
Intermediate
(CENTRAL) Cerebellum

Brainstem
and
Spinal Cord

Maintain Posture

Move

LOWER
(PERIPHERAL) Peripheral Nervous System

FIG. 32-1
Schematic representation of the hierarchy of the neural structures involved in motor control. The
left column indicates the hierarchical level and the right column the major function of the neural
structures shown in the center column during motor performance. (Adapted from Cheney PD: Role
of cerebral cortex in voluntary movements: a review, Phys Ther 65[5]:624-635, 1985.)
YAU OCCUPATIONAL THERAPY INTERVENTIONS

Area 4
AreaG= = «Central ate :
motte puma M1 sulcus 51 orl
SMA Area 5
Prefrontal
cortex y Area 7

FIG. 32-2
A person reaching out for a glass of water.

FIG. 32-3
by exteroceptors and proprioceptors for accuracy, the Areas of the neocortex intimately involved in planning and instruc-
structures of the brain that control movement are often tion of voluntary movement. Areas 4 and 6 constitute motor
cortex. (From Bear MF Connors BW, Paradiso MA: Neuroscience:
referred to as the sensorimotor system.
exploring the brain, Baltimore, 1996, Williams & Wilkins.)
Given the motivation-ideation-programming-execu-
tion scheme of organization of information through the
nervous system, it is obvious that control of voluntary
movement involves almost all of the neocortex. Volun-
tary movement depends on knowledge of where the idenced by the presence of the long latency stretch
body is in space, where the body intends to go with reflex.'° In addition, there are other networks of de-
respect to this external space, the internal and external scending, ascending, and cortico-cortical connections of
loads that must be overcome, and formulation of a the sensorimotor cortex.”
strategy or plan to perform the movement. Once a strat- Each area of the sensorimotor cortex (primary motor
egy or plan has been formulated, it must be held in cortex, primary somatosensory cortex, posterior pari-
memory until execution, at which point appropriate in- etal cortex, supplementary motor area, and premotor
structions are sent to the spinal motor neurons. The cortex) is arranged in a manner that provides a topo-
major functional aspects of some of the sensorimotor graphical representation of the contralateral body seg-
areas involved in motor control are examined below. ments. '”’!* Each of these areas is principally responsible
References 2, 10, and 14 provide more details on this for certain aspects of movement generation. In the case
topic. of the previous example of reaching out for the glass of
water, the mental image of the body and its relation to
Sensorimotor Cortex the surrounding space depends on somatosensory, pro-
The sensorimotor cortex is the major integrating center prioceptive, and visual inputs to the posterior parietal
of sensory input and motor output. It is composed of cortex. Patients with a lesion in this area demonstrate
cortical areas located immediately anterior and poste- impairment of body image and its relation to extraper-
rior to the central sulcus (Fig. 32-3). The three principal sonal space, and in the extreme situation a neglect of the
motor regions located in the frontal lobe are the contralateral body segments.
primary motor area, the supplementary motor area, and The posterior parietal cortex integrates and translates
the premotor area. The two principal sensory regions sensory information so that the ensuing movements are
located in the parietal lobe are the primary somatosen- directed appropriately in extrapersonal space. It is exten-
sory cortex and the posterior parietal cortex. Both ante- sively interconnected with the association areas of the
rior and posterior regions contribute to the descending frontal lobe that are considered to be involved in deter-
corticospinal tract, which influences the activity of the mining the consequences of movement strategies such
motor neurons located in the ventral spinal cord. The as moving the arm forward, curling the fingers around
output from the sensory cortical areas goes to the dorsal the plastic cup, and lifting the cup to the mouth. The
spinal cord and modulates peripheral sensory input, ev- fingers begin to curl appropriately before there is any
 Traditional Sensorimotor Approaches to Treatment: Overview oy |

contact with the cup; therefore the size and shape of the presents the classic picture of muscle weakness, spastic-
cup must be recognized before grasping. Both the pre- ity, and decreased fractionation of movement with cor-
frontal association areas and the posterior parietal responding loss of function.
cortex project to the premotor area, which is thought to
be concerned with orientation of body segments before
Relation to Sensorimotor
initiation of movement. The input of the posterior pari-
etal cortex to the premotor area may be important in the
Treatment Approaches
somatosensory guidance of movement.’ Lesions of the The CNS components for movement can be grouped
premotor area or posterior parietal cortex have been functionally into higher, middle, and lower levels. The
demonstrated to result in the generation of inappropri- higher level consists of the limbic system and associa-
ate movement strategy.® tion areas. The sensorimotor areas, along with the basal
Planning of movement is considered to be the func- ganglia and cerebellum, form the middle level, and the
tion of the supplementary motor area. Electrophysio- lower level consists of the nuclei in the brainstem and
logical recordings of the cells in this area in behaving spinal cord. Under normal circumstances the repertoire
animals indicate that the cells typically increase dis- of muscle activity is quite large. Following damage to
charge rates about a second before the execution of higher centers there is a loss of descending excitatory
movement of either hand.'® The same findings have input. The possible levels of modulation of spinal
been corroborated in humans, using imaging studies to motor neurons become quite limited, and the muscle
study patterns of cortical activation. Imaging studies response may be limited or stereotyped. Traditional sen-
using positron emission tomography (PET) monitor sorimotor approaches to treatment (described in the
changes in local blood flow, since an increase in the subsequent chapters) can be viewed as targeting the
local cerebral blood flow is associated with increased middle sensorimotor level, the motor planning-strategy
neuronal activity. Under these conditions, when sub- formulation process, and the lower-level execution
jects were asked to imagine a movement without actu- process, with the aim of reintegrating, as far as possible,
ally moving the finger, the blood flow to the supple- a complete motor control hierarchy. It easily can be seen
mentary motor cortex increased and no similar increase that the motor relearning program should be cogni-
in blood flow was seen in the primary motor area.'* tively oriented and targeted toward achieving a goal or
When subjects were asked to perform a series of finger “occupational” task.
movements from memory, blood flow to the supple- Patients need to be taught motor strategies or com-
mentary motor cortex increased in advance of the move- pensatory mechanisms to adapt to the deficits pro-
ment, but not during the performance of the move- duced by a lesion. Compensatory mechanisms and the
ment. Unilateral lesions of the supplementary motor shaping of motor programs are brought about by the
area result in apraxia (the loss of the ability to perform use of sensory inputs. The sensorimotor approaches
movement in the absence of motor or sensory impair- use sensory stimulation to elicit specific movement
ments). Another effect of such lesions is the inability to patterns. Early in the treatment phase, the emphasis is
produce the correct sequence of muscle activation for on the use of external sensory stimuli. Once a move-
complex motor activities such as speaking, writing, but- ment response is obtained, in order to reinforce and
toning, typing, sewing, and playing the piano. strengthen the response, the focus shifts to the use of
The primary somatosensory cortex projection to the intrinsic sensory information, thereby encouraging vol-
primary motor cortex and association areas provides untary motor control.
the sensory input needed for motor planning, move- The four traditional sensorimotor treatment ap-
ment initiation, and regulation of ongoing movement.* proaches historically used by occupational therapy (OT)
The primary motor cortex integrates the information practitioners are the Rood approach, the Brunnstrom
it receives from other areas of the brain and generates (movement therapy) approach, the proprioceptive neu-
the descending command for the execution of move- romuscular approach (PNF), and the neurodevelop-
ment. Not only is this descending command sent to the mental (Bobath) approach. These approaches, devel-
brainstem and spinal cord, but a copy of it is also sent oped in the 1950s and 1960s, all have their theoretical
to the basal ganglia and cerebellum. The descending basis in the reflex and hierarchical models of motor
command specifies the muscles to be activated and the control. Although more contemporary models are cur-
direction, speed, and required force.* Lesions of the rently being used to guide treatment with patients who
primary somatosensory cortex typically result in con- demonstrate CNS dysfunction, an understanding of
tralateral sensory loss. Movements are uncoordinated these traditional approaches is warranted to appreciate
because of an inability to register sensory feedback their contributions to clinical practice and to recognize
during and after the movement. Damage to the primary the appropriate application of these approaches in se-
motor area results in execution deficits. The patient lected patient populations.
 OCCUPATIONAL THERAPY INTERVENTIONS
Reflex and Hierarchical Models
CNS occurs, there is a resurgence of reflexive motor
of Motor Control 8
activity and an inability to modulate these reflexive
Both reflex and hierarchical models of motor control movements.
view movement developmentally. There are two major 2. Motor control is hierarchically arranged. In a hierarchi-
fundamental assumptions underlying the reflex and cal model of motor control, it is believed that the
hierarchical models: CNS has a specific organizational structure and
1. The basic units of motor control are reflexes. Reflexes are motor development and function are dependent
motor responses that occur in response to specific upon that structure. This organization is in a top-
sensory stimuli. Reflexes are automatic, predictable, down orientation; that is, the higher centers of the
and stereotypical; they are normal responses that are brain regulate and exert control over lower centers of
seen from early infancy. As the CNS matures, reflexes the CNS. The higher centers, specifically the cortical
become integrated and are believed to form the and subcortical areas, are responsible for regulating
foundation for volitional motor control. Volitional and controlling volitional, conscious movement. The
(purposeful) movement is the summation and inte- lower levels regulate and control reflexive, automatic,
gration of reflexive movement. When damage to the and responsive movement. Based on this conceptual-

of Key Treatment Strategies Used in the Traditional Sensorimotor Approaches

Proprioceptive
Key Treatment Brunnstrom Approach Neuromuscular Neurodevelopmental
Strategies Rood Approach (Movement Therapy) Approach Treatment
Sensory stimulation YES YES YES VES
used to evoke a motor : Bore ;
Sere ve (Uses direct application (Movement occurs in (Tactile, auditory, visual (Abnormal muscle
P of sensory stimuli to response to sensory sensory stimuli tone occurs, in part,
muscles and joints) stimuli) promote motor because of abnormal
responses) sensory experiences)

Reflexive movement eS Nes) VES NO

used as a precursor for
(Move patient along a (Volitional movements
volitional movement (eHeave WOverien
achieved initially continuum of reflexive can be assisted by
through the application to volitional movement reflexive supported
of sensory stimuli) patterns) postures)

Treatment directed YES YES ES YES

t d infl
coo (Sensory stimuli used (Postures, sensory (Movement patterns ’ (Handling techniques
muscle tone ae zi oa aie :
to inhibit or facilitate stimuli used to inhibit used to normalize and postures can
tone) or facilitate tone) tone) inhibit or facilitate
muscle tone)
Developmental YES MES (ES NO
patterns/sequences
(Ontogenic motor (Flexion and extension (Patterns used to
used for the
patterns used to synergies; proximal to facilitate proximal to
development of motor
develop motor skills) distal return) distal motor control)
skills

Conscious attention is NO YES SEES NO

directed toward
movement

Treatment directly NO NO NO NO
emphasizes
development of skilled
movements for task
performance
 Traditional Sensorimotor Approaches to Treatment: Overview 573

ization , when damage occurs to the CNS, it is be- reduction of muscle tone, which may increase the ease
lieved that the damaged area can no longer regulate in which the arm is moved through the sleeve of a shirt.
and exert control over the underlying areas. Motor Limitations in the use of Rood’s approach are nu-
control, according to this belief, becomes a function merous and include the passive nature of the sensory
of the next lower functioning level of the CNS. Typi- stimulation (it is applied “to” a patient) and the short-
cally this means a return to more reflexive and prim- lasting and unpredictable effect of some of the sensory
itive movement patterns. stimulation.
The four traditional sensorimotor treatment strate-
gies rely heavily on these basic assumptions about
The Brunnstrom (Movement Therapy)
motor development and motor control. Consequently,
treatment strategies used in these approaches frequently
Approach
involve the application of sensory stimulation to Signe Brunnstrom, a physical therapist, developed a
muscles and joints to evoke specific motor responses, treatment approach specifically for patients who had
handling and positioning techniques to effect changes sustained a cerebrovascular accident (CVA). The ap-
in muscle tone, and the use of developmental postures proach she designed draws strongly from both the reflex
to enhance the ability to initiate and carry out move- and hierarchical models of motor control. Brunnstrom
ments. Table 32-1 presents a comparison and summary conceptualized patients who had sustained a CVA as
of key treatment strategies used in each of the four tra- going through an “evolution in reverse”; within this
ditional sensorimotor approaches. concept the early reflexive movement that may be
present is seen as a normal process of this evolution.
Spastic or flaccid muscle tone and the presence of reflex-
OVERVIEW: THE TRADITIONAL ive movements that might be evident after a CVA are
SENSORIMOTOR TREATMENT considered a normal process of recovery; they are
APPROACHES viewed as necessary intermediate steps in regaining voli-
tional movement.'® Brunnstrom clearly detailed stages
Rood Approach
of motor recovery following a CVA. These stages include
Margaret Rood drew heavily from both the reflex and the description of flexor synergy patterns and extensor
the hierarchical models in designing her treatment ap- synergy patterns for the upper and lower limbs.
proach. Key components of the Rood approach are the In the Brunnstrom approach emphasis is on facilitat-
use of sensory stimulation to evoke a motor response ing the progress of patients by promoting movement,
and the use of developmental postures to promote from reflexive to volitional. In the early stages of recov-
changes in muscle tone." Sensory stimulation is applied ery this may include the incorporation of reflexes and
to muscles and joints to elicit a specific motor response. associated reactions to affect tone and achieve move-
Stimulation has the potential to have either an in- ment. For example, to generate reflexive movement in
hibitory or a facilitatory effect on muscle tone. Types of the upper limb, resistance may be applied to one side of
sensory stimulation described by Rood include the use the body in order to increase muscle tone on the oppo-
of slow rolling, neutral warmth, deep pressure, tapping, site side. This technique is applied until the patient
and prolonged stretch. Examples of how this stimula- demonstrates volitional control over the movement
tion may be applied include tapping over a muscle belly pattern.
to facilitate (increase) muscle tone and applying deep In current clinical practice most OT practitioners do
pressure to a muscle’s tendinous insertion to elicit an not use Brunnstrom’s treatment strategies for fear of in-
inhibitory (decreased) effect. Rood also described the creasing and encouraging the development of abnormal
use of specific developmental sequences believed to movement patterns, which may be difficult to undo
promote motor responses. These sequences were proxi- later on. However, the stages of recovery are used in
mal to distal and cephalocaudal. Treatment strategies some rehabilitation settings to describe motor recovery.
move patients through these developmental sequences.
In current clinical practice, practitioners may use se- Proprioceptive Neuromuscular
lected principles from Rood’s work as adjunctive or pre-
Facilitation Approach
liminary interventions in order to prepare a patient to
engage in a purposeful activity—for example, the appli- The proprioceptive neuromuscular facilitation (PNF)
cation of quick stretch over the triceps before instructing approach is grounded in both the reflex and hierarchical
a patient to reach for a cup. A patient may be instructed models of motor control. Major emphasis in this ap-
in ways to apply his or her own sensory stimulation proach is on the developmental sequencing of move-
in order to enhance ADL performance. For example, ment and the balanced interplay between agonist and
during upper extremity dressing, a patient might antagonist in producing volitional movement.'? PNF
perform a prolonged stretch to the biceps, resulting in a describes mass movement patterns, which are diagonal
574 OCCUPATIONAL THERAPY INTERVENTIONS

in nature, for the limbs and trunk. Treatment strategies

use these patterns to promote movement. The use of
aaa melllscualol
sensory stimulation, including tactile, auditory, and 1. Which structures constitute the upper motor
visual inputs, is also actively incorporated into treat- neurons?
ment to promote a motor response. 2. What are the four general processes of information
In OT clinical practice the inclusion of PNF patterns flow related to control of movement?
often can be seen in the way functional activities are de- 3. Define motivational urge and name the locus of this
signed, especially in the placement of objects during function in the brain.
purposeful activities. Asking a patient to reach into a 4. Where in the brain is motivational urge transformed
shopping bag placed on his left side in order to retrieve to ideas?
objects that will then be placed into a cabinet on the 5. Define motor program.
right side is an example of this. i>). Trace the flow of information in the central and pe-
ripheral nervous systems that leads to purposeful
movement.
Neurodevelopmental Treatment Approach . What is the sensorimotor system?
Neurodevelopmental treatment, also known as the . List the areas of the sensorimotor cortex.
Bobath treatment approach, is based on normal devel- ON
© . Where does movement planning take place?
opment and movement. It draws from the hierarchical 10. List the structures that constitute the higher, middle,
model of motor control. The primary objectives of neu- and lower levels of the central nervous system com-
rodevelopmental treatment are to normalize muscle ponents for movement.
tone, inhibit primitive reflexes, and facilitate normal 11. Name the four traditional sensorimotor approaches
postural reactions.’ Improving the quality of movement to treatment and the theorist responsible for each.
and helping patients relearn normal movement patterns 12. Which two models of motor control form the basis
are key objectives of treatment. To achieve these objec- for the sensorimotor approaches to treatment?
tives, therapists employ numerous techniques, includ- 13. Briefly describe each of the four traditional sensori-
ing handling techniques, weight bearing over the af- motor approaches to treatment. Compare and con-
fected limb, the use of positions that encourage the use trast their similarities and their differences.
of both sides of the body, and the avoidance of any 14. List some techniques used by therapists to influence
sensory input that might adversely affect muscle tone. or modify motor responses in each of the tradi-
In clinical practice today, many of these techniques and tional sensorimotor approaches.
strategies are used in treatment within the context of 15. How are the sensorimotor approaches used in
purposeful activities. current clinical practice?

SUMMARY REFERENCES
1. Bobath B: Adult hemiplegia: evaluation and treatment, ed 3, London,
Movement takes place within an occupational context. 1991, Heinemann Medical Books.
Emotional needs influence motor strategies. The spinal 2. Brooks VB: The neural basis of motor control, New York, 1986,
Oxford University Press.
cord or brainstem can mediate reflexive responses, but
3. Cheney PD: Role of cerebral cortex in voluntary movements: a
interpretation and transformation of sensory signals by review, Phys Ther 65(5):624-635, 1985.
all areas of the sensorimotor system are essential for vol- 4. Fromm C, Wise SP, Evarts EV: Sensory response properties of py-
untary movement to occur with precision. The primary ramidal tract neurons in the precentral motor cortex and postcen-
somatosensory cortex and posterior parietal cortex are tral gyrus of the rhesus monkey, Exp Brain Res 54(1):177-185,
1984.
primarily responsible for processing sensory informa-
5. Georgopoulus AP et al: The motor cortex and the coding of force,
tion. The premotor area uses sensory information for Science 256(5064):1692-1695, 1992.
the planning of movements, the supplementary motor 6. Holstege G: The emotional motor system, Eur JMorphol 30(1):67-
area is important for bimanual coordination, and the Visk: MOR.
motor cortex is important for execution. 7. Houk JC, Keifer J, Barto AG: Distributed motor commands in the
limb premotor network, Trend Neurosci 16(1):27-33, 1993.
The traditional sensorimotor treatment approaches
8. Jeannerod M: The neural and behavioral organization of goal-directed
have their theoretical basis in reflex and hierarchical movements, Oxford, 1988, Clarendon Press.
models of motor control. These approaches offer a valu- 9. Kalaska JE, Crammond DJ: Cerebral cortical mechanisms of reach-
able link between neurophysiological principles and the ing movements, Science 255(5051):1517-1523, 1992.
rehabilitation treatment of patients with CNS dysfunc- 10. Kandel ER, Schwartz JH, Jesell TM, editors: Principles of neural
science, ed 3, New York, 1991, Elsevier.
tion. In contemporary practice many of the techniques
11. McCormack G: The Rood approach to treatment of neuro-
described in these approaches are used as adjunctive or muscular dysfunction. In Pedretti LW, editor: Occupational ther-
preliminary techniques or are incorporated into more apy: practice skills for physical dysfunction, ed 4, St Louis, 1996,
task-directed treatment activities. Mosby.
 Traditional Sensorimotor Approaches to Treatment: Overview 575

12 Penfield W: The excitable cortex in conscious man, Liverpool, 1958, 16. Sawner K, LaVigne J: Brunnstrom's movement therapy in hemiplegia: a
Liverpool University Press. neurophysiological approach, ed 2, Philadelphia, 1992, JB Lippin-
A ey Roland P et al: Supplementary motor area and other cortical areas cott.
in organization of voluntary movements in man, J Neurophysiol V7, Sherrington C: The integrative action of the nervous system, ed 2,
43(1):118-136, 1980. New Haven, Conn, 1947, Yale University Press.
14. Rothwell JC: Control of human voluntary movement, ed 2, London, 18. Tanji J, Taniguchi K, Saga T: Supplementary motor area: neuronal
1994, Chapman & Hall. ‘ response to motor instructions, J Neurophysiol 43(1):60-68, 1980.
15. Rothwell JC et al: Physiological studies in a patient with mirror WS Voss DE, lonta MK, Myers BJ: Proprioceptive neuromuscular facilita-
movements and agenesis of the corpus collosum, J Physiol tion, ed 3, Philadelphia, 1985, Harper & Row.
438:34P, 1991.
 LEARNING OBJECTIVES
Chaos theory After studying this chapter the student or practitioner
Dynamic systems will be able to do the following:
Coeffect 1. Identify the importance of Margaret Rood’s work.
Nonlinear 2. Define key concepts first proposed by Margaret
Generalizability Rood.
Somatic marker 3. Delineate how Rood’s concepts have been redefined
Meta-emotion in light of current understanding of neuroscience.
Reciprocal inhibition 4. Recognize the four components of motor control
Cocontraction emphasized by Rood.
Heavy work 5. Describe the major motor patterns of development
Skill identified by Rood.
Supine withdrawal 6. Delineate examples of how Rood’s major motor
Rollover patterns are used during occupation.
Pivot prone 7. State reasons for caution when employing Rood’s
Neck cocontraction treatment techniques.
Ontogenetic patterns 8. Give two examples of Rood techniques still used
Proprioceptive neuromuscular techniques today.
Vestibular stimulation 9. Contrast the traditional Rood approach and the
Inversion Rood approach reconstructed for occupation-based
Inhibitory techniques practice.

argaret S. Rood was formally educated in both therapists such as Ayres,’ Farber,*” Heininger,'* Ran-
occupational and physical therapy. She originated her dolph,*° Huss, '* and Stockmeyer.”°
theory in the 1940s and revised it many times. Rood did Theories and related frames of reference exist within
not write extensively, she seemed to prefer clinical teach- the context of the time and level of knowledge from
ing for the dissemination of her ideas. Most of the litera- which they originate. Many would say that the work of
ture that describes the Rood approach is based on inter- Margaret Rood is out of date and thus not worthy of
pretations by accomplished occupational and physical study. Many of the particular techniques and some of the
hypotheses posed by Rood have never been adequately
tested or researched. Nonetheless, to discount Rood’s
The first author wishes to acknowledge the inspirational leadership of work as out of date is to discount an important historical
Virginia Scardina in promoting the work of Margaret Rood. perspective of occupational therapy (OT) and to dismiss
 The Rood Approach: A Reconstruction

the possibility of incorporating elements of her work 7

into more recent understanding of central nervous 4

system (CNS) processing linked to therapeutic interven- Summary of Main Concepts of Rood’s Work
tion. Thus the purpose of this chapter is to offer a recon- Traditional Rood Reconstruction of Rood
struction of Rood’s work based on current understanding Normalization of muscle tone Muscle tone and motor
_ of CNS processing and occupation-based intervention. ‘is a prerequisite for move- control coeffect each other
A measure of the contribution of a scholar to a field ment.
is not whether he or she is ultimately determined to be
Treatment begins at the Flexion and extension
right or wrong, but how much research and deliberation
TT.

developmental level of patterns coeffect each other.

the person’s work engendered. Rood’s work continues functioning.
to be valuable to OT in terms of orientation to the inter-
action of the nervous system with behavior, function, Reeducation of muscular Repetition of muscular
and, most significantly, occupation. For all of these responses occurs through responses creates movement
repetition. patterns.
reasons, the work of Margaret Rood is important for
therapists to study. Movement is directed toward Intention or goal direction
The work of Margaret Rood was set in the context of functional goals. coeffects movement.
the developmental and neurophysiological literature of Approximation of real life Approximation of real life
the 1930s through the 1970s. At that time the neuro- context increases treatment context increases treatment
science literature was based on assumptions of the hier- effectiveness and generaliz- effectiveness and
archical nature of the nervous system that have subse- ability.* generalizability.
quently been revised. In light of current understanding
Therapeutic use of self should Therapists use somatic
of the heterarchial (flattened hierarchy) nature of
match client needs.” markers to select interaction
nervous system functioning, a reconstruction of Rood’s methods with clients.*
work is executed based in part on current understanding
of chaos theory and dynamic systems. Rood’s main *This was a basic Rood premise taught to the first author by Margaret Rood
contribution has been to highlight the importance of during a 2-week training course in Cincinnati in the 1970s.
interactions that occur between the nervous system and tSee Chapter 8,""The Somatic Marker Hypothesis,” in Damasio AR: Descartes’
error: emotion, reason and the human brain, New York, 1994, Avon Books.
occupation (i.e., that the nervous system and occupa-
tion coeffect one another in a dynamic, nonlinear
manner). Coeffect refers to the interaction of one or
more forces upon the other force(s), suggesting a state that affect movement. Yet they are singled out for this
or condition of active interdependence. special emphasis because Rood was the person who
Specifically, Rood identified (1) that the feedback called for therapists to look at muscle tone as a contrib-
loop of motor and sensory signals coeffect ‘each other, utor to movement. It is now known that muscle tone is
(2) that patterns of sensory-motor behaviors emerge not the only prerequisite for motor control and that rel-
over time, and (3) that the psychic, somatic, and auto- ative degrees of motor control can, in fact, exist in spite
nomic functions operate within a system of coeffects or of poor or inadequate muscle tone.
interrelationships. “Flexion and extension patterns coeffect each other”
refers to the dynamic relationship between flexion pat-
terns experienced through everyday occupations and ex-
RECONSTRUCTION OF ROOD’S THEORY
tension patterns also experienced through everyday oc-
FOR OCCUPATION-BASED PRACTICE
cupations (e.g., sitting in a flexion pattern while reading
Rood’s work has been synthesized into the essential this text!). It is hypothesized that the total balance or
concepts presented in Table 33-1, which provides a his- imbalance between flexion and extension patterns
torical view with a reinterpretation of concepts that still affects both in a dynamic system of postural patterns.
apply. “Repetition of muscular response creates movement
As delineated in Table 33-1, six key concepts of Rood patterns” refers to the learning that occurs through
have been reconstructed (right column) from the tradi- repeated neuromuscular actions that lay down the
tional view, (left column), in light of current knowledge engrams for the repertoire of motor behavior available
and understanding pertaining to the areas. Each of these to a given individual.
reconstructed concepts is briefly discussed in the follow- “Intention or goal direction coeffects movement”
ing paragraphs. refers to the developing research base that shows that
“Muscle tone and motor control coeffect each other” intent of a motor action influences the nature and
refers to the relationship that exists between the tone of quality of motor action.
the muscles and the execution of the motor act. These “Activities which provide approximation of real life
are but two parameters among a myriad of variables context increase treatment effectiveness and generaliz-
578 OCCUPATIONAL THERAPY INTERVENTIONS

ability” refers to the supposition that performance in proximal muscles contract and move, whereas the distal
real life or simulated contexts increases the effectiveness segment is fixed. A good example of heavy work is creep-
of “practice” and indeed of therapy itself. ing. In the quadruped position, the distal segments,
“Therapists use somatic markers to select interaction wrists, and ankles are in a fixed position. The proximal
methods with clients” refers to a working hypothesis joints, such as the neck and thorax, are stable, whereas
that master clinicians intuitively and automatically “fit” the shoulder and hip girdles are free to move. Heavy
their demeanor and emotional state to those of the work patterns may be associated with many of the occu-
client being served. Somatic marker, a term coined by pations typically involved with agriculture and industry,
Damasio,’ is used here to refer to the collection of feel- such as lifting, moving, or pulling. It is hypothesized
ings or emotional tone of a person at any given time, in that modern society (Western civilization) lacks “heavy
a learned response to a given situation. Somatic marker work” patterns, resulting in a functionally deficient neu-
is a concept related to the larger conceptualization of rophysiological state for members of this society.
meta-emotion. The term meta-emotion is used here to
refer to the conceptualization and study of the interac-
Skill
tions or coeffects between emotions, the body, and oc-
cupation (i.e., “feeling while doing”). Skill is the highest level of motor control and combines
the effort of mobility and stability."’?? In the execution
of a skilled pattern the proximal segment is stabilized
ROOD’S FOUR COMPONENTS
while the distal segment moves freely. The art of oil
OF MOTOR CONTROL
painting demonstrates this pattern. The artist stands
Table 33-1 reveals that Margaret Rood’s concepts per- back from the canvas, holds his or her arm at full length,
taining to motor function were far ranging. An impor- and manipulates the brush freely in the hand. Skill is as-
tant contribution of her work is the emphasis she placed sociated with many of the functions needed in the in-
on components of motor control. She was a forerunner formation age, such as typing and fine eye-hand coordi-
of current motor control theories in that she was among nation for computer work. It is further hypothesized
the first to identify and articulate the importance of that modern society has an excessive preponderance of
components of motor control in the therapeutic skill demands, to the exclusion of heavy work patterns,
context. Therapists can apply these same concepts today with a resultant imbalance.
in occupation-based practice. Accordingly, the four
components of motor control Rood emphasized are
MOTOR PATTERNS
summarized below.
In this section the major motor patterns of development
that Rood emphasized are reviewed. For each motor
Reciprocal Inhibition (Innervation)
pattern photographs of humans engaged in the postural
Reciprocal inhibition is an early mobility pattern that pattern as an activity or an occupation are shown.
serves a protective function. It is a phasic (quick) type of
movement that requires contraction of the agonist
Supine Withdrawal (Supine Flexion)
muscle as the antagonist muscle relaxes. This basic
movement pattern is primarily a reflex governed by Supine withdrawal is a total flexion response toward the
spinal and supraspinal centers. It is, in fact, the under- vertebral level of T10. This position is protective because
pinning for movement needed to engage in occupation. the flexion of the neck and the crossing of the arms and
legs protect the anterior surface of the body. This posi-
tion is a mobility posture requiring reciprocal innerva-
Cocontraction (Coinnervation)
tion, yet it also requires heavy work of the proximal
Cocontraction or coinnervation provides stability and muscles and the muscles of the trunk.” Therapeutically,
is considered a tonic (static) muscle pattern. This supine withdrawal aids in the integration of the tonic
muscle pattern provides the ability to hold a position or labyrinthine reflex. Rood recommended this pattern for
an object for a longer duration. Cocontraction is the si- patients who lacked reciprocal flexion pattern and for in-
multaneous contraction of the agonist muscle and an- dividuals dominated by extensor tone (Fig. 33-1).
tagonist muscle, with the antagonist supreme. It is the
foundation of postural control, which provides the sta-
Rollover (Toward Side Lying)
bility needed for engaging in occupation.
When an individual is rolling over, the arm and leg flex on
the same side of the body. This movement, rollover, is a
Heavy Work
mobility pattern for the extremities and activates the
Heavy work is described by Stockmeyer as “mobility su- lateral trunk musculature.?° Rollover is encouraged for
perimposed on stability.”*° In this postural pattern the individuals who are dominated by tonic reflex patterns in
 The Rood Approach: A Reconstruction

FIG. 33-2
Rollover toward side lying.

ities. This pattern has been called both a mobility

pattern and a stability pattern. The position is difficult
to assume and hold against gravity. Therefore the pivot-
prone position plays an important role in preparation
for stability of the extensor muscles in the upright posi-
tion. The pivot-prone position has been associated with
the labyrinthine righting reaction of the head. The
ability to maintain the position indicates integration of
the symmetric tonic neck reflexes and the tonic
labyrinthine reflexes (Fig. 33-3).

Neck Cocontraction (Coinnervation)

FIG. 33-1
Supine withdrawal or supine flexion.
Neck cocontraction is the first genuine stability
pattern. In keeping with the cephalo-caudal and
cephalo-rostral rules, cocontraction of the neck pre-
the supine position. The rolling action also stimulates the cedes cocontraction of the trunk and extremities. As
semicircular canals of the vestibular system, which in turn the head bobs up and down, the extensors and rotators
_ activate the neck and extraocular muscles (Fig. 33-2). are stretched. This action is thought to activate both
flexors and deep tonic extensors of the neck.*? It is im-
portant to make sure the neck flexors are well estab-
Pivot Prone (Prone Extension) lished, however, before the prone position is assumed.
The pivot-prone position demands a full range of ex- To raise the head against gravity, the patient needs to
tension of the neck, shoulders, trunk, and lower extrem- have good cocontraction of the flexors and extensors of
 OCCUPATIONAL THERAPY INTERVENTIONS

FIG. 33-3
Pivot prone or prone extension.

FIG. 33-4
Neck cocontraction or coinnervation.

On Elbows (Prone on Elbows)

the neck.* Neurologically this pattern elicits the tonic
labyrinthine righting reaction when the face is perpen- After cocontraction of the neck and prone extension,
dicular to the floor. As the head flexes, it stretches the weight bearing on the elbows is the next pattern to be
proprioceptors in the neck and upper trapezius, causing achieved. Bearing weight on the elbows stretches the
them to contract against the forces of gravity.'?"? upper trunk musculature to influence stability of the
This position also promotes neck stability and extraoc- scapular and glenohumeral regions. This position
ular control (Fig. 33-4). gives the patient better visibility of the environment
and an opportunity to shift weight from side to side.
It is also inhibitory to the symmetrical tonic neck
ONTOGENETIC DEVELOPMENT PATTERNS reflex (Fig. 33-5). :
Ontogenetic development patterns observed in
normal development are outlined in the following sec- All Fours (Quadruped Position)
tions. In the past these patterns were used as a basis for
therapy. It was assumed that motor control could be in- The quadruped position follows stability of the neck
hibited or facilitated by positioning in the patterns. It and shoulders. The lower trunk and lower extremities
may be the case that these patterns have beneficial are brought into a cocontraction pattern. Initially the
effects when combined with occupational engagement, position is static and the abdomen may sag at the
but that these effects are not necessarily or exclusively T10 level, causing stretching of the trunk and limb
on motor control. Future research will shed more light girdles. This stretching develops cocontraction of the
on these assumptions. trunk flexors and extensors. Eventually shifting weight
 The Rood Approach: A Reconstruction

FIG, 33-5
_ Prone on elbows.

forward, backward, side to side, and diagonally provides length.*° Walking is a sophisticated process requiring
a mobility superimposed on the stability phase. The coordinated movement patterns of various parts of the
weight shifting may be preparatory to equilibrium re- body, including weight shifting (Fig. 33-8).
sponses (Fig. 33-6). In addition to the theoretical emphasis Rood placed
upon the previously discussed motor patterns, she de-
veloped many innovative treatment strategies and tech-
Static Standing
niques, as described in the following section.
Assuming the upright bipedal position, static standing is
thought to be a skill of the upper trunk because it frees TRADITIONAL ROOD TREATMENT
the upper extremities for prehension and manipula-
TECHNIQUES FOR OCCUPATION-BASED
tion.*° Weight is first equally distributed on both legs,
PRACTICE
and then weight shifting begins. This position brings
into play higher level neurological integration, such as The reader is likely to encounter Rood techniques in
righting reactions and equilibrium reactions (Fig. 33-7). practice. However, these techniques lack empirical study
to determine their effectiveness, and knowledge of ad-
vanced neuroscience is needed to even consider the use
Walking of these techniques in practice. Table 33-2 presents a
The gait pattern unites skill, mobility, and stability. Ac- summary of traditional treatment techniques employed
cording to Murray,'* normal locomotion entails the by Rood.
ability to support the body weight, maintain balance, Caution is urged in adopting any or all of these tech-
and execute the stepping motion. Walking includes a niques in current occupation-based practice because
stance phase, push off, swing, heel strike, and stride these interventions are designed to specifically influence
 OCCUPATIONAL THERAPY INTERVENTIONS

FIG. 33-6
Quadruped (all fours).

ummary of Rood Facilitatory and Inhibitory

Cutaneous Proprioceptive
Facilitation Facilitation Inhibitory
Techniques Techniques Techniques
Light moving Heavy joint Neutral warmth
touch* compression

Fast brushing* Resistance Joint approximation

Icing* Vestibular Slow stroking
stimulation

Inversion Rocking

Stretch pressure* Gentle shaking or

rocking*

Stretch* Tendinous pressure*

Intrinsic stretch* Maintained stretch*

Secondary ending ~ Slow rolling*

stretch*

Tapping*

Therapeutic
vibration*

Osteopressure*

*These techniques are well beyond the scope of entry-level practice and are
therefore not dealt with in this chapter

FIG. 33-7
Static standing.
unduly address motor function as isolated from the dy-
namical system of engagement in occupation.
performance components and not occupation per se. Of the previously identified Rood intervention tech-
Thus, occupation-based practice would never include niques, those most relevant to today’s practice and those
the provision of any of these treatment techniques iso- consistent with the current understanding of neuro-
lated from an occupation. Also, these interventions science were selected for summary presentation in this
 The Rood Approach: A Reconstruction

FIG, 33-8
Weight shifting.

section. Further, only interventions enHropEste for above the supporting joint.”’'* Heavy joint compression
entry-level practice are discussed. is used to facilitate cocontraction at the joint undergo-
ing compression. This approach can be combined with
developmental patterns, such as prone on elbows,
Proprioceptive Facilitatory Techniques
quadruped, sitting, and standing positions. The joint
Proprioceptive stimulation refers to the facilitation of compression may be done manually by the therapist or
muscle spindles, Golgi tendon organs, joint receptors, with weighted wrist cuffs or sandbags. Clinically, joint
and the vestibular apparatus. '”'”’*? In general, proprio- compression is most effective when applied through the
ceptive stimulation gives the therapist and the client longitudinal axis of long bones such as the humerus
more control over the motor response. Proprioceptors (glenohumeral joint) and the femur (acetabulum).
adapt more slowly than exteroceptors and can produce
sustained postural patterns.’ There is little or no neu- Resistance
ronal recruitment in the proprioceptive system. There- Rood used heavy resistance to stimulate both primary
fore the motor response is thought to last as long as the and secondary nerve endings of the muscle spindle. Re-
stimulus is applied.”*° Four types of proprioceptive fa- sistance is used in an isotonic fashion in developmen-
cilitatory techniques are described in the following para- tal patterns to influence the stabilizer muscles. Accord-
graphs: heavy joint compression, resistance, vestibular ing to Stockmeyer,~° resistance to contraction of muscles
stimulation, and inversion. in the shortened range facilitates muscle spindle affer-
ents in the deeper, tonic postural muscles. Fast brushing
Heavy Joint Compression is used over the stabilizers before resistance is applied,
Heavy joint compression is joint compression greater to maximize the response. Farber’ used quick stretch
than body weight applied through the longitudinal axis before resistance to increase the responsiveness of the
of the bone.’ The amount of force in heavy joint com- muscle spindle. In addition, when a muscle contracts
pression is more than that of the normal body weight against resistance, it assumes a shortened length that

583
584 OCCUPATIONAL THERAPY INTERVENTIONS

Inhibitory Techniques
causes the muscle spindles to contract to readjust to
the shorter length. This is the process of biasing the Four inhibitory techniques are neutral warmth, slow
muscle spindle so it is more sensitive to stretch. Inter- stroking, light joint compression, and rocking in devel-
mittent resistance graded to the desired motion is opmental patterns.
better than manual stretching for alleviating tight
muscles. 11°77 Neutral Warmth
The neutral warmth technique most likely affects the
Vestibular Stimulation temperature receptors of the hypothalamus and stimu-
Vestibular stimulation is a powerful proprioceptive lates the parasympathetic nervous system.*” Neutral
input.° The static labyrinthine system can be used to warmth can be used for individuals with hypertonia,
promote extensor patterns of the neck, trunk, and ex- particularly those with spasticity and rigidity. It may
tremities.*° The kinetic labyrinth can be used to elicit also be helpful for children with attention deficit disor-
phasic subcortical responses such as protective exten- ders.” The provision of neutral warmth can be accom-
sion.'° Jones and Watt'* studied muscular responses to plished by having the individual assume a recumbent
unexpected falls in human subjects. Their findings position while the entire body is wrapped in a cotton
demonstrate that the vestibular system activates the blanket or comforter for approximately 5 to 10 minutes.
antigravity muscles and their antagonists before the Neutral warmth provides a moderate amount of heat
stretch reflex of the muscle spindles. The vestibular that is homeostatically compatible with the receptors of
system is a divergent system that affects tone, balance, the hypothalamus. The individual usually feels relaxed,
directionality, protective responses, cranial nerve func- and muscle tone is decreased.*’'*
tion, bilateral integration, auditory language develop-
ment, and eye pursuits.*'*° The vestibular system is Slow Stroking
stimulated during linear acceleration and deceleration Slow stroking has been described as an inhibitory tech-
in horizontal and vertical planes and during angular ac- nique. The individual lies in the prone position while the
celeration and deceleration, such as spinning, rolling, therapist provides rhythmic, moving, deep pressure over
and swinging. Vestibular stimulation can be either facil- the dorsal distribution of the primary posterior rami of
itatory or inhibitory, depending on the rate of stimula- the spine. The therapist applies fingertip pressure on
tion. Fast rocking tends to stimulate, whereas slow, both sides of the spinous process to affect the nerve
rhythmic rocking tends to cause a generalized relax- endings and the sympathetic outflow of the autonomic
ation response.'’? nervous system. The stroking action is done slowly and
continuously from the occiput to the coccyx. The hands
Inversion are alternated so that as one hand reaches the bottom of
Rood encouraged the use of the inverted position (in- the spine, the other is starting downward from the
version) to alter muscle tone in selected muscles. In top.”’'*'? Inhibition techniques have been found to be
the inverted position the static vestibular system pro- clinically beneficial when accompanied by soft music.
duces increased tonicity of the muscles of the neck, Music also has been used as a closure technique follow-
midline trunk extensors, and selected extensors in the ing sensory integrative therapy to calm children after
limbs.'* Tokizane?’ used human subjects to study the vestibular and proprioceptive facilitation. Slow stroking
effects of head position on selected skeletal muscles. should not exceed 3 minutes because it may cause a
His findings indicate that extensor tone is maximized rebound phenomenon, resulting in excitation of the
in certain muscles in the head-down position, whereas sympathetic branch of the autonomic nervous system.~°
extensor tone is minimized in those muscles in the
upright position. For best results, the head must be in Light Joint Compression (Approximation)
normal alignment with the neck. If the neck is flexed Joint compression of body weight or less than body
or extended, the tonic neck reflex interferes with the re- weight can be used to inhibit spastic muscles around a
sponse.*'’*’ Inversion should be used with extreme care joint.** This technique may be used with individuals who
for individuals with cardiovascular disease. As the head have hemiplegia, to alleviate pain and temporarily offset
approaches a point below the level of the shoulders, the muscle imbalance around the shoulder joint.’ The in-
baroreceptors in the carotid sinus are stimulated by dividual can be sitting or lying in the supine position. The
blood pressure changes. This positioning produces a therapist places one hand over the individual's shoulder
physiological response through the parasympathetic and the other hand under the flexed elbow joint. The arm
nervous system, reducing blood pressure, decreasing is abducted 35° to 45°, and a compression force of body
muscle tone, and promoting generalized relaxation. In- weight or less is applied through the longitudinal axis of
version techniques can be combined with vibration or the humerus.’ This procedure compresses both the gleno-
neck compression to change tone in_ selected humeral joint and the articulation between the humerus
muscles.”1? and ulna. Moreover, if applied properly, this technique
 The Rood Approach: A Reconstruction 585

compresses two joints but has the most dramatic effect on of the Rood approach is that activity should be
the shoulder. Once the muscles begin to relax, the thera- purposeful—that is, occupation based. The introduc-
pist can slowly and gently circumduct the humerus in tion of purposeful activities leading to occupation
small circles to reduce pain and stiffness in the shoulder adds meaning and relevance to the endeavor. Rood’s
joint.” Joint compression of the shoulder and elbow methods are most useful in preparation for engagement
joints can also be achieved when the patient is in the on- in occupation. Reconceptualization of her work in light
elbows position.*° Light joint compression is also benefi- of current research and knowledge is most useful in
cial when applied through the longitudinal axis of the understanding and thinking about occupational per-
wrist and elbow joints.’ The therapist places one hand formance in context. Specifically, Rood’s conceptual
behind the elbow and places the individual's forearm in framework is reconstructed in the next section.
midposition; the wrist joint is extended, and compression
is applied through the heel of the patient's hand. Joint
ROOD’S CONCEPTUAL FRAMEWORK:
compression has its greatest effect during the time that the
A RECONSTRUCTION
stimulus is applied.**
Five key assumptions underlie thinking about occupa-
Rocking in Developmental Patterns tion-based practice in context (Fig. 33-9). These func-
In keeping with the developmental sequence and tions are adapted from Stockmeyer,*° who presented
Rood’s concept of mobility superimposed on stability, Rood’s initial work.
Rood encouraged movement as the individual gained Assumption 1: Neuromuscular function related to occu-
mastery of the static position.7° Developmentally, the pation is a chaotic system of multiple networks inter-
individual first must assume and be able to achieve a acting and changing, based upon coeffects and sensi-
static position and then integrate coordinated move- tivity to initial conditions.
ments while maintaining the posture. Rood referred to Assumption 2: As a chaotic system, neuromuscular func-
this process as the development of “skill.” For example, tion unfolds in a dynamic process.
in the quadruped position, the patient shifts weight to a Assumption 3: Key control parameters influencing the
three-point stance so that one hand is free to reach neuromuscular system are the somatic, autonomic,
forward to grasp and explore the immediate environ- emotional, and cognitive or motivational variables.
ment. Movement may begin by shifting the weight Assumption 4: Motor and sensory systems coeffect each
forward and backward. The shifting may progress to other.
side-to-side and diagonal patterns as the patient Assumption 5: Occupation shapes function.
becomes comfortable with the rhythmic movements.’
In the quadruped position, individuals with hemiplegia
are assisted by achieving stability of the involved elbow
when the therapist applies pressure and stretch to the
triceps brachii and anconeus. As the therapist applies
compression that is greater than body weight to facili-
tate cocontraction, the pressure exerted on the extended for
y th
wrist and heel of the hand inhibits the wrist flexors.
Light, moving touch over the dorsum of the hand is per-
Stabirit
Gr
Ow

formed to promote finger extension.** Rocking in the

quadruped position should first be performed with the
INTERRELATE
neck in a straight, normal relationship to the body so
COEFFECT
that the proprioceptors of the neck do not influence the
tonicity of the limbs.’ As the individual moves in an an-
teroposterior plane, the shoulder and pelvic girdles are
mobilized. Later in treatment, the therapist may want to
incorporate flexion, extension, and rotation of the neck
as a reflex inhibition measure.'”

RECONSTRUCTION OF THE ROOD Wherein:

APPROACH FOR OCCUPATION-BASED Stability based upon structural and functional design
PRACTICE Mobility for survival through protection and movement

Traditionally, occupational therapists used the previ- FIG. 33-9

ously described techniques primarily to prepare an in- A reconstruction of Rood’s conceptual framework. (Figure de-
dividual for purposeful activities. Hence, a basic tenet signed by Rene Padilla, OTR-L.)
 OCCUPATIONAL THERAPY INTERVENTIONS

heuristic is provided to identify the networks that sub-

serve motor function as a foundation for occupation.
istic of Rood Reconstructed
Neuro-- Key REVIEW QUESTIONS
Muscular Control Associated
Network Function Parameter Outcome . Why is it important to study Margaret Rood’s work?
Network | Inspiration Cranial nerveV. — Supine . How have key concepts identified by Rood been re-
NR
Suck Medial flexion: defined today?
Swallow longitudinal body
. What were the four components of motor control
Flexion fasciculus functions
emphasized by Rood?
(MLF) . What were the major motor patterns of development
Network Il Extension Vestibulospinal Pivot described by Rood?
tract (VST) prone: . Give examples of how Rood’s major motor patterns
antigravity
are used during occupation.
Network Ill ©Cocontrac- | Muscle spindle Joint stability: . It was stated that caution is needed when using tradi-
tion posture tional Rood treatment techniques in current occupa-
tion-based practice. What reasons are given for this
Network IV Mobility Corticospinal Movement
tract (CST) through caution?
space: skill . List which Rood techniques are used today and why.
Give examples of two techniques.
NetworkV — Motivation — Limbic system Engagement
. What are the similarities and differences of the tradi-
Frontal lobe in
tional Rood approach and the Rood approach in
Cognition occupation
Emotions
occupation-based practice?
9. Name the five key assumptions underpinning the re-
construction of Rood.

In the future, it is likely that others will elaborate on

REFERENCES
these key assumptions based on the work of Rood.
1. Ayres J: The development of sensory integrative theory and practice,
Finally, as a way to think about the networks that Dubuque, Iowa, 1974, Kendall/Hunt.
subserve motor function as a foundation for occupa- 2. Ayres J: Sensory integration and learning disorders, Los Angeles,
tion, Table 33-3 is provided as an heuristic. Note that 1972, Western Psychological Services.
this heuristic links networks to function, control param- 3. Buchwald J: Exteroceptive reflexes and movement, Am J Phys Med
46(1):141-150, 1967.
eters, and associated outcomes and reflects the essence
4. Clark B: The vestibular system. In Mussen PH, Rosenzweig MR,
of Rood’s thinking as updated with current neuroscien- editors: Annual review of psychology, New York, 1970, Harper & Row.
tific knowledge and understanding. 5. Damasio AR: Descartes’ error: emotion, reason and the human brain,
New York, 1994, Avon Books.
6. DeQuiros JB: Diagnosis ofvestibular disorders in the learning dis-
SUMMARY abled, Learning Disabilities 9:50, 1974.
7. Eldred E: Peripheral receptors: their excitation and relation to
This chapter offers a reconstruction of Margaret Rood’s reflex patterns, Am J Phys Med 46(1):69-87, 1967.
work based on current understanding of CNS processing 8. Farber S: Sensorimotor evaluation and treatment procedures for allied
and therapeutic intervention. Chaos theory and health personnel, Indianapolis, 1974, Indiana University and
dynamic systems theory are used to help reconstruct her Purdue University Medical Center.
9. Faber S: Neurorehabilitation: a multisensory approach, Philadelphia,
theory for occupation-based practice. Rood’s original
1982, WB Saunders.
components of motor control in therapeutic interven- 10. Fukuda T: Studies on human dynamic postures from the view-
tion provide the basis for engagement in occupation. point of postural reflexes, Acta Otolaryngol 161(suppl):8, 1961.
Major motor patterns of development originally devel- 11. Gardner E: Fundametals of neurology, ed 6, Philadelphia, 1975, WB
oped by Rood and their purpose in occupations are de- Saunders. ;
lineated. Traditional Rood treatment techniques for 12. Heininger M, Randolph S: Neurophysiological concepts in human be-
havior, St Louis, 1981, Mosby.
entry-level practice and the application of these tech- 13. Huss AJ: Sensorimotor approaches. In Hopkins H, Smith H, editors:
niques to occupation-based practice are summarized, Willard and Spackman’s occupational therapy, Philadelphia, 1978, JB
based on current findings in neuroscience. In conjunc- Lippincott.
tion with Rood’s tenet that activity should be purposeful, 14. Jones GM, Watt D: Muscular control of landing from unexpected
the context of occupational performance is emphasized. falls in man, J Physiol 219(3):729-737, 1971.
15. Loeb GE, Hoffer JA: Muscle spindle function: in muscle receptors in
A conceptual framework is proposed based on Rood’s movement control, London, 1981, Macmillan.
important concepts, which provided five key assump- 16. Matthews PBC: Muscle spindles and their motor control, Physiol
tions in occupation-based practice in context. Finally, a Rev 44:219, 1964.
 The Rood Approach: A Reconstruction 587

1a McCloskey DI: Kinesthetic sensibility, Physiol Rev 58:763, 1978. with neuromuscular dysfunction, Dubuque, Iowa, 1962, William C
18. Murray MP: Gait as a total pattern of movement, Am J Phys Med Brown.
46(1)290-333, 1967. 25. Schmidt R: Fundamentals of sensory physiology, New York, 1978,
LD. Payton R et al, editors: Scientific basis for neurophysiologic approaches Springer-Verlag.
to therapeutic exercise: an anthology, ed 2, Philadelphia, 1978, FA 26, Stockmeyer S: An interpretation of the approach of Rood to the
Davis. treatment of neuromuscular dysfunction, NUSTEP proceedings,
0: Randolph G: Therapeutic and physical touch: physiological re- ' Am J Phys Med 46(1):900-961, 1967.
sponse to stressful stimuli, Nurs Res 33(1):33-136, 1984. Dive Tokizane T et al: Electromyographic studies on tonic neck, lumbar
mally Roberts T: Neurophysiology of postural mechanisms, New York, 1976, and labyrinthine reflexes in normal persons, Jpn J Physiol 2:30,
Plenum. 1951.
22 Rood M: Neurophysiological mechanisms utilized in the treat- 28. Vallbo A et al: Somatosensory proprioceptive and sympathetic ac-
ment of neuromuscular dysfunction, Am J Occup Ther 10:4, tivity in human peripheral nerves, Physiol Rev 59(4):919-957,
1956. 1979;
23), Rood M: Occupational therapy in the treatment of the cerebral 29; Werner J: Neuroscience: a clinical perspective, Philadelphia,
1980,
palsied, Phys Ther Rev 32:220, 1952. WB Saunders.
24. Rood M: The use of sensory receptors to activate, facilitate and 30. Wilson VJ, Paterson BW: The role of the vestibular system in
inhibit motor response, automatic and somatic, in developmental posture and movement. In Mountcastle V, editor: Medical physiol-
sequence. In Sattely C, editor: Approaches to the treatment of patients ogy, St Louis, 1979, Mosby.
 Cringe The Brunnstrom Approach
f Hemiplegia
io . IN

LEARNING OBJECTIVES
Associated reactions After studying this chapter the student or practitioner
Proximal traction response will be able to do the following:
Limb synergies 1. Describe the theoretical foundations for movement
Flexor synergy (upper and lower limbs) therapy.
Extensor synergy (upper and lower limbs) 2. Describe the evaluation procedure for the upper
Resting posture (upper extremity) limb.
Homolateral limb synkinesis 3. List the goal of treatment for each recovery stage of
Grasp reflex the upper limb.
Instinctive grasp reaction 4. Describe facilitation techniques used in this
Instinctive avoiding reaction approach.
Souques’ finger phenomenon 5. List the sequential stages of motor recovery for arm,
Glenohumeral subluxation hand, and leg.
Wrist fixation for grasp . Define terms associated with this approach.
ND . Identify the synergy patterns of the arm and leg.
8. Identify characteristic movements for each stage of
recovery of arm function.
9. Describe applications of movement patterns
available in stages three to six to purposeful
activities.

PROFILE
Signe Brunnstrom was a physical therapist from ment Therapy in Hemiplegia (1970).* Signe Brunnstrom
Sweden. Her practice, teaching, and theory develop- died in February 1988."
ment in the United States extended from the World War The theoretical foundations, therapeutic goals, and
II years through the 1970s. Her clinical observation and intervention techniques described in this chapter are an
research at major treatment and educational institu- overview of and introduction to some of the procedures
tions, primarily in the Northeast, led to the develop- that constitute movement therapy. This treatment ap-
ment of the treatment approach called movement proach is valuable for its historical significance, its de-
therapy. It was the first systematic approach to the treat- scription of the recovery process, its approach to motor
ment of motor dysfunction after cerebrovascular acci- assessment, and the effectiveness of selected interven-
dent (CVA). The last of the three major works tion strategies. To learn the details of the treatment ap-
Brunnstrom published in the United States was Move- proach, the reader is referred to the original source.’
 Movement Therapy: The Brunnstrom Approach to Treatment of Hemiplegia 589
THEORETICAL FOUNDATIONS
potheses have been challenged and are being modified
Brunnstrom developed her treatment approach on the by newer concepts in neurophysiology.°”
basis of an extensive review of the literature in neuro- The successive levels of CNS integration, and the re-
physiology, central nervous system (CNS) mechanisms, flexes and reactions thought to be integrated at each
effects of CNS damage, sensory systems, and related level, are summarized as follows:
topics, as well as clinical observation and application of 1. Spinal level (apedal): flexor withdrawal, extensor
training procedures.” thrust, crossed extension
The work of several major theorists, such as Gell- 2. Brainstem level (apedal): tonic neck reflexes (TNRs),
horn, Denny-Brown, Hagbarth, Jackson, Magnus and
vr
™
tonic labyrinthine reflex (TLR), associated reactions,
Sherrington, and Twitchell, served as the foundation for positive and negative supporting reactions
the treatment approach. Sherrington, whose work dates 3. Midbrain level (quadrupedal): neck righting, body
to the late 1800s, stated that afferent-efferent (sensory- righting, labyrinthine righting, optical righting, am-
motor) mechanisms in phylogenesis are retained in phibian reaction, Moro reflex
humans, and that these mechanisms serve as the basis 4. Cortical level (bipedal): equilibrium reactions”
for the evolutionary process that result in human move- Twitchell’? described a sequence of motor recovery
ments being more voluntary than automatic. Sherring- after CVA. He hypothesized that recovery after CVA con-
ton postulated that sensory denervation abolished all stitutes a reversal of the regression of CNS function. He
voluntary movement and that sensation is necessary for stated that primitive responses are the bases for the evo-
effective movement.° lution of more elaborate motor responses. Twitchell
In the early 1900s Magnus stated that peripheral in- also postulated that all proprioceptive responses are in-
fluences continuously affect the CNS and may work fluenced by neck- and body-righting reactions, reflexes,
together to facilitate a movement or exert opposite in- and tactile stimulation. He replicated Sherrington’s
fluences that compete with each other. Magnus demon- study and concluded that (1) sensation is critical to
strated in experimental animals that the same stimulus movement, (2) a limb is essentially useless without sen-
can evoke opposite motor responses, depending on the sation, (3) preservation of cutaneous sensation in the
position of the responding part.* The studies of Magnus hand is indispensable for motor function of the upper
support the hypothesis that sensory stimuli and posi- limb, and (4) movements of the upper limb, particu-
tioning can be used to influence motor behavior. larly grasp function, are directed by contactual stimuli.
In the late 1800s Hughlings Jackson described the The recovery process after CVA described by Twitchell is
successive levels of CNS integration. He postulated that summarized sequentially as follows:
the spinal cord and cranial nerve nuclei are located at 1. Flaccidity
the lowest motor centers and that muscles in all parts 2. Stretch reflexes
of the body are represented at this level, but few move- 3. Complex proprioceptive reactions such as the proxi-
ment combinations are possible. Movements | are mal traction response
simple and more automatic than voluntary at this 4, Limb synergies with ability to use these movement
level. Jackson described the middle motor centers in patterns
the Rolandic region of the brain. All the muscles repre- 5. Decline in spasticity
sented at the lowest motor centers also are represented 6. Improvement of willed movement and ability to be
here. More complex movements are possible, however, influenced by tactile stimuli‘?
but movement is still more automatic than voluntary Brunnstrom subscribed to the concept that the dam-
at the middle motor centers. Jackson stated that the aged CNS has undergone an evolution in reverse and re-
frontal lobes contain the highest motor centers, along gressed to phylogenetically older patterns of movement.
with corresponding sensory centers. The body parts These include the limb synergies, gross patterns of limb
represented at the middle and lowest motor centers are flexion and extension that are primitive spinal cord pat-
represented here in a still more complex manner than terns, and primitive reflexes.”* These primitive move-
before. This level subserves complex voluntary move- ment patterns are modified in humans during develop-
ment.” ment through the influence of higher centers of nervous
Jackson hypothesized that the damaged CNS has un- system control. After CVA they return to their primitive,
dergone an “evolution in reverse.” The same reflexes stereotyped character. Thus, when the influence of
present in earlier phylogenesis and ontogenesis are higher centers is disturbed or destroyed, reflexes present
present once again after CNS damage. Therefore these in early life (e.g., TNRs, tonic lumbar reflex, and TLR)
reflexes were considered normal for the regressed CNS. reappear and normal deep tendon reflexes (DTR)
Jackson also stated that reflexes are precursors of pur- become exaggerated. In this approach the TNRs, TLR,
poseful movement and that they support purposeful and tonic lumbar reflex are considered “normal” when
movement.* Brunnstrom’s treatment approach was the central nervous system (CNS) has regressed to an
based on Jackson's hypotheses. In recent years these hy- earlier developmental stage, as in hemiplegia.”
590 OCCUPATIONAL THERAPY INTERVENTIONS

Movement therapy is based on the use of motor pat-

terns available to the patient at any point in the recovery
process. Its goal is to enhance progress through the
stages of recovery toward more normal and complex
movement patterns. Brunnstrom saw synergies, reflexes,
and other abnormal movement patterns as a normal
part of the process that the patient has to go through
before normal voluntary movement could occur.
Brunnstrom believed that the synergies constituted a
necessary intermediate stage for further recovery. Ac-
cordingly, gross movement synergies of flexion and ex-
tension always precede the restoration of advanced
motor functioning after hemiplegia.* Therefore, during
the early stages of recovery (stages one to three) the
patient is aided to gain control of the limb synergies. Se-
lected afferent stimuli (TNRs, TLR, cutaneous and
stretch stimuli, positioning, and associated reactions)
are used to help the patient initiate and gain control of FIG. 34-1
movement. Once the synergies can be performed volun- Flexor synergy of upper limb in hemiplegia. The flexor synergy is
being performed voluntarily and is facilitated by the tonic neck
tarily with some ease, they are modified and simple to
reflex. (From Brunnstrom S: Movement therapy in hemiplegia, New
complex movement combinations are initiated (stages
York, 1970, Harper & Row. Used by permission, Lippincott
four and five). These combined movements deviate Williams & Wilkins).
from the stereotypical synergy patterns of flexion and
extension.’ Synergistic movements are used by normal
persons all of the time, but they are controlled, occur in
a wide variety of patterns, and can be modified or
stopped at will.
The advisability of using reflexes, synergies, and asso-
ciated reactions to effect motion was challenged by
Bobath.' It was argued that no pathological responses
should be used in training because by repeated use the
efferent pathways may become too readily available for
use at the expense of normal pathways.” Brunnstrom,
however, concluded that the opposite was true. She be-
lieved that during the early stages of recovery the devel-
opment of the synergies should be facilitated and that
the use of selected exteroceptive and proprioceptive
stimuli was justified for this purpose.*’* Both Bobath
and Brunnstrom based their hypotheses on neurophysi-
ology. Brunnstrom proposed that the approaches may
not be as opposed as they appear. She stated that in the
early recovery stage, only reflex movement is available,
whereas at later stages of recovery, reflex activity is in-
hibited and more normal movement is_ possible. FIG. 34-2
Brunnstrom proposed that both approaches can be Extensor synergy of the upper limb in hemiplegia. This semivolun-
useful if applied to a specific patient at a specific time.* tary performance of the extensor synergy is being facilitated by
stabilization of the unaffected arm and rotation of the head to the
affected side for facilitation through the ATNR. (From Brunnstrom
Limb Synergies S: Movement therapy in hemiplegia, New York, 1970, Harper & Row.)

A limb synergy of flexion or extension is a pattern of

movement acting as a bound unit in a primitive and
stereotypical manner.’ The muscles in the pattern are perform isolated movements when bound by these
neurophysiologically linked and cannot act alone or synergies.
perform all of their functions. If one muscle in the The flexor synergy of the upper limb consists of
synergy is activated, each muscle in the synergy re- scapular adduction and elevation, shoulder abduction
sponds partially or completely. The patient thus cannot and external rotation, elbow flexion, forearm supina-
 Movement Therapy: The Brunnstrom Approach to Treatment of Hemiplegia 591

tion, wrist flexion, and finger flexion. Hypertonicity and internal rotation; knee extension; ankle plantar
(spasticity) is usually greatest in the elbow flexion com- flexion and inversion; and toe flexion (Fig. 34-4). Hip
ponent and least in shoulder abduction and external ro- adduction, knee extension, and ankle plantar flexion are
tation (Fig. 34-1). The extensor synergy consists of usually the most hypertonic components, whereas hip
scapula abduction and depression, shoulder adduction extension and internal rotation are usually less so.
and internal rotation, elbow extension, forearm prona-
tion, and wrist and finger flexion or extension. Shoulder
Characteristics of Synergistic Movement
adduction and internal rotation are usually the most hy-
pertonic components of the extensor synergy, with much The flexor synergy dominates in the arm, and the exten-
less tone in the elbow extension component (Fig. 34-2). sor synergy dominates in the leg. Performance of syner-
In the lower limb the flexor synergy consists of hip gistic movement, either reflexively or voluntarily, may
flexion and abduction and external rotation, knee be influenced by the postural mechanism. When the
flexion, ankle dorsiflexion and inversion, and toe exten- patient performs the synergy, the components with the
sion (Fig. 34-3). Hip flexion is usually the component greatest degree of hypertonicity are often most appar-
with the highest tone, and hip abduction and external ent, rather than the entire classic patterns described pre-
rotation are the components with the least tone. The ex- viously (Fig. 34-5). With facilitation or voluntary effort,
tensor synergy is composed of hip adduction, extension, however, the more classic synergy pattern can usually be

FIG. 34-3
Flexor synergy of the lower limb is evoked as an associated reaction by giving resistance to ankle
plantar flexion on the unaffected side. (From Brunnstrom S: Movement therapy in hemiplegia, New
York, 1970, Harper & Row.)

FIG. 34-4
Extensor synergy of the lower limb is evoked as an associated reaction by giving resistance to ankle
dorsiflexion on the unaffected side. (From Brunnstrom S: Movement therapy in hemiplegia, New York,
1970, Harper & Row.)
392 OCCUPATIONAL THERAPY INTERVENTIONS

flexion, forearm pronation, and wrist and finger flexion

(Fig. 34-6).

Motor Recovery Process

Brunnstrom observed that after a CVA resulting in hemi-
plegia, the patient progresses through a series of recov-
ery steps or stages in a fairly stereotypical fashion (Table
34-1). The progress through these stages may be rapid
or slow.
Spontaneous motor recovery follows an ontogenetic
process, usually proximal to distal, so that shoulder
movement can be expected before hand movement.
Flexor patterns occur before extensor patterns, reflex
motion occurs before voluntary movement, and gross
movement patterns can be performed before isolated,
selective movement.*
Recovery may cease at any stage and is influenced by
such factors as sensation, perception, cognition, motiva-
FIG, 34-5
Flexor synergy of the upper limb, alternate pattern with hyperex-
tion, affective states, and concomitant medical problems.
tension at the shoulder and half-range forearm supination. (From Few patients make a very good recovery of arm function,
Brunnstrom S: Movement therapy in hemiplegia, New York, 1970, and the greatest loss is usually in the wrist and hand.
Harper & Row.) No two patients are exactly alike. There is much indi-
vidual variation in the characteristic motor disturbances
and the recovery process among patients. The motor be-
havior and recovery process described represent
common characteristics that may be observed in most
persons after CVA occurs.*

DEFINITION OF TERMS
A definition of terms is necessary before the discussion of
treatment principles that follows. Associated reactions are
movements on the affected side in response to voluntary,
forceful movements in other parts of the body.* Resis-
tance to flexion movements of the normal upper extrem-
ity (UE) usually evokes a flexor synergy or some of its
components in the affected UE. Resistance to extension
on the sound side evokes the extensor synergy on the af-
fected side. In the lower extremities the responses are re-
versed. Resisted flexion of the normal limb evokes exten-
sion of the affected limb, and vice versa.”
Homolateral limb synkinesis is a mutual depend-
ency between the synergies of the affected upper and
lower limbs. The same or similar motion occurs in the
limb on the same side of the body. For example, efforts
FIG. 34-6 at flexion of the affected UE evoke flexion of the lower .
Typical resting posture of the upper limb in standing. Shoulder ad- extremity (LE).*° The mirroring of movements at-
duction, elbow flexion, forearm pronation, and wrist and finger tempted or performed on the affected side by the unaf-
flexion. (Adapted from Brunnstrom S: Movement therapy in hemiple- fected side, perhaps in an effort to facilitate the move-
gia, New York, 1970, Harper & Row.) ment, is called imitation synkinesis.*
Several specialized reactions can be noted in the
evoked.* The resting posture of the limb, particularly hemiplegic hand. The proximal traction response is
the arm, is characterized by a position that represents elicited by a stretch to the flexor muscles of one joint of
the most hypertonic components of both flexor and ex- the upper limb, which evokes contraction of all flexors
tensor synergies-that is, shoulder adduction, elbow of that limb, including the fingers. This response may
 Movement Therapy: The Brunnstrom Approach to Treatment of Hemiplegia

Motor Recovery After Cerebrovascular Accident*

Characteristics

Leg Arm ) Hand

Flaccidity Flaccidity; inability to perform any No hand function
movements

Spasticity develops; minimal Beginning development of Gross grasp beginning; minimal

voluntary movements spasticity; limb synergies or finger flexion possible
some of their components
begin to appear as associated
reactions
Spasticity peaks; flexion and Spasticity increasing; synergy Gross grasp, hook grasp possible;
extension synergy present; hip- patterns or some of their no release
knee-ankle flexion in sitting and components can be performed
standing voluntarily
Knee flexion past 90° in sitting, Spasticity declining; movement Gross grasp present; lateral
with foot sliding backward on combinations deviating from prehension developing; small
floor; dorsiflexion with heel on synergies are now possible amount of finger extension and
floor and knee flexed to 90° some thumb movement
possible

Knee flexion with hip extended in Synergies no longer dominant; Palmar prehension, spherical and
standing; ankle dorsiflexion with more movement combinations cylindrical grasp and release
hip and knee extended deviating from synergies possible
performed with greater ease
Hip abduction in sitting or Spasticity absent except when All types of prehension, individual
standing; reciprocal internal and performing rapid movements; finger motion, and full range of
external rotation of hip isolated joint movements voluntary extension possible
combined with inversion and performed with ease
eversion of ankle in sitting

From Brunnstrom S: Movement therapy in hemiplegia, New York, 1970, Harper & Row.
*Recovery of hand function is variable and may not parallel the six recovery stages of the arm.

therefore be used to elicit the flexor synergy. To elicit the hemiplegia. Brunnstrom found that although this phe-
grasp reflex, the examiner applies deep pressure to the nomenon may not be exhibited, the elevated position
palm and moves the pressure distally over the hand and of the affected arm is favorable for the facilitation of
fingers, mostly on the radial side. The responses are finger extension.*
complex, but in general, adduction and flexion of the
digits are present. The instinctive grasp reaction was
MOTOR ASSESSMENT OF THE PATIENT
differentiated by Brunnstrom from the grasp reflex. It is
WITH HEMIPLEGIA
a closure of the hand in response to contact of a station-
ary object with the palm of the hand. The person is Brunnstrom in Movement Therapy in Hemiplegia de-
unable to release the object-stimulus once the fist has scribed an assessment procedure that measures muscle
been closed. tone, stage of recovery, movement patterns, motor
A hyperextension reaction of the fingers and thumb speed, and prehension patterns of the UE.° The assess-
in response to forward-upward elevation of the arm is ment is based on the recovery stages after the onset of
the instinctive avoiding reaction. Brunnstrom reported hemiplegia. In this test the patient performs motor acts
that with the arm in this position, stroking distally over that are graduated in complexity and require increas-
the palm and attempting to reach out and grasp an ingly finer neuromuscular control.
object resulted in an exaggeration of the reaction. The Progress through the recovery stages is gradual, and
automatic extension of the fingers when the shoulder is signs of two stages may be apparent at any given time in
flexed is known as the Souques’ finger phenomenon, the patient's recovery. Because it is not possible to estab-
and can be observed in some, but not all, patients with lish an absolute point between one recovery stage and
594 OCCUPATIONAL THERAPY INTERVENTIONS

Gross Sensory Testing

the next, the patient may be classified as being at stages
two and three or three and four, for example. This rating Sensory testing precedes motor assessment and includes
indicates progression from one stage to the next. The assessment of passive motion sense and touch localiza-
Hemiplegia Classification and Progress Record is pre- tion in the hand. Tests of passive motion sense of the
sented in Fig. 34-7. The reader should refer to this form shoulder, elbow, forearm, wrist, and fingers are carried
while reading the directions for test administration, out by procedures similar to those described in Chapter
which have been summarized from Movement Therapy in 25. Results are recorded on the first and second pages of
Hemiplegia.* the form (shown in Fig. 34-7, A and B).

HEMIPLEGIA CLASSIFICATION AND PROGRESS RECORD

Upper limb-test sitting

Name Age Date of onset Side affected

Date
____ Passive motion sense: Shoulder Elbow
___ Pronation-supination.___— «Wrist flexion-extension
—— 1. NO MOVEMENT INITIATED OR ELICITED
__ 2. SYNERGIES OR COMPONENTS FIRST APPEARING. — Spasticity developing
— Flexor synergy
= Extensor synergy ee
es
__ 3. SYNERGIES OR COMPONENTS INITIATED VOLUNTARILY. Spasticity marked
FLEXOR SYNERGY ACTIVE JOINT RANGE REMARKS
___ Shoulder girdle Elevation
Retractionae a
ae
Shoulda oni erent a
a
a External rotation Linge? eT Ag aoe a
_—_ Elbow Flexion eea
__._ Forearm Pronation
EXTENSOR SYNERGY
____ Shoulder Pectoralis major
____ Elbow Extension
__- Forearm Pronation
4. MOVEMENTS — Hand to sacral
aoe DEVIATING region
FROM BASIC Raise arm forward-
mee SYNERGIES. _ horizontally
Spasticity Pronate-supinate
ie decreasing elbow at 90 degrees
5. RELATIVEIN- Raise arm sideways
DEPENDENCE _ -horizontally
OF BASIC Raise arm
SYNERGIES. over head |
Spasticity Pronate-supinate
a waning elbow extended
6. MOVEMENT COORDINATION NEAR
NORMAL. Spasticity minimal 1

FIG. 34-7
Hemiplegia classification and progress record. (From Brunnstrom S: Movement therapy in hemiplegia,
New York, 1970, Harper & Row.)
 Movement Therapy: The Brunnstrom Approach to Treatment of Hemiplegia 595

Fingertip recognition is tested by asking the patient be initiated.* The examiner should move the limb pas-
to localize touch stimuli to specific fingers. The patient sively through the synergy patterns and assess the degree
is seated, with forearms pronated and resting on a of resistance to passive movement. The patient should
pillow in the lap. The test is given with the vision oc- be asked to attempt movement during these maneuvers.
cluded after a rehearsal in full view. The palmar surface During recovery stage one the limb is predominantly
of the fingertips is lightly touched with a pencil eraser in flaccid and feels heavy, there is little or no resistance to
a random sequence. The patient must indicate which passive movement, and the patient is unable to initiate
finger is being touched. Results are recorded on the or effect any movement voluntarily.
second page of the form (Fig. 34-7, B). During recovery stage two, tone begins to increase
and the limb synergies or some of their components
may be evoked on voluntary effort or as associated reac-
Motor Tests of Upper Extremity
tions. The flexor synergy usually appears first.* The ther-
The patient is classified as being in recovery stage one apist may again move the limb passively, alternating
when no voluntary movement of the affected arm can between flexor and extensor synergy patterns. The

HEMIPLEGIA CLASSIFICATION AND PROGRESS RECORD

Upper limb-test sitting cont’d

Date

SPEED TESTS FOR Classes 4, 5, 6 Strokes per 5 seconds

Hand from Normal
lap to chin Affected
Hand from lap Normal
to opposite knee Affected
Passive motion sense, digits
Fingertip recognition
Wrist stabilization ip Elbow extended
or grasp
Elbow flexed
Wrist flexion ay
A Elbow extended
and extension
Fist closed Zs Elbow flexed
Wrist circumduction

DIGITS
Mass grasp Dynamometer test Normal lb.
Affected lb.
Mass extension
Hook grasp (handbag, 2 |b.)
Lateral prehension (card)
Palmar prehension (pencil)
Cylindrical grasp (small jar)
Spherical grasp (ball) Catch Throw
Indiv. thumb movements,
hands in lap ulnar side 1. Vertical movements
own PD Horizontal movements
Individual finger movements
Button and ~ Using both hands
unbutton shirt Using affected hand only
Other skilled activities

FIG. 34-7 cont’d

Hemiplegia classification and progress record. (From Brunnstrom S: Movement therapy in hemiplegia,
New York, 1970, Harper & Row.)
Continued
596 OCCUPATIONAL THERAPY INTERVENTIONS

HEMIPLEGIA CLASSIFICATION AND PROGRESS RECORD

Trunk and lower limb

Name Evaluation date

SUPINE
Passive Hip Knee
motion
sense Ankle Big toe
Flexor synergy
Extensor synergy
Hip: — Abduction Adduction
SITTING ON CHAIR STANDING

Trunk balance With without support

(no back support) Balance, normal limb sec.
Sole sensation Correct Double scale (a) (b) ae
(no. of answers) Incorrect reading
Hip-knee-ankle flexion Hip-knee-ankle flexion
Knee flexion-extension small range Knee flexion-extension small range
Knee flexion beyond 90° Knee flexion hip extended
Ankle, isolated dorsiflexion Ankle, isolated dorsiflexion
Reciprocal hamstring action* Hip abduction knee extended
AMBULATION Evaluation date
Brace? Cane? In parallel bars
Supported Escorted Alone
Arm in sling Arm swings loosely Elbow held flexed
Arm swings near normal
GAIT ANALYSIS Evaluation date

STANCE PHASE SWING PHASE

Ankle
Knee
Hip
Walking cadence: Steps per min. Speed: Feet per min.

*Inward and outward rotation at knee with inversion-eversion at ankle.

tRecorded as normal /affected; (a) preferred stance, (b) weight shift on affected limb.

Cc

FIG. 34-7 cont’d

Hemiplegia classification and progress record. (From Brunnstrom S: Movement therapy in hemiplegia, ~
New York, 1970, Harper & Row.)

therapist should ask the patient to help in the move- verely involved patients may never progress beyond it.
ments. Thus it is possible to assess the degree of hyper- The pectoralis major, pronators, and wrist and finger
tonicity and to assess whether the subject’s voluntary flexors may be very hypertonic, causing limited per-
efforts are evoking any movement responses. formance of their antagonists.
During recovery stage three, hypertonicity is in- The patient is seated, and the therapist demonstrates
creased and may be marked. The limb synergies or some the complete flexor synergy. The patient is asked to
of their components are performed voluntarily, al- perform the movement pattern with the unaffected side
though with much effort and cognitive control. The to demonstrate that the directions are understood. The
patient may remain at this stage for a long time, and se- patient is then asked to perform the movement pattern
 Movement Therapy: The Brunnstrom Approach to Treatment of Hemiplegia 597

with the affected side after a command such as “touch pertonicity during any recovery stage, provided that the
your ear” or “touch your mouth,” which gives purpose patient has enough range of active motion to perform
and direction to the effort. A similar procedure is used the necessary movement. The tests are especially useful
to assess performance of the extensor synergy. The in stages four, five, and six. The normal side is tested first
patient is asked to reach forward and downward to for comparison, then the affected side is tested. The two
touch the therapist's hand, which is held between the movements that are tested are (1) hand to chin and (2)
patient's knees. The responses may be influenced by the hand to opposite knee. The patient is seated in a sturdy
predominant hypertonicity seen in components of each chair without armrests. The trunk should be stabilized
of the synergies. For instance, the very spastic pectoralis against the back of the chair, and the head should be
major and elbow flexors may predominate during the erect. The hand is closed, but not tightly, and rests in the
patient's efforts and result in the patient reaching across lap. For the hand-to-chin test, the forearm is at 0° neutral
the thorax to touch the opposite shoulder. The status of between pronation and supination. The therapist asks
the synergies is recorded on the evaluation form in the patient to bring the hand from lap to chin as rapidly
terms of the active joint range achieved for each motion as possible, first with the unaffected side and then with
in the pattern. The joint ranges are estimated and the affected side, and records the number of full back-
recorded as 0, 4, ‘4, *4, or full range. and-forth movements accomplished in 5 seconds. If
When the patient has reached recovery stage four, speed is slow because of marked spasticity, half move-
there is a decrease in spasticity and the patient is ments may be counted. The same procedure is followed
capable of performing gross movement combinations for the hand-to-opposite knee test, except that the
that deviate from the limb synergies. Brunnstrom chose forearm is positioned in full pronation on the lap. The
three movements to represent stage four. These are (1) hand is moved from the lap to the opposite knee, using
placing the hand behind the body to touch the sacral full range of elbow extension. These two tests measure
region, (2) raising the arm forward to 90° of shoulder the hypertonicity of elbow flexors and extensors.
flexion with elbow extended, and (3) pronating and Wrist stabilization, which is automatic during
supinating the forearm with the elbow flexed to 90° normal grasp, is often lacking after a stroke. Therefore it
and stabilized close to the side of the body. The patient is important to evaluate wrist stabilization during fist
performs all of the movements while seated, and as in closure. This test is performed with the elbow both
all test items, no facilitation is allowed. During the test flexed and extended. During the recovery stages when
for pronation-supination, bilateral performance is the synergies are dominant, the wrist tends to flex when
allowed so that the therapist can compare the two sides. the elbow flexes. The patient is asked to make a fist
Further decrease of hypertonicity and ability to while the elbow is extended across the front of the
perform more complex combinations of movement body. The patient is then asked to make a fist while the
characterize recovery stage five. The patient is relatively elbow is flexed at the side of the body. Whether the wrist
free of the influence of the limb synergies and performs remains stabilized in the neutral position or extends
the stage four movements with greater ease. Three slightly is observed. This test is followed by a request for
movements chosen to represent stage five are (1) raising wrist flexion and extension with the fist closed. The
the arm to 90° of shoulder abduction with the elbow ex- patient holds an object such as a wide dowel rod and
tended and forearm pronated, (2) raising the arm extends and flexes the wrist. This is done in the elbow-
forward, as in stage four, but above 90° of shoulder extended and elbow-flexed positions as on the previous
flexion, and (3) pronating and supinating the forearm test. Circumduction of the wrist indicates significant re-
with the elbow extended. The third movement is per- covery to the advanced stages. When evaluating the
formed with the arm in the forward or side horizontal ability to perform this movement, the therapist should
position and is not isolated from shoulder internal and stabilize the forearm in pronation. The upper arm
external rotation. should be stabilized against the trunk.
Persons who progress to recovery stage six are able to Mass grasp is tested with a dynamometer, which
perform isolated joint motions and demonstrate coor- measures pounds of pressure of grasp strength. The
dination that is comparable or nearly comparable to normal side is tested first, then the affected side, and the
that of the unaffected side. On close inspection the results are recorded for comparison. Mass extension is
trained observer may detect some awkwardness of evaluated by asking the patient to release and actively
movement, and there may be some incoordination extend the fingers to the degree possible. Whether active
when rapid movement is attempted. The patient may be extension is accomplished and the approximate
assessed while performing a variety of daily living tasks, amount of range achieved should be noted on the form.
provided that recovery of hand function has kept pace Active release to full range of extension is very difficult
with recovery of arm function. for many persons with CVA.
The tests of motor speed on the second page of the All types of prehension are evaluated in order oftheir
evaluation form (Fig. 34-7, B) may be used to assess hy- difficulty. Everyday tasks that require the particular
598 OCCUPATIONAL THERAPY INTERVENTIONS

prehension pattern are used. Hook grasp may be as- cadence.*> The physical and occupational therapists
sessed by asking the patient to hold a bag by its handle. perform the motor assessment cooperatively and use an
Holding a card demands lateral prehension. Palmar pre- integrated approach in treatment, which incorporates
hension is required for grasping a pencil. Cylindrical upper limb, trunk, and lower limb function, according
grasp may be assessed by asking the patient to hold a to prescribed treatment goals.
small, narrow jar. Grasping a ball requires spherical
grasp. The patient's ability to catch and throw the ball
TREATMENT GOALS AND METHODS
may be observed. These activities are difficult for
persons with hemiplegia because they require rapid Before the initiation of any intervention strategies, the
grasp and release, coordination of the entire limb, and occupational and physical therapists make a thorough
time-space judgment. In all the prehension tests the evaluation of the motor, sensory, perceptual, and cogni-
normal side should be observed first for purposes of tive functions of the patient. The motor assessment
comparison. yields information about stage of recovery, muscle tone,
Individual thumb movements are assessed with the Passive motion sense, hand function, sitting and stand-
patient's hand resting in the lap, ulnar side down. The ing balance, leg function, and ambulation.
normal side is observed first, then the affected side. The goal of Brunnstrom’s movement therapy is to fa-
The patient is asked to move the thumb up and down cilitate the patient’s progress through the recovery stages
(flexion-extension) and side to side (adduction- that occur after onset of hemiplegia (Table 34-1). Use of
abduction). the available afferent-efferent mechanisms of control is
The therapist tests individual finger movements by the means for attainment of this goal. Postural and atti-
asking the patient to tap the index and middle fingers tudinal reflexes are used as means to increase or de-
on the tabletop or on a pillow held in the lap. Isolated crease tone in specific muscles.” For instance, changes in
control of metacarpophalangeal (MP) flexion and ex- head and body position can influence muscle tone by
tension is assessed and noted on the evaluation form. evoking the tonic reflexes, such as the TNRs, tonic
Fine, coordinated use of the affected hand and arm lumbar reflex, TLR, and equilibrium and protective reac-
and of both hands together usually is indicative of ad- tions. Associated reactions can be used to initiate or
vanced recovery. Patients who have succeeded well at elicit synergies in the early stages of recovery by giving
the prehension tests may be asked to button and unbut- resistance to the contralateral muscle group on the
ton a shirt, first using both hands, then using the af- normal side. Through homolateral limb synkinesis,
fected hand only. Other skilled activities, such as efforts at flexion synergy of the affected leg are used to
writing, threading a needle, removing a small bottle cap, elicit a flexor synergy of the arm.
and picking up and placing small objects such as Stimulating the skin over a muscle by rubbing with
mosaic tiles or coins, may be used to further test skilled the fingertips produces contraction of that muscle and
hand use. facilitation of the synergy to which the muscle belongs.
An example is brisk stimulation of the triceps muscle
during other efforts at performance of the extensor
Motor Tests of Trunk and Lower Extremity
synergy, which enhances elbow extension and amplifies
To assess trunk and LE function, the patient is tested first the synergy pattern. Muscle contraction is facilitated
in the supine position, then in the sitting position, and when muscles are placed in their lengthened position,
then in the standing position. If the patient is ambula- and the quick stretch of a muscle facilitates its contrac-
tory, a gait analysis is made (Fig. 34-7, C). Tests in the tion and inhibits its antagonist. Resistance facilitates the
supine position include tests of passive motion sense, contraction of muscles resisted. Synergistic movement is
flexor and extensor synergies, and hip abduction and augmented by the voluntary effort of the patient. Visual
adduction. In the sitting position trunk balance, sole stimulation through the use of mirrors, videotape, and
sensation, and specific movements of the lower limb are movement of parts facilitates motion in some patients.
tested. These tests include hip-knee-ankle flexion, knee Loud and repetitive commands to perform the desired
flexion and extension in small range, knee flexion movement can also be used as facilitation.
beyond 90°, isolated ankle dorsiflexion, and reciprocal The strongest component of a synergy pattern in-
hamstring action (inward and outward rotation at the hibits its antagonist through reciprocal innervation. It
knee with inversion-eversion at the ankle). In the stand- follows that if relaxation of the stronger or hypertonic
ing position balance and selected movements are as- muscle can be effected, it may be possible to evoke
sessed. These tests are hip-knee-ankle flexion, knee some activity in the weaker antagonist, which may
flexion-extension in small range, knee flexion with the appear to be functionless because of its inability to over-
hip extended, isolated ankle dorsiflexion, and hip ab- come the very hypertonic agonist.*”
duction with the knee extended. The LE assessment con- Some treatment goals and methods are summarized
cludes with a gait analysis, including timed walking below. The point at which the therapist initiates treat-
 Movement Therapy: The Brunnstrom Approach to Treatment of Hemiplegia 599

ment depends on the stage of recovery, muscle tone, and humerus in relation to the scapula is prevented
sensory status of the individual patient. because in this position the stabilizing action of the
lower portion of the glenoid fossa on the humeral
Bed Positioning head is reduced and the superior portion of the joint
capsule is slackened. This position can predispose the
Proper bed positioning begins immediately after the humeral head to downward subluxation. When the
onset of the stroke, when the patient is in the flaccid patient is being handled, traction on the affected UE is
stage.* During this period the limbs can be placed in the avoided. The patient is instructed to use the unaffected
most favorable positions without interference from hy- hand to support the affected arm when moving about
pertonic muscles. Correct bed positioning is often the in bed.
responsibility of the nurse; therefore it is essential that
the physical therapist or occupational therapist provide
Bed Mobility
information about the influence of the limb synergies
on bed postures. Turning toward the affected side is easier than turning
If left unsupervised, the lower limb tends to assume a toward the unaffected side because it requires little ac-
position of hip external rotation and abduction and tivity of the affected limb(s). The affected arm is placed
knee flexion. This posture is partly a result of mechani- close to the body, and the patient rolls over the affected
cal influences on the flaccid limb; that is, the weight of arm when turning. Turning toward the unaffected side
the part tends to pull the hip into external rotation. requires muscular effort of the affected limbs. The unaf-
Neurologically, this position mimics the flexor synergy fected arm is used to elevate the affected arm to a verti-
of the LE. The advent of muscular tension in the flexor cal position over the face, with the shoulder in 80° or
and abductor muscle groups of the hip and the flexor 90° of flexion and the elbow fully extended. The af-
group of the knee contributes to the posture of the LE as fected LE is positioned in partial flexion at the knee and
described previously. hip and could be stabilized in this position momentar-
If the extensor synergy is developed in the LE, the leg ily by the therapist. The patient turns by swinging the
may assume a different position. Hypertonicity of the arms and the affected knee across the body toward the
extensor muscles usually exceeds that of the flexor unaffected side. The movements of the limbs assist in
muscles in the lower limb. In this case, hip extension the turn of the upper body and pelvis. When control im-
and adduction, knee extension, and ankle plantar proves, the patient carries out the maneuver independ-
flexion characterize the posture of the leg. If adductor ently, in one smooth, continuous movement, to turn
hypertonicity is severe, the patient may habitually place from the supine position to the side-lying position on
the unaffected leg under the affected leg, which allows the unaffected side.
the affected limb to adduct even more and results in a
crossed-limb posture.
Trunk Movement and Balance
If the extensor synergy dominates in the lower limb,
the recommended bed position in supine is slight One of the early goals in treatment is for the patient to
flexion of the hip and knee maintained by a small achieve good trunk or sitting balance. Most persons
pillow under the knee. Lateral support of the leg at the with hemiplegia lean to the affected side, which may
knee with pillows or a rolled blanket or bolster should cause a fall when the appropriate equilibrium responses
be provided to prevent abduction and external rotation. do not occur. To evoke balance responses the therapist
The bed covers should be supported to prevent them deliberately disturbs the patient's erect sitting posture in
from resting on the foot. This helps to prevent excessive forward-backward and side-to-side directions while the
ankle plantar flexion. The position of slight flexion at patient sits on a chair, edge of a bed, or mat table. The
the hip and knee is beneficial because it has an in- patient is prepared for the procedure with an explana-
hibitory effect on the extensor muscles of the knee and tion, and is pushed, at first gently and then more vigor-
ankle, counteracting the development of severe hyper- ously. The patient may support the affected arm by
tonicity in these muscles, which hinders ambulation. cradling it to protect the shoulder. This prevents the
If the flexor synergy dominates in the lower limb, the patient from grasping the supporting surface during the
knee must be maintained in extension. Hip external ro- procedure. Later, the therapist initiates and assists the
tation can be prevented with supports as described pre- patient with bending the trunk directly forward and
viously. The choice of bed position is determined on an obliquely forward. The patient sits and supports the af-
individual basis. The position selected is opposite the fected arm as previously described. The therapist's
pattern of the greatest amount of muscle tone to effect hands are held under the patient's elbows. The therapist
the inhibition of excessive hypertonicity. can use his or her knees to stabilize the patient's knees if
The affected UE is supported on a pillow, in a posi- balance is poor. In this position the therapist guides the
tion comfortable for the patient. Abduction of the patient while inclining the trunk forward and obliquely
600 OCCUPATIONAL THERAPY INTERVENTIONS

and obtains some passive glenohumeral and scapular trapezius with the fingertips. At the same time the thera-
motion at the same time. pist assists the patient to elevate the arm. Active shoulder
Trunk rotation is encouraged in a similar manner, elevation tends to elicit other components of the flexor
with the therapist sitting in front of the patient or synergy. That, in turn, tends to inhibit the very hyper-
standing behind and supporting the patient’s arms as tonic adduction component of the extensor synergy
before. Trunk rotation is first performed through a (pectoralis major). This allows the therapist to elevate
limited range and is gently guided by the therapist. The the arm into abduction by small degrees each time the
range is gradually increased. Some neck mobilization patient repeats the active shoulder girdle elevation. The
can be obtained almost automatically during these ma- procedure is repeated, and the therapist gives the appro-
neuvers. As the trunk rotates, the patient cradles the af- priate verbal commands “Pull up” and “Let go.”
fected arm and moves the arms rhythmically from side The abduction movement is at an oblique angle
to side to achieve shoulder abduction and adduction between forward flexion and full abduction. Sideward ~
alternately. The shoulder components of the flexor and abduction with the arm in the same plane as the trunk is
extensor synergies may be evoked during these proce- likely to be painful and should be avoided. Alternate
dures through the TNR and tonic lumbar reflexes.* pronation and supination of the forearm by the thera-
pist accompany the elevation and lowering of the arm
throughout the procedure. The forearm is supinated
Shoulder Range of Motion
when the shoulder is elevated and pronated when the
A second important early goal in treatment is maintain- arm is lowered. Head rotation to the normal side in-
ing or achieving pain-free range of motion (ROM) at the hibits activity in the pectoralis major muscle through
glenohumeral joint. There appears to be a relationship the ATNR. When abduction movement above the hori-
between the shoulder pain common in patients with zontal is accomplished without pain, the patient is di-
hemiplegia and the stretching of hypertonic muscles rected to reach overhead and straighten out the elbow if
around the shoulder joint. Traditional forced passive ex- there has been sufficient recovery to do so. The patient is
ercise procedures may actually produce this stretching directed to rotate the head to the affected side to facili-
and contribute to the development of pain. Such exer- tate the elbow extension, while observing the move-
cise is harmful and contraindicated. Once the patient ment of the arm.
has felt the pain, the anticipation of pain increases the These techniques result in increased ROM at the
muscular tension which in turn decreases the joint mo- shoulder and also help the development of the flexor
bility and increases the pain experienced on passive synergy. A small ROM in the path of the extensor
motion. Therefore the shoulder joint is mobilized synergy is performed between the patient's efforts at
through guided trunk motion, without forceful stretch- flexion so that both synergies are developed. As training
ing of hypertonic musculature about the shoulder and progresses, greater emphasis is placed on the develop-
shoulder girdle. ment of the extensor synergy.
The patient sits erect, cradling the affected arm. The
therapist supports the arms under the elbows while the
Shoulder Subluxation
patient leans forward. The more the patient leans, the
greater the range of shoulder flexion that can be at- Brunnstrom believed that glenohumeral subluxation
tained. The therapist guides the arms gently and pas- resulted from dysfunction of the rotator cuff muscles
sively into shoulder flexion while the patient's attention (supraspinatus, infraspinatus, teres minor, and sub-
is focused on the trunk motion. In a similar fashion the scapularis). Activation of these muscles in treatment is
therapist guides the arms into abduction and adduction necessary if subluxation is to be minimized or pre-
while the patient rotates the trunk from side to side. The vented. Function of the supraspinatus muscle is particu-
asymmetrical tonic neck reflex (ATNR) and tonic lumbar larly important for the prevention of subluxation. Slings
reflex facilitate relaxation of muscles during this maneu- were used in an effort to hold the humeral head in the
ver. When the patient is confident that the shoulder can glenoid fossa. However, slings do not in any way acti-
be moved painlessly, active-assisted movements of the vate the muscles needed to protect the integrity of the
arm in relation to the trunk are begun. First, the patient shoulder joint.* The use of slings has been found to be
moves both shoulders into elevation and depression of little value and may actually be harmful.* A more
and scapula adduction and abduction. These move- complete discussion of shoulder problems and slings
ments are then combined with glenohumeral move- appears in Chapter 36.
ments. The therapist supports the arm from behind,
with the shoulder between forward flexion and abduc-
Upper Limb Training
tion and the elbow flexed less than 90°, and supports
the wrist in slight extension. The therapist asks the The training procedures for improving arm function
patient to elevate the shoulders, while tapping the upper are geared to the patient's recovery stage. During
 Movement Therapy: The Brunnstrom Approach to Treatment of Hemiplegia 601

stages one and two, when the arm is essentially flaccid from antagonistic synergies to perform new and increas-
or some components of the synergy patterns are be- ingly complex patterns of movement. One means for ac-
ginning to appear, the aim is to elicit muscle tone and complishing this goal is to use exercises in arcs of move-
the synergy patterns on a reflex basis. This improve- ment to get elbow flexion, combined with shoulder
ment is accomplished through a variety of facilitation horizontal adduction and forearm pronation, and alter-
procedures. Associated reactions and tonic reflexes are nating with shoulder horizontal abduction and elbow
employed to influence tone and evoke reflexive move- extension with forearm supination, such as with a skate-
ment. The proximal traction response is used to acti- board or powder board. Later the patient might be able
vate the flexor synergy. Tapping over the upper and to perform the more complex figure-eight pattern. In
middle trapezius, rhomboids, and biceps is used to the final recovery, stages five and six, increasingly
elicit components of the flexor synergy. Tapping over complex movement combinations and _ isolated
the triceps and stretching of the serratus anterior is motions are possible. The aims in treatment are to
used to activate components of the extensor synergy. achieve ease in performance of movement combina-
Quick stretch and surface stroking of the skin are also tions and isolated motion, and to increase speed of
used to activate muscles. Passive movement alternately movement.
through each of the synergy patterns is not only an Although the hemiplegic UE seldom makes a full re-
excellent means for maintaining ROM of several covery, the patient should be trained to use the limb to
joints, but also provides the patient with propriocep- assist the unaffected arm to whatever extent possible in
tive and visual feedback for the desired patterns of bilateral activities.
early movement.
The methods are not employed in any set order or
Hand Training
routine but are selected to suit the particular responses
of each individual patient. Because the flexor synergy Because recovery of hand function does not always co-
usually appears first, it is useful to begin trying to elicit incide with arm recovery, methods for retraining hand
the flexor patterns. This attempt is followed immedi- function are addressed separately. Hand retraining com-
ately with facilitation of the extensor synergy compo- mensurate with the recovery status of the patient should
nents, which tend to be weaker and more difficult to be carried out continuously.
perform in later stages of recovery.’”* The first goal of hand retraining is to achieve mass
When the patient has recovered to stages two and grasp. The proximal traction response and grasp reflex
three, the synergies or their components are present and are used to elicit early grasp movement on a reflex level.
sometimes can be performed voluntarily. Hypertonicity During the proximal traction response maneuver, the
is developing and reaches its peak in stage three. During therapist maintains the patient's wrist in extension and
this period the aim is for the patient to achieve volun- gives the command “Squeeze.”
tary control of the synergy patterns. This goals reached Because the normal association between wrist exten-
by repetitious, alternating performance of the synergy sion and grasp is disturbed, the second goal is to achieve
patterns, first with the assistance and facilitation of the wrist fixation for grasp. Wrist extension often accom-
therapist. Facilitation is provided through resistance to panies the extensor synergy. Wrist extension can be
voluntary motion, verbal commands, tapping, and cuta- evoked if the therapist applies resistance to the proximal
neous stimulation. This step is followed by voluntary palm or fist while supporting the arm in the position
repetition of the synergy patterns without the facilita- described earlier for elevation of the arm into abduc-
tion and, finally, concentration on the components of tion. Percussion ofthe wrist extensors with the elbow in
the synergies from proximal to distal, first with facilita- extension and arm elevated and supported by the thera-
tion and then without. pist can activate wrist extension. The proximal portions
Bilateral rowing movements with the _ therapist of the extensors are tapped, and the therapist directs the
holding the patient's hands are used for reciprocal patient to squeeze simultaneously. The commands to
motion of the synergies and are started during this time. squeeze and stop squeezing are given at appropriate
Bearing weight on the affected arm is employed to rein- points in the facilitation procedures.
force elbow extension. The patient uses the normal During the wrist extension and fist closure the thera-
hand to guide the affected hand, fist clenched, to a low pist carries the elbow forward into extension. During
stool positioned in front of him or her. A sandbag or the wrist and finger relaxation the therapist carries the
cushion is placed on the stool, and a concavity is made elbow back into flexion. While the patient maintains fist
in it to accommodate the fist. The patient's body weight closure, the therapist can withdraw the wrist support
is shifted to the affected arm to facilitate the elbow ex- and give the command “Hold.” The therapist may con-
tensors through weight bearing.””* tinue tapping the wrist extensors while the patient at-
The treatment aim during stages four and five is to tempts to hold the posture. The goal is to synchronize
break away from the synergies by mixing components the muscles for fist closure with wrist extension.
602 OCCUPATIONAL THERAPY INTERVENTIONS

This procedure is alternated with the command

“Stop squeezing,” and the wrist is allowed to drop and
fingers to open while the elbow is moved into flexion.
These steps are alternated, and the wrist extension-fist
closure is performed gradually, with increasing amounts
of elbow flexion, so that the patient can learn to grasp
with wrist stabilization when the arm is in a variety of
positions.
A third objective in hand retraining is to achieve
active release of grasp. This movement is difficult
because there is usually a considerable degree of hyper-
tonicity in the flexor muscles of the hand. A release of
tension in the finger flexors, then, is primary to the
achievement of any active finger extension. Active grasp
is alternated with manipulations to release tension in
the flexors. The therapist sits facing the patient and pulls FIG. 34-8
the thumb out of the palm by gripping the thenar emi- Finger extension exercise glove.
nence. The forearm is supinated. The wrist is allowed to
remain in slight flexion. The therapist maintains the
grasp around the thumb and alternately pronates and decreased by the maneuvers just described, the therapist
supinates the forearm, with emphasis on supination. stands on the affected side and maintains the thumb in
Pressure on the thumb is decreased during pronation abduction and extension and the forearm in pronation.
and increased during supination. Cutaneous stimula- The fingers are kept in extension by pressure over the IP
tion is given to the dorsum of the hand and wrist when joints and stabilization of the fingertips. The grip on the
the forearm is supinated. This manipulation facilitates thumb is released, and the arm is raised above the hori-
some tension in the finger extensors, and the fingers are zontal position.
extended. The patient could actually participate in The therapist strokes distally over the IP joints with
opening the hand when the forearm is supinated. the heel of the hand. The fingers extend or hyperextend,
Strong efforts on the part of the patient may evoke and the therapist gradually discontinues contact with
flexion instead, however, and are to be avoided. the patient's hand. If the patient is ready, slight volun-
If the manipulation is inadequate, stretch of the tary mental effort can be superimposed on the reflex ex-
finger extensors can be used. With the therapist and tension, which might bring about additional extension
patient positioned and the hand manipulated as just de- of the fingers. If the forearm is supinated while the arm
scribed, the therapist uses the free hand for distally di- is elevated, thumb extension is enhanced. The hand is
rected, rapid stroking movements over the proximal positioned overhead for this maneuver. To facilitate ex-
phalanges of the affected hand. This action causes mo- tension of the fourth and fifth fingers, the forearm is
mentary flexion of the MP joints, which then bounce pronated as the arm is elevated and friction is applied
back into partial extension. The stroking movement is over the ulnar side of the dorsum of the forearm.
performed so that the proximal, then distal interpha- When reflex extension of the fingers is well estab-
langeal (IP) joints are included. The movement is per- lished, alternate fist opening and closing begins. The arm
formed rapidly and continuously, causing rapid flexion is lowered passively, and the elbow is flexed. The forearm
and then bounce back of MP and IP joints. The fingers and wrist are supported, and the patient is asked to
become extended, and the finger flexors are relaxed squeeze, then stop squeezing. As soon as the fingers
because they are reciprocally inhibited by the stretch relax, the manipulations to facilitate finger extension are
reflex response in the extensors. If the flexors are carried out. These two steps are alternated, and the
stretched or stroking is performed over the palmar patient’s voluntary efforts are superimposed on the
surface of the fingers, the spasticity returns to the finger reflex activity so that the movements begin to assume a .
flexors and they act to close the hand.® For this reason semivoluntary character. Semivoluntary finger extension
the fingers should not be pulled into extension. is influenced by the position of the limb and appears to
Active finger extension may be further facilitated by be linked to gross movements other than the synergy
the use of a finger extension exercise glove with rubber patterns. Voluntary movements of the thumb appear
bands, which the patient uses while the hand is manip- when semivoluntary mass extension becomes possible.
ulated into supination with the thumb pulled out of the Once the flexor muscles are relaxed, the hand is
palm as described earlier (Fig. 34-8). placed in the patient’s lap, ulnar side down, and the
Elevation above the horizontal position evokes the patient attempts to move the thumb away from the first
extensor reflexes of the fingers. After flexor spasticity is finger, a preliminary for lateral prehension. The thera-
 Movement Therapy: The Brunnstrom Approach to Treatment of Hemiplegia 603

pist can stimulate the tendons of the abductor pollicis fected limb can be used in many ways to assist with
and the extensor pollicis brevis by tapping or friction at function. Encouraging the use of the affected arm in
the point where they pass over the wrist, to enhance the everyday activities decreases the possibility of the
patient's effort. The patient can learn to twiddle the patient's functioning strictly as a one-handed person.
thumbs to attain further control of thumb motion. The During stages three and four, when the patient has
patient folds the hands, with wrists slightly flexed, and voluntary control of the synergies and can begin to use
moved the thumbs around each other. Initially the movement combinations that deviate from the syner-
normal thumb could push the other around, but the in- gies, the occupational therapist helps the patient to use
volved thumb may begin to participate actively. The the newly learned movement for functional and pur-
willed effort, visual input, and sensory feedback from poseful activities. Some of the activities that can be
affected and unaffected sides contribute to the develop- adapted to use the synergy patterns or gross combined
ment of this movement. movement patterns are skateboard or powder board ex-
During treatment sessions the patient has to be com- ercises, sanding, leather lacing, braid weaving, finger
fortable and relaxed. The patient's willed efforts should painting, sponging off tabletops, and using a push
be slight because too much effort can evoke a flexor re- broom or carpet sweeper. Activities that demand too
sponse rather than the desired extensor response. Exces- much conscious effort tend to increase fatigue and hy-
sive muscle tension in the limb and entire body has to pertonicity and should be avoided.
be avoided, or finger extension will not occur. Brunnstrom> described several possible uses for the
Many patients with hemiplegia never achieve good flexor and extensor synergies in stage three. The extensor
voluntary extension or coordinated fine hand motions. synergy may be used to stabilize an object on a table
If semivoluntary extension can be well established, vol- while the unaffected arm is performing a task; examples
untary extension usually follows so that the patient can are stabilizing stationery while writing letters or stabiliz-
open the hand in all positions.’ The accomplishment of ing fabric for sewing. The extensor synergy can also be
palmar prehension and fine hand movements requires used to stabilize a jar against the body while unscrewing
the achievement of voluntary opening of the hand, op- the lid or to hold a handbag or newspaper under the
position of the thumb to the fingers, and ability to arm. When pushing the affected arm through the sleeve
release objects in contact with the palm of the hand. of a garment, the individual can position the garment
so that the arm follows the path of the extensor synergy.
The forearm has to be pronated first, however, to facili-
Lower Limb Training
tate elbow extension.
Lower limb training is directed toward restoring safe The flexor synergy or its components can be used for
standing and development of a gait pattern that is as such tasks as carrying a coat or handbag over the forearm
nearly normal as possible. The goal is to modify the or holding a toothbrush while the unaffected hand
gross movement synergies and facilitate movement squeezes the toothpaste. Bilateral pushing and pulling
combinations that are more nearly like those used activities that alternate the paths of both synergies can be
during normal ambulation. Lower limb training in- helpful for some patients. Examples are sweeping, vacu-
cludes trunk balance and activation of specific muscle uming, and dusting. Such activities can be performed
groups, followed by gait training. Training procedures with the unaffected hand stabilizing the affected one.
for the LE are primarily the domain of the physical ther- The affected hand can be more hindrance than help until
apist. When training the patient in functional activities, greater control is gained. Strongly motivated patients try
however, the occupational therapist uses procedures to use available movements under the guidance and en-
that are in concert with the work of the physical thera- couragement ofthe occupational therapist.
pist—for example, transfer training, dressing, toileting, To promote transition from stage three to stage four,
and ambulating that involves the lower limb. Therefore movement combinations are facilitated and practiced in
it is important for the occupational therapist to know upper limb training. These movements are (1) hand to
which LE training procedures are in progress, which chin, (2) hand to ear on the same side and opposite side,
movement patterns are to be encouraged or inhibited, (3) hand to opposite elbow, (4) hand to opposite shoul-
and which methods facilitate the desired gait pattern der, (5) hand to forehead, (6) hand to top of head, (7)
when assisting or accompanying the patient during hand to back of head, and (8) stroking movements from
functional tasks. top to back of head and from dorsum ofthe forearm to
the shoulder and toward the neck on the normal side. As
soon as possible, these movement patterns are trans-
OCCUPATIONAL THERAPY APPLICATIONS
lated to functional activities. Success at functional tasks
Controlled movements achieved in upper limb training increases motivation and establishes a purpose for the
have more significance if the patient can use them for training. Contact with body parts where sensation is
functional activities. Even with limited control, the af- intact is instrumental in guiding the hand to its goal.
604 OCCUPATIONAL THERAPY INTERVENTIONS

Examples of these movements in daily activities are 2. List the motions in the flexor and extensor synergies
eating finger foods, combing hair, washing the face, of the arm.
washing the unaffected arm, and reaching the opposite 3. What is the most hypertonic component of the
axilla for washing or application of deodorant.’ The flexor synergy of the arm?
therapist's role is to analyze activities for movement pat- 4. What is the least hypertonic component of the ex-
terns that are possible for the patient, and to select activ- tensor synergy of the arm?
ities that have meaning and areinteresting to the patient. 5. What is the basis of the Brunnstrom approach to
At this point the occupational therapist stresses the the treatment of hemiplegia?
use of any voluntary movement of the affected limb in 6. For what purposes does Brunnstrom recommend
performance of activities of daily living. Using the arm the use of reflexes and associated reactions in the
for dressing and hygiene skills translates the movements early recovery stages after onset of hemiplegia?
to purposeful function. The patient's sensory status, and 7. Define or describe the following terms: limb
not only the motor recovery achieved, influences the synergy, associated reactions, imitation synkinesis,
degree to which purposeful, spontaneous use of the arm proximal traction response, grasp reflex, and the
is possible. If the patient surpasses stage four, the Souques’ finger phenomenon.
number of activities that can be performed increases, 8. Describe or demonstrate the procedure that
and more movement combinations are possible. The in- Brunnstrom recommended to maintain or achieve
volvement of the affected limbs in activities of daily pain-free ROM at the glenohumeral joint.
living is encouraged. The activities mentioned earlier 9. What is the aim of treatment for functional recovery
can be performed in their usual manner, and may be of the arm during stages one and two? Stages two
graded to demand finer and more complex movement and three? Stages three and four?
patterns. Gardening, furniture refinishing, leather 10. List two treatment methods that could be used to
tooling, rolling out dough, sweeping, dusting, and achieve each of the aims in the previous question.
washing dishes are a few of the activities that are used to 11. Describe three activities other than those listed in
engage the affected arm purposefully if hand recovery is the text that may be used in occupational therapy to
adequate. enhance voluntary control of the flexor and exten-
sor synergies.
todas 12. What is the effect of the proximal traction response
SUMMARY : on muscle function?
13. Describe or demonstrate the procedure that
Signe Brunnstrom was a physical therapist who devel-
Brunnstrom recommends to establish wrist fixation
oped a treatment approach for CVA called movement
in association with grasp.
therapy. The approach is based in neurophysiological
14. Describe the procedure that may be used to relax
principles of successive levels of CNS integration.
hypertonic finger flexors and facilitate finger exten-
Brunnstrom described stages of motor recovery follow-
sion.
ing CVA and developed treatment methods designed to
15. Which muscle group is thought to play a substantial
enhance the progress of the patient from one stage to
role in maintaining glenohumeral joint stability?
the next, to higher levels of motor skill. Her approach
16. Describe proper bed positioning for the patient
uses techniques of facilitation such as synergies, reflexes,
with a dominant extensor synergy of the leg. What
associated reactions, resistance, tapping, and stretch.
is the rationale for this position?
The use of reflexes or synergistic movement in treat-
ment is controversial, and the concept of the hierarchi-
cal organization of the nervous system has been modi-
fied in neurophysiology in recent years. However, REFERENCES
Brunnstrom’s observations of motor recovery and 1. Bobath B: Adult hemiplegia: evaluation and treatment, London,
motor behavior are valid, and many of the techniques ee
till hilentreat S Fenian if 2. Brunnstrom S: Motor behavior in adult hemiplegic patients, Am J
are Stiil use in treatment. some similarities can De Occup Ther 15(1):6-12, 1961.

seen between Brunnstrom’s methods and those of other 3. Brunnstrom S$: Movement therapy in hemiplegia, New York, 1970,
sensorimotor theorists. The assessment of motor recov- Harper & Row.
ery and some elements of treatment methodology con- 4. Cailliet R: The shoulder in hemiplegia, Philadelphia, 1980, FA Davis.

tinue to be used in the treatment of CVA. 5. Fiorentino MR: Reflex testing methods for evaluating CNS develop-
ment, Springfield, Ill, 1973, Charles C Thomas.
6. Ghez C: The control of movement. In Kandel ER, Schwartz JH,
Jessel TM: Principles of neural science, New York, 1991, Elsevier.
REVIEW (@} 8)ESTIONS 7. Giuliani CA: Theories of motor control: new concepts for physical
: j therapy. In Contemporary management of motor control problems: pro-
1. List the stages of recovery of arm function after CVA, ceedings of the II Step Conference, Alexandria, Va, 1991, Foundation
as described by Brunnstrom. for Physical Therapy.
 Movement Therapy: The Brunnstrom Approach to Treatment of Hemiplegia 605

8. Perry C: Principles and techniques of the Brunnstrom approach to 11. Taylor J, editor: Selected writings of Hughlings Jackson, New York,
the treatment of hemiplegia, Am J Phys Med 46:789, 1967. 1958, Basic Books (abstract). Cited in Brunnstrom S: Movement
9. Sawner K: Brunnstrom approach to treatment of adult patients with therapy in hemiplegia, New York, 1970, Harper & Row.
hemiplegia: rationale for facilitation procedures, Buffalo, State Univer- 12. Twitchell TE: The restoration of motor function following hemi-
sity of New York. Unpublished manuscript, 1969. plegia in man, Brain 74:443-480, 1951 (abstract). Cited in
10. Schleichkorn J: Signe Brunnstrom, physical therapy pioneer, master cli- Brunnstrom S: Movement therapy in hemiplegia, New York, 1970,
nician and humanitarian, Thorofare, NJ, 1990, Slack. Harper & Row.
 LEARNING OBJECTIVES
After studying this chapter the student or practitioner
Mass movement patterns will be able to do the following:
Diagonal patterns 1. Name the theorists who developed the
Stretch proprioceptive neuromuscular facilitation (PNF)
Verbal commands approach
Verbal mediation 2. Define PNF
Manual contacts Nae List the principles of PNF
Part-task practice 4. Describe the influence of sensory input on motor
Whole-task practice learning
Stepwise procedures 5. List the elements of the PNF evaluation
Unilateral patterns 6. Identify and perform upper and lower extremity
Bilateral patterns (LE) diagonal patterns
Symmetrical patterns 7. Describe applications of PNF principles and
Asymmetrical patterns methods in occupation therapy
Reciprocal patterns 8. Define key terms associated with this approach
Combined movements
Traction
Approximation
Maximal resistance
Repeated contractions
Rhythmic initiation
Slow reversal
Rhythmic stabilization
Contract-relax
Hold-relax
Slow reversal-hold-relax
Rhythmic rotation

606
 Proprioceptive Neuromuscular Facilitation Approach 607

application to OT treatment.**°'!*!??3 It was not until

1974 that the first PNF course for occupational thera-
he purpose of this chapter is to introduce the reader pists, taught by Dorothy Voss, was offered at Northwest-
to proprioceptive neuromuscular facilitation (PNF) ern University. Since then, Beverly Myers, an occupa-
and its application to evaluation and treatment in occu- tional therapist, and others have offered courses for
_ pational therapy (OT). This chapter includes the basic occupational therapists throughout the United States.
principles, diagonal patterns, and a few of the more com- In 1984 PNF was first taught concurrently to both phys-
monly used facilitation techniques of PNF. A case study is ical and occupational therapists at the Rehabilitation In-
used to apply the concepts discussed. To use PNF effec- stitute in Chicago.'*?* Today combined courses are
tively, it is necessary to understand normal development, offered throughout the United States.
learn the motor skills to use the techniques, and apply
the concepts and techniques to OT activities. This chapter
PRINCIPLES OF TREATMENT
should form the basis for further reading and training
under the supervision of a therapist experienced in PNE Voss presented 11 principles of treatment at the North-
PNF is based on normal movement and motor devel- western University Special Therapeutic Exercise Project
opment. In normal motor activity the brain registers total in 1966. These principles were developed from concepts
movement and not individual muscle action.'? Encom- in the fields of neurophysiology, motor learning, and
passed in the PNF approach are mass movement pat- motor behavior.*°
terns that are spiral and diagonal in nature and that re- 1. All human beings have potentials that have not been fully
semble movement seen in functional activities. In this developed. This philosophy is the underlying basis of
multisensory approach, facilitation techniques are super- PNE. Therefore in evaluation and treatment plan-
imposed on movement patterns and postures through ning, the patient's abilities and potentials are em-
the therapist's manual contacts, verbal commands, and phasized. For example, the patient who has weak-
visual cues. PNF is effective in the treatment of numerous ness on one side of the body can use the intact side to
conditions, including Parkinson’s disease, spinal cord in- assist the weaker part. Likewise, the hemiplegic
juries, arthritis, stroke, head injuries, and hand injuries. patient who has a flaccid arm can use the intact head,
neck, and trunk musculature to begin reinforcement
of the weak arm in weight-bearing activities.
HISTORY
2. Normal motor development proceeds in a cervicocaudal
PNF originated with Dr. Herman Kabat, physician and and proximodistal direction. The cervicocaudal and
neurophysiologist, in the 1940s. He applied neurophys- proximodistal direction is followed in evaluation
iological principles, based on the work of Sherrington, and treatment. When severe disability is present, at-
to the treatment of paralysis secondary to poliomyelitis tention is given to the head and neck region, with
and multiple sclerosis. In 1948 Kabat and Henry Kaiser its visual, auditory, and vestibular receptors, and to
founded the Kabat-Keiser Institute in Vallejo, California. the upper trunk and extremities. If the superior
Here Kabat worked with physical therapist Margaret region is intact, an effective source of reinforcement
Knott to develop the PNF method of treatment. By 1951 for the inferior region is available.2? The proxi-
the diagonal patterns and several techniques were es- modistal direction is followed by developing ade-
tablished. Essentially no new techniques have been de- quate function in the head, neck, and trunk before
veloped since 1951, although new methods have been developing function in the extremities. This ap-
applied. PNF is now used to treat numerous neurologi- proach is of particular importance in treatment that
cal and orthopedic conditions. often facilitates fine motor coordination in the
In 1952 Dorothy Voss, a physical therapist, joined upper extremities. Unless there is adequate control
the staff at the Kaiser-Kabat Institute. She and Knott un- in the head, neck, and trunk region, fine motor
dertook the teaching and supervision of staff therapists. skills cannot be developed effectively.
In 1954 Knott and Voss presented the first 2-week 3. Early motor behavior is dominated by reflex activity.
course in Vallejo. Two years later, the first edition of Pro- Mature motor behavior is supported or reinforced by pos-
prioceptive Neuromuscular Facilitation by Margaret Knott tural reflexes. As the human being matures, primitive
and Dorothy Voss was published by Harper & Row. reflexes are integrated and available for reinforce-
During this same period several reports in the Ameri- ment to allow for progressive development such as
can Journal of Occupational Therapy described PNF and its that of rolling, crawling, and sitting. Reflexes also
have been noted to have an effect on tone changes
in the extremities. Hellebrandt and associates”
I want to thank Beverly Myers and Diane Harsch for their assistance in
studied the effect of the tonic neck reflex (TNR) and
reviewing and editing this chapter. I also want to thank Barbara Gale
for using her technical skills to take photographs for the illustrations the asymmetrical tonic neck reflex (ATNR) on
and Diane Harsch for her patience in posing for them. changes in tone and movement in the extremities of
608 OCCUPATIONAL THERAPY INTERVENTIONS

normal adults. They found that head and neck backward [flexor dominant] on hands and knees).
movement significantly affected arm and leg Postural control and balance must be achieved
movement. In applying this finding to treatment, before movement can begin in this position. In
weak elbow extensors can be reinforced with the treatment it is important to establish a balance
ATNR by having the patient look toward the side of between antagonistic muscles by first observing
weakness. Likewise, the patient can be assisted in where imbalance exists and then facilitating the
assuming postures with the influence of reflex weaker component. For example, if the stroke
support. For example, the body-on-body righting patient demonstrates a flexor synergy (flexor domi-
reflex supports the patient in assuming a side-sitting nant), extension should be facilitated.
position from the side-lying position. . Normal motor development has an orderly sequence but
. Early motor behavior is characterized by spontaneous lacks a step-by-step quality. Overlapping occurs. The
movement, which oscillates between extremes of flexion child does not perfect performance of one activity
and extension. These movements are rhythmic and re- before beginning another, more advanced activity.
versing in character. In treatment it is important to In trying to ascertain in which total pattern to posi-
attend to both directions of movement. When the tion the patient, normal motor development should
OT practitioner is working with the patient on be heeded. If one technique or developmental
getting up from a chair, attention also must be given posture is not effective in obtaining the desired
to sitting back down. Often with an injury the eccen- result, it may be necessary to try the activity in
tric contraction (e.g., sitting down) is readily lost and another developmental posture. For example, if an
becomes very difficult for the patient to regain. If not ataxic patient is unable to write while sitting, it may
properly treated, the patient may be left with inade- be necessary to practice writing in a more supported
quate motor control to sit down smoothly and thus posture, such as prone on the elbows. Just as the
may “drop” into a chair. Similarly, in training for ac- infant reverts to a more secure posture when at-
tivities of daily living (ADL) the patient must learn tempting a complex fine motor task, so must the
how to get undressed, as well as how to get dressed. patient. On the other hand, if the patient has not
. Developing motor behavior is expressed in an orderly se- perfected a motor activity such as walking on level
quence of total patterns of movement and posture. In the surfaces, he or she may benefit from attempting a
normal infant the sequence of total patterns is higher-level activity such as walking up or down
demonstrated through the progression of locomo- stairs, which in turn can improve ambulation on
tion. The infant learns to roll, to crawl, to creep, and level surfaces. It is natural for the patient to move up
finally to stand and walk. Throughout these stages and down the developmental sequence, and this
of locomotion the infant also learns to use the ex- allows multiple and varied opportunities for practic-
tremities in different patterns and within different ing motor activities. The cognitive demands of the
postures. Initially the hands are used for reaching task in relation to the developmental posture also
and grasping within the most supported postures, must be considered. When the patient's position is
such as supine and prone. As postural control devel- varied, either by changing the base of support or by
ops, the infant begins to use the hands in side-lying, shifting weight on different extremities, the quality
sitting, and standing. To maximize motor perform- of visual and cognitive processing is influenced. '
ance the patient should be given opportunities to . Locomotion depends on reciprocal contraction of flexors
work in a variety of developmental postures. and extensors, and the maintenance of posture requires
The use of extremities in total patterns requires continual adjustment for nuances of imbalance. Antago-
interaction with component patterns of the head, nistic pairs of movements, reflexes, and muscles and
neck, and trunk. For example, in swinging a tennis joint motion interact as necessary with the movement or
racquet in a forehand stroke, the arm and the head, posture. This principle restates one of the main ob-
neck, and trunk move in the direction of the swing. jectives of PNF—to achieve a balance between an-
Without the interaction of the distal and proximal tagonists. An example of imbalance is the head-
components, movement becomes less powerful and injured patient who is unable to maintain adequate
less coordinated. sitting balance for a tabletop cognitive activity
. The growth of motor behavior has cyclic trends, as evi- because of a dominance of trunk extensor tone.
denced by shifts between flexor and extensor dominance. Another example is the hemiplegic patient with
The shifts between antagonists help to develop tight finger flexors secondary to flexor-dominant
muscle balance and control. One of the main goals tone in the hand. In treatment, emphasis is placed
of the PNF treatment approach is to establish a on correcting the imbalances. In the presence of
balance between antagonists. Developmentally the spasticity, first the spasticity is inhibited and then
infant establishes this balance before creeping (i.e., the antagonistic muscles, reflexes, and postures are
when rocking forward [extensor dominant] and facilitated.
 Proprioceptive Neuromuscular Facilitation Approach 609

9. Improvement in motor ability is dependent upon motor approach used with an aphasic patient differs from the
learning. Multisensory input from the therapist fa- approach used with a hand-injured patient. Similarly,
cilitates the patient's motor learning and is an inte- the approach used with a child varies greatly from that
gral part of the PNF approach. For example, the used with an adult.
therapist may work with a patient on a shoulder
flexion activity such as reaching into the cabinet for
a cup. The therapist may say, “Reach for the cup,” to Auditory System
add verbal input. This approach also encourages the Verbal commands should be brief and clear. It is im-
patient to look in the direction of the movement to portant to time the command so that it does not come
allow vision to enhance the motor response. Thus too early or too late in relation to the motor act. Tone of
tactile, auditory, and visual input are used. Motor voice may influence the quality of the patient's re-
learning has occurred when these external cues are sponse. Buchwald’? states that tones of moderate inten-
no longer needed for adequate performance. sity evoke gamma motor neuron activity and that
10. Frequency of stimulation and repetitive activity are used louder tones can alter alpha motor neuron activity.
to promote and retain motor learning and to develop Strong, sharp commands simulate a stress situation and
strength and endurance. Just as the therapist who is are used when maximal stimulation of motor response
learning PNF needs the opportunity to practice the is desired. A soft tone of voice is used to offer reassur-
techniques, the patient needs the opportunity to ance and to encourage a smooth movement, as in the
practice new motor skills. In the process of develop- presence of pain. When a patient is giving the best
ment the infant constantly repeats a motor skill in effort, a moderate tone can be used.””
many settings and developmental postures until it Another effect of auditory feedback on motor per-
is mastered, as becomes apparent to anyone who formance was studied by Loomis and Boersma.'* They
watches a child learning to walk. Numerous at- used a “verbal mediation strategy to teach wheelchair
tempts fail, but efforts are repeated until the skill is safety before transferring out of the chair to patients
mastered. After the activity is learned, it becomes with right cerebrovascular accident (CVA). Loomis and
part of the child. He or she is able to use the activity Boersma taught patients to say aloud the steps required
automatically and deliberately as the occasion to leave the wheelchair safely and independently. They
demands.” The same is true for the person learning found that only patients who used verbal mediation
to play the piano or to play tennis. Without the op- learned the wheelchair drill sufficiently to perform safe
portunity to practice, motor learning cannot suc- and independent transfers. These patients also had
cessfully occur. better retention of the sequence of steps, suggesting that
11. Goal-directed activities coupled with techniques of facil- verbal mediation is beneficial in reaching independence
itation are used to hasten learning of total patterns of with better sequencing and fewer errors.
walking and self-care activities. When facilitation
techniques are applied to self-care, the objective is
improved functional ability, but improvement is Visual System
obtained by more than instruction and practice Visual stimuli assist in initiation and coordination of
alone. The correction of deficiencies is accom- movement. Visual input should be monitored to ensure
plished by directly applying manual contacts and that the patient is tracking in the direction of move-
techniques to facilitate a desired response.” In ment. For example, the therapist's position is important
treatment this approach may mean applying stretch because the patient often uses the therapist's movement
to finger extensors to facilitate release of an object or position as a visual cue. If the desired direction of
or providing joint approximation through the movement is forward, the therapist should be posi-
shoulders and pelvis of an ataxic patient to provide tioned diagonally in front of the patient. In addition to
stability while the patient is standing to wash the therapist's position, placement of the OT activity
dishes. also should be considered. If the treatment goal is to in-
crease head, neck, and trunk rotation to the left, the ac-
tivity is placed in front and to the left of the patient.
fee LEARNING Because OT is activity oriented, an abundance of visual
Motor learning requires a multisensory approach. Audi- stimuli is offered to the patient.
tory, visual, and tactile systems are all used to achieve
the desired response. The correct combination of
Tactile System
sensory input with each patient should be ascertained,
implemented, and altered as the patient progresses. The Developmentally the tactile system matures before the
developmental level of the patient and the ability to co- auditory and visual systems.’ Furthermore, the tactile
operate also should be taken into consideration.** The system is more efficient. This is because it has both
oy Ee) OCCUPATIONAL THERAPY INTERVENTIONS

temporal and spatial discrimination abilities, as op- Therefore the patient needs opportunities to practice
posed to the visual system, which can make only spatial motor skills in the context of functional life situations.
discriminations, and the auditory system, which can Initially the therapist's manual contacts and sensory
make only temporal discriminations.® Affolter? states input are needed. These should be decreased, however,
that during development, processing of tactile-kines- as the patient demonstrates and learns skilled move-
thetic information can be considered fundamental for ment. The amount of feedback from the therapist
building cognitive and emotional experience. Looking should also be decreased as the patient learns to rely on
at and listening to the world does not result in change; his or her own internal feedback system for error detec-
however, the world cannot be touched without some tion and correction.
change taking place. A Chinese proverb often cited at
PNF courses reinforces this viewpoint: “I listen and I
ASSESSMENT
forget, I see and I remember, I do and I understand.”
It is important for the patient to feel movement pat- Assessment of the patient requires astute observational
terns that are coordinated and balanced. With the PNF skills and knowledge of normal movement. An initial
approach, tactile input is supplied through the thera- assessment is completed to determine the patient's abil-
pist’s manual contacts to guide and reinforce the ities, deficiencies, and potential. After the treatment
desired response. This approach may involve gently plan is established, ongoing assessment of the patient is
touching the patient to guide movement, using stretch necessary to ascertain the effectiveness of treatment and
to initiate movement, and providing resistance to to make modifications as the patient changes.
strengthen movement. The type and extent of manual The PNF assessment follows a sequence from proxi-
contacts depend on the patient's clinical status, which is mal to distal. First, vital and related functions are con-
determined through evaluation and reevaluation. For sidered, such as breathing, swallowing, voice produc-
example, the use of stretch or resistance in the presence tion, facial and oral musculature, and visual-ocular
of musculoskeletal instability may be contraindicated. control. Any impairment or weakness in these functions
Likewise, stretch or resistance should not be used if they is noted.
cause increased pain or tone imbalance. The head and neck region is observed after vital func-
To increase speed and accuracy in motor perform- tions. Deficiencies in this area directly affect the upper
ance, the patient needs the opportunity to practice. trunk and extremities. Head and neck positions are ob-
Through repetition, habit patterns that occur automati- served in varying postures and total patterns during
cally without voluntary effort are established. The PNF functional activities. It is important to note (1) domi-
approach uses the concepts of part-task practice and nance of tone (flexor or extensor), (2) alignment
whole-task practice. In other words, to learn the whole (midline or shift to one side), and (3) stability and mo-
task, emphasis is placed on the parts of the task that the bility (more or less needed).'°
patient is unable to perform independently. The term After observation of the head and neck region, the as-
stepwise procedures is descriptive of the emphasis on a sessment proceeds to the following parts of the body:
part of the task during performance of the whole.** Per- upper trunk, upper extremities, lower trunk, and lower
formance of each part of the task is improved by com- extremities. Each segment is assessed individually in
bining practice with appropriate sensory cues and tech- specific movement patterns, as well as in developmental
niques of facilitation. For example, the patient learning activities in which the body segments interact. For
to transfer from a wheelchair to a tub bench may have example, shoulder flexion can be observed in an indi-
difficulty lifting the leg over the tub rim. This part ofthe vidual upper-extremity movement pattern, as well as
task should be practiced, with repetition and facilitation during a total developmental pattern such as rolling.
techniques to the hip flexors, during performance ofthe During assessment of developmental activities and
transfer. When the transfer becomes smooth and coor- postures, the following issues should be addressed:
dinated, it is no longer necessary to practice each part 1. Is there a need for more stability or mobility?
individually. It is also unnecessary for the therapist to 2. Is there a balance between flexors and extensors, or is
provide continued facilitation. one more dominant?
In summation, several components are necessary for 3. Is the patient able to move in all directions?
motor learning to occur. In the PNF treatment ap- 4. What are the major limitations (e.g., weakness, inco-
proach, these components include multisensory input ordination, spasticity, and contractures)?
from the therapist's verbal commands, visual cues, and 5. Is the patient able to assume a posture and to main-
manual contacts. Touch is the most efficient form of tain it? If not, which total pattern or postures are in-
stimulation and provides the opportunity for the adequate?
patient to feel normal movement. Current motor- 6. Are the inadequacies more proximal or distal?
learning theory argues that for motor learning to occur, 7. Which sensory input does the patient respond to
the patient cannot be a passive recipient of treatment. most effectively—auditory, visual, or tactile?
 Proprioceptive Neuromuscular Facilitation Approach 611

8. Which techniques of facilitation does the patient tional movement, changing from one pattern or combi-
respond to best? nation to another, when they cross the transverse and
Finally the patient is observed during self-care and sagittal planes of the body. '”
other ADL to determine whether performance of indi-
vidual and total patterns is adequate within the context Unilateral Patterns
of a functional activity. The patient's performance may 1. Upper extremity (UE) D, flexion (antagonist of D, ex-
vary from one setting to another. After the patient leaves tension): Scapula elevation, abduction, and rotation;
the structured setting of the OT or physical therapy shoulder flexion, adduction, and external rotation;
clinic for the less structured home or community envi- elbow in flexion or extension; forearm supination;
ronment, deterioration of motor performance is not wrist flexion to the radial side; finger flexion and ad-
unusual. Thus the treatment plan must accommodate duction; thumb adduction (Fig. 35-1, A). Examples
the practice of motor performance in a variety of set- in functional activity: hand-to-mouth motion in
tings in locations appropriate to the specific activity. feeding, tennis forehand, combing hair on the left
side of the head with right hand (Fig. 35-2, A),
rolling from supine to prone.
TREATMENT IMPLEMENTATION
2. UE D, extension (antagonist of D, flexion): Scapula de-
After assessment a treatment plan is developed that in- pression, adduction, and rotation; shoulder exten-
cludes goals the patient hopes to accomplish. The tech- sion, abduction, and internal rotation; elbow in
niques and procedures that have the most favorable in- flexion or extension; forearm pronation; wrist exten-
fluence on movement and posture are used. Similarly, sion to the ulnar side; finger extension and abduc-
appropriate total patterns and patterns of facilitation tion; thumb in palmar abduction (Fig. 35-1, B). Ex-
are selected to enhance performance. amples in functional activity: pushing a car door
open from the inside (Fig. 35-2, B), tennis backhand
stroke, rolling from prone to supine.
Diagonal Patterns
3. UE Dj flexion (antagonist of D> extension): Scapula el-
The diagonal patterns used in the PNF approach are evation, adduction, and rotation; shoulder flexion,
mass movement patterns observed in most functional abduction, and external rotation; elbow in flexion or
activities. Part of the challenge in OT assessment and in- extension; forearm supination; wrist extension to the
tervention is recognizing the diagonal patterns in ADL. radial side; finger extension and abduction; thumb
Knowledge of the diagonals is necessary for identifying extension (Fig. 35-3, A). Examples in functional ac-
areas of deficiency. Two diagonal motions are present tivity: combing hair on the right side of the head
for each major part of the body: head and neck, upper with the right hand (Fig. 35-4, A), lifting a racquet in
and lower trunk, and extremities. Each diagonal pattern tennis serve, back stroke in swimming.
has a flexion and extension component, together with 4. UE Dz extension (antagonist of D> flexion): Scapula de-
rotation and movement away from or toward the pression, abduction, and rotation; shoulder exten-
midline. sion, adduction, and internal rotation; elbow in
The head, neck, and trunk patterns are referred to as flexion or extension; forearm pronation; wrist flexion
(a) flexion with rotation to the right or left and (b) ex- to the ulnar side; finger flexion and adduction;
tension with rotation to the right or left. These proximal thumb opposition (Fig. 35-3, B). Examples in func-
patterns combine with the extremity diagonals. The tional activity: pitching a baseball, hitting a ball in
upper and lower extremity diagonals are described ac- tennis serve, buttoning pants on the left side with the
cording to the three movement components at the right hand (Fig. 35-4, B). The rotational component
shoulder and hip: (1) flexion and extension, (2) abduc- in LE D, flexion and extension parallel the UE
tion and adduction, and (3) external and internal rota- patterns.
tion. Voss*° introduced shorter descriptions for the ex- 5. LE D, flexion (antagonist of D, extension): Hip flexion,
tremity patterns in 1967 and referred to them as adduction, and external rotation; knee in flexion or
diagonal 1 (D,) flexion/extension and diagonal 2 (D>) extension; ankle and foot dorsiflexion with inversion
flexion/extension. The reference points for flexion and and toe extension. Examples in functional activity:
extension are the shoulder and hip joints of the upper kicking a soccer ball, rolling from supine to prone,
and lower extremities, respectively. putting on a shoe with legs crossed (Fig. 35-5, A).
The movements associated with each diagonal and 6. LE D, extension (antagonist of D, flexion): Hip exten-
examples of these patterns seen in self-care and other sion, abduction, and internal rotation; knee in
ADL are presented in the following sections. Note that flexion or extension; ankle and foot plantar flexion
in functional activities, not all components of the with eversion and toe flexion. Examples in func-
pattern or full range of motion (ROM) are necessarily tional activity: putting leg into pants (Fig. 35-5, B),
seen. Furthermore, the diagonals interact during func- rolling from prone to supine. The rotational
 Diagonal One
(D,)
D, extension begins in the shortened range of
D, flexion with hand closed toward radial side.
Diagonal 1 (D,) extension leads with hand
opening toward ulnar side.
Eyes follow hand of leading arm so that head
and hand cross midline.
Elbows may remain straight, may flex or
extend.

FIG. 35-1
A, Upper extremity D, flexion pattern. B, Upper extremity D, extension pattern. (From Myers B}:
Unit I: PNF diagonal patterns and their application to functional activities, videotape study guide, Rehabil-
itation Institute of Chicago, 1982.)

FIG. 35-2
A, Upper extremity D, flexion pattern is used in combing hair, opposite side. B, Upper extremity
D, extension pattern is used in pushing a car door open.

612
 Diagonal Two
(D,)
D, flexion begins in shortened range of D,
extension with hand closed toward the ulnar
side.
Diagonal 2 (D,) flexion leads with hand
opening toward radial side.
All diagonal patterns, head to foot, cross
midline when performed through full range.
Elbows may remain straight, may flex or
extend.

FIG. 35-3
A, Upper extremity D, flexion pattern. B, Upper extremity D extension pattern. (From Myers B):
Unit I: PNF diagonal patterns and their application to functional activities, videotape study guide, Rehabil-
itation Institute of Chicago, |982.)

FIG. 35-4
A, Upper extremity D, flexion pattern is used in combing hair, same side. B, Upper extremity Dz
extension pattern is used in buttoning trousers, opposite side.

613
 OCCUPATIONAL THERAPY INTERVENTIONS

FIG. 35-5
A, Lower extremity D, flexion pattern is demonstrated in crossed leg when putting on shoe.
B, Lower extremity D, extension pattern is used when pulling on trousers.

component of LE D, flexion and extension is oppo- cal D> flexion, such as reaching to lift a large item off
site to the UE patterns. a high shelf (Fig. 35-8, C). Bilateral symmetrical UE
7. LE Dz flexion (antagonist of Dz extension): Hip flexion, patterns facilitate trunk flexion and extension.
abduction, and internal rotation; knee in flexion or Da Asymmetrical patterns: Paired extremities perform
extension; ankle and foot dorsiflexion with eversion movements toward one side of the body at the same
and toe extension. Examples in functional activity: time, which facilitates trunk rotation (Fig. 35-7, B).
karate kick (Fig. 35-6, A), drawing the heels up The asymmetrical patterns can be performed with
during the breaststroke in swimming. the arms in contact, such as in the chopping and
8. LE Dz extension (antagonist of D> flexion): Hip exten- lifting patterns in which greater trunk rotation is seen
sion, adduction and external rotation: knee in (Figs. 35-9 and 35-10). Furthermore, with the arms
flexion or extension; ankle and foot plantar flexion in contact, self-touching occurs. This is frequently
with inversion and toe flexion. Examples of func- observed in the presence of pain or in reinforcement
tional activity: push-off in gait, the kick during the of a motion when greater control or power is
breaststroke in swimming, long sitting with legs needed.** This phenomenon is observed in the base-
crossed (Fig. 35-6, B). ball player at bat and in the tennis player who uses a
two-handed backhand to increase control and
Bilateral Patterns power. Examples of asymmetrical patterns are bilat- .
Movements in the extremities may be reinforced by eral asymmetrical flexion to the left, with the left arm
combining diagonals in bilateral patterns as follows: in D, flexion and the right arm in D, flexion, such as
1. Symmetrical patterns: Paired extremities perform when putting on a left earring (Fig. 35-11), and bilat-
similar movements at the same time (Fig. 35-7, A). eral asymmetrical extension to the left, with the right
Examples: bilateral symmetrical D, extension, such arm in D, extension and the left arm in D, exten-
as pushing offa chair to stand (Fig. 35-8, A); bilateral sion, such as when zipping a left-side zipper.
symmetrical D, extension, such as starting to take off a Reciprocal patterns: Paired extremities move in oppo-
a pullover sweater (Fig. 35-8, B); bilateral symmetri- site directions simultaneously, either in the same di-
 Proprioceptive Neuromuscular Facilitation Approach

ll
i
i
i
iii
ia
a
ral

FIG. 35-6
A, Lower extremity D, flexion pattern is shown in karate kick. B, Lower extremity D, extension
pattern is used in long sitting with legs crossed.

agonal or in combined diagonals. If paired extremi- while opposite contralateral extremities move in the op-
ties perform movements in combined diagonals (Fig. posite direction (Fig. 35-7, D, E, and F).
35-7, C), there is a stabilizing effect on the head, The combined movements of the upper and lower
neck, and trunk because movement of the extremi- extremities are observed in such activities as crawling
ties is in the opposite direction while head and neck and walking. Awareness of these patterns is important
remain in midline. During activities requiring high- in the assessment of the patient's motor skills. The ipsi-
level balance, the reciprocal patterns with combined lateral patterns are more primitive developmentally and
diagonals come into play with one extremity in D, indicate a lack of bilateral integration. Less rotation also
extension and the other extremity in D, flexion. Ex- is observed in ipsilateral patterns. Therefore the goal in
amples of this are pitching in baseball, sidestroke in treatment is to progress from ipsilateral to contralateral
swimming, and walking a balance beam with one ex- to diagonal reciprocal patterns.
tremity in a diagonal flexion pattern and the other in There are several advantages to using the diagonal
a diagonal extension pattern (Fig. 35-12). In con- patterns in treatment. First, crossing of midline occurs.
trast, reciprocal patterns in the same diagonal, such This movement is of particular importance in the reme-
as D, in arm swing during walking, facilitate trunk diation of perceptual motor deficits such as unilateral
rotation. neglect, in which integration of both sides of the body
and awareness of the neglected side are treatment goals.
Combined Movements of Upper and Lower Second, each muscle has an optimal pattern in which it
Extremities functions. For example, the patient who has weak
Interaction of the upper and lower extremities results in thumb opposition benefits from active movement in D,
(1) ipsilateral patterns, with extremities of the same side extension. Similarly, D, extension is the optimal pattern
moving in the same direction at the same time, (2) con- for ulnar wrist extension. Third, the diagonal patterns
tralateral patterns, with extremities of opposite sides use groups of muscles, which is typical of movement
moving in the same direction at the same time, and (3) seen in functional activities. For example, in eating, the
diagonal reciprocal patterns, with contralateral extremi- hand-to-mouth action is accomplished in one mass
ties moving in the same direction at the same time movement pattern (Dj, flexion) that uses several
616 OCCUPATIONAL THERAPY INTERVENTIONS

Symmetrical Asymmetrical Reciprocal

Ipsilateral Contralateral Diagonal Reciprocal

FIG. 35-7
A, Symmetrical patterns. B, Asymmetrical patterns. C, Reciprocal patterns. D, Ipsilateral pattern. E,
Contralateral pattern. F, Diagonal reciprocal pattern. (From Myers BJ: Unit I: PNF diagonal patterns
and their application to functional activities, videotape study guide, Rehabilitation Institute of Chicago,
1982.)

muscles simultaneously. Therefore movement in the di- an injury or the aging process, rotation frequently is im-
agonals is more efficient than movement performed at paired and can be facilitated with movement in the di-
each joint separately. Finally, rotation is always a com- agonals. In treatment, attention should be given to the
ponent in the diagonals (e.g., trunk rotation to the left placement of activities so that movement occurs in the
or right and forearm pronation and supination). With diagonal. For example, if the patient is working on a
 B Cc

FIG. 35-8
A, Upper extremity bilateral symmetrical D, extension pattern is shown in pushing off from chair.
B, Upper extremity bilateral symmetrical D2 extension pattern is used when starting to take off
pullover shirt.C, Upper extremity bilateral symmetrical D2 flexion pattern is used when reaching to
lift box off high shelf.

Bilateral
Asymmetrical
‘Chopping’

© Opposite extremity (R) moves in D, extension.

Hand grips wrist of leading arm (L).
e Reversing from extension (D, and D,) to flexion
(D, and D,) is “reversal of chop.”

FIG. 35-9
Bilateral asymmetrical chopping. (From Myers BJ: Unit I: PNF diagonal patterns and their application to
functional activities, videotape study guide, Rehabilitation Institute of Chicago, |982.)

617
 Bilateral
Asymmetrical
‘Lifting’

e In lifting the hand opens with abduction, D,

flexion, and D, flexion, and closes with
adduction, D, extension and D, extension.
Reversing from flexion (D, and D,) to extension
(D, and D,) is “reversal of the lift.”
Contact with opposite extremity, self-touching,
promotes stability and perception.

FIG. 35-10
Bilateral asymmetrical lifting. (From Myers BJ: Unit I: PNF diagonal patterns and their application to func-
tional activities, videotape study guide, Rehabilitation Institute of Chicago, 1982.)

FIG. 35-11 FIG. 32-12

Putting on earring requires use of upper extremity bilateral asym- Bilateral reciprocal pattern of upper extremities is used to walk
metrical flexion pattern. balance beam.

618
 Proprioceptive Neuromuscular Facilitation Approach on Be]

wood-sanding project, trunk rotation with extension fective when applied directly to the skin. Pressure from
can be facilitated by placing the project on an inclined the therapist's touch is used as a facilitating mechanism
plane in a diagonal. and serves as a sensory cue to help the patient under-
stand the direction of the anticipated movement.?? The
amount of pressure applied depends on the specific
Total Patterns
technique being used and on the desired response. The
In PNE, developmental postures also are called total pat- location of manual contacts is chosen according to the
terns of movement and posture.'® Total patterns require groups of muscles, tendons, and joints responsible for
interaction between proximal (head, neck, and trunk) the desired movement patterns. If the patient is having
and distal (extremity) components. The assumption of difficulty reaching to comb the back of the hair because
postures is important, as is the maintenance of postures. of scapular weakness, the desired movement pattern is
When posture cannot be sustained, emphasis should be D, flexion. Manual contacts should be on the posterior
placed on the assumption of posture.*! For example, surface of the scapula to reinforce the muscles that
before the patient can be expected to sustain a sitting elevate, adduct, and rotate the scapula.
posture, he or she must have ability in lower develop- Stretch is used to initiate voluntary movement and
mental total patterns of movement, such as rolling and enhance speed of response and strength in weak
moving from side-lying to side-sitting. muscles. This procedure is based on Sherrington’s neu-
The active assumption of postures can be included in rophysiological principle of reciprocal innervation.'®
OT activities. For example, a reaching and placing activity When a muscle is stretched, the Ia and II fibers in the
could beset up so that the patient must reach for the object muscle spindle send excitatory messages to the alpha
in the supine posture and place the object in the side-lying motor neurons, which innervate the stretched muscle.
posture. The use of total patterns also can reinforce indi- Inhibitory messages are sent to the antagonistic muscle
vidual extremity movements. For example, in an activity simultaneously.’
such as wiping a tabletop, wrist extension is reinforced When stretch is used in the PNF approach, the part to
when the patient leans forward over the supporting arm. be facilitated is placed in the extreme lengthened range
Several facts support the use of total patterns in the of the desired pattern (or where tension is felt on all
PNF treatment approach.’° First, total patterns of move- muscle components of a given pattern). This range is
ment and posture are experienced as part of the normal the completely shortened range of the antagonistic
developmental process in all human beings. Therefore pattern. Special attention is given to the rotatory com-
recapitulation of these postures is meaningful to the ponent of the pattern because it is responsible for elon-
patient and acquired with less difficulty. Second, move- gation of the fibers of the muscles in a given pattern.
ment in and out of total patterns and the ability to After the correct position for the stretch stimulus has
sustain postures enhance components of normal devel- been achieved, stretch is superimposed on the pattern.
opment, such as reflex integration and support, balance The patient should attempt the movement at the exact
between antagonists, and development of motor time that the stretch reflex is elicited. The use of verbal
control in a cephalocaudal, proximodistal direction. commands also should coincide with the application of
Third, the use of total patterns improves the ability to stretch, to reinforce the movement. Discrimination
assume and maintain postures, which is important in should be exercised when using stretch, to prevent an
all functional activities. increase in pain or muscle imbalances.
The sequence and procedures for assisting patients Traction facilitates the joint receptors by creating a
with the developmental postures were developed by separation of the joint surfaces. It is thought that trac-
Voss. In 1981 Myers developed a videotape showing use tion promotes movement and is used for pulling
of the sequence and procedures in OT.'° This video motion.~~ In activities such as carrying a heavy suitcase
demonstrates more information on the application of or pulling open a jammed door, traction can be felt on
the total patterns and postures to OT. joint surfaces. Although traction may be contraindi-
cated for patients with acute symptoms, such as after
surgery or a fracture, it can sometimes provide relief of
Procedures pain and promote greater ROM in painful joints.
PNF techniques are superimposed on movement and Approximation facilitates joint receptors by creating
posture. Among these techniques are basic procedures a compression of joint surfaces. It promotes stability
considered essential to the PNF approach. Two proce- and postural control and is used for pushing motion.”*
dures, verbal commands and visual cues, were discussed Approximation is usually superimposed on a weight-
previously. Other procedures are described in the fol- bearing posture. For example, to enhance postural
lowing sections. control in the prone on elbows posture, approximation
Manual contacts refers to the placement of the thera- may be given through the shoulders in a downward
pist’s hands on the patient. These contacts are most ef- direction.
620 OCCUPATIONAL THERAPY INTERVENTIONS

Maximal resistance is a procedure that involves Sher- is asked to “reach toward your feet.” This sequence is
rington’s principle of irradiation—namely, that stronger repeated either until fatigue is evident or until the
muscles and patterns reinforce weaker components.'® patient is able to reach the feet. The pattern can be re-
This procedure is frequently misunderstood and inforced further by asking the patient to hold with
applied incorrectly. The procedure is defined as the another isometric contraction at the end of the
greatest amount of resistance that can be applied to an sequence.
active contraction while allowing full ROM to occur, or Rhythmic initiation is used to improve the ability
to an isometric contraction without defeating or break- to initiate movement, which may be a problem with
ing the patient's hold.** Maximal resistance is not the Parkinson's disease or apraxia. This technique involves
greatest amount of resistance that the therapist can voluntary relaxation, passive movement, and repeated
apply. The objective is to obtain maximal effort on the isotonic contractions of the agonistic pattern. The
part of the patient because strength is increased by verbal command is, “Relax and let me move you.” As
movement against resistance that requires maximal relaxation is felt, the command is, “Now you do it
effort.” with me.” After several repetitions of active move-
If the resistance applied by the therapist results in un- ment, resistance may be given to reinforce the move-
coordinated or jerky movement or if it breaks the ment. Rhythmic initiation allows the patient to feel
patient's hold, too much resistance has been given. the pattern before beginning active movement. Thus
Movement against maximal resistance should be slow the proprioceptive and_ kinesthetic senses are
and smooth. To use this technique effectively, the thera- enhanced.
pist must sense the appropriate amount of resistance.
For patients with neurological impairment or pain, the Reversal of Antagonists Techniques
resistance may be very light, and light resistance is prob- Reversal of antagonists techniques employ a characteris-
ably maximal for the patient's needs. The therapist's tic of normal development—namely, that movement is
manual contacts may offer light resistance that actually reversing and changes direction. These techniques are
assists by providing the patient with a way to track the based on Sherrington’s principle of successive induc-
desired movement. In the presence of spasticity, resist- tion, according to which the stronger antagonist facili-
ance may increase existing muscle imbalance and thus tates the weaker agonist.’* The agonist is facilitated
needs to be monitored. For example, if an increase in through resistance to the antagonist. The contraction of
finger flexor spasticity is noted with resisted rocking in the antagonist can be isotonic, isometric, or a combina-
the hands-knees position, resistance should be de- tion of the two. These techniques may be contraindi-
creased or eliminated or an alternate position should be cated for patients in whom resistance of antagonists in-
used. creases symptoms such as pain and spasticity. For
example, the facilitation of finger extension (agonist)
would not be achieved effectively through resistance
Techniques
applied to spastic finger flexors (antagonist). In this sit-
Specific techniques are used in conjunction with these uation, finger extension may be better facilitated
basic procedures. A few have been selected for discus- through the use of repeated contractions, in which the
sion. These techniques are divided into three categories: emphasis is only on the extensor surface.
those directed to the agonists, those that are a reversal of Slow reversal is an isotonic contraction (against re-
the antagonists, and those that promote relaxation.** sistance) of the antagonist followed by an isotonic con-
traction (against resistance) of the agonist. Slow rever-
Techniques Directed to the Agonist sal-hold is the same sequence, with an isometric
Repeated contractions is a technique based on the as- contraction at the end of the range. For the patient who
sumption that repetition of an activity is necessary for has difficulty reaching his mouth for oral hygiene
motor learning and helps develop strength, ROM, and because of weakness in the D, flexion pattern, the slow
endurance. The patient's voluntary movement is facili- reversal procedure is as follows: an isotonic contraction
tated with stretch and resistance, using isometric and against resistance in D, extension with the verbal
isotonic contractions. Repeated contractions could be command, “Push down and out,” followed by an iso-
used to increase trunk flexion with rotation in the tonic contraction of D, flexion against resistance with
patient who has difficulty reaching to put on a pair of the verbal command, “Pull up and across.” An increase
shoes from the sitting position. The patient bends or buildup of power in the agonist should be felt with
forward as far as possible. At the point where active each successive isotonic contraction.
motion weakens, the patient is asked to “hold” with an Rhythmic stabilization is used to increase stability
isometric contraction. This action is followed by iso- by eliciting simultaneous isometric contractions of an-
tonic contractions, facilitated by stretch, as the patient tagonistic muscle groups. Cocontraction results if the
 Proprioceptive Neuromuscular Facilitation Approach 621

patient is not allowed to relax. This technique requires during self-care activities such as shampooing hair and
repeated isometric contractions, leading to increased zipping a shirt in back.
circulation or the tendency for the patient to hold his or Slow reversal-hold-relax begins with an isotonic
her breath, or both. Therefore rhythmic stabilization contraction, followed by an isometric contraction, relax-
may be contraindicated for patients with cardiac in- ation of the antagonistic pattern, and then by active
volvement, and no more than three or four repetitions movement of the agonistic pattern. When the patient
should be done at a time on any patients. has the ability to move the agonist actively, the tech-
In rhythmic stabilization manual contacts are nique is preferred. For example, to increase active elbow
applied on both agonist and antagonist muscles, with extension in the presence of tight elbow flexors, the
resistance given simultaneously. The patient is asked to therapist asks the patient to perform D, flexion with
hold the contraction against graded resistance. Without elbow flexion as resistance is applied. When the ROM is
allowing the patient to relax, manual contacts are complete, the patient is asked to hold with an isometric
switched to opposite surfaces. Rhythmic stabilization is contraction, followed immediately by relaxation. When
useful with patients lacking postural control because of relaxation is felt, the patient moves actively into D, ex-
ataxia or proximal weakness. Used intermittently during tension with elbow extension. This technique helps in-
an activity requiring postural stability, such as meal crease elbow extension for such activities as reaching to
preparation in standing posture, this technique en- lock the wheelchair brakes or picking up an object off
hances muscle balance, endurance, and control of the floor.
movement. Rhythmic rotation \is effective in decreasing spas-
ticity and increasing ROM. The therapist passively
Relaxation Techniques moves the body part in the desired pattern. When
Relaxation techniques are an effective means of increas- tightness or restriction of movement is felt, the thera-
ing ROM, particularly in the presence of pain or spastic- pist rotates the body part slowly and rhythmically in
ity, which may be increased by passive stretch. both directions. After relaxation is felt, the therapist
Contract-relax involves passive motion to the point continues to move the body part into the newly
of limitation in movement patterns. This is followed available range. This technique is effective in prepar-
by an isotonic contraction of the antagonist pattern ing the paraplegic patient with LE spasticity or clonus
against maximal resistance, with only the rotational to put on a pair of pants. The technique is also effec-
component of the diagonal movement allowed. This tive in preparing for splint fabrication on a spastic
action is followed by relaxation, then by further extremity.
passive movement into the agonistic pattern (e.g., con-
tract-relax could involve passive motion to the point
SUMMARY
of limitation in D, flexion, which would be followed
by an isotonic contraction of D, extension, then by The PNF approach emphasizes the patient's abilities
further passive movement into D, flexion). This proce- and potential so that strengths assist weaker compo-
dure is repeated at each point in the ROM in which nents. Strengths and deficiencies are assessed and ad-
limitation is felt to occur.*? Contract-relax is used dressed in treatment within total patterns of movement
when no active range in the agonistic pattern is and posture. A battery of techniques is superimposed on
present. However, the ultimate goal is active move- these total patterns to enhance motor response and fa-
ment through the full range. Therefore once relaxation cilitate motor learning.
and increased ROM occur, active movement should be PNF uses multisensory input. The coordination and
facilitated. timing of sensory input are important in eliciting the
Hold-relax is performed in the same sequence as desired response from the patient. The patient's per-
contract-relax but involves an isometric contraction (no formance should be monitored, and sensory input
movement allowed) of the antagonist, followed by re- should be adjusted accordingly.
laxation and then active movement into the agonistic To use PNF effectively, the therapist must understand
pattern. Because this technique involves an isometric the developmental sequence and the components of
contraction against resistance, it is particularly benefi- normal movement. The therapist must learn the diago-
cial in the presence of pain or acute orthopedic condi- nal patterns and how they are used in ADL, must know
tions. For the patient with reflex sympathetic dystrophy when and how to use the techniques of facilitation and
(RSD) who has pain with shoulder flexion, abduction, relaxation, and must be able to apply patterns and tech-
and external rotation, the therapist asks the patient to niques of facilitation to OT evaluation and treatment.
hold against resistance in the D, extension pattern, then Attaining these skills requires observation and practice
to initiate active movement into the D, flexion pattern. under the supervision of a therapist experienced in the
This technique is beneficial for the patient with RSD PNF approach.
622 OCCUPATIONAL THERAPY INTERVENTIONS

CASE STUDY 35-1

Case Stupy
A 50-year-old woman was referred for OT services with a right pants. At the end of the range, the patient was instructed to hold
cerebrovascular accident (CVA) resulting in left hemiplegia. with isometric contraction. After the pants were donned, manual
Before the CVA she had a history of hypertension but otherwise contacts were switched to the posterior surface of either
good health. Referral to OT was made |0 days after onset of scapula. Resistance was applied as the patient returned to the
CVA for evaluation and treatment in ADL, visual perceptual skills, upright position. The verbal command was, “Look up and over
and left UE function. your right shoulder’’When the patient was upright, she was again
instructed to hold with isometric contraction. In addition to rein-
Assessment forcing trunk control, this technique alleviated the patient's fear of
An initial assessment revealed intact vital and related functions, leaning forward, because the therapist was in continual contact
such as oral and facial musculature and swallowing. Voice produc- with the patient.
tion was good. The patient had a tendency to hold her breath An indirect benefit of the flexion and extension patterns of
during activities, and subsequent decreased endurance was the head, neck, and trunk was the reinforcement of respiration.
noted. Visual tracking was impaired, with an inability to scan past The patient was encouraged to inhale during extension and
midline and apparent left-side neglect. exhale during flexion. This approach eliminated the patient's ten-
The head and neck were observed to be frequently rotated dency to hold her breath.
to the right and slightly flexed because of weak extensors. The Treatment consisted of total patterns and techniques to facil-
trunk was noted to be asymmetric in sitting posture, with most itate proximal stability in the left UE and to provide propriocep-
of the weight supported on the right side. The patient's posture tive input. Weight-bearing activities were selected because no
was flexed because of weak extensors. Static sitting balance was active movement was available in the left arm. The patient used
fair and dynamic sitting balance was poor with the patient listing the right UE in diagonal patterns to perform perceptual tasks such
forward and left. as a mosaic tile design, paper and pencil activities, and board
The patient's right arm was normal in sensation and strength, games. These activities were performed to include the side-lying
although motor planning was impaired. The left arm was essen- posture on the left elbow, the prone posture on elbows, the side-
tially flaccid, with impaired sensation of light touch, pain, and pro- sitting posture with weight on the left arm, and on all fours.To re-
prioception. The patient complained of mild glenohumeral pain inforce stability at the shoulder girdle, approximation and rhyth-
during passive movement at the end ranges of shoulder abduc- mic stabilization were used with manual contacts at both
tion and flexion. Scapular instability was noted. No active move- shoulders and then at the shoulder and pelvis. The performance
ment could be elicited in the left arm. of perceptual tasks in diagonals improved the patient's motor
Perceptual testing showed apraxia (especially during activities planning, left-side awareness, and trunk rotation.
requiring crossing of midline) and left-side neglect. The patient The patient was instructed in bilateral asymmetrical chopping
was alert and oriented, with good attention span and memory. and lifting patterns to support the scapula and left UE in rolling
Carryover in tasks was adequate. and other activities. These patterns also enhanced left-side
The patient needed moderate assistance in ADL and moder- awareness and trunk rotation. To facilitate scapular movement
ate to maximum assistance with transfers. Impaired balance and during chop and lift patterns, the therapist applied stretch to ini-
apraxia were the most limiting factors in performance of ADL. tiate movement, followed by slow reversal technique. In prepara-
tion for the lift pattern, manual contacts were placed on the pos-
Treatment implementation terior surface of the scapula. Stretch was applied in lengthened
Following the cervicocaudal direction of development, alignment range. As the patient initiated the lifting pattern, resistance was
of the head and neck was the appropriate starting point for given and maintained throughout the ROM. This procedure was
treatment. Left-side awareness, sitting posture, and trunk balance repeated for antagonistic or reverse of lift pattern, with manual
were directly influenced by the position of the head and neck. contacts switching to the anterior surface of the scapula.
Before the start of self-care activities,
the patient performed head About 3 to 4 weeks after the injury the patient was able to
and neck patterns of flexion and extension with rotation.To rein- initiate left UE movement in synergy with predominance of
force rotation to left, the therapist was positioned to the left of flexor tone. Weight-bearing activities and rhythmic rotation were
the patient. Clothing and hygiene articles also were placed to the helpful in normalizing tone, and both techniques were used with
left of the patient. ADL such as dressing and bathing. Wrist and finger extensions
A lack of trunk control was another problem. During bending were facilitated in the D, extension and D3 flexion patterns using
activities, the patient reported a fear of falling and was unsure of repeated contractions.
her ability to return to the upright position. Consequently, the
patient had difficulty leaning forward to transfer from wheelchair. Outcomes
Slow reversal-hold technique was used to reinforce trunk pat- Reevaluation after 5 weeks of OT revealed increased endurance
terns during ADL. For example, as the patient prepared to don and ability to coordinate breathing with activity, and consistency
her left pant leg, the therapist was positioned in front and to the in crossing midline during visual scanning activities. The patient
left of the patient. Manual contacts were on the anterior aspect was able to turn her head and neck to the left without cues from
of either scapula. The therapist moved with the patient and the therapist. The fear of falling forward with bending had dimin-
applied resistance as the patient leaned forward to don her ished, and the patient automatically turned her head to look up
 Proprioceptive Neuromuscular Facilitation Approach 623

and over her shoulder to reinforce assumption ofthe upright po- eral weight-bearing through both hips. Shoulder pain decreased
sition. As trunk strength continued to improve, reinforcement and scapular stability improved during weight-bearing activities.
with head and neck rotation was no longer necessary, Visual The patient initiated left UE movement out of flexor synergy
tracking alone, in the direction of movement, was sufficient to re- pattern. Right UE motor planning was within functional limits for
inforce assumption of the upright position. Eventually the patient ADL Transfers and self-care required only minimal assistance, and
was able to obtain an upright position without apparent visual or cues were no longer needed for left UE awareness.
head and neck reinforcement. Sitting balance improved with bilat-

REVIEW QUESTIONS . Buchwald JS: Exteroceptive reflexes and movement, Am J Phys Med
. Give examples of how the TNR and the ATNR rein- 46(1):121-128, 1967.
. Carroll J: The utilization of reinforcement techniques in the
force motor performance. program for the hemiplegic, Am J Occup Ther 4(5):211, 1950.
. Is rolling from prone to supine a flexor- or extensor- . Cooke DM: The effects of resistance on multiple sclerosis patients
dominant activity? with intention tremor, Am J Occup Ther 12(2):89, 1958.
. In the presence of pain, what tone of voice should . Farber SD: Neurorehabilitation: a multisensory approach, Philadel-
be used when giving verbal commands? phia, 1982, WB Saunders.
. Hagbarth KE: Excitatory and inhibitory skin areas for flexor and
. Discuss the significance of auditory, visual, and extensor mononeurons, Acta Physiol Scand 26(suppl 94):1, 1952.
tactile input in motor learning. . Hellebrandt FA: Physiology. In Delorme TL, Watkins AL: Progres-
. Which UE diagonal pattern is used for the hand-to- sive resistance exercise, New York, 1951, Appleton, Century, &
mouth phase of eating? For zipping front-opening Crofts.
10. Hellebrandt FA, Schade M, Carns ML: Methods of evoking the
pants?
tonic neck reflexes in normal human subjects, Am J Phys Med
. Discuss the advantages of using the chop and lift 4(90):139, 1962.
patterns. inte Humphrey TL, Huddleston OL: Applying facilitation techniques
. Which trunk pattern is used when donning a left to self care training, Phys Ther Rev 38(9):605, 1958.
sock? . Jackson JH: Selected writings, vol 1, London, 1931, Hodder &
. List three advantages of using the diagonal patterns. Staughton (edited by J Taylor).
iS Kabat H, Rosenberg D: Concepts and techniques of occupational
. What is the developmental sequence of total pat- therapy for neuromuscular disorders, Am J Occup Ther 4(1):6,
terns? 1950.
10. If a patient needs more stability, which of the fol- 14. Loomis JE, Boersma FJ: Training right brain damaged patients in a
lowing total patterns should be chosen: side-lying wheelchair task: case studies using verbal mediation, Physiother
or prone posture on elbows? Can 34(4):204, 1982.
It. Myers BJ: Proprioceptive neuromuscular facilitation: concepts and
1s Which PNF technique facilitates postural control application in occupational therapy as taught by Voss. Notes from
and cocontraction? course at Rehabilitation Institute of Chicago, September 8-12,
t2. Discuss the neurophysiological principles of Sher- 1980.
rington upon which the PNF techniques of facilita- 16. Myers BJ: Assisting to postures and application in occupational therapy
activities, Chicago, Rehabilitation Institute of Chicago, 1981
tion are based.
(videotape).
13s What is an effective technique to prepare the patient Nee Myers BJ: PNF: patterns and application in occupational therapy,
with UE flexor spasticity to don a shirt? Chicago, Rehabilitation Institute of Chicago, 1981 (videotape).
14. Define maximal resistance. 18. Sherrington C: The integrative action of the nervous system, New
15. Name two PNF techniques that facilitate initiation Haven, Conn, 1961, Yale University Press.
. Voss DE: Application of patterns and techniques in occupational
of movement.
therapy, Am J Occup Ther 8(4):191, 1959.
20. Voss DE: Proprioceptive neuromuscular facilitation, Am J Phys
REFERENCES Med 46(1):838-899, 1967.
the Abreu BF, Toglia JP: Cognitive rehabilitation: a model for occupa- 21g Voss DE: Proprioceptive neuromuscular facilitation: the PNF
tional therapy, Am J Occup Ther 41(7):439-448, 1987. method. In Pearson PH, Williams CE, editors: Physical therapy serv-
2 Affolter F: Perceptual processes as prerequisites for complex ices in the developmental disabilities, Springfield, Ill, 1972, Charles C
human behavior, Int Rehabil Med 3(1):3-10, 1981. Thomas.
3; Ayres JA: Proprioceptive neuromuscular facilitation elicited 225 Voss DE, Ionta MK, Myers BJ: Proprioceptive neuromuscular facilita-
through the upper extremities. I. Background, Am J Occup Ther tion, ed 3, Philadelphia, 1985, Harper & Row.
9(1):1. Il. Application, Am J Occup Ther 9(2):57. III. Specific appli- 2B: Whitaker EW: A suggested treatment in occupational therapy for
cation to occupational therapy, Am J Occup Ther 9(3):121, 1955. patients with multiple sclerosis, Am J Occup Ther 4(6):247, 1950.
KEY TERMS | "LEARNING OBJECTIVES
Neurodevelopmental treatment After studying this chapter the student or clinician will
Symmetry be able to do the following:
Mixed tone 1. State the primary goal of the neurodevelopmental
Weight bearing treatment (NDT) approach.
Associated movement 2. List the advantages of the NDT approach.
Associated reactions 3. Describe the typical hemiplegic posture.
Inhibition 4. List the key elements of the NDT assessment.
Facilitation 5. List factors that can increase spasticity.
Key points of control 6. Describe the elements of a vicious circle that can
Trunk rotation contribute to the maintenance of spasticity.
Subluxation 7. List possible causes of asymmetrical shoulder

8. Describe treatment methods designed to normalize

tone.
9. List the purposes of trunk rotation and bilateral
activities.
10. Describe bed positioning for the patient with
hemiplegia.
11. Discuss how the affected upper extremity (UE) can
be incorporated into activity.
12. Discuss why real life activities, rather than
simulated or contrived activities, are advantageous
in the treatment program.
13. Perform and teach methods of dressing described
in this chapter.
14. Discuss the importance of scapula protraction in
positioning and movement of the hemiplegic arm.
15. List possible causes of shoulder subluxation.
16. Discuss the treatment of subluxation
recommended in the NDT approach.
17. List the problems with use of the hemiplegic sling.
18. Describe the role of the occupational therapist in
preparing the patient to go home.

624
 Neurodevelopmental Treatment: The Bobath Approach 625

that will best serve the needs of the patient throughout

recovery.
e ultimate goal of occupational therapy (OT) for
the patient with hemiplegia is to regain as much inde- TYPICAL PROBLEMS OF HEMIPLEGIA
pendence as possible, under safe conditions, regardless
Motor Problems
of the therapy setting or length of treatment. A founda-
tion of treatment should be established that allows the The major motor problem in hemiplegia is the lack of
patient to make positive changes beyond the time limita- postural control affecting voluntary movement. Flaccid-
tions of therapy. Changes often occur for many months ity ismost common atthe onset ofa CVA. During this time
or even years after a cerebrovascular accident (CVA). the patient is often passive, displaying low endurance and
Working within the confines of the current health care low tolerance to activity. This condition may last a few
system, most therapists will not have the opportunity to days or as long as several months. Although the patient
follow a patient throughout the recovery process. The does not display movement in the affected extremities at
limitations of a therapist's time with the patient should this time, a proper treatment program can have a strong
not dictate the theme of the treatment program. impact on the eventual functional outcome.”
Occupational therapists want to establish a program After the flaccid stage, patients enter a stage of mixed
that facilitates optimal learning and promotes recovery. tone, displaying a combination of flaccidity and spastic-
Neurodevelopmental treatment (NDT) provides a ity. For example, the upper extremity (UE) may have an
sound foundation for such a program. First developed increase in tone proximally (scapular retraction, depres-
in the 1940s by Berta Bobath, a physical therapist, and sion or downward rotation, internal rotation of the
her husband, Dr. Karel Bobath,?7 NDT is based on humerus) but a decrease in tone distally (at the wrist,
normal development and movement. The term neurode- hand, or fingers). During the mixed-tone phase, trauma
velopmental treatment was coined by the Bobaths from to the shoulder is common. If treatment does not
their work with children with cerebral palsy. Also address the problems of high tone at this stage, the
known as the Bobath approach, NDT has been used suc- patient progresses to the next stage.
cessfully in the treatment of adult hemiplegia. Spasticity is the most commonly identified problem
During recovery a patient typically overuses the unin- and the most difficult motor problem to treat after a
volved side, compensating for the loss of sensory and CVA. If not treated correctly, spasticity can progress until
motor function on the hemiplegic side. Resulting prob- independent living is nearly impossible. Spasticity inter-
lems in posture, alignment, balance, strength, tone, and feres with the patient's selective motor function. It pro-
coordination often lead to less effective patterns of duces abnormal sensory feedback and contributes to
movement and may eventually cause orthopedic prob- weakness of the antagonist muscles. It can cause con-
lems, pain, or decreased safety. If patients are trained tractures, pain, and an all-consuming fear in many pa-
only in the use of adaptive equipment, compensatory tients. Fear, pain, and spasticity are often so intertwined
movement is reinforced and the potential for obtaining that they cause a vicious circle. The spasticity causes an
the highest level of function is hindered. increase in pain, which causes an increase in fear, which
In NDT the therapist develops a program to help the in turn increases the amount of spasticity.”
patient avoid these abnormal patterns of movement. If measures are taken to reduce pain and fear, the
The program provides a foundation that promotes the therapist has a much better chance for success with the
highest level of functional recovery based on relearning methods used to reduce spasticity. Other factors that
normal movement rather than on compensation. NDT may influence the amount of spasticity are emotional
techniques are intended for more than just the move- stress, physical effort (on the hemiplegic side or the un-
ments of an arm or leg. The client is encouraged to use affected side), temperature, and the rate at which an ac-
both sides of the body. One of the central principles of tivity is performed.
NDT is that alignment and symmetry of the trunk and The typical posture in the adult patient with hemi-
pelvis are necessary for good alignment and symmetry plegia (Fig. 36-1) can be described as follows:
of the extremities. Adaptive equipment is used when ab- Head: Lateral flexion toward the involved side with rota-
solutely necessary for safety, but not as a first resort and tion away from the involved side
not as a replacement for treatment. UE: A combination of the strongest components of the
With good handling and treatment skills the occupa- flexion and extension synergies
tional therapist can facilitate positive changes for the 1. Scapula—depression, retraction
patient with hemiplegia at any stage of recovery. It is 2. Shoulder—adduction, internal rotation
important to know what to avoid in treatment, as well 3. Elbow—flexion
as what to promote and facilitate. Therapists must 4. Forearm—pronation
become efficient in problem-solving and prioritizing 5. Wrist—flexion, ulnar deviation
patient needs to design an effective treatment program 6. Fingers—flexion
626 OCCUPATIONAL THERAPY INTERVENTIONS

Trunk: Lateral flexion toward the involved side (trunk side. Many factors make weight-bearing difficult over
shortening) the weak side. Loss of sensation, loss of strength, and
Lower extremity: Typical posture in adult with hemiple- fear of falling contribute to this problem.
gia is the extension synergy
1. Pelvis—posterior elevation, retraction Fear
2. Hip—internal rotation, adduction, extension Fear may be the most debilitating factor for many pa-
3. Knee—extension tients. Fear magnifies other problems that cause the
4. Ankle—plantar flexion, supination, inversion patient to be dependent rather than independent. Fear
5. Toes—flexion can be caused by loss of sensation, poor balance reac-
tions, lack of protective extension (i.e., fear of falling),
and perceptual or cognitive problems. Fear is a major
Additional Problems
factor influencing spasticity.”
In addition to motor problems, patients often have
many problems that can be debilitating either alone or Sensory Loss
in combination. The following are some of the most Sensory loss may include loss of stereognosis, kines-
common problems. thetic awareness, light touch, and pressure. A patient's
extremity may remain useless because of sensory loss
Weight bearing even though there is good motor control.”
Most patients avoid weight bearing on the affected side
of the body. Instead of the weight being equally distrib- Neglect
uted over both hips (in sitting) or over both feet (in Unilateral neglect may be a combination of one or more
standing), it is usually shifted to the nonhemiplegic of the following: sensory loss, perceptual or cognitive
dysfunction, or visual field deficit (homonymous hemi-
anopsia). The patient may have good motor recovery but
is unable to use it functionally because of the neglect.’
Many other problems are related to CVA, such as
aphasia, apraxia, perceptual motor and cognitive defi-
cits, and psychological dysfunction. These conditions
are discussed in Chapters 25 to 28.

ASSESSING THE PATIENT

When the patient is assessed, emphasis is placed on the
quality of movement (i.e., the way the patient moves).
The therapist observes coordination, changes of tone,
and postural reactions rather than looking at specific
muscles and joints.” The therapist must have knowledge
of normal posture and movement, to identify patterns
that may be abnormal. Each patient presents a different
picture, based upon age, premorbid physical condition,
and normal degenerative changes.

Importance of Observation
Good observation skills are the foundation for a good
assessment. Therapists must learn to be specific in their
observations and in their analysis of these observations.
Although certain characteristics are common to most
patients with hemiplegia, each patient demonstrates a
unique set of problems. Therapists with the most ad-
vanced skills see problems that others may miss.

FIG. 36-1 Basic Observation Process

Typical posture of adult with hemiplegia in standing position. During assessments, patients must be observed from the
(Courtesy of Graphic Arts Department, Harmarville Rehabilitation front, back, and side. Most information about patient
Center, Pittsburgh, Pa.) symmetry is gained by observing both the hemiplegic
 Neurodevelopmental Treatment: The Bobath Approach 627

and nonhemiplegic sides from head to toe. Observa- Observation Guide

tions should be both static and dynamic; the patient [RS Se areas |

should be sitting, standing, or supine in a static posi-

tion, and the observation should be made while the Midline Symmetry
patient tries to move for dynamic changes in the trunk, A
head and neck, and both upper extremities. I
To assess asymmetry in posture and pelvic and shoul- I

der girdles, the therapist should have the patient in an I

i
upright position. If the patient is unable to maintain the
!
sitting posture, the assessment may be performed in a I
supine position, but observations will be limited. It jE a ag pya a a estat
helps to have the patient's shirt off to detect asymme-
tries in the trunk, shoulder girdle, and upper extremi-
ties. For privacy the therapist may want to perform the
assessment in the patient's room. It is also helpful to
keep a tank top in the OT department for female pa-
tients. Outpatients often wear a bathing suit, halter top,
or tank top under their shirts.
A good way to structure observation is to imagine ref-
erence lines, as shown in Fig. 36-2, which will help to
identify deviations. The first line of reference is vertical C=
at midline (Fig. 36-2, A). The therapist should look for
asymmetries by comparing the right and left sides of the
patient. Is the head centered in midline? Are the medial
borders of both scapulae equidistant from the spine? Is ==

the trunk shifted to one side? Next the therapist visual-

Look for: Check:
izes a level, horizontal line at the top of the shoulders ¢ unilateral creases, folds ¢ distances
(Fig. 36-2, B). Is one shoulder higher than the other? Is ¢ equal weight-bearing ¢ head position
one shoulder abnormally high or the other abnormally ¢ height of shoulders
* symmetry of trunk
low? The third reference is a level horizontal line at the
height of the hips (Fig. 36-2, C). Is one hip higher or FIG. 36-2
lower? Is the patient bearing weight equally over both Observation guide. (Courtesy of International Clinical Educators,
hips? The therapist also should look for unilateral Inc, 1993.)
creases or folds on the trunk (Fig. 36-2, D), that might
indicate additional problem areas.
Observations of asymmetry do not necessarily indi- tion. This information will help the therapist determine
cate what the problem is; asymmetry indicates only that the cause of the pain.
there is a problem. To understand the cause of the As the patient is passively moved, the therapist feels
problem, the therapist continues the assessment. The deviations from normal. If resistance is felt, the patient
therapist should never assume the obvious. The detec- probably has abnormally high tone. It is important to
tive work begins as the pieces of the puzzle come to- take the limb slowly through ROM to prevent a quick
gether. In problem solving, information from observa- stretch followed by clonus, which increases the problem
tions is combined with information about the medical of high tone. If no resistance is felt but the arm feels
history and premorbid conditions and, most important, heavy, the patient probably has abnormally low tone.
the handling by the therapist. For the dynamic assessment the therapist observes
To identify the underlying cause when asymmetries any movement initiated by the patient on the weak side.
are noted, the therapist takes the affected limb through As the patient attempts to move the weak side, some-
Passive range of motion (PROM). It is important for the times the strong side attempts to make the same move-
therapist to move the UE within normal patterns of ments. The effect, called associated movement, is
movement and in normal alignment to avoid orthope- normal. Everyone has associated movements at one
dic problems (e.g., microtearing of structures or soft- time or another. These movements are most commonly
tissue impingement). Any pain or discomfort on move- identified in children; for example, when cutting with
ment should be noted, and the limb should not be scissors, the child’s tongue protrudes. The patient may
moved past the point of pain or discomfort. If able, the use compensatory movements or movements influ-
patient should be asked to describe the pain (e.g., stab- enced by abnormal synergy patterns. These abnormal
bing, aching, dull, or pulling) and show its specific loca- patterns of movement, called associated reactions, can
 OCCUPATIONAL THERAPY INTERVENTIONS

Integrating Assessment and Treatment

be caused by excessive effort on the sound side that
“overflows” to the weak side or by excessive effort on the When the therapist observes the patient both statically
weak side, which causes a synergy pattern. Associated and dynamically, the information collected is followed
reactions are abnormal and should be discouraged or by the identification of specific problem areas. Next the
inhibited.° therapist determines what to do in treatment. According
By comparing the patient's movement pattern with to Bobath, “Every evaluation is a treatment and every
the normal pattern, the therapist can identify problem treatment is an evaluation.””
areas interfering with normal movement. For example, The primary goal of NDT is to relearn normal move-
when the patient with a hemiplegic arm reaches for an ments. The methods used are intended to treat the
object, the shoulder elevates and retracts, the elbow person as a whole, encouraging the use of both sides of
maintains a flexed position, and the forearm is in partial the body. The patient makes less use of adaptive equip-
pronation with wrist and finger flexion; the trunk flexes ment (e.g., slings, braces, and canes) and is more able to
forward to position the hand nearer the object (Fig. move about freely with more normal muscle tone.” This
36-3). In comparison, in a normal pattern of movement approach creates a better atmosphere for the psychoso-
trunk stability with scapular protraction, selective elbow cial adjustment to family life and everyday living. The
extension with pronation, wrist extension, and finger more normal a person appears to others, with less de-
flexion might be displayed (Fig. 36-4). The therapist formity from spasticity, the better he or she is accepted.
must thoroughly understand the components of nor-
mal movement to compare it with abnormal movement Fluctuations in Tone
for assessment. Table 36-1 lists a few common prob- Under stressful conditions anyone’s muscle tone might
lems observed during static assessment, along with their be higher; for example, muscle tension increases when a
possible causes. person is presenting a paper in front of the class for the

FIG. 36-3 FIG. 36-4

Patient reaching forward using abnormal movement patterns. Patient using normal movement patterns while reaching forward
with the uninvolved side.
 Neurodevelopmental Treatment: The Bobath Approach

| Observations
and Possible Causes
STRUCTURED OBSERVATION (STATIC)
Observation Possible Causes of Problem*
Lateral flexion to affected side Shortened upper trapezius
Poor head righting
Midline orientation deficit

Hemiplegic shoulder lower Weak trunk with lateral flexion to the hemiplegic side
Low tone in shoulder girdle with arm hanging to the side
Increased tone in depression and downward rotation of the scapula
Unaffected shoulder higher Bracing or holding with strong side caused by poor
sitting balance, weak trunk control, or fear
Downward rotation of scapula Increased tone of muscles acting on scapular downward rotation
(rhomboids, levator scapulae, serratus anterior)
Decreased tone of stabilizing muscles of the scapula allowing it to
fall into downward rotation
Winging of the scapula Weakness of serratus anterior |
Increased tone of the subscapularis pulling the scapula and causing
it to wing

Trunk Unilateral crease on affected side Lateral flexion of trunk caused by weak abdominals or increased
tone in scapular retraction and depression with pelvic retraction
and elevation causing shortening on the hemiplegic side
*These are some examples. A problem may have one or more causes.

first time. Conversely, tone may be lower during relaxing 5. Facilitation of slow, controlled movements
experiences such as after a big lunch or when the in- 6. Proper positioning
' structor turns down the lights for a slide presentation. These six techniques, discussed in the paragraphs
Patients with a neurological insult, on the other hand, that follow, provide the foundation for treatment of the
demonstrate abnormally high tone and abnormally low adult patient with hemiplegia using the Bobath (NDT)
tone. It is the therapist's job to determine where. the approach. The techniques are most effective and
patient displays abnormally high or low tone and then provide the best potential in rehabilitation when they
to implement a treatment program designed to normal- are started in the acute phase but can be useful in any
ize tone. Decreasing abnormally high tone is called phase of the treatment program.
inhibition; increasing abnormally low tone is called
facilitation. NEURODEVELOPMENTAL TREATMENT
The points of contact or hand placement of the ther-
Weight Bearing Over Affected Side
apist that are most effective in regulating tone are called
key points of control. Proximal key points are the Weight bearing over the hemiplegic side is the most ef-
shoulder and pelvic girdles, helpful with more gross fective way of helping to regulate tone, or bring the
patterns of movement. Distal key points of control are muscle tone into a more normal range. With patients
the hand, thumb, or foot. These can be helpful for more displaying low tone it is facilitative, and with patients
refined movement patterns. Abnormal patterns (syner- displaying high tone it can be inhibitory. Weight
gies) must be suppressed or inhibited before normal, se- bearing not only helps to regulate tone, but also pro-
lective isolated movement can take place. It is impossi- vides sensory input to the hemiplegic side through pro-
ble to superimpose normal movement on abnormal prioception. Additionally this approach improves the
tone.* Muscle tone may be normalized by using one or patient’s awareness of that side and helps to decrease
more of the following techniques”: neglect. As the awareness of the weak side improves, the
1. Weight bearing over the affected side patient is often less fearful, thus establishing a better
2. Trunk rotation foundation for the recovery process.
3. Scapular protraction The positive effects of weight bearing can be ob-
4. Positioning of the pelvis forward toward an anterior served in nearly every stage of recovery. Correct weight
pelvic tilt bearing can be as simple as positioning the patient in a
630 OCCUPATIONAL THERAPY INTERVENTIONS

side-lying position on the hemiplegic side in bed or as

difficult as the facilitation of stance phase in gait train-
ing. When weight bearing is introduced early, the bene-
fits can be seen throughout the rehabilitation program.
The patient should be taught to bear weight equally
through both hips in sitting and through both feet in
standing. ;
Weight bearing through the UE in sitting or standing
can help to regulate tone throughout the UE. This is
most effective with patients displaying a flexion synergy
of the UE. The patient can be brought into a weight-
bearing position before or during treatment in func-
tional daily living tasks.
Before the patient begins weight bearing through the
UE, the UE and shoulder girdle must be prepared. The
therapist must make sure the scapula is gliding in
forward protraction, elevation, and upward rotation.
After mobilization of the scapula the patient’s hand
should be placed on the mat or bench several inches
from the hip; if the hand is placed next to the hip,
extreme hyperextension of the wrist may occur. The
humerus is in external rotation with the elbow in exten-
sion. As the patient shifts weight over the hemiplegic
side, the therapist should be careful not to allow inter-
nal rotation of the upper arm and not to allow the
elbow to collapse. Weight bearing is not allowed if the
patient complains of pain or if the hand is edematous.
The patient should not be allowed to hang on the arm
in weight bearing, but instead should move the body
over the arm to regulate tone without putting undue
stress on the joint (Fig. 36-5). FIG. 36-5
When the therapist facilitates weight bearing during Proper position for weight bearing over hemiplegic side.
functional activities, he or she normally allows the
patient's elbow to bend slightly. The best rule of thumb
is to check the position usually assumed by nondis- shift to the hemiplegic side. Additional benefits from ac-
abled persons for the activity and then see if the tivities facilitating trunk rotation include increased
patient's position is similar. sensory input to the hemiplegic side, improved aware-
ness of the hemiplegic side, and trained compensation
for visual field deficit (Figs. 36-6 to 36-8). It is easiest
Trunk Rotation
and most effective to facilitate trunk rotation during
Trunk rotation, or dissociation of the upper and lower functional daily activities.
trunk, is another very effective way of regulating tone
and facilitating normal movement throughout the
upper and lower extremities. Patients with hemiplegia
Scapular Protraction
often move in a block-like pattern, with little separation Scapular protraction benefits patients who display a
of the shoulder girdle and pelvic girdle. To facilitate flexion synergy of the UE. High tone involving finger
normal movement the therapist should set up activities flexion, wrist flexion, or elbow flexion with either
to stimulate or facilitate trunk rotation, which activates supination or pronation of the forearm can be difficult
trunk musculature and aids in trunk stability. Without to inhibit. The therapist must remember the basic prin-
stabilization of the trunk the patient will be unable to ciple of treatment and work from proximal to distal;
use the upper extremities effectively. before trying to pry open clenched fingers the therapist
When facilitating trunk rotation in sitting or standing first brings the scapula forward into protraction and
the therapist should vary the height of the task. This ap- does not pull on the arm. Instead, the arm is gently
proach not only helps to incorporate the rotational cradled while the therapist's other hand is placed along
components of movement, but also mobilizes the the medial border of the scapula and the scapula is
shoulder girdle and pelvic girdle and improves weight brought forward. Once the scapula is forward, the posi-
 Neurodevelopmental Treatment: The Bobath Approach

FIG. 36-6
Trunk rotation, side to side,to a high surface. FIG. 36-7
Trunk rotation, side to side, to counter height.

tion should be maintained for a few seconds before the humerus, and encourages flexion synergy of the UE. If
arm is returned to the starting position. The therapist the pelvis is brought forward into a more neutral posi-
must remember never to force the arm into scapular tion, proper alignment ofthe pelvis, shoulder, and head
retraction. position in sitting can be attained.
In addition to facilitating the pelvis into a more
forward position, the therapist can bring the patient
Positioning Pelvis Forward forward to help inhibit extensor tone at the hip. The
The neutral position of the pelvis is the preferred sitting patient should be sitting with both feet flat on the floor.
position for patients with hemiplegia. Patients are often The therapist is on the weak side and helps guide the
seen in the posterior pelvic tilt position, and these pa- patient’s hands toward the shoes. The benefits of this
tients look as if they are sliding out of the wheelchair. position are that it (1) inhibits extension synergy ofthe
Sitting in this position encourages abnormal posture, lower extremity, (2) promotes weight bearing equally
resulting in increased hip extension (often associated through both lower extremities, (3) permits gravity as-
with extension synergy of the lower extremity) and sistance in bringing both scapulae into forward protrac-
rounding of the upper thoracic region (kyphosis), with tion, (4) facilitates thoracic and neck extension for pa-
resultant head and neck extension. This posture has an tients who fall forward in a sitting position, and (5)
adverse affect on swallowing (see Chapter 40), impedes helps to decrease the fear factor for patients fearful of
normal and proper alignment of the scapula and coming forward.
 OCCUPATIONAL THERAPY INTERVENTIONS
litation of Slow, Controlled
movement throughout the recovery process. Abnormal
vements
postures manifested in flexion or extension synergies of
Slow, controlled movements benefit patients with high the upper or lower extremities promote compensatory
tone. Patients who move too quickly should be slowed movement and should be avoided. Proper positioning
down. Whether they are doing home exercise programs, in bed is extremely important during the acute stage but
changing position (e.g., moving from side-lying to sitting is effective at any stage of recovery. In sitting, excessive
or coming from sit to stand), or trying to use the affected posterior pelvic tilt, lower extremity external rotation,
UE functionally, quick movements increase tone and asymmetry of the trunk and head, and scapular retrac-
tend to set off an associated reaction, resulting in a tion should be avoided. The patient should have the feet
flexion synergy of the UE. To be most effective in bring- flat on the floor, hips near 90° of flexion, knees and
ing muscle tone within a normal range, the therapist ankles at less than 90° of flexion, and trunk extended
must teach the patient to use slower and more controlled (thoracic flexion is discouraged). The head should be in
movements. Another basic treatment principle is that the midline and the arm fully supported when the patient is
therapist must act as the patient's biofeedback, that is, working at a table. In standing, the head should be in
give feedback appropriate to the patient's response. The midline, the trunk symmetrical, and weight equally dis-
patient is told that he or she has done something well ifit tributed on both lower extremities.*
is so; otherwise, the patient will not learn to distinguish
proper movements from compensatory movements. the Upper Extremity Into
Praneocr Positioning
Proper Pacitinninage
The involved UE can be incorporated into functional ac-
Proper position of the patient in the side-lying, supine, tivities in three ways: weight bearing through the in-
sitting, or standing position facilitates more normal volved UE (Fig. 36-9), bilateral activities, and guiding.

Proper position for weight bearing over hemiplegic side during

Trunk rotation, side to side, to a lower surface. functional activity.
 Neurodevelopmental Treatment: The Bobath Approach

FIG. 36-10 FIG. 36-11

Bilateral use of upper extremity during functional activity. Guiding upper extremity during functional activity.

Weight bearing was discussed previously. Bilatéral activ- benefit. During NDT the therapist must advise the
ities with hands clasped together (Fig. 36-10) are used patient specifically whether he or she is moving cor-
to do the following: rectly (normally) or incorrectly (abnormally, with com-
. Increase awareness of the hemiplegic side pensatory movements). If the patient is unable to move
. Increase sensory input to the hemiplegic side selectively when the therapist asks, the therapist should
. Bring the affected arm into the visual field take the patient through the normal pattern of move-
. Begin purposeful movement of the hemiplegic arm ment, either during isolated movement or during func-
OM
Re
WH . Discourage flexion synergy by protraction of the tional activities and tasks, so that the patient can experi-
scapula and extension of the elbow and wrist ence the movement.
ion. Develop abduction of fingers and thumb that dis-
courages spasticity of the hand
NEURODEVELOPMENTAL TREATMENT IN
7. Teach the patient reflex-inhibiting patterns that can
EVERYDAY LIVING
be performed without help
To guide the patient's hand (Fig. 36-11) through It may be difficult to bridge the gap between facilitation
normal patterns of movement during functional ac- of selective UE control and incorporation of these
tivities, the therapist can place his or her hand over movements and NDT principles into daily living skills.
the patient's hand and perform firm but not forceful The patient's inability to function independently is ex-
movements.° tremely complex, involving much more than just move-
Each therapeutic activity can be performed in the ment and motor control. Problems of perception, cog-
sitting or standing position, depending on the patient's nition, sensation, motor planning, and language can
level of function. At every possible opportunity the complicate the rehabilitation process, making it espe-
patient should be treated in a straight chair (or stand- cially difficult for the therapist to treat something as
ing), rather than the wheelchair, to obtain maximal specific and refined as motor control.
634 OCCUPATIONAL THERAPY INTERVENTIONS

Selecting a Therapeutic Activity tion. As the patient moves through the functional activ-
To incorporate the desired movement into functional ity, the therapist facilitates, inhibits, or guides as needed
activity, the therapist should think of a functional activ- to elicit normal movement patterns. The therapist does
ity that will require or elicit the movement. There are a not just modify the patient's movements, but modifies
great number of variations on normal movement. If a the activity to elicit better movements or modifies the
patient attempts the task with a movement sequence position of the patient to elicit more appropriate move-
different from the therapist's, it is important to deter- ments. The speed of movement is monitored; a good
mine if the sequence is abnormal or just a variation of pace is usually slightly slower than normal. Patients
normal. This task sounds simple, but it is critical to need time to process incoming information and motor
bridging the gap between movement and function. responses. The therapist increases the difficulty of the
The best learning experiences come from real life sit- activities as the patient improves, to stimulate both
uations that are practical, functional, and familiar.' problem-solving and motor skills.
Contrived (simulated) activities are exercises or tasks A number of factors influence the quality ofa patient's
that have little or no direct relation to real-life situa- movement within a functional context:
tions. Contrived activities weaken the carryover from 1. How the patient is positioned, and on which
movement to functional performance. Stacking cones, surface(s)
using parquetry cubes, and tossing beanbags are con- 2. The patient's base of support
trived activities that are often difficult for perceptually 3. The patient’s response when the base of support
disturbed patients to translate into functionally signifi- changes (e.g., are there any associated reactions?)
cant tasks. It is much easier for patients to attend to and 4. Where the activity is set up in relation to the patient
be motivated by activities that are purposeful and relate (to facilitate the desired movement and weight shift)
to real-life situations. When a patient relates to an activ- 5. Where weight shifts are initiated
ity, more normal movement patterns are displayed, as 6. Physical properties of the objects to be manipulated.
well as increased attention and endurance. As the patient moves within the context of function,
A primary goal of therapy is independence. A great the therapist gains additional information and insight
deal of treatment time is spent practicing skills that do into the patient's problem areas and observes where the
not relate to actual daily tasks or routines. Teaching specific difficulties are.
problem solving allows the patient to transfer and adapt During each treatment session the therapist should
those skills to any situation. In rehabilitation programs constantly be asking the following questions:
therapists must make sure they are teaching problem 1. Was the patient able to do the task?
solving, rather than splinter skills with little if any carry- 2. How did the patient do the task?
over. Part of the problem-solving process is anticipating 3. Which components of the task appeared to be
problems before they occur. Therapists are often guilty normal?
of planning an activity that is contrived or that fixes a 4. Which components were in abnormal movement
problem before the patient has an opportunity to solve patterns?
it. This approach does not encourage learning and does The activity is broken down into its components.
not promote carryover into functional daily life tasks. What is lacking? Movement? Stability? Weight shift?
When a functional activity is being selected, the fol- Sensation? Motor planning? Treatment priorities are re-
lowing questions should be asked: defined as new problem areas are identified.
1. Is the activity meaningful to the patient?
2. Does the patient see the purpose of the activity? NEURODEVELOPMENTAL TREATMENT IN
3. Does the activity require problem solving?
ACUTE CARE, REHABILITATION, OR
With the most effective activities the answer is “yes”
LONG-TERM CARE
to all questions.
NDT is more than muscle reeducation for a specific
limb; it is 24-hour management of the patient with
Initiating Treatment
hemiplegia. NDT principles should be incorporated
The therapist introduces the patient to the activity. If into the daily management of the patient, whether in
possible, the patient should take part in preparing for the hospital, in long-term care (skilled nursing facility),
the activity. For example, the patient can help get the or at home. The following tips help the patient to (1)
supplies from the cabinet. The additional cues from the become more aware of the hemiplegic side, (2) better
environment often help the patient understand what is integrate both sides of the body, and (3) increase
expected, especially for patients with aphasia. The ther- sensory stimulation to the hemiplegic side. By following
apist gets the patient in a good starting position: feet flat these tips, family members and all members of the
on the floor, good base of support, and good pelvic health care team can help prevent or minimize some
alignment with trunk, shoulder, neck, and head posi- problems that are characteristic of hemiplegia.
 Neurodevelopmental Treatment: The Bobath Approach 635

Room Arrangement
methods and be able to apply them appropriately. The
The hemiplegic side of the patient should face the Bobaths strongly emphasized that this approach is nota
source of stimulation. The patient's hemiplegic side series of exercises and that the upper and lower extremi-
should face the door and be positioned so that the tele- ties must not be treated independently.* The occupa-
phone, night stand, and television encourage the tional therapist must be constantly aware of the tonus,
patient to turn toward that side, thus increasing integra- motor patterns, positions, and reflex mechanisms of
tion of both sides of the body (Fig. 36-12). The one ex- both the upper and lower extremities.
ception is the call light for the nurse.*”°
Bed Positioning
Approach
The patient should be properly positioned (Figs. 36-13
Always approach the patient from the hemiplegic side to 36-15). The benefits of positioning patients in the
to encourage eye contact. Sometimes the patient has dif- proper manner are that (1) weight bearing normalizes
ficulty turning his or her head and may need assistance. tone and inhibits spasticity, (2) weight bearing increases
The therapist should simply assist the patient by gently awareness of the hemiplegic side and increases sensory
but firmly turning the patient's head until the patient is input, (3) weight bearing on the weak side helps the
able to establish eye contact. Family members can be patient to be less fearful, and (4) lengthening of the
encouraged to give tactile input to the patient by hemiplegic side inhibits spasticity.
holding the patient's hand or stroking the arm. The three basic positions are listed in order of their
therapeutic value: lying on the hemiplegic side, lying on
the nonhemiplegic side, and lying supine. Patients
Naming
should be repositioned as often as nursing procedures
During nursing tasks such as washing, each body part is require (usually every 2 hours) for the prevention of
named to increase the patient's awareness of the part. decubiti.

Encouraging Independence
The patient should begin to assist in simple ADL. If the
patient is unable to complete a task independently, the
therapist or caregiver can guide the patient's hands so
the patient can feel the movement pattern necessary to
complete an activity. This approach encourages the
patient to learn to carry out the task sooner.’
In each medical setting the roles of OT and physical
therapy may differ slightly. Yet the methods described
are imperative for proper patient treatment, and all
persons in professional services should be aware of the

FIG. 36-12
Room arranged so that patient must turn to affected side. Shaded FIG. 36-13
area represents affected side of body. Bed position when lying on affected side.
636 OCCUPATIONAL THERAPY INTERVENTIONS

Lying on the Hemiplegic Side not be allowed to drop off the pillow into flexion. The af-
This position is preferred for the hemiplegic patient fected lower extremity is in hip flexion and knee flexion
(Fig. 36-13). ~’ The patient's back should be parallel and fully supported on a pillow. The foot and ankle must
with the edge of the bed. The patient's head is placed on be supported to keep the foot from inverting.
the pillow symmetrically but not in extreme flexion. The
shoulder is fully protracted with at least 90° of shoulder Lying Supine
flexion (less than 90° encourages a flexion synergy). The The head should be symmetrical on the pillow (Fig. 36-
forearm is supinated, and the elbow is flexed. The 15). 7° The body and trunk are also symmetrical to
patient's hand is placed under the pillow. An alternative prevent the shortening of the hemiplegic side of the
position is with the elbow extended and the wrist either trunk. A pillow is placed under the affected shoulder,
supported on the bed or slightly off the bed, which en- supporting the shoulder so that it is no more than level
courages wrist extension. These positions are familiar to with the nonhemiplegic shoulder. If the affected shoul-
most patients and encourage external rotation at the der is higher, an anterior subluxation may occur at the
shoulder. The unaffected leg is placed on a pillow. The glenohumeral joint. The affected arm is fully supported,
affected leg is slightly flexed at the knee with hip exten- with the elbow extended and forearm in supination and
sion. A pillow can be placed behind the patient to entirely supported in elevation on a pillow. A small
prevent the patient from rolling onto the back. pillow may be placed under the hip to reduce retraction
of the pelvis. The therapist should not place a pillow
Lying on the Nonhemiplegic Side under the knees or a foot board at the end of the bed
In this position the back should be parallel with the edge because the former encourages knee flexion contrac-
of the bed (Fig. 36-14).*° The head is placed symmetri- tures and the latter encourages an extension synergy of
cally on the pillow. The shoulder is in full protraction, the lower extremity.
with the shoulder in at least 90° of flexion. The arm and
hand are fully supported on a pillow. The wrist should

\
‘

FIG. 36-14 FIG. 36-15

Bed position when lying on unaffected side. Bed position when lying supine.
 Neurodevelopmental Treatment: The Bobath Approach 637

Dressing Activities
Tips
Dressing and grooming activities are a part of every OT The patient should not attempt to get dressed in bed.
program. These activities are purposeful, functional, fa- Instead the patient should be seated on a chair, prefer-
miliar to the patient, and necessary for improving the ably a straight chair next to the bed. The therapist
patient's level of independence. Relearning how to dress should always assist from the affected side and should
may be one of the most frustrating activities requested always begin dressing with the hemiplegic side. The
of the patient. Dressing requires not only trunk stability same sequence in dressing is maintained to increase
in sitting, but also the ability to perform motor plan- learning. Following are specific instructions for the
ning, sequencing, and problem solving. Dressing is patient to follow when dressing.
one of the most difficult tasks required by the occupa-
tional therapist, yet it is nearly always the first one DONNING SHIRT
introduced.' 1. Position the shirt across the knees with the armhole
With the difficulty of dressing in mind, the therapist visible and the sleeve between the knees (Fig. 36-16).
should grade a dressing-training activity to the sitting 2. Bend forward at the hips (inhibiting extension
balance, endurance, frustration level, and cognitive-per- synergy of the LE), placing the affected hand in the
ceptual status of the patient. As the patient learns to sleeve (Fig. 36-17).
bear weight over both hips in sitting and to shift weight 3. Drop the arm into the sleeve; shoulder protraction
to either side (or forward) as necessary, he or she moves and gravity inhibit UE flexion synergy.
more normally and with less compensation. The patient 4. Bring the collar to the neck.
learns to inhibit his or her own spasticity. The procedure On . Sit upright; dress the nonhemiplegic side.

breaks up typical hemiplegic patterns of LE extension 6. Button the shirt from bottom to top.
synergy and UE flexion synergy. With the NDT ap-
proach, dressing is learned faster than by traditional, DONNING UNDERCLOTHES AND PANTS
one-handed methods, especially for patients with per- (FIG. 36-18)
ceptual problems. The patient learns to carry over tech- 1. Clasp hands and cross the affected leg over the non-
niques of inhibition into daily living skills. The follow- hemiplegic leg (the therapist helps when needed).
ing methods are examples of how the principles of NDT 2. Release hands. The hemiplegic arm can dangle and
can be used in ADL training. The facilitation of each should not be trapped in the lap. When able, use the
task should be modified to fit each patient's abilities affected hand as needed.
and problem areas. 3. Pull the pant leg over the hemiplegic foot.
4. Clasp hands to uncross the leg.
5. Place the nonhemiplegic foot in the pant leg (no
need to cross legs). This step is difficult because the
patient must bear weight on the hemiplegic side.
6. Pull pants to the knees.
7. While holding onto the waistband, stand with the
therapist's help.

FIG. 36-16 FIG. 36-17

Dressing training. Shirt positioned across patient’s knees, armhole Patient bends forward at hips (inhibiting extension synergy of
visible, and sleeve dropped between knees. lower extremity) and places affected hand into sleeve.
638 OCCUPATIONAL THERAPY INTERVENTIONS

FIG. 36-18
Proper position while putting on pants and underclothes.
FIG. 36-20
Composite drawing of shoulder girdle. (From Cailliet R: The shoul-
der in hemiplegia, Philadelphia, 1980, FA Davis.)

can hinder the entire rehabilitation program. The re-

sponsibility of the therapist is to learn how to evaluate
these problems and prepare a treatment program that is
effective in dealing with them. An understanding of the
basic anatomy and functional mechanism of the shoul-
der girdle is important. Those interested in expanding
their knowledge in this area are directed to the refer-
ences, particularly The Shoulder in Hemiplegia by Rene
Cailliet.* The shoulder girdle is made up of seven joints
(Fig. 36-20): glenohumeral, suprahumeral, acromio-
clavicular, scapulocostal, sternoclavicular, costosternal,
and costovertebral.
For full pain-free range of motion (ROM), all seven
joints need to work synchronously. The glenohumeral
joint allows considerable mobility but lacks stability. It
is dependent on the proper alignment of the scapula
FIG. 36-19 and humerus for mechanical support and on the
Proper position while putting on shoes and socks. supraspinatus for muscular support.
The therapist must understand the relationship of
the scapula to the humerus and the significance of that
8. Zip and snap the pants. relationship in pain-free shoulder flexion and abduc-
9. Return to sitting position with the therapist's help. tion. When the arm is raised in forward flexion or ab-
duction, the scapula must glide and rotate upward. The
DONNING SHOES AND SOCKS (FIG. 36-19) humerus and the scapula work in unison; more specifi-
1. Clasp hands and cross legs (as before). cally, they work in a 2:1 ratio pattern. In other words, if
2. Put sock and shoe on hemiplegic foot. the shoulder moves into 90° of abduction, the humerus
3. Cross the nonhemiplegic leg and put on sock and moves 60° and the scapula moves 30°. As another
shoe. example, when there is 180° of shoulder flexion, the
humerus moves 120° and the scapula moves 60°
(again, a 2:1 ratio).*
SHOULDER IN HEMIPLEGIA
If for any reason,the arm is raised in shoulder flexion
Problems of the hemiplegic shoulder are often frustrat- or abduction without the scapula’s gliding along, joint
ing and confusing to the occupational therapist. Pain trauma and pain can occur. The therapist must be aware
 Neurodevelopmental Treatment: The Bobath Approach 639

of this effect and take it into consideration during ROM, strated over the past several years that “the commonly
ADL, transfers, and all other activities. used hemiplegic sling has no appreciable effect on ulti-
In the hemiplegic shoulder the scapula can fall into mate ROM, subluxation, pain, or peripheral nerve trac-
downward rotation because of a heavy, flaccid UE or tion injury.”” It has also been stated that “there is no
because the muscles that move the scapula in downward need to support a pain free shoulder in order to prevent
rotation (rhomboids, latissimus dorsi, and levator or correct subluxation since the sling does not prevent,
scapulae) are spastic. This condition makes it difficult for improve, cure or reduce such a deformity. 8 The use of a
the scapula to glide upward, which is necessary for pain- sling on the hemiplegic arm can actually contribute to
free movement. The scapula must first be mobilized and subluxation and lead to a painful, disabling condition
the spasticity reduced to regain the ROM and allow selec- called shoulder-hand syndrome. The therapist should
tive movement. The arm must never be raised over 90° realize that when a patient wears a sling, the arm is sup-
before the scapula has been mobilized and the therapist ported in a position that is compatible with the typical
can feel its gliding movements. Even in a seemingly hemiplegic posture, which discourages the patient from
flaccid arm the scapula can be influenced by spasticity of using the arm either bilaterally or unilaterally. Even the
the rhomboids, trapezius, and latissimus dorsi. The tech- sling that was previously described by the Bobaths is no
niques previously described assist the therapist. longer being used.” This sling was found to hinder the
Because the hemiplegic shoulder can often be pulled circulation of the arm and to push the head of the
back into retraction by hypertonicity, the emphasis of humerus into lateral subluxation. If the patient has a
treatment is placed on forward gliding of the scapula. By painful shoulder or swollen hand, a thorough assess-
protracting the scapula, the patient is able to reduce the ment should be done to determine the cause. Then ap-
hypertonicity of the UE, allowing more isolated move- propriate treatment can be started.
ment and selective control. When the spasticity is too
strong for the patient to obtain protraction of the shoul-
PREPARING THE PATIENT FOR HOME
der, the therapist must assist. The therapist should use
reflex-inhibiting patterns to control and reduce spasticity. The benefits of the treatment program are lost if the
As Bobath stated, “The main reflex-inhibiting pattern patient is not adequately prepared for returning home.
counteracting spasticity in the trunk and arm is the exten- This preparation should include (1) prescribing a home
sion of neck and spine and external rotation of the arm at exercise program, (2) providing family education, and
the shoulder with elbow extended. Further reduction of (3) communicating with the follow-up therapist when
flexor spasticity can be obtained by adding extension of applicable. The hospital or clinic is a very secure setting,
the wrist with supination and abduction of the thumb.”” and both the patient and family must feel comfortable
and confident on the return home. The home exercise
program is important for maintaining mobility and
Subluxation
movement. The therapist should select exercises that
Many health care professionals are particularly con- can be performed easily and correctly without assis-
cerned about the subluxed shoulder. Numerous efforts tance. If stress or excessive effort is used to complete the
are made to protect the shoulder and prevent subluxa- exercises, the patient is likely to form bad habits and
tion, but subluxation cannot be prevented. If the spasticity will increase.
muscles around the shoulder girdle (which are attached After selecting exercises the therapist must train the
to the humerus and scapula) are weak enough, the patient in each exercise. To encourage consistency the
shoulder will be subluxed. Slings do not help subluxa- patient should follow the same sequence of exercises
tion. They keep the arm in a poor position and may each day. This program should begin long before dis-
contribute to pain and swelling. Subluxation itself does charge from OT so that it is a well-established part of the
not cause pain; the pain is caused by improper handling daily routine.
of a subluxed arm. Forcing the head of the humerus A description of the exercises should be written down
back into place before moving the arm above 90° of in proper sequence. The description should include
shoulder flexion or abduction can cause trauma and how often the exercises should be done (e.g., twice a
pain. Performing standard ROM procedures on an arm day) and the number of repetitions (e.g., 10 times each).
without a gliding scapula can also cause pain. Treat- Diagrams should be used if necessary. Some family
ment of the subluxed arm should include proper sitting, members have found videotape to be especially helpful
weight bearing, mobilization of the scapula, and proper in following through with a home program. During a
positioning in bed (Figs. 36-13 to 36-15). treatment session the therapist can videotape the home
program (exercises, bed positioning, or other tasks im-
portant to continue at home); the family then has a
Slings copy to use at home.
The application of a sling to the hemiplegic arm is a Next, the family should be trained so that they are also
source of considerable controversy. It has been demon- well acquainted with each exercise and thus can guide
640 OCCUPATIONAL THERAPY INTERVENTIONS

the home program properly. For best results in family 11. List and describe at least three treatment methods
teaching, the occupational therapist should demonstrate designed to normalize tone and promote normal
and explain the importance of tasks, emphasize each movement.
major point (e.g., position of arm and placement of 12. What are the purposes of trunk rotation? Bilateral
hands), have the family work with the patient under the activities?
therapist's guidance, and repeat instructions as often as 13. Describe recommended positioning and mobiliza-
needed until the family and patient are confident tion procedures to prevent shoulder pain and severe
enough to do the exercises at home alone. spasticity around the shoulder and shoulder girdle.
Family education should include a home exercise 14. How can the affected upper extremity be incorpo-
program and ADL training in the areas of dressing, rated into activity? What effects will this approach
eating, grooming, hygiene, bathing, transfers, and have?
cooking. This program should also include instruction 15. Why is it important to use functional activities from
in proper position (lying, sitting, and standing) and the real life in the treatment program?
proper use of equipment. Before discharge from the 16. List at least four factors that will influence the
treatment center the therapist should give the family his quality of the patient's movement when performing
or her name and telephone number at work, set up a functional activities.
date for a reevaluation if necessary, and contact the ther- 17. How should the therapist evaluate the effectiveness
apist treating the patient after discharge from the treat- of the treatment session?
ment facility to ensure proper carryover. 18. Describe and assume the recommended positions
for the patient with hemiplegia in the supine, prone,
and side-lying positions on the affected and unaf-
SUMMARY
fected sides. What is the rationale for these postures?
Neurodevelopmental treatment, developed by Karel 19. When using the NDT approach, what is the recom-
and Berta Bobath, is used successfully in the treatment mended method for donning a shirt? Put on your
of adult hemiplegia. This treatment emphasizes relearn- own shirt using this method, and then teach it to
ing normal movement and avoiding abnormal move- another person.
ment patterns. Quality of movement, control, and coor- 20. Why is scapula protraction stressed in positioning
dination are emphasized through the use of treatment and movement of the hemiplegic arm?
methods to normalize abnormal muscle tone and the 21. What are some possible causes of shoulder subluxa-
avoidance of abnormal patterns of movement. tion in hemiplegia?
22. What is the recommended treatment for shoulder
subluxation in the NDT approach?
REVIEW QUESTIONS
23. Why is the common hemiplegic sling contraindi-
. What is the primary goal of the NDT approach? cated?
Re
NO . List three advantages of the NDT approach stated in 24. What is the role of the occupational therapist in
the text. preparing the patient to go home?
3. Describe and assume the typical posture of the
adult patient with hemiplegia. REFERENCES
4. List the key points of control used to normalize 1. Affolter F: Perceptual processes as requisites for complex human behav-
tone ior, Bern, Switzerland, 1980, Hans Huber.
5. What is the key element of an NDT assessment? 2. Bobath B: Adult hemiplegia: evaluation and treatment, London,
1978, Heinemann.
6. List four factors that can cause or increase spasticity.
3. Cailliet R: The shoulder in hemiplegia, Philadelphia, 1980, FA Davis.
7. Describe the observation process using the NDT ap- Ps . Cash J: Neurology for physiotherapists, London, 1977, Faber & Faber.
proach in evaluating a patient. 5. Davies P: Treatment techniques for adult hemiplegia: study coutse,
8. Why is skilled observation critical to treatment ef- Valens, Switzerland, 1979, Klinik Valens.
fectiveness? 6. Davies P: Steps to follow, Berlin, 1985, Springer-Verlag.
9. Describe the elements of the vicious circle that may 7. Eggers O: Occupational therapy in the treatment of adult hemiplegia,
Rockville, Md, 1984, Aspen Systems. ;
contribute to the maintenance of spasticity. 8. Friedland F: Physical therapy. In Licht S, editor: Stroke and its reha-
10. What are some of the possible causes of asymmetri- bilitation, Baltimore, 1975, Williams & Wilkins.
cal shoulder height observed in the patient with 9. Hurd MM, Farrell KH, Waylonis FW: Shoulder sling for hemiple-
hemiplegia? gia: friend or foe? Arch Phys Med Rehabil 55:519, 1974.
 . Cerebrovascular Accident
GLEN GILLEN

AINIFRED SCHULTZ-KROHN
 an BS) PasiS ; oy)5 iS)D
RAL CONSIDERATIONS OF
EXTREMITY AMPUTATIONS

—UPP 3R EXTREMITY AMPUTATIONS

‘POWERED PROSTHESES

> POWERED PROSTHESES

 Gavee
ra catlein eaters
37
LEARNING OBJECTIVES
Ischemia After studying this chapter the student or practitioner
Transient ischemic attack will be able to do the following:
Dysarthria ile List and describe evaluation procedures for
- Client-centered assessment survivors of a stroke.
Top-down approach to assessment va Discuss the neuropathology of a stroke.
Postural control *. Identify risk factors associated with a stroke.
Balance strategies . Identify multiple factors that impede task
Aphasia performance after a stroke.
Neurobehavioral deficits . Describe evaluation procedures for
Motor control neurobehavioral deficits.
Weight bearing . Identify balance strategies that support functional
- Subluxation performance.
. Describe motor control dysfunction associated
with stroke.
. Identify standardized stroke assessments for
multiple areas of dysfunction.
. Apply a client-centered approach to stroke
rehabilitation.
10. Develop comprehensive function-based treatment
plans to remediate or compensate for underlying
deficits.

- . accident (CVA), or stroke, contin- . Onaverage, a United States citizen suffers a stroke every
ues to be a national health problem despite recent ad- 53 seconds; every 3.3 minutes someone dies ofastroke.
vances in medical technology. The American Heart Asso- . Each year, 600,000 people suffer a new or recurrent
ciation’ publishes stroke statistics that demonstrate the stroke. Approximately 500,000 strokes are first attacks,
severity of this problem. Selected statistics include the and 100,000 are recurrent.
following’: . About 4,400,000 stroke survivors are alive today.
1. Stroke ranks as the third leading cause of death . The percentage of strokes that result in death within
| behind heart disease and cancer. 1 year is about 29%, less if the stroke occurs before
age 65.
a
.
: a a a
7 The author would like to acknowledge the contribution of Michael
Lawrence to this chapter.

or)

—
644 TREATMENT APPLICATIONS

CAUSES OF CEREBROVASCULAR
6. Twenty-eight percent of people who suffer a stroke are
ACCIDENT
under age 65. For people over 55, the incidence of
stroke more than doubles for each successive decade. “Stroke is essentially a disease of the cerebral vascula-
7. The incidence of stroke is about 19% higher for ture in which failure to supply oxygen to the brain cells,
males than for females. which are the most susceptible to ischemic damage,
In addition, the aftermath of stroke is a substantial leads to their death. The syndromes that lead to stroke
public health and economic problem. For example: comprise two broad categories: ischemic and hemor-
1. Stroke is a leading cause of serious, long-term dis- thagic stroke. Ischemic strokes account for approxi-
ability in the United States. mately 80% of strokes, whereas hemorrhagic strokes
2. Stroke accounts for more than half of all patients account for the remaining 20%.””
hospitalized for acute neurological disease.
3. The average cost of a stroke from hospital admission
Ischemia =
to discharge is $18,244. In a survey year, $3.7 billion
was paid to Medicare beneficiaries who survived a Ischemic strokes may be the result of embolisms to the
stroke. brain from cardiac or arterial sources. Cardiac sources
4. Among long-term stroke survivors, 48% have hemi- include atrial fibrillation (pooling of blood in the dys-
paresis, 22% cannot walk, 24% to 53% report com- functional atrium leads to emboli production), sino-
plete or partial dependence on activities of daily atrial disorders, acute myocardial infarction, endocardi-
living (ADL) scales, 12% to 18% are aphasic, and tis, cardiac tumors, and valvular (both native and
32% are clinically depressed. artificial) disorders. Cerebral ischemia caused by perfu-
Obviously, stroke rehabilitation as a practice area for sion failure occurs with severe stenosis of the carotid
occupational therapists is a specialization that crosses and basilar arteries, as well as when there is microsteno-
multiple settings, from the intensive care unit to sis of the small deep arteries.*”
community-based programs. The Agency for Health Age, gender, race, ethnicity, and heredity are consid-
Care Policy and Research has critically reviewed the ered nonmodifiable risk factors for ischemic strokes. In
practice area of stroke rehabilitation.°’ The agency has contrast, a major focus of stroke prevention and educa-
published guidelines to “improve the effectiveness of tion programs is on the potentially modifiable risk
stroke rehabilitation in helping the person with disabil- factors discussed in the following list***:
ities from a stroke to achieve the best possible func- 1. Hypertension is considered the single most important
tional outcome and quality oflife.”°° modifiable risk factor for ischemic stroke. Forty
percent of strokes have been attributed to systolic
blood pressures greater than 140 mm Hg.°”
DEFINITION OF CEREBROVASCULAR
2. Management of cardiac diseases, particularly atrial fib-
ACCIDENT rillation (a-fib), mitral stenosis, and structural ab-
CVA is a complex dysfunction caused by a lesion in normalities (patent foramen ovale and atrial septal
the brain. The World Health Organization®® defines aneurysm), can reduce the risk of stroke.
stroke as an “acute neurologic dysfunction of vascular 3. Management of diabetes and glucose metabolism can
origin. . . with symptoms and signs corresponding to also reduce the risk of stroke.
the involvement of focal areas of the brain.” CVA results 4. Cigarette smoking increases the relative risk of
in upper motor neuron dysfunction that produces hemi- ischemic stroke nearly two times.
plegia or paralysis of one side of the body, including limbs 5. Although excessive use of alcohol is a risk factor for
and trunk and sometimes the face and oral structures that many other diseases, moderate consumption of alcohol
are contralateral to the brain hemisphere that has the may reduce incidence of cardiovascular disease, in-
lesion. Thus a lesion in the left cerebral hemisphere (left cluding stroke.
CVA) produces right hemiplegia. Conversely, a lesion in 6. Use of illegal drugs, particularly cocaine, is commonly
the right cerebral hemisphere (right CVA) produces a left associated with stroke. Other drugs linked to
hemipleia. When reference is made to the patient's dis- stroke include heroin, amphetamines, LSD, PCP, and
ability as right or left hemiplegia, the reference is to the marijuana.
paralyzed body side and not to the locus of the lesion.”” 7. Lifestyle factors such as obesity, physical inactivity,
Accompanying the motor paralysis may be a variety diet, and emotional stress are associated with stroke
of dysfunctions other than the motor paralysis. Some risk.
of these are sensory disturbances, perceptual dysfunc- “The realization that the probability of stroke is in-
tion, visual disturbances, personality and intellectual creased several fold by the presence of multiple risk
changes, and a complex range of speech and associated factors may help the patient . . . fully appreciate the
language disorders.’°*° The neurological deficits persist need for serious risk factor management.”* The respon-
longer than 24 hours. sibility for stroke prevention education (including the
 Cerebrovascular Accident

prevention of recurrence) falls on each member of the tify neurological deficits that affect function. The infor-
stroke rehabilitation team. mation may also help the therapist develop hypotheses
regarding recovery and plan appropriate treatment.
Initial information may be collected during a medical
Hemorrhage
record review that focuses on the chief complaint of the
Hemorrhagic strokes include subarachnoid and intra- patient on admission, previous medical and surgical
cerebral hemorrhage, which accounts for only 15% to history, results of diagnostics, and current pharmacolog-
25% of total strokes.* This type of stroke has numerous ical management. The following section and Tables 37-1
causes. The four most common causes are deep hyper- and 37-2 explain patterns of impairment resulting from
tensive intracerebral hemorrhages, ruptured saccular CVA in both cortical and noncortical areas.
aneurysms, bleeding from arteriovenous malforma-
tions, aa spontaneous lobar hemorrhages.”
Pericallosal
artery
Related Syndromes Callosomarginal Fornix
artery
Cerebral anoxia and aneurysm can also result in hemi-
plegia.’” Some of the treatment approaches outlined in
this chapter may be applicable to hemiplegia that results
from causes other than CVA or stroke, such as head in- Corpus
juries, neoplasms, and infectious diseases of the brain. callosum

Transient Ischemic Attacks

Vascular disease of the brain can result in a completed
CVA or cause transient ischemic attacks (TIAs). A TIA Septum
pellucidum
occurs as mild, isolated, or repetitive neurological symp-
toms that develop suddenly, last from a few minutes to Anterior Posterior
several hours but not longer than 24 hours, and clear cerebral Optic cerebral
completely. The TIA is seen as a sign of impending CVA. A artery nerve artery
Most TIAs occur in people with atherosclerotic disease.
Of those who experience TIAs and do not seek treatment,
an estimated one third will sustain a completed stroke, The Cerebral Hemispheres
another third will continue to have additional TIAs
without stroke, and one third will experience ho further Branches of Central
incidence.°’ If the TIA is caused by extracranial vascular anterior cerebral artery SUICUS

disease, surgical intervention to restore vascular flow

(carotid endarterectomy) may be effective in preventing
the CVA and the resultant disability.’”°

EFFECTS OF CEREBROVASCULAR
ACCIDENT
The outcome of the CVA depends on which artery sup-
plying the brain was involved (Fig. 37-1). Dysfunction
of performance components and performance areas
depends on various pathological conditions resulting in
CVA and the different anatomical structures involved.
Stroke diagnostic workups help localize the lesion and
find a cause of the stroke. Techniques include such cere- deat Branches of
brovascular imaging techniques as computerized tomog- ipher ra Ane posterior cerebral artery
artery
raphy (CT scanning), magnetic resonance imaging
(MRI), and more recently, positron emission tomogra- FIG. 37-1
phy (PET) and single photon emission computerized to- Blood supply to brain. Middle cerebral, anterior cerebral, and pos-
mography (SPECT). The information collected using terior cerebral arteries supply blood to cerebral hemispheres. A,
these techniques (e.g., the extent of damage and location Medial surface. B, Lateral surface. (From Nolte J: The human brain,
of the lesion) may help the occupational therapist iden- ed 3, St Louis, 1993, Mosby.)
 Cortical Involvement and Patterns of Impairment
Location Possible Impairments
Middle cerebral artery: Lateral aspect of frontal and Dysfunction of Either Hemisphere
upper trunk parietal lobe Contralateral hemiplegia, especially of the face and the upper
extremity
Contralateral hemisensory loss
Visual field impairment
Poor contralateral conjugate gaze
Ideational apraxia
Lack of judgment
Perseveration
Field dependency
Impaired organization of behavior
Depression
Lability
Apathy

Right Hemisphere Dysfunction

Left unilateral body neglect
Left unilateral visual neglect
Anosognosia
Visuospatial impairment
Left unilateral motor apraxia

Left Hemisphere Dysfunction

Bilateral motor apraxia
Broca's aphasia
Frustration

Middle cerebral artery: Lateral aspect of right temporal Dysfunction of Either Hemisphere
lower trunk and occipital lobes Contralateral visual field deficit
Behavioral abnormalities

Right Hemisphere Dysfunction

Visuospatial dysfunction

Left Hemisphere Dysfunction

Wernicke's aphasia

Middle cerebral artery: both Lateral aspect of the involved Impairments related to both upper and lower trunk
upper and lower trunks hemisphere dysfunction as listed in previous two sections

Anterior cerebral artery Medial and superior aspects of Contralateral hemiparesis, greatest in foot
frontal and parietal lobes Contralateral hemisensory loss, greatest in foot
Left unilateral apraxia
Inertia of speech or mutism
Behavioral disturbances

Internal carotid artery Combination of middle cerebral Impairments related to dysfunction of middle and anterior
artery distribution and anterior cerebral arteries as listed above
cerebral artery

Anterior choroidal artery, Globus pallidus, lateral geniculate Hemiparesis of face, arm, and leg
a branch of internal carotid body, posterior limb of the internal Hemisensory loss
artery capsule, medial temporal lobe Hemianopsia

Posterior cerebral artery Medial and inferior aspects of Dysfunction of Either Side
right temporal and occipital lobes, Homonymous hemianopsia
posterior corpus callosum and Visual agnosia (visual object agnosia, prosopagnosia, color
penetrating arteries to midbrain agnosia)
and thalamus Memory impairment
Occasional contralateral numbness

646
 Cerebral Artery Dysfunction: Cortical Involvement and Patterns of Impairment—cont’d
Location Possible Impairments
Right Side Dysfunction
~ Cortical blindness
Visuospatial impairment
Impaired left-right discrimination

Left Side Dysfunction

Finger agnosia
Anomia
Agraphia
Acalculia
Alexia
Pons Quadriparesis
Bilateral asymmetrical weakness
Bulbar or pseudobulbar paralysis (bilateral paralysis of face,
palate, pharynx, neck, or tongue)
pa Paralysis of eye abductors
[ees Nystagmus
et Ptosis
Cranial nerve abnormalities
Diplopia
Dizziness
Occipital headache
Coma

Basilar artery distal Midbrain, thalamus, and caudate Papillary abnormalities

: Abnormal eye movements
Altered level of alertness
Coma
; Memory loss
Agitation
Hallucinations

Vertebral artery Lateral medulla and cerebellum Dizziness

Vomiting
Nystagmus
Pain in ipsilateral eye and face
Numbness in face
Clumsiness of ipsilateral limbs
Hypotonia of ipsilateral limbs
Tachycardia
Gait ataxia

Systemic hypoperfusion Watershed region on lateral side Coma

of hemisphere, hippocampus and Dizziness
surrounding structures in medial Confusion
temporal lobe Decreased concentration
Agitation
Memory impairment
Visual abnormalities as a result of disconnection from frontal
: eye fields
Simultanognosia
Impaired eye movements
Weakness of shoulder and arm
Gait ataxia

From Arnadottir G: Impact of neurobehavioral deficits of activities of daily living, In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-based approach, St
Louis, 1998, Mosby.

647
 TREATMENT APPLICATIONS

rtical Areas: Patterns of Impairment

Location Possible Impairments Location Possible Impairments
Anterolateral thalamus, Minor contralateral motor Caudate Dysarthria
either side abnormalities Apathy
Long latency period Restlessness
Slowness Agitation
Confusion
Right side Delirium
Visual neglect Lack of initiative
Poor memory
Left side Contralateral hemiparesis
Aphasia Ipsilateral conjugation deviation of
the eyes
Lateral thalamus Contralateral hemisensory symptoms
Putamen Contralateral hemiparesis
Contralateral limb ataxia
Contralateral hemisensory loss
Bilateral thalamus Memory impairment
Decreased consciousness
Behavioral abnormalities
Ipsilateral conjugate gaze
Hypersomnolence
Motor impersistence
Posterior thalamus Numbness or decreased
sensibility of face and arm
Right Side
Choreic movements
Visuospatial impairment
Impaired eye movements
Hypersomnolence
Left Side
Decreased consciousness
Aphasia
Decreased alertness
Pons Quadriplegia
Right Side Coma
Visual neglect Impaired eye movement
Anosognosia
Cerebellum Ipsilateral limb ataxia
Visuospatial abnormalities
Gait ataxia
Vomiting
Left Side
Impaired eye movements
Aphasia
Jargon aphasia
Good comprehension
of speech
Paraphasia
Anomia
From Arnadottir G: Impact of neurobehavioral deficits of activities of daily living. In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-based approach, St
Louis, 1998, Mosby. :

Internal Carotid Artery

hemiplegia, making ambulation and two-dimensional
In the absence of adequate collateral circulation, occlu- constructional tasks difficult.’°
sion of the internal carotid artery results in contralateral
hemiplegia, hemianesthesia, and homonymous hemi-
anopsia.*” Additionally, involvement of the dominant
Middle Cerebral Artery
hemisphere is associated with aphasia, agraphia or dys- Involvement of the middle cerebral artery (MCA) is
graphia, acalculia or dyscalculia, right-left confusion, the most common cause of CVA.*”?° Ischemia in the
and finger agnosia. Involvement of the nondominant area supplied by the MCA results in contralateral
hemisphere is associated with visual perceptual dysfunc- hemiplegia with greater involvement of the arm, face,
tion, unilateral neglect, anosognosia, constructional or and tongue; sensory deficits; contralateral homony-
dressing apraxia, attention deficits, and loss of topo- mous hemianopsia; and aphasia if the lesion is in the
graphic memory. A tendency to tilt space in a counter- dominant hemisphere. There is a pronounced devia-
clockwise direction is seen in some persons with left tion of the head and neck toward the side on which
 Cerebrovascular Accident 649

the lesion is located.2°*”’’®’° Perceptual deficits such MEDICAL MANAGEMENT

as anosognosia, unilateral neglect, impaired vertical Specific treatment of CVA depends on the type and loca-
perception, visual spatial deficits, and persevera- tion of the vascular lesion, the severity of the clinical
tion are seen if the lesion is in the nondominant deficit, concomitant medical and neurological prob-
hemisphere.® lems, availability of technology and personnel to ad-
minister special types of treatment, and the cooperation
and reliability of the patient.
Anterior Cerebral Artery
Early medical treatment involves maintenance of an
Occlusion of the anterior cerebral artery (ACA) pro- open airway, hydration with intravenous fluids, and
duces contralateral lower extremity weakness that is treatment of hypertension. Appropriate steps should be
more severe than that of the arm. Apraxia, mental taken to evaluate and treat coexisting cardiac or other
changes, primitive reflexes, and bowel and bladder in- systemic diseases. Measures should be taken to prevent
continence may be present. Total occlusion of the ACA the development of deep venous thrombosis (DVT).
results in contralateral hemiplegia with severe weakness DVT is the formation of emboli (blood clots) in the deep
of the face, tongue, and proximal arm muscles and veins of the lower extremities, acommon risk for patients
marked spastic paralysis of the distal lower extremity. who have prolonged periods of bed rest and immobility.
Cortical sensory loss is present in the lower extremity. The incidence of DVT in stroke ranges from 22% to 73%.
Intellectual changes such as confusion, disorientation, Emboli that are released from deep veins and subse-
abulia, whispering, slowness, distractibility, limited quently lodge in the lungs are referred to as pulmonary
verbal output, perseveration, and amnesia may be emboli. A pulmonary embolus is the most common
seen.*’”””° cause of death in the first 30 days after the CVA.”’'®
The physician oversees routine surveillance for
thrombosis that includes daily evaluation of leg temper-
Posterior Cerebral Artery
ature, color, circumference, tenderness, and appearance.
The scope of posterior cerebral artery (PCA) symptoms Preventive treatments for DVT may involve medication,
is potentially broad and varied because this artery sup- the use of elastic stockings, the use of reciprocal com-
plies the upper brainstem region, as well as the tempo- pression devices, and early mobilization of the patient.
ral and occipital lobes. Possible results of PCA involve- Respiratory problems and pneumonia may compli-
ment depend on the arterial branches involved and cate the early poststroke course. The National Survey of
the extent and area of cerebral compromise. Some Stroke reported that one third of stroke patients studied
possible outcomes are sensory and motor deficits, in- had respiratory infections.°°
voluntary movement disorders (e.g., hemiballism, pos- Symptoms are a low-grade fever and increased
tural tremor, hemichorea, hemiataxia, and intention lethargy. Medical management involves the administra-
tremor), memory loss, alexia, astereognosis, -dysesthe- tion of fluids and antibiotics, aggressive pulmonary
sia, akinesthesia, contralateral homonymous hemi- hygiene, and mobilization of the patient. Ventilatory in-
anopsia or quadrantanopsia, anomia, topographic dis- sufficiency is a major factor contributing to the high fre-
orientation, and visual agnosia.*”*”’’° quency of pneumonia. The hemiparesis of stroke in-
volves the muscles of respiration. Exercise programs that
involve strengthening and endurance training of both
Cerebellar Artery System inspiratory and expiratory muscles help improve
Cerebellar artery occlusion results in ipsilateral ataxia, breathing and cough effectiveness and reduce the fre-
contralateral loss of pain and temperature sensitivity, ip- quency of pneumonia.'®
silateral facial analgesia, dysphagia and dysarthria Cardiac disease is another frequently occurring con-
caused by weakness of the ipsilateral muscles of the dition that complicates the poststroke course. The
palate, nystagmus, and contralateral hemiparesis.*””’*°*” stroke itself may cause the cardiac abnormality, or the
patient may have had a preexisting cardiac condition.
The former is treated like any new cardiac diagnosis. A
Vertebrobasilar Artery System preexisting cardiac condition is reevaluated and the
A CVA in the vertebrobasilar artery system affects brain- treatment regime modified as appropriate. Monitoring
stem functions. The outcome of the stroke is some com- of heart rate, blood pressure, and an electrocardiogram
bination of bilateral or crossed sensory and motor ab- (ECG) during self-care evaluations is frequently indi-
normalities, such as cerebellar dysfunction, loss of cated to determine cardiac response to activity.°~”°*
proprioception, hemiplegia, quadriplegia, and sensory During the acute phase bowel and bladder dysfunc-
disturbances, with unilateral or bilateral cranial nerve tion iscommon. The physician is responsible for ordering
involvement of nerves III to XII.’° a specific bowel program that includes a time schedule,
650 TREATMENT APPLICATIONS

adequate fluid intake, stool softeners, suppositories, oral treatment plan may be established. The Canadian Occu-
laxatives, and medications or procedures to treat fecal im- pational Performance Measure”> is a standardized tool
paction. A timed or scheduled toilet program is essential that uses a client-centered approach to allow the recipi-
in treating urinary incontinence. Catheterization may be ent of treatment to identify performance areas of diffi-
necessary in stroke rehabilitation. culty, rate the importance of each area, and rate his or
her satisfaction with current performance.
EVALUATION PROCEDURES
FOR STROKE SURVIVORS Top-Down Approach to Assessment
The evaluation of a stroke survivor is a complicated A top-down approach to assessment process has been
process requiring the assessment of the multiple per- described in the literature’* and is applicable to the
formance components and performance areas” that evaluation of the stroke survivor. Principles of this ap-
may be affected by the CVA. Therapists may have two or proach include the following:
three stroke survivors assigned to their caseloads, each 1. Inquiry into role competency and meaningfulness is
with completely different patterns or impairment and the starting point for evaluation.
resulting functional deficits. Therefore the most logical 2. Inquiry is focused on the roles that are important to
starting point in the evaluation process is the use of a the stroke survivor, particularly those in which the
client-centered approach to evaluation. patient was engaged before the stroke.
3. Any discrepancy of roles in the past, present, or future
is identified to help determine a treatment plan.
Client-Centered Assessments
4. The tasks that define a person are identified, as well
“Client-centered practice is an approach to providing oc- as whether those tasks can be performed and the
cupational therapy which embraces a philosophy of re- reasons that the task is problematic.
spect for, and partnership with, people receiving services. 5. A connection is determined between the compo-
Client-centered practice recognizes the autonomy of in- nents of function and occupational performance.
dividuals, the need for client choice in making decisions A top-down approach to evaluation is in contrast to a
about occupational needs, the strengths clients bring to a bottom-up approach that first focuses on performance
therapy encounter, the benefits of client-therapist part- component dysfunction.*?
nership, and the need to ensure that services are accessi-
ble and fit the context in which a client lives.””* Effects of Neurological Deficits
Law, Baptiste, and Mills’* and Pollack’ suggest that
on Activity Performance
the therapist implementing this approach to evaluation
include the following concepts: Using activity analysis and keen observation allows
1. Recognizing that the recipients of occupational therapists to identify errors during task performance
therapy (OT) are uniquely qualified to make deci- and to analyze the errors and determine the underlying
sions about their occupational functioning deficits blocking independent functioning. “A system-
2. Offering the patient a more active role in defining atic evaluation of daily activities can be used as a struc-
goals and desired outcomes ture for clinical reasoning that helps therapists detect
3. Making the patient-therapist relationship an interde- neurobehavioral dysfunction or impaired neurologic
pendent one to enable the solution of performance performance components and assess functional inde-
dysfunction pendence in self-care activities. This method allows the
4. Shifting to a model in which occupational therapists therapist to analyze the nature or cause of a functional
work with patients to enable them to meet their own problem that requires occupational therapy interven-
goals tion, so the analysis is made from the view of occupa-
5. Evaluation (and intervention) focusing on the con- tions” (Fig. 37-2).°
texts in which patients live, their roles and interests, Since the performance of a single functional task
and their culture (e.g., donning a shirt) requires the use of multiple un-
6. Allowing the patient to be the “problem-definer,” so derlying skills that may have been affected by a stroke,
that in turn the patient will become the “problem- multiple performance components may be evaluated in
solver.” the context of one patient-chosen activity (Fig. 37-3).”*
7. Allowing the client to evaluate his or her own per-
formance and set personal goals?”
Standardized Tools
Through the use of these strategies the evaluation
process becomes more focused and defined, patients The Clinical Practice Guidelines for Post-Stroke Rehabilita-
become immediately empowered, the goals of therapy tion®” encourages the use of tools that are reliable, valid,
are understood and agreed on, and a patient-tailored and sensitive to change. In addition, the assessment
 Performance components

Presentation of
a meaningfu Dysfunction of | ~ Dysfunction of |
task
cognitive perceptual
| performance performance
| component component
Life-space
influences

Task performance
dysfunction: lack of
independence in feeding

Ideational Spatial relation

apraxia impairment
indicating a indicating a
ie dea dysfunction of
of cognitive a perceptual
performance sensorimotor
component component

FIG. 37-2
Dysfunction of multiple performance components such as ideational apraxia and spatial relations
can be revealed by activity and error analysis during functional tasks such as feeding. (Modified from
Arnadottir G: The brain and behavior: assessing cortical dysfunction through activities of daily living, St
Louis, 1990, Mosby.)
652 TREATMENT APPLICATIONS

Possible behavioral deficits interfering with

function
Premotor perseveration: pulling up sleeve
Spatial-relation difficulties: differentiating front
from back on shirt
Spatial-relation difficulties: getting an arm into
the right armhole
Unilateral spatial neglect: not seeing shirt
located on neglected side (or a part of the
shirt)
Unilateral body neglect: not dressing the neg-
lected side or not completing the dressing on
that side
Comprehension problem: not understanding
verbal information related to performance
Ideational apraxia: not knowing what to do to get
shirt on or not Knowing what the shirt is for
Ideomotor apraxia: having problems with the Distraction: becomes interrupted by other things
planning of finger movements in order to Attention deficit: difficulty attending to task and
perform quality of performance
Tactile agnosia (astereognosis): having trouble Irritated or frustrated when having trouble per-
buttoning shirt without watching the perform- forming or when not getting the desired assis-
ance tance
Organization and sequencing: dressing the unaf- Aggressive when therapist touches patient in
fected arm first and getting into trouble with order to assist her (tactile defensiveness)
dressing the affected arm; inability to continue Difficulties recognizing foreground from back-
the activity without being reminded ground or a sleeve of a unicolor shirt from the
Lack of motivation to perform rest of the shirt

FIG. 37-3
Possible behavioral deficits interfering with function during donning a shirt. (From Arnadottir G: The
brain and behavior: assessing cortical dysfunction through activities of daily living, St Louis, 1990, Mosby.)

FUNCTIONAL LIMITATIONS COMMONLY

tools focused on task performance should be used.
OBSERVED AFTER STROKE
Tools that are focused on performance component eval-
uation in isolation from task performance, that use Multiple factors can impede effective and efficient per-
novel nonfunctional tasks, and that do not consider the formance of various tasks on which the patient desires
affect of environmental context should be interpreted to focus in OT. The following section reviews blocks to
with caution. Tools are available to the occupational function that are typically observed during work with
therapist that directly relate performance dysfunction stroke survivors.
observed during activities of daily living (ADL) with the
effect of underlying skills necessary for independent Inability to Perform Chosen
performance of activities.
Tasks While Seated
The Arnadottir Occupational Therapy Neurobehavioral
Evaluation’ (A-ONE) correlates the dysfunction of per- A commonly observed deficit after stroke is the loss of
formance components (e.g., left neglect, apraxia, and trunk and postural control.
spatial dysfunction) with self-care and mobility tasks. Impairment in trunk control may lead to the follow-
The Assessment of Motor and Process Skills’? (AMPS) uses ing problems””:
instrumental activities of daily living (IADL) to evaluate 1. Dysfunction of limb control
underlying motor function (e.g., reaching, grasping, and 2. Increased risk for falls
posture) and process skill dysfunction (e.g., using items 3. Impaired ability to interact with the environment
and searching and locating). See Table 37-3 for a 4. Visual dysfunction secondary to resultant head and
summary of evaluation tools used with stroke survivors. neck malalignment
 Description and Usage
Stroke deficit scale that scores |5 items (e.g,, consciousness, vision, extraocular movement, facial
control, limb strength, ataxia, sensation, and speech and language)
26
Stroke deficit scale that scores 8 items (e.g., consciousness, orientation, speech, motor function,
and facial weakness)
Global disability scale with six grades indicating degrees of disability
ia Occupational Client-centered assessment tool based on clients’ identification of performance area dysfunction;
nance Measure?*? (COPM) clients rate importance of self-care, productivity, and leisure skills, as well as their perception of
J
performance and satisfaction with performance
Used as outcome measure, as well as patient satisfaction survey
Barthel Index*5” Measure of BADL disability that ranges from 0 to 20 or 0 to 100 (by multiplying each item by 5);
includes 10 items: bowels, bladder, feeding, grooming, dressing, transfer, toileting, mobility, stairs, and
: bathing

~ Kohiman Evaluation of Living Living skills evaluation that includes ratings of |7 tasks (e.g, eetsty awareness, money aROTS
Skills (KELS)” phone book use, and money and bill management)
Functional Independence Measure of BADL disability that includes 18 items scored on a seven-point scale; includes
Measure* (FIM)*® subscores for motor and cognitive function; performance areas include self-care, sphincter control,
mobility, locomotion, cognition, and socialization

; Frenchay Activities Index**° |5-item IADL scale that evaluates domestic, leisure, work, and outdoor activities

PCG Instrumental Activities of IADL evaluation of telephone use, walking, shopping, food preparation, housekeeping, laundry,
Daily Living*?° public transportation, and medication management

_ Assessment of Motor and Process 16 motor skills (e.g,, reach, manipulation, calibration, coordination, posture, and mobility) and 20
Skills?? process skills (e.g., attends, organizes, searches and locates, initiates, and sequences) evaluated
within context of patient-chosen IADL skills; patients choose familiar and culturally relevant tasks
from list of 50 standardized activities of various difficulties

Mini-Mental State Examination**° Mental status screening test of orientation to time and place, registration of words, attention,
calculation, recall, language, and visual construction

Glasgow Coma Scale*”® Level of consciousness scale that includes three sections scoring eye opening, motor, and verbal
responses to voice commands or pain

Arnadottir Occupational Therapy Evaluates apraxias, neglect syndromes, body scheme disorders, organization/sequencing
Neurobehavioral Evaluation dysfunction, agnosias, and spatial dysfunction via BADL and mobility tasks; directly correlates
(A-ONE)’ impairment and disability levels of dysfunction

Neurobehavioral Cognitive Status Mental status screening test that includes the domains of orientation, attention, comprehension,
Examination*°° naming, construction, memory, calculation, similarities, judgment, and repetition

Fugl-Meyer Test**° Motor function evaluation that uses a 3-point scale to score the domains of pain, range of motion,
sensation, volitional movement, and balance

Functional Test for the Hemiparetic Arm and hand function are assessed via |7 hierarchical functional tasks based on Brunnstrom's
Upper Extremity®” view of motor recovery; sample tasks are folding a sheet, screwing in a light bulb, stabilizing a jar,
and zipping a zipper

Arm Motor Ability

Test (AMAT) Arm function evaluated by functional ability and quality of movement; test involves performance of
28 tasks (e.g., eating with a spoon, opening jar, tying shoelace, and using telephone)

TEMPA?0?! Upper extremity performance test composed of nine standardized tasks (bilateral and unilateral)
measured by three criteria: length of execution, functional rating, and task analysis; sample tasks are
handle coins, pick up a pitcher and pour water, write and stamp an envelope, and unlock a lock

From references 7, | |-13, 17,21, 23, 24, 26, 29-31, 33-38, 42, 45, 47-50, 52,53, 55, 57, 78-80, 86, 87, and 90.
*Recommended in AHCPR’s Clinical Practice Guidelines #16, Post-Stroke Rehabilitation, 1995. Continued

653
 TREATMENT APPLICATIONS

“ith the Stroke Survivor Population—cont’d

Instrument 7 Description and Usage
Jebsen Test of Hand Function*” Hand function evaluation; includes seven test activities: writing a short sentence, turning over index
cards, simulated eating, picking up small objects, moving empty and weighted cans, and stacking
checkers during timed trials
Motor Assessment Scale**? Motor function evaluation; includes disability and impairment measures; includes arm and hand
movements, tone, and mobility (bed, upright, and ambulation)
Motricity Index*?? Measures impairments of limb strength with a weighted ordinal scale
Trunk Control Test?” Trunk control evaluated on a 0-100 point scale; tasks used: rolling, supine to sit, and balanced sitting

Berg Balance Scale*!? Balance assessment of |4 items scored on a O- to 4-point ordinal scale
Tinetti Test®? Evaluates balance and gait in the older adult population
Rivermead Mobility Index*** Measures bed mobility, sitting, standing, transfers, and walking on a pass or fail scale
Functional Reach Test?? Balance evaluation; objectively measures length of forward reach in the standing posture
Boston Diagnostic Aphasia Assesses sample speech and language behavior, including fluency, naming, word finding, repetition,
Examination**? serial speech, auditory comprehension, reading and writing

Western Aphasia Battery**” Includes an ““Aphasia Quotient” and “Cortical Quotient” scored on a |00-point scale: assesses
spontaneous speech, repetition, comprehension, naming, reading, and writing
Beck Depression Inventory*!' 2|-item, self-rating scale with attitudinal, somatic, and behavioral components
Geriatric Depression Scale*”° Self-rated depression scale of 30 items with a yes-or-no format
Family Assessment Device*** Family assessment of problem solving, communication, roles, affective responsiveness, affective
involvement, behavioral control, and general functioning
Medical Outcomes Study/Short Quality of life measure that includes the domains of physical functioning, physical and emotional
Form Health Survey*8° problems, social function, pain, mental health, vitality, and health perception
Sickness Impact Profile*! Quality of life measure in the format of a |36-item scale with 12 subscales that measure
ambulation mobility, body care, emotion, communication, alertness, sleep, eating, home
management, recreation, social interactions, and employment
From references 7, | |-13, 17,21, 23, 24, 26, 29-31, 33-38, 42, 45, 47-50, 52, 53,55, 57, 78-80, 86, 87, and 90,
*Recommended in AHCPR's Clinical Practice Guidelines #16, Post-Stroke Rehabilitation, 1995.

5. Symptoms of dysphagia secondary to proximal tional Independence Measure scores,> ? and scores on
malalignment the Barthel Index” after stroke.
6. Decreased independence in ADL Specific effects of a stroke on the trunk include the
The loss of trunk control after a stroke may be ob- following:
served as an inability to sit in proper alignment, the 1. Inability to perceive midline as a result of spatial re-
loss of righting and equilibrium reactions, the inabil- lations dysfunction and resulting in sitting postures
ity to reach beyond the arm span because of lack of that are misaligned from the vertical
postural adjustments, and falling during attempts to 2. Assumption of static postures that do not support
function. engagement in functional activities (e.g., posterior
Stroke survivors who lose trunk control need to use pelvic tilt, kyphosis, and lateral flexion)
the more functional upper extremity (UE) for postural 3. Multidirectional trunk weakness’°
support to remain upright and prevent falls. In these 4. Spinal contracture secondary to soft-tissue short-
cases the patient effectively eliminates the ability to ening
engage in ADL and mobility tasks because lifting the 5. Inability to move the trunk segmentally (i.e., the
more functional arm from the supporting surface can trunk moves as unit) (Examples of this phenomenon
result in a fall. “Trunk control appears to be an obvious are patients using “log rolling” patterns during bed
prerequisite for the control of more complex limb activ- mobility and an inability to rotate the trunk while
ities that in turn constitute a prerequisite to complex be- reaching for an item across the midline.)
havioral skills.”*” Studies have found trunk control to 6. Inability to shift weight through the pelvis anteriorly,
be a predictor of gait recovery,” sitting balance,'?Func- posteriorly, and laterally.
 Cerebrovascular Accident 655

Specific deficits in trunk control are evaluated during ment (similar to a typist’s posture) is a prerequisite
observation of task performance (Box 37-1). Observing to engaging the limbs in an activity. The desirable
tasks allows the therapist to evaluate trunk control in posture is as follows:
many directions (i.e., isometric, eccentric, and concentric @ Feet flat on floor and bearing weight
control of the trunk muscle groups [extensors, abdomi- m Equal weight bearing through both _ ischial
nal muscles, and lateral flexors]) and the patient's limits tuberosities
of stability. Limits of stability refers to “boundaries of an @ A neutral to slight anterior pelvic tilt
area of space in which the body can maintain its position m@ An erect spine
without changing the base of support”’® or “an area ™ Head over the shoulders and shoulders over the
about which the center of mass may be moved over any hips
given base of support without disrupting equilibrium.”*? The reader should attempt reaching activities from
The therapist must differentiate between the patient's the above posture and do the same activities with a
perceived limits of stability and the actual limits of sta- posterior pelvic tilt and flexed spine (a typical trunk
bility. After a stroke it is common to have a disparity pattern after stroke). The freedom of movement and
between the two because of body scheme disorder, fear of the available range for each posture should be com-
falling, or lack of insight into or awareness of disability. If pared (Fig. 37-4).
the patient's perceived limits are greater than his or her . Establishing the ability to maintain the trunk in midline
actual limits, there is a risk for falls. In other cases the using external cues. Many patients have difficulty as-
patient's perceived limits are less than actual limits. In suming and maintaining the correct posture. The
such instances the patient will not attempt more dynamic therapist can provide verbal feedback (e.g., “Sit up
activities or will overrely on adaptive equipment. nice and tall”). Visual feedback (e.g., using a mirror
Treatment interventions aimed at increasing the or the therapist assuming the same postural mis-
patient's ability to perform chosen tasks in seated pos- alignment as the patient) may be helpful. Environ-
tures include the following”: mental cues may be used to correct the posture For
1. Establishing a neutral yet active starting alignment, i.e. a example, the patient may be instructed to maintain
position of readiness to function. This starting align- contact between the shoulder and an external target
such as a bolster or wall, positioned so that the trunk
is in the correct posture.
. Maintaining trunk range of motion (ROM) by wheel-
chair and armchair positioning that maintains the trunk
Ti cae Evaluation During Task in proper alignment. The therapist can provide an exer-
cise program focused on trunk range of motion and
_ Performance: Examples of Postural flexibility. Activities that elicit the desired movement
_ Adjustments
That Support Participation patterns can be chosen, and hands-on mobilization
in Chosen Activities of the trunk can be used if needed. Trunk ranges that
should be addressed include flexion, extension,
lateral flexion, and rotation.
Feeding . Prescribing dynamic weight-shifting activities to allow
Anterior weight shift occurs to bring upper body toward table,
practice of weight shifts through the pelvis. The most ef-
to prevent spillage of food from utensils, and to support a
fective way to train weight shifts is to coordinate the
hand-to-mouth pattern.
trunk and limbs. Positioning of objects during reach
Dressing beyond the span of either arm requires the patient
Lateral weight shift to one side of the pelvis occurs so that to adjust the posture to be successful. The reader is
pants and underwear can be donned over hips. encouraged to reach beyond arm span in all direc-
tions while seated (preferably while reaching for an
Oral Care object) and to analyze the corresponding postural
Anterior weight shift occurs so that saliva and paste may be adjustment of the pelvis and trunk. The position
expectorated. and goal of the task will dictate the required weight
shift.
Transfer
. Strengthening the trunk, best achieved by using tasks that
Trunk extends with concurrent hip flexion to initiate a sit-to-
require the patient to control the trunk against gravity.
stand transition.
Some examples are bridging ofthe hips in the supine
Meal Preparation position to strengthen the back extensors and initiat-
Trunk flexes into gravity in a controlled fashion to support a ing a roll with the arm and upper trunk to strengthen
reach pattern to the lower shelf of the refrigerator. the abdominal muscles. Strengthening occurs within
SS| the context of an activity.
656 TREATMENT APPLICATIONS

| :
Trunk
Scoliosis Kyphosis rotation

FIG. 37-4
Normal and poststroke sitting alignment. (From Donato SM, Pulaski KH: Overview of balance im-
pairments: functional implications. In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-
based approach, St Louis, 1998, Mosby.)

6. Using compensatory strategies and environmental adapta- effectively blocks weight bearing through the sole of the
tions when trunk control does not improve to a sufficient foot),”’ and perceptual dysfunction.
level and the patient is at risk for injury. Examples of in- In addition to asymmetry and an inability to bear
terventions include wheelchair seating systems (e.g., weight or shift weight through the affected leg, many
lateral supports, lumbar rolls, chest straps, and tilt- stroke patients lose upright postural control and
in-space frames with head supports) and adaptive balance strategies. Effective upright control depends on
ADL equipment (e.g., reachers, long-handled equip- the following automatic postural reactions*”’”*:
ment) to decrease the amount of required trunk dis- 1. Ankle strategies are used to maintain the center of
placements (see Chapter 13). mass over the base of support when movement is
centered around the ankles. These strategies control
small, slow, swaying motions such as standing in a
Inability to Engage in Chosen
movie line, engaging in conversations while stand-
Activities in Standing
ing, and stirring a pot on a stovetop. They are most
The inability to assume and maintain a standing effective when the support surface (floor) is firm and
posture has a significant effect on the type of activities a longer than the foot. Ankle weakness, loss of ankle
person may engage in and may play a significant role in range of motion, and proprioceptive deficits may all
the eventual discharge destination for the inpatient re- contribute to ineffective ankle strategies and balance.
covering from stroke. Impaired upright control has been 2. Hip strategies are used to maintain or restore equilib-
correlated with an increased risk of falls,°? as well as rium. These strategies are used specifically in re-
with less than optimal functional outcomes’’ on the sponse to larger, faster perturbations, when the
Barthel Index. Because many basic and instrumental support surface is compliant, or when the surface is
ADL and work and leisure skills require control of smailer than the feet (e.g., walking on a beam).*°
standing postures, early training in upright control is a 3. A stepping strategy is used when ankle and hip strate-
necessary component of stroke rehabilitation programs. gies are, or are perceived to be, ineffective. This strat-
Similar to the deficits seen in sitting, upright standing egy results in movement of the base of support.
postures are characterized by asymmetrical weight dis- toward the center of mass movement. A step is taken
tribution; unlike deficits in sitting, the weight distribu- to widen the base of support. Tripping over an
tion in standing is seen through the lower extremities*®” uneven sidewalk or standing on a bus that unexpect-
in addition to the trunk. Stroke survivors commonly edly stops elicits this strategy.
have an inability to bear weight through the affected leg. Both the loss of postural reactions and the inability
There may be several reasons for this, including a fear of to bear and shift weight onto the affected leg will result
falling or buckling, patterns of weakness that will not in such functional limitations as gait deviations or dys-
support the weight of the body, spasticity that impedes function, an inability to climb stairs, transfer, and
proper alignment (i.e., plantar flexion spasticity that perform upright basic ADL (BADL) and IADL, and an
 Cerebrovascular Accident 657

increased risk of falls. The assessment process provides on the affected leg. For example, a modified soccer
the therapist with more specific information regarding activity requires the patient to fully shift weight to
the cause of dysfunction. “Specifically, therapists should kick the ball. The environment (e.g., work surface
observe what happens when patients have to move their height and placement of objects) is manipulated in
center of mass over their base of support, move their conjunction with the patient's positioning to elicit
head, stand on uneven surfaces, function in lower light- the required weight shift.
ing, move from one type of surface to another, or func- . Encouraging dynamic reaching activities in multiple envi-
tion on a narrower base of support. Therapists should ronments to develop task-specific weight-shifting abilities.
also observe patients’ postural alignment, whether a For example, kitchen activities that require retrieval of
bias in posture exists and in which direction that bias cleaning supplies under the sink, in a broom closet,
occurs, patients’ limits of stability, the width between and in overhead cabinets require mastery of multiple
their feet during functional tasks, and what patients do postural adjustments and balance strategies.
after losing their balance.”*? . Using the environment to grade task difficulty and pro-
Treatment strategies aimed at improving the patients’ vide external support. Proper use of the environment
ability to perform chosen tasks in standing postures can decrease the patient's fear of falling and simul-
include the following*”’”**”: taneously improve confidence and challenge under-
1. Establishing a symmetrical base of support and proper lying balance skills. Examples include working in
alignment to prepare to engage in activities. This starting front of a high countertop, using one hand for
alignment is assumed to provide ample proximal sta- weight bearing as a postural support, and using a
bility and to support engagement in functional tasks. walker for support. The patient must not rely too
The therapist may use hands-on support or visual or much on external supports because balance strate-
verbal feedback to establish proper alignment as gies may not be fully challenged to reach optimal
follows: recovery.
@ Feet approximately hip width apart B Training upright control within the context of func-
@ Equal weight bearing through the feet tional tasks that are graded. Tasks are graded in rela-
# A neutral pelvis tion to length of required reach, speed, and pro-
® Both knees slightly flexed gressively more challenging bases of support.
@ Aligned and symmetrical trunk Examples include making a bed, changing a pet's
2. Establishing the ability to bear weight and shift weight food bowl, setting a table, stepping up a curb,
through the more affected lower extremity.** The ability cleaning a wall mirror, playing horseshoes or
to bear weight may be graded at first. For example, if shuffleboard, and doffing slippers in a standing
a patient cannot assume standing because of pos- posture. All of these activities require various
tural insecurity or imbalance, sitting on a high weight shifts, balance strategies, and the ability to
surface (e.g., stool or raised therapy mat) allows the bear weight through both lower extremities. The
patient to begin to bear weight but does not require activity choice is driven by the patient's desires,
bearing full body weight. As the patient improves, and the therapist designs positioning and setup of
full standing is encouraged, followed by graded the activity to elicit the desired postural strategies
weight shifts and progressing to full weight bearing (Fig. 37-5).

|
M FIG. 37-5
Activity is positioned to elicit the desired pos-
tural strategies. (From Donato SM, Pulaski KH:

a
Overview of balance impairments: functional im-
plications. In Gillen G, Burkhardt A, editors: Stroke
rehabilitation: a function-based approach, St Louis,
== 1998, Mosby.)
lend

il
==)
658 TREATMENT APPLICATIONS

Inability to Communicate Secondary

back, with fluent, well-articulated paraphasic speech.
to Language Dysfunction Paraphasic speech consists of word substitution errors.
CVA may result in a wide variety of speech or language Speech may occur at an excessive rate and may be hy-
disorders that may vary from mild to severe. These perfluent. The patient uses few substantive words and
deficits occur most frequently in CVA resulting from many function words. The patient produces running
damage to the left hemisphere of the brain. They can speech composed of English words in a meaningless se-
also occur less frequently with damage to the right quence. English-speaking patients produce neologisms
hemisphere. All persons with CVA should be evaluated (non-English nonsense words) interspersed with real
by the speech pathologist for the presence of speech and words. Reading and writing comprehension is often
language disorders. The speech pathologist can provide limited, and mathematical skills may be impaired.**
valuable information to other members of the rehabili-
tation team and to the family regarding the best tech- ANOMIC APHASIA. Persons with anomic aphasia
niques for communicating with a particular patient. The have difficulties with word retrieval. Anomia, or word-
occupational therapist should carry over the work of the finding difficulty, occurs in all types of aphasia.
speech therapist in the treatment sessions, as appropri- However, patients in whom word-finding difficulty is
ate. Carryover may occur in reinforcing communication the primary or only symptom may be said to have
techniques the patient is learning and in presenting in- anomic aphasia. The speech of these patients is fluent,
struction in ways the patient is able to understand and grammatically correct, and well articulated, but there is
integrate. significant difficulty with word finding. This problem
The specific speech and language dysfunctions de- can result in hesitant or slow speech and the substitu-
scribed below can exist in mild to severe form and in tion of descriptive phrases for actual names of things.
combination with one another. Mild to severe deficits in reading comprehension and
written expression occur, and mild deficits in mathe-
Aphasia matical skills may be present.*’**
Aphasia is a language disorder that results from neuro-
logical impairment. It can affect auditory comprehen- Dysarthria
sion, reading comprehension (alexia), oral expression, Patients with dysarthria have an articulation disorder, in
written expression (agraphia), and the ability to inter- the absence of aphasia, because of a dysfunction of the
pret gestures. Mathematical deficits (acalculia) can also central nervous system (CNS) mechanisms that control
be present in aphasia. There are several different types of speech musculature.®” This disorder results in paralysis
aphasia. and incoordination of the organs of speech, causing the
speech to sound thick, slurred, and sluggish.
GLOBAL APHASIA. Global aphasia is characterized
by a loss of all language skills. Oral expression is lost, Communication with Patients
except for some persistent or recurrent utterance. Global Who Have Aphasia
aphasia is usually the result of involvement of the Although the speech pathologist is responsible for the
middle cerebral artery of the dominant cerebral hemi- treatment of speech and language disorders, the occupa-
sphere. The patient with global aphasia may be sensitive tional therapist can facilitate communication and mean-
to gestures, vocal inflections, and facial expression. Con- ingful interaction with patients who have aphasia.
sequently, the patient may appear to understand more Patients respond best to intelligent and empathetic
than he or she actually does.** understanding from professional staff and family
members. Staff and family members communicating
BROCA'S APHASIA. Speech apraxia and agramma- with patients should adopt an attitude of patience, re-
tism characterize Broca’s aphasia. The apraxia is mani- laxation, and acceptance. When talking to the patient,
fested by slow, labored speech with frequent misarticu- the staff or family member should use simple, short,
lations. Syntactical structure is simplified because of the concrete sentences. Instructions and explanations
agrammatism, sometimes referred to as telegraphic should be kept simple. The patient should be encour-
speech. The patient with this aphasia has good auditory aged, but not pressured, to respond in any way possible.
comprehension, except when speech is rapid, grammat- The use of gestures for communication should be en-
ically complex, or lengthy. Reading comprehension and couraged. Having the patient demonstrate through per-
writing may be severely affected, and the patient with formance is the best way to ensure that instructions are
Broca’s aphasia usually has deficits in monetary con- understood.
cepts and the ability to do calculations.** The occupational therapist can use routine ADL as
opportunities to encourage speech. The patient needs to
WERNICKE’S APHASIA. Wernicke’s aphasia is char- be reassured that the language disorder is part of the dis-
acterized by impaired auditory comprehension and feed- ability and is not a manifestation of mental illness. In
 Cerebrovascular Accident

addition, Rubio®® has outlined strategies for the occupa-

tional therapist to use with patients and their caregivers:
1. Understanding is facilitated when one person talks at :BLgoth Brushing Task: Treatment
a time. Extra noise creates confusion. _ of Neurobehavioral Impairments
2. Give the patient time to respond.
3. Carefully phrase questions to make it easier for the
patient to respond; for example, use “yes-no” and Spatial Relations and Spatial Positioning
“either-or” questions. Positioning of toothbrush and toothpaste while applying paste
to brush.
4. Use visual cues or gestures with speech to help the
Placement of toothbrush in mouth
patient understand.
Positioning of bristles in mouth
5. Never force a response. Placement of brush under faucet
6. Use concise sentences.
Do not rush communication because this may Spatial Neglect
increase frustration and decrease the effectiveness of Visual search for and use of brush, paste, and cup in affected
communication.°® hemisphere
Visual search and use of faucet handle in affected
hemisphere
Inability to Perform Chosen Tasks
Secondary to Neurobehavioral Body Neglect
Impairments Brushing of affected side of mouth

Neurobehavioral deficit is defined as “a functional im-

Motor Apraxia
pairment of an individual manifested as defective skill Manipulation of toothbrush during task performance
performance resulting from a neurologic processing Manipulation of cap from toothpaste
dysfunction that affects performance components such Squeezing of toothpaste onto brush
as affect, body scheme, cognition, emotion, gnosis, lan-
guage, Memory, motor movement, perception, person- Ideational Apraxia
ality, sensory awareness, spatial relations, and visuospa- Appropriate use of objects (brush, paste, cup) during task.
tial skills.”* A major responsibility of the occupational
therapist treating a stroke survivor is evaluating which Organization and Sequencing
neurobehavioral deficits are blocking independent per- Sequencing of task (removal of cap, application of paste to
brush, turning on water and putting brush in mouth)
formance of chosen tasks.
Continuation of task to completion
Arnadottir® has proposed a relationship between the
ability to perform daily activities, neurobehavioral im- Attention
pairments, and the CNS origin of the neurobehavioral Attention to task (for greater difficulty, distractions such as
dysfunction (a CVA, for the purposes of this chapter). conversation, flushing toilet, or running water may be
She supports this theory with the following relational added)
statements: Refocus on task after distraction
1. Behaviors required for task performance are related
to neuronal processing at the CNS level. Therefore a Figure-Ground
relationship also exists between the defective behav- Distinguishing white toothbrush and toothpaste from sink
ioral responses of an individual with CNS damage
Initiation and Perseverance
during performance of ADL and the dysfunction of
Initiation of task on command
neuronal processing and performance components Cleaning parts of mouth for appropriate period of time, then
resulting from CNS damage. moving bristles to another part of mouth
2. Performance of daily activities requires adequate Discontinuation of task when complete
function of specific parts of the nervous system. Con-
sequently, CNS impairment may result in dysfunc- Visual Agnosia
tion of specific aspects of ADL. For example, a CVA Use of touch to identify objects
that causes a lesion of the posteroinferior parietal
lobe of the left hemisphere commonly results in bi- Problem Solving
lateral motor apraxia. “This neurobehavioral impair- Search for alternatives if toothpaste or toothbrush is
missing
ment may make manipulation of objects difficult
during functional activities such as combing hair,
From Gillen G, Burkhardt A: Stroke rehabilitation: a function-based approach, St
brushing teeth, or holding a spoon while eating.”*
Louis, 1998, Mosby.
3. Neurological impairment can be observed through
the patient's engagement in daily activities. Thus
660 TREATMENT APPLICATIONS

through the analysis of ADL the integrity of the CNS Arnadottir’’® proposed a system of observing patients
can be evaluated (Box 37-2). engaged in functional activities, allowing errors (as long
To properly evaluate the effect of neurobehavioral as they are safe) to occur, analyzing the errors, and,
deficits on task performance, the therapist must develop finally, detecting the impairments that are interfering
activity analysis skills with the goal of analyzing which with task performance so that an appropriate treatment
performance components are necessary to achieve an plan can be developed. She cautioned that when the
outcome that is satisfactory to the patient. Even the therapist analyzes errors and observed behaviors,
“simplest” of BADL tasks challenge multiple underlying knowledge of neurobehavior, cortical function, activity
skills (Fig. 37-3 and Boxes 37-3 and 37-4).°°° analysis, and clinical reasoning must be considered in
the results of the evaluation (Table 37-4).
Treatment aimed at counteracting the effects of neu-
robehavioral dysfunction may be based upon an adap-
tive and compensatory approach or a restorative and re-
xamples of Environmental and Task medial approach.?”’*’’°® A combination of approaches
Manipulation to Challenge Component has also been suggested (Table 37-5).'
Decisions regarding choosing a treatment approach
il s During Meal Preparation may be difficult. Neistadt?”’°° suggested evaluating a
patient's learning potential in the context of ADL evalu-
Spatial Neglect ation and training, focusing on such issues as the
Place ingredients in both visual fields number of repetitions needed to learn new approaches
Choose a task that requires use of right and left burners to tasks and the type of transfer of learning that is
demonstrated.
Figure-Ground Toglia®’ has suggested that the transfer of learning
Place necessary utensils in a cluttered drawer from one context to another (e.g., transferring skills
Use utensils that match the color of the counter
learned from making a cup of tea in the OT clinic to
meal preparation at home) may be facilitated by the
Spatial Dysfunction
therapist through the following methods:
Prepare items that require the patient to pour ingredients
from one container to another (e.g., pour pasta into a bowl 1. Varying treatment environments
or fill a pot with water) 2. Varying the nature of the task
3. Helping patients become aware of how they process
Motor Apraxia information
Choose recipes that require manipulation of food items 4. Teaching processing strategies
Choose recipes that require control of distal extremity 5. Relating new learning to previously learned skills
adjustments (e.g,, using a ladle, whisking, and stirring) Toglia®' has identified degrees of transfer of learning.
The degree of transfer is defined by the number of task
characteristics that differ from those of the original task.
Examples of these characteristics are spatial orientation,
mode of presentation (e.g., auditory or visual), move-
ment requirements, and environmental context.
A near transfer of learning involves transfer between
pensatory Strategies two tasks that are different by one to two characteris-
ae Nateleel ieBY-viletas tics. Intermediate transfer involves transfer of learning
to a task that varies by three to six characteristics. A far
transfer involves a task that is conceptually similar but
has one or no characteristics in common. Finally, a
Spatial Neglect very far transfer involves the “spontaneous application
Place necessary clothing on right side of closet and drawers of what has been learned in treatment to everyday .
Move dresser to right side of room living.”*!
From her review of the literature, Neistadt™ reached
Motor Apraxia
the following conclusions:
Utilize loose-fitting clothing without fasteners
Use Velcro closures 1. Near transfer from remedial tasks to similar tasks is
possible for all patients with brain injury.
Spatial Dysfunction 2. Intermediate, far, and very far transfer from remedial
Use shirts with a front emblem to identify proper orientation to functional tasks will occur only with localized
Lay out clothing in the proper orientation brain lesions and good cognitive skills and after
training with a variety of treatment tasks.
 Cerebrovascular Accident

_ Observed Behavior Possible Impairment

Difficulty adjusting grasp on razor or toothbrush Motor apraxia
Using a comb to brush teeth Ideational apraxia
Repetitive brushing of one side of the mouth Premotor perseveration
Not eating food on the left side of the plate Spatial neglect
Overestimating or underestimating distance of glass results in knocking Spatial relations dysfunction
over glass
“Forgetting” that a glass of orange juice is in the hand results in Eillagt Body neglect
as the patient attends to another aspect of ule meal
Hand is placed in cereal bowl Body neglect
Patient attempts to put socks on after he or she has put on Organization and sequencing
sneakers dysfunction
Patient cannot locate armholes in an undershirt Spatial relations dysfunction
Only the right side of the body is dressed Body neglect
Patient attempts to dress the therapist's arms instead of his or her own Somatoagnosia
Patient not able to locate the bathroom in his or her hospital room Topographic disorientation
Patient does not lock brakes or remove wheelchair footrests before Organization and sequencing
attempting to transfer dysfunction
s

Biss a transfer, only the intact buttock is on the seat of the chair Body neglect

From Arnadottir G: The brain and behavior: assessing cortical dysfunction through activities of daily living, St Louis, |990, Mosby; Anadottir G: Impact of neurobehavioral
deficits of activities of daily living. In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-based approach, St Louis, 1998, Mosby.

Treatment Approaches for Neurobehavioral Deficits After Stroke

& ‘Compensatory and Restorative and Remedial
‘Adaptive Approach Approach Combination Approach
etitive practice of tasks Restoration of component skills Rejects dichotomy between compen-
satory and restorative approaches
Top-down approach Bottom-up. approach
Uses optimally relevant occupations and
phasizes intact skill training Deficit-specific
environments as the treatment modality
Emphasizes modification Targets cause of symptoms and to challenge components
emphasizes components
ses environmental or task modifications Treatment choice is driven by tasks
to support optimal performance Assumes transfer of training will occur relevant to patient needs; tasks are
presented so that the underlying deficits
-y Activity choice driven by performance Assumes improved component are challenged via the task
_ challenges, not component deficits performance will result in increased skill
Rejects usage of contrived activities
P Treats symptoms, not the cause Activity choice driven by component
deficits
_ Patient-driven compensatory strategies
Research demonstrates short-term
. Caregiver-therapist environmental
results with skills generalizable to very
_ adaptations similar tasks
_ Task-specific and not’ generalizable

3. Far and very far transfer from remedial to functional underlying performance components. ’°° It is up to the
tasks will not occur for clients with diffuse injury and therapist to present the task by manipulating the envi-
severe cognitive deficits. ronment in a way that challenges the underlying skills.
Using a functional and meaningful task as a treat- If a compensatory approach is chosen, adaptive tech-
ment modality promotes acquisition of a desired skill, niques are used to counteract the effects of the underly-
and the therapist may use this task to challenge multiple ing neurobehavioral deficits.
662 TREATMENT APPLICATIONS

Inability to Perform Chosen Tasks

refrigerator. This movement pattern can be used in
Secondary to Upper Extremity
multiple tasks and at the same time strengthens
Dysfunction various muscle groups used to eventually support
The loss of UE control is common after stroke, with reach in space.
88% of stroke survivors having some level of UE dys- 3. Reach and manipulation. Reviews of research on UE
function.®” The stroke survivor's ability to integrate the motor control”? have identified two components
affected arm into chosen tasks may be limited by such of function during reaching activities. The first com-
multiple factors as the following:*” ponent is the transportation component, which is
Pain defined as the trajectory of the arm between the
. Contracture and deformity starting position and the object. The second compo-
. Loss of selective motor control nent is the manipulation component, which is the
Weakness’? formation of grip by combined movements of the
. Tonal dysfunction’* thumb and the index finger during arm movement.
. Superimposed orthopedic limitations Finger posturing anticipates the real grasp and
Loss of postural control to support UE control occurs during transportation of the hand toward
. Learned nonuse’’ the object.* The shaping of the hand is independent
. Loss of biomechanical alignment” of the manipulation itself. Trombly’s®** reaching
= oO . Inefficient and ineffective movement patterns studies of patients with left hemiparesis docu-
mented that the ability to reach smoothly and with
Integration into Function coordination was significantly less on the affected
UE evaluation procedures should focus primarily on than on the unaffected side. The continuous move-
assessing the patient's ability to integrate the UE into ment strategy was lost, movement time was longer,
performance of functional tasks. Standardized evalua- peak velocity occurred earlier, and weakness indica-
tions such as the TEMPA,*”*! AMAT,*? Jebsen,*” and tors were present.
AMPS*° (Table 37-3) are available to objectively Trombly®’ demonstrated that although muscular ac-
measure the patient's ability to use the affected extrem- tivity did not improve in the patients in her study, the
ity during task performance. discontinuity improved over time. She stated that the
The UE may be used during functional performance “level and pattern of muscle activity of these subjects
in different ways, including but not limited to the fol- depended on the biomechanical demands of the task
lowing*”: rather than any stereotypical neurological linkages
1. Weight bearing. Weight bearing through the hand and between the muscles.”
forearm with an extended elbow is a pattern used Patients are commonly observed demonstrating the
during ADL and mobility tasks. The establishment of use of stereotypical movement patterns of the UE. These
weight bearing is a goal of UE rehabilitation.'* Effec- patterns are characterized by scapula elevation and fixa-
tive control of weight bearing depends on enough tion, humeral abduction, elbow flexion, and wrist
trunk and scapula stability to accept partial body flexion. Mathiowetz and Bass Haugen”® suggested that
weight, control of active elbow extension, and ability the use of these movement patterns is evidence of at-
of the hand to bear weight without losing the palmar tempts to use remaining systems to complete tasks.
arches. Once weight bearing is established, the They gave an example of a patient with weak shoulder
patient can effectively use the arm as a postural flexors trying to lift an arm. The patient flexes the elbow
support (e.g., by supporting the upper body weight when trying to raise the arm because this movement
with the affected arm while wiping crumbs from the strategy shortens the lever arm and makes shoulder
table with the more functional arm), as an assist flexion easier.
during transitional movements (e.g., while pushing The following are examples of using treatment activi-
up from side-lying to sitting), and for fall prevention ties to improve the patient's ability to integrate the UE
into tasks20714:42.39,41,70.74,
(increased postural support is provided).
2. Moving objects across a work surface with a static grasp. 1. Using objects of different sizes and shapes to encour-
Such activities as ironing, opening or closing a age control of the hand during reach and manipula-
drawer, polishing, and sliding a paper across the tion
table are all examples of UE control of movement 2. Choosing activities that are appropriate to the
that does not occur with the arm in space. The hand patient's level of available motor control
is in contact with the objects involved in the task or 3. Using constraint-induced movement techniques: a
is supported on the work surface; therefore these technique in which the less affected UE is con-
types of tasks do not require the same control as, and strained (e.g., with a sling and splint) to force use of
may require less effort than, activities performed the affected extremity, providing massed practice of
while the patient is reaching in space, such as remoy- graded activities for the affected side to increase
ing dishes from a cabinet or reaching for food in the functional use’’
 Cerebrovascular Accident 663

4. Specifically training the arm to be used in weight Upper Extremity Complications After Stroke
bearing, reach, and manipulation situations within SUBLUXATION. Subluxation, or malalignment
the context of ADL and mobility caused by instability of the glenohumeral joint, is a
5. Presenting the patient with graded tasks related to common occurrence after stroke. The subluxation may
the number of degrees of freedom, the level of re- be inferior (head of the humerus below the glenoid
quired antigravity control, and the resistance in- fossa), anterior (head of the humerus anterior to the
volved in the task (Fig. 37-6) fossa), or superior (head of the humerus lodged under

FIG. 37-6
The task is designed to elicit the desired motor pattern; purpose of the activity drives the motor
output. (From Gillen G: Upper extremity function and management. In Gillen G, Burkhardt A,
editors: Stroke rehabilitation: a function-based approach, St Louis, 1998, Mosby.)
664 TREATMENT APPLICATIONS

the acromion-coracoid).” Cailliet** and Basmajian’® muscle activity. Most commonly, in the acute state there is
have described the mechanism of inferior subluxation, low tone (“low-tone stage”). During this low-tone stage
in which the head of the humeral head drifts inferior to the limbs and trunk become increasingly influenced by
the glenoid fossa. This common subluxation occurs as a the pull of gravity. Little or no available muscle activity is
result of malalignment of the scapula and the trunk. available at this stage, resulting in deviations from the
The normal position of the scapula is one of upward ro- normal resting alignment of the musculoskeletal system.
tation, an orientation that “cradles” the head of the Generally the inability to recruit and maintain
humerus and stabilizes it in alignment. After stroke the muscle activity is the greatest limiting factor at this stage.
scapula commonly assumes a position of downward ro- Because of the generalized lack of muscle activity and
tation, resulting in subluxation of the glenohumeral the dependent nature of the trunk and limbs, secondary
joint (Fig. 37-7). problems can occur.*' These include the following:
A common misunderstanding about subluxation is 1. Edema of the dorsal surface of the hand that pools
that it is associated with pain. The literature does not under the extensor tendons, effectively blocking
support this relationship.”' Because the shoulder is un- active or passive digit flexion
stable after a stroke, care must be taken to support the 2. Overstretching of the joint capsule of the gleno-
flail shoulder in bed (e.g., using pillows to maintain humeral joint
alignment), wheelchair (e.g., with lap boards or pillows), 3. Eventual shortening of muscles that are passively po-
and in upright position (e.g., putting the hands in a sitioned, in an effort to support a weak limb (Com-
pocket or taping the shoulder). Treatment to reduce a monly, flaccid upper extremities are positioned in
subluxation should focus on achieving trunk alignment the patient's lap, on a pillow, on a lap tray, or in a
and scapula stability in a position of upward rotation.”” sling. These static positions, although they support
the arm, result in prolonged positioning of certain
ABNORMAL -SKELETAL MUSCLE ACTIVITY. A muscle groups [internal rotators, elbow flexors, and
change in the resting state of the limb and postural wrist flexors] in a shortened position, placing them
muscles is common after stroke.'* Immediately after a at risk for mechanical shortening. Interestingly, these
stroke, there is a change in available/resting skeletal are the muscle groups that tend to become spastic as
time progresses. )
4. Overstretching of the antagonists to the previously
mentioned muscles
5. Risk of joint and soft-tissue injury during ADL and
mobility tasks (Because of the lack of control associ-
ated with a low-tone stage, the arm dangles and is
not positioned appropriately during dynamic activi-
ties. Common examples include an arm being
caught in the wheel during wheelchair mobility,
pinning of the arm during bed mobility or rest,
sitting on the arm after a transfer, or weight bearing
through a flexed wrist during engagement in self-care
activities. ) ae
The progression to a state of increased or excessive
skeletal muscle activity (increased tone) with clonus,
stereotypical posturing of the trunk and limbs, hyperac-
tive stretch reflexes, and increased resistance to passive
limb movements that are velocity dependent may occur
within several days or months of the stroke.”
As spasticity increases, the risk for soft-tissue shorten-
ing is heightened. This factor may lead to a vicious circle
of spasticity to soft-tissue shortening to overrecruitment
of shortened muscles to increased stretch reflexes. Sec-
ondary problems that may occur if the spasticity is not
managed in a therapy program include the following”:
1. Deformity of the limbs, specifically the distal upper
FIG. 37-7 limb (elbow to digits)
Biomechanics of subluxation. (From Gillen G: Upper extremity 2. Tissue maceration of the palm
function and management. In Gillen G, Burkhardt A, editors: Stroke 3. Possible “masking” of underlying selective motor
rehabilitation: a function-based approach, 1998, Mosby.) control
 Cerebrovascular Accident 665

4. Pain syndromes resulting from loss of normal joint (traumatic synovitis) and may be considered candidates
kinematics (These syndromes are usually related to for splinting to protect the wrist. *”
soft-tissue contracture that blocks full joint excur- MAINTAINING SorT-TissuE LENGTH. Patients who have
sion. A typical example is the loss of full passive ex- both increased and decreased skeletal muscle activity
ternal rotation of the glenohumeral joint. Attempts are at risk for soft-tissue contracture secondary to the
at forced abduction in these cases will result in a immobilization that occurs during both low-tone and
painful impingement syndrome of the tissues in the increased tone stages. The maintenance of tissue length
subacromial space.) is a 24-hour regimen. This regimen involves frequent
5. Impaired ability to manage BADL tasks, specifically variations in resting postures during waking hours,
UE dressing and bathing of the affected hand and teaching the patient and significant others appropriate
axilla when flexor posturing is present ROM procedures, daytime and nighttime positioning
6. Loss of reciprocal arm swing during gait activities programs, and staff and family education so that posi-
In the past, the sensorimotor approaches were used tioning and exercise programs may be carried out in the
to treat patients with abnormal skeletal muscle activity home environment.”
(see Chapters 32 through 36). These approaches were There must be no prolonged static positioning (e.g.,
developed by Rood, Bobath, Knott and Voss, and prolonged use of a sling). Rather, teaching patients to
Brunnstrom and are based on an understanding of adjust their resting postures during the day will help
CNS dysfunction at the time these clinicians were prevent soft-tissue tightness.
doing their research (the mid-1900s). Although these POSITIONING PRoGRaMs. The same wheelchair and
interventions may be used, their effectiveness is being bed positioning programs should not be applied to
challenged as occupational therapists move toward every patient. Instead positioning should be individual-
models of evidence-based practice. When choosing ized and focus on (1) promoting normal resting align-
treatment techniques or a treatment approach, thera- ment of the trunk and limbs in an effort to maintain
pists must consider that “neither research evidence nor tissue length on both sides of the joints and (2) provid-
expert consensus adequately supports recommenda- ing stretch to muscle groups that have been identified as
tions concerning the superiority of one type of exercise contracture prone or already shortened.
regimen over another. . . .”° Sort-TissuE ELONGATION. If soft-tissue shortening
and length-associated changes have already developed,
PREVENTION OF PAIN SYNDROMES the treatment of choice is low-load prolonged stretch
AND CONTRACTURE (LLPS). LLPS involves placing the soft tissues in ques-
PROTECTION OF UNSTABLE JOINTS. During the low-tone tion on submaximal stretch for prolonged periods.
stage, joints tend to become malaligned secondary to This technique is quite different from the common
loss of muscular stabilization. In these cases patients are passive range of motion with terminal stretch (high-
at risk for injury to unstable joints (traction injuries and load brief stretch) programs commonly used to treat
joint trauma) because of the joint instability. The gleno- this population.”®
humeral and wrist joints are particularly at risk. The LLPS programs can be implemented in various ways,
glenohumeral joint (usually already inferiorly sublux- including splinting, casting, and positioning programs.
ated at this stage) is at risk for a superimposed orthope- For example, during a UE assessment, a patient is noted
dic injury if another individual unknowingly pulls on to have tightness in the internal rotators, overactive in-
the affected arm during self-care and mobility or during ternal rotation during attempts to move, and weakened
unskilled passive range of motion (PROM) of the joint. external rotators. An effective LLPS would involve
The unstable glenohumeral joint is in a malaligned having the patient rest in a supine position with both
state, putting the patient at risk for an impingement syn- hands behind his or her head, allowing the elbows to
drome during PROM if normal joint mechanics is not drop toward the bed. This is a normal resting posture
addressed. Key joint motions of concern are upward ro- during recumbent leisure activities (e.g., watching tele-
tation of the scapula and external (lateral) rotation of vision) and effectively elongates the muscle group iden-
the shoulder. If these motions are not present and range tified as a contracture risk for a prolonged period.”
of motion is forced, the patient is at risk for the devel- LLPS can also be achieved through splinting pro-
opment of an impingement and pain syndrome.” grams. A common example is that of a splint designed
Patients with low tone also have an unstable wrist. to elongate the long flexors of the hand during sleeping
Care should be taken to protect the wrist if the patients hours.
are not controlling the joint during ADL and mobility SPLINTING. Commonly a controversial subject in the
tasks. Patients commonly practice a bed mobility or management of stroke, splinting should be considered
lower extremity dressing sequence, then complete the on a case-by-case basis and may be quite effective for
task while bearing weight through a malaligned flexed many clients.°® In the low-tone stage the most com-
wrist. These patients are at risk for orthopedic injury mon uses for splints are maintaining joint alignment,
666 TREATMENT APPLICATIONS

protecting the tissues from shortening or overstretching,

preventing injury to the extremity, and serving as an ad-
junctive treatment for edema control.?® Specifically, Es mples of Assistive Devices Used
splinting support may be needed to provide palmar fter Stroke to Improve Task Performance
arch support and maintain neutral wrist deviation and
the neutral position of the wrist between flexion and ex-
tension. For most cases the fingers do not require splint- Rocker knife
ing in this stage of recovery.’® Elastic laces and lace locks
Splints may also be effective for patients developing Adapted cutting board
spasticity. In these cases the splints may be used to Dycem
Plate guards
maintain soft-tissue length, provide LLPS, place muscles
Pot stabilizer
at their resting lengths on both sides of the joints, and
Playing card holder
attempt distal relaxation by promoting proximal align- Suction devices to stabilize mixing bowls, cleaning brushes
ment.?®
PATIENT MANAGEMENT. In addition to the interven-
tions already described, it is helpful to train the patient
to manage his or her UE. For a patient with low tone the in this population are also candidates for dominance re-
most important information to share with the patient training. Deformity control to prevent body image
and significant others is the method for protecting the issues is paramount for these patients.
unstable joints and maintaining full range of motion. In
the spastic stage the treatment of choice is to teach posi- Inability to Perform Chosen Tasks
tioning that will provide prolonged elongation to the
Secondary to Visual Impairment
overactive muscles and that will prevent contracture.
Examples of positions that may be prescribed during The processing of visual information is a complex act
leisure or self-care activities include the following”: that requires intact functioning of multiple peripheral
1. Weight bearing on the extended arm (elongates com- and CNS structures to support functional independence.
monly shortened UE musculature) The site of the lesion determines the visual dysfunction
2. In supine position, hands behind the head while al- and the effect on task performance (Fig. 37-8).’
lowing the elbows to drop toward the bed (provides Visual dysfunction and its treatment are detailed in
stretch to the internal rotators) Chapter 24. In general, treatment may focus on remedi-
3. In supine position, a pillow protracting the scapula ation such as eye calisthenics, fixations, scanning, visual
and under the elbow to promote glenohumeral joint motor techniques, and bilateral integration. Adaptive
alignment techniques are also used, including a change in working
4. Lying on a protracted scapula to maintain stretch of distance, the use of prisms, adaptations for driving,
the retractors and maintain scapulathoracic mobility adaptations for reading, changes in lighting, and en-
5. Supporting the involved wrist with the more func- larged print.*’’?
tional hand and reaching down toward the floor
with both hands (This pattern will elongate muscles
Psychosocial Adjustment _
that tend to contract during difficult activities, which
is particularly helpful after gait activities or difficult An important role of the occupational therapist is helping
self-care activities. ) in the patient’s adjustment to hospitalization and, more
The keys to prescribing a proper resting posture are to important, to disability. Much patience and a supportive
identify muscle groups in the trunk and upper limb that approach by the therapist are essential. The therapist
are shortening, overactive, or at risk to develop shorten- must be sensitive to the fact that the patient has experi-
ing, and to select a comfortable posture that elongates enced a devastating and life-threatening illness that has
the muscle group for a prolonged period. caused sudden and dramatic changes in the patient's life
roles and performance. The therapist must be cognizant
The Nonfunctional Upper Extremity of the normal adjustment process and must gear the ap-
Although the restoration of UE control is a realistic goal proach and performance expectations to the patient's
for some patients, many patients will not regain enough level of adjustment. Frequently the patient is not ready to
control to integrate the affected UE into ADL and mo- engage in rehabilitation measures with wholehearted
bility tasks. Patients who will not regain enough control effort until several months after onset of the disability.
require extensive retraining in BADL and IADL® (see Family education is extremely important throughout
Chapter 13) using one-handed techniques and prescrip- the treatment program. The family can be better
tion of appropriate assistive devices (Box 37-5). Persons equipped to assist their loved one with the adjustment
 Cerebrovascular Accident 667

>

*
ewVeeO
wvoe®®@ ae
LOT)
OS
=
Cosh

Lack of controlled eye movements Lack of controlled

Visual field inattention eye movements
or neglect
Spatial relation Visual field
dysfunction inattention

Visual object
agnosia

Visual loss
Anomia and grammatical
language problems
LEFT HEMISPHERE RIGHT HEMISPHERE
FIG. 37-8
Visual processing deficits. (From Arnadottir G: The brain and behavior: assessing cortical dysfunction
through activities of daily living, St Louis, 1990, Mosby.)

to disability if they have knowledge and understanding

SUMMARY
of the disability and its implications.
Many patients dwell on the possibility of full recovery CVA is a complex disability that challenges the skills of
of function and need to be made aware gradually that professional health care workers. Although the number
some residual dysfunction is likely. The therapist may ap- and effectiveness of approaches for the remediation of
proach this probability by discussing in objective terms affected motor, sensory, perceptual, cognitive, and per-
what is known about prognosis for functional recovery formance dysfunctions have increased considerably,
from CVA. This information may have to be reviewed many limitations in treatment remain. The occupa-
many times with the patient before the patient begins to tional therapist must bear in mind that the degree to
apply it to his or her recovery, and it should be done ina which the patient achieves treatment goals depends on
way that is honest and yet does not destroy all hope. the CNS damage and recovery, psychoneurological
The OT program should focus on the skills and abili- residuals, psychosocial adjustment, and the skilled ap-
ties of the patient. The patient’s attention should be plication of appropriate treatment by all concerned
focused, through the performance of activity, on his or health professionals.
her remaining and newly learned skills. The OT Some patients remain severely disabled in spite of
program can also involve therapeutic group activities the noblest efforts of rehabilitation workers, whereas
for socialization and sharing of common problems and others recover quite spontaneously with minimal help
their solutions. The discovery that there are residual in a short period. Most patients benefit from the profes-
abilities, and perhaps new abilities and success at per- sional skills of occupational therapists and other reha-
forming many daily living skills and activities that were bilitation specialists and achieve improvement of
initially thought to be impossible, can improve the performance skills and resumption of meaningful
patient's mental health and outlook. occupational roles.
 TREATMENT APPLICATIONS

CASE STUDY 37-1

Case Stupy—Mr.L.
Mr. L. is a 64-year-old man who lives in an elevator apartment Mr. L. was a private person and identified the desire to toilet,
by himself. He works as a manager for a garden center and was bathe, and dress in at least his undergarments independently as
looking forward to retiring next year to enjoy his lifelong an initial focus of OT intervention. Activities of interest, such as
hobbies of furniture refinishing and antiquing. plant care and modified sports activities, were chosen in con-
Mr L. has a medical history of atrial fibrillation and one junction with Mr. L. These activities were presented in such a
morning woke up with slurred speech and an inability to move manner as to remediate trunk control and standing balance. The
his left side. His medical workup revealed a large right cere- activities were graded to promote increasing amounts of weight
brovascular accident of the middle cerebral artery. Mr L. was shifting and tolerance for sitting and standing postures.
medically stabilized and admitted to the local rehabilitation Specific one-handed techniques for dressing and toileting
center, were taught to Mr L. He was encouraged to practice independ-
Mr. L. was seen by occupational therapy (OT), as well as by ently. Durable medical equipment (tub bench and commode)
physical therapy, speech-language pathology, and respiratory was prescribed to increase Mr. L's safety during bathroom activi-
therapy. His OT evaluation revealed that he was cognitively intact ties and to compensate for his balance dysfunction. As he mas-
except for mild, short-term memory loss that was attributed to tered his chosen tasks, Mr. L's affect brightened, he was able to
his being overwhelmed with his situation. The evaluation also re- continue his participation in treatment, and his outlook related to
vealed the appearance of depression (poor eye contact, no initi- his future remained optimistic.
ation of conversation), 0/5 strength in his left upper extremity Although Mr. L. did not regain use of his upper extremity,
with an inferior subluxation, loss of trunk control characterized adaptive techniques and equipment allowed him to be inde-
by falling to the left, and an impaired ability to stand secondary to pendent in his chosen activities. He was provided with a home
knee buckling. He required moderate assistance for basic ADL exercise program to maintain upper extremity flexibility and
(except being independent with oral care and shaving while prevent pain. He continued to work on instrumental ADL and
seated) and maximal assistance for instrumental ADL requiring leisure task participation during his rehabilitation stay and with his
bilateral upper extremities. home care occupational therapist.

REVIEW QUESTIONS
15. How can occupational therapy assist with the psy-
1. Define CVA and list three of its causes. chosocial adjustment of the hemiplegic patient?
2. List the disturbances that can result from occlusion
of the ACA, MCA, PCA, and cerebellar arteries.
3. Name three modifiable risk factors associated with REFERENCES
1. Abreu B et al: Occupational performance and the functional
stroke. approach. In Royeen C: AOTA self-study: cognitive rehabilitation,
4. Define transient ischemic attack. Bethesda, Md, 1994, American Occupational Therapy Association.
5. Name three functional deficits that occur as a result 2. Ada L et al: Task-specific training of reaching and manipulation.
of loss of trunk control. In Bennett KMB, Castiello U, editors: Insights into the reach to grasp
6. Besides the paralysis of limbs and trunk after CVA, movements, New York, 1994, Elsevier Science.
3. Aloisio L: Visual dysfunction. In Gillen G, Burkhardt A, editors:
what important motor disturbances can result? Stroke rehabilitation: a function-based approach, St Louis, 1998,
7. Name two components of a “client-centered ap- Mosby.
proach” to evaluation. 4. American Heart Association: 1999 Heart and stroke statistical
8. What are two frames of reference used to treat neu- update, Dallas, 1998, The Association.
robehavioral impairments after stroke? 5. American Occupational Therapy Association: Uniform terminol-
ogy for occupational therapy, ed 3, Am J Occup Ther 48(11):1047-
9. Name three postural reactions that support stand- 1054, 1994.
ing activities. 6. Andersen LT: Shoulder pain in hemiplegia, Am J Occup Ther
10. How does aphasia differ from dysarthria? 39(1):11-19, 1985.
11. Describe four ways to aid effective communication 7. Arnadottir G: The brain and behavior: assessing cortical dysfunction
with an aphasic patient. through activities of daily living, St Louis, 1990, Mosby.
8. Arnadottir G: Impact of neurobehavioral deficits of activities of
12. What is the importance of comprehensive occupa- daily living. In Gillen G, Burkhardt A, editors: Stroke rehabilitation:
tional therapy evaluation of patients with hemi- a function-based approach, St Louis, 1998, Mosby.
plegia? 9. Bartels MN: Pathophysiology and medical management of stroke.
13. Describe two methods used to maintain range of In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-
motion. based approach, St Louis, 1998, Mosby.
10. Basmajian JV: The surgical anatomy and function of the arm-trunk
14. List four major elements of the occupational mechanism, Surg Clin North Am 43:1471-1482, 1963.
therapy program for hemiplegia. Describe the pur- 11. Beck AT, Steer RA: Beck Depression Inventory Manual, rev ed, New
poses of each. York, 1987, Psychological Corp.
 Cerebrovascular Accident 669

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 38
Traumatic Brain Injury

LEARNING OBJECTIVES
Closed head injury After studying this chapter the student or practitioner
Open head injury will be able to do the following:
Substance use 1. Describe the pathology underlying traumatic brain
Neuroplasticity injury (TBI).
Posttraumatic amnesia 2. State current medical, surgical, and pharmaceutical
Decorticate rigidity interventions for acute TBI.
Decerebrate rigidity 3. Identify levels of consciousness in TBI patients using
Spasticity standard scales.
Unilateral neglect syndrome 4. Describe the clinical picture of individuals with
Disinhibition TBI, including common physical, cognitive, and
Behavioral management psychosocial sequelae.
Sensory stimulation 5. Identify occupational therapy (OT) evaluation
methods for beginning, intermediate, and advanced
patients with TBI.
6. Identify several standard OT assessments for
physical, cognitive, and psychosocial impairment
after TBI.
7. Describe OT treatment methods for beginning,
intermediate, and advanced patients with TBI.
8. Describe the continuum of care services available for
a patient with TBI in the acute, subacute, and
postacute stages of rehabilitation.

‘a brain injury (TBI) is an insult to the brain located on the underside of the skull. Such rapid move-
resulting from an external physical force (as differenti- ment of the brain pulls apart and damages nerve fibers
ated from a degenerative or congenital condition), often that regulate all sensations traveling to the brain and all
causing impairment of cognitive, perceptual, and physi- motor signals emerging from the brain and leading to all
cal functioning. There are two basic categories of TBI: body parts. OHI is a visible injury that often results from
closed head injury (CHI), in which the skull remains gunshot and knife wounds and accidents causing pene-
intact, and open head injury (OHI), in which the skull is tration of the skull and exposure ofbrain substance.”
fractured or penetrated. CHI usually results from motor Nontraumatic brain injury may result from organic,
vehicle accidents (MVAs) and falls that cause rapid accel- degenerative, and congenital conditions. Cardiac arrest,
eration and deceleration of the head. The stress of accel- stroke, and drowning accidents all can cause anoxia or
eration and deceleration causes the brain to be jolted loss of oxygen to the brain, leading to brain injury. Tu-
back and forth and bounce off the bony prominences mors, toxic substances (e.g., carbon monoxide poisoning

671
672 TREATMENT APPLICATIONS

and drug overdose), and infection (e.g., encephalitis) can sulting from TBI. Primary damage is the original physi-
also cause brain injury.?? This chapter focuses on brain cal impairment resulting directly from the event that
injury of the traumatic categories (CHI and OHI). caused the TBI. Secondary damage is produced as a con-
Medical technology to prolong the lives of individu- sequence of the original primary tissue damage.
als who sustain TBI emerged in the 1980s with the in-
vention of high-powered imaging tools such as mag-
Primary Damage
netic resonance imaging (MRI), computed tomography
(CT), positron emission tomography (PET), and more The first category of primary damage, focal brain injury,
effective clinical pathways and medical practices.*° Each is localized, meaning that damage to specific brain areas
year, approximately 373,000 Americans are hospital- can be identified on imaging scans (e.g., CT and MRI
ized as a result of TBI. Of these, 99,000 individuals scans). A focal brain injury is commonly caused by pen-
sustain moderate to severe brain injuries that result in etrating wounds (e.g, gunshot and knife wounds) and is
lifelong disabling conditions. It is estimated that 56,000 often a result of an open head injury.
Americans die each year as a result of TBI.” A diffuse brain injury is not localized, but rather in-
The cost of TBI in the United States is estimated to be volves widespread damage to brain tissue; this damage
$48.3 billion annually. Approximately $31.7 billion of is more difficult to pinpoint on imaging scans. A diffuse
this figure is attributed to postacute hospitalization and axonal injury (DAI) often results from high-speed auto
supportive living arrangements because individuals accidents that cause severe strain and shearing of axons
with moderate to severe TBI often require lifelong reha- throughout the white matter (neuronal axons) and
bilitative assistance.” damage to small capillaries and veins. Shearing occurs
as the brain accelerates, decelerates, or rotates against
the sharp bony prominences (the sphenoid wings, the
POPULATION
petrous bones, and the orbital bones) on the underside
Eighty percent of individuals who sustain TBI are men of the skull, causing tearing of the gray matter (cell .
between the ages of 18 and 30. TBI occurs more fre- bodies). Shearing of brain structures that are more
quently in men than in women by a ratio of 4:1. It is loosely connected to the underneath of the skull and
suggested that males are more likely to sustain TBI the gray matter causes axonal stretching and tearing.**
because of lifestyle and risk exposure activities. Most Both focal and diffuse brain injury may involve skull
young men sustain TBI as a result of MVAs, violence, fractures. Three basic types of skull fractures occur with
and sports that have a safety-risk element. Alcohol use is TBI: linear, depressed, and basilar. Linear skull fractures
a leading contributor to TBI. Two thirds of individuals occur most frequently. These fractures are considered to
who have sustained TBI have measurable blood alcohol be the least serious and extend from the site of impact
levels. Although substance abuse is a major concomi- in a linear fashion. Depressed skull fractures occur
tant of TBI, very few TBI rehabilitation programs are when a small object contacts the skull with great force,
prepared to address adequately both the physical and resulting in a depression or cavitation of the bone at the
cognitive sequelae of TBI and the precipitating alcohol point of impact. Basilar skull fractures are fracture lines
abuse. This is a serious problem because one third of all that radiate from the point of contact to the base of the
individuals with TBI who are released from rehabilita- skull. Basilar skull fractures create an abnormal pathway
tion services return to substance use.’ between air contained in the neural sinuses and the sub-
The risk of TBI is also great among infants, toddlers, arachnoid space, leading to cerebrospinal fluid (CSF)
and the elderly. According to the National Pediatric leakage. Depressed and basilar skull fractures place pa-
Trauma Registry, more than 30,000 children sustain per- tients at a higher risk for infection. Such patients are
manent disability as a result of TBI. Mortality, however, treated prophylactically with antibiotics. Because basilar
is higher in adults than in children because of a child's skull fractures frequently involve the petrous bone,
greater neuroplasticity, the ability for the central cranial nerve damage often results. The most commonly
nervous system (CNS) to reorganize neurological path- damaged cranial nerves as a result of TBI are I, II, III, VI,
ways to compensate for damaged brain areas.** Appro- VII, and VIII because of their position within the skull.°
priate rehabilitation treatment for the cognitive, percep-
tual, psychosocial, and physical sequelae of TBI is vital
because a second head injury occurs in 15% to 20% of
Secondary Damage
those who sustain TBI.” After the initial primary damage of a TBI occurs, various
secondary responses are produced. The most common
of these secondary responses is an increase in intracra-
PATHOPHYSIOLOGY
nial pressure (ICP). Because intracranial contents (e.g.,
Two commonly described categories of TBI are diffuse brain matter, sinuses, CSF, arteries, and veins) are en-
and focal. Both are considered to be primary damage re- closed within a rigid skull, ICP increases as a result of
 Traumatic Brain Injury

cerebral edema, hematoma, or obstruction of CSE. As patient should be transported as quickly as possible to a
ICP increases, cerebral blood flow is compromised and trauma unit that specializes in TBI care. Upon the
anoxic brain damage can occur. Uncontrolled increased patient’s admission to the emergency room the first
ICP causes diffuse hypoxia (lack of oxygenated blood to concern is to address the ABCs: airway, breathing, and
brain areas), eventually leading to cardiovascular and blood circulation. An obstructed airway may require
renal failure, brain herniation, and death. Uncontrolled suctioning, intubation, or tracheostomy. The patient
ICP accounts for 50% of TBI-related deaths.!° may be in shock and need intravenous (IV) fluids,
Cerebral edema is a natural body response result- plasma, blood transfusions, or vasopressor agents.
ing from hypoxia. Again, because brain contents are Imaging (e.g., MRI or CT) is performed to evaluate the
encased in a rigid, nonexpandable skull, there is no extent of damage and detect focal abnormalities. It is
natural way for the body to accommodate increased often difficult to evaluate the extent of damage soon
volume. Uncontrolled cerebral edema is a major factor after a TBI because CT scans may not identify a diffuse
that causes increased ICP, leading to morbidity.'” type of brain injury.
Posttraumatic hydrocephalus is an abnormal accumu- Traditional methods of treating acute TBI involved
lation of CSF that can also cause increased ICP.A common restricting fluids to prevent further swelling. However,
treatment for obstructive hydrocephalus is ventroperi- research has shown that IV fluids are critical for adding
toneal shunting, in which a tube is placed to circumvent volume to increase pressure to the circulatory system. A
the ventricular blockage and discharge excess CSF to the strong blood pressure forces oxygenated blood to the
peritoneal cavity.”'° Normal-pressure hydrocephalus brain. Restricting fluids causes blood pressure to drop,
occurs when the ventricles enlarge without an increase in resulting in poorer patient outcomes.”
CSF pressure. Normal-pressure hydrocephalus is indi- Standards of care for acute TBI have changed over the
cated by a slow onset of symptoms, including dementia, years. Medical professionals now know that the second-
incontinence, and an unsteady gait. Such symptoms can ary damage from TBI (i.e., increased ICP, cerebral
progress over weeks to months following TBI.** edema, hydrocephalus, hematoma, subarachnoid hem-
A hematoma is a collection of blood in a space- orrhage, and seizures) causes more impairment to brain
occupying lesion. In other words the pooling of blood structures and functioning than does the initial primary
displaces areas where brain tissue should normally lie. damage. It is therefore critical to treat the secondary
Hematomas may result in distortion of brain tissue, ob- damage of TBI aggressively in the first week of hospital-
struction of CSE and decreased cerebral circulation. ization. '’ Two of the newest critical pathways (or guide-
Treatment may involve evacuation of the blood through lines for practice) for acute TBI that have been shown to
burr holes.°** be effective through scientific research methods are ven-
A subarachnoid hemorrhage involves bleeding into triculostomy with continued monitoring of ICP and
the subarachnoid space and ventricles and often results cooling hypothermia treatment.
from contusions over orbital surfaces. Hemorrhages— Ventriculostomy involves the insertion of a tube into
rather than hematomas—form because the pooling the brain (where the CSF is produced) to drain the in-
blood does not clot as it is diluted by the CSE Symp- creased fluid and relieve swelling. The surgeon drills a
toms include blood in the CSE, painful stiff neck, head- hole into the skull and punctures the dura until the CSF
ache, and restlessness. The most common treatment of a sinus is tapped. A catheter is placed 5 to 7 mm into the
subarachnoid hemorrhage is drainage through a ven- CSF canal. The catheter is then connected to a monitor
troperitoneal shunt. '’ that continuously measures fluid pressure for several
Posttraumatic epilepsy is a sudden abnormal dis- days. A normal ICP level is 0 to 10. Patients exhibiting
charge of cerebral neurons that is characterized by an ICP of 20 or higher are at severe risk for further brain
brief attacks of altered consciousness, motor activity, or damage. When brain swelling cannot be controlled, the
sensory phenomena. Medication is commonly pre- brain chokes off the supply of oxygenated blood. In the
scribed for this condition.'® ventriculostomy procedure, medications are used to
Further secondary damage includes brain distortion, raise and maintain the blood pressure at 70 points
shift, and herniation. In the presence of expanding fluid higher than the ICP. A raised blood pressure will force
and increased ICP, the brain will eventually attempt to oxygenated blood through the brain.**
compensate by distorting its normal shape. Treatment If the ICP does not decrease and a hematoma occurs,
may involve surgery and control of the increased ICP a hole must be drilled through the skull to drain the
and edema.*** fluid and remove the hematoma. Either the patient's
removed skull section is replaced, or a metal brain plate
is secured over the surgically removed skull section.
MEDICAL MANAGEMENT OF ACUTE TBI
Signs that the acute crisis is over include the patient's
Few emergency trauma units are set up to adequately opening the eyes with visual tracking and responding to
handle the acute medical management of TBI. Thus the commands (e.g., “squeeze my hand”). Because research
674 TREATMENT APPLICATIONS

has demonstrated that these guidelines for the acute As mentioned, posttraumatic epilepsy is a common
treatment of TBI are effective, the World Health Organi- occurrence with TBI. Seizures may begin immediately at
zation approved and adopted them as standard care the time of injury or even several years later. Prophylac-
practices in 1997.8 tic treatment with anticonvulsants in comatose patients
One other method that has been shown to be effec- should be started in the emergency room because re-
tive in the treatment of acute TBI is the cooling hy- search suggests that the risk of early posttraumatic
pothermia treatment. The cooling hypothermia method seizures may be reduced by the administration of such
involves the use of ice water to decrease the patient's medication.° The patient is transferred to a subacute re-
metabolism, thereby diminishing the cascade of neuro- habilitation service when he or she is considered med-
chemical reactions that immediately follows TBI and ically stable—that is, the cardiovascular, respiratory, and
culminates in further destruction of brain cells. After neurological status have stabilized and there are no
TBI a flood of a neurotransmitter called glutamate is re- acute signs and symptoms of serious infection.
leased throughout the brain at 1000 times its normal
level. It is believed that this flood of glutamate initiates
COMA AND LEVELS OF CONSCIOUSNESS
a series of biochemical events that further damages and
destroys brain cells.” A TBI typically results in an altered level of conscious-
The conventional method for preventing the mass de- ness. The continuum of consciousness includes coma at
struction of brain cells resulting from abnormal gluta- one end, a stuporous state in the middle, and con-
mate levels involves the administration of medications sciousness at the opposite end. The individual's progres-
to lower ICP and the placing ofthe patient on a respirator sion along this continuum of consciousness is unique
to increase oxygenated blood levels. High ICP and low and depends on age, prior health status, substance
oxygen levels are thought to initiate the overproduction abuse history, and, especially, severity of injury.
of glutamate. In hypothermia treatment the patient is Coma is a state of sleeplike (eyes closed) unarous-
placed in a specialized bed in which the arms and legs are ability as a result of extensive brain damage. Coma that
wrapped in cool packs that are attached to pumps pro- involves severe damage to the brainstem often indicates
viding a constant infusion of ice. For 8 hours the body a poor prognosis. The brainstem contains the reticular
temperature is gradually lowered to 89° to 90° F—a tem- activating system, which is the arousal system for the
perature low enough to slow metabolism but not cause entire brain. When severe damage occurs to the reticular
life-threatening complications such as irregular heart- activating system, all communication between the body
beat. By slowing the metabolism, the cooling decreases and the cerebral hemispheres is disrupted. The brain-
ICP and inhibits the release of glutamate. Patients ‘stem controls vegetative functions such as respiration
remain in a state of hypothermia for 48 hours, the and primitive stereotyped reflexes such as cough reflex,
longest time possible before dangerous reactions ensue. gag reflex, and swallowing reflex. Because individuals
Then the patient's body temperature is gradually warmed with severe brainstem involvement lose the cough, gag,
to normal, and ICP continues to be monitored until and swallowing responses, they are likely to have fatal
normal. For cooling hypothermia to be most effective, it respiratory infections in 6 months to 1 year.7°
must begin within the first 6 hours after injury.”””" Persistent vegetative state is a form of coma in which
Drug therapy is among the experimental methods the brunt of neurological destruction has occurred to
being used to treat acute TBI. One such drug, aptiganel the cerebral hemispheres but the brainstem has re-
hydrochloride, is designed to prevent the destruction of mained intact. A persistent vegetative state often results
brain cells by breaking one link in the chain of chemical from hypoxia, or a lack of oxygen to the brain for a
reactions that follows excessive glutamate production. period of minutes. Because the brainstem is fairly resist-
Research is needed to demonstrate the effectiveness of ant to hypoxia, it is often spared, although cerebral
aptiganel hydrochloride.” hemisphere tissue is commonly destroyed. Sparing of
Nutrition begins by IV within the first few days after the brainstem allows the continued functions of respira-
injury. Later, parenteral nutrition (nasogastric [NG] tion and the cough, gag, and swallowing reflexes, which
tube) or enteral nutrition (gastric tube) is often needed significantly decreases the likelihood of fatal respiratory
to ensure that the patient receives adequate nutrition if infections. As a result, individuals can live for years in
the level of awareness is decreased or oral-bulbar func- persistent vegetative states. A persistent vegetative state
tion is impaired. In these procedures either an NG tube may be a transient coma that continues for a period of
is inserted through the nose or a gastrostomy tube days to months (or longer). When the patient begins to
is surgically placed within the stomach cavity.° Bowel emerge from a vegetative state, he or she will awaken
and bladder function is often impaired, necessitating into a condition of eyes-open, unresponsive uncon-
catheterization. Later in rehabilitation, as bowel and sciousness but demonstrate a reflexive response to
bladder function begins to return, a bowel and bladder painful or vigorous stimulation. This state is particularly
program is initiated. difficult for family members because the patient appears
 Traumatic Brain Injury

Glasgow Coma Scale

Patient’s Response Assigned Score
ening Spontaneous Opens eyes on own 4
ee ees : Speech “Opens eyes when asked to in a loud voice 8
“Ss ; Pain Opens eyes when pinched 2
i ws Pain Does not open eyes |
%Best motor response Commands Follows simple commands 6

ieee Pain Pulls examiner's hand away when pinched 5

Pain Pulls a part of body away when examiner pinches patient 4
Pain Flexes body inappropriately to pain (decorticate posturing) 3

Pain Body becomes rigid in an extended position when examiner pinches 2

victim (decerebrate posturing)

Pain Has no motor response to pinch |

Verbal response (talking) Speech Carries on a conversation correctly and tells examiner 5
where he is, who he is, and the month and year

Speech Seems confused or disoriented a

Speech Talks so examiner can understand victim but makes no sense 5

Speech Makes sounds that examiner can't understand zl

Speech Makes no noise |

From Rosenthal M and associates: Rehabilitation of the head-injured adult, Philadelphia, 1984, FA Davis.

conscious (eyes open) but does not interact with any

person or object in the environment.”°
If the patient emerges from a vegetative state, he or ration of Posttraumatic Amnesia
she will have a clouding of consciousness characterized | Severity of Injury
by reduced wakefulness, reduced clarity of thought, PTA Duration Severity
confusion, decreased attention span, and memory Less than 5 min Very mild
lapses. Conversely, in complete consciousness the indi-
vidual possesses awareness of the self and the surround- 5 to 60 min Mild
ing environment, is able to perceive and correctly inter- | to 24 hr Moderate
pret his or her perceptions, and displays appropriate
| to 7 days Severe
responses. Complete consciousness is a function of an
intact cortex. | to 4 weeks Very severe
The Glasgow Coma Scale (GCS) has been the tradi-
More than 4 weeks Extremely severe
tional method used by health care professionals t&
assess levels of consciousness after a TBI (Table 38-1). From Rosenthal M and associates; Rehabilitation of the head-injured adult,
The GCS has been used to quantify the severity of brain Philadelphia, 1984, FA Davis.
injury and predict outcome. Three behavioral areas as- PTA, Posttraumatic amnesia.

sessed in the GCS are motor responses, verbal re-

sponses, and eye opening. Although more recent studies
have suggested that the GCS is not an effective predictor events. There is evidence that the duration of PTA is
of long-term TBI outcomes, the GCS is an effective indi- highly correlated with patient outcomes. Longer PTAs
cator of acute TBI status.”” are associated with poorer long-term cognitive and
Posttraumatic amnesia (PTA) has traditionally been motor abilities. A PTA of4 weeks or greater is correlated
used as another predictor of outcome (Table 38-2). PTA with significant long-term disability.°
is the length of time from the injury to the moment The Ranchos Los Amigos Scale is an assessment that
when the patient regains ongoing memory of daily measures levels of awareness and cognitive function.”
 TREATMENT APPLICATIONS

vels of Cognitive Functioning

I. No response. Patient appears to be in a deep sleep and is patient does not, however, discriminate among persons or
completely unresponsive to any stimuli presented to him or objects and is unable to cooperate directly with treatment
her. i effort. Verbalization is frequently incoherent and
Generalized response. The patient reacts inconsistently inappropriate to the environment. Confabulation may be
and nonpurposefully to stimuli in a nonspecific manner. present; the patient may be euphoric or hostile. Thus gross
Responses are limited in nature and are often the same, attention is very short and selective attention is often
regardless of the stimulus presented. Responses may be nonexistent. Being unaware of present events, the patient
physiological changes, gross body movements, or lacks short-term recall and may be reacting to past events.
vocalization. Often the earliest response is to deep pain. He or she is unable to perform self-care (e.g., feeding and
Responses are likely to be delayed. dressing) without maximum assistance. If not disabled
Ill. Localized response. The patient reacts specifically but physically, the patient may perform motor activities as in
inconsistently to stimuli. Responses are directly related to sitting, reaching, and ambulating, but as part of the agitated
the type of stimulus presented, as in turning the head state and not as a purposeful act or on request.
toward a sound or focusing on an object presented. The V. Confused, inappropriate, nonagitated. The patient
patient may withdraw an extremity or vocalize when appears alert and is able to respond to simple commands
presented with a painful stimulus. He or she may follow fairly consistently. However, with increased complexity of
simple commands in an inconsistent, delayed manner, such commands or lack of any external structure, responses are
as in closing the eyes, squeezing, or extending an extremity. nonpurposeful, random, or at best fragmented toward any
After the external stimulus is removed, the patient may lie desired goal. The patient may show agitated behavior not on
quietly. He or she may also show a vague awareness of self an internal basis (as in Level IV), but rather as a result of
and body by responding to discomfort by pulling at a external stimuli, and usually out of proportion to the
nasogastric (NG) tube or catheter or resisting restraints. stimulus. He or she has gross attention to the environment,
The patient may show bias by responding to some persons but is highly distractible and lacks the ability to focus
(especially family, friends) but not to others. attention to a specific task without frequent redirection back
IV. Confused-agitated. The patient is in a heightened state to it.With structure, the patient may be able to converse on
of activity with a severely decreased ability to process a social, automatic level for short periods oftime.
information. He or she is detached from the present and Verbalization is often inappropriate; confabulation may be
responds primarily to his or her own internal confusion. triggered by present events. Memory is severely impaired,
Behavior is frequently bizarre and nonpurposeful relative to with confusion of past and present in his or her reaction to
the immediate environment. The patient may cry out or ongoing activity. The patient lacks initiation of functional tasks
scream out of proportion to stimuli even after removal and and often shows inappropriate use of objects without
may show aggressive behavior attempt to remove restraints external direction. He or she may be able to perform
or tubes, or crawl out of bed in a purposeful manner. The previously learned tasks when they are structured for him or

An abridged version of the scale appears below; for a function. However, it is not meant to be used as a pre-
complete description of the assessment, see Box 38-1. dictive scale.
Level I No response. Unresponsive to any stimulus. No accurate predictive measures of long-term out-
Level II Generalized response. Nonspecific, inconsistent, come have been developed. The GCS predicts outcome
and nonpurposeful responses to stimuli (often more accurately in patients with a GCS score of 7 or
only to pain). more. * In addition to severity of injury, age, and prior
Level III Localized response. Response directly related to
the type of stimuli presented, yet responses
health status, social factors can significantly determine
still inconsistent and delayed. an individual's long-term prognosis. Individuals who
Level IV Confused-agitated. Heightened state of activity, have large and committed supportive networks and can
confusion, disorientation; may exhibit access financial and material resources fare the best, par-
aggressive behaviors; agitation appears related ticularly if they receive aggressive and effective acute
to internal confusion.
Level V Confused-inappropriate. Appears alert, responds
care. For individuals with histories of alcohol abuse, a
to simple commands, distractible; does not return to substance use after injury appears to be a pre-
concentrate on task; agitated responses to dictor of a possible second brain injury. Patients who
external stimuli; verbally inappropriate; does receive substance abuse counseling and who do not
not learn new information.
return to alcohol use have better prognoses.*” Studies
The Ranchos Los Amigos Scale can be used at any time have also suggested that although cognitive, perceptual,
after injury to assess level of awareness and cognitive psychosocial, and physical gains occur most rapidly in
 Traumatic Brain Injury

Lever of Cognitive Functioning—cont’d

_ her, but the patient is unable to learn new information. He or goes through the daily routine automatically, but is
__ she responds best
to self, body, comfort—and often family frequently robot-like. The patient has minimal to absent
members. The patient can usually perform self-care activities confusion but has shallow recall of what he or she has been
with assistance and may accomplish feeding with maximum doing. He or she shows increased awareness of self, body,
“supervision. Management on the ward is often a problem if family, foods, people, and interaction in the environment. The
_ the patient is physically mobile, as he or she may wander off patient has superficial awareness of, but lacks insight into, his
either randomly or with vague intention of ‘going home.” or her condition, demonstrates decreased judgment and
vi Confused-appropriate. The patient shows goal-directed problem solving, and lacks realistic planning for the future.
behavior but is dependent on external input for direction. He or she shows carryover for new learning, but at a
The response to discomfort is appropriate and the patient decreased rate. He or she requires at least minimal
is able to tolerate unpleasant stimuli (e.g, NG tube) when supervision for learning and for safety purposes and is
the need is explained. The patient follows simple directions independent in self-care activities and supervised in home
consistently and shows carryover for tasks that have been and community skills for safety, With structure the patient is
_ relearned (such as self-care). He or she is at least able to initiate tasks in social and recreational activities in
supervised with old learning and is unable to maximally which he or she now has interest. Judgment remains
assist for new learning with little or no carryover. Responses impaired, such that the patient is unable to drive a car.
may be incorrect because of memory problems, but they Prevocational or avocational evaluation and counseling may
are appropriate to the situation. Responses may be delayed, be indicated.
and the patient shows a decreased ability to process Vill. Purposeful and appropriate. The patient is alert and
information with little or no anticipation or prediction of oriented, is able to recall and integrate past and recent
events. Past memories show more depth and detail than events, and is aware of and responsive to his or her culture.
recent memory. The patient may show beginning awareness He or she shows carryover for new learning if it is
of his or her situation by realizing he or she doesn’t know acceptable to him or her and his or her life role. The patient
an answer The patient no longer wanders and is needs no supervision after activities are learned within his or
inconsistently oriented to time and place. Selective attention her physical capabilities. He or she is independent in home
to tasks may be impaired, especially with difficult tasks and and community skills, including driving. Vocational
in unstructured settings, but the patient is now functional for rehabilitation, to determine ability to return as a contributor
common daily activities (30 min with structure). He or she to society (perhaps in a new capacity), is indicated. The
~ shows at least vague recognition of some staff, has increased patient may continue to show a decreased ability, relative to
awareness of self, family, and basic needs (e.g., food), again in premorbid abilities, in reasoning, tolerance for stress,
an appropriate manner, as in contrast to LevelV. __. judgment in emergencies, or unusual circumstances. His or
VII. Automatic-appropriate. The patient appears her social, emotional, and intellectual capacities may continue
appropriate and oriented within hospital and home settings, to be at a decreased level, but are functional for society.

From Rancho Los Amigos Medical Center, Downey, Calif, Adult Brain Injury Service: Original Scale, Levels of Cognitive Functioning, 1980.

the first 2 years after injury, subtle and slow recovery rigidity. In decorticate rigidity the upper extremities
from deficits can continue throughout an individual's (UEs) are in a spastic flexed position with internal ro-
life.° tation and adduction. The lower extremities (LEs) are
in a spastic extended position, but also internally
CLINICAL PICTURE OF INDIVIDUALS rotated and adducted. Decorticate rigidity results from
WITH TRAUMATIC BRAIN INJURY damage to the cerebral hemispheres (particularly the
internal capsules), causing an interruption in the
Physical Status corticospinal tracts—the spinal cord tracts that emerge
Most individuals with moderate to severe TBI exhibit from the cortex and send voluntary motor messages to
primitive reflexes, impaired muscle tone, decreased all extremities.
motor control and coordination, decreased muscular In decerebrate rigidity both the UEs and LEs are in
strength and endurance, postural deficits, decreased a position of spastic extension, adduction, and inter-
range of motion (ROM) in one or more joints, de- nal rotation. The wrist and fingers flex, the feet plantar
creased sensation, and impaired proprioception. flex and invert, the trunk extends, and the head re-
tracts. Decerebrate rigidity occurs as a result of
Decorticate and Decerebrate Rigidity damage to the brainstem and extrapyramidal tracts—
Comatose individuals often display one of two the tracts that send involuntary motor messages from the
common positions: decorticate rigidity and decerebrate brainstem to the extremities. Patients with decerebrate
678 TREATMENT APPLICATIONS

rigidity have a poorer prognosis than do those exhibit-

ing decorticate rigidity."”"”
Generally, patients emerging from coma have a re- Pe miitive Reflex Levels
duction in spasticity as neurological recovery pro-
gresses. However, patients with moderate to severe spas-
Spinal Cord Level Reflexes
ticity tend to experience some degree of spasticity or
Flexor withdrawal
abnormal tone for the remainder of their lives. Extensor thrust
Crossed extension
Abnormal Muscle Tone and Spasticity
Although decorticate rigidity and decerebrate rigidity Brainstem Level Reflexes
are the most severe types of abnormal muscle tone Asymmetrical tonic neck
caused by TBI and tend to occur in comatose individu- Symmetrical tonic neck
als, spasticity in a patient with TBI may range from Tonic labyrinthine reflex
minimal to severe in any muscle group. Patients who Positive supporting reaction
are functioning at a higher cognitive level than coma Associated reactions
generally display a combination of both hypotonicity
Midbrain
(decreased tone, or flaccidity) and hypertonicity (in-
Righting reactions
creased tone, or spasticity). Depending on the injury
site, spasticity and flaccidity can occur on one side of the Basal Ganglia
body in both the UEs and LEs, bilaterally in any of the Protective extension
four extremities, or unilaterally in one limb (either Equilibrium reactions
upper or lower extremity). It is important to understand Cortical reactions
and to teach family members and the patient that tone Optical righting
fluctuates as a result of changes in position, volitional
movement, medication, infection and illness, hormonal
changes (particularly the monthly hormonal changes
that occur in female patients), pain, and changes in who display associated reactions commonly have in-
emotional state.” creased spasticity in their involved extremity when
they attempt volitional movement with their opposite
Primitive Reflexes extremity.
If present beyond their usual time of disappearance, If damage has occurred to the midbrain, impaired
primitive reflexes are indicative of moderate to severe righting reactions are commonly observed. Similarly,
brain injury. The adult patient with a TBI often dis- damage to the basal ganglia can result in the absence
plays one or more CNS levels of primitive reflexes. of equilibrium reactions and protective extension. The
The absence of primitive reflexes on reevaluation is absence of righting reactions, equilibrium reactions,
a sign of progress in recovery. Primitive reflexes and protective extension places the patient at a signifi-
emerge from the five CNS levels: spinal cord, brain- cant risk for further injury from falls during such activi-
stem (medulla and lower pons), midbrain, basal ties as transfers, getting out of bed, toileting, bathing,
ganglia, and the cerebral hemispheres.” The level of and dressing. .
primitive reflexes that emerge in the patient with TBI
depends on the injury site and interruption of nerve Muscle Weakness
signals to the body (Box 38-2). For example, an indi- A decrease in muscular strength—without spasticity—
vidual with brain damage interrupting signals to the can occur in the patient with TBI. Often such decondi-
spinal cord may experience extensor thrust when the tioning results from a lack of physical activity or ex-
heel is stimulated by contact with the floor. This ex- tended bed rest caused by secondary factors associated
tensor thrust reflex will interfere with transfers to a with the TBI (e.g., compromised respiration, fractures,
seated position. It is common to observe an asymmet- and infection).
rical tonic neck reflex, a positive supporting reaction,
and associated reactions if damage has occurred to the Decreased Endurance
brainstem area. The asymmetrical tonic neck reflex Decreased endurance and vital capacity usually accom-
prevents rolling from a supine to a prone position to pany reduced muscular strength as a result of medical
get out of bed. The presence of a positive supporting complications such as pneumonia or infections, and
reaction will inhibit the ability to flex the LEs alterna- as a result of prolonged bed rest. Increasing the patient's
tively in walking. Associated reactions are stereotyped muscular strength and endurance are primary goals
movement patterns, in which one extremity influences in the intensive care unit and in the initial stages of
the posture of another extremity. Individuals with TBI rehabilitation.
 Traumatic Brain Injury 679

Ataxia 3. Upper extremities. Depending on the area and severity

Ataxia is a movement abnormality characterized by inco- of brain damage, the UEs may be bilaterally or uni-
ordinated movements and decreased tone. Ataxia results laterally involved. When both UEs are involved, it is
from impairment of the cerebellum or the sensory path- common to see asymmetry between the UEs. For
ways leading to and from the cerebellum. Thus impaired example, one extremity may be hypertonic, whereas
sensation often accompanies ataxia.’ Ataxia can occur the other displays hypotonicity. In unilateral involve-
in the entire body, in the trunk, or in the UEs and LEs. ment it is common to see variations in ROM, tone,
The patient with ataxia has lost the ability to perform and strength in each muscle group and joint of the
minute adjustments in the distal and proximal extremi- arm, forearm, wrist, and hand. For example, the
ties that are necessary for smooth, coordinated move- biceps may exhibit reduced strength and a moderate
ment. The degree of ataxia can range from mild to severe. degree of hypertonicity, whereas the digits may be
The patient with truncal ataxia displays decreased pos- nonfunctional because of extreme spastic flexion.
tural stability in standing and sitting. He or she has diffi- Primitive reflexes such as the asymmetrical tonic
culty maintaining the trunk in a stable position to free neck and associated reactions commonly reinforce
the UEs for activities. The patient may compensate for UE postural deformities.
this deficit by holding onto a stable surface such as a 4. Lower extremities. Severe extension patterns are often
tabletop. Ataxia in the UEs causes dysfunction in activi- observed in both LEs in the comatose patient. Pa-
ties in which the patient attempts to perform gross or fine tients exhibiting a higher cognitive level may dis-
motor movements, such as bringing a glass of water to play bilateral or unilateral involvement of the LEs.
the mouth. The UE oscillates back and forth, causing In bilateral involvement it is common to see mus-
spillage of the water. Ataxia in the LEs results in an im- cular weakness in one LE and moderate to severe
paired ability to ambulate while maintaining balance; spastic extension in the other. In unilateral involve-
falls can easily occur with this condition. ment the involved LE may display some degree of
spastic extension and primitive reflexes that rein-
Postural Deficits force postural deformities, such as a positive sup-
Postural deficits develop as a result of an imbalance in porting reaction. Other commonly observed pos-
muscle tone throughout the body. A patient may inad- tural deficits include hip adduction and internal
vertently accentuate postural deficits by using ineffective rotation, knee flexion, plantar flexion, and inversion
strategies to compensate for impaired motor control, of the feet.
delayed or absent righting reactions or impaired vision, 5. Trunk: Kyphosis, scoliosis, and lordosis may all be
cognition, or perception. The therapist must possess a present secondary to weak or spastic muscles (e.g.,
thorough knowledge of the patient's postural deficits to abdominal, spinal, and paraspinal). It is also com-
properly position the patient in a wheelchair with the mon to observe lateral flexion and rotation of the
appropriate seating equipment, which is necessary’ to involved side as a result of hypertonicity.
obtain an upright posture, maintain good postural 6. Pelvis: A posterior pelvic tilt is common because of
alignment, and prevent further postural deformities. hypertonicity of the intrinsic back muscles (e.g., the
Abnormal postures frequently exhibited in adults with iliocostalis and longissimus). A posterior pelvic tilt
moderate to severe TBI include the following: results in sacral sitting and facilitates kyphosis.
1. Head and neck. Many patients with TBI exhibit Another typical pattern is retraction of one side of
forward flexion or hyperextension of the neck. The the pelvis with a pelvic obliquity, in which one side
head may be laterally flexed to the involved side. of the pelvis sits lower than the other side as a result
Lateral flexion of the head often accompanies lateral of hypertonicity of the quadratus lumborum on the
flexion of the trunk because the muscle groups involved side.
on the involved side may be spastic and commonly
pull the head, neck, and trunk into lateral flexion. Limitations of Joint Motion
Because equilibrium reactions and kinesthesia are Patients with TBI frequently exhibit loss of ROM in the
often impaired, the patient does not have con- joints in the involved extremities. It is often difficult to
scious knowledge of this postural deformity and will distinguish between several possible causes of decreased
not voluntarily attempt to correct it. Primitive re- ROM, such as the following: increased muscle tone,
flexes such as the asymmetric tonic neck reflex may spastic contractures, heterotopic ossification (in which
be exhibited. abnormal bone substance forms in the joint capsule,
2. Scapula. The scapula may be depressed, protracted or causing immobility of the joint), fractures or disloca-
retracted, downwardly rotated, or all of these at once. tions, and tissue pain. Because the treatment of de-
This results from an imbalance in scapular muscle creased ROM depends on the cause, it is important for
tone; some muscles are hypertonic, whereas others the therapist to determine the cause of the decreased
are hypotonic. ROM before initiating treatment.
680 TREATMENT APPLICATIONS

Loss of Sensation patient will have difficulty monitoring the amount and
Patients with TBI may display absent or diminished sen- rate of food brought to the mouth, thus causing cough-
sation. Lost or diminished light touch, sharp-dull dif- ing and possible aspiration. Oral apraxia, the inability
ferentiation, proprioception, kinesthesia, and vibration to perform an intended action or execute an act on
result from brain damage that interrupts the signals command with the mouth or lips, may occur. If the
from the dorsal columns (or medial lemniscus tracts) patient possesses an ideational apraxia, he or she will
leading to the postcentral gyrus. Lost or diminished have difficulty understanding the demands required of
temperature and pain sensations result from brain the self-feeding activity and will be unable to recognize
damage that interrupts the signals from the lateral utensils as tools for eating. A patient may also have lost
spinothalamic tracts leading to the postcentral gyrus. the motor plan for self-feeding (ideomotor apraxia) and
Lost or diminished stereognosis, two-point discrimina- be unable to access the neurological motor pattern for
tion, and graphesthesia (the ability to interpret letters bringing food to the mouth. A hemianopsia (visual field
written on the hand without visual input) result from cut) may prevent a patient from seeing one half of the
damage to the parietal lobe (specifically the sensory as- plate of food.
sociation areas). Lost or diminished taste, smell, and
sensation of the face result from cranial nerve damage.”
Cognitive Status
Loss of the Integration of Total Body Movements Cognitive deficits in the patient with TBI are always
Total body movements include the integration of head, evident to varying degrees. The most common include
neck, and trunk control, with dynamic sitting and decreased attention and concentration, impaired mem-
standing balance while reaching, bending, stooping, ory, impaired initiation and termination of activities,
and ambulating. To perform total body movements, the decreased safety awareness and poor judgment, impul-
patient must coordinate and modulate gross and fine © sivity, and difficulty with executive functions and ab-
motor movements of the trunk-head-neck and the stract thinking (e.g., problem solving, planning, the in-
limbs while performing activities of daily living (ADL). tegration of new learning, and generalization).
A patient with severe physical involvement often dis-
plays poor sitting and standing balance and is unable to Reduced Attention and Concentration
maintain an upright position in order to free the UEs for Reduced attention and concentration impair the ability
activities. The patient at a more advanced level may to maintain an activity without distractibility and to
exhibit subtle deficits in total body movements, making resume an activity when interrupted. The patient with
it difficult to bend down, to reach overhead to retrieve TBI often loses both the ability to concentrate for a
items in a cabinet, or to stoop to retrieve an item fallen length of time and the ability to filter out distractions
to the floor. Integrated total body movements are neces- from the surrounding environment. A patient who is
sary for the performance of almost all ADL. conversing with one individual may detect a peripheral
conversation (among others in the environment) and
incorporate pieces of that conversation into his or her
Dysphagia and Self-Feeding
own sentences. The inability to attend to and concen-
Dysphagia is a difficulty in the four stages of chewing trate on activities severely impedes the ability to func-
and swallowing, caused by cranial nerve damage (see tion at work and school and to complete ADL. Although
Chapter 40). There is a higher incidence of oral prep- deficits in attention and concentration can diminish
aratory, oral, and pharyngeal stage dysphagia than as neurological recovery progresses, such deficits can
esophageal stage dysphagia. Typically, more than one remain in varying degrees throughout an individual's
stage of chewing and swallowing is impaired.* life. Even patients who experience mild TBI can demon-
With dysphagia the cognitive, visual-perceptual, and strate subtle deficits in attention and concentration that
neurological problems evident in the patient with TBI often linger for years after injury.
further complicate the ability to self-feed. A patient may
display oral muscular hypotonicity or hypertonicity as a Impaired Memory
result of cranial nerve damage. A patient may exhibit in- Impaired memory is the most frequently observed cog-
stability of the jaw because of cranial nerve damage and nitive deficit in the patient with TBI and can remain a
secondary fractures. A patient may also possess abnor- problem for the remainder of the individual’s life.
mal oral reflexes, such as rooting, biting, sucking, Memory impairment can range from the inability to
gagging, or coughing, that prevent the activity of eating. recall several words just heard (immediate memory), to
Cognitively, the patient may experience difficulty in se- forgetting which family members visited the patient last
quencing chewing, swallowing, and breathing. The night (short-term memory), to having lost memory of
patient may also be unable to sustain attention long events that occurred years before the injury (long-term
enough to self-feed. If impulsivity is apparent, the memory). Despite neurological recovery, most patients
 Traumatic Brain Injury 681

with moderate to severe TBI continue to demonstrate is important for the therapist to recognize the presence
short-term memory deficits. Often, patients recover of delayed processing and to distinguish the delay from
long-term memory of events that occurred years before the absence of function. For example, during a sensory
the injury. This can be emotionally devastating because evaluation a patient may exhibit a delay in response to a
the individual with TBI commonly has a clear memory dull stimulus. The therapist may mistakenly interpret
of who he or she was before the injury, as well as his or the patient's delayed processing time as an absence of
her accomplishments, goals, and plans for the future— sensory awareness. A delay in the processing of external
all of which were severely disrupted and perhaps lost as information from the environment can include visual,
a result of TBI. auditory, sensory, and perceptual processing.

Impaired Initiation and Termination Impaired Executive Functions

of Activities and Abstract Thinking
Impaired initiation and termination of activities affect Executive function skills include the ability to plan, set
the ability to start and end activities. The inability to ini- goals, understand the consequences of one’s actions,
tiate activities without assistance significantly affects the and modify behaviors in accordance with environmen-
individual's ability to live independently. In general, the tal responses. Abstract thinking is the ability to hold
patient who exhibits deficits in initiation progresses best and manipulate a concept in one’s mind using critical
in a rehabilitation setting that provides assistance and reasoning and analytical skills. Many patients with TBI
structure. Patients discharged home rather than to a exhibit concrete thinking, in which they are able to in-
supportive living arrangement commonly regress if left terpret information only at the most literal level. For
alone to complete daily activities. Similarly, patients example, a patient with impaired executive and abstract
may exhibit difficulty terminating an activity once it is functions may be able to complete a meal preparation
started. Perseveration may develop, in which the patient activity accurately and safely only if step-by-step direc-
cannot end the neurological motor pattern started for a tions are provided. If the directions do not specifically
specific activity. For example, a client with a TBI in a vo- state to modify the cooking temperatures, the patient
cational program may refuse to end his work task to may burn the food because he or she is unable to
break for lunch because he or she feels compelled to foresee the consequences of maintaining the stove on a
continue. Sometimes perseveration involves a thought high setting.
process. A patient may be unable to concentrate on
one activity because he or she is perseverating on the Generalization
idea that another activity (e.g., the laundry) must be Generalization of new learning is the ability to learn a
completed. specific task and transfer the skills needed for that task
to a similar activity. Deficits in executive functions, ab-
Decreased Safety Awareness and Poor Judgment stract thinking, and short-term memory significantly
Frontal lobe damage often results in an impairment of impair the generalization of new learning. For example,
insight regarding a person’s limitations, as well as im- a patient who has learned in a group home the skills for
pulsivity, or the inability to consider consequences completing a laundry task may be unable to transfer the
before acting. These results cause the patient to dem- skills to an unfamiliar laundromat. Often this occurs as
onstrate poor safety awareness and judgment. For a result of concrete thinking and the inability to make
example, a patient may attempt to rise out of a wheel- abstractions. Although the cognitive pattern for com-
chair without locking the brakes or moving the foot pleting laundry tasks using the laundry machine in the
plates. A higher-level client who has been reintegrated group home is established, the patient cannot transfer
into the community may attempt to cross streets that cognitive pattern to a similar but unfamiliar
without observing traffic signals or remove pots from laundry machine in a different environment. Impaired
the stove or oven without using protective oven mitts or generalization of new learning is one of the most sig-
pot holders. It is important for the occupational thera- nificant problems impeding the individual’s ability
pist to structure the patient’s environment to reduce ac- to resume independent functioning in a community
cidents and increase the patient’s awareness of his or her setting.
limitations through repeated opportunities to practice
and relearn safe and appropriate behaviors.
Visual Status
Delayed Processing of Information Visual skills involve the ability to accurately see stimuli
Most individuals with TBI have some degree of difficulty from the external environment (see Chapter 24). Vi-
with the processing of external information from the sual skills do not involve the identification of objects,
environment. A delay in response time is often noted which is a function of perception. Among the many
and can range from a few seconds to several minutes. It deficits in visual skills that may result from TBI are
682 TREATMENT APPLICATIONS

accommodative dysfunction (causing blurred vision), but also can occur as a result of frontal and occipital
convergence insufficiency (the inability to maintain a lobe damage. The patient with a left unilateral neglect
single vision while fixating on an object), lateral or may disown his or her left extremities as though they
medial strabismus, nystagmus, hemianopsia, and im- belonged to someone else. For example, a patient may
pairment of scanning and pursuits. Saccades (fast, jerky shave only the right side of his face or dress only the
movements of the eyes as they change from one posi- right side of his body.”*”
tion of gaze to another, as are needed to track the puck Perceptual-speech and language dysfunctions, or the
in a hockey game) may also be compromised by TBI. aphasias, involve impairment in the expression and
Reduced blink rate, ptosis of the eyelid (drooping of the comprehension of language. There are two primary
eyelid), and lagophthalmos (incomplete eyelid closure) types of aphasia: receptive and expressive. The aphasias
are also common visual deficits resulting from oculo- can result from both left and right occipital, parietal,
motor nerve damage.”’*” and temporal lobe damage. Wernicke’s aphasia is a type
A dysfunction in any of these visual elements can of receptive aphasia that results from left temporal-
profoundly affect daily life function. Individuals rely on parietal lesions. In Wernicke’s aphasia the individual
vision indirectly in social and interpersonal interac- cannot comprehend what others have said to him or
tions. Vision is used as a cueing and feedback system in her; however, the person’s own speech is fluid and
motor skills such as ambulation and in eye-hand coor- intact. If receptive aphasia results from a right hemi-
dination activities. Deficits in vision can affect all daily sphere lesion, aprosodia occurs. Aprosodia causes im-
life activities, including the areas of hygiene and groom- paired comprehension of the tonal inflections or emo-
ing, meal preparation and eating, wheelchair mobility, tional tone of another's speech. For example, a receptive
reading and writing, and driving. aphasic with a left hemisphere disorder can still accu-
rately interpret the emotional tone of a conversation but
cannot understand the literal meaning of the words
Perceptual Skills
spoken (Wernicke’s aphasia). A receptive aphasic with a
Perception is the ability to interpret stimuli from the ex- right hemisphere disorder can understand the concrete
ternal environment (see Chapter 26). Perception is a meaning of the words spoken but cannot accurately in-
function of the secondary cortical areas of the right terpret the emotional tone of the conversation (aproso-
hemisphere, including the secondary visual area, the dia). This latter type of patient may miss the point of a
secondary somatosensory area, the secondary auditory joke or story because he or she could not comprehend
area, and the multimodal parietal-occipital-temporal the subtle innuendoes and the implicit meanings con-
area. Perceptual deficits are more often a result of right veyed through tonal qualities and inflections.*°
hemisphere damage but also sometimes occur in left Receptive aphasias also include alexia, or dyslexia
hemisphere lesions. Perception can be categorized into (difficulty comprehending the written word), and asym-
visual perception, body schema perception, motor percep- bolia (difficulty comprehending the meaning of ges-
tion, and speech and language perception. A patient with tures and symbols such as shaking the head no). Expres-
visual perceptual impairments may exhibit difficulty sive aphasia includes Broca’s aphasia (the inability to
with right-left discrimination, figure-ground discrimina- express and transfer thoughts to spoken words), anomia
tion, form constancy, position in space, and topograph- (the inability to transfer the word or name for a specific
ical orientation. Visual perceptual deficits also include object or person from the mind into spoken words), and
visual agnosia, in which the patient displays difficulty agrommation (a difficulty arranging words in a sentence
recognizing familiar objects and people. For example, in an accurate sequence).*° Patients with TBI commonly
prosopagnosia is the inability to connect faces with display one or more aphasias, making communication
names. Prosopagnosia results from damage to the mul- with others difficult. The inability to communicate needs
timodal association area.” often causes added frustration and agitation.
Body schema perception is the awareness of the Perceptual-motor dysfunction is an impairment in
spatial characteristics of a person’s own body. This motor planning, or an apraxia. The apraxias are usually a
awareness is derived from a neural synthesis of tactile, result of impairment to the premotor cortex and the
proprioceptive, and pressure sensory associations about primary motor area of the frontal lobe. It is in these corti-
the body and its individual parts. A common problem cal areas that established motor patterns for specific ac-
in persons with TBI is anosognosia, a failure to recog- tivities are stored and accessed for the execution of
nize defects or limitations. This may lead to the body common movement patterns. Ideational apraxia is the
schema perceptual dysfunction of unilateral neglect inability to understand the demands of a task or the use
syndrome, in which the individual has lost the ability of the wrong motor plan for a specific task. For example,
to integrate perceptions from one side of the body or a patient may not understand that a shirt is an item of
environment (usually the left). A unilateral neglect is clothing to be placed on the torso and UEs. Not under-
commonly caused by a lesion to the right parietal lobe standing the demands of the task, he may be unable to
 Traumatic Brain Injury

activate the motor plan for UE dressing, or he may acti- Many individuals with TBI report that the feeling of iso-
vate the wrong plan and attempt to place his legs through lation and the inability to form and maintain social re-
the sleeve holes. Sometimes this is referred to as a dress- lationships is their most troubling postinjury concern.
ing apraxia. Ideomotor apraxia is the loss of the kinetic The loss of the roles of dating or of partner or spouse
memory of amovement pattern for a specific activity. The commonly leave the individual feeling a deep sense of
patient may understand that a shirt is an item of clothing loss and failure if he or she cannot rebuild a postinjury
to be placed on the torso and UEs but be unable to life that includes intimacy with another human being,
execute the appropriate movement plan because it is no partnership in a committed relationship, and parenting
longer accessible. Constructional apraxia is the inability of children. The loss of the work role and the inability
to accurately put together pieces of an object to form a to support oneself are intimately tied to the feelings of
three-dimensional whole. For example, a patient whose dependence and lack of personal control.?°
profession was carpentry may now be unable to put to-
gether the wooden pieces of a birdhouse kit.” Independent Living Status
As a result of the physical, cognitive, and psychosocial
sequelae of TBI, many individuals find that they require
Psychosocial Factors
supportive living arrangements or that they must live
Researchers have found that the greatest concerns of in- with their parents. The loss of the ability to live inde-
dividuals 1 or more years after injury are the psychoso- pendently in the community further reinforces feelings
cial deficits that prevent them from rebuilding a satisfac- of dependence and decreased personal control. As a
tory postinjury quality of life. As time after injury result of these role losses, adults who sustain a TBI com-
increases, patients and family members view such psy- monly experience role strain and feel that they cannot
chosocial factors as more detrimental than both the reenter their communities. The TBI, particularly if it oc-
physical and cognitive sequelae of TBI. curred between the ages of 18 and 30, disrupts the de-
velopmental transition from adolescence to adulthood,
Self-Concept leaving individuals feeling inadequate and unable to
One of the most difficult psychosocial sequelae of TBI attain a postinjury adult status. Depression, withdrawal,
is the alteration in the individual's self-concept. Self- and apathy are common psychosocial sequelae of the
concept is the internal image a person holds about per- alterations in self-concept discussed earlier and of the
sonal human identity, sexual and gender identity, body loss of desired social roles.**
‘image, personal strengths and limitations, and position
in the family, peer group, and community systems. An Dealing With Loss
individual's self-concept changes drastically after TBI. Individuals with TBI often experience a process that is
One of the most difficult characteristics of TBI is that al- similar to the stages of death and dying experienced by
though short-term memory is often impaired, long- terminally ill patients.*° These stages begin with denial,
term memory commonly remains intact. The individual in which the individual denies that he is experiencing
has a clear memory of who he or she was before injury physical, cognitive, or psychosocial deficits. Denial can
and must now resolve the emotional conflict of having impede therapy because the patient may refuse to partic-
to let go of the preinjury self-concept to rebuild a ipate, believing that therapy is unnecessary. Denial sub-
postinjury self-concept that is both meaningful and sat- sides (by degrees) as the patient is continually con-
isfying. Some patients describe this process as an un- fronted with his or her limitations in daily life activities.
wanted death and rebirth. They say that the person who Anger follows denial. The patient grows increasingly
lived before the injury is now gone, replaced by another aware of his or her deficits and becomes frustrated and
who is very different from the individual they remem- angry because recovery is slower than desired. Bargaining
ber themselves to be.*” is the next stage. The patient strikes a deal with the
Creator or the fates, offering to work as diligently as pos-
Social Roles sible in therapy if the creator will restore the individual's
Self-concept is derived largely from the social roles the preinjury lifestyle. Often this stage is marked by in-
person attains in the family, peer group, and larger com- creased motivation and optimism. Depression tends to
munity systems. Commonly the individual with TBI emerge next. The patient begins to realize the severity of
loses most preinjury roles and the activities that sup- the injury and the meaning that the injury holds for the
ported those roles. Family and peer group roles change. rest of the individual's life. Acceptance of the injury and
Family members and friends are often readily visible resultant limitations is the next stage in the process and is
during the acute and subacute stages of TBI rehabilita- necessary for the individual to become sufficiently moti-
tion. However, as time after injury increases, family and vated to attempt to build a postinjury life that, although
friends become less and less involved with the individ- drastically different from preinjury goals and expecta-
ual, leaving him or her feeling isolated and abandoned. tions, is nevertheless meaningful and personally valu-
684 TREATMENT APPLICATIONS

able. These stages may require years of transition. Often TBI and may involve using obscenities, making indis-
denial, anger, and bargaining occur in the first months to criminate sexual advances to staff or strangers in the
a year after the injury. Depression sets in as the individual community, and removing clothing in public settings.
is able to let go of some of the denial and becomes aware Such disinhibition results from damage to the frontal
ofthe effect the injury will have on his or her future life. It lobe areas that mediate behavioral control according to
may take years before an individual can truly accept the learned social norms.
injury and the alterations in personality, skill, and A patient's agitation may occur sporadically in iso-
lifestyle and move on to rebuild a new life. The process of lated contexts. Many patients experience periods of agi-
denial, anger, depression, and acceptance does not gen- tation and confusion for weeks or months during the
erally proceed in a linear fashion. Patients commonly ex- subacute recovery period. These periods tend to be re-
perience repeated periods of denial, anger, and depres- placed by more appropriate behaviors as neurological
sion throughout their years of rehabilitation. Renewed recovery progresses. However, some patients experience
denial, anger, and depression may occur in response to a severe behavioral disturbances that do not change with
new environmental demand, such as a change in life time. It is important to provide a behavioral manage-
condition (e.g., a need to move from the parental home ment program for patients displaying long-term and
to a community group home) or the development of chronic behavioral problems.
further physical, cognitive, or psychosocial deterioration
over time (e.g., the need for increased ambulatory assis-
EVALUATION OF THE BEGINNING-LEVEL
tance because of a deterioration in visual skills).
PATIENT
Affective Changes A beginning-level patient with TBI (Ranchos Los Amigos
Depression, increased emotional lability, and decreased Scale score of 1 to 3) may be comatose, exhibit minimal
affect can result from the neurological damage itself. Pa- arousal, or display severe confusion and attentional
tients with left hemisphere damage tend to exhibit in- deficits. Evaluation of such patients may have to be com-
creased depression and emotional lability. Lesions of pleted in short segments because of the patients’ low
the left orbitofrontal lobe often cause severe depression level of functioning. A quiet environment with minimal
and heightened affect (including excitement, agitation, distractions will enhance the patients’ concentration and
and tearfulness). Lesions of the left dorsolateral frontal ability to attend to the therapist's requests. Evaluation
lobe commonly result in a decreased or flat affect. A will include assessment of the following items:
patient with these lesions may appear depressed to the 1. Cognition. Is the patient oriented and alert? Can the
observer even though he or she may feel fine. Neurolog- patient respond to simple verbal commands, such as
ical damage to the right hemisphere often causes a “Squeeze my finger”? Can the patient communicate
strange sense of euphoria or lack of emotional response through verbalizations or eye movements?
to the severity of injury.” 2. Vision. Is the patient able to scan an object or main-
tain eye contact with the therapist? Does the patient's
eye open in response to the sound of a human voice?
Behavioral Factors
3. Sensation. Does the patient respond to external stim-
Behavioral disturbance is common in TBI recovery. ulation such as pain or cold?
Most behavioral disturbances are organically based and 4. Joint ROM. Has the patient lost ROM in certain joints
result from specific neurological damage. Cognitive as a result of decorticate or decerebrate rigidity, in-
levels IV and V of the Ranchos Los Amigos Scale de- creased tone and spasticity, contractures, or hetero-
scribe the patient who is confused and agitated and topic ossification?
behaves in a socially inappropriate manner. Patients 5. Muscular strength. Does the patient demonstrate
may exhibit behavioral problems on a continuum from weakness in muscle groups without accompanied
severely verbally and physically combative to mildly changes in tone?
confused and agitated. Patients who are experiencing 6. Motor control. Is the patient exhibiting decorticate or
severe confusion are often impatient, easily irritated, decerebrate rigidity? Is the patient experiencing in-
and combative (both physically and verbally). They creased tone and spasticity bilaterally, unilaterally, or
may shout, scream, and be restless. Such agitation is in one or more limbs? Does the patient have de-
neither purposeful nor permanent, but rather results creased tone and hypotonicity? Are deep tendon re-
from the patient's inability to correctly interpret events sponses present, diminished, or absent? Does the
in the environment. Displays of anger are often quickly patient exhibit the presence of primitive reflexes?
forgotten, allowing the therapist to redirect the patient 7. Dysphagia. If the patient is self-feeding, can he or she
to another, less confusing activity. eat without aspirating? Is the patient able to exhibit
Social inappropriateness and disinhibition are also oral motor control without pocketing the food in his
common behavioral problems in some patients with or her cheeks or drooling?
 Traumatic Brain Injury 685

8. Psychosocial and behavioral factors. Is the patient's eyes. Gustatory stimulation involves the controlled
affect flat, agitated, or emotionally labile? presentation of tastes to the patient's lips and tongue
Evaluation of the beginning-level patient with TBI is using a cotton swab. Such stimulants include salty tastes
generally accomplished with such tools as a goniometer (sodium chloride solution), sweet tastes (sucrose solu-
and with manual muscle testing, a traditional neurolog- tion), bitter tastes (quinine), and sour tastes (vinegar or
ical screening, and clinical observation. Many TBI acute lemon juice). Any response from the patient is noted.
facilities use their own initial evaluation forms. The Treatment progresses from the introduction of isolated
Glasgow Coma Scale and the Ranchos Los Amigos sensory stimulants to the presentation of multisensory
Scales are often used to assess cognitive status in the be- stimuli to activate the integration of several structures of
ginning level patient. the brain simultaneously. For example, a therapist may
use tactile stimulation on the patient's face while soft
TREATMENT OF THE BEGINNING-LEVEL music is playing. The most effective types of sensory
PATIENT WITH TRAUMATIC stimulants are those that have personal meaning to the
BRAIN INJURY patient. The therapist could play the patient's favorite
songs, present the perfume worn by his girlfriend or
The general aims of treatment for the beginning-level mother, or introduce tastes for which the patient has
patient are to increase the patient's level of response and particular preferences. The therapist should learn about
awareness of self and the environment. All stimulation the patient's preinjury history, personality, and interests
must be well structured, broken down into simple steps so as to introduce meaningful sensory stimulation.
and commands. Sufficient time must be allowed for a Often patients respond more readily to the verbal com-
patient's response because cognitive processing is often mands, touch, and scents of family members than those
significantly delayed during this phase of rehabilitation. of unfamiliar health care professionals. For this reason
Treatment at this stage can be grouped into six areas: and others, it is helpful to include family members in
sensory stimulation, wheelchair positioning, bed posi- therapy from the beginning of the patient's treatment.
tioning, casting or splinting, dysphagia management, The functional approach to sensory stimulation may
behavioral and emotional management, and family and be used for the patient who displays some response to
caregiver education. sensory stimulation and verbal commands. The patient
is actively assisted by the therapist to perform simple
functional activities, such as rolling in bed, cleaning the
Sensory Stimulation
face with a damp washcloth, combing the hair, and ap-
Treatment of the beginning-level patient should start as plying lotion to the skin. The theoretical aim of the
soon as the patient is medically stable. Treatment gener- functional sensory stimulation approach is to reactivate
ally begins in the ICU. At this stage the patient often highly processed neural pathways that had been estab-
lacks responsiveness to pain, touch, sound, or sight. The lished before the injury. Some therapists use the func-
patient also may exhibit a generalized response to pain tional sensory stimulation approach in sequence, fol-
that appears reflexive (e.g., attempting to push away a lowing the presentation of isolated and multisensory
painful stimulus). The goal of treatment is to increase stimulation. The therapist observes the patient during
the patient's level of awareness by presenting controlled the activity for any changes, such as the following:
sensory stimulation. Sensory stimulation increases neu- 1. Turning of the patient’s head toward the direction of
rological signals to the reticular activating system, the sound
structure of the brainstem that alerts the brain to impor- 2. Visual attention and tracking of objects used in the
tant sensory input from the external environment.” activity
Stimulation of the reticular activating system is believed 3. Physical responses (e.g., changes in respiration,
to decrease the threshold necessary for cortical respon- muscle tone, voluntary use of the extremities, and
siveness in the beginning-level patient with TBI. posture)
Traditional methods of sensory stimulation include 4. Vocalizations (e.g., groans, sighs, or one word)
introducing isolated visual, auditory, tactile, olfactory, 5. The following of oral commands
and gustatory stimulants to the patient to heighten
arousal of the reticular activating system. For example, a
Wheelchair Positioning
flashlight may be used to elicit eye opening and visual
tracking. A therapist may ring a bell or play music and Seating and positioning are important components.
observe the patient's response to auditory stimulation. Because wheelchair ambulation provides the first op-
During olfactory stimulation a variety of scents (e.g., portunity for the patient to interact with the immediate
vanilla and banana) may be placed under the patient's environment in an upright posture, positioning aims to
nose to stimulate arousal. The therapist waits for the help the patient keep the head erect and see people and
patient to respond in some way, such as opening the objects in the environment. A proper wheelchair seating
686 TREATMENT APPLICATIONS

position helps prevent skin breakdown and joint con- buttocks should bear weight evenly, with both ischial
tractures, facilitate normal tone, inhibit primitive re- tuberosities firmly resting on the wheelchair seat; sacral
flexes, promote safety, and enhance cognitive skills sitting is contraindicated. A seat belt angled across the
(Fig. 38-1). pelvis helps maintain this desired position. The patient
Effective seating and positioning require a stable base must be able to release the seat belt because restraining
of support at the pelvis, maintenance of the trunk in devices are illegal and could cause agitation in the con-
midline, and placement of the head in an upright fused patient.
posture. This position frees the UEs for use and allows
the patient to visually scan the environment. Trunk
The trunk should be positioned after the pelvis because
Pelvis it is the next most proximal body structure. A solid back
Wheelchair positioning should begin at the pelvis, since insert or solid contoured back should be placed behind
poor hip placement adversely alters trunk and head the patient's back to maintain the spine in an erect
alignment and influences tone in the extremities. posture. A back insert that is contoured to the curves in
Because sling-seat wheelchairs contribute to internal ro- the spine will maintain the lumbar and thoracic curves.
tation and adduction of the hips, it is important to Lateral trunk supports can be used to reduce scoliosis
insert a hard, solid seat (padded with foam and covered and lateral trunk flexion caused by imbalanced tone of
by vinyl) to facilitate a neutral to slightly anterior pelvic the intrinsic muscles of the back. A chest strap (with
tilt. A lumbar support will also help to maintain the easily opened Velcro fasteners) can be used to decrease
natural curve in the lumbar spine. A wedged seat insert kyphosis, facilitate shoulder retraction and abduction,
(with the downward slope pointing toward the back of and expand the upper chest for proper diaphragmatic
the chair) can be used to facilitate hip flexion and breathing.
inhibit extensor tone in the hips and LEs. The patient's
Lower Extremities
An abductor wedge placed between the LEs just proxi-
mal to the knees may be used to decrease hip adduction
and internal rotation. If hip abduction is present, foam
pads can be placed along the lateral aspect of the thigh
to reduce LE abduction. Ideally the knees should be po-
sitioned at 90°, with the heels slightly behind the knees
in sitting. However, many patients with TBI exhibit LE
extensor spasticity and need adjustable, raised foot
plates that can place the knee in a position of extension
or a flexed position greater than 90°. It is desirable to
maintain both feet securely on the foot plates to provide
proprioceptive input and facilitate weight bearing in
both heels to normalize tone.

Upper Extremities
The UEs should be positioned with the scapulae in a
neutral position (neither elevated nor depressed), the
shoulders slightly externally rotated and abducted, the
elbows in a neutral position of slight flexion with
forearm pronation, and the wrists and digits in a func-
tional position. This position is often difficult to achieve
because of severe spasticity and soft-tissue contractures
of the UEs. A splint or cast (discussed later) may be
applied to decrease spasticity and facilitate a functional
position of the UEs. Frequently a lap tray is used to
provide support for the UEs and to encourage bilateral
UE use.

Head
FIG. 38-1 The beginning-level patient with TBI often has little or
Improved posture and trunk alignment is achieved with positioning no active head control. Attaining a neutral-midline head
devices. position, which affords the patient optimal visual
 Traumatic Brain Injury 687

contact with the environment, is difficult. A U-shaped flexed; the top elbow extended. Both wrists and all
device that cradles the head posteriorly and laterally digits should be maintained in extension, often with the
may be used to support the head in a midline position. aid of splints. The top LE should be moved into slight
A forehead strap (fabricated from soft, padded material) hip and knee flexion, supported with pillows or bol-
may be used to prevent the head from falling forward. sters. A foam wedge placed between the knees will de-
Slightly reclining the patient’s back (in an adjustable crease hip internal rotation and adduction. The bottom
wheelchair) also prevents the head from falling forward hip and knee should also be slightly flexed. This side-
and facilitates visual interaction with the environment. lying position may be maintained with bolsters or
The patient should be reclined between 10° to 15°; re- pillows behind the back, pelvis, and shoulders. The feet
clining the patient beyond this point reduces weight should not extend to the bed footboard because this
bearing through the trunk and pelvis and tends to facil- could elicit extensor thrust.
itate a posterior pelvic tilt and sacral sitting. If the patient must be maintained in a supine bed po-
As the patient progresses in rehabilitation, wheel- sition, a small pillow under the head with lateral foam
chair seating and positioning should be reevaluated wedges will keep the head in midline. The patient's
continually to better meet the needs of the patient. shoulders should be positioned in slight abduction and
Devices should be modified gradually or removed as the external rotation. Both elbows are extended, and splints
patient begins to control his or her body actively and may be used to maintain the wrist and digits in a
manipulate more items in the environment. A schedule neutral position. The use of cones or rolled towels
is necessary to indicate the length of time the patient between the digits and the palmar surface is contraindi-
should be seated in the wheelchair. Keeping the patient cated because these devices will easily move against the
in a wheelchair longer than can be tolerated will in- muscle bellies of the finger flexors and elicit further
crease behavioral problems and decrease the patient's flexor spasticity. Both hips should be maintained in
cognitive awareness. slight external rotation and abduction, with the support
of lateral bolsters placed between the patient's legs. The
patient's knees should be slightly flexed by placing
Bed Positioning
pillows or small bolsters under the distal thigh just
Proper bed positioning is also difficult to maintain above the knee joint.
because of spasticity, primitive reflexes, and abnormal
posturing. Other complications that prevent proper bed
Splinting and Casting
positioning include UE and LE casts or splints, IV tubes,
NG tubes, heterotopic ossification, fractures with open Splinting or casting is indicated when (a) spasticity has
reduction, compressive neuropathies, and active move- limited functional movement and ADL independence,
ment of the patient by other staff who need to clean the (b) joint ROM limitations are present, and (c) there is
patient, perform neurological examinations, administer potential for soft-tissue contractures. Splinting of the
medications, and access IV and NG tubes. Prolonged hands and wrists is often implemented to maintain a
use of any one position may lead to decubitus ulcers, functional position at rest and to reduce tone. Serial
particularly over bony prominences. Thus a bed posi- casting is a more aggressive intervention to increase
tioning program must include several appropriate posi- joint ROM in the elbow when severe spasticity is
tions that can be alternated during an 8-hour rest period present. Both splinting and serial casting are used to
to reduce this risk. prevent skin breakdown (particularly when severe finger
If the patient is exhibiting abnormal posturing, a flexor spasticity has caused the fingers and nails to
side-lying or semi-prone position is preferable. A supine embed in the palmar surface) and to maintain ROM for
position will elicit the tonic labyrinthine reflex, and a self-care (bathing, dressing, and bowel and bladder
supine position with the head in a lateral position will care).
elicit the asymmetrical tonic neck reflex. Because the The stretch splint is a resting splint that is worn
patient with TBI commonly has bilateral involvement, it when the patient is not involved in functional activities
is best to create a bed positioning program that involves (Fig. 38-2). Once the splint has been fabricated, a splint
alternate side-lying on both sides. This may be impossi- schedule must be established for nursing staff and care-
ble, however, given the placement of IV tubes. In the givers to follow. A typical splint schedule has the patient
side-lying position the patient's head should rest on a wearing the splint for repeated, alternating 2-hour
small pillow in a neutral, midline position, aligned with periods (2 hours on, followed by 2 hours off). The
the trunk. The bottom UE should be moved into scapu- patient must be monitored frequently for skin break-
lar protraction and shoulder external rotation. The top down or irritation caused by wearing the splint. If irrita-
UE also should be moved into scapular protraction with tion is noted, the splint must be modified. Nursing staff
slight shoulder flexion, supported on a pillow to avoid and caregivers should be trained in application and
horizontal adduction. The bottom elbow should be removal of each splint. It is also advisable to post the
688 TREATMENT APPLICATIONS

splint schedule above the patient's bed and on the ity again increases and any gain in joint ROM is often
patient's wheelchair and to mark each splint (in perma- lost.
nent marker) “right” and “left.” The most common UE casts are the elbow cast, used
Other splints that may be indicated include a wrist for decreased ROM in the elbow flexors, and the wrist,
cock-up splint, used to stabilize the wrist while enhanc- thumb, and finger cast, used for decreased ROM in the
ing finger prehension, and a thumb opposition splint. wrist, thumb, and finger flexors. Other variations of
used to facilitate palmar pinch or three-point pinch. casts include elbow and wrist casts and wrist and thumb
Splints are modified as needed and may eventually be casts. However, the casting of more than one joint at a
discontinued if the patient’s motor -control and tone time often leads to skin breakdown as a result of multi-
improve. ple pressure points. It is thus recommended that casting
A serial casting program is indicated when severe be applied to one joint at a time.
spasticity cannot be managed by splints (i.e., when the Casting is frequently used in conjunction with motor
spasticity is so great that it breaks the splint). The goal point blocks and baclofen pumps. Blocks involve the in-
of serial casting is to increase ROM and decrease tone jection of a chemical substance (e.g., Lidocaine, Mar-
gradually using a progressive succession of separately caine, phenol, Botulinum toxin) into the nerve or motor
fabricated casts, each worn continuously for a period of point to inhibit the innervation of spastic muscles tem-
weeks. Successive casts are designed to increase ROM porarily. A baclofen pump is surgically inserted into a
further until a functional joint range is achieved and patient's abdomen and time-releases the chemical to
maintained. The common difficulty that prevents the inhibit the nerve innervation of spastic muscles. Motor
success of serial casting is skin breakdown. If skin point blocks and baclofen pumps are inserted by physi-
breakdown occurs because of a cast that is worn for cians before the initiation of serial casting. The combi-
several days, the cast must be removed until the skin nation of blocks and casting is more effective than
has healed. While wound healing is occurring, spastic- casting alone~*’*° (see Chapter 23).
Indications for the completion of a casting program
include obtaining a functional ROM or plateauing (i.e.,
the patient has not gained significant improvement in
ROM after two consecutive casts). When improvement
has been made and the goal has been reached, the final
cast is cut in half, the edges are finished, and the cast is
used as a bivalved cast with Velcro straps (Fig. 38-3). A
wearing schedule is then established. The wearing of a
cast is often ended if continual treatments with baclofen
are sufficient to maintain ROM.

Dysphagia
The patient emerging from coma is fed through an NG
tube or gastrointestinal tube. Once the patient is alert
and more oriented, the physician decides when tube
feeding can be stopped, and a dysphagia evaluation is
then initiated. Dysphagia programs usually begin in the
intermediate- to advanced-level stages of rehabilitation
(see Chapter 40).

Behavioral and Emotional Management

A patient who has begun to become more alert and
aware of his or her environment will often display con-
fusion, emotional lability, or a flat affect. For the begin-
ning-level patient the therapist should provide orienta-
tion and a calming presence. The therapist should
reintroduce himself or herself to the patient at each
session, describe the therapist's role, indicate how he or
she will work with the patient, clarify why the patient is
FIG. 38-2 in the hospital (if the patient cannot remember), and
Stretch splint. orient the patient to the place (the hospital), date, time,
 Traumatic Brain Injury 689

and season. If the patient is emotionally labile, care always respect a family member's need to express anger
providers should take the time necessary to allow the and grief and should address the family member's ques-
patient to express his or her emotions, help the patient tions without personalizing any expression of anger. It
to feel that he or she has been heard by an empathic lis- is important for family members to feel that their con-
tener (the therapist), and reassure the patient that the cerns have been heard by an understanding therapist.
hospital staff are there to help him or her get better. To The unfamiliarity of the hospital setting and the serious
teduce confusion and enhance cooperation in the be- condition of a loved one often heighten fear in family
ginning-level patient, therapy should be provided in a members. A therapist who can act as a calming presence
quiet setting (e.g., bedside or in a private therapy room), while providing the family member with information is
and no more than one family member should be best able to establish the rapport necessary to elicit
present. Stimuli in the environment (e.g., other people, family cooperation and assistance in the patient's reha-
extraneous noise, and personal items) should be kept to bilitation process.
a minimum. Involving family members in therapy is a particularly
beneficial way of providing information about the loved
one’s condition while alleviating their confusion and
Family and Caregiver Education anger. Family members (or one primary family member
The therapist is in a position to provide information who is integral to the patient's well-being, such as a
and emotional support to family members and care- parent or spouse) should be involved in therapy
givers. Family members may display confusion, anger, from the beginning of the patient’s hospital stay. Fre-
and grief. At times family members direct their anger quently the patient responds first to the familiar faces
and emotional responses toward the therapist, but these of relatives when emerging from a coma. Family
actions stem from fear, feelings of lost control, and a members should be involved in therapy to elicit patient
lack of knowledge regarding TBI. The therapist should responses, assist in the sensory stimulation program,
maintain proper bed positioning, and contribute to the
ROM program. Later, when the patient is more alert and
mobile, family members can be involved in wheelchair
positioning, feeding programs, and ADL retraining.

EVALUATION OF THE INTERMEDIATE-

TO ADVANCED-LEVEL PATIENT
The intermediate- to advanced-level patient (Rancho
Los Amigos Scale score of 4 to 8) is alert but often dis-
plays confused, agitated, and inappropriate responses.
The patient may be able to follow simple two- to three-
step verbal commands but is easily distracted. Often,
minimal or moderate cues are necessary to assist the
patient in the performance of ADL. Generally, the inter-
mediate- to advanced-level patient with TBI can com-
plete most components of the OT evaluation, but
because of distractibility or agitation the patient may
need several breaks during the evaluation process. The
evaluation for the intermediate to advanced patient
with TBI is similar to that for the beginning-level
patient, in that physical status, dysphagia, psychosocial
and behavioral factors, vision, sensation, and percep-
tion are assessed. Additionally, the intermediate- to ad-
vanced-level patient requires more extensive evaluation
of ADL (including driving), work readiness, and ability
to reintegrate into the community.

Physical Status
The physical status evaluation includes an assessment
FIG. 38-3 of joint ROM, muscular strength, sensation, proprio-
Bivalved cast. ception, kinesthesia, fine and gross motor control, and
690 TREATMENT APPLICATIONS

Cognition
total body control (1.e., the patient is able to integrate
movement of separate body parts during the perform- Cognitive skills of the patient with TBI should be as-
ance of an activity that requires bilateral integration and sessed within a functional task (e.g., ADL) because
dynamic sitting or standing balance). Limitations in paper and pencil tasks do not provide the real-life situa-
physical status will probably be the result of abnormal tions that will reveal cognitive deficits. For example, a
tone, spasticity, muscle weakness without abnormal therapist may assess a patient's cognitive skills during
tone, heterotopic ossification, fractures, soft-tissue con- a cold meal preparation that requires the ability to
tractures, and peripheral nerve compression. Tools to (1) follow two- to three-step written or spoken direc-
evaluate physical status include goniometers, dynam- tions, (2) correctly sequence the order of steps, (3) attend
ometers, manual muscle testing, and clinical observa- to the task with minimal distraction, and (4) display
tion. Standard assessments may include the Jebsen good safety and judgment. When the therapist is evalua-
Hand Function Test,** the Minnesota Rate of Manipula- ting the patient's cognitive status during ADL, measure-
tion Tests,’ the Minnesota Manual Dexterity test,*” and ment of cognitive skills can be assessed by (1) counting
the Purdue Pegboard.*° the number of errors and correct responses, (2) assess-
ing the amount of assistance or cueing needed
(minimal, moderate, or maximal), and (3) totaling the
Dysphagia
percentage of the task completed correctly. Assessment
Assessment of the patient with TBI should include both of the complexity of the activity (simple versus multi-
a clinical (bedside) dysphagia assessment and videoflu- step) and the conditions of the environment (isolated
oroscopy. The bedside examination will provide the versus multistimulus) is also important.
therapist with information regarding impulsivity (does When assessing a patient's cognitive skills, it is im-
the patient gulp large portions of food quickly, thus portant to consider other factors that may affect per-
causing aspiration?), and oral motor control (can the formance. These include language barriers (e.g., the
patient make a bolus, or does the patient pocket food in presence of aphasia, a primary language other than
cheeks; can the patient manage saliva production while English), visual-perceptual deficits, the effects of med-
eating, or is drooling apparent; does the patient chew ication on cognitive level, educational and cultural
with both sides of his jaw, or is one used to compensate background, and previous experience with the task.
for decreased function on the opposing side?). The Formal cognitive assessments that may be used with a
bedside dysphagia examination will also provide the TBI population include the Allen Cognitive Level Test,’
therapist with information regarding cognitive status the Loewenstein Occupational Therapy Cognitive As-
(does the patient appear to understand what to do with sessment,*! the Rivermead Behavioural Memory Test,*°
the utensils and food items?), perceptual skills (is a and the Cognitive Assessment of Minnesota.**
neglect present, causing the patient to leave one side of
the plate untouched?), and language functioning (does
Vision
the patient know the names of the utensils and food
items, or is aphasia suspected?). Adults with TBI should undergo a vision screening.
The videofluoroscopy must be performed by a physi- The vision screening should be completed as early as
cian and will provide information regarding the possible in the rehabilitation process, since early detec-
anatomy and physiology of the oral, pharyngeal, and tion of vision deficits will allow the treatment team to
esophageal stages of swallowing. Videofluoroscopy is obtain more reliable information regarding the patient's
the only dysphagia assessment tool that can provide in- overall health status. For example, diplopia (double vi-
formation regarding the patient's ability to manage sion) or accommodative dysfunction (inability to adjust
liquids and solid foods. This information will be used focus for changes in distance) will probably influence
to design a feeding program that may require a diet of the results of the neuropsychology or speech-language
thick liquids and pureed foods. Reevaluation should be pathology assessments.
made as the patient improves in rehabilitation and can A vision screening is a tool that allows therapists to
progress to thin liquids and solid foods. (See Chapter identify potential vision deficits. Although therapists
40 for more information on dysphagia.) cannot diagnose conditions of vision dysfunction, they
Improper positioning, behavioral disorders, and cog- can determine if a patient passes or fails a visual screen-
nitive-perceptual impairment have all been implicated ing based on standard criteria. The screening is a means
as factors contributing to swallowing disorders. Dyspha- to determine which patients require a referral to an
gia treatment must address seating and positioning, be- optometrist or ophthalmologist for a complete evalua-
havioral management while self-feeding, and cognitive- tion and treatment. A comprehensive vision treatment
perceptual distortions. Formal assessments to evaluate program is designed by an optometrist and imple-
dysphagia include the Dysphagia Evaluation Protocol? mented by an occupational therapist or vision therapist.
and the Evaluation of Oral Function in Feeding.** A vision history questionnaire should be completed as
 Traumatic Brain Injury Che|

well. The vision history questionnaire should contain observe cognitive skills, perceptual skills, and behav-
an ophthalmologic history, questions regarding the use ioral appropriateness.
of glasses and contact lenses, and questions regarding The patient with a history of alcohol abuse requires
the presence of blurred vision, dizziness, headaches, eye assessment of leisure patterns. An interest history and
strain, diplopia, and visual field loss. interest checklist may reveal healthful leisure interests
Common areas evaluated in a vision screening that can replace alcohol use. The combination of leisure
include visual attention, near and distant acuities, skills development and substance abuse rehabilitation
ocular movement (e.g., pursuits and saccades), conver- will help the patient manage time more effectively, so as
gence, accommodation, ocular alignment, depth per- to avoid a return to alcohol use after discharge. Formal
ception (stereopsis), and visual field function. Vision assessments that can be used with a population with
dysfunction can also be identified during the clinical TBI to assess ADL skills include the Arnadottir OT-ADL
observation of the patient's performance in functional Neurobehavioral Evaluation,” Assessment of Motor and
activities. Tilting the head as a result of a field deficit, Process Skills,'* Functional Independence Measure,!®
closing or covering one eye to decrease blurred vision, and Klein-Bell Activities of Daily Living Scale.*’
and bumping into walls or objects in the environ-
ment because of a field deficit or unilateral neglect Driving
are all easily observed behaviors indicative of vision Many states require physicians to report to the Depart-
dysfunction. ment of Motor Vehicles any patient who has lapses of
consciousness, seizure disorders, and cognitive, visual,
and perceptual dysfunction caused by TBI. Regulations
Perceptual Function
regarding such disorders often mandate that the driver's
The perceptual evaluation should be administered license be revoked until further assessment confirms
when the therapist has obtained a clear understanding that the patient can drive without posing a safety risk to
of the patient's cognitive, sensory, motor, and language self or others.
status because deficits in these areas may skew the Advanced-level patients with TBI who do not have
patient's performance on a perceptual evaluation. Eval- seizure disorders or severe cognitive deficits must
uation of visual perception should include right-left undergo a comprehensive driving evaluation to assess
discrimination, form constancy, position in space, topo- their ability to resume driving. Two types of driving
graphical orientation, and the naming of objects. Evalu- evaluations are completed for the patient with TBI: a
ation of perceptual-speech and language function clinical assessment (evaluation of the patient's visual,
should assess for aphasia, agrommation, and anomia. cognitive, perceptual, and physical status as it relates to
Evaluation of perceptual motor function should include driving) and an on-road assessment. Both driving evalu-
the functions of ideational praxis, ideomotor praxis, ations are necessary because the patient may fail the
three-dimensional constructional praxis, and body clinical assessment but pass the on-road assessment
schema perception (including the identification of uni- using compensatory strategies. Conversely, the patient
lateral neglect). Formal perceptual assessments that can may perform successfully on the clinical assessment but
be used with a population of adults with TBI include fail the on-road assessment (see Chapter 14).
the Hooper Visual Organization Test,*° Motor-Free Patients with TBI frequently exhibit deficits (e.g.,
Visual Perception Test—Revised,'* Rivermead Percep- visual processing disorders, figure-ground discrimina-
tual Assessment Battery,” Loewenstein Occupational tion dysfunction, and impulsivity) that significantly
Therapy Cognitive Assessment,’ and Behavioural Inat- affect the ability to drive safely. When visual processing
tention Test.”° is delayed, the patient hesitates during driving maneu-
vers and stops unsafely (e.g., in the middle of the road
or at a corner) to allow adequate time to process visual
Activities of Daily Living information. A patient with figure-ground impairments
The intermediate-level patient with TBI should be as- may be unable to identify stop signs and traffic signals
sessed in all basic ADL—grooming, oral hygiene, at intersections or locate the gearshift near the dash-
bathing, toileting, dressing, functional mobility (in- board. An impulsive patient may respond aggressively
cluding transfers), and emergency response. The ad- rather than defensively when driving, increasing the risk
vanced-level patient with TBI should also be assessed of accidents. The patient may use poor judgment when
with regard to instrumental activities of daily living making driving decisions and may be unable to inhibit
(IADL)—hot and cold meal preparation, money man- inappropriate responses. The Elemental Driving Simu-
agement, community shopping, household mainte- lator'® and Driving Assessment System'® constitute an
nance, cleaning and clothing care, safety procedures, off-the-road clinical driving assessment that can be
medication routine, and work readiness. During assess- used, with an on-road assessment, to determine a
ment the therapist will have ample opportunity to patient's ability to resume driving after brain injury.
692 TREATMENT APPLICATIONS

Vocational Rehabilitation
of Communication and Interaction Skills,** the Occu-
An advanced-level patient with TBI may be evaluated for pational Role History,'* and the Role Checklist.**
return to work. It has been well documented that the
return to work after a moderate to severe brain injury is TREATMENT OF THE INTERMEDIATE-
generally unsuccessful. High unemployment rates have
TO ADVANCED-LEVEL PATIENT
been attributed to the adverse emotional, behavioral,
and neuropsychological changes arising from brain Treatment of the intermediate- to advanced-level
injury. Substance abuse in the TBI population is also a patient with TBI involves two primary approaches: the
major factor inhibiting the ability to return to and rehabilitative model and the compensatory model. The re-
maintain employment.” habilitative model is supported by the theory of neuro-
The vocational assessment for the advanced-level plasticity, which holds that the brain can repair itself or
patient with TBI must involve assessment in the actual reorganize its neural pathways to allow the relearning
work setting because psychometric tests and job simula- of functions that had been lost as a result of neural
tions do not accurately determine work potential. The damage sustained in the accident. The compensatory
individual with TBI is often able to compensate in the model holds that the repair of damaged brain tissue
work setting for deficits that may appear as significant either has occurred to its full extent or cannot occur,
impairments on a psychometric test. The therapist's vo- leaving the patient unable to perform lost functions
cational evaluation should summarize the patient's in- without external assistance. Tools used in the compen-
terests, strengths, and areas of deficit. The report should satory model are adaptive equipment, environmental
conclude with recommendations that state the patient's modification, and compensatory strategies that allow
realistic job goals and a plan for achieving those goals the patient to perform ADL. Treatment using both the
with professional assistance. rehabilitative and compensatory approaches can ad-
dress neuromuscular impairment, cognitive deficits,
perceptual deficits, vision dysfunction, and behavioral
Psychosocial Skills disorders. Generally a rehabilitative approach is used in
The advanced-level patient with TBI who will be dis- the acute stages of TBI recovery until the patient has
charged to home or a community-supported living res- plateaued or has been unable to progress, at which time
idence should also receive a psychosocial skill evalua- a compensatory approach is attempted.
tion. Such an evaluation should assess role loss, social
conduct, interpersonal skills, self-expression, time
Neuromuscular Impairments
management, and self-control. The therapist should
also assess the patient’s social support system, the As with a beginning-level patient with TBI, numerous
patient's ability to form and maintain friendships, and types of neuromuscular impairment can be present in
resources to decrease feelings of isolation (such as TBI the intermediate- to advanced-level patient with TBI.
support groups). The ability to form and maintain inti- Spasticity, rigidity, soft-tissue contractures, the presence
mate and sexual relationships after TBI will be of para- of primitive reflexes, diminished or lost postural reac-
mount concern to single individuals who sustained tions, muscular weakness (without accompanying spas-
their TBI between the ages of 18 and 30. Child rearing ticity), and impaired sensation affect the patient's
and care of family members will be of concern for ability to perform activities independently and with
patients responsible for children and other family normal control. The prerequisites for normal move-
members. ment include normal postural tone, a balanced integra-
The assessment of psychosocial skills in the patient tion of flexor control (reciprocal innervation), normal
with a brain injury is critical, since a year or more proximal stability, and the ability to implement selec-
after injury individuals with TBI report that their psy- tive movement patterns.
chosocial deficits significantly diminish life satisfac- The common principles of treatment for neuromus-
tion and are a greater problem than physical and cogni- cular impairment are to facilitate control of muscle
tive deficits combined. Often psychosocial impairment groups, progressing proximally to distally; encourage
is neglected in the rehabilitation setting as the treat- symmetrical posture; facilitate integration of both sides
ment of acute physical, cognitive, and perceptual of the body into activities; encourage bilateral weight
deficits is prioritized. Psychosocial difficulties appear bearing; and introduce a normal sensory experience.
more readily after discharge, when the individual has The variety of effective rehabilitation techniques for
left the structured and safe setting of the rehabilitation the intermediate- to advanced-level patient with TBI
hospital to reenter the community. It is important to include neurodevelopmental treatment (NDT), propri-
address psychosocial difficulties before the patient is oceptive neuromuscular facilitation (PNF), myofascial
discharged. Psychosocial assessment tools that can be release, Rood techniques, and some physical agent
used for a population with TBI include the Assessment modalities (see Chapters 30 and 32 through 36). These
 Traumatic Brain Injury

clinical treatments require education beyond the entry crease scapular stability and improve fine motor
level and must be either incorporated into or followed control. A goal of treatment is to improve the patient's
by a meaningful functional activity that requires the speed while maintaining good coordination.
same movement. The following brief overview of princi-
ples is not meant to substitute for training in the specific
techniques.
Ataxia
The treatment of impaired neuromuscular control Ataxia is a common motor dysfunction that occurs pri-
should begin at the pelvis, since positioning of the marily as a result of damage to the cerebellum or to the
pelvis affects motor control of all other body parts. A neural pathways leading to and from the cerebellum.
variety of approaches may be used to normalize pelvic Ataxia develops early in the acute stages of recovery and
_ positioning. For example, it is common for a patient may remain permanently. Ataxia is a clinical problem
_ with TBI to have a posterior pelvic tilt. To move the for which rehabilitation methods are generally ineffec-
patient to a more functional erect pelvic position, a tive. More often, therapists use compensatory strategies
therapist trained in NDT might use an anterior pelvic to control the effects of ataxia. For example, weighting
tilt mobilization. A therapist with a different approach of body parts and the use of resistive activities often
might use a bedsheet behind the pelvis to lift and rotate improve control during the performance of tasks but
the pelvis forward over the heads of the femurs. In show inconsistent carryover of muscular control when
either case the patient would be directed to “sit up tall.” the weights or resistance is removed. When applying
The trunk is positioned after the pelvis. Proper posi- weights to the patient, ‘the therapist must identify at
tioning of the trunk frees the UEs for functional activi- which joint(s) the tremor originates. Applying weights
ties. Major principles include (1) facilitating trunk to a patient's wrists when the tremor emerges from the
alignment, (2) stimulating reciprocal trunk muscle ac- trunk and shoulders is ineffective.
tivity (balancing the dorsal and ventral flexor-extensor Weighted eating utensils and cups are also used as
muscle groups), (3) encouraging the patient to shift compensatory aids to reduce effects of ataxia in the UEs.
weight out of a stable posture into all directions These assistive devices are limited in their effectiveness.
(bending forward, bending backward, reaching to each Another alternative used more successfully in the LEs
side while laterally flexing the trunk), and (4) helping than the UEs is to wrap Theraband in a figure-eight
the patient move the lower trunk on a stable upper pattern around the extremity during treatment. The
trunk, or to move the upper trunk on a stable lower Theraband provides increased proprioceptive input to
trunk. Once trunk control improves, treatment should the extremity and decreases the degree of ataxia.
progress to the UEs.
Rehabilitative techniques may be applied in various
Cognition
ways by the service-competent practitioner. The patient
with soft-tissue contractures or spasticity in a particular Treatment designed to enhance cognitive skills should
muscle group may benefit from NDT mobilizations and be implemented through functional ADL and IADL.
inhibitory techniques of the agonistic muscle group. Because impairment of cognition often results in con-
The patient with low tone or weak muscles (without the crete thinking, the patient with TBI is likely to have dif-
presence of spasticity) may benefit from NDT, PNE ficulty with abstract concepts. Activities that require the
Rood, and physical agent modalities. Neuromuscular generalization of skills from one task to another will
electrical stimulation can effectively stimulate UE also present difficulty for the patient with TBI. It is best
muscle groups, including the triceps, pronators, supina- to engage the patient in activities needed in his or her
tors, and wrist and finger extensors, to enhance muscle everyday life. For example, if the patient will return to a
strength, increase sensory awareness, and assist in community environment in which she or he needs to
motor learning and coordination." use public transportation, interpreting bus schedules is
Many advanced-level patients with TBI have fairly a meaningful and relevant activity that addresses con-
intact motor control. These patients ambulate inde- centration, frustration tolerance, sequencing, and cate-
pendently and incorporate both UEs in functional activ- gorization. Planning a trip to the hardware store to
ities. However, close observation reveals subtle trunk purchase supplies to install a hand-held shower ad-
and extremity deficits related to coordination and speed dresses organization, problem solving, and money
of movement. The treatment for trunk control with management.
these patients focuses on developing full isolated move- Advanced-level patients with TBI who demonstrate
ments of the trunk and extremities, good dynamic high-level cognitive skills often display subtle cognitive
standing balance for all activities (including reaching deficits in the areas of organization, planning, sequenc-
and bending to high and low surfaces), and the ability ing, and short-term memory. Activities such as estab-
to shift weight naturally from one LE to the other during lishing a monthly budget to live independently in the
activities. UE treatment programs are designed to in- community and negotiating the community public
694 TREATMENT APPLICATIONS

transportation system to pay a bill at the electric diplopia and eventually eliminate the need for prisms
company provide a context for cognitive retraining or occluders.
to address subtle cognitive deficits. Activities should Vision exercises consist of a series of activities that
be challenging, age appropriate, and relevant to the (1) maximize residual vision, (2) enhance impaired
patient's real-life needs. The activities mentioned earlier vision skills (the rehabilitative approach), (3) increase
are based on the rehabilitative approach. Compensatory the patient's awareness of his or her vision deficits, and
strategies include the use of a schedule or memory (4) help the patient learn compensatory strategies.
book, the use of a monthly budget chart, and the use of Treatment progresses from monocular to binocular
simplified maps of the patient’s community. vision and follows a developmental progression (supine
The use of computers in cognitive retraining has to sitting to standing). Exercises initially address basic
been implemented largely by neuropsychologists and skills such as visual attention, pursuits, and saccades
cognitive educators. Computer programs have been de- and may progress to more difficult skills such as fusion
signed to enhance sequencing, categorization, cognitive and stereopsis. These vision exercises are based on the
processing time, and concentration. Such programs, rehabilitative model that holds that impaired vision
however, bear no functional relevance and have not skills can improve with training.
been shown to generalize to the cognitive skills needed Environmental adaptations for vision deficits are
to improve performance in IADL.*’ Computers should based on the compensatory model. Compensatory
be used in therapy only if the patient needs to use a strategies for vision deficits include using a colored
computer for work, school, word processing, e-mail ex- border along one side of a page to facilitate reading,
change, and Internet access. Software programs that do using a colored strip of tape along one side of a plate or
not represent functional activities should be avoided. meal tray to promote self-feeding, using large objects
Therapy should address the individual's specific com- such as a clock with bold numbers or a telephone with
puter needs. For example, therapists may reprogram a enlarged buttons, using contrasting colors to highlight
patient's home computer to make it less complicated to controls and knobs (e.g., marking a TV/VCR remote
use, by simplifying tool bars and menus and program- control buttons with fluorescent paint), increasing
ming step-by-step written directions that appear on lighting in an environment, and using textures as cues
screen. (e.g., adhering textured tape to a banister by the bottom
step to cue the individual that the bottom step is
coming, to reduce falls). This last compensatory strategy
Vision
is particularly valuable for patients with vertical gaze
Treatment alternatives for the patient with TBI and paralysis who can look neither up nor down. Patients
vision dysfunction include the use of corrective lenses, who have lost pupil constriction should wear sunglasses
occlusion (patching one eye), prism lenses, vision whenever they are in bright light.
exercises, environmental adaptations, and corrective Corrective surgery performed by an ophthalmologist
surgery. An optometrist or ophthalmologist can evalu- may be indicated to align the eyes and eliminate double
ate and prescribe glasses for patients with accommoda- vision; however, the patient must wait at least a year
tive dysfunction caused by brain injury. However, the after the injury to allow for any improvement that may
glasses should not be prescribed until the patient has occur naturally in the course of recovery.
passed the subacute phase of rehabilitation because an
accommodative dysfunction that presents in the acute
Perception
stages of brain injury may improve during the recovery
process. Treatment of perceptual deficits involves both rehabili-
A common technique to eliminate double vision tative and compensatory approaches. For example, im-
(diplopia) is patching, or occlusion. The patient wears a pairment of figure-ground perception might be treated
patch over one eye that blocks the image seen by that using a rehabilitative approach through repeated prac-
eye, eliminating diplopia. Patching is a temporary com- tice of locating objects against a similar background
pensatory strategy. Prism glasses or binasal occluders (e.g., finding a white shirt on a bed with white sheets or
may be prescribed by an optometrist for patients with finding a spoon in a drawer of similar stainless-steel
consistent diplopia resulting from permanent oculomo- utensils). Using a compensatory approach, the therapist
tor nerve damage. The prisms assist the eyes in fusing would help the patient to arrange the kitchen drawers so
images. Prism glasses are not effective for patients with a that utensils were categorized (perhaps color-coded)
significant lateral strabismus or for patients with exo- and distinctly divided to facilitate identification.
tropia (outward eye turn). Binasal occluders encourage Aphasia (a perceptual-speech disorder) can also be
the malaligned eye to fixate centrally. Prism glasses and treated using both rehabilitative and compensatory ap-
binasal occluders are used conjointly with vision exer- proaches. An expressive aphasia may be treated rehabil-
cises. The goal of this treatment is to decrease the itatively through repeated conversation exercises in
 Traumatic Brain Injury 695

which the patient is provided with feedback regarding interventions alter objects or other environmental fea-
his or her incorrect spoken words and challenged to tures to facilitate appropriate behaviors, inhibit un-
express the correct words that he or she meant to verbal- wanted behaviors, and maintain patient safety. The agi-
ize. If the patient has not made significant gains in ex- tated patient should be placed in a quiet, isolated room
pressive speech through the use of the rehabilitative ap- without a roommate. All extraneous stimuli (e.g., radios
proach, the compensatory approach should be used to and televisions) should be removed. Similarly, therapy
help the patient articulate his or her needs to caregivers. is provided in a private, quiet room away from other pa-
For example, a chart with letters, words, or pictures (or a tients and extraneous stimuli.
combination of the three) of important items in the An agitated patient who demonstrates severe behav-
patient's environment can be used to help the patient ioral problems may require one-to-one care. The patient
identify such needs as eating, toileting, and medica- is assigned a rehabilitation aide who remains with the
tions. Such a chart may be used concomitantly with re- patient throughout the day (including during therapy)
habilitative approaches. to monitor and regulate the patient's behavior. Such a
Through a rehabilitative approach, apraxia can be patient may also wear an alarm bracelet that signals staff
treated by helping the patient perform specific tasks when the patient attempts to wander off the appropriate
(such as dressing) hand-over-hand (i.e., the therapist's floor or out of the building. Walkie-talkies and pagers
hands guide the patient's hands during the performance may be used with patients who are at risk of eloping.
of dressing). The rehabilitative approach holds that One walkie-talkie or pager remains in the nursing
through repeated hand-over-hand exercise the patient's station; the other is held by the rehabilitation aide who
brain can repair the neural pathways that mediate spe- is providing one-to-one care to the patient. If the patient
cific motor patterns (such as those needed in dressing) begins to act aggressively or attempts to elope, the reha-
or can reorganize pathways so that different areas of the bilitation aide can alert the staff that assistance is
brain (that have not been damaged) can establish new needed.
pathways for specific motor patterns. Using a compen- Interactive interventions are the approaches that the
satory approach, the patient may perform dressing by staff and caregivers use to interact with the patient.
following the steps through the visual interpretation These interventions should be implemented in a consis-
of pictures sequentially depicted (pictures) or listed tent way by the entire team. These include speaking in a
(words) on a poster or note card. calm, soothing, and concise manner to an agitated
Neglect syndrome (a disorder of body schema) can patient, deliberately avoiding detailed explanations that
also be addressed using rehabilitation and compensa- will only increase the patient's confusion. For safety’s
tory strategies. Severe neglect syndromes tend to de- sake, therapists should also keep the bedroom door
crease as a natural part of the recovery process. However, open when working with the patient at bedside and
some neglect syndromes may continue into the posta- should maintain an awareness of the patient in relation
cute rehabilitation stage. In a rehabilitative approach to self.
the patient is encouraged to use the neglected extremity The patient who is in the postacute stages of rehabil-
in all ADL. The patient's room may be rearranged to en- itation and who continues to exhibit behavioral prob-
courage interaction with the neglected part of the envi- lems should be placed on a behavioral modification
ronment (e.g., placing the television or standing-bed program. Such a program should allow the patient to
tray in the left side of the room if a patient has a left experience the natural consequences of inappropriate
neglect). A compensatory model is used when the behavior (such as losing community recreational privi-
patient has not demonstrated significant improvement leges) in an effort to help the patient learn more appro-
in attending to the neglected side of the body or envi- priate responses. Drug therapy may be used for a patient
ronment. Colored tape may be placed along the side of who has not made significant improvement in his or
the meal tray to cue the patient to attend to the food on her behaviors and presents a safety risk to self and
the neglected side of the tray. Similarly, a colored border others.
may be placed on the left side of book pages to cue the
patient to read the entire page. The patient's home envi-
Dysphagia and Self-Feeding
ronment is set up to maximize safety; for example, all
objects that the patient could bump into (e.g., furniture Treatment strategies for dysphagia follow the same
legs) are moved to the nonneglected side. guidelines as for other neurological impairments; inter-
vention, however, may be more complex in the popula-
tion with TBI as a result of bilateral neurological in-
Behavioral Management volvement, cognitive and behavioral issues, and severe
The types of intervention strategies used to decrease and muscular spasticity. A self-feeding program begins in
eliminate problem behaviors may be divided into two isolated areas such as the patient’s bedroom. Eating is
categories: environmental and interactive. Environmental graded to more social situations such as the hospital
696 TREATMENT APPLICATIONS

dining room. Common pieces of adaptive equipment, or she may need to learn how to lift the wheelchair in
such as a rocker knife, plate guard, and nonspill mug, and out of a car. Such a skill, however, is infrequently re-
may be used if a patient demonstrates diminished quired by a population with TBI. Customized wheel-
strength, coordination, or perceptual deficits. If a chairs may be ordered for the patient who is in the
patient displays decreased attention, introducing one postacute stages of rehabilitation and exhibits neuro-
piece of adaptive equipment at a time may help. A muscular impairment that requires use of a wheelchair
patient who displays heightened impulsivity may for long-term ambulatory needs. A custom wheelchair
benefit from the strategy of placing the fork down after provides a seating and positioning design that contours
each bite to ensure that the patient chews and swallows the individual's body for comfort and decubiti reduc-
completely before initiating the next bite. Depending tion, includes adaptive supports for proper pelvis and
on the patient's level of dysphagia (preoral, oral, pha- trunk alignment, and offers a seating position that
ryngeal, and esophageal), a diet of thick liquids or enhances the individual's ability to interact with the
pureed foods may be indicated until the patient pro- environment. Electric wheelchairs are ordered for the
gresses in recovery. patient who cannot control the wheelchair manually
and needs an electric chair for independent distance
ambulation.
Functional Mobility
Mobility training can be subdivided into bed mobility, Functional Ambulation
transfer training, wheelchair mobility, functional ambu- Functional ambulation refers to the patient's ability to
lation in ADL, and community travel. The NDT princi- walk during functional activities. Whereas physical
ples of bilateral extremity use, equal weight bearing, and therapists address gait training, occupational therapists
tone normalization are used in intervention strategies facilitate the carryover of ambulation skills into daily
that address functional mobility. The rehabilitation life activities. Often ambulation during ADL requires
model, based on the principles of NDT and PNE should the integrated use of UEs and LEs to carry and manipu-
be used with the intermediate patient with TBI in the late objects (e.g., carrying a plate to a table, holding a
acute and subacute stages of rehabilitation. Allowing book bag or purse, sweeping with a broom or vacuum
the patient with loss of function to use compensatory cleaner, or carrying an infant). Functional ambulation
strategies, such as grabbing a bed rail with one hand also requires the ability to negotiate an ambulatory
and rolling or standing on one leg to transfer, may device (e.g., straight or quad cane and walker) with one
appear to enable the patient tofunction more inde- or both UEs during ADL. This is a high-level activity
pendently earlier. However, the use of such strategies di- that requires eye-hand coordination and the integra-
minishes the patient's ability to perform activities using tion of total body movements. Compensatory aids to
a bilateral UE pattern at a later point. In time, the uni- improve the individual’s ability to negotiate an ambu-
lateral performance of activities results in hemiplegic latory device while performing ADL include walker
postures, contractures, and abnormal gait deviations. bags and baskets, wheeled carts (to provide balance
Compensatory strategies should be used only in the and support while transporting items such as plates to
later stages of recovery and when the patient has not a table), canes with built-in reachers, and pouch belts
been able to demonstrate significant improvement in worn abdominally (to hold keys, wallet, and memory
functional mobility skills and so must learn compensa- books). See also Chapter 14, Section 1.
tory strategies to enhance the ability to live independ-
ently in the community. Community Travel
For the advanced-level patient who will be discharged to
Bed Mobility home or a community supportive living arrangement,
An intermediate-level patient with TBI may require the ability to negotiate uneven sidewalks and curb cuts
training in bed mobility skills. These include (1) scoot- and to correctly interpret traffic light signals and the di-
ing up and down in bed, (2) rolling, (3) bridging, and rection and speed of oncoming traffic is important for
(4) moving from a supine position to and from sitting independent community travel. Functional ambulation
and standing positions. in the community requires the client to respond quickly,
initiate actions (to cross the street when the light turns
Wheelchair Management green quickly enough, before it turns red), perceive
Wheelchair management includes the ability to manage depth and spatial relations (to correctly judge the dis-
wheelchair parts (e.g., removing foot plates and locking tance and speed of oncoming and turning traffic), and
brakes) and propel the wheelchair both indoors and visually identify and avoid environmental hazards that
outdoors on a variety of surfaces (e.g., low-pile carpet- could cause falls (e.g., pot holes and broken sidewalks).
ing, sidewalks, and ramps). If a patient needs to use a Electric mobile scooters are often recommended for in-
wheelchair but is cognitively and perceptually intact, he dividuals who must perform long-distance ambulation
 Traumatic Brain Injury

in the community but who fatigue easily or are unable to Some patients do not perform household cleaning ac-
walk independently. The use of an electric mobile tivities except for making their bed and doing the
scooter requires good static sitting balance and the laundry. Common sense dictates that therapy first
ability to quickly integrate UE hand control and cogni- address the activities that individuals performed before
tive decisions regarding the environment. their injury.
As in all other areas of treatment, home management
Transfers skills are graded to accommodate the patient's func-
tional level. Beginning meal preparation tasks may
Because patients with TBI commonly have memory involve the completion of a cold sandwich, whereas be-
deficits and limited carryover of information, transfer ginning money management skills may involve learn-
training should be consistent (in technique and se- ing to read and interpret a utility bill. As the patient
quence) among all staff members treating the patient. It progresses in home management skills, the meal prepa-
is preferable that transfers for the intermediate- and ad- ration task may be graded to the completion of a hot
vanced-level patient be practiced moving to both the meal using a microwave and preparation of microwave-
right and left sides. Without this practice a patient who packaged foods. Money management skills may be
becomes proficient in a transfer toward the uninvolved graded to writing checks and balancing a checkbook. As
side (in the hospital) may be dismayed to find that the the patient continues to gain skills, activities requiring
home setting or public restroom requires transfers higher-level demands are made until the patient reaches
toward the opposite side. Additionally, teaching pa- desired goals.
tients to transfer to both sides provides weight bearing Child care is an often overlooked area of treatment.
on both LEs, the use of bilateral trunk muscles, and bi- Family involvement is critical if a mother or father is to
lateral sensory input. return effectively to his or her role as a spouse and
Family members and caregivers should be trained in parent. Sensory overload and its resultant agitation in
proper transferring techniques (including proper body the parent with a TBI is a commonly reported problem
mechanics) and cleared by a therapist before transfer- for patients and their children. OT sessions should grad-
ring a patient alone. The decision about when to begin ually reintroduce the parent to the role of caring for his
caregiver training depends on the patient's functional or her children. Some hospitals have a patient and
level and ability to cooperate, the discharge date, and family suite where the family members can practice
the caregiver's physical and cognitive abilities. ADL and interpersonal skills with the patient on week-
ends, in preparation for the patient's discharge home.
This provides the opportunity for family members to
Home Management
gain a greater awareness of their loved one’s impair-
As the patient's skills and independence in self-care, ments and need for assistance. It also makes the transi-
dressing, self-feeding, and functional mobility increase, tion from hospital to home less stressful for both pa-
treatment is expanded to include home management tients and family members.
skills in preparation for discharge to the community. The occupational therapist can also assist the parent
Home management skills include meal preparation, with TBI in the adaptation. of strollers, cribs, and child
laundry, cleaning, money management (e.g., balancing care equipment to make the handling of such items
a checkbook, paying bills, and budgeting), home repairs easier for an adult parent with a disability. Safely
(e.g., changing a washer in a leaking faucet), and com- bathing a baby, preparing a meal while simultaneously
munity shopping (which includes planning a shopping caring for children, one-handed diapering and dressing
list, locating the correct items in the store, and paying techniques, and carrying a child are examples of the
the correct amount of money at the cash register). areas that could be addressed by OT services.
Examples of high-level activities include planning a
monthly budget, organizing a file cabinet, ordering
Community Reintegration
from a catalogue or the Internet, and filing income
taxes. These are skills that adults need to live independ- Patients who will be discharged from the subacute re-
ently in the community and are thus relevant for most habilitation hospital to home or to a postacute, resi-
patients with TBI. dential supportive-living arrangement should receive
The degree to which individuals participate in home training to facilitate the transition from the hospital to
management activities varies. For example, some indi- the community. A patient who achieves a maximal level
viduals prepare only simple meals, using a microwave of independence in the protected and structured envi-
oven. For patients who must prepare meals to live inde- ronment of the rehabilitation hospital may find that
pendently in the community but who do not possess an community reintegration holds even greater challenges.
interest in cooking, the goal is to help the patient to Community trips—in which the advanced-level patient
safely prepare simple hot and cold meals at home. with TBI is accompanied in the community by the
 TREATMENT APPLICATIONS

occupational therapist (and perhaps one family mem- made a transition through as a result of TBI. Rites of
ber) to practice IADL in the natural environment— passage are socially recognized events that mark the
should be implemented to provide the patient with the transition from one life stage to another. Common rites
opportunity to rebuild daily life skills. Depositing or of passage in Western society include obtaining a
withdrawing money from the bank or ATM, using the driver's license, graduating from secondary school or
public transportation system, and planning a shopping obtaining a higher education degree, securing full-time
list and purchasing items at the grocery or hardware employment, living independently in the community,
store are activities that will facilitate the beginning of dating, marrying, and parenting.
the patient's community reentry. Having the patient Once desired occupational and social roles, activities,
perform daily life activities within the community set- and rites of passage have been identified by the individ-
ting will also allow the therapist to observe the patient's ual, the therapist helps the person to approach these
social interaction skills and social appropriateness. The using adaptation, compensatory strategies, and the
patient will be provided with a chance to receive feed- integration of new learning. The therapist will also help
back from others in the community regarding his or her the client enhance interpersonal skills, self-expression,
behaviors. social appropriateness, time management, and self-
Some patients are discharged from the subacute re- control. Such psychosocial skills will be critical for the
habilitation center to a transitional living center for in- individual to reintegrate into the community—to live in
dividuals with TBI. Transitional living centers are de- a neighborhood setting, hold a job, perform volunteer
signed to develop daily life skills by providing the work in the community, and participate in desired recre-
patient an opportunity to live temporarily in a com- ational opportunities along with other adult commu-
munity group setting with 24-hour staff supervision nity members.
and assistance. The goal of transitional living centers is Group treatment is beneficial, because it enables the
to facilitate the patient's progression from supervised individual to meet others experiencing the same life
living to greater independence in community living. concerns (thus decreasing feelings of isolation), offers
The patient is usually discharged from the transitional exposure to peer reactions to behaviors (particularly
living center to a relative’s home or to a residential helpful if the individual exhibits socially inappropriate
supportive-living facility that provides various levels of behaviors), and facilitates problem solving by providing
living arrangements (e.g., Community apartments and the opportunity to speak with others who have success-
shared community group homes). Because long-term fully dealt with the same or similar problems. Individu-
residential community facilities for people with brain als who have been in the group for a while can become
injury are expensive for insurance companies, many peer mentors to new group members. The opportunity
patients are discharged home and then receive contin- to help others—to share one’s experience of having a
ued treatment in outpatient rehabilitation or in day brain injury with others who can benefit from that
treatment programs that provide community reentry knowledge—has been shown to enhance an individ-
services. ual’s life satisfaction, feelings of competency, and sense
of usefulness. Many states have support groups for indi-
viduals with TBI, run by state associations for brain
Psychosocial Skills
injury.
As mentioned previously, a year or more after injury in-
dividuals with TBI commonly report that psychosocial
Substance Use
impairment is the greatest obstacle to rebuilding a
meaningful postinjury lifestyle. Individuals report feel- If a patient's preinjury history includes substance use,
ing a deep sense of isolation and loneliness. Loss of the individual should receive drug and rehabilitation
such roles as date, partner or spouse; worker or student; services specifically designed for patients with TBI. Pa-
independent home maintainer; friend; and community tients with histories of substance use may not display
member often leaves individuals feeling as though they any signs of a desire to return to substance use while in
have lost their identity. The goal of the occupational the structured and protective environment of the suba-
therapist, particularly in postacute TBI centers (e.g., day cute rehabilitation facility. Substance use may become a
treatment programs, outpatient rehabilitation, transi- problem only after the individual has been discharged
tional living sites, and long-term community supportive to home, a community supported-living arrangement,
living arrangements) is to help clients rebuild desired or any residential situation in which long periods of
occupational and social roles. This involves a three-step time may be spent alone and unsupervised. Drug reha-
process: (1) identifying the desired roles that the indi- bilitation services are critical for the patient with a sub-
vidual lost secondary to TBI; (2) identifying the activi- stance abuse history because a return to substance use
ties that would support desired roles; and (3) identifying after brain injury has been implicated in the occurrence
rites of passage that the individual either lost or never of a second TBI.
 Traumatic Brain Injury 699

Discharge Planning
patient may have progressed sufficiently during the
Planning for the patient's discharge from OT services course of rehabilitation to stand in the shower while
begins at the initial evaluation and continues until the using only a grab bar.
last day of treatment. Components of discharge plan-
ning include a home safety evaluation (if the patient Family and Caregiver Education
will be discharged home), equipment evaluation and Family members and caregivers should be involved
ordering, family and caregiver education, recommenda- in the patient's rehabilitation and should be consid-
ees for a driver's training program (if indicated), and ered members of the treatment team. Education of the
recommendations for vocational retraining and work caregivers in such activities as transfers, wheelchair mo-
skills. bility, ADL, bed positioning, splint schedules, equip-
ment usage, ROM exercises, and self-feeding techniques
Home Safety will facilitate follow-through with the skills that the
If a patient is to be discharged home, the therapist patient learned in the rehabilitation hospital. As men-
should visit the home (or transitional living setting) to tioned previously, patient safety is of primary impor-
recommend modifications to enhance the patient's tance for caregiver education. Ifa home program is to be
safety. For example, a patient with balance difficulties given to the patient (in either written or videotape
should have grab bars in the shower stall or tub, around form), the caregivers should be trained in the imple-
the toilet and sink, in hallways, and by all interior and mentation of the home program. Home programs may
exterior steps. Increased lighting should be added in include the areas listed earlier, as well as specific activi-
dark interiors for a patient with vision deficits because ties for the improvement of cognition, vision, percep-
low lighting has been linked to falls. Recommendations tion, and motor control.
should also be made regarding the patient's ability to
handle sharp items (e.g., knives and glass items that Recommendations for Driver's Training
could shatter easily), use of the stove, and the ability to If the patient passes the clinical and on-road driver's
remember to turn off the water, stove, and other appli- evaluation, a specific number of hours of driver's train-
ances. The temperature setting on the hot water system ing may be recommended by the occupational ther-
should be set at or below 120° F to prevent scalding. apist. Driver's training should be implemented by an
Anything that the patient could trip over (e.g., throw occupational therapist or a driving instructor who
tugs, appliance cords, furniture legs, or objects placed has experience working with individuals with TBI (see
on steps) should be removed. If feasible, nonslip floor- Section 3 of Chapter 14).
ing should be added to slippery surfaces (e.g., bathroom
and kitchen tiles). If the patient needs a wheelchair, the Recommendations for Vocational Training
therapist should recommend modifications to door- and Work Skills
ways and bathroom spaces and should suggest the re- An occupational therapist may make recommendations
placement of high-pile carpeting with tiles, wood, or for vocational training if the individual is discharged to
other surfaces that can be easily traversed by a wheel- an outpatient rehabilitation center or to a transitional
chair. Additionally, family members and caregivers living site. Vocational training of the patient with TBI is
should be educated in the appropriate steps to follow an extended process requiring the involvement ofan oc-
during a seizure, should understand how to evacuate cupational therapist and a vocational counselor. The
the patient in case of emergency, and should practice patient's eventual return to work may require the assis-
how to transfer the patient safely. Caregivers should be tance of a job coach. The occupational therapist in the
able to identify unsafe activities in which their loved subacute rehabilitation center may make vocational
one should not participate and should know the length training recommendations to be implemented by an oc-
of time the patient can safely be left alone (if the patient cupational therapist working in an outpatient site, a
can be left alone). transitional living site, a day treatment program, or a
community supportive-living residence.
Equipment Evaluation and Ordering
A patient who will be discharged from the subacute re-
SUMMARY
habilitation facility will require an evaluation for equip-
ment needed in the next setting. This may necessitate a Treatment of the adult with TBI is challenging and re-
reevaluation of the patient's equipment needs because quires flexibility, stamina, and creativity. Behavioral and
many of the adaptive devices that were valuable in the psychosocial deficits greatly influence recovery. Sub-
beginning and intermediate stages of rehabilitation may stance abuse may be a contributing factor and must be
be discarded as the patient improves. For example, a assessed and addressed. Most patients have a multitude
patient may initially have needed a tub bench to shower of problems requiring intervention. Coordination of
because of dynamic standing balance difficulties. This evaluation and goal setting with the interdisciplinary
vA TREATMENT APPLICATIONS

CASE STUDY 3
Case StupY—JoE
Joe is an |8-year-old Caucasian man who sustained a mild brain crease his concentration for a return to school and work; (4)
injury in a motor vehicle accident. He is a high school senior who help Joe learn compensatory strategies to enhance his study skills
lives at home and is planning to attend college next fall. As a as a student; (5) teach time management and stress-reduction
result of the injury, Joe demonstrates mild cognitive deficits, in- skills in preparation for a return to school and work; (6) help Joe
cluding short-term memory loss, decreased concentration, and to adopt an organizational system for budgetary and money
increased distractibility. He also demonstrates word-finding and management skills; and (7) reprogram Joe's personal computer to
word-generation difficulties. Joe is presently taking Dilantin for a simplify tool bars, menus, and commands to accommodate his
seizure disorder secondary to the brain injury. He plans to return decreased concentration and increased distractibility.
home with his parents and shortly thereafter move into his own Joe received 3 months of OT, during which he learned how to
community apartment. Joe also plans to take several community use a memory and schedule book to keep appointments and or-
college courses and work part time as a clerk in a hardware ganize his daily occupations. He learned to use three different bus
store. routes from his parents’ house (|) to and from a small local com-
Results of the OT evaluation indicate that Joe is independent munity college, (2) to and from the hardware store, where he re-
in all basic self-care skills (e.g., bathing, dressing, grooming, and toi- turned to his part-time job, and (3) to and from the rehabilitation
leting) but requires minimal assistance in several instrumental hospital for outpatient services. Joe also learned to use a com-
ADL (e.g., laundry, use of public transportation, meal preparation, puter program independently for money management, budget-
money management and banking, and computer use). Joe ing, and bill paying. The time management and study skill habits he
demonstrates no insight into his deficits. Occupational therapy learned in OT helped him prepare for his enrollment in several
was initiated to accomplish the following: (1) minimize the effects part-time community college courses. Upon discharge Joe was
of short-term memory deficits; (2) enhance Joe's use of public referred to outpatient OT to help him make the transition from
transportation, since he is no longer able to drive because of his his parents’ home to an independent apartment located in the
seizure disorder; (3) help Joe use compensatory strategies to in- community near his parents’ home.

team (including the patient and family) is assumed. 9. Whatarethe

goals ofaproper wheelchair-positioning
Treatment should be individualized and oriented to- program?
ward functional outcomes that are important to the 10. What are the indications for splinting? Casting?
patient. Effective transition of the patient from acute 11. Describe three areas that should be addressed
care to intermediate care and then to the community re- during discharge planning.
quires the therapist to plan thoughtfully and to commu- 12. Why is it important to address substance use with a
nicate clearly. For the patient, recovery and adjustment population with TBI?
may be a lifelong challenge.

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 seases of the Central

CAROLYN GLO

KEY TERM EARNING OBJECTIVES

SECTION 1 After studying each section, the student or practitioner will be able to do the
Amyotrophic Lateral Sclerosis following:
(ALS) Section 1
Upper motor neuron 1. Describe the course of ALS.
Lower motor neuron 2. Describe the differences between FALS and SALS.
Bulbar 3. Describe the role of the occupational therapist for a client with ALS.
Fasciculations 4. Describe the three subtypes of ALS.
Dysphagia Section 2
1. Identify the symptoms and incidence of Alzheimer’s disease.
SECTION 2
2. Describe the pathophysiology of Alzheimer’s disease.
Alzheimer’s Disease
3. Describe the overall model of medical management used by primary care
Executive function
providers and other health professionals.
Apraxia
4. Describe an approach to evaluation used by occupational therapists.
Aphasia
5. Identify stages of disease progression and general methods of treatment
Agnosia
interventions associated with stages of dementia.
SECTION 3 Section 3
Huntington's Disease (HD) 1. Describe the course and stages of HD.
Choreiform movements 2. Identify current research regarding the etiology of the disease.
Chorea 3. Describe the medical management of HD.
Rigidity 4. Describe the purpose of occupational therapy for a client with HD.
Dysarthria Section 4
Akinesia Describe the three typical forms of multiple sclerosis.
Describe current research regarding the etiology of the disease.
SECTION 4
Describe the symptoms of multiple sclerosis.
Multiple Sclerosis (MS)
Describe complications that may occur as a result of the disease.
Exacerbation
ee
aed Describe the role of the occupational therapist for the person with
axpaegh
Myelin sheath
multiple sclerosis.
Remission
Section 5
SECTION 5 1. Describe the course and stages of PD.
Parkinson's Disease (PD) 2. Identify current research regarding the etiology of the disease.
Resting tremor 3. Describe the medical management of PD.
Bradykinesia 4. Describe the role of the occupational therapist for a client with PD.
Festinating gait
Micrographia

as
7a. Degenerative Diseases of the Central Nervous System rAUR

Introduction OT intervention aims to support the client's ability to

WINIFRED SCHULTZ-KROHN
function within his or her environment. The rate of a
client's symptom progression influences the interven-
tion plan. A client who displays a progressive loss of fine
This chapter addresses the impact of degenerative neu- motor skills over 20 years has a much different profile
- rological disorders on a person's occupational perform- from a client who loses all upper extremity function
ance and outlines the role of occupational therapy (OT) within 2 years. Use of adaptive equipment must be care-
in treating clients with these disorders. The specific dis- fully considered against the rate of deteriorating skills.
orders are discussed in this chapter are amyotrophic The OT practitioner needs to be knowledgeable
lateral sclerosis (ALS), Alzheimer’s disease (AD), Hunt- about support services and respite care available to
ington’s disease (HD), multiple sclerosis (MS), and clients with a degenerative neurological disorder. A PD
eS
we
—
Parkinson’s disease (PD). support group may provide the needed social support
In degenerative neurological disorders the disease both for a man with this disorder and for his family. MS
progresses and an individual's performance areas and support groups may offer clients information regarding
components are increasingly compromised. Occupa- new treatments available, along with the opportunity to
=se
se
— tional therapy aims to help the client compensate and share experiences of living with this disorder.
adapt as function declines secondary to the disease An OT intervention plan should address not only the
process. Environmental adaptations and modifications physical limitations associated with various disorders
are often necessary to maintain functional skills for as but also the cognitive, social, and emotional implica-
long as possible. tions of the disorder. Many individuals with neurode-
Degenerative neurological diseases may occur be- generative disorders have concomitant depression. De-
“he

cause of structural or neurochemical changes within the pression can be reactive to the loss of function in some
central nervous system (CNS).* In the disorders dis- disorders or may be the primary symptom of other dis-
cussed in this section, the client's CNS most often func- orders. Occupational therapists should regularly screen
tions normally during the childhood and adolescent for depressive features. An instrument such as the Beck
years. After these years the client then experiences signs Depression Inventory can effectively evaluate this com-
and symptoms indicating that CNS functions are deteri- ponent.’ In addition to the evaluation of depression
orating. The progressive nature of the disorder varies in clients with neurodegenerative disorders, cognitive
from person to person. Some clients have a rapid abilities should be evaluated. Patients may have con-
decline in function, whereas others maintain functional comitant cognitive problems because of the destruction
skills for many years. of neurological structures, and these deficits can have a
The decline in function may compromise the individ- dramatic effect on intervention. Brief assessments such
ual’s sense of self-efficacy in performing various tasks.’ as the Mini Mental State Examination (MMS)* or the
No longer is the individual able to perform personal or Cognistat® can be used to determine cognitive abilities
instrumental activities of daily life at the same level of in- and establish a baseline of performance.
dependence. Dependence on others can alter the client's Most often the occupational therapist is a member of
concept of self-worth and self-control. The OT practi- a team providing services to the individual with a de-
tioner serves an important role in reframing the client's generative neurological disorder.” As a team member,
sense of self even though functional independence may the occupational therapist must consider the roles other
be deteriorating. A man with PD who is unable to dress professionals and family members play in the client's
independently may now direct a personal care attendant life and incorporate this knowledge into the interven-
(PCA) or home health aide (HHA) to perform these tion plan. Occupational therapy practitioners provide a
tasks. Awoman with MS who was previously responsible unique and needed service to individuals with degener-
for household finances may need to instruct a member of ative neurological disorders. A client who is able to
the family to complete these activities. engage in meaningful occupations despite deteriorating
The disorders discussed in this chapter are most often skills reflects the significant contribution of occupa-
diagnosed during adult or later adult life, after habits tional therapy.
and patterns of independent behavior are well estab-
lished. A client may encounter a significant change in ey
rr
social relationships and interactions secondary to a SECTION 1
decline in functional abilities. The OT practitioner must
Amyotrophic Lateral Sclerosis
consider how progressive loss of function affects the
person's social and occupational roles, whether those DIANE FOTI
roles are as husband, wife, parent, adult child, worker,
sibling, or friend. Occupational therapy must address The term amyotrophic lateral sclerosis (ALS) is used to
the needs of the client within the context of his or her identify a group of progressive, degenerative neuromus-
social, physical, and cultural environment. cular diseases. The underlying neurological process
704 TREATMENT APPLICATIONS

involves destruction of the motor neurons within the

CLINICAL PICTURE
spinal cord, brainstem, and motor cortex.” There is a The symptoms of ALS are variable, depending on the
combination of both upper motor neuron (UMN) and initial area of motor neuron destruction. The individual
lower motor neuron (LMN) deficits at some point in with ALS typically has a focal weakness beginning in the
the progression of the disease. arm, leg, or bulbar muscles. The individual may trip or
The term motor neuron disease is used interchangeably drop things and may have slurred speech, abnormal
with ALS. In the United States ALS is also known as Lou fatigue, and uncontrollable periods of laughing or crying
Gehrig's disease, and in France it is referred to as (emotional lability). With progression of the disease
Charcot's disease.’ As mentioned initially, the term ALS there are marked muscle atrophy, weight loss, spasticity,
refers to a group of diseases. This group of diseases con- muscle cramping, and fasciculations (twitching of the
sists of progressive bulbar palsy (PBP), progressive muscle body at rest). The individual may have greater
spinal muscular atrophy (PSMA), and primary lateral difficulty with walking, dressing, fine motor activities,
sclerosis (PLS). See Table 39-1 for a description of each swallowing, and breathing. In the end stages the individ-
of these distinct subtypes of ALS. The classic forms of ual may need tube feedings and the support of a ventila-
ALS are presented in this section. tor for respiration. ALS is fatal, and the mean duration of
The incidence of ALS is estimated to be between the disease after onset is between 2 and 4 years.
1.4 and 2.0 per 100,000 people. There are two forms ALS does not affect eye function, cognition, or bowel
of ALS, familial (FALS) and sporadic (SALS). Between and bladder function. There is no loss of sensory func-
5% and 10% of individuals with ALS are found to tion.
have a family history of the disease. Families with Prognosis is difficult to predict. Generally, individu-
FALS have been found to have an autosomal domi- als with early bulbar involvement have a poorer prog-
nant transmission pattern.? There is no difference in nosis. A more positive prognosis is usually associated
symptoms of clients with FALS and those with SALS. with the following factors: young age of onset; onset in-
Differences between FALS and SALS pertain to age of volving the spine; deficits of either UMN or LMN, nota
onset and incidence. Onset for FALS is between 45 combination of both areas; absent or slow changes in
and 52 years of age, and onset for SALS is between 55 respiratory function; fewer fasciculations; and a longer
and 65 years of age. The ratio of male to female inci- time from onset of symptoms to diagnosis. In some
dence for FALS is 1:1, but with SALS the ratio is cases the patient's condition has stabilized with little
between 1.5:1 and 2:1.* progression of the disease.*

PATHOPHYSIOLOGY MEDICAL MANAGEMENT

The etiology of ALS has not been established. There are Symptoms such as muscle cramping, excessive saliva,
multiple theories regarding the cause of the motor and depression are managed with medication. The indi-
neuron destruction, including metabolic disorders of vidual’s swallowing status should be reevaluated fre-
glutamate insufficiency, metal toxicity, autoimmune quently to prevent aspiration when and if symptoms of
factors, genetic factors, and viral infection.” dysphagia progress.

Name Area of Destruction Symptoms

Progressive bulbar palsy (PBP) (‘‘Bulbar Corticobulbar tracts and brainstem motor Dysarthria, dysphagia, facial and tongue
form’’) nuclei involved weakness and wasting
Progressive spinal muscular atrophy (PMA) Lower motor neurons in the spinal cord Marked muscle wasting of the limbs, trunk,
or (PSMA) (LMN form) and sometimes the brainstem and sometimes the bulbar muscles

Primary lateral sclerosis (PLS) (UMN Destruction of the cortical motor neurons, Progressive spastic paraparesis
form)* may involve both corticospinal and
corticobulbar

From Belsh JM, Schiffman PL, editors: ALS diagnosis and management for the clinician, Armonk, NY, 1996, Futura Publishing; Guberman A: An introduction to clinical
neurology, pathophysiology, diagnosis, and treatment, Boston, |994, Little, Brown.
*The World Federation of Neurology Classification of SMAs and other disorders of the motor neurons does not identify PLS as a subtype of ALS.' | include PLS
in the list because many other articles, texts, and clinicians recognize it as a subtype ofALS.
 Degenerative Diseases of the Central Nervous System 7AVe)

In 1995 the Federal Drug Administration approved independence. Some clients with ALS may choose to
the drug riluzole (Rilutek). This is the first drug used have the maximum environmental and life support pro-
specifically to alter the course of the disease by prolong- vided to extend life. In this case the occupational thera-
ing survival. Riluzole is an antiglutamate. It inhibits the pist may provide periodic reevaluations to determine
release of glutamate from nerve endings and blocks the the client's need for adapting self-care, work, and leisure
- amino acid receptors on the cell bodies.° Researchers activities: Table 39-2 gives a list of the functional deficits
believe the success of riluzole indicates that an excess of at various stages of the disease and interventions that
glutamate leads to the death of the motor neuron. may be required.
Three other medications, grouped as neurotrophic
factors, are undergoing clinical trials for treatment of
ALS. These medications are ciliary neurotrophic factor
SUMMARY
(CNTF), insulin-like growth factor-1 (IGH-1), and ALS is a rapidly progressing, fatal condition of unknown
brain-derived neurotrophic factor (BDNF). Exactly how etiology. Occupational therapy intervention aims to
these factors act on the motor neuron is unclear.” maximize functional independence by providing stage-
It is essential to work with the client and family specific compensatory strategies.
throughout the progression of the disease as needs
change. The client and family must often update deci-
ee
eeeee
sions about care. Decisions range from when or if to use
SECTION 2
a wheelchair or adaptive eating device to whether to
undergo a tracheostomy, choose tube feeding, or use a Alzheimer’s Disease
ventilator.’ Psychosocial support regarding decisions
CAROLYN GLOGOSKI
about the extent of life support and medical interven-
tion should be provided by the entire health care team,
with the physician and patient having primary responsi- Alzheimer’s disease (AD), the most common form ofde-
bility. The family’s and client's cultural and social values mentia, is an insidious and progressive neurological dis-
must be understood as they struggle to make ongoing order. Alzheimer’s disease is labeled as a mental disorder
decisions about personal care and life support. by the American Psychiatric Association.* The exact etiol-
Cobb and associates’ found that physicians fre- ogy of AD is unknown. Because of the disease’s damag-
quently tell patients “nothing can be done,” and that ing effects on the brain, higher mental processes are im-
families often are not informed of services that can be paired, behavior is altered, and mood is disturbed. The
provided by occupational, physical, and speech therapy. onset of the disorder is gradual, with multiple cognitive
Education is needed for nursing staff and physicians to deficits, a significant decline from previous levels of func-
improve understanding of the occupational therapist's tioning, and noticeable impairment in social and occu-
role with the client with ALS. Ongoing OT assessment is pational functioning. Effects on the motor and sensory
also essential to provide the client with needed infor- systems are not apparent until later in the disease
mation regarding choices about available therapy serv- process. Dementia is a significant health care problem
ices as the disease progresses. because of the increasing number of individuals who are
living longer, the higher incidence of dementia among
older persons, the very high cost of supervised care, and
ROLE OF THE OCCUPATIONAL
the extensive use of medical resources.** Early recogni-
THERAPIST tion of cognitive decline by physicians, occupational
ALS progresses rapidly. The occupational therapist therapists, and all other health care professionals is criti-
needs to determine which form of ALS the client has cal. The AD diagnosis is often overlooked or mistaken for
because this suggests the most pertinent areas to evalu- other disorders, especially in the early stages. Occupa-
ate. The intervention plan should focus on occupational tional therapists have an essential role in helping the in-
performance, since the client's functional status is fre- dividual with AD experience quality oflife and remain as
quently changing and intervention with physical per- self-sufficient as possible and in supporting families and
formance components is limited. As the client’s physical care providers over the course ofthis difficult disease.
status declines, there is a greater need for environmental
support through providing durable medical equipment,
INCIDENCE
modifying the home, and providing adaptive equip-
ment. Depending on the client's understanding, life Alzheimer’s disease accounts for almost two thirds of
support choices, and acceptance of the disease, the OT the cases of dementia, and the incidence increases dra-
intervention may focus on death and dying issues matically as people age.**’’* Approximately 6% to 8%
through structuring the client’s environment to support of adults aged 65 and older have AD. The disease
 Interventions With Occupation Interventions With Occupational Performance |
Patient Characteristics as a Focus Components as a Focus ‘
Phase I (Independent)
Stage |
@ Mild weakness Continue normal activities or increase @ Begin program of ROM (stretching,
@ Clumsiness activities if sedentary to prevent disuse yoga, tai chi)
@ Ambulatory atrophy and prevent depression @ Add strengthening program of gentle
@ Independent with ADL Integrate energy conservation into daily resistance exercises to all musculature
activities, work, and leisure with caution not to cause overwork
Provide opportunity for individual to fatigue
voice concerns (provide psychological
support as needed)
Stage Il
@ Moderate, selective weakness Assess self-care, work, and leisure skills @ Continue stretching to avoid
@ Slightly decreased independence in impaired by loss of function; if patient contractures
ADL: for example, difficulty continues to work, focus on how to M@ Continue cautious strengthening of
climbing stairs, difficulty raising adapt tasks with current deficits; assist muscles with MMT grades above F+
arms, or difficulty buttoning with balance between work, home, and (3+). Monitor for overwork fatigue.
clothing leisure activities; include significant others @ Consider orthotic support (e.g, AFOs,
in treatment wrist or thumb splints—short
Use adaptive equipment to facilitate ADL opponens splint)
(e.g., button hook, reacher, built-up
utensils, shower seat, grab bar)
Integrate hand orthotic use into daily
activities
Baseline dysphagia evaluation;
reevaluation throughout each stage of
the disease
Stage III
@ Severe, selective weakness in Prescribe manual or power wheelchair ™@ Keep patient physically independent as
ankles, wrists, and hands with modifications to allow eventual long as possible through pleasurable
@ Moderately decreased reclining back with head rest, elevating activities and walking
independence in ADL leg rests, adequate arm and trunk ™ Encourage deep breathing exercises,
H Becomes easily fatigued with long- support chest stretching, and postural draining if
distance ambulation Help patient prioritize activities and needed
& Ambulatory provide work simplification
@ Slightly increased respiratory effort Reassess for adaptive equipment needs
(universal cuff to eat)
Assess and adapt use of communication
devices such as phone to cordless or
speaker phone; writing to using
computer to type; and adapted typing aid
Provide support if there is loss of
employment or other activities; explore
alternative activities
Begin discussing need for home
modification, such as installing ramps or
moving the bedroom to the lowest floor
Instruct in type of bathroom equipment
available for energy conservation and
safety

Modified from YaseY,Tsubaki T, editors: Amyotrophic lateral sclerosis: recent advances in research and treatment, Amsterdam, |988, Elsevier Science. In Umphred DA,
editor: Neurological rehabilitation, ed 3, St Louis, 1995, Mosby.
 Interventions With Occupation Interventions With Occupational Performance
as a Focus Components as a Focus
Phase II (partially independent)

2 Hanging-arm syndrome with Try arm slings, deltoid aids, overhead slings, ball- @ Heat, massage as indicated to control
___ shoulder pain and sometimes bearing feeders for eating, typing, page turning spasm
~ edemainthe hand lf arm supports are not used, provide arm Preventive antiedema measures
| Wheelchair dependent troughs or wheelchair lap tray for wheelchair Active assisted or passive ROM
|Severe lower extremity weakness positioning; wrist cock-up splints or full resting exercises to the weak joints; caution
_ (with or without spasticity) hand splints may be needed for positioning to support, rotate shoulder during
__M Able to perform ADL but fatigues Motorized chair if the patient wants to be abduction and joint accessory
easily independently mobile; adapt controls as needed motions
Evaluate the need for high-tech devices such as Encourage isometric contractions of
environmental control systems, voice-activated all musculature to tolerance
computer
Help the patient prioritize activities and
consider negotiating roles with significant others
Reinforce the need for home modifications
4
Reinforce the need for shower seat or transfer
tub bench and shower hose
Assist with patient's ability to participate in
closure activities such as writing letters or
making tapes for children, life history, writing a
.=a log on household management for the family

Stage V
@ Severe lower extremity weakness Instruct family in methods to assist patient with Instruct in use of electric hospital bed
_ M@ Moderate to severe upper self-care, especially bathing and dressing; aim to and antipressure device
extremity weakness minimize caregiver's burden and stress Adapt wheelchair for respiratory unit
et
@ Wheelchair dependent Family training to learn proper transfer, if needed; reassess adequacy of
®@ Increasingly dependent in ADL positioning principles, and turning techniques wheelchair cushion for pressure relief
™@ Possible skin breakdown secondary Instruct in use of mechanical lift if needed for
to poor mobility transfersout of bed (sling needs head support)
Adapt and select essential control devices for
telephone, stereo, television, electric hospital
bed controls for independent use
Adapt wheelchair for respiratory unit if needed
to allow for continued community access
Instruct family and patient in skin inspection
techniques

Phase III (dependent)

Stage VI
M@ Bedridden/dependent with Eating: evaluate dysphagia, recommend @ Continue with PROM to all joints
wheelchair positioning appropriate diet; may discuss tube feedings if ™@ Provide sensory stimulation with
@ Completely dependent in ADL high-risk for aspiration; recommend suction massage, skin care
machine for handling secretions/aspiration
precaution
Augmentative speech devices may be
recommended (speech therapy may be
requested if not providing services)

Modified from YaseY,TsubakiT,editors: Amyotrophic lateral sclerosis: recent advances in research and treatment, Amsterdam, |988, Elsevier Science. In Umphred DA,
editor: Neurological rehabilitation, ed 3, St Louis, 1995, Mosby.

707
VAs) TREATMENT APPLICATIONS

affects approximately 4 million people in the United rillary tangles are also seen in the temporal areas and to
States. Age is a primary risk factor. The incidence of AD a lesser degree in the parietal association areas.
doubles every 5 years after age 65, and AD is expected Neuritic plaques are large, extraneuronal bodies con-
to occur in 20% to 40% of the population of old-old sisting of accumulated B-amyloid and neuronal debris—
(85+ years) adults.’” Family history is another primary small axons and dendrites. This material degenerates,
risk factor for AD. Early-onset, familial forms of AD are taking up cellular space. Extracellular accumulation of
linked to genetic mutations on chromosomes 1, 14, too much insoluble B-amyloid into neuritic plaques
and 21.°'4”7! Late-onset AD has been linked to the contributes to neuron degeneration. Distribution of
apolipoprotein E-4 (APOE-4) allele-on chromosome neuronal plaques predominates in the temporal and
19, but it should be noted that this allele has also been parietal areas in early AD. The production of high levels
found in older persons who do not have AD.*””? Pre- of insoluble B-amyloid, associated with familial AD,
vious head trauma, lower educational levels, Down's has been linked to genetic markers on chromosomes
syndrome, and female sex are other potential risk 14,1, and 21.*"*””! The accumulation of amyloid de-
factors. posits may be affected by APOE-4 on chromosome 19
Although the incidence of dementia is growing and can also affect the development of neurofibrillary
rapidly, it does not occur in all older adults. Many older tangles.°?
adults experience a normal slowing of information pro- The ongoing neurodegenerative process itself may
cessing but do not develop clinically significant cogni- lead to further damage to cell membranes, enzymes,
tive deficits. Senility is a misleading and nonspecific DNA, and proteins through the excess production of
term that has been used in conjunction with older oxygen-based free radicals.°’ The metabolic processes
persons and aging. Early signs of what could really be a triggering excess free radicals may further be associated
dementing illness have been erroneously attributed to with activation of the amyloid precursor protein (APP)
the normal aging process’* and identified as senility. gene and the formation of insoluble B-amyloid.
The use of the term senility perpetuates stereotypical im- Cholinergic dysfunction is the process responsible
pressions that progressive cognitive decline occurs in for the expression of clinical symptoms, such as
normal aging. Such ideas prevent early recognition and memory deficits and word-finding problems, in early
accurate diagnosis of dementia. AD. Specifically, cholinergic deficits, thought to be
linked to APOE-E4, include less choline acetyltrans-
ferase (ChAT) activity in the frontal cortex and less
PATHOPHYSIOLOGY
ChAT activity in the hippocampus and temporal
Alzheimer’s disease is the result of degenerative changes cortex.°”’°°°’ These areas of the brain are associated
in the CNS. Neuroanatomical (structural) and neuro- with the symptoms of AD, such as recent memory im-
chemical changes occur in genetically or environmen- pairment and problems with executive functions.
tally susceptible brains. The result of these changes is
progressive and diffuse neuronal loss in the cerebral
CLINICAL PICTURE
cortex and the hippocampus.*’°’ Pathological changes
have been found through microscopic examination of Symptoms and patterns of behavior in AD are most
brain tissue after death. These changes include increased often described in terms of stages. The simplest descrip-
neuritic plaques and neurofibrillary tangles, with loss of tion of staging, useful for caregivers and consumers,
neurons and synapses. Early AD is associated with de- defines the progression of AD either in terms of a three-
creased cholinergic markers in areas of the brain where point scale using early, middle, and late stages or in
there is also increased distribution of plaques and terms of a four-point scale (Table 39-3).*”°*? More
tangles. Many of the changes in the brains of persons clinically and diagnostically complex scales, such as the
with AD can be seen only at autopsy, though neu- seven-point Global Deterioration Scale,°*’** are used in
roimaging techniques (e.g., CT, MRI, and PET) provide research or modified for diagnostic purposes and used
further diagnostic information. as part of an assessment battery.
Degenerative changes in the brain involve several The primary symptom of AD is impairment in recent
processes that affect neurotransmission and result in memory that worsens as time goes on, followed by at
neuronal death.°’ An inflammatory process causes the least one other cognitive deficit such as apraxia,
tau proteins in the cortical and limbic neurons to aphasia, agnosia, or impaired executive function, ac-
undergo microtubular dysfunction, preventing the cording to the American Psychiatric Association.*
neurons from sending nutrients and hormones along Memory impairment involves increased difficulty learn-
the axons. The paired filaments of these intracellular ing new information and recalling information after
proteins actually become cross-linked in an abnormal more than a few minutes.’* Over time the ability to
metabolic process. These filaments form neurofibrillary learn deteriorates further and the ability to recall old
tangles that eventually lead to neuron death. Neurofib- memories also declines. Symptoms such as speech and
 Progression of Alzheimer’s Disease and Intervention Considerations
Intervention Using Occupational
atient Characteristics Intervention Using Occupation Performance Components

tage I: Very mild to mild cognitive decline

Feels loss of control, less spontaneous; B |isten to client concerns; collaborate Encourage physical exercise and
may become more anxious and hostile with client on identifying areas that are wellness behavior
ifconfronted with losses challenging and identify associated
Help client and caregiver establish a
feelings (depression or anxiety)
ild problems with memory and less daily routine and post it in a central
initiative; difficulty with word choice, Begin training the caregiver to serve as a place
attention, and comprehension; need case manager
for repetition at times; conversation Use environmental aids such as
Provide educational and other resources calendars, appointment books,
__ more superficial; mild problems with
for disease information, support and adhesive notes, and notebooks to
:ae gnosis or praxis may be first noticed
relaxation, groups or activities for both enhance memory and reinforce
-m Sociallyand physically seems intact client and caregiver engagement in occupation
- except to intimates, job performance
_ declines Identify roles, activity frequency and Identify appropriate environments or
configuration; encourage continuation of adapt for activities that are currently
or increase in enjoyable activities by challenging
keeping a log and planning enjoyable
In learning new tasks use auditory,
activity daily or weekly’*; use activity or
visual, and kinesthetic input:and
task as a focus in socialization
provide supportive or positive
Explore meaning of eccupations and feedback; grade activity for success to
occupational role changes with client and decrease anxiety
caregiver
Communication training, rehearse with
Identify needs, preferences, and goals of client how to use ‘'l’’ statements and
the caregiver assertively express self and needs in
response to changed ability and the
Discuss driving skills and plan for future
feelings aroused
evaluation and restrictions
Educate and train caregiver on how to
empower client to keep active and
facilitate initiation of tasks

Stage II: Mild to moderate decline (problems from Stage | are exacerbated)
= Use of denial, labile moods, anxious or ™@ Emphasize to caregiver the importance Maintain routines and design
hostile at times; excessive passivity and of environment in managing dementia at environmental support (e.g,, lists,
withdrawal in challenging situations; home
19 posters, and pictures) and level of
paranoia may develop assistance for cues to remember daily
Analyze and adapt meaningful leisure,
routine and important events
@ Moderate memory loss with some home management, and other
gaps in personal history and for recent productive activities so as to allow the Avoid tasks involving new learning;
or current events; concentration client to safely participate and exert help to simplify surroundings and tasks,
decreases; may lose valued objects; initiation, independence, and control make objects accessible, establish
difficulty with complex information expectations for object use, simplify
@ Identify needs and design ways to adapt
and problem solving; difficulty learning instructions and clarify what is “success”
and grade activity by simplifying complex
new tasks; visuospatial deficits more
tasks, train the caregiver to provide Help caregiver interpret behavioral
apparent
cognitive support (verbally) with the problems by understanding source of
@ Need for supervision slowly increases; client on IADL and some ADL’ frustration because of the effects of
decreased sociability; moderate memory loss on behavior
M@ Encourage look at family structure and
impairment in IADL that are compli-
resources to respond to increasing need Maintain socialization and structure
cated and mild impairment in some
for supervision, consider outside opportunities in which others initiate
ADL (finances, marketing, medications,
resource (e.g,, day care, legal planning, socialization to ensure satisfying
community mobility, cooking complex
friendly visitor volunteer, public relationships in group activity and
meals); no longer employed;
transportation for the disabled) other social activities
complicated hobbies dropped

Adapted from Baum C: Addressing the needs of the cognitively impaired elderly from a family policy perspective, Am |Occup Ther 45:594-596, 1991; Morscheck P:
An overview of Alzheimer's disease and long term care, Pride JLong-Term Health Care 3:4-10, 1984; Glickstein J: Therapeutic interventions in Alzheimer's disease,
Gaithersburg, Md, 1997, Aspen Publishers; Gwyther L, Matteson M: Care for the caregivers, JGerontol Nurs 9, 1983. Continued
 TREATMENT APPLICATIONS

Alzheimer’s Disease and Intervention Considerations

Intervention Using Occupational
Patient Characteristics Intervention Using Occupation Performance Components

Stage II: Mild to moderate decline (problems from Stage I are exacerbated)—cont’d
@ Use reality orientation activities, photo
albums, pictures around the home as a
reminder of the past and past
competence and for socializing
@ Encourage stretching, walking, and
other balance activities

Stage lll: Moderate to moderately severe decline in cognition (problems from Stage II are exacerbated—difficulties
involving physical status more prominent)
M@ Reduced affect, increased apathy; sleep @ Maintain involvement in meaningful @ In managing problem behaviors such
disturbances; repetitive behaviors; activity and reactivate alternative roles; as assaultiveness teach caregivers to
hostile behavior, paranoia, delusions, identify and design tasks in home identify problem, understand and
agitation and violence may surface if management activity; client can assist consider possible precipitants for the
overwhelmed caregiver with design of productive behavior (e.g., feelings; antecedent
activity related to former work events; who, where, when; medical
™@ Progressive memory loss for well- role#4675
problem or task; environment; or
known material; some past history
communication problem), and adapt
retained; unaware of most recent Help caregiver problem solve and
own behavior or change the
events; disorientation to time and recognize degree of need for initiation,
environment! ®?!'8°
place and sometimes extended family; verbal cues, and physical assistance and
progressively impaired concentration; completion with ADL; provide time ™@ Essential to maintain consistent daily
deficits in communication severe; orientation; simplify environment routines as means of facilitating
apraxia and agnosia more evident participation in overlearned tasks,
Support socialization at home and with
maintain function, and continue to
M@ Slowed response, impaired visual and family or in structured settings outside of
define the self!®
functional spatial orientation the home
M@ Educate and train family that
@ Unable to perform most IADL; in Ensure safety in the home environment
overlearned tasks are possible but
ADL, assistance eventually needed and other environments by making
require safe environment; overall, tasks
with toileting, hygiene, eating, and adaptations suited to level of client
take longer need to be simplified,
dressing; urinary and fecal incontinence functioning (e.g., alarms, restrict use of
require setup and grading to comprise
begins; wandering behavior heating devices and sharps, cabinet
two steps or less
latches, ID bracelet, visual cues for item
location, and visual camouflaging)'”7°°.7° @ Make further environmental
adaptations to-compensate for
perceptual deficits and ensure safe
mobility

M™ Rehearse and review names of family

and others with pictures

™@ Encourage standby or assisted

ambulation, stretching, and exercise on
a regular basis

@ In new environments cue and assist

client in navigation and provide more
light and pictorial representations to
cue

Adapted from Baum C: Addressing the needs of the cognitively impaired elderly from a family policy perspective,
Am |Occup Ther 45:594-596, 1991; Morscheck P:
An overview of Alzheimer's disease and long term care, Pride | Long-Term Health Care 3:4-10, 1984; Glickstein J: Therapeutic interventions in Alzheimer's disease,
Gaithersburg, Md, 1997, Aspen Publishers; Gwyther L, Matteson M: Care for the caregivers, |Gerontol Nurs 9, 1983.
 Degenerative Diseases of the Central Nervous System

Progression of Alzheimer’s Disease and Intervention Considerations

Intervention Using Occupational
‘ Patient Characteristics Intervention Using Occupation Performance Components

Stage IV: Severe cognitive decline and moderate to severe physical decline
@ Memory impairment severe, may @ For ADL (hygiene, feeding), instruct care ™@ Encourage and support caregiver to
forget family member name but providers (family or nursing assistants) use respite programs and maintain
recognizes familiar people; can on need for simple communication, one- recreation and leisure activity for
become confused even in familiar step commands, step-by-step verbal cues himself or herself
surroundings and physical guidance
M@ Encourage assisted ambulation until
@ Gait and balance disturbances, Encourage continued socialization by patient/client no longer able
difficulty negotiating environmental family; socialization dependent on
barriers, generalized motoric slowing M@ Maintain proper positioning in bed and
initiation of conversation by others and
wheelchair; instruct family in skin
may not consistently include a response
@ Often unable to communicate inspection
from t he client
except for word or grunt;
M@ Provide controlled sensory stimulation
psychomotor skills deteriorate until M@ Use dysphagia techniques to promote
involving sound, touch, vision, and
unable to walk; incontinent of both swallowing, prevent choking, and
olfaction to maintain contact with
urine and feces; inability to eat; encourage eating
reality
nursing home placement often
@ Instruct family on transfer techniques
occurs at this time M@ Begin program of active and assisted
and passive ROM

Adapted from Baum C: Addressing the needs of the cognitively impaired elderly from a family policy perspective, Am |Occup Ther 45:594-596, 1991; Morscheck P:
An overview of Alzheimer's disease and long term care, Pride J Long-Term Health Care 3:4-|0, 1984; Glickstein J: Therapeutic interventions in Alzheimer's disease,
Gaithersburg, Md, 1997, Aspen Publishers; Gwyther L, Matteson M: Care for the caregivers, |Gerontol Nurs 9, 1983.

language problems, impaired recognition of previously ability to perform even basic self-care tasks in activities
familiar objects, and impaired ability to perform of daily living (ADL). The trend is for cognitive deficits to
planned motor movement are more variable and may increase and executive function to become more im-
not be seen in all persons with AD. The expression of paired (Table 39-3).'*?”7°°* Motivation and percep-
symptoms depends on the areas of the brain most af- tion can influence functional performance but may not
fected by the disease. Executive function (the ability to be routinely considered in individuals with AD.*°
initiate, plan, organize, safely implement, and judge
and monitor performance) inevitably deteriorates as
MEDICAL MANAGEMENT
AD progresses. Visuospatial dysfunction is common.
Mood and behavioral changes are often observed in the According to Larson,*’ medical management of the in-
early stages of AD, with personality shifts and the devel- dividual with AD in primary care settings generally in-
opment of depression, anxiety, and increased irritabil- cludes several areas. Many aspects of what is termed
ity. Later in the course of the disease, troubling behav- medical management may also be performed by certain
ior problems such as agitation, psychosis (delusions other members of an interdisciplinary health care team,
and hallucinations), aggression, and wandering can including the nurse, social worker, physical therapist, or
emerge.’°*’* Motor performance areas such as gait occupational therapist. First, there is a need for early
and balance may become impaired, and sensory recognition and diagnosis of AD.*” Second, there is the
changes usually arise in the mid to later stages in the issue of how to treat the person with AD who is living in
course of AD (Table 39-3). Frequently delirium and de- the community, before institutionalization or more re-
pression complicate the clinical picture. The average du- strictive care. The third area concerns treatment issues as
ration of AD is from 8 to 10 years but can range from 3 the disease progresses. Last is the role of health care
to 20 years with a variable rate of progression. providers in recognizing and addressing treatment of
Deterioration in the individual's functional perform- other conditions that lead to excess disability in the
ance usually occurs in a hierarchical pattern. This pattern person with AD.
of decline consists of a gradual progression from mild Although dementia is a relatively common disease in
impairments in work and leisure performance to more persons over 80 years of age, such individuals often are
moderate difficulties in performing instrumental activi- not diagnosed until approximately 2 to 4 years after the
ties of daily living (IADL) to a progressive loss of the onset of dementia symptoms.***”*!*! A comprehensive
75 TREATMENT APPLICATIONS

physical examination, laboratory evaluation, mental becomes an overwhelming burden for caregivers, espe-
status examination, brief neurological examination, cially those who are aged.
and informant interview are essential in diagnosing AD. According to Small and colleagues,’* pharmacother-
It is important to identify and treat medical conditions apy for the treatment of individuals with AD should
(e.g., metabolic disturbances, infections, alcohol use, be assessed carefully and justified at regular intervals.
vitamin deficiencies, chronic obstructive pulmonary Although OT practitioners do not prescribe medica-
disease, heart disease, and drug toxicity) that can con- tions, knowledge of pharmacotherapy is useful. Cho-
tribute to comorbidity. MRI, PET, and CT scan results linesterase inhibitors such as tacrine and donezepil
can be useful, but overreliance on these techniques may improve cognition and functional performance, at
should avoided because their value is in identifying rel- least in the short term. Promising research is under
atively uncommon, treatable causes of cognitive impair- way in this area. Other agents that may improve cog-
ment. A comprehensive and skillful interview with a re- nitive function include estrogen, nonsteroidal antiin-
liable informant is essential to the evaluation and flammatory agents, gingko biloba, and vitamin E.°°
diagnostic process in order to recognize decline by Evidence about the benefits of these agents is inconclu-
comparing current changes with past performance. In- sive. Antidepressant medications, especially selective
formant questionnaires, interviews, and screening mea- serotonin reuptake inhibitors (SSRIs), are often pre-
sures may be performed by many health care profes- scribed.’ However, some of the tricyclic antidepres-
sionals other than physicians and are important to the sants (amitriptyline, imipramine, and clomipramine)
diagnostic process. and monoamine oxidase inhibitors (MAOIs) can have
The goal of health care providers in the successful troublesome side effects in older adults. Atypical an-
management of an individual with dementia, whether tipsychotics such as clozapine, risperidone, and olanza-
in the community or in a semiinstitutional or institu- pine may be used to reduce agitation and psychosis.’””°
tional setting, is to “minimize behavior disturbances, Benzodiazepines are prescribed for treating anxiety and
maximize function and independence, and foster a safe infrequent agitation but have been found to be less ef-
and secure environment”’* (p. 1367). Increased mortal- fective than antipsychotics when the symptoms are
ity is associated with dementia.'* Regular health main- severe. ’*
tenance visits in primary care settings are important for
all older adults, but especially those with AD, to identify ROLE OF THE OCCUPATIONAL
treatable illnesses such as depression, Parkinson’s
THERAPIST
disease, low folate levels, arthritic conditions, urinary
tract infections, and other conditions that may exacer- In the early stages of Alzheimer’s disease most individu-
bate dementia.*"’’* als with the disorder live alone or with family and
Depression and dementia easily may be mistaken for friends, rather than in institutions. A predominant
each other, or they may coexist.’* Careful attention to feature of AD is significant and progressive deterioration
whether the onset of symptoms has been gradual (de- of function from previous levels of performance
mentia) or more recent (depression) is an important di- because of advancing brain atrophy and pathological
agnostic issue because affective and cognitive symptoms tissue changes. These changes cause deficits in occupa-
frequently occur together.°* Cognitive impairments and tional performance components, which in turn lead to
especially functional performance may improve in indi- deterioration in occupational performance areas and
viduals with both dementia and depression after they major changes in occupational roles. Over time, more
are treated for depression. Delirium (impairment in at- structured and supervised living environments are
tention, alertness, and perception) and dementia fre- needed. Increased difficulties in everyday functioning
quently coexist as well, especially in hospital settings.’ create challenges for the individual with the disorder
Both conditions involve global cognitive impairment, and have an impact on the quality of life for the patient,
but delirium is usually acute in onset, shows fluctuating the family, and caregivers as the disease progresses. Ef-
symptoms, disrupts consciousness and attention, and fective OT interventions must be directed at the chang-
interferes with sleep. Adverse drug reactions are more ing meaning of occupation for the individual. Priority
common in AD because of the vulnerable, impaired interventions include maintaining capabilities and
brain.*° Often a cause of delirium, such as drug toxicity, adapting tasks and environments or otherwise compen-
is treatable. sating for declining function in individuals with
Hearing, vision, and other sensory impairments are Alzheimer’s disease while trying to help them retain as
known to make dementia worse and cause greater strain much control as possible over their lives in the least re-
on the caregiver.’®’’ Falls with hip fractures are 5 to 10 strictive environment.*
times more common in persons with AD than in Support for the caregiver is a must. Collaboration
normal persons of the same age and often result in with and training of the caregiver is essential in the
earlier institutionalization for the individual and the management of persons with dementia. Family mem-
need for higher levels of care.'* Unsafe mobility quickly bers should encounter an open and encouraging
 Degenerative Diseases of the Central Nervous System 713

environment in which to discuss safety, security, and de- are used to assess occupational performance, functional
pendence issues. Legal, financial, and health concerns abilities, and skills, using measures such as the Func-
that require advance directives (medical and legal), tional Behavior Profile,’ the Activity Profile,’ the Care-
trusts, activity restrictions (e.g., driving, financial, and giver's Strain Questionnaire,°’ the Katz Activities of
medication management), and contingency and transi- Daily Living Scale (KADL),*’ and the Instrumental Ac-
tional care plans (e.g., day care, residential care, and tivities of Daily Living Scale (IADL).*? Informant rating
long-term care) are important in preparation for the in- measures should routinely be followed by an interview
evitable progression of the disease. *”’’? Behavior prob- either before or during the first visit. The use of a few
lems can be expected in the client with AD until the ter- brief screening instruments for mental status (e.g., the
minal or bed-bound stage. Encouragement to use respite MMS),”° depression,'”’’? and anxiety** provides base-
care, in-home support services, and support groups is line data and a wealth of information about factors that
important. Caregivers also need effective strategies for are likely to influence performance.
dealing with behavioral disturbances and disruptions in The functional evaluation of an individual with AD
mood. The use of environmental adaptations, therapeu- depends on the stage of cognitive decline.* The Ameri-
tic interpersonal approaches, referral to other disci- can Occupational Therapy Association's statement on
plines, and resource sharing helps in collaborating with services for persons with Alzheimer’s disease suggests
the patient's family and handling these problems. that tasks involving work, home management, driving
Health professionals use education, training, counsel- skills, and safety should be targeted in the early stages of
ing, and support to help caregivers deal with their feel- the disease. In the later stages, the focus shifts to self-
ings, manage behaviors, and maintain quality of life for care, mobility, communication, and leisure skills. The
themselves and for the client with AD. Awareness of the concerns and observations of the caregiver are impor-
multidimensional effects of this illness on the individ- tant, but the therapist's observation of task performance
ual and on the family and the society at large is impor- is also necessary. Unfortunately, many of the functional
tant to promote more effective and efficient care.°" ADL scales developed for use with older adults have tar-
geted physical performance and are not appropriate for
persons experiencing cognitive decline.** Fortunately,
EVALUATION
several excellent, standardized measures that determine
An OT screening is often performed before the evalua- whether individuals are able to use their cognitive skills
tion. Occupational therapy services are indicated for in- to perform tasks in ADL and IADL have been developed
dividuals who have demonstrated a recent decline in over the last 15 years. The Kitchen Task Assessment
function; pose a safety hazard to family, staff, other res- (KTA) determines the level of cognitive support a
idents, or self because of their behaviors; or may experi- person with AD needs to complete a cooking task suc-
ence improved quality of life.''’ Much of the therapist's cessfully.* The Allen Cognitive Level (ACL)! test deter-
time in community settings and in long-term care is mines the quality of problem-solving an individual uses
spent helping families and caregivers develop strategies while engaged in perceptual motor tasks. Levy*”’*® has
and environmental adaptations to cope with the over- written at great length about the use of the ACL for
whelming stresses of safely managing a cognitively im- clients with cognitive impairments. Consistent with the
paired individual.’ Allen theoretical approach, the Cognitive Performance
The type of assessment and the depth of the evalua- Test (CPT)*'* was developed to identify cognitive
tion process used depends on the setting, the stage of deficits that are predictive of functional capacity, using
progression of AD, the reimbursement process, the pres- several ADL and IADL tasks. Another measure, the As-
ence of other medical and mental health disorders, and sessment of Motor and Process Skills (AMPS),°” has
the cooperation and interest of the caregiver or care been used with individuals who have dementia.**°°
staff. The consequences of caregiving and the needs of The AMPS measures motor (posture, mobility, and
the caregiver can vary greatly, depending on gender, strength) and process (attentional, organizational, and
family relationships, culture, and ethnicity. The care- adaptive) skills by using task performance in IADL. A
giver's understanding of dementia, reaction to demen- promising new measure, the Disability Assessment for
tia-related behaviors, use of problem-solving skills, use Dementia (DAD),** uses informant ratings to deter-
of the environment, use of formal and informal support mine the ability of the individual with AD to complete
systems, and decision-making style greatly affect the tasks in both ADL and IADL. The DAD also provides in-
caregiver's ability to participate in the care plan and formation relevant to executive functioning, such as the
treatment of persons with dementia.°'* ****’® person’s ability to initiate, plan, and execute the activity.
Evaluation should be comprehensive despite chang- Further information regarding the evaluation of cogni-
ing reimbursement. Much information can be gathered tive function and ADL performance is given in Chapters
before an interview and treatment session by asking 13 and 27. After obtaining through evaluation a good
caregivers, family members, and staff informants to understanding of the disease process and the functional
complete questionnaires and rating scales. These scales level of the person with AD, the therapist can begin to
714 TREATMENT APPLICATIONS

look at the all-important question of what aspects of the formance and the establishment of a baseline of per-
occupational performance context, especially the envi- formance. Recommendations for OT treatment for AD
ronment and care provider interactions, must be modi- have been identified. The focus of treatment must be
fied to optimize function of the person with AD.”° flexible and depends on an understanding of the par-
ticular expression of the disease process in the individ-
ual, the specific treatment setting, and the needs of the
TREATMENT METHODS person giving care. Generally, the goal of OT services
The goals of OT are to provide services to persons with for persons with dementia are to maintain or enhance
dementia and their families and caregivers so as to em- function, promote continued participation in meaning-
phasize remaining strengths, maintain physical and ful occupation, and optimize health and quality of life,
mental activity for as long as possible, decrease caregiver and work collaboratively with the caregiver to ease the
stress, and keep the person in the least restrictive setting burden of caregiving.
possible.*°°° Treatment planning takes into account
the progressive nature of the disorder, the expected Mer ee eee eee
decline in function, and the care setting itself. Occupa- SECTION 3
tional therapy interventions for persons with dementia
are directed toward maintaining, restoring, or improv-
Huntington's Disease
ing functional capacity; promoting participation in oc- WINIFRED SCHULTZ-KROHN
cupations that are satisfying and that optimize health
and well-being; and easing the burdens of caregiving.’
INCIDENCE
The methods therapists use in the intervention process
include activity analysis, caregiver training, behavior Huntington's disease (HD) is a fatal, degenerative neu-
management techniques, environmental modification, rological disorder that affects 5 to 10 of every 100,000
use of purposeful activity, and the provision of re- individuals.'?The disorder is transmitted in an autoso-
sources and referrals. Treatment takes place in many dif- mal dominant pattern. Each offspring of an affected
ferent settings, such as home care, adult day care, and parent has a 50% chance of having HD. Genetic studies
semiinstitutional or institutional long-term care. The have identified a mutation on chromosome 4 as the
treatment setting and the stage of the illness help frame cause of this.”'*’'*’> Presymptomatic diagnosis of HD
the focus of intervention, determine the recipients of is possible with genetic testing when the family history
service, and prescribe the methods used (Table 39-3). shows this disease.'”'? Diagnosis is also made through
clinical examination when the family history is unavail-
able or unknown.
SUMMARY
Alzheimer’s disease (AD) is a neurological condition
PATHOPHYSIOLOGY
characterized by the development of multiple cognitive
impairments with a gradual onset. The effect of these The neurological structure associated with HD is the
impairments is a significant and progressive decline corpus striatum. Deterioration of the caudate nucleus is
from previous levels of functioning. The course of the more severe and occurs earlier than atrophy of the
disorder is variable, but loss of function generally occurs putamen.~” The corpus striatum plays an important
in a hierarchical pattern, beginning with work and pro- role in motor control. The caudate nucleus is also
gressing to difficulties with home management, driving, linked to cognitive and emotional function through
and safety until even basic self-care skills such as dress- connections with the cerebral cortex. A progressive loss
ing, functional mobility, toileting, communication, and of tissue occurs in the frontal cortex, gious pallidus,
feeding are affected. and thalamus as the disease advances.'* The degenera-
OT interventions should be directed at enhancing tion of the corpus striatum results in a decrease in the
the abilities of the person with AD by continually neurotransmitter gamma-aminobutyric acid (GABA).
adapting tasks of daily living and modifying the physi- Additional deficiencies in acetylcholine and substance
cal and social environment as the individual experi- P, both neurotransmitters, are noted in clients with HD.
ences progressive loss of function. Given many of the The triggering mechanism for the neuronal degenera-
current limitations in treatment time imposed by third- tion has not been clearly identified, but it is linked to
party payment, therapists may find it useful to employ genetic coding on chromosome 4.'”
some of the self-report and informant report measures
identified in this chapter as a means of gathering infor-
CLINICAL PICTURE
mation more efficiently during the evaluation process.
Several standardized measures also have been identi- Huntington’s disease is characterized by progressive dis-
fied to assist with the assessment of functional per- orders of both voluntary and involuntary movement, in
 Degenerative Diseases of the Central Nervous System 715

addition to a significant deterioration of cognitive and depressants. Periods of mania have also been reported
behavioral abilities.'*'’ A client usually experiences an in approximately 10% of patients with HD.
insidious onset of symptoms in the third to fourth As the disease progresses, the chorea becomes more
decade of life, but cases have been reported in teenage severe and may be observed throughout the entire
and younger clients.'* The symptoms progress over a body, including the face.'* Disturbances in gait are
15- to 20-year period, ultimately necessitating long- often observed during the middle stages of the disease,
term care or hospitalization for the client.'? Death is and balance is frequently compromised.* The individ-
often the result of “secondary causes, such as pneumo- ual with HD may display a wide-based gait pattern and
nia”° (p. 341). have difficulties walking on uneven terrain. This stag-
The initial symptoms vary but are most often re- gering gait is at times misinterpreted by others in the
ported as alterations in behavior, changes in cognitive client's life as evidence of alcoholism." The client also
function, and choreiform movements of the hands.'® has progressive difficulty with voluntary movements.'*
The early symptoms of cognitive disturbances are prob- The performance of voluntary motor tasks is slowed
ably related to the degeneration of the caudate nucleus. (bradykinesia), and the initiation of movement is com-
The client may appear forgetful or display difficulty in promised (akinesia). Although handwriting ability
concentrating. During the initial stages of HD a client may be spared initially, the client displays increasing
may have difficulty maintaining adequate work per- difficulties with this task as the disease progresses.
formance. Family members often identify the initial Letter size is enlarged, and letter formation, such as
behavioral changes seen in the person with HD as in- slant and shape, is distorted. Saccadic eye movements
creased irritability or depression. Irritability and depres- and ocular pursuits may be slowed at this stage of
sion may be attributed inappropriately to the decline in HD." Slight dysarthria may be noted, which compro-
work performance rather than to the disease process. mises communication.’ Dysphagia is seen, and the
Emotional and behavioral changes are often the earliest client may choke on various foods. Difficulties may be
symptoms of HD.’ Chorea, seen in clients with HD, noted with the coordination of both chewing and
consists of rapid, involuntary, irregular movements.'* breathing while eating.
During the early stages of HD, chorea is often limited to In the later stages of HD, choreiform movements
the hands. These irregular movements are exacerbated may be reduced because of the further deterioration of
during stressful conditions and decrease during volun- the corpus striatum and globus pallidus.'* Hypertonic-
tary motor activities. Chorea is absent when the client is ity often replaces the chorea, and the client experiences
sleeping. Onset of HD in teenage years is associated a severe reduction in voluntary movements. Severe diffi-
more often with early symptoms of rigidity than with culties in eye movement are common during the final
chorea.'® stage of the disease." At this stage the client often needs
Cognitive and emotional abilities progressively dete- significant support from others or resides in a long-term
riorate over the course of the disease.'* Disturbances in care facility. The client is usually unable to talk, walk, or
memory and in decision-making skills become more perform basic ADL without significant assistance.’
apparent during the middle stages of HD. A patient may
be able to complete familiar tasks at work or in the
MEDICAL MANAGEMENT
home, but if the environment is changed or if addi-
tional demands are placed on the individual, task per- Medical management of clients with HD can address
formance is significantly compromised. Further deterio- symptoms, but no effective course of treatment has
ration of cognitive abilities may result in dismissal from been identified to arrest the progression of this
employment for the person with HD. The cognitive disease.'* Intervention based on replacing the deficient
deficits most frequently associated with HD are prob- neurotransmitters has not been effective in changing the
lems with mental calculations, the performance of se- course or rate of progression of HD. Tricyclic antide-
quential tasks, and memory.’ Verbal comprehension pressants are often used to treat the depression seen in
often is spared until the later stages of the disease and clients with HD, but monoamine oxidase inhibitors
even then appears to be more compromised by (MAOIs) are contraindicated because of possible exacer-
dysarthria than by difficulty in comprehension. bation of chorea.'* Haloperidol may be used to de-
As HD progresses, depression often worsens and crease the negative effects of chorea on the performance
suicide is not uncommon.'® Clients with HD are often of functional activities.'? Haloperidol is prescribed cau-
hospitalized because of various psychiatric problems, tiously and only when the chorea significantly compro-
including depression, emotional lability, and behav- mises a person’s daily activities.
ioral outbursts. Although the loss of function may con- Systematic evaluation of a client with HD must
tribute to the client's level of depression, depression is be performed at regular intervals to identify the rate
clearly identified as a specific characteristic of HD.* This of symptom progression and modify intervention
affective disorder frequently is treated with various anti- strategies. Standardized instruments are available for
716 TREATMENT APPLICATIONS

determining the presence and severity of various symp- The OT intervention plan must include community
toms.”’’° One evaluation tool, known as the Unified support services for the client with HD.
Huntington's Disease Rating Scale (UHDRS), combines The motor disturbances during the early stages of HD
aspects from several instruments into a scale that can be are usually limited to fine motor coordination prob-
administered within 30 minutes. The UHDRS is often lems.° The characteristic chorea may be noticed only asa
administered by a team. This tool provides an accurate twitching of hands when the patient is anxious. OT
means of determining a change in the areas of “motor should provide modifications to diminish the effect of
function, cognitive function, behavioral abnormalities chorea and fine-motor incoordination on performance
and functional capacity.”” The occupational therapist of functional activities.° Home modifications should be
should complete additional assessments before an in- instituted at this stage to allow the person with HD to
tervention plan is developed. An evaluation would become familiar with the changes. Typical modifications
address functional daily living skills; cognitive abilities are the use of cooking and eating utensils with built-up
such as problem solving, motor performance, and handles, unbreakable dishes, a shower bench or seat
strength; and personal interests and values. The occupa- with tub safety bars, and sturdy chairs with high backs
tional therapist must consider the client's role within and armrests. Throw or scatter rugs should be eliminated
the family and community and incorporate these data wherever possible in the home, and walkways should be
into the intervention plan. An evaluation at both the kept free of clutter. The occupational therapist should es-
home and work site would provide needed information tablish a home exercise program with the client to
that could be modified if necessary. address the flexibility and endurance of the entire body.
These exercises will be incorporated into the client's daily
routine. As the movement disorder progresses, the client
ROLE OF OCCUPATIONAL THERAPY
will have to discontinue driving a car. These further
The role of the OT practitioner varies, depending on the losses of independent function and control must be con-
stage of the disease.° During the early stages of HD an sidered within the OT intervention plan. Alternative
occupational therapist should address the cognitive community mobility must also be explored.
components of memory and concentration. At this As HD progresses, the role of OT changes to meet the
stage a client may still be employed. Strategies such as client's needs.° During the middle stages of HD, further
establishment of a daily routine, the use of checklists, deterioration of cognitive abilities is noted, often re-
and task analysis to break tasks down into manageable quiring the person to terminate a job. Engagement in
steps can be very helpful. These strategies provide the purposeful activities is greatly needed at this stage
external structure and support to help the person with and should be a focus of the OT intervention plan.*’””
HD maintain functional abilities at both the workplace Decision-making and arithmetic skills show further de-
and home. A work-site evaluation can identify changes terioration, and family members may need to arrange
that would allow the person with HD to continue for others to handle the client's financial matters.**
working. The use of a kitchen timer or a watch with a Generally, comprehension of verbal information is
beeper can serve as a reminder to perform a specific better preserved than ability to complete sequential tasks
task. Family members should be instructed in the use of during this stage. The occupational therapist should en-
these techniques. Environmental modifications such as courage the family to use simple written cues or words
providing a quiet workplace and reducing extraneous to help the family member with HD complete self-care
stimuli will decrease the impact of compromised and simple household activities. For example, selecting
memory and concentration on functional tasks. clothing items for the person with HD and placing the
Psychological issues during this stage of the disease clothes in a highly visible area can provide the prompt
often include anxiety, depression, and irritability.** A to change from pajamas to clothes in the morning.
client may express guilt that any of his or her children During the middle stage of HD the client may display
have a 50% chance of having HD." The diagnosis of HD increasing levels of irritability and depression.'® Pa-
often is not confirmed until a person is 30 to 40 years old. tients with HD may attempt suicide. The OT interven-
The patient may already be married and have children by tion plan should focus on the client’s engagement in
that time. Decisions on whether to complete predictive purposeful activities, particularly leisure activities. Selec-
genetic testing on children may be a significant stress for tion of craft activities should always consider the
the client with HD and for his or her family members. client’s interests but should avoid the use of sharp in-
Maintaining social contacts and engaging in pur- struments.*’* Modification of craft activities allows the
poseful activities is important in the treatment of client with HD to successfully complete a task with
patents with HD." Changes in cognitive abilities and minimal support.
emotional responses may result in the loss of a job and Motor problems become more apparent during the
decreased income for the family, even during this early middle stage of HD, necessitating further modifications
stage of the disease.* This additional stress should also in daily living tasks.°'® The client's compromised
be considered when developing an intervention plan. balance may require that tasks such as dressing, brush-
 Degenerative Diseases of the Central Nervous System 717

ing teeth, shaving, and combing hair be performed Dementia is part of the HD profile and must be consid-
while seated. The client may require the use of a walker ered in development of the intervention plan. A patient
or wheelchair at this stage. A rollator walker is preferred may still recognize family members and enjoy watching
to a standard walker without wheels. The walker may television. The occupational therapist should explore
need to be fitted with forearm supports to provide addi- the use of various environmental controls to allow the
tional support when the client is ambulating. When a client control of and access to the immediate environ-
wheelchair becomes necessary, it should have a firm ment.’ Providing a touch pad or switch for selecting tel-
back and seat; however, additional padding is often re- evision channels may prove successful for the client.
quired on the armrests because of the chorea. Many Behavioral outbursts have been reported in approxi-
clients with HD are better able to move the wheelchair mately one third of patients with HD living in long-
with their feet than with their hands. The seat height of term care facilities.’ Occupational therapy can decrease
the wheelchair should be fitted to allow the client to use the frequency of these outbursts by organizing consis-
his or her feet to move the chair, if possible. tent daily schedules and routines for the client with HD.
Fatigue is a common issue during the middle stage of
HD and can be addressed by taking frequent breaks
SUMMARY
during the day. Breaks must be scheduled, because the
person with HD may not readily recognize fatigue. Although HD is a progressive, degenerative process, OT
Clothing should have few or no fasteners, and shoes has much to offer the client with this disease.*’°*" The
should be sturdy with low heels.® Additional adapted diminishing ability to’ control the environment has
equipment that may prove helpful for the patient with been identified as one of the variables contributing to
HD includes shower mitts, electric razor or chemical the deterioration of function in patients with HD.
hair removal, covered mugs, and nonskid placemats.° Throughout the course of the disease, OT addresses the
The choreic movements may become so severe as to ne- ability of the person with HD to exercise a degree of
cessitate the use of a bed with railings. Padding should control over the environment and to engage in purpose-
be used on the railings, and additional cushions should ful activity.
be used in the bed.
Because of excessive movements associated with Pe ar es be i er rte
chorea, the client with HD often needs to consume 3000 SECTION 4
to 5000 calories per day to maintain weight.* Smaller,
high-calorie meals should be provided five times a day.
Multiple Sclerosis
This schedule may require additional support from DIANE FOTI
family members ora personal care attendant. Dysphagia,
poor postural control, and deficient fine motor coordina-
INCIDENCE
tion compromise the client's ability to eat.° Positioning
during feeding is crucial, and the trunk should be well Multiple sclerosis (MS) is a progressive neurological
supported during mealtime. The person with HD should disease that damages the myelin sheath in the CNS.
be able to support his or her arms on the table while the Onset usually occurs between the ages of 20 and 40
feet are stabilized. Feet may be supported on the floor, or years.’ The disease affects 60 to 100 people per
the person may wrap the feet around the legs of the chair 100,000.° It is more prevalent in women than in men.”
for additional support. Problems with dysphagia can be Five percent of people with MS have a brother or sister
addressed with positioning, oral motor exercises, and with the same diagnosis, and approximately 20% have a
changes in diet consistency. Soft foods and thickened close relative with the same diagnosis. The highest
fluids are preferable to chewy foods and thin liquids. prevalence of the disease is in Caucasians of northern
During the final stages of HD the client is often de- European ancestry.
pendent upon others for all self-care tasks because of The myelin is typically damaged in discrete regions of
the lack of voluntary motor control.*’ The chorea may the white matter, with the axon remaining preserved. Dis-
diminish in some clients, to be replaced by rigidity. The ruption of the myelin sheath has differing effects on the
occupational therapist provides important input on po- axonal conduction, depending on the degree of break-
sitioning and the use of splints to prevent contractures down and the length of the damaged segment.* When
at this stage. Because of the risk of aspiration, oral feed- axons are conducting in a slower manner because of in-
ings are provided by trained personnel; alternatively, the flammation of the myelin sheath, the individual with MS
client may receive nutrition through a feeding tube.* A may have intermittent symptoms of sensory distortions,
combination of oral feedings and tube feedings may be incoordination, or weakness. This inflammatory process
used during this stage. results in the remitting and relapsing form of MS.
Although cognitive abilities continue to deteriorate, In advanced cases of MS acute and chronic plaques
the level of functional decline is difficult to assess develop throughout the white matter, especially in the
because of dysarthria and the loss of motor control.’ the spinal cord, optic nerve, and periventricular white
718 TREATMENT APPLICATIONS

. ° 8
matter, including the corpus callosum.” Axons may be a pattern of relapses and remissions but evolves into the
damaged and severed in advanced cases, resulting in ex- progressive form of the disease. The primary-progressive
tensive loss of function. form of MS is distinguished by a downward course and
little recovery after exacerbations. Individuals with this
form eventually are nonambulatory and incontinent of
ETIOLOGY
urine and may have dysphagia and dysarthria, little
The specific cause of MS is unknown, although it is sus- lower extremity function, and varying degrees of upper
pected to be the result of acombination of environmen- extremity function. For individuals with the primary-
tal and genetic factors. The most current theory is that progressive form of MS the average time to reach the
MS is an immune system reaction that acts on the stage of severe disability is 10 to 25 years. Overall, life ex-
nervous system. Recent studies have shown that 30% to pectancy is near normal for those with MS.'*
60% ofthe new clinical attacks of the disease occur after The two atypical patterns of MS are the benign course
a cold, flu, or common viral illness. Some researchers and the progressive-relapsing form. The clinical signs of
theorize that the immune system mistakes a portion of a benign course are a younger age at onset, female sex,
the myelin protein for a virus and destroys it. Other re- and onset with sensory symptoms. The symptoms
searchers believe that the viral infection damages the usually resolve within 6 weeks, and there may be only a
myelin and releases small amounts into the body, re- few residual deficits. If the disability is minimal after five
sulting in an autoimmune reaction.'* years, the course is considered benign.” The progressive-
relapsing form of MS is rare. It is identified as steadily
progressive but has specific relapses.”
CLINICAL PICTURE
The symptoms that occur with MS are related to the area
MEDICAL MANAGEMENT
of the CNS affected.* Early symptoms may be paresthe-
sias, diplopia, or visual loss in one eye; fatigability, emo- In recent years new treatments have been introduced to
tional lability; and sensory loss in the extremities. Cog- limit inflammation during periods of exacerbation and
nitive deficits have also been documented in individuals to slow the immune system response. Medical manage-
with a disease duration of less than 2 years and with few ment centers primarily on treating the symptoms of the
neurological signs.’ Other initial symptoms are trigemi- disease.
nal neuralgia and a worsening of symptoms when the Antiinflammatory medications such as prednisone or
body temperature is elevated. These symptoms may be methylprednisolone are used during an exacerbation.
temporary and may resolve. These medications are usually given in high doses for
In advanced stages the individual may have varying short periods because of their extensive side effects. In
degrees of paralysis, from total lower extremity paralysis lower doses that can be tolerated for long periods, these
to involvement of the upper extremities, dysarthria, dys- medications have not demonstrated the ability to
phagia, severe visual impairment, ataxia, spasticity, nys- prevent further exacerbations or change the long-term
tagmus, neurogenic bladder, and impaired cognition. course of the disease but are effective primarily for
Cognitive deficits are reported to occur in 30% to 70% of shortening the duration of an exacerbation.‘
persons with MS but do not necessarily correlate with a In the relapsing and remitting form of MS several
physical decline.'"’ Emotional changes such as depres- new medications are being used and are thought to
sion may also be present; less commonly seen are eupho- have an effect in preventing the slow, stepwise decline.
ria and a sense of indifference. Dementia may develop in Three different medications for this group have recently
individuals who exhibit euphoria and indifference. De- been introduced: interferon B-1 b (Betaseron), inter-
mentia occurs in less than 5% of the population with MS.° feron B1 a (Avonex), and glatiramer (Copaxone).” Indi-
The course of MS is unpredictable. It is marked by viduals treated with these medications, given by subcu-
episodes of exacerbation and remission. An exacerba- taneous self-injection, showed a one-third reduction in
tion may be an episode as minor as fatigue and sensory frequency of exacerbations. Studies are ongoing regard-
loss or as extensive as total paralysis in all extremities ing the effects of these medications for individuals with
and loss of bladder control. Remissions may involve a the progressive form of the disease.
total resolution of the symptoms, may result in a short Symptom management includes treatment of spas-
plateau, or may result in some loss of function. ticity, bladder management, prevention of bladder in-
The three typical patterns seen in MS are: (1) relaps- fection, management of pain, and management of
ing and remitting, (2) secondary-progressive, and (3) fatigue. Spasticity is often managed with medication;
primary-progressive.* The relapsing and remitting form unfortunately, this may. also worsen muscle weakness.
of MS involves episodes of exacerbation and remission Bladder management may involve the use of inconti-
resulting in a slow, stepwise progression as the deficits ac- nence pads or catheters, along with the prevention of
cumulate. The secondary-progressive course begins with bladder infections. Fatigue should be managed with
 Degenerative Diseases of the Central Nervous System 719

good nutrition, the prevention of overfatigue with ADL may be evaluated with a check-off list, a stan-
energy conservation methods, regular exercise, and dardized assessment such as the Assessment of Motor
control of stress.'* Bowel incontinence is rarely a and Process Skills,° or other standardized assessments
problem related to a neurological deficit but is usually a for ADL.* The most widely accepted tool to measure
functional impairment as a result of immobility. clinical impairment for the person with MS is the Ex-
panded Disability Status Scale (EDSS).'* The scale
ROLE OF THE OCCUPATIONAL should be completed by a physician because it includes a
THERAPIST detailed neurological examination. The EDSS combines
an assessment of neurological function and a scale to
The OT practitioner may treat the person with MS in a measure a client's ambulatory and functional mobility
number of settings. The type and degree of intervention status. There are limitations with this tool; it does not
provided will be determined by the setting, the type of allow for detail in measuring all ADL and has been
reimbursement, and the patient's and caregiver's re- found to be insensitive to cognitive deficits in MS.'* The
sponse to treatment. OT practitioner should be familiar with the EDSS
The evaluation should include the gathering of infor- because it is mentioned often in much of the literature as
mation about all performance areas: work and produc- a baseline for evaluating disability and has been adopted
tive activities, self-care, and leisure. All performance by the International Federation of MS Societies. '?’!°
components should be evaluated: motor, psychological, Evaluation of the social environment is important to
sensory-perceptual, and social. Optimally, a home eval- consider with each client. MS is usually identified
uation should be completed. Since not all treatment set- during the phase of life in which a person is raising a
tings allow a home evaluation, the occupational thera- family and developing a career. Because the disease is
pist should interview the client and caregiver regarding unpredictable and fluctuating, it leads to disruptions in
the home environment and potential barriers. Because normal daily activities and in family life. This places
MS has an unpredictable course, the client may need re- stress on the spouse or partner, children, and other
ferral for other resources and periodic reevaluation by family members. The occupational therapist must deter-
an occupational therapist. mine what type of support the client can expect from
The evaluation of performance components and per- family members.
formance areas is generally accomplished with a combi- Behavioral issues for the person with MS vary de-
nation of standardized and nonstandardized assess- pending on the person’s premorbid personality, pro-
ments, through the use of interviews with the family gression of the disease, coping skills, and social environ-
and client, and through observation. If the client has a ment. Cognitive deficits and denial of the progressive
cognitive deficit, a family member or significant other nature of the disease may lead to behavior that places
should be included in the evaluation process to provide the individual at risk and makes management difficult.
accurate information. If families do not understand or recognize the client's
Evaluation of the sensorimotor components is dis- behavioral problems, there may be further complica-
cussed thoroughly in previous chapters of this text. tions when the behavior is not restricted or modified by
Since endurance is such a significant factor, it is impor- the family. For example, an individual with MS is able to
tant not to rely solely on the results of an evaluation of ambulate to the car but has cognitive deficits that are ex-
performance components. Observing a client perform- acerbated with fatigue in the afternoon. Because the
ing a functional activity over a period of time will client has already had to discontinue work, the family
provide the clinician with a more accurate evaluation of members do not want to take away driving privileges as
fatigue.” Perceptual processing and cognition should be well. Continuing to drive places the client and others at
included in each reassessment to determine specific risk of injury. The occupational therapist may need to
deficits and the functional impact and to incorporate educate the family about the deficits by providing exam-
this information into family training. The client's per- ples of how cognition is evaluated and by discussing the
ceptual and cognitive deficits may determine whether client's performance on the assessment and how the
that client can stay home alone or needs close, constant deficits relate to driving and other daily activities. Also,
supervision. Various standardized cognitive and percep- in this example the occupational therapist is responsible
tual assessments are included in previous chapters of for reporting the driving risk to the client's physician.
the text. Basso developed a screening tool for cognitive Other behavioral examples include the client who is de-
dysfunction for individuals with MS. Basso’s tool was pressed or labile, has poor memory, refuses assistance
found to be both sensitive to functional impairment from outside caregivers, or uses poor judgment regard-
and cost effective.* This tool could be used by an occu- ing safety with medications and transfers. Each client
pational therapist or recommended to another disci- demonstrates a unique set of behavioral issues and re-
pline when evaluating the person with MS for cognitive quires individual evaluation and a treatment approach
deficits. that encompasses the family, client, and caregivers.
ray TREATMENT APPLICATIONS

GOAL SETTING
ee ee ee ee eee
For the individual with a progressive disease such as MS, SECTION 5
goal setting focuses on the need for the client to adapt
Parkinson's Disease
as the disability progresses. Families often need to nego-
tiate role changes to accommodate the individual with WINIFRED SCHULTZ-KROHN
MS, who may not be able to participate consistently in a
previously established family role. A client may initially
INCIDENCE
be capable of working outside the home and may be
able to complete household management tasks. The in- Parkinson's disease (PD) is one of the most common
dividual with the progressive form of MS may have such adult-onset, degenerative neurological disorders.° Three
a significant decline that work is eventually given up, classic symptoms are associated with PD: tremor,
and then household management, so that finally the rigidity, and bradykinesia. The prevalence rate for PD
client is responsible only for basic self-care activities. varies greatly, from 10 to over 400 per 100,000.** In-
Eventually the client may become totally dependent for cidence increases with age, and the disease affects 1.4%
basic self-care. The adaptation of roles requires working of the population over the age of 55.*” Gender dif-
not only with the client but also with family members ferences have been noted, and the prevalence of PD
and significant others. The occupational therapist may in men between the ages of 55 and 74 is slightly
identify areas of difficulty the family and client are expe- higher than in women of the same age. After the age of
riencing and provide training in methods to better 74, women show a slightly greater prevalence of PD
handle those situations. The therapist may also refer the than do men. Diagnosis is most often made after the
client and family to a social worker or psychologist for age of 60.
further support. The etiology for PD has not been definitively estab-
lished.''* Although a positive family history has been
established as a risk factor for PD, a clear genetic marker
SUMMARY
has not been identified. Twin studies have not conclu-
MS affects each person in a unique way, necessitating sively identified a genetic factor as the cause for PD.
individual evaluation to determine the affected per- Current genetic work is looking at a specific gene muta-
son’s deficits and strengths. Working with an individual tion on chromosome 4 in familial PD, but whether this
with MS requires the practitioner to use expertise in the genetic mutation will also be identified as the causal
evaluation and treatment of all performance areas and factor in sporadic occurrences of PD is unknown. A mu-
performance components. Because of exacerbations tation on the gene that encodes a specific protein has
and remissions, developing an intervention plan in- also been linked to PD."
volves particularly difficult challenges. The client may Environmental factors have been considered as a
be expecting the return of function and therefore deny possible cause of PD.'* The possibility of an exogenous
deficits, creating safety problems or refusing to adapt to agent’s producing PD gained considerable recognition
a change in status as he or she waits for further return when narcotic addicts began using 1-methyl-4-phenyl-
of function. The OT practitioner focuses on assessing 1,2,3,6-tetrahydropyridine (MPTP). After use of MPTP
the current level of functioning and the best methods many addicts quickly exhibited parkinsonism that
for the client to adapt to current changes in status. The “strictly mimics the clinical and anatomical features of
occupational therapist may also assist the family with Parkinson's disease”’* (p.143). Other toxins, such as
making long-range, realistic plans. For example, if the manganese and hydrocarbon solvents, produced more
family is planning to remodel the bathroom, the thera- widespread neurological damage and lacked the selec-
pist may help the family consider a roll-in shower and tive deterioration in the basal ganglia.
not just a standard shower stall with a shower seat. Researchers have also considered dietary habits as a
Working with the individual with MS requires a potential risk factor for PD. The incidence of PD was
multidisciplinary approach. The physician, physical higher among persons with a diet high in animal fat.
therapist, registered nurse, and social worker may be The incidence of PD was inversely related to a diet
involved as team members. Because the social envi- high in nuts, legumes, and potatoes. Many researchers
ronment may create complex and difficult problems, are now investigating a possible interactional effect
good communication among all team members is between a genetic predisposition and environmental
needed to ensure that the team goals are congruous. agents as the possible cause of PD. Although many pos-
The occupational therapist has a unique perspective to sible etiologies are being considered, the majority of
offer to the team as cognition, perception, psychoso- individuals with diagnosed PD are identified as having
cial, and motor abilities are assessed in a functional idiopathic parkinsonism.’
context.
 Degenerative Diseases of the Central Nervous System 721

PATHOPHYSIOLOGY
Additional symptoms of PD are disturbances in gait
The neurological structure associated with PD is the and postural reactions and masked face with decreased
substantia nigra, specifically the pars compacta facial expressions and depression.*” Deterioration in
portion.~° The pars compacta receives input from other gait is seen throughout the course of the disease.*® Ini-
basal ganglia nuclei and appears to serve as a modulator tially gait may be fairly normal, but as the disease pro-
of striatal activity.** The substantia nigra nuclei undergo gresses, changes in stride length and speed of gait are
significant deterioration as the disease progresses. The noted. The characteristic festinating gait is often seen; as
significant reduction in the dopaminergic neurons in the client walks, the stride length decreases in length and
the substantia nigra pars compacta produces a decrease the speed slightly increases. This produces a shuffling
in activity within the basal ganglia and an overall “re- appearance. A reduced arm swing during ambulation is
duction in spontaneous movement”** (p. 426). The noted. Another motor disturbance associated with gait
substantia nigra serves as one of the major output nuclei is the phenomenon of “freezing.”"" Freezing occurs
for the basal ganglia to other structures.”' In addition to when the person ceases to move, often after attempting
the loss of dopaminergic neurons, intracytoplasmic in- to initiate, maintain, or alter a movement pattern.
clusions are found on postmortem examination within During gait, freezing may be seen as the client attempts
the substantia nigra.*° These intracytoplasmic inclu- to change directions or approaches a narrow hallway or
sions are also known as Lewy bodies.’ Although the great- stairs. Freezing can also be seen during other motor tasks
est amount of neurodegeneration is found in the pars such as writing, brushing teeth, and speaking.
compacta substantia nigra, destruction of other neuro- Postural abnormalities associated with PD include a
logical structures has been reported.*° Deterioration is flexed, stooped posture with the head positioned
also seen in the remainder of the substantia nigra, locus forward.'* The client tends to stand with flexion at the
ceruleus, nucleus basilis, and hypothalamus. knees and hips. In addition to the stooped posture,
balance reactions are compromised.~* Righting and equi-
librium reactions are markedly reduced in effectiveness,
CLINICAL PICTURE
and the person with PD may experience frequent falls.
PD is characterized as a slowly progressive, degenerative Approximately 50% of individuals with diagnosed
movement disorder.** The diagnosis of PD is most often PD exhibit depression,** which is not merely reactive to
made after the age of 55. Although PD is not considered the severity of symptoms or the chronic nature of the
fatal, the degeneration of various neurological struc- disease.’ The depression seen in individuals with PD
tures severely compromises performance of functional appears to be related to a serotonergic deficit, which is
tasks. A person with PD may live for 20 to 30 years with similar to that in patients without PD who have depres-
progressive loss of motor function, ultimately requiring sion. Complicating the feature of depression is a de-
specialized care.’ This person then has an increased risk crease in facial expressiveness caused by akinesia.** This
for the development of pneumonia, which may be fatal. “masked face” or decrease in spontaneous facial expres-
PD is characterized by dysfunction in both voluntary sions is characteristic of clients with PD. Initially, de-
and involuntary movements.** A classic triad of symp- creased facial expressions are seen unilaterally, but as the
toms includes a tremor, rigidity, and a voluntary move- disease progresses, spontaneous expression decreases on
ment disorder. The disturbances in voluntary move- both sides of the face.’ Individuals with PD may also self-
ment are identified as difficulty initiating movement limit social interaction because of their embarrassment
(akinesia) and slowness in maintaining movement at decreased facial expressions and movement disorders.
(bradykinesia). The bradykinesia and akinesia are often Mental status is fairly normal throughout the early
the most disabling motor symptoms for the client with stages of PD, but visual-spatial perception is often
PD. The delay in initiating movement patterns and the compromised.** Higher-order cognitive disorders are
slowness in executing the motion compromise func- common in patients with PD. The person with PD often
tional tasks such as driving, dressing, and eating. has difficulty shifting attention between various stimuli.
In addition to the slowness of movement, rigidity is Processing simultaneous information is often difficult
seen in individuals with PD. Rigidity is the stiffness for the individual with PD, and tasks that require a
within a muscle that impedes smooth movement. This sequential process are somewhat easier to perform.
stiffness is not isolated to one direction but occurs in Although dementia is seldom seen in the younger-onset
both directions for each plane of motion at a specific person with PD, approximately one third of patients
joint.*° The characteristic resting tremor with a rate over 70 years old display dementia.
between 4 and 5 Hz is a disturbance of involuntary Additional symptoms associated with PD include au-
movement.'’ This tremor often diminishes with activ- tonomic dysfunction, dysphagia, and dysarthria.** A
ity, but in some clients the tremor persists during per- patient with PD may have bowel and bladder problems,
formance of functional activities. with reduced intestinal motility producing constipation.
722 TREATMENT APPLICATIONS

MEDICAL MANAGEMENT
Patients often report an increase in the frequency and
urgency of urination. Patients also frequently complain The most frequently used medical management strategy
of orthostatic hypotension, but syncope is rare.’ Individ- for PD is the provision of a dopamine agonist to make
uals with PD occasionally report periods of sweating and up for the depletion of dopamine caused by the destruc-
abnormal tolerances of heat and cold.** Speech volume tion of the substantia nigra.°*” Levodopa is the medica-
is often decreased, and the person with PD seems to tion most commonly used in the treatment of PD.**
whisper. Articulation is imprecise and speech is mono- This oral medication is actually a precursor to dopa-
tone. Dysphagia tends to occur in the later stages of PD, mine because dopamine is too large to cross the blood-
and the individual may be at risk for choking and aspira- brain barrier. Levodopa provides substantial relief from
tion pneumonia resulting from the dysphagia. tremors and rigidity during the initial stages of PD. After
The course of the disease varies from person to approximately 5 to 10 years of chronic use of levodopa,
person, but the first clinical symptom identified is typi- motor side effects are reported.** Those most often re-
cally a unilateral resting tremor in the hand.'? Hoehn ported are dyskinesias and motor fluctuations. This so-
and Yahr'® established a scale identifying the progres- called on-off phenomenon is related to the levodopa
sion of symptoms in PD. A client at stage I exhibits uni- dosage. A decrease in tremors and rigidity occurs during
lateral involvement, typically a hand tremor, but no im- the “on” period after administration of levodopa, but
pairment of functional abilities is reported. During this the patient also has various dyskinesias, such as abnor-
stage the client's handwriting may become very small mal movements of the limbs. As the dosage of levodopa
with letters that are cramped together.’ This change in wears off, the motor symptoms associated with PD
handwriting is referred to as micrographia. The client return. Timing of the medication and the periods of
may also complain of muscle cramping when required “on-off” are important considerations in planning the
to write for extended periods. Slight rigidity may be seen client's daily activities. Even though abnormal move-
when the client is asked to rapidly open and close the ments are observed during the “on” period, the client
involved hand. Stage II denotes a progression of symp- has greater freedom of movement to complete func-
toms, and in this stage the person has bilateral motor tional activities.
disturbances. Although the course of PD is variable, this As PD progresses, control of various motor symptoms
stage is usually seen 1 to 2 years after initial diagnosis. through the use of levodopa becomes less effective.**
Even though tremors or rigidity may be noted bilater- Surgical intervention, known as stereotactic surgery,
ally, the client is still independent in ADL skills. Posture has been used. In this surgery, specific lesions are made
becomes slightly stooped, with flexion at the knees and in neurological structures to decrease the severity of PD
hips. The person with stage II PD is still able to ambu- symptoms. Stereotactic surgery of the globus pallidus in-
late independently. As PD progresses to stage III, the ternus has been used to decrease the severity of motor
client experiences delayed righting and equilibrium re- symptoms associated with PD and thus reduce the
actions. Balance is impaired; the client will have diffi- needed dosage of levodopa.'*’'” This surgical procedure
culty performing daily tasks that require standing, such is known as a pallidotomy. Pallidotomies have also been
as showering and meal preparation. A person in Stage shown to reduce the dyskinesias associated with long-
IV PD has significant deficits in completing daily living term use of levodopa.** Stereotactic surgery has also
tasks. The client is still able to ambulate at this stage, but been used to create lesions in portions of the thalamus
motor control is severely compromised and negatively to reduce tremor and rigidity associated with PD.’
affects dressing, feeding, and hygiene skills. Stage V is Neural transplantation has been used selectively for
the final stage of PD. The client is typically confined to a patients with PD.” This process involves harvesting fetal
wheelchair or bed and depends on others for most self- mesencephalic neural tissue and then transplanting this
care activities. The rate of progression through these tissue into the basal ganglia of patients with PD.* The
stages varies from person to person, but PD is a slowly results of fetal brain transplants have been varied. The
progressive disorder. best success for this procedure has been reported when
The extent of PD symptoms in individual clients has bilateral implants are placed in the putamen from mul-
been measured using the Unified Parkinson’s Disease tiple fetuses. The transplanted fetal tissue produces
Rating Scale.* This scale evaluates a patient's motor dopamine and thereby reduces the debilitating symp-
skills, functional status, and extent of disability. Motor toms of progressive PD. Patients must continue to use
skills are evaluated by a trained observer.?° The func- levodopa, but at a reduced dosage.
tional status and extent of disability are measured
through a patient interview that includes items address-
ing ADL skills and cognitive and emotional factors.'®
ROLE OF OCCUPATIONAL THERAPY
This instrument has been used for research and clinical Occupational therapy services vary, depending on the
practice to measure the effectiveness of various interven- client’s stage of PD. Typically, an OT program would
tions in reducing PD symptoms. provide compensatory strategies, patient and family ed-
 Degenerative Diseases of the Central Nervous System 723

ucation, environmental and task modifications, and stress on the family. Involvement in a community-based
community involvement. group may provide the support needed to accommo-
During the initial stages of the disease, OT services date the changes in family roles and interaction.
should establish a daily, routine exercise program ad- As the disease progresses, additional exercises can
dressing full range of motion.*° It is preferable to have a improve gait.*’ Rhythmic auditory stimulation in the
client with PD perform a short exercise program for 5 to form of music with an accentuated initial beat has been
10 minutes daily rather than a longer program three found to significantly improve stride length and speed
times a week. Postural flexibility exercises should be in- in clients with PD. Dancing can also enhance gait pat-
cluded in the program, with specific attention given to terns, in addition to providing a social environment for
trunk extension. The most common postural change the client with PD. As akinesia becomes more apparent,
noted with the progression of PD is a stooped posture. the client with PD should be instructed to use a rocking
In addition to the flexibility exercises, occupational motion to begin movement activities. Rocking forward
therapists should instruct patients in the use of relax- and backward a few times while seated can produce the
ation techniques and controlled breathing. Inhaling momentum needed to rise from a chair.
slowly through the nose and exhaling through pursed During the middle stages of PD a person may have
lips two or three times in succession, combined with decreased oral motor control.** Dysphagia and drool-
improved postural alignment, can promote relaxation. ing may embarrass a client and further restrict social en-
Modification of household items may decrease the gagements. The occupational therapist should encour-
impact of tremors during the initial stage of the disease age oral motor exercises and provide education
process. The use of built-up handles for eating and for regarding food selection. Food consistencies can be
writing utensils should be introduced during the initial altered to improve the client's ability to eat.
stages of PD. Handwriting often becomes small and dif- As PD progresses, the client has further deterioration
ficult to read during the initial stage of PD. Time man- of motor skills, particularly the execution of skilled, se-
agement techniques should be introduced at this stage. quential movements.* These types of movements are
Paying bills, signing forms, or other written work needed to complete personal care and household tasks.
should be done soon after taking levodopa, using the Curra and associates* found that external cues im-
built-up handle writing utensil. Even though tremors proved the speed and sequential performance of novel
are not severe during the early stages of PD, clothing fas- motor tasks. The occupational therapist should suggest
teners should be modified. The use of slip-on shoes or modifications to activities to include visual cues, verbal
Velcro closures for clothing should be considered at this prompts, and rehearsal of movements. These strategies
time. Although a client may be able to complete the fas- increase a client's ability to perform personal care and
tening of clothing during this stage of PD, the occupa- household activities.
tional therapist must consider the amount of energy The ability to complete personal care tasks has been
and time needed to perform such a task. In addition to identified as a critical variable in a client's perception of
the modification of specific tasks, household changes quality of life.” Although progressive movement prob-
should be made at this time. Loose rugs should be lems are characteristic of PD, the occupational therapist
removed from floors and furniture placed close to the can minimize the impact the movement disorder has on
wall to decrease obstacles. Chairs should have armrests functional activities. Tremors have less effect on the
to allow the client to push up to stand from the chair. completion of personal care tasks than does postural in-
Although balance is not significantly compromised stability."° The use of group OT sessions has been
during the early stages of PD, the family and client demonstrated to be effective in reducing the impact of
should become familiar with the new arrangement of postural instability in patients with PD. An additional
furniture before it is a necessity. Bath and toilet railings benefit of these group sessions is the reported improve-
and a raised toilet seat should be provided within the ment in the perception of quality of life in clients at-
home. Fatigue is a common complaint, and clients tending the sessions.
should develop a habit of taking frequent breaks during Access to community mobility and support programs
the day. Modifying the household setting early in the should be included in the OT intervention plan during
course of PD allows the client and family members to the middle stages of PD. A client with PD is often de-
adjust to changes and incorporate these changes into pendent on others for transportation. The use of com-
daily routines before they become a necessity. munity mobility services can decrease the client's de-
During the early stages of the disease the client and pendence on family members for shopping and errands.
family should be informed of community resources and During the last stages of PD a client's movement dis-
support groups. In one study, clients with PD were order and rigidity may eliminate the ability to perform
found to be far more dependent on others for personal personal care tasks such as dressing and grooming." ”
care and household activities than were same-age peers Depression caused by the decreased ability to perform
without PD.*? This dependence can place additional these tasks can significantly compromise a person's
724 TREATMENT APPLICATIONS

quality of life? OT services should be provided to

further modify the home environment for access and
SUMMARY
control. The use of environmental control units such as Although PD is a progressive, neurodegenerative disor-
a switch-operated television or radio can be helpful. The der, OT has much to offer the client with this disease.”
switch plate should be activated with only light touch. The diminishing ability to perform personal care and
Voice- or sound-activated environmental control units engage in self-selected tasks has been identified as one
may not be as useful because of decreased vocal volume of the variables contributing to depression and the de-
and poor articulation control during speech production. creased quality of life in patients with PD. Throughout
The client's ability to control the immediate environ- the progressive course of PD, OT addresses the ability of
ment can compensate for the loss experienced during the person to engage in meaningful activities. The
the final stages of PD. The person with PD may no client's wishes and the family circumstances are incor-
longer be able to dress himself or herself, but through porated into the OT intervention plan at every stage of
the use of various switches the client can select preferred the disease process.
television or radio programs, access room lighting, and
control a computer using minimal motor action.

CASE STUDY 39-1

Case StUDY—DEGENERATIVE DISEASES OF THE
CENTRAL NERVOUS SYSTEM: PARKINSON’S DISEASE b, Give suggestions regarding clothing modifications such as
Mr S is a 62-year-old college professor in whom Parkinson's clip-on ties and slip-on shoes
disease was diagnosed at the age of 57. He is married and lives in c. Instruct in use of momentum to initiate movement, such
a small one-story home with his wife. He has two adult children as rocking back and forth to rise from a chair
who live in another state. Mr S reports that he enjoys traveling, 2. Modify home environment
reading, painting, and attending concerts. a. Remove throw rugs and obstacles in walkways
Mr. S has recently considered early retirement because of the b, Provide a tub seat and shower extension hose
increase in tremors in both hands and difficulties with correcting c. Provide a raised toilet seat
papers. He also reports some problems with endurance as a d. Provide a cushion on dining room chairs
result of stiffness. Mr. S indicates that he is no longer able to paint 3. Assess work setting for modifications
because of the tremors. He also reports that he is unsure if he a. Assess for computer access
should continue driving because of the tremors in both hands. b. Instruct in energy conservation to take frequent breaks
Results of the OT evaluation indicate that Mr S is cooperative and schedule activities during ‘‘on’’ phase of medications
and motivated for therapy. Although he does not indicate that he 4. Investigate leisure pursuits
is depressed, his wife reports features of depression such as a de- a. Provide modifications to his easel using forearm supports
creased interest in going to concerts or planning summer vaca- to allow him to continue to paint
tions to see their adult children and grandchildren. His wife also b. Provide information regarding community-based Parkin-
reports that Mr S seems depressed about his possible early retire- son's disease support groups
ment and loss of status as a college professor. 5. Instruct in daily AROM exercise program
Mr. S is able to complete most personal ADL independently a. Trunk extension and rotation exercises
but has difficulties stepping into and out of the tub and shower. b. Bilateral upper extremity exercise
His wife reports that she is afraid he will fall and that she often c. Use of music during exercise program
assists him in getting into and out of the shower. Mr S also has dif- Mr S responded well to OT intervention: He was able to
ficulty tying his tie and buttoning his shirt. Tremors are noted bi- complete the academic school year but decided to retire after
laterally in his hands, and slight rigidity is present during PROM. that year. He stopped driving, but his wife began to drive them to
Dynamic balance is slightly compromised on uneven surfaces and concerts and art exhibits. He was able to complete personal
stairs. ADL safely with the use of adapted equipment and home modi-
Mr S has been taking Sinemet (levodopa and carbidopa med- fications. He resumed painting during the “on” periods of his
ication) for the past 3 years to decrease the rigidity and tremors. medications schedule, using the forearm supports attached to an
He does not report any dyskinesias. angled table. He attended a Parkinson's support group two times
When asked about his personal goals, Mr. S replies,"'lguess |'ll a week and began to socialize with members from that group. Mr
have more time to read now.’ S reported that the daily exercises seemed to decrease his stiff-
OT was initiated to accomplish the following: ness, and he and his wife took frequent “‘strolls”’ in the park when
|. Improve ADL performance weather permitted. He and his wife also joined a book club,
a. Instruct in use of a buttonhook
 Degenerative Diseases of the Central Nervous System C23

SECTION 5
REVIEW QUESTIONS
. What are the initial symptoms of PD?
SECTION 1
. What is the underlying degenerative neurological
process associated with PD?
is What are the symptoms of ALS at onset?
. What changes in symptoms occur over the course of
pe What is the underlying neurological process in ALS?
the disease?
Si What bodily functions remain intact throughout the
. How do the changes in symptoms affect occupa-
disease process?
tional performance?
. What is the prognosis for ALS? With this in mind,
. What is the prognosis for a client with PD?
what is the goal of the occupational therapist?
. What OT interventions are appropriate for the client
oa]. What are the symptoms at each stage of the disease?
with PD?
. What interventions are appropriate at each stage of
. How does the medication schedule of levodopa
the disease?
affect a client's daily routine?
SECTION 2 . What environmental modifications should be made
1. What are the initial symptoms of AD? to accommodate the client with PD?
Pe What is the underlying degenerative neurological
process associated with AD? REFERENCES
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at each stage of AD? cian, J Psychiatr Res 12(3):189-198, 1975.
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to accommodate the client with AD? worth-Heinemann.
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SECTION 3 New York, 1997, Huntington's Disease Society of America.
si What are the symptoms of MS at onset? . Northern California Neurobehavioral Group: Cognistat: the neu-
robehavioral cognitive status examination, Fairfax, Calif, 1995, The
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Group.
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they differ? ficacy in people with multiple sclerosis: a validation study, Arch
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tion? What are the side effects of the medication
SECTION 1
management?
Amyotrophic Lateral Sclerosis
. How is medication management in the relapsing and iN Belsh JM: Definitions of terms, classifications, and diagnostic crite-
remitting form of MS different than in the other ria of ALS. In Belsh JM, Schiffman PL, editors: ALS diagnosis and
forms of MS? management for the clinician, Armonk, NY, 1996, Futura Publishing.
. What does the OT evaluation include for the person . Belsh JM, Schiffman PL, editors: ALS diagnosis and management for
the clinician, Armonk, NY, 1996, Futura Publishing.
with MS2
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SECTION 4 agnosis, and treatment, Boston, 1994, Little, Brown.
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2: What is the underlying degenerative neurological chemical, genetic, and other theories. In Belsh JM, Schiffman PL,
editors: ALS diagnosis and management for the clinician, Armonk, NY,
process associated with HD? 1996, Futura Publishing.
=e What changes in symptoms occur over the course of
the disease?
RECOMMENDED READING
. How do the changes in symptoms affect occupa-
Bello-Haas VD, Kloos AD, Mitsumoto H: Physical therapy for a
tional performance? patient through six stages of amyotrophic lateral sclerosis, Phys Ther
. What is the prognosis for a client with HD? 78(12):1312-1324, 1998.
. What OT interventions are appropriate for the client
with HD at the various stages of the disease? WEB SITES
. What environmental modifications should be made Amyotrophic Lateral Sclerosis Association
to accommodate the client with HD? http://www.alsa.org
726 TREATMENT APPLICATIONS

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Med Rehabil Clin North Am 9(3):603-614, 1998. tion of the historical section of the Unified Parkinson’s Disease
Newman EM, Echevarria ME, Digman G: Degenerative diseases. In Rating Scale, Mov Disord 11(2):185-192, 1996.
Trombly CA, editor: Occupational therapy for physical dysfunction, ed 17. Misulis KE: Neurologic localization and diagnosis, Boston, 1996,
4, Boston, 1995, Williams & Wilkins. Butterworth-Heinemann.
 Degenerative Diseases of the Central Nervous System 729

18. Muller V, Mohr B, Rosin R, et al: Short-term effects of behavioral 20. Richards M, Marder K, Cote L, et al: Interrater reliability of the
treatment on movement initiation and postural control in Parkin- Unified Parkinson's Disease Rating Scale Motor Examination, Mov
son's disease: a controlled clinical study, Mov Disord 12(3):306- Disord 9(1):89-91, 1994.
314, 1997. 2%. de Rijk MC, Breteler MM, Graveland GA, et al: Prevalence of
19. Olanow CW: Gpi pallidotomy—have we made a dent in Parkin- Parkinson’s disease in the elderly: the Rotterdam study, Neurology
son’s disease? Ann Neurol 40(3):341-343, 1996. 45(12):2143-2146, 1995.
e200) Olanow CW, Jenner P, Tatton NA, et al: Neurodegeneration and 28. Rosin R, Topka H, Dichgans J: Gait initiation in Parkinson's
Parkinson’s disease. In Jankovic J, Tolosa E, editors: Parkinson's disease, Mov Disord 12(5):682-690, 1997.
disease and movement disorders, ed 3, Baltimore, 1998, Williams & 29; Sage JI, Duvoisin RC: The modern management of Parkinson's
Wilkins. disease. In Chokroverty S, editor: Movement disorders, New
21, Parent A, Cicchetti F: The current model of basal ganglia organiza- Brunswick, NJ, 1990, PMA Publishing.
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ee
= tion under scrutiny, Mov Disord 13(2):199-200, 1998. 30. Stern G, Lees A: Parkinson's disease, Oxford, 1990, Oxford Univer-
22. Phillips JG, Stelmach GE: Parkinson's disease and other involun- sity Press.
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Saladin LK, editors: Pathophysiology of the motor systems, Philadel- lation in gait training for Parkinson’s disease patients, Mov Disord
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23. Poewe W, Wenning G: Levodopa in Parkinson's disease: mecha- Se Tison FE, Barberger-Gateau P, Dubroca B, et al: Dependency in
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Tolosa E, editors: Parkinson's disease and movement disorders, ed 3, elderly subjects, Mov Disord 12(6):1073-1074, 1997.
Baltimore, 1998, Williams & Wilkins. 33% Zhang Z, Roman GC: Worldwide occurrence of Parkinson's
24. Pollak P: Parkinson’s disease and related movement disorders. In disease: an updated review, Neuroepidemiology 12(4):195-208,
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25; Prochazka A, Bennett D, Stephens M, et al: Measurement of rigid-
ity in Parkinson's disease, Mov Disord 12(1):24-32, 1997.
KAREN NELSON JENI

KEY TERM: LEARNING OBJECTIVES

Deglutition After studying this chapter the student or practitioner
Dysphagia will be able to do the following:
Sulcus 1. Define key terms.
Bolus 2. Name and locate oral structures concerned with
Viscosity swallowing.
Faucial arches 3. Name and describe the stages of the normal
Velum swallow.
Velopharyngeal port 4. List the components of the swallowing assessment.
Pyriform sinuses 5. Name and describe normal and abnormal oral
Aspiration reflexes.
Nasogastric tube 6. Describe the role of the occupational therapist in
Gastrostomy tube the clinical assessment of swallowing.
Videofluoroscopy 7. Describe four steps in the swallowing assessment.
Tracheostomy 8. Describe the appropriate progression of foods and
Fenestrated liquids in the assessment and treatment of
Cannula dysphagia.
Fiberoptic endoscopy 9. Name two types of tracheostomy tubes, and list the
Diet progression advantages and disadvantages of each.
10. List symptoms of swallowing dysfunction.
11. List treatment goals for patients with dysphagia.
12. Describe the roles of the dysphagia treatment team
members.
13. Describe proper positioning for treatment.
14. Describe and demonstrate two hand-hold
techniques for head stabilization during treatment.
15. Describe two methods of nonoral feeding.
16. List principles of oral feeding.
17. List and describe treatment techniques for
management of dysphagia.

ating is the most basic activity of daily living, nec- solids or liquids. Dysphagia is difficulty with swallowing
essary for survival from birth until death. The compo- or the inability to swallow.
nents of eating include seeing and reaching for food, Occupational therapists are trained to assess and
placing it in the mouth, chewing the food, and swallow- treat all components of eating. These components are
ing. Deglutition refers to the normal consumption of motor control; muscle tone; positioning of the trunk,

730
 Dysphagia 731

head, and upper and lower extremities; inhibition of tional therapist treating the patient with dysphagia must
primitive reflexes; oral and pharyngeal function; and have a thorough understanding of the anatomy, includ-
_ sensory, perceptual, and cognitive dysfunction, which ing the muscle origin and insertion and the physiology
may interfere with the eating process. Continuing educa- of swallowing (Table 40-1). The swallowing process can
tion and special training are required for competence in treat- be divided into four stages: oral preparatory phase, oral
ment of dysphagia. phase, pharyngeal phase, and esophageal phase (Fig.
This chapter provides the occupational therapist with 40-2)
a foundation for the assessment and treatment of the
adult patient with an acquired dysphagia. Some of the
_
eee
ee
Oral Preparatory Phase
conditions that can result in an acquired dysphagia are
cerebrovascular accident (CVA), head injury, brain The oral preparatory phase of swallowing begins with
tumor, anoxia, Guillain-Barré syndrome, multiple scle- the act of looking at and reaching for food.'**' Visual
rosis, amyotrophic lateral sclerosis, Parkinson’s disease, and olfactory information stimulates salivary secretions.
myasthenia gravis, poliomyelitis, and quadriplegia. Salivation plays an important role as a triggering mech-
Anatomic or developmental dysphagia is beyond the anism for the entire swallowing process.’”? As tactile
scope of this chapter. contact is made with the food, the jaw comes forward to
open. The lips close around a glass or utensil to remove
the food or liquid. The labial musculature forms a seal
ANATOMY AND PHYSIOLOGY
to prevent any material from leaking out of the oral
OF NORMAL SWALLOW
cavity.
Deglutition, the normal consumption of solids or As chewing begins, the mandible and tongue move
liquids, is a complex sensorimotor process involving in a strong, combined rotary and lateral direction. The
the brainstem, the cerebral cortex, six cranial nerves, upper and lower teeth shear and crush the food.
the first three cervical nerve segments, and 48 pairs of The tongue moves laterally to push the food between
muscles.”*”** A normal swallow requires all these the teeth. The buccinator muscles of the cheeks contract
structures to be intact (Fig. 40-1). Therefore the occupa- to act as lateral retainers, to prevent food particles from

Nasopharynx

Soft Palate
(Velum)

Posterior
Pharyngeal
Wall

Vallecular
Sinus

Epiglottis

Aryepiglottic
Fold
Laryngeal
Vestibule
Bone Pyriform
False & True Sinus
Vocal Folds
Larynx: Arytenoid
Cartilage
Thyroid
Superior Crico-
Carcione Cricoid pharyngeal
Cartilage Sphincter
Trachea
Esophagus

FIG. 40-1
Oral structures, swallowing mechanism at rest. (Courtesy of Rene Padilla, MS, OTR, Occupational
Therapy Department, Creighton University, 1994.)
 Structure Muscle Movement Cranial Nerve Sensation

Oral Preparatory Stage

Jaw Pterygoideus medialis Opens jaw «Trigeminal (V)> Face, temple, mouth,
teeth, mucus

Pterygoideus medialis Protrudes lower Jaw;

and lateralis moves jaw laterally

Masseter Closes jaw

Digastricus; Depresses lower jaw

mylohyoideus;
geniohyoideus
Mouth Oprbicularis oris Compresses and < Facial (VII)
protrudes lips

Zygomaticus minor Protrudes upper lip

Zygomaticus major Raises lateral angle of

mouth upward and
outward (smile)

Levator anguli oris Moves angle of mouth

straight upward

Risorius Draws angle of mouth

backward (grimace)

Depressor labii Draws lower lip

inferioris downward and
outward

Mentalis Protrudes lower lip

(pouting)
Depressor anguli oris Draws down angles
of mouth
Tongue Superior longitudinal Shortens tongue; Facial (VII) Taste, anterior two
raises sides and tip thirds of tongue
of tongue

Transverse Lengthens and <-Glossopharyngeal Taste, posterior third

narrows tongue (IX of tongue

Vertical Flattens and <Hypoglossal (XI!)

broadens tongue

Inferior longitudinal Shortens tongue

Turns tip of tongue
downward

ORAL STAGE
Tongue Styloglossus Elevates and pulls <Accessory (XI)
tongue posteriorly

From Bass N:The neurology of swallowing. In Groher M, editor: Dysphagia: diagnosis and management, ed 3, Newton, Mass, 1997, Butterworth-Heinemann Pub-
lishers; Davies P: Steps to follow, New York, 1985, Springer-Verlag; Hislop H, Montgomery J,Connelly B: Daniels & Worthington’s muscle testing: techniques of manual
examination, ed 6, Philadelphia, 1995, WB Saunders; Liebman M: Neuroanatomy made easy and understandable, Rockville, Md, 1986, Aspen Publishers; Netter F,
Dalley A: Atlas of human anatomy, ed 2, |998, Ciba-Geigy.
<, Movement function; >, sensory function.

732
 Swallowing Process
Movement _ Cranial Nerve Sensation
Palatoglossus Elevates and pulls
tongue posteriorly;
narrows fauces
Genioglossus Depresses, protrudes, <Hypoglossal (XI!)
and retracts tongue;
elevates hyoid
Hyoglossus Depresses and pulls
tongue posteriorly
Tensor veli palatini Tenses soft palate <Trigeminal (V)> Mouth
Levator veli palatini Elevates soft palate <Accessory. (XI)
Uvulae Shortens soft palate
ec

_PHARYNGEAL STAGE
- Fauces Palatoglossus Narrows fauces <Vagus (X)—> Membranes of
pharynx
Palatopharyngeus Elevates larynx and
pharynx
_ Hyoid Suprahyoidei Elevates hyoid <Trigeminal (V)
anteriorly, posteriorly
Stylohyoideus
Sternothyroideus Depresses thyroid <Cervical segments |, 2, 3
cartilage
Omohyoideus Depresses hyoid
Pharynx Salpingopharyngeus Pharynx elevation <-Glossopharyngeal (IX)
~
Palatopharyngeus Pharynx elevation

Stylopharyngeus Pharynx and larynx

elevation

Constrictor Sequentially constricts <Vagus (X)> Membranes of

pharyngeus the nasopharynx, pharynx
superior oropharynx,
laryngopharynx

Constrictor pharyngeus
medius
Constrictor pharyngeus
inferior
Cricopharyngeus Relaxes during swallow;
prevents air from
entering esophagus

Larynx Aryepiglotticus Closes inlet of larynx <Vagus (X)> Membranes of larynx

Thyroepiglotticus

Thyroarytenoideus Closes glottis;

shortens vocal cords

From Bass N:The neurology of swallowing. In Groher M, editor: Dysphagia: diagnosis and management, ed 3, Newton, Mass, |997, Butterworth-Heinemann Pub-
lishers; Davies P: Steps to follow, New York, 1985, Springer-Verlag; Hislop H, Montgomery J, Connelly B: Daniels & Worthington’s muscle testing: techniques of manual
examination, ed 6, Philadelphia, 1995, WB Saunders; Liebman M: Neuroanatomy made easy and understandable, Rockville, Md, 1986, Aspen Publishers; Netter F,
Dalley A: Atlas of human anatomy, ed 2, |998, Ciba-Geigy.
<, Movement function; —, sensory function. Continued

733
 TREATMENT APPLICATIONS

Structure Muscle Movement Cranial Nerve Sensation

Arytenoid-oblique, Adducts arytenoid
transverse cartilages

Lateral _ Adducts and rotates

cricoarytenoid arytenoid cartilage

Vocalis Controls tension of

vocal cords

Postcricoary- Widens glottis

tenoideus

Cricothyroideus- Elevates cricoid arch

straight, oblique

Esophageal Stage
Esophagus Smooth Peristaltic wave <Vagus (X)

From Bass N:The neurology of swallowing. In Groher M, editor: Dysphagia: diagnosis and management, ed 3, Newton, Mass, 1997, Butterworth-Heinemann Pub-
lishers; Davies P: Steps to follow, New York, 1985, Springer-Verlag; Hislop H, Montgomery J,Connelly B: Daniels & Worthington’s muscle testing: techniques of manual
examination, ed 6, Philadelphia, 1995, WB Saunders; Liebman M: Neuroanatomy made easy and understandable, Rockville, Md, 1986, Aspen Publishers; Netter F,
Dalley A: Atlas of human anatomy, ed 2, 1998, Ciba-Geigy.
<, Movement function; >, sensory function.

falling into the sulcus between the jaw and cheek.” The palate. The tongue forms a central groove to funnel the
tongue sweeps through the mouth, gathering food par- food posteriorly. The amount of food swallowed is in-
ticles and mixing them with saliva.’ Sensory receptors versely related to the viscosity of the food. For less
throughout the oral cavity carry information of taste, viscous foods, such as thin liquids, larger amounts may
texture, and temperature of the food or liquid through be swallowed. In contrast, more viscous foods or thick
the seventh and ninth cranial nerves to the brainstem. liquids require that a smaller amount be swallowed.
The chewing action of the mandible and tongue is re- This is necessary to make it easier for the bolus to pass
peated rhythmically, repositioning the food until a co- through the pharynx.”
hesive bolus is formed. The length of time needed to The oral stage of the swallow is voluntary, requir-
form a swallowable bolus varies. A short time is needed ing the person to be alert.'”*"** A normal voluntary
for soft foods, and a longer time is needed for hard swallow is necessary to elicit a strong swallow response
foods.** Large amounts of thick liquids or thick and during the pharyngeal stage that follows. Overall, the
hard foods require the tongue to divide the food into oral phase takes approximately 1 second to complete
smaller parts to be swallowed one at a time.*’ The pos- with thin liquids and slightly longer with thick liquids.
terior portion of the tongue forms a tight seal with the
velum, preventing slippage of the bolus or liquid into
the pharynx.'”'>? Pharyngeal Phase
In preparation for the next stage, the solid or liquid The pharyngeal phase of swallowing begins when the
bolus, having been formed into a cohesive and swallow- bolus passes through the anterior faucial arches and the
able mass, may be held between the anterior tongue and middle of the tongue base into the pharynx, marking
palate, with the tongue tip elevated or with the tongue the start of the involuntary component of the swallow.
tip dipped toward the floor of the mouth.*' The tongue After the swallow response has been triggered, it contin-
cups around the bolus to seal it against the hard palate. ues with no pause in bolus movement until the total act
The larynx and the pharynx are at rest during this phase is completed. The swallow response is controlled by
of the swallowing process. The airway is open. the medulla oblongata of the brainstem.** Within the
medulla oblongata the medullary reticular formation is
responsible for screening out all extraneous sensory pat-
Oral Phase
terns and for responding only to those patterns that in-
The oral phase of swallowing begins when the tongue dicate the need to swallow. The reticular formation also
moves the bolus toward the back of the mouth.* The assumes control of all motor neurons and related
tongue elevates to squeeze the bolus up against the hard muscles needed to complete the swallow. Higher brain
 Soft Palate

FIG. 40-2
The normal swallow. A, Lateral view of bolus propulsion during the swallow, beginning with the
voluntary initiation of the swallow by the oral tongue. B, Triggering of the pharyngeal swallow.
C, Arrival of the bolus in the vallecula. D, Tongue base retraction to the anteriorly moving pharyn-
geal wall. E, Bolus in the cervical esophagus and the cricopharyngeal region. (From Logemann J: Eval-
uation and treatment of swallowing disorders, Austin, Texas, 1998, ProEd Publishers)

735
736 TREATMENT APPLICATIONS

SWALLOWING ASSESSMENT
functions such as speech, in addition to the respiratory
reflex center, are preempted.** When a referral is received from a physician, a thorough
When the swallow response is triggered, several phys- swallowing assessment for possible dysphagia must
iological functions occur simultaneously. The velum el- be completed. The occupational therapist reviews the
evates and retracts, closing the velopharyngeal port to patient's medical history and assesses the patient's
prevent regurgitation of material into the nasal cavity. visual, perceptual, and cognitive skills; physical control
The tongue base elevates to direct the bolus into the of head, trunk, and extremities; oral structures; and
pharynx. The entire pharyngeal tube elevates and con- swallowing ability.
tracts from the top to the bottom in the’pharyngeal con-
strictors, carrying the bolus into and through both sides
Medical Chart Review
of the pharynx to the upper esophageal sphincter. ° This
movement must be rapid and efficient so that respira- A review of the patient’s medical chart before the assess-
tion is interrupted only briefly. ment often reveals important information. The thera-
Concurrently, the larynx elevates beneath the back of pist should take note of the patient's diagnosis, perti-
the tongue base, protecting the airway. Three actions nent medical history, prescribed medications, and
occur to facilitate closure of the larynx. These are: soft current nutritional status.
palate elevation and retraction and closure of the na- The medical diagnosis may indicate the cause or type
sopharynx; laryngeal displacement anteriorly and supe- of swallowing problem the patient is experiencing. For
riorly with obliteration of the laryngeal vestibule and example, the presence of a neurological disorder
closure at the epiglottis and true vocal cords, preventing should alert the therapist that dysphagia problems
food from entering the airway; and relaxation and could exist. It is important to learn whether the dyspha-
opening of the upper esophageal sphincter.'”***' As the gia was of sudden or gradual onset. The therapist should
sphincter relaxes, food passes through the pharynx, di- seek information regarding the onset and duration of
viding in half at the valleculae and moving down each the patient's swallowing difficulties. The therapist also
side through the pyriform sinuses. The bolus reforms should note any previous surgeries involving the head,
into a whole at the top of the esophagus and then passes neck, and gastrointestinal tract that affect deglutition.
through the esophagus. If the involuntary swallow re- Particular attention should be paid to reported
sponse does not occur, neither do these physiological episodes of pneumonia or aspiration (entry of material
functions, thus preventing a safe, normal swallow.*”*" into the airway).”’”*° Aspiration pneumonia is a compli-
The pharyngeal phase of the swallow takes about 1 cation that occurs when food enters or penetrates the
second to complete for thin liquids. Both voluntary and lungs. An elevated temperature may indicate that a
involuntary components are needed in a normal patient is aspirating.
swallow. Neither mechanism alone is sufficient to A description of the patient’s current nutritional
produce the immediate, consistent swallow necessary status may be found in the dietary section of the chart or
for normal eating.” in the nursing progress notes. Consideration should be
given to prescribed medications that may alter the
patient's alertness, orientation, and muscle control.?®
Esophageal Phase
How the patient is receiving food is important—for
The esophageal phase of the swallow starts when the example, whether the patient is taking food orally or
bolus enters the esophagus through the cricopharyngeal through a nasogastric tube (NG tube) or gastrostomy
juncture or upper esophageal sphincter. The esophagus tube, (G tube) and whether the patient is able to take all
is a straight tube, about 10 inches long, that runs from nutrients orally or is receiving supplemental tube feed-
the pharynx to the stomach. The pharynx is separated ings. The nurses’ notes may indicate whether the patient
from the esophagus by the upper esophageal sphincter. has difficulty managing certain food or liquid consisten-
The lower esophageal sphincter separates the esophagus cies and whether the patient coughs or chokes during
from the stomach.'*”*! The upper third of the esophagus eating or when taking medication. The patient's intake
is composed of striated muscle and is innervated by the and output (I & O) record provides additional informa-
central nervous system. The middle section is made up tion about hydration status.
of striated and smooth muscle and is innervated by the
enteric nervous system that is visceral. The lower third of
Cognitive-Perceptual Status
the tube is composed of smooth muscle.'***** The
bolus is transported through the esophagus by peri- The patient's cognitive and perceptual functions must
staltic wave contractions. The overall transit time be assessed to determine the patient's ability to partici-
needed for the bolus to reach the stomach varies from 8 pate actively in a feeding assessment or treatment
to 20 seconds. program. The therapist should establish whether the
 Dysphagia 737

patient is alert; oriented to name, day, and date; and jaw, and lips. Working within the patient's visual field,
able to follow simple directions, either verbal or with the therapist moves his or her hand(s) slowly toward
manual guidance. The therapist should also establish the patient's face. This allows the patient time to process
whether the patient is able to see the food clearly and and acknowledge the approach. If the patient is hyper-
motor plan hand-to-mouth and oral movements. The sensitive or resistant to the therapist's touch, the thera-
patient who exhibits confusion, dementia, poor aware- pist can first guide the patient's hand as needed to eval-
ness, Or poor perception may require close supervision uate that area.
during eating or may not even be a good candidate for It is important for the patient to feel comfortable
eating, since chewing and swallowing require voluntary with the therapist's touch during the assessment. If a
control,7“°2°35 patient is not comfortable with the face or lips being
touched, he or she will certainly be less inclined to
allow the therapist's hand inside his or her mouth.
Physical Status
Control of head and trunk is an important component SENSATION. Indications of poor oral sensation are
of a safe swallow. To assess head control, the therapist drooling, food on the mouth, and food falling out of
asks the patient to turn the head from side to side and the mouth of which the patient is unaware. To assess the
up and down. Assessment should include the quality of patient's awareness of touch, the therapist occludes the
head movement, whether it is smooth and coordinated patient's vision and uses a cotton-tipped swab to touch
and whether it is adequate to allow the patient to main- the patient gently with a quick stroke to different areas
tain control with assistance. The therapist also should of the face. The patient is asked to point to where he or
move the head passively from side to side and up and she was touched. If pointing is difficult for the patient,
down to look for stiffness or abnormal muscle tone. the patient is asked to nod or say yes or no when
Poor head control may indicate decreased strength, de- touched. The patient with intact sensation responds ac-
creased or increased muscle tone, or decreased aware- curately and quickly.
ness. Head control is important because it develops first, The patient's ability to sense hot and cold should be
followed by jaw movement and, last, by quality tongue assessed. The therapist may use two test tubes, one filled
movement. Head control is also necessary to provide with hot water and one with cold water. A laryngeal
adequate jaw and tongue movement for an optimal mirror that is first heated and then cooled with hot and
swallow response. cold water may also be used. The patient is touched on
In assessing the patient's trunk control, the therapist the face or lips in several places and is asked to indicate
observes whether the patient is sitting in midline with whether the touch was hot or cold. An aphasic patient
equal weight bearing on both hips. Thus the therapist may have difficulty answering correctly. In this instance
learns whether the patient can maintain the midline po- the therapist must make an assessment from clinical
sition when provided with postural supports (such as observations.
wheelchair trunk supports or a lap board) and whether Poor sensory awareness affects the patient's ability to
a return to midline is possible if loss of balance occurs. move facial musculature appropriately. The patient's self-
To participate in an eating and swallowing training esteem also may be affected, especially in social situa-
program, the patient must maintain an upright position tions, if decreased awareness causes the patient to ignore
with head and trunk in midline to provide correct align- saliva, food, or liquids remaining on the face or lips.
ment of the swallowing structures.” If the patient has
poor head or trunk control, the therapist may assist the MUSCULATURE. An assessment of the facial
patient during assessment and treatment. muscles provides the therapist with information about
the movement, strength, and tone available to the
patient for chewing and swallowing. The therapist first
Oral Assessment
observes the patient's face at rest and notes any visible
Outer Oral Status asymmetry. If a facial droop is obvious, the therapist
The face and mouth are sensitive areas to assess. Most should observe whether the muscles feel slack or taut. A
adults are cautious about or even threatened by having masked appearance, with little change in facial expres-
another person touch their faces. Therefore each step of sion, may also be observed. The therapist should
the assessment process should be carefully explained, observe whether the patient appears to be frowning or
using terms that the patient understands. The therapist grimacing with jaw clenched and mouth pulled back.
also should tell the patient how long he or she will be These symptoms may indicate increased or decreased
touching the face; for example, “For a count of three.” muscle tone. Information obtained through clinical ob-
The therapist assesses the outer oral structures, includ- servations should be compared with that seen during
ing the facial musculature and mobility of the cheeks, actual movement.
 TREATMENT APPLICATIONS

Assessment
Function Instruction to Patient Testing Procedure*
Facial expression Lift your eyebrows as high as you can Place one finger above each eyebrow. Apply downward
pressure.
Bring your eyebrows toward your nose in a frown. Place one finger above each eyebrow. Apply pressure
outward.

Wrinkle your nose upwards. Place one finger on tip of nose and apply downward
pressure.
Suck in your cheeks. Apply pressure outward against each inside cheek.

Lip control Smile. Observe for symmetrical movement. Palpate over

each cheek.

Press your lips together tightly and puff out your Place one finger above and one finger below lips. Apply
cheeks, pressure, moving fingers away from each other; check for
ability to hold air
Pucker your lips as in a kiss. Apply pressure inwardly against lips (toward teeth).
Jaw control Open your mouth as far as you can. Help patient maintain head control. Apply pressure from
under chin upward and forward.
Close your mouth tightly. Don't let me open it. Help patient maintain head control. Apply
pressure on chin downward.

Push your bottom teeth forward. Place two fingers against chin and apply pressure
backward.

Move your jaw from side to side. Place one finger on left cheek and apply pressure to
right.

From Alta Bates Hospital Rehabilitation Services: Bedside dysphagia evaluation protocol, Berkeley, Calif, 1999; Community Hospital of Los Gatos, Rehabilitation Ser-
vices: Dysphagia protocol, Los Gatos, Calif, 1999; Logemann J: Evaluation and treatment of swallowing disorders, Austin, Tex, 1998, Pro-Ed Publishers; Miller R: Clinical
examination for dysphagia. In Groher M: Dysphagia diagnosis and management, ed 3, Newton, Mass, 1997, Butterworth-Heinemann Publishers.
*Apply resistance only in the absence of abnormal muscle tone.

The therapist tests the facial musculature by asking ORAL REFLEXES. A patient with clearly docu-
the patient to perform the movements listed in Table mented neurological involvement may demonstrate
40-2. The therapist should note how much assistance primitive oral reflexes that interfere with a dysphagia re-
the patient needs to perform these movements. As the training program. The rooting, bite, and suck-swallow
patient moves through each task, bilateral symmetry is reflexes, normal from 0 to 5 months of age, may reap-
assessed. Asymmetry could indicate weakness or in- pear in adults when higher cortical structures are
creased tone. Musculature is palpated for abnormal re- damaged. The gag, palatal, and cough reflexes, which
sistance to the movement. Resistance, which feels as if should be present in adults and act to protect the
the patient is fighting the movement, is caused by hy- airway, may be impaired. Specific assessment tech-
pertonicity in the antagonistic muscle group. niques can be found in Table 40-3. Persistence of these
If the patient is able to hold the position at the end of primitive oral reflexes interferes with the patient's devel-
the movement, the therapist applies pressure against the opment of isolated motor control, which is needed for
muscle to determine the muscle’s strength. The patient chewing and swallowing.
with normal strength is able to hold the position
throughout the applied resistance. The patient who is Inner Oral Status
able to hold the position briefly against pressure may An assessment of the patient's inner oral status includes
have adequate strength for chewing and swallowing with an examination of oral structures, tongue musculature,
assistance. The patient who is unable to move into the » palatal function, and swallowing. By performing the
testing position independently or with assistance will outer oral status assessment first, the therapist has estab-
have difficulty with eating and with facial expression. lished a rapport and trust with the patient. Each proce-
 Dysphagia

Oral Reflexes
Assessment Functional Implications
Stimulus: touch patient on right or left Limits isolated motor control of lip muscles
corner of mouth
Response: patient moves lips and head in Moves head out of midline altering alignment
direction of stimulus of swallowing mechanism
:Bite(4-7 months) Stimulus; touch crowns of teeth with Prevents normal forward, lateral, and rotary
unbreakable object movements of jaw necessary for chewing
Response: patient involuntarily clamps
teeth shut.
:Suck-swallow (0-4 months) Stimulus: introduction of food and liquid Prevents development of normal voluntary swallow

Response: sucking
Tongue thrust (abnormal) Stimulus: introduction of food and liquid Interferes with ability to keep lips and mouth closed
Response: tongue comes forward to front Prevents tongue from propelling food to back of
of teeth mouth in preparation for swallow; prevents formation
of bolus, loss of tongue lateralization
Gag (O-adult) Stimulus: pressure on back of tongue Protects airway (not always present in normal adult);
hypersensitive gag reflex can interfere with chewing,
swallowing,

Response; tongue humping, pharyngeal

constriction

Palatal (O-adult) Stimulus: stroke along faucial arches Protects airway, closes off nasal passages, triggers
swallow response

Response: constriction of faucial arches;

elevation of uvula

From Avery-Smith W: Management of neurologic disorders: the first feeding session. In Groher M, editor: Dysphagia: diagnosis and management, ed 3, Newton,
Mass, 1997, Butterworth-Heinemann; Farber S: Neurorehabilitation, a multisensory approach, Philadelphia, 1982, WB Saunders; Logemann J:Evaluation and treatment
of swallowing disorders, Austin, Tex, 1998, Pro-Ed Publishers; Schulze-Delrieu K, Miller R: Clinical assessment of dysphagia. In Perlman A, Schulze-Delrieu K, editors:
Deglutition and its disorders: anatomy, physiology, clinical diagnosis and management, San Diego, Calif, 1997, Singular Publishing; Silverman EH, Elfant IL: Am J Occup Ther,
O79:

dure is first explained to the patient. The therapist works For assessment purposes, the mouth is divided into
within the patient's visual field and gives the patient four quadrants: right upper, right lower, left upper, and
time to process the instructions found in Table 40-4. left lower. Each quadrant is assessed separately, as is
It is important that the therapist place only a wet each side (e.g., assess right upper side, then right lower
finger or tongue blade into the patient’s mouth, because side). First the therapist slides a wet fifth finger under
the mouth is normally a wet environment. A dry finger the patient's upper lip and moves it back toward the
or tongue blade is uncomfortable.'* After a count of cheek, rubbing the gums three times.'* The therapist
three, the therapist removes the finger and allows the notes whether the patient's gums are bleeding, tender,
patient to swallow the saliva. The therapist should wear or inflamed and whether the gums feel spongy or firm.
latex gloves for protection from infections. Appropriate Loose teeth and sensitive or missing teeth are also
hand washing techniques are also necessary. noted. The therapist should take caution to avoid placing his
or her finger between the patient's teeth until it has been de-
DENTITION. Because the adult uses teeth to shear termined that the patient does not have a bite reflex.
and grind food during bolus formation, the therapist After assessing the gums, the therapist turns over his
needs to assess the condition and quality of the patient's or her finger, sliding the pad of the finger against the
teeth and gums.'*** inside of the patient's cheek and gently pushing the
 ‘al Motor Assessment
Function Instruction to Patient Testing Procedure*
Tongue
Protrusion Stick out your tongue. Apply slight resistance toward the back of the throat with
tongue blade after patient exhibits full range of motion.

Lateralization Move your tongue from side to side. Apply slight resistance in opposite direction of motion with
tongue blade.

Touch your tongue to your inside cheek— Using finger on outside of cheek, push against tongue inwardly,
right, then left; move your tongue up and
down.
Tipping Touch your tongue to your upper lip. With tongue blade between tongue tip and lip, apply downward
pressure.

Open your mouth. With tongue blade between tongue and teeth, apply downward
Touch your tongue behind your front teeth. pressure on tongue.
Dipping Touch your tongue behind your bottom With tongue blade between tongue and bottom teeth, apply
teeth. upward pressure.

Humping
Say, ‘ng’; Say, ‘ga.’
Observe for humping of tongue against hard palate. Tongue
should flow from front to back.

Run your tongue along roof of your mouth, Observe for symmetry and ease of movement.
front or back.

Swallow
Hard palate Open your mouth and hold it open. Using flashlight, gently examine for sensitivity by walking finger
from front to back.

Soft palate Say, "‘ah’’ for as long as you can (5 seconds). Observe for tightening of faucial arches, elevation of uvula. Using
Change pitch up an octave. laryngeal mirror, stroke juncture of hard and soft palate to elicit
palatal reflex. Observe for upward and backward movement of
soft palate.

Hyoid Elevation Can you swallow for me? Place finger at base of patient's tongue underneath the chin, and
(base of tongue) feel for elevation just before movement of the larynx.

Laryngeal
Range of motion | am going to move your Adam's apple Grasp larynx by placing fingers and thumb along sides. Move
side to side. larynx gently side to side; evaluate for ease and symmetry of
movement.

Elevation Can you swallow for me? Place fingers along the larynx: first finger at hyoid, second finger
at top of larynx, and so on. Feel for quick and smooth elevation
of larynx as the patient swallows.

Cough
Voluntary Can you cough? Observe for ease and strength of movement, loudness of cough,
swallow after cough.

Reflexive Take a deep breath. As patient holds breath, using palm of hand, push downward
(toward stomach) on the sternum. Evaluate strength of reaction.

From Community Hospital of Los Gatos, Rehabilitation Services: Dysphagia protocol, Los Gatos, Calif, 1999; Coombes K: Swallowing dysfunction in hemiplegia and
head injury, course presented by International Clinical Educators, Aug 24-27, 1986, and Aug 24-28, 1987, Los Gatos, Calif; Hislop H, Montgomery J, Connelly B:
Daniels & Worthington’s muscle testing: techniques of manual examination, ed 6, Philadelphia, 1995, WB Saunders; Miller R: Clinical examination for dysphagia. In
Groher M: Dysphagia diagnosis and management, ed 3, Newton, Mass, |997, Butterworth-Heinemann Publishers; Schulze-Delrieu K, Miller R: Clinical assessment of
dysphagia. In Perlman A, Schulze-Delrieu K, editors: Deglutition and its disorders: anatomy, physiology, clinical diagnosis and management, San Diego, Calif, 1997, Singu-
lar Publishing.
*Apply resistance in absence of abnormal muscle tone.

740
 Dysphagia 741

cheek outward to feel the tone of the buccal muscula- exhibiting tongue deviation with protrusion may have
ture. The therapist notes whether the cheek is firm with muscle weakness on the affected side, causing the
an elastic quality, too easy to stretch, or tight without tongue to deviate toward the unaffected side because
any stretch. The therapist observes the condition of the the stronger muscles dominate. The patient also may
inside of the patient's mouth, checking for bite marks on have abnormal tone, which results in the tongue deviat-
the tongue, cheeks, and lips. Next, the therapist should ing toward the affected side.
remove the finger from the patient's mouth, allow or Grasping the tongue gently between the forefinger
assist the patient to swallow saliva, and assist the patient and thumb, the therapist can pull the tongue slowly
to move the lip and cheek musculature into the normal forward. A wet gauze square wrapped around the tip of
resting position. This procedure is repeated for each the tongue may help the therapist to grip it.'* Next, the
quadrant. The therapist should avoid moving the finger therapist walks a wet finger along the tongue from front
across midline from the right to the left side of the to back, to determine whether the tongue feels hard,
patient's gums because this practice can be annoying. firm, or mushy. The right side of the tongue is compared
If the patient has dentures, the therapist must discern with the left side. An abnormally hard tongue may be
whether the fit is adequate for chewing. Because den- the result of increased muscle tone.
tures are held in place and controlled by normal muscu- While continuing to grip the tongue between forefin-
lature and sensation, changes in these areas, or marked ger and thumb, the therapist can assess the patient's
weight loss, affect the patient's ability to use dentures range of motion by moving the tongue forward, side to
effectively.'° The dentures should fit over the gums side, and up and down. The tongue with normal range
without slipping or sliding during eating or talking. will move freely in all directions without resistance.'***
Because the patient needs to wear dentures throughout Moving the tongue through its range, the therapist can
the dysphagia training period, necessary corrections or simultaneously evaluate tone. As the therapist pulls the
repairs should be completed quickly.*”’*’ A dental con- tongue forward, he or she determines whether it comes
sultation may be needed to ensure appropriate fit if den- easily or whether resistance feels as if the tongue were
tures cannot be held firmly with commercial adhesive pulling back against the movement, indicating in-
creams or powders. Patients who have gum or dental creased tone. A tongue that seems to stretch too far
problems require appropriate follow-up and good oral beyond the front teeth is indicative of decreased tone.
hygiene to participate in a feeding program. Loose den- When moving the tongue side to side, the therapist
tures or teeth may necessitate changes in food consis- notes whether it is easier to move in one direction or the
tencies that the patient might have otherwise managed. other. Increased abnormal tone makes it difficult for the
therapist to move the tongue in any direction without
TONGUE MOVEMENT. The tongue is an intricate feeling resistance against the movement. The amount of
part of the normal chewing and swallowing process. assistance needed to decrease or increase tone to within
Controlled tongue movement is necessary for moving normal limits should be noted. Patients who are con-
and shaping food in the mouth. The tongue propels the fused or apraxic may resist this passive motion but not
food back in preparation for swallowing; therefore a have an actual increase in tone.
thorough assessment of the tongue’s strength, range of To assess the tongue’s motor control (strength and
motion, control, and tone is needed.'"1*°*4" coordination), the therapist asks the patient to elevate,
The patient is asked to open the mouth, and the ther- stick out, and move the tongue laterally (Table 40-4). If
apist can assess the appearance of the tongue with a the patient has difficulty following verbal directions, the
flashlight and note whether the tongue is pink and therapist can use a wet tongue blade to guide the patient
moist, very red, or a heavily coated white. A heavily through the desired movements. The patient is asked to
coated tongue may decrease the patient's sensations of place the tongue against the tongue blade and to keep it
taste, temperature, and texture and may indicate poor there. The therapist then moves the tongue blade slowly,
tongue movement or be a sign of infection. guiding the patient's tongue in the testing direction.'?
When examining the shape of the tongue, the thera- Ease of movement, strength of movement, and coordi-
pist notes whether it is flattened out, bunched up, or nation of movement are assessed for each direction.
rounded. Normally the tongue is slightly concave with a Poor muscle strength or abnormal tone decreases the
groove running down the middle. The therapist ob- ability of the tongue to sweep the mouth and gather
serves the position of the tongue. The therapist should particles to form a cohesive bolus. If the tongue loses
determine whether it is at midline, resting just behind even partial control of the bolus, food may fall into the
the front teeth in the normal position, retracted or valleculae, the pyriform sinuses, or the airway, possibly
pulled back away from the front teeth, or deviated to the leading to aspiration before the actual swallow.” The
right or left side. A retracted tongue may indicate an in- back of the tongue must also elevate quickly and
crease of abnormal muscle tone or a loss of range of strongly to propel the bolus past the faucial arch into
motion as a result of soft-tissue shortening. The patient the pharynx to trigger the swallow response.'*** The
742 TREATMENT APPLICATIONS

therapist must carefully assess the tongue’s function. a semithick drink such as fruit nectar or a yogurt drink,
The patient with poor tongue control may not be a can- and a thin liquid such as water.’
didate for eating. The therapist must first normalize To minimize the risk of aspiration, pureed foods are
tone and improve tongue movement before attempting chosen for patients with decreased motor control and
to feed the patient. The correct selection of appropriate chewing difficulties or apraxia. Soft foods are easily
foods also facilitates motor control when the patient is formed into a bolus and require less chewing than
ready for eating. Close supervision by an experienced ground meat for patients who have poor oral motor
therapist is required for this type of patient to partici- control. Soft foods also stay together in a cohesive bo-
pate in eating. lus. Ground foods allow the therapist to assess a pa-
tient’s ability to chew, form a cohesive bolus, and move
it in the mouth. Thick liquids move more slowly from
Clinical Assessment of Swallowing front to back, giving the patient with a delayed swallow
Because aspiration is a primary concern in swallowing, more time to control the liquid until the swallow re-
the occupational therapist must carefully assess the sponse is triggered. Thin liquids are the most difficult to
patient's ability to swallow safely. Before the therapist control because they require an intact swallow to
presents the patient with material to swallow, he or she prevent aspiration.
should assess the ability of the patient to protect the For the patient who appears to have some ability to
airway. The patient must have an intact palatal reflex, el- chew, the therapist should start with pureed and soft
evation of the larynx, and a productive cough. Direc- foods and introduce solid materials if the patient is
tions for assessing all the components of the swallow doing well."’'*°”*? The following procedures should
are described in Table 40-4. The therapist should note be completed after each swallow of food or liquid:
the speed and strength of each component. The patient 1. Using a fork, the therapist places a small amount
with intact cognitive skills may accurately report to the (‘4 teaspoon) on the middle of the patient's tongue.
therapist where and when there is difficulty with the A fork allows the therapist greater control of food
swallow.” placement in the mouth.'”!**! This procedure is re-
The occupational therapist must assimilate all the in- peated for each substance for two or three bites to
formation from the assessment process. Clinical judg- check for fatigue.
ment plays an important role in the accurate assessment 2. The therapist palpates for the swallow by placing the
of dysphagia.”’”’’* The following are questions that index finger at the hyoid notch, the second finger at
must be asked: the top of the larynx, and the third finger along the
1. Is the patient alert enough to follow through with midlarynx. The therapist can feel the strength and
bolus formation and an immediate swallow when smoothness of the swallow and also notes whether
presented with food? the patient needs subsequent or additional swallows
2. With assistance, does the patient maintain adequate to clear the bolus.'**' The therapist can also evaluate
trunk and head control, normalizing tone and facili- the oral transit time by noting when food entered the
tating quality movement? mouth, when tongue movement was initiated, and
3. Does the patient display adequate tongue control to when the elevation of the hyoid notch was felt, indi-
form a partially cohesive bolus and to regulate the cating the beginning of the swallow process. The
speed with which the bolus enters the pharynx? therapist can time the swallow from the time that
4. Is the larynx mobile enough to elevate quickly and hyoid movement begins to when laryngeal elevation
strongly? occurs, indicating triggering of the swallow re-
5. Can the patient handle the saliva with minimal sponse.*' A normal swallow takes only 1 second to
drooling? complete for thin liquids.
6. Does the patient have a productive cough, strong 3. The therapist asks the patient to open the mouth to
enough to expel any material that may enter the check for remaining food. Food is commonly seen in
airway? the lateral sulci, under the tongue, on the base of
If the answer is yes to all of the above questions, the the tongue, and against the hard palate.’”* Food re-
therapist may assess the patient's oral and swallow maining in the mouth indicates decreased or poor
control with a variety of food consistencies. oral transit skills. The patient who exhibits oral
The therapist should request an assessment tray from motor deficits has increasing difficulty with chewing,
dietary services. The tray should contain a sample of shaping a bolus, and channeling food backward as
pureed food such as pudding or applesauce, soft food harder consistencies of food are introduced.’*
such as a banana or macaroni and cheese, and ground 4. The therapist asks the patient to say, “ah.” By listen-
tuna with mayonnaise or chopped meat with gravy. The ing carefully, the therapist can assess the patient's
tray also should include a thick drink such as nectar voice quality and classify the sound production as
blended with one half banana for a seven-ounce drink, strong, clear, or gurgly or gargling.’*”*"
 Dysphagia 743

A gurgly voice may result from a delayed swallow re- rally during meals. The therapist presents the patient
sponse, which allows material to collect in the larynx. with an easily managed food bolus, followed by the
The therapist asks the patient to take a second “dry” safest type of liquid tolerated, and then assesses the
swallow to clear any pooling of material. Asking the patient for coughing when the consistency of the food is
patient to say, “ah” again enables the therapist to assess changed.
whether the voice quality remains gurgly or gargling for A patient with a tracheostomy tube in place can be
any length of time after the dry swallow. In addition, the assessed as previously described. The same criteria must
therapist asks the patient to pant for a few seconds. This be met before the therapist assesses the patient's eating
will shake loose any material that may remain in the and swallowing of food or liquids. The therapist must
pytiform sinuses or valleculae." If the voice is still have a thorough understanding of the types of tra-
gurgly, the therapist should be concerned with the pos- cheostomy tubes and varied functions.
sibility that material has come into contact with or is There are two main types of tracheostomy tubes:
sitting on the vocal cords.*" fenestrated and nonfenestrated (Figs. 40-4 and
If the patient has significant coughing episodes, par- 40-5).'*°"4? A fenestrated tube is designed with an
ticularly before the therapist feels the initiation of the opening in the middle to allow increased air flow. This
swallow (elevation of hyoid notch) with any consis- type of tube is frequently used for patients being
tency, the procedure should not be continued. If there is weaned from a tube because it allows a patient to
coughing from food with a pureed consistency, the ther- breathe nasally as he or she relearns a normal breathing
apist may try a soft food such as a banana, if the patient pattern. Placement of an inner cannula piece into the
has good anterior to posterior tongue movement.’ If tracheostomy tube allows the fenestrated opening to be
problems persist, a videofluoroscopy may be indicated. closed off. With the inner cannula removed, a trachea
A neurologically impaired patient with poor sensa- button may be used to allow the patient to talk. A non-
tion may have difficulty with a food of pureed consis- fenestrated tube has no opening. A fenestrated tube is
tency because it does not stay together as a bolus. The preferred for treating a patient with dysphagia.
weight of soft foods may adequately trigger the swallow A tracheostomy tube may be cuffed or uncuffed. A
response. If the patient continues to cough even with cuffed tube has a balloonlike cuff surrounding the
soft foods, the swallow assessment should be discontin- bottom of the tube.'**' When inflated, the cuff comes
ued. In this instance videofluoroscopy is indicated. If a into contact with the trachea wall, preventing the aspira-
patient is having difficulty at this level, only a prefeed- tion of secretions into the airway. A cuffed tube is used
ing treatment program can be considered appropriate. in cases in which aspiration has occurred. The therapist
A patient who has difficulty managing solid consis- should consult with the patient's attending physician to
tencies may or may not have difficulty with liquids. To see whether the patient is still at risk of aspirating, or if
assess the patient's swallow with liquids, the therapist it is safe to deflate the cuff for an eating and swallowing
starts with a thickened (thick) nectar, then a pure nectar assessment.
(semithick), and finally a thin liquid such as water or Before the therapist presents any food matter to the
juice (see Table 40-8). Small amounts of the liquid are patient with a tracheostomy who has a fenestrated tube,
placed on the middle of the patient's tongue with a the inner cannula should be in place. If the patient has a
spoon. The therapist proceeds by following the four- cuffed tube, the therapist should thoroughly suction
step sequence described earlier for solid foods. The ther- orally and around the cuff, present food, and slowly
apist assesses the patient's skill at moving material from deflate the cuff while suctioning to prevent substances
front to back, the time of oral transit and swallow, and from penetrating the airway. The airway again needs to be
the voice quality after each swallow. Each liquid consis- suctioned orally and through the tracheostomy to ensure
tency is assessed for two or three swallows to check for that all secretions have been cleared.'”’”’*' The nursing
fatigability. If the patient tolerates and swallows liquids staffora therapist who has been trained and is considered
by spoon without difficulty, the therapist assesses the competent can perform the suctioning procedure.
ability to tolerate liquids from a cup or with a straw." After presenting food or liquids the therapist should
Again, the patient's voice quality is checked. check for oral transit skills and swallow as previously
A patient with a poor swallow may aspirate directly or described. Blue food coloring added to food or liquids
pool liquids in the pyriform sinuses and valleculae, can help the therapist identify material in the trachea.
which, when full, overflow into the laryngeal vestibule The patient can use a gloved finger to cover the trachea
and down into the trachea. If a patient continues to have opening, to achieve a more normal tracheal pressure
a gurgling or gargling voice after a second dry swallow or during the swallow.”
substantial coughing with any of the liquid consisten- If the tracheostomy tube is cuffed, the cuff is slowly
cies, the assessment should be discontinued (Fig. 40-3). deflated. The airway is suctioned through the tra-
The therapist must also assess the patient's ability to cheostomy tube to determine whether any material
alternate between liquids and solids, which occurs natu- entered the airway. The swallow assessment should not
744 TREATMENT APPLICATIONS

Cricopharyngeal
Cricopharyngeal muscle
muscle

Esophagus

Valleculae
Cricopharyngeal
muscle
Cricopharyngeal
muscle

Esophagus Esophagus

FIG. 40-3
Types of aspiration. A, Aspiration before swallow caused by reduced tongue control. B, Aspiration
before swallow caused by absent swallow response. C, Aspiration during swallow caused by
reduced laryngeal closure. D, Aspiration after swallow caused by pooled material in pyriform sinuses
overflowing into airway. (From Logemann J: Evaluation and treatment of swallowing disorders, San
Diego, 1983, College-Hill Press).

Indicators of Eating and Swallowin

. ‘cf . . . O 9 3

be continued if material is found in the trachea.17!?*!

The presence of a tracheostomy tube may affect a Dysfunction
patient's swallow as secretions are increased and laryn- The indicators of swallowing dysfunction include the
following” 13,31,38,40,
geal mobility is decreased. When assessment is com-
plete, the airway is thoroughly suctioned. The inner 1. Difficulty with bringing food to the mouth
cannula is removed from the fenestrated tube, or the 2. The inability to shape food into a bolus
cuff inflated to the level prescribed by the physician.'*'!” 3. Coughing or throat clearing before, during, or after
The patient's performance on the swallowing assess- the swallow
ment determines whether the patient is able to partici- . Gurgling voice quality
pate in a feeding program and at which food and liquid a . Changes in breathing pattern
&

consistencies he or she is able to function efficiently. . Delayed or absent swallow response

The therapist must decide which consistency is the NO. Poor cough
safest for the patient. The safest consistency is that 8. Reflux of food after meals
which the patient is able to chew, move through the oral The presence of any swallowing dysfunction can lead
cavity, and swallow with the least risk of aspiration. to aspiration pneumonia. The following are acute
 OBTURATOR OUTER CANNULA INNER CANNULA

kK Luer Lock

ei m@ Fenestration
\ (not present Flange on
on all tubes) Outer
Cannula
Cuff (not
present on
all tubes)
Cuff Inflation Line

Pilot Balloon

FIG, 40-4
Tracheostomy tube components. (From Logemann J: Evaluation and treatment of swallowing disorders,
Austin, Tex, 1998, ProEd Publications.)

FIG, 40-5
A, Midsagittal section of the head and neck showing the position of an uncuffed tracheostomy tube.
B, Midsagittal section of the head and neck showing the passage of air between the tracheostomy
tube and the tracheal wall. (From Logemann J:Evaluation and treatment of swallowing disorders, Austin,
Tex, 1998, ProEd Publications.)

745
746 TREATMENT APPLICATIONS

symptoms of aspiration occurring immediately after the silent aspirators during the clinical assessment.*'’*° It is
swallow!*18:!9.49.
important to rule out the occurrence of aspiration.
1. Any change in the patient's color, particularly if the Other indicators for videofluoroscopy are difficul-
airway is obstructed ties with liquid consistencies and a need to identify
2. Prolonged coughing specific pharyngeal problems. Some clinicians, how-
3. Gurgling voice, and extreme breathiness or loss of ever, advocate that all patients be evaluated by video-
voice fluoroscopy, regardless of these indicators. Contraindi-
During the 24 hours immediately after the swallow, cations to performing videofluoroscopy include rapid
the therapist and medical staff must observe the patient progress of the patient, a poor level of awareness or
for additional signs of aspiration. These may be a nasal poor cognitive status, oral stage problems only, and
drip, an increase to profuse drooling of a clear liquid, the physical inability of the patient to undergo the
and temperatures of 100° F or greater, which may not test.
have been evident during the clinical examina- Three people are involved in performing videofluo-
tion.'**?" If aspiration pneumonia develops, the pa- roscopy: the radiologist, the occupational therapist, and
tient must be reevaluated for a change in diet levels or the video technician. The patient should be positioned
taken off the feeding program, if necessary. An alterna- to allow a lateral view, with the fluoroscopy tube
tive feeding method is required. focused on the lips, hard palate, and posterior pharyn-
geal wall. The lateral view is most frequently used
Assessment With Videofluoroscopy because it allows the therapist to evaluate all four stages
Videoflouroscopy is an important technique for assess- of the swallow. This view clearly shows the presence
ing a patient’s swallow. Videofluoroscopy is a radi- of aspiration. A posterior-anterior view also may be
ographic procedure using a modified barium swallow needed to evaluate asymmetry in the vocal cords and
recorded on videotape.”’ This technique allows the pooling of the valleculae or pyriform sinuses.
therapist to see the patient’s jaw and tongue move- During a videofluoroscopy assessment the therapist
ment, to measure the transit times of the oral and pha- presents the patient with food or liquid to which
ryngeal stages, see the swallow, see any residue in the barium paste or powder has been added."*’”** The
valleculae and the pyriform sinuses, and observe any therapist mixes or spreads small amounts of paste or
aspiration. With videofluoroscopy the therapist can de- powder onto or into each food or liquid consistency.
termine the cause of aspiration. Videofluoroscopy may Premixing the consistencies with the barium paste or
also be used to determine which treatment techniques powder prevents time-consuming interruptions during
to use and the safest diet level to help the patient the actual assessment procedure.
achieve a safe swallow. Food and liquids are presented in the same sequence
Aspiration can occur before the swallow because of used for the clinical assessment. Starting with pureed
poor tongue control, pooled material in the valleculae, foods, the patient is given ') teaspoon at a time of each
or a delayed or absent swallow response. Poor laryngeal consistency and asked to swallow when instructed.”
closure can result in aspiration during the swallow. As- Liquids are tested separately, beginning with the thick-
piration after the swallow is the result of pooled mate- ened substance. Material is given in small amounts to
rial in the pyriform sinuses or of the valleculae over- reduce the risks of aspiration, if it occurs. An experi-
flowing into the trachea. Knowing the reason why a enced dysphagia therapist may choose to use only foods
patient is aspirating can help the occupational therapist or liquids that the patient had difficulty with during the
plan appropriate treatment.*'”** clinical examination, rather than to proceed through
A fluoroscopy machine has three components: a fluo- the entire sequence. The therapist continues to assess
roscopy tube, a monitor for viewing the picture, and an with each consistency until aspiration occurs.
elevation table or platform. A television videocassette If the patient aspirates during the swallow, allowing
recorder is set up to record the image. Other necessary material to fall directly into the airway, the therapist
pieces of equipment normally available in a radiology should discontinue the assessment with that consis-
department are lead-lined aprons, lead-lined gloves, tency. If aspiration occurs before the swallow, secondary
and foam positioning wedges.*'** Because it may not to poor tongue control or a delayed swallow reflex, a
be possible to lower the fluoroscopy machine enough to thicker or denser substance should be tried because it is
view a patient seated in a wheelchair, a special plywood easier for the patient to control. If the patient aspirates
seat system or wheelchair platform with a ramp may be after the swallow because of pooling in the valleculae or
needed. Commercially made seating systems are also pyriform sinuses, the assessment with that consistency
available. is discontinued.
Videofluoroscopy is necessary for ruling out silent as- The videofluoroscopy procedure can also be used to
piration. Forty to sixty percent of patients with neuro- observe for fatigue. The patient is asked to take repeated,
logical impairment who have dysphagia are found to be or serial, swallows of solids and liquids. The therapist
 Dysphagia 747

should assess the patient's ability to control mixed con- cavity and swallowing structures. Food and liquids are
sistencies of solids and liquids such as soups and to al- then introduced as described previously. The therapist
ternate between solids and liquids. Various compensa- notes bolus formation, tongue movement, swallow, and
tory techniques may also be assessed to determine if the aspiration, if it occurs. The FEES allows the therapist to
airway can be protected, which may allow the therapist see the pharynx and the larynx before and after the
to initiate a feeding program.*!’** swallow, assessing for the possibility of aspiration.*” The
The solid and liquid consistency that the patient evaluation procedure requires advanced training and should
manages without aspiration is selected as the starting be performed only by appropriately trained therapists.
point for feeding training. A patient aspirating on The results of a thorough assessment determine the
pureed or soft foods is not suited for an oral program. course of treatment to increase a patient's ability to eat.
The patient who is aspirating thick liquids is not a can- Upon completion of the entire dysphagia assessment,
didate for liquid intake. the therapist should clearly document the patient's
Videofluoroscopy is a valuable tool to be used in major problems, treatment goals and objectives, and
conjunction with the clinical examination. It can provide treatment plan. The objectives should be concise and
the therapist with additional information regarding the measurable. The treatment plan should include the type
patient's difficulties. By identifying silent aspirators, the of diet needed, the training and facilitation that the
therapist can feel comfortable with the decisions made patient requires, positioning techniques to be used
in determining a course of treatment. Because videofluo- during feeding, and the type of supervision that must be
roscopy exposes the patient to radiation, the therapist provided. Treatment recommendations should be com-
should exercise good clinical judgment when deciding municated to the appropriate nursing and medical staff.
whether videofluoroscopy is needed. The therapist must
keep in mind that videofluoroscopy records the patient's
TREATMENT
performance in an isolated instance and is not a conclu-
sive indicator of the patient's potential ability in a Because a patient may display more than one problem
feeding program. If a patient continues to progress at each stage of deglutition, the intervention program
without difficulty, a second videofluoroscopy is not nec- for dysphagia is multifaceted. Treatment of the patient
essary. A second videofluoroscopy may be needed, with dysphagia involves trunk and head positioning
however, to reevaluate a patient who shows signs of and control, hand-to-mouth skills, oral motor skills,
readiness to participate in a feeding program or to deter- and swallowing. Perceptual and cognitive deficits that
mine whether a patient can progress to thin liquids.'*"*! interfere with eating are also addressed. To treat the
When the results of a videofluoroscopy test are docu- patient the occupational therapist needs to devote 35%
mented, foods that were presented, problems that oc- to 45% of the patient's total daily treatment time to oral
curred at each stage, and the number of swallows taken motor and swallowing retraining.** A patient with
to clear the food or liquid are recorded. The therapist severe problems can require up to 6 months of intense
also should document any facilitation techniques that intervention before he or she reaches optimal recovery.
worked effectively.""°!"*? This assessment procedure re- In preparing a treatment plan for the patient with ac-
quires advanced training and should be done only by appro- quired dysphagia, the therapist must identify the symp-
priately trained therapists. toms and causes of the patient's deficits.7° 191°?!

Assessment With Fiberoptic Endoscopy

Goals
Fiberoptic endoscopy (FEES) is an alternative tech-
nique used to assess swallowing. This technique is valu- The overall goals of OT in the treatment of dysphagia
able when it is not possible for the patient to participate are as follows*7717"77".
in videofluoroscopy or when it is used as a follow-up as- 1. Facilitation of appropriate positioning during eating
sessment for the patient making rapid progress. It can 2. Improvement of motor control at each stage of
be repeated as often as necessary without exposure to swallow, through normalization of tone and the fa-
radiation.**??”°” cilitation of quality movement
The equipment needed for a FEES includes a flexible 3. Maintenance of an adequate nutritional intake
fiberoptic nasopharyngolaryngoscope, a portable light a . Prevention of aspiration
source, a video camera, a video recorder, and a televi- 5. Reestablishment of oral eating to the safest, opti-
sion monitor. Placed on a rolling cart, this system can mum level
be brought directly to the patient. The therapist first top-
ically anesthetizes one nasal fossa. After a brief amount
Team Management
of time the therapist passes a flexible fiberoptic tube
through the nasal fossa, positioning the tip just above Because of the complex nature of dysphagia treatment, the
the palate.*® The therapist initially examines the oral patient's optimal progress is facilitated by development
748 TREATMENT APPLICATIONS

of a team approach. The dysphagia team should consist usually is the first to notice changes in the patient's con-
of the patient's attending physician, the occupational dition, such as an elevated temperature, an increase in
therapist, the dietitian, the nurse, the physical therapist, pulmonary congestion, and an increase in secretions in-
the speech-language pathologist, the radiologist, and dicating swallowing dysfunction.'? The nurse informs
the patient's family. Each professional contributes ex- the physician and occupational therapist of these
pertise toward patient improvement. All members of changes. The patient's oral and fluid intake is recorded
the dysphagia team should have a thorough working in the nursing notes, and the nurse notifies the dyspha-
knowledge of treating patients with dysphagia. Interde- gia team when the patient's nutritional status is ade-
partmental inservice education is frequently required so quate or inadequate. Supplemental tube feedings that
that team members have a similar frame of reference. have been ordered by the physician are administered by
The occupational therapist's role is to assess the the nursing staff, which also provides oral hygiene, tra-
patient and implement the appropriate course of treat- cheostomy care, and supervision for appropriate pa-
ment. The occupational therapist is also responsible for tients during meals."
coordinating the team effort, which includes obtaining The patient's family is included on the team to act as
physician's orders as needed, communicating with all program supporters. The family frequently underesti-
other team members and staff, providing family educa- mates the danger of aspiration. Therefore it is important
tion to ensure proper follow-through, and selecting the to educate the family and the patient from the first day
appropriate diet. The occupational therapist initiates of assessment. The family and patient should under-
changes in the patient’s program whenever neces- stand which food consistencies are safe to eat and which
sary. 4,6,13,39 foods must be avoided.”*”
The attending physician's role involves the medical The roles of the various team members may vary
management of the patient's health and safety. The from one treatment facility to another. Designated roles
physician oversees all decisions regarding treatment for must be clearly defined to ensure a coordinated team
diet level selection, oral and nonoral feeding proce- approach. Therapists who are responsible for direct
dures, and the progression of treatment as recom- treatment should have advanced knowledge and train-
mended by the team. The physician should reinforce ing in the treatment procedures.
the course of treatment with the patient and the
family. 19223139
The dietitian is responsible for monitoring the
Positioning
patient's caloric intake. He or she makes recommenda- Proper positioning is essential for treating the patient
tions to ensure that the patient receives a balanced, nu- with dysphagia. The patient should be positioned sym-
tritional diet in accordance with the medical condition. metrically with normal alignment between the head,
The dietitian is involved in suggesting types of feeding neck, trunk, and pelvis. The ideal position is as
formulas for the nonoral patient. Diet supplements to follows*’”’°*'"°:
augment oral intake may be recommended. In conjunc- 1. The patient is seated on a firm surface, such as a chair.
tion with the occupational therapist, the dietitian 2. The patient's feet are flat on the floor.
ensures that the proper food and liquid consistencies 3. The patient's knees are at 90° flexion.
are served to the patient. Additional training may be 4. There is equal weight bearing on both ischial
necessary for the dietary staff because dysphagia diets tuberosities of the hips.
vary from traditional medical diets. 5. The patient's trunk is flexed slightly forward (100°
The patient's physical therapist is involved in muscle hip flexion) with the back straight.
reeducation and tone normalization techniques of the 6. Both of the patient’s arms are placed forward on the
trunk, neck, and face. The patient receives treatment in table.
balance, strength, and control. The physical therapist is 7. The head is erect, in midline, and the chin is slightly
involved in increasing the patient's pulmonary status tucked.
for breath support, chest expansion, and cough.’ For the patient who may be bed bound, the same prin-
The role of the speech-language pathologist involves ciples apply: equal weight bearing on both ischial
the reeducation of the oral and laryngeal musculature tuberosities for the hips, the trunk flexed slightly
used in speaking and voice production. Because these forward (100° hip flexion) with the back straight, knees
muscles are also used in swallowing, a therapist with slightly flexed, and both arms placed forward on a
dysphagia experience may participate in oral motor and bedside table.
swallowing training during prefeeding and feeding ses- Fig. 40-6 shows two hand-hold techniques that allow
sions.”” the therapist to help the patient maintain head control.
The nurse is another key member of the dysphagia Correct positioning normalizes tone, thereby facilitat-
team. The nursing staff is responsible for monitoring ing quality motor control and function of the facial
the patient's medical and nutritional status. The nurse musculature, jaw and tongue movement, and the swal-
 Dysphagia 749

FIG. 40-6
Head control. A, Side hold position for patients requiring maximum to moderate assistance.
B, Front hold position for patients requiring minimal assistance. (From Meadowbrook Neurological
Care Center, San Jose, Calif, 1988.)

lowing process, all of which minimize the potential for therapist's finger. Sensitive gums can also be firmly
aspiration. rubbed, preparing the patient for the toothbrush.
A patient who has difficulty moving into the correct For cleaning purposes, the mouth can be divided into
position or maintaining the position presents a chal- four quadrants. A toothbrush with a small head and soft
lenge to the occupational therapist. A more careful bristles is used to clean each quadrant, starting with the
analysis of the patient is needed to determine the major top teeth and moving from front to back. When brush-
problem preventing good positioning. Poor positioning ing the bottom teeth, the therapist brushes from back to
may be a result of decreased control or balance second- front. Next, holding the toothbrush at a vertical angle,
ary to hypertonicity or hypotonicity or poor body the therapist brushes the inside teeth downward from
awareness in space secondary to perceptual dysfunction gums to teeth. Finally, the cutting surfaces of the teeth
(Fig. 40-7).**1*.'° After the cause is identified, the ther- are brushed. An electric toothbrush can be morte effec-
apist can treat it accordingly. Specific treatment sugges- tive, if the patient can tolerate it.
tions are described later in this chapter. To assist in After each procedure the patient is allowed to dispose
maintaining trunk position, the therapist may consider of secretions. After brushing, the patient is carefully as-
the use of an adaptive lateral trunk support. Seating the sisted in rinsing the mouth. If the patient can tolerate
patient at a table provides forward trunk support. thin liquids, small amounts of water can be given.
Having the patient flex the chin slightly toward the chest
helps prevent the water from being swallowed. The ther-
Oral Hygiene apist can help the patient expel the water, by placing
Oral care by nursing and therapy team members pre- one hand on each cheek and, simultaneously, pushing
vents gum disease, the accumulation of secretions, the inward on the cheeks while the chin remains slightly
development of plaque, and the aspiration of food par- tucked. If the patient has no ability to manipulate
ticles that remain after eating. The appropriate therapy liquids, a dampened sponge toothette can be used. The
team member begins the oral hygiene process by posi- therapist and nursing staff also can consider using small
tioning the patient upright and symmetrically. The amounts of baking soda instead of toothpaste because it
patient who is apprehensive or who displays a hyper- is easier to rinse out.'*’'®
sensitive oral cavity may first require preparation by the Oral hygiene for the nonoral or oral patient can be
therapist. Preparation steps may include firmly stroking used as effective sensory stimulation of touch, texture,
outside the patient's mouth or lips with the patient's or temperature, and taste. It can be used to facilitate
750 TREATMENT APPLICATIONS

FIG. 40-7
Positioning of the patient with dysphagia. A, Incorrect positioning. B, Correct positioning. (From
Meadowbrook Neurological Care Center, San Jose, Calif, 1988.)

beginning jaw and tongue movements and to encourage 1. The NG tube can be inserted and removed nonsurgi-
an automatic swallow.'* Lack of oral stimulation over a cally, if necessary.
prolonged time leads to hypersensitivity within the oral 2. The NG tube allows the physician to choose between
cavity. Patients who display poor tongue movement and continuous or bolus feedings (a feeding that runs no
who are eating, frequently have food remaining on their more than 40 minutes).
teeth or dentures or between the cheek and gum. A 3. The NG tube allows the therapist to begin prefeeding
patient with decreased sensation is not aware of the re- and feeding training while the tube is in place.
maining food. A thorough cleaning should follow each There are also some disadvantages of the NG
tube!?7!31.
time the patient eats.
1. It can desensitize the swallow response.
2. It can interfere with a positioning program (the
Nonoral Feedings
patient needs to be elevated to 30° during feeding).
A patient who is aspirating more than 10% of food or 3. It can increase aspiration risk, pharyngeal secretions,
liquid consistencies or whose combined oral and pha- and nasal reflux.
ryngeal transit time is more than 10 seconds, regardless 4. It can decrease the patient's self-esteem.
of positioning or facilitation techniques, is an inappro- Placement of a G tube is a minor surgical procedure.
priate candidate for oral eating.'**' Such a patient The patient receives a local anesthetic, and a small skin
needs a nonoral nutritional method until eating and incision is made to create an external opening in the ab-
drinking capability is regained. Patients who lack the dominal wall for a percutaneous endoscopic gastros-
endurance to take in sufficient calories also may require tomy (PEG) procedure. A tube is passed through the
nonoral feedings or supplements. opening into the stomach. There are several advantages
The two most common procedures for nonoral feed- of using a G tube:
ings involve the NG tube and the G tube.’*'” The NG 1. Using a G tube allows the physician to choose
tube is passed through the nostril, through the na- between continuous or bolus feedings.
sopharynx, and down through the pharynx and esopha- 2. It allows the therapist to begin a prefeeding or
gus to rest in the stomach.'” The NG tube is a temporary feeding program while the tube is in place.
measure that should not be used for longer than 1 3. It carries less risk of reflux and aspiration.
month.” There are several advantages to using the NG 4. It does not irritate or desensitize the swallowing
tube: mechanisms.
 Dysphagia 751

5. It does not interfere with a positioning program.

Oral Feedings
6. It can be removed when the patient no longer re- For a patient to be an appropriate candidate for oral
quires supplemental feedings or liquids. feeding, several criteria must be met. The therapist can
phere are some disadvantages of using a G use the criteria for evaluating a patient's swallow with
tubes: foods or liquids. To participate in an oral feeding
1. The stoma site can become irritated or inflamed. program, a patient must (1) be alert, (2) be able to
2. The family can perceive the tube as being permanent. maintain adequate trunk and head positioning with as-
A G tube is the ideal choice for the patient who may sistance, (3) have beginning tongue control, (4) manage
require tube feeding or supplemental feedings for secretions with minimal drooling, and (5) have a reflex-
longer than 1 month. '**! ive cough. The therapist needs to identify the food or
A commercially prepared liquid formula that pro- liquid consistency that is most appropriate for the
vides complete nutrition usually is used for tube feed- patient. The safest consistency with which to initiate the
ings. Many types and brands are available. The physi- oral program is one that enables the patient to complete
cian and dietitian determine which formula is best the oral and pharyngeal stages combined in less than 10
suited to the patient. The feedings are administered seconds and to swallow with minimal aspiration (10%
by either a bolus or a continuous method. A bolus or less).*' The ultimate goal of an oral feeding program
feeding takes 20 to 40 minutes to run through either is for the patient to achieve swallowing without any
the NG tube or the G tube. It can be gravity assisted aspiration.
or run through a feeding pump. Bolus feedings can be
scheduled at numerous times throughout a 24-hour
Diet Selection
period.
Continuous feedings, which may be better toler- A dysphagia diet must be carefully selected to reflect the
ated by the patient, are smaller amounts that are needs of the patient. In general, foods chosen for dys-
administered continuously by a feeding pump. The phagia diets should (1) be uniform in consistency and
feeding pump can be set to regulate the rate at which texture, (2) provide sufficient density and volume, (3)
the formula is dripped into the tube. A disadvantage remain cohesive, (4) provide pleasant taste and temper-
of continuous feedings is that the patient is less ature, and (5) be easily removed or suctioned when nec-
mobile because the pump always accompanies the essary.'*’'*!” The following foods are contraindicated
patient. for dysphagia diets: foods with multiple textures, such
While the patient is on a nonoral program, the oc- as vegetable soup and salads; fibrous and stringy vegeta-
cupational therapist concentrates efforts on retraining bles, meats, and fruits; crumbly and flaky foods; foods
the patient in oral motor control and swallowing. The that liquefy, such as gelatin and ice cream; and foods
prefeeding retraining can occur whether the patient is with skins and seeds.’ Garnishes such as lettuce,
on bolus or on continuous feedings. As a patient parsley, and orange wedges should also be avoided
begins to eat enough to require an adjustment in the because they may be unsafe for the confused patient.
intake amount of formula, however, bolus feedings The occupational therapist should work closely with
become the preferred method. A bolus feeding allows the dietitian to develop dysphagia diet levels. Using spe-
the therapist to work with the physician to wean the cific dysphagia diets facilitates ordering appropriate
patient from formula feeding. A bolus feeding can be foods consistently. Once the diets are developed, the
held back before a feeding session, and the number of medical, nursing, and therapy staff should be educated
bolus feedings per day can be decreased as the patient about which foods are in each level, to ensure the
improves. If satisfied by the tube feedings, the patient patient's safety. Liquid diet levels should also be estab-
will not have an appetite and will have decreased moti- lished. When requesting a dysphagia diet, the therapist
vation to eat. should specify both levels desired, liquid and solid,
As the patient improves, oral intake can be increased, because a patient may handle each differently.
and the formula feeding can be used to supplement the
patient's caloric intake. An accurate calorie count, deter-
Diet Progression
mined by recording the percentage of oral intake, assists
the physician in decreasing the calories received Tables 40-5 through 40-7 list foods in three progressive
through the tube feedings as the patient begins to meet dysphagia stages.'’"'*°’ After mastering stage III, or
nutritional needs orally. If the patient has progressed ground food items, the patient may progress to a regular
only enough to handle solids, the NG or G tube can be diet. Stage I foods are pureed. This food group is best for
used to meet the patient's total or partial fluid require- patients with little or no jaw or tongue control, a mod-
ments. Either tube can be removed when the patient is erately delayed swallow, and a decreased pharyngeal
safely able to eat and drink enough to meet caloric and transit, resulting in pooling in the valleculae and pyri-
fluid needs.'"""*" form sinuses.'**' Pureed foods move more slowly past
 TREATMENT APPLICATIONS

Vagia, Stage | Food Level (Pureed)

Food Groups Foods Allowed Foods to Avoid
Cereals and breads Cooked refined cereals; creamed wheat or rice; All others
Malt-o-Meal

Eggs Custard; pureed egg salad (without onions or celery) All others

Fruits Pureed fruit; applesauce Whole fruits; juicy fruits; all others
Potatoes or substitutes Mashed (white or sweet) potatoes mixed with thick gravy All others
Vegetables Pureed asparagus; beets; carrots; green beans; peas; All others
spinach; squash
Soups Thickened, strained cream soups, with consistency of a All others
pureed vegetable

Meat, fish, poultry, cheese Pureed meat; pureed poultry with gravy All others

Fats Butter; margarine; cream mixed with pureed foods All others
Desserts Plain puddings; smooth yogurt without fruit; custard Any with nuts, coconut, seeds; all others

Sugars and sweets Honey; sugar; syrup; jelly mixed in with pureed food All others

From American Occupational Therapy Association: AOTA resource guide: feeding and dysphagia, Rockville, Md, 1997; Avery-Smith W: An occupational therapist co-
ordinated dysphagia program, Occup Ther Pract 3:10, 1998; Community Hospital of Los Gatos, Rehabilitation Services: Dysphagia protocol, Los Gatos, Calif, 1999;
Curran J:Nutritional consideration. In Groher M, editor: Dysphagia: diagnosis and management, ed 3, Newton, Mass, 1997, Butterworth-Heinemann; RaderT,Rende
B: Swallowing disorders: what families should know, Tucson, Ariz, 1993, Communication Skill Builders.

the faucial arches and into the pharynx, allowing time of consistencies. Meats should be finely cut to facilitate
for the swallow response to trigger. Because pureed a controlled swallow. Smaller particles are less likely to
foods cannot be formed into an-adequate bolus, they obstruct the airway and are less of a health risk than
offer little opportunity for increasing oral motor large pieces, if minimal aspiration occurs. These foods
control.'* Stage I foods are best used only to increase are safer than items found on a regular diet, yet require
the patient's oral intake. The patient should be ad- work on the part of the patient. Stage III foods work well
vanced to the next level as soon as possible. for the patient who has minimal problems with jaw or
Stage II items are soft foods that stay together as a co- tongue control and a mildly delayed but intact swallow
hesive bolus; thus the possibility of particles spilling response. The patient who has reached a stage III level
into the airway is decreased. Stage II foods are best for needs to be concerned with a delayed swallow only
patients with a beginning rotary chew, enough tongue when fatigued.
control with assistance to propel food back toward the When a patient is ready to progress to the next diet
pharynx, and a minimally delayed swallow.'*'* Me- level, the therapist can adjust the meals by requesting
chanical soft foods reduce the risk of aspiration in pa- one or two items from the higher group, enabling as-
tients who have both a motor and a sensory loss affect- sessment at the new level. This technique is also ap-
ing the start of the swallow response.”*"*? Mechanical propriate for patients who become fatigued. The
soft foods with a density provide increased propriocep- patient is thus able to work with the therapist on the
tive input throughout the mouth. These foods also stay harder food item first and continue the meal with
together as a cohesive bolus rather than crumbling and foods that are easier. The therapist also may consider
falling uncontrolled into the airway. Because patients arranging several small meals throughout the day for
who are at this diet stage display improved tongue the patient who fatigues, rather than three traditional
control, the swallow response may be triggered faster as meals.
the back of the tongue elevates toward the hard palate. A patient should progress to a regular diet when oral
For the patient who is just beginning to chew, mashing motor control is within functional limits, allowing the
the food with a fork enhances the patient's ability to patient to chew and form any consistency into a bolus
keep the food together as a bolus.'® and propel it back toward the faucial arches. The patient
Stage III, chopped ground food items, requires at this level should be able to swallow any food or
chewing, controlled bolus formation, and a fair or liquid consistency with only occasional coughing. Con-
delayed swallow. This food group offers a wider variety tinuing dietary precautions for a patient with a history
 Dysphagia

Dysphagia, Stage I] Food Level (Mechanical Soft)

_ Food Groups Foods Allowed Foods to Avoid
Cooked refined cereals; creamed wheat or rice; Hard rolls; bread with nuts, seeds, coconut, and fruit; bread
Malt-o-Meal; oatmeal; white, wheat, or rye bread with cracked wheat particles; sweet rolls; waffles; Melba
- (without crust or seeds); graham crackers; soft toast; English muffins; popcorn; cereals such as Rice
French toast without crust Krispies, corn flakes, puffed rice
Custard; boiled, poached, and scrambled eggs; All others
minced egg salad (without onions or celery)
Pureed fruit; applesauce; ripe banana and avocado; Fruits with seeds, coarse skins, and fibers; fruits with
de
Al
nated
soft, canned and cooked fruits such as peaches, pits; all raw fruit except those listed as allowed; raisins;
pears, apricots, pitted plums, stewed prunes, grapes; fruit cocktail
grapefruit, and orange sections (no membrane),*
baked apple (no skin), cranberry sauce
~ Potatoes or Mashed potatoes (white or sweet); baked Fried potatoes; potato or corn chips; rice
substitute | - potatoes (no skin); soft noodles, spaghetti,
3 : and macaroni, finely chopped
7
. _ Vegetables Cooked or canned artichoke hearts, asparagus All other raw, stringy, fried, and dried vegetables; pickles
tips, beets, carrots, mushrooms, squash, pumpkin,
green beans, tomato puree and paste (no skins
or seeds)
~ Soups Thickened, strained, cream soups made with All others
pureed allowed vegetables

Meat, fish, Finely ground meat; poultry; tuna (without Fish (because of bones); meat, any consistency
poultry, cheese celery or onions); soft casseroles; soft sandwiches other than finely ground; bacon; all other cheeses
(without crust); cream or cottage cheese;
American cheese
Fats Butter; margarine; cream; mayonnaise mixed Nuts; olives; all other
with food; thick gravy; thick cream sauce
Desserts Plain puddings; custard; tapioca; fruit whip; smooth Cookies; cake with nuts, seeds, raisins, dates, coconuts,
yogurt; soft cake; cream pie with graham cracker and fruits not on allowed list; all others
crust

Sugars and sweets Honey; sugar; syrup; jelly; plain, soft milk chocolate Marmalade; coconut; all others
bars

From American Occupational Therapy Association: AOTA resource guide: feeding and dysphagia, Rockville, Md, 1997, The Association; Avery-Smith W: Occup Ther
Pract 3:10, 1998; Community Hospital of Los Gatos, Rehabilitation Services, Dysphagia protocol, Los Gatos, Calif, 1999; RaderT, Rende B: Swallowing disorders: what
families should know, Tucson, Ariz, 1993, Communication Skill Builders Publishers.
*Allowed only if thin liquids are appropriate.

of dysphagia include avoiding raw vegetables, stringy achieve an added “honeylike” viscosity. A dietitian can
foods, and foods containing nuts or seeds.'’"""'* provide the occupational therapist with specific recipes.
Because a patient may exhibit a difference in ability These substances are usually added to the liquids and
to manage different liquids, a progression of liquid power-blended for smoothness. The thick drink or soup
levels, separate from the solid levels, should be devel- should stay blended and not be allowed to separate or
oped. The liquid progression is divided into three liquefy. Thick liquids are the appropriate choice for pa-
groups: thick, semithick, and thin liquids.'’"’'* Exam- tients with markedly delayed swallow. A thick liquid
ples of liquids in these levels are given in Table 40-8. moves more slowly through the faucial arches, giving
Thick liquids are made by adding such thickening some time for the swallow response to be triggered.
agents as banana, pureed fruit, yogurt, dissolved gelatin, Semithick liquids such as fruit nectars, buttermilk,
baby cereal, cornstarch, or a commercial thickener to tomato juice, and yogurt drinks, which have a natural
 ilFood |EC=WY/-) |(@iate) ) oY-Le re)am ©]ge]U[are))
Food Groups Foods Allowed Foods to Avoid ees
Cereals and Cooked cereals, ready-to-eat cereals* such as Rice Krispies, Hard rolls, bread with nuts, seeds, coconut, — <<
breads corn flakes, puffed rice; pancakes, French toast, white, wheat, and fruit, coarse cereals such as granola, 4
and rye bread (with crust), salt crackers, soda and graham Grapenuts; popcorn
crackers; sweet rolls, English muffins, Melba toast, donuts
Eggs Soft- and hard-boiled, poached, fried, scrambled eggs; egg All others
salad (without onions and celery)

Fruits Banana, avocado: soft, canned, and cooked fruit, ripe fruit Fruits with seeds, coarse skins and fibers, pits;
; fruit cocktail ba
Potatoes or Mashed potatoes (white or sweet), creamed potatoes, Fried potatoes, potato and corn chips,
substitute baked potatoes (without skin), noodles, spaghetti, and rice without gravy
macaroni

Vegetables Cooked and canned vegetables (without skins, seeds, All raw, stringy, fried, and dried vegetables
and stringy fibers), drained
Soups Thickened, creamed soups made with pureed or whole All others
allowed vegetables only*
Meat, fish, Finely diced or minced meat, poultry, tuna (without onions Bacon; fish with bones; poultry with skin
poultry, cheese or celery), flaked fish, fish sticks; soft casseroles, sandwiches,
and cheeses
Fats Butter, margarine, cream, mayonnaise, gravy, cream sauces Nuts; all others
Desserts Soft cookies, cakes, pies, puddings, custard, yogurt Cookies, cake with nuts, seeds, coconuts, and
fruits not on allowed list; hard pies, crusts, and
pastries; all others

Sugars and sweets Honey, sugar, syrup, jelly; plain soft milk chocolate bars Marmalade, coconut; all others

From American Occupational Therapy Association: AOTA resource guide: feeding and dysphagia, Rockville, Md, 1997; Avery-Smith W: An occupational therapist co-
ordinated dysphagia program, Occup Ther Pract 3:10, 1998; Community Hospital of Los Gatos, Rehabilitation Services: Dysphagia protocol, Los Gatos, Calif, 1999;
Curran J: Nutritional considerations. In Groher M, editor: Dysphagia: diagnosis and management, ed 3, Newton, Mass, 1997, Butterworth-Heinemann Publishers;
RaderT,Rende B: Swallowing disorders: what families should know, Tucson, Ariz, 1993, Communication Skill Builders Publishers.
*Allowed only if thin liquids are appropriate.

Thin Liquids Semithick Liquids Thick Liquids

Water Extrathick milkshake Nectar thickened with banana

Coffee, tea Extrathick eggnog Nectar with pureed fruit

Decaffeinated coffee Strained creamed soup Regular applesauce with juice

Milk Tomato juice,
V-8 juice Egsnog with baby cereal

Hot chocolate Plain nectars Creamed soup thickened with mashed potatoes

All fruit juices Yogurt and milk blended Commercial thickener

Broth or consomme

Gelatin dessert

Ice cream

Sherbert

From American Occupational Therapy Association: AOTA resource guide: feeding and dysphagia, Rockville, Md, 1997; Avery-Smith W: An occupational therapist co-
ordinated dysphagia program, Occup Ther Pract 3:10, 1998; Community Hospital of Los Gatos, Rehabilitation Services: Dysphagia protocol, Los Gatos, Calif, 1999;
Curran J: Nutritional considerations. In Groher M, editor: Dysphagia: diagnosis and management, ed 3, Newton, Mass, 1997, Butterworth-Heinemann Publishers;
RaderT,Rende B: Swallowing disorders: what families should know, Tucson, Ariz, 1993, Communication Skill Builders Publishers.

754
 Dysphagia 755

medium viscosity, are used with patients who have a sesses the patient's voice quality upon completion of
moderate swallow delay of 3 to 5 seconds.'****! Thin the swallow.
or low-viscosity liquids, the highest liquid level, require The frequency with which the therapist must check
intact swallowing ability. each component depends on the skill level and per-
formance of the patient. The more difficulty the patient
exhibits, the more frequent the assessment. The thera-
Principles of Oral Feeding
pist may find it necessary to assess after each bite or
The therapist should incorporate certain principles into sip, after a few bites or sips, or after each food item.
the oral feeding program. First, an important aspect of Use of good observational skills allows the therapist to
the oral preparation stage is looking at and reaching for make the appropriate clinical decision. Specific tech-
food. The patient must actively participate in the eating niques for assessment during feeding trials can be
process. Food should be presented within the patient's found in the swallowing assessment section of this
visual field. If the patient has a severe visual field deficit chapter. After completing the feeding process, the
or unilateral neglect, the therapist needs to assist the patient should remain in an upright position for 15 to
patient to scan the plate or tray visually. 30 minutes to reduce the risk of refluxing food and of
When physically possible the patient should be aspirating small food particles that may remain in the
allowed self-feeding. If the patient does not have a throat.'’>""!
normal hand-to-mouth movement pattern, the thera- The therapist also must continue to monitor the
pist must help the patient achieve one by guiding the patient for signs of aspiration while eating and for the
extremity in the correct pattern. Abnormal movement of development of aspiration pneumonia over time. Al-
the upper extremity facilitates abnormal movement in though a conservative estimate of aspiration is 10% of
the trunk, head, face, tongue, and pharynx and de- material swallowed, measurement is difficult while a
creases the patient's functioning. patient eats. Patients vary in the amount of aspiration
If the patient is not capable of self-feeding, the thera- they can tolerate before developing aspiration pneumo-
pist can keep the patient actively involved by allowing nia, according to age, health, and pulmonary status. The
the patient to choose which food or liquid is preferred signs of acute and chronic aspiration were outlined
for each bite. Food is presented by moving the utensil previously.
slowly from the front, toward the mouth, so that the When a patient is participating in oral feedings,
patient can see the food the entire time. The utensil careful monitoring of the nutritional status is neces-
should not be brought in from the side because the sary. The patient's caloric needs are determined by
patient will have less preparation time. The patient the dietitian and the physician and depend on the
should be allowed as much control of the situation as patient's height, weight, activity level, and medical
possible. condition.'**' Fluid intake is monitored by having
The patient should eat in a normal setting, if possi- the physician order a calorie count and a liquid intake
ble. For adults, eating is a social activity shared with and output hydration count (I and O)." Each person
friends and family. The patient can be redirected if dis- who supervises or works with the patient should
tracted and can use environmental cueing when eating record, in percentages, the caloric amount of each
in a dining room with others. Adjustments, such as item the patient eats or drinks. The dietitian converts
eating in the dining room but at a separate table, can be the percentages into a daily calorie total. The patient
made to facilitate patient concentration. The therapist also should be monitored for physical signs of nutri-
must be conscious of how the patient appears to others, tional deficiency and dehydration. These symptoms
and help the patient to eat in a normal manner. are weakness, irritability, decreased alertness, changes
The occupational therapist must continually assess in eating habits, hunger, thirst, decreased turgor, and
the patient's positioning, upper extremity movement, changes in amounts or color of urine.'*7*” If a
muscle tone, oral control, and swallow. The therapist patient is not able to take in the necessary calories
helps the patient perform the task correctly and does (50% of the determined total), supplemental feedings
not allow eating while the patient exhibits an abnor- are necessary to make up the difference." The physi-
mal pattern. If the patient displays poor oral motor cian and dietician decide on the number of supple-
skills, the therapist looks for food pocketing after every mental feedings.
few bites. The rate of the patient's intake is monitored.
The therapist should determine when too much food is Techniques for the Management
in the mouth and when the patient puts food into the
of Dysphagia
mouth before the previous bite has been cleared. The
therapist feels for the swallow with a finger at the Tables 40-9 through 40-12 provide treatment techniques
hyoid notch if the patient displays abnormal laryngeal for the management of dysphagia. These techniques are
tone or a delayed swallow.'**' The therapist also as- not intended to be used in all situations. Each patient
 tment: Oral Preparatory Stage
Structure Symptoms Problem Prefeeding Technique Feeding Technique
Trunk Leaning to one side Decreased trunk tone Facilitate trunk strength Assist patient to hold
Ataxia Exercises at midline correct position; assist
Increased trunk tone Have patient clasp hands, with head control
Poor body awareness lean down, and touch Assist patient to hold
in space foot, middle, other foot; correct feeding position;
rotate trunk with hands provide with perceptual
clasped and shoulders flexed boundary; consider
to decrease or normalize tone _ lateral trunk support

Hips sliding forward out Increased tone in hip See previous entry above Adjust positioning so that
of chair extensors Provide firm seating patient leans slightly
Poor body awareness service forward at hips, arms
in space forward on table
Head Inability to hold head in Decreased tone Facilitate strength through Assist with head control
midline Weakness neck and head exercises
in flexion, extension,
and lateral flexion

Inability to move head Increased tone Tone reduction of head, Assist with head control
Poor range of motion shoulders, and trunk
Facilitate normal movement
Myofascial release techniques
Soft tissue mobilization
Upper extremity — Spillage of food from Decreased tone Facilitate increased tone Guide patient through
utensils Apraxia through weight bearing, correct movement pattern
Decreased sweeping, or tapping Provide adaptive
coordination muscle belly of desired equipment or utensils as
muscle needed

Inability to self-feed Increased tone Reduce proximal tone with Guide patient through
Abnormal movement scapula mobilization, correct movement pattern
patterns weight bearing through Provide adaptive
Weakness or arm equipment or utensils as
decreased motor Strengthening exercises needed
control Facilitation of normal
movement

Face Drooling, food spillage Decreased lip control Place a wet tongue blade Using side handgrip for
from mouth Poor lip closure between patient's lips; head control, the therapist
secondary to decreased ask patient to hold approximates lip closure
tone, poor sensation tongue blade while by guiding and assisting
Apraxia therapist tries to pull it with jaw closure
out Have patient use a straw
Vibrate lips with back of when drinking liquids
electric toothbrush down until control improves
cheek and across lips Place food to unimpaired
Lip exercises: movements side
described in outer oral Use cold food or liquids
motor evaluation;
patient performs
repetitions 2-3 times daily
Blow bubbles into glass of
liquid with straw

From American Occupational Therapy Association: Am | Occup Ther, 1996; Avery-Smith W: Management of neurologic disorders: the first feeding session. In Groher
M, editor: Dysphagia; diagnosis and management, ed 3, Newton, Mass, |997, Butterworth-Heinemann Publishers; Bobath B: Adult hemiplegia: evaluation and treatment,
ed 2, London, !978, William Heinemann Medical Books; Community Hospital of Los Gatos, Rehabilitation Services:-Dysphagia protocol, Los Gatos, Calif, 1999;
Coombes K: Swallowing dysfunction in hemiplegia and head injury. Course presented by International Clinical Educators, Aug 24-27, 1986, and Aug 24-28, 1987, Los
Gatos, Calif; Davies P: Steps to follow, New York, 1985, Springer-Verlag; Farber S: Neurorehabilitation: amultisensory approach, Philadelphia, 1982, VB Saunders; Loge-
mann J:Manual for the videofluorographic study of swallowing, ed 2, Austin, Tex, 1993, Pro-Ed Publishers.

756
 Dysphagia

Dysphagic Treatment: Oral Preparatory Stage

cture — Symptoms Problem Prefeeding Technique Feeding Technique
Decreased sensation Fan lips so that patient Teach patient to pat mouth
feels drool or wetness on (versus wiping mouth)
lips or chin to increase and chin every few bites
awareness or sips
Pocketing of food in Poor tongue control for Tongue exercises: use Avoid crumbly foods
‘ cheeks or sulci lateralization or tipping movements described in Stroke patient's outside
ie Poor bolus formation Decreased tone inner oral motor cheek where pocketing
Poor sensation evaluation occurs with index finger
back and up toward
patient's ear; instruct
patient to check cheek for
pocketing
Retracted tongue Increased tone Tongue range of motion: Avoid crumbly foods
Retracted jaw wrap tip of tongue in, Reduce tone as needed
wet gauze; gently pull » during meal
tongue forward, side to Double swallow
side and up and down; Resist head flexion to
move slowly facilitate jaw closure
Pull tongue wrapped in Resist head extension to
wet gauze forward past facilitate Jaw opening
front teeth, using index
and middle finger to
vibrate tongue back
and forth sideways
to decrease tone
and facilitate
protrusion

From American Occupational Therapy Association: Am | Occup Ther, 1996; Avery-Smith W: Management of neurologic disorders: the first feeding session. In Groher
M, editor: Dysphagia: diagnosis and management, ed 3, Newton, Mass, 1997, Butterworth-Heinemann Publishers; Bobath B: Adult hemiplegia: evaluation and treat-
ment, ed 2, London, |978, William Heinemann Medical Books; Community Hospital of Los Gatos, Rehabilitation Services: Dysphagia protocol, Los Gatos, Calif, 1999;
Coombes K: Swallowing dysfunction in hemiplegia and head injury. Course presented by International Clinical Educators, Aug 24-27, 1986, and Aug 24-28, 1987, Los
Gatos, Calif, Davies P: Steps to follow, New York, 1985, Springer-Verlag; Farber S: Neurorehabilitation: a multisensory approach, Philadelphia, 1982, VB Saunders; Loge-
mann J:Manual for the videofluorographic study of swallowing, ed 2, Austin, Tex, 1993, Pro-Ed Publishers.

presents a different clinical picture and may display one facilitating the return of normal eating patterns in
deficit or a combination of deficits. After careful assess- each patient.
ment the therapist must determine the primary cause of Ongoing assessment of treatment by the therapist is
the patient's deficits, and treat accordingly. The patient essential. The therapist must continually assess the
must be assessed and treated as a whole person, rather patient's response, which should reflect desired change.
than treated as a person with a single deficit. Therefore the therapist must develop good clinical ob-
Treating a patient with dysphagia requires a logical servation skills.*!**! The clinician needs to adapt treat-
and consistent approach.*’? Abnormal tone, for ment to performance and progress. For difficult patients
example, should be normalized before the therapist the clinician should seek a consultation with an experi-
can expect good motor control. Motor control must enced dysphagia therapist. To develop expertise in dys-
be improved before a patient can shape food into a phagia management, it is recommended that the thera-
cohesive bolus and achieve an effective swallow. Indi- pist continue education in this area.
vidualized prefeeding techniques can prepare the
patient for eating. The therapist should strive toward Text continued on p. 762
 a ment: Oral Stage
Structure Symptoms Problem Prefeeding Techniques Feeding Technique

Tongue Slow oral transit Poor anterior to Practice “'ng-ga’ sounds Tuck chin toward chest
Tongue retraction _ posterior movement; Grasping tongue wrapped Position food in center,
decreased tone, poor in gauze, pull tt forward midtongue
sensation past front teeth; use Avoid crumbly foods
Increased tone finger or tongue blade to Use cold or hot foods
vibrate base of tongue instead of warm
back and forth sideways Correct positioning
Improve tongue range of Place index finger at
motion base of tongue
under chin; stroke
up and forward

Slow oral transit Inability to form central Grasping tongue wrapped Tuck chin toward chest
time groove in tongue in gauze, pull forward to Position food in center,
Inability to Apraxia front teeth; stroke firmly midtongue
channel food back down middle of tongue Avoid crumbly foods
toward pharynx with edge of tongue Use cold or hot foods
blade instead of warm
Correct positioning
Place index finger
at base of tongue
under chin; stroke
up and forward

Repetitive movement Tongue thrust Facilitate tongue retraction Correct positioning

of tongue; food to bring tongue back Place food away from
is pushed out front into normal resting midline of tongue
of mouth position; vibrate on toward back of mouth
either side of the Provide downward and
frenulum found inside forward pressure to
the mouth, under the back of tongue with
tongue with finger spoon after food
Increase jaw control; teach placement
isolated tongue movements

Food falls off tongue Poor sensation Ice tongue with ice chips Use foods with high
into sulci or food placed in gauze to viscosity or density
remains on tongue prevent ice chips from Alternate presentation of
without patient slipping into pharynx cold and hot foods
awareness Brush tongue with during meal
toothbrush to stimulate
receptors

From Community Hospital of Los Gatos, Rehabilitation Services: Dysphagia protocol, Los Gatos, Calif, 1999; Coombes K: Swallowing dysfunction in hemiplegia and
head injury. Course presented by International Clinical Educators, Aug 24-27, 1986, and Aug 24-28, 1987, Los Gatos, Calif, Davies P: Steps to follow, New York,
1985, Springer-Verlag; Farber S: Neurorehabilitation: a multisensory approach, Philadelphia, 1982, WB Saunders; Logemann J: Evaluation and Treatment of Swallowing
Disorders, ed 2, Austin, Tex, 1998, Pro-Ed Publishers; Martin BJW: Treatment of dysphagia in adults. In Cherney L, editor: Clinical management of dysphagia in adults —
and children, Gaithersburg, Md, 1994, Aspen Publishers; Silverman EH, Elfant IL: Am J Occup Ther, 1979.

758
 Dysphagic Treatment: Oral Stage
pace
Symptoms Problem Prefeeding Techniques Feeding Technique

~ Slow oral transit time; Poor tongue elevation; Ask patient to practice Correct positioning
food remains on hard _ decreased tone AG ee ued. and With finger under chin at
palate; coughing before “t’ sounds base of tongue, move
swallow Lightly touch tongue blade finger upward and
or soft toothbrush to forward to facilitate
roof of mouth at back of elevation
tongue, instruct patient Avoid crumbly foods
to press spot with Double swallow
tongue; resist movement
with blade or brush to
increase strength
Vibrate tongue at
base below chin;
provide quick stretch
by pushing down on
base of tongue
Slow oral transit time Decreased sensation Tone reduction; grasping Adjust correct positioning
Food remains on back Increased tone tongue with gauze by increasing forward
of tongue as patient is Decreased range of wrapped around tip, pull flexion at hips, arms
unable to elevate motion tongue forward with forward to decrease tone
tongue to push food Soft tissue shortening finger or tongue blade Reduce tone as needed;
to hard palate Apply pressure to base of give patient breaks
Coughing before the tongue right to left because tone increases
swallow Grasping base of tongue with effort
Retracted tongue under chin between two With finger under chin at
fingers, move it back base of tongue, move
and forth to decrease finger upward and
tone forward to facilitate
Tone reduction tongue elevation
Range of motion exercises
Place a variety of tastes on
lips to facilitate tongue-
licking lips

From Community Hospital of Los Gatos, Rehabilitation Services: Dysphagia protocol, Los Gatos, Calif, 1999; Coombes K: Swallowing dysfunction in hemiplegia and
head injury. Course presented by International Clinical Educators, Aug 24-27, 1986, and Aug 24-28, 1987, Los Gatos, Calif; Davies P: Steps to follow, New York,
1985, Springer-Verlag; Farber S: Neurorehabilitation: a multisensory approach, Philadelphia, 1982, WB Saunders; Logemann J: Evaluation and Treatment of Swallowing
Disorders, ed 2, Austin, Tex, 1998, Pro-Ed Publishers; Martin BJW: Treatment of dysphagia in adults. In Cherney L, editor: Clinical management of dysphagia in adults
and children, Gaithersburg, Md, 1994, Aspen Publishers; Silverman EH, Elfant IL: Am J Occup Ther, 1979.

759
 atment: Pharyngeal Stage
Structure Symptoms Problem Prefeeding Technique Feeding Technique t

Soft palate Tight voice; nasal Increased tone Facilitate normal Facilitate normal head and —
regurgitation Decreased tone head/neck positioning neck positioning
Air felt through nose or Rigidity Have patient tuck chin into With head and neck in
mist seen on mirror when therapist's cupped hand, midline, have patient
patient says “ah” then push into hand as tuck chin slightly to
Decreased tone therapist applies decrease rate of food
Nasal speech resistance; patient says, entering into pharynx
“ah” afterward; speed
and height of uvula
elevation should increase;
follow by thermal
application

Delayed swallow Decreased triggering of Thermal application: using Alternate presentation of

swallow response a laryngeal mirror #00 food; start very cold
after being placed in ice substance, then warm;
water or chips for 10 cold substance can
seconds, touch base of increase sensitivity of
faucial arch; repeat up to faucial arches; tuck chin
10 times; process can be slightly forward to
repeated several times prevent bolus entering
a day airway

Hyoid Delayed elevation of hyoid Delayed swallow Increase tongue humping Place index finger under
bone Incomplete swallow as elevation of tongue and chin at base of tongue
Poor tongue elevation hyoid stimulates and push up forward to
triggering of response facilitate tongue
elevation

Tongue retraction Abnormal tongue tone; Tone reduction

poor range of motion

Pharynx Coughing after swallow Decreased pharyngeal None lf appropriate, alternate

movement presentation of liquid
Penetration into laryngeal with stage Il or stage III
vestibule solids; liquid material
moves solids through
pharynx

Coating of pharynx seen Pharyngeal weakness Isometric or resistive head Have patient take second
on videofluoroscopy and neck exercises dry swallow to clear
Gurgling voice valleculae and pyriform
sinuses
Tilt head to stronger
side
Supraglottic swallow

From Community Hospital of Los Gatos, Rehabilitation Services, Dysphagia protocol, Los Gatos, Calif, 1999; Coombes K: Swallowing dysfunction in hemiplegia and
head injury. Course presented by International Clinical Educators, Aug 24-27, 1986,
and Aug 24-28, 1987, Los Gatos, Calif; Davies P: Steps to follow, New York, 1985,
Springer-Verlag; Kaatzke-McDonald M, Post E, Davis P: Dysphagia, 1996; Logemann J: Evaluation and treatment of swallowing disorders, Austin, Tex, 1998, Pro-Ed Pub-
lishers; Martin BJW: Treatment of dysphagia in adults. In Cherney L, editor: Clinical
management of dysphagia in adults and children, Gaithersburg, Md, 1994, Aspen
Publishers; Schulze-Delrieu K, Miller R: Clinical assessment of dysphagia. In PerlmanA, Schulze-Delrieu, editors: Deglutition and its disorders: anatomy, physiology, clini-
cal diagnosis and management, San Diego, Calif, 1997, Singular Publishing; Smith C, Logemann J, Colangelo L, et al: Dysphagia |4(1):1-7, 1999.

760
 Dysphagia Treatment: Pharyngeal Stage
_ Symptoms Problem Prefeeding Technique Feeding Technique

Seen on videofluoroscopy, Unilateral pharyngeal None Compensatory technique

anteroposterior view; movement for patients with low
~ material residue seen on tone: have patient turn
one side; weak or hoars head toward affected
voice side during swallow to
prevent pooling in
affected pyriform
sinuses; evaluate
technique against tts
effect on patient
positioning and tone in
trunk, upper extremities
Larynx Coughing, choking after Decreased laryngeal Quickly ice up sides of Teach patient to clear
swallow elevation larynx; ask patient to throat immediately after
Decreased tone swallow; assist movement swallow to move
Weakness by guiding larynx upward residual
Vibrate laryngeal Use supraglottic swallow,
musculature from under Mendelsohn maneuver
chin, downward on each effortful swallow
side to sternal notch

Noisy or audible swallow Increased tone Range of motion—place Placing fingers and thumb
Rigidity fingers and thumb along along both sides of
Uncoordinated swallow both sides of larynx and larynx, assist patient
gently move it back and with upward elevation
forth until movement is before swallow
smooth and easy, tone Double swallow
decreased
~~,

Using chipped ice, form

pack in washcloth and
place around larynx for
5 min

Trachea Continuous coughing Aspiration—before: poor Teach patient how to Encourage patient to keep
before, during, after tongue control; during: produce a voluntary . coughing; facilitate
swallow delayed swallow cough; ask patient to take reflexive cough; push
response; after: a deep breath and cough downward on sternum
decreased pharyngeal while breathing out; as patient breathes out;
movement therapist uses palm of suction patient if
hand to push downward problem increases
(toward stomach) on the Push into patient's sternal
sternum notch to assist with
cough

Patient grabs or reaches Blocked airway None Perform Heimlich

for throat maneuver
Reddening in the face Seek medical assistance
No voice or cough

From Community Hospital of Los Gatos, Rehabilitation Services, Dysphagia protocol, Los Gatos, Calif, 1999; Coombes K: Swallowing dysfunction in hemiplegia and
head injury. Course presented by International Clinical Educators, Aug 24-27, 1986, and Aug 24-28, 1987, Los Gatos, Calif; Davies P: Steps to follow, New York, 1985,
Springer-Verlag; Kaatzke-McDonald M, Post E, Davis P: Dysphagia, 1996; Logemann J:Evaluation and treatment of swallowing disorders, Austin, Tex, 1998, Pro-Ed Pub-
lishers; Martin BJW: Treatment of dysphagia in adults. In Cherney L, editor: Clinical management of dysphagia in adults and children, Gaithersburg, Md, 1994, Aspen
Publishers; Schulze-Delrieu K, Miller R: Clinical assessment of dysphagia. In Perlman A, Schulze- Delrieu, editors: Deglutition and its disorders: anatomy, physiology, clini-
cal diagnosis and management, San Diego, Calif, |997, Singular Publishing; Smith C, Logemann J, Colangelo L, et al: Dysphagia |4(1):1-7, 1999.
 TREATMENT APPLICATIONS

nagia Treatment: Esophageal Stage

Structure Symptoms Problem Prefeeding Technique Feeding Technique
Esophagus Frequent regurgitation of Esophageal diverticulum Requires a medical Report symptoms to —
food or liquid and diagnosis; problem can be medical staff (therapist
coughing or choking seen through traditional cannot treat)
after the swallow: barium x-ray examination
material collecting in a Surgical correction is
side pocket in esophagus needed ;
Regurgitation of food, Partial or total obstruction Requires a medical Report symptoms to eS
coughing, or choking on of the pharynx or diagnosis; problem can be medical staff (therapist
food after the swallow: esophagus seen through traditional cannot treat) n
inability of food to pass Impaired esophageal barium x-ray examination
through the pharynx, peristalsis Surgical correction Is
esophagus, or stomach needed

From Coombes K;: Swallowing dysfunction in hemiplegia and head injury. Course presented by International Clinical Educators, Aug 24-27, 1986, and Aug 24-28, 1987,
Los Gatos, Calif; Davies P: Steps to follow, New York, 1985, Springer-Verlag; Logemann J: Evaluation and treatment of swallowing disorders, Austin, Tex, 1998, Pro-Ed
Publishers; Smith C, Logemann J, Colangelo L, et al: Dysphagia, 1999; Martin B: Treatment of dysphagia in adults. In Cherney L, editor: Clinical management of dys-
phagia in adults and children, Gaithersburg, Md, 1994, Aspen. Workman J, Pillsbury H, Hulka G: Surgical interventions in dysphagia. In Groher M: Dysphagia: diagnosis
and management, ed 3, Newton, Mass, |977, Butterworth-Heinemann.

as vice president of a local marketing company. Mr.B. lives with his

SUMMARY wife. He and his wife have two grown children living in the area.
Eating is the most basic activity of daily living. Several Before the onset of the CVA, Mr B. was independent in all activi-
performance components are required for the patient to ties of daily living and instrumental activities ofdaily living. He was
an active member of the community.
eat and swallow effectively. Dysphagia refers to difficulty
Results of the occupational therapy evaluation indicate that
with swallowing or an inability to swallow. The occupa-
Mr. B. needs moderate to maximum assistance in dressing, toilet-
tional therapist is trained to treat many of the problems ing, bathing, eating and swallowing, and transfers.
that interfere with normal eating. An understanding of The clinical assessment of eating indicates that the patient has a
the normal anatomy of swallowing and special training mild to moderate increase in jaw and facial tone with poor rotary
are required to treat dysphagia. chew, poor isolated tongue control, and mild increase in laryngeal
Assessment of the patient with dysphagia includes tone with delayed swallow.
testing of head and trunk control, sensation, perception, The videofluoroscopy confirmed that the patient had a mildly
cognition, inner and outer oral structures, oral reflexes, delayed swallow with minimal pooling in the valleculae and pyri-
and swallowing. Assessment may also include videoflu- form sinuses. Aspiration was less than 10% on pureed foods. The
oroscopy or fiberoptic endoscopy. patient was seen three times a day for 6 weeks by occupational
Several members of the rehabilitation team are in- therapy. A summary of evaluation results and treatment plan are
shown in Fig. 40-8.
volved in the treatment of the patient with dysphagia.
The patient responded well to treatment. The G tube was
Positioning, selection of appropriate feeding proce-
removed after 5 weeks. The patient achieved all treatment goals
dures, diet selection, diet progression, and special tech- by the time of discharge. He went home with family supervision
niques to facilitate normal patterns of swallowing are for correct diet, positioning, and swallowing techniques during
part of the treatment program. The social and psycho- meals. The patient was referred to home health occupational
logical aspects of eating are important considerations in therapy for 2 to 3 weeks for activities of daily living and home
the treatment program. modification so that independence at home could be achieved.
The patient returned for follow-up outpatient visits.

Pana i a
CASE STUDY 40-|
Case Stupy: Mr. B.
Mr. B. is a 65-year-old man who suffered a right cerebrovascular
accident (CVA) with left hemiplegia 2 weeks ago. He has a G
tube in place for nutrition. He recently retired from his position
 Dysphagia Evaluation and Treatment Plan

py: OF _ male
i iia
Onset: __Z weeks ago
ee tical hx: Elevated BP — 5 years, Elevated blood lpide, Otherwise
unremarkable, (ndependent in AVL ADL rior Co onget

Current nutritional status: 03572, G

Adequate—
without
WNL assistance Unable Comments
Mental status: oflented To Name,
Alert/oriented ak &55/S7 fal Ja
Direction following DP raatD GS, G

Physical status (symmetry, control, tone):

Head control
Trunk control
Endurance
Respiratory
Suctioning required
Tracheostomy

Outer oral status:

Facial expressions Sat affect =9¢t'/ tane to
mModesase AYLCE

a re
Jaw movement

Le F

ae | at
Lip movement

Sensation

Abnormal reflexes

Inner oral status (symmetry, control, tone):

Dentition 00d, Hightle mtlammed 94 ms
Tongue sloht white coating ¢ mid & Tongue
Appearance [aterarion
Tone assist |__| [4
Y=©retraction
CTL ACTiO
Movement: Protrusion a neared fe Rates Ves, A
Lateralization emelesraasr | Mild Wwe e168
WW
ng’ um —"“ga
WW um

Soft palate /gag reflex: a mena

avula. rises symmetr, oc

Cough (reflexive
/voluntary):

Swallow:
Spontaneous
Voluntary rt er
Laryngeal movement
Tongue Z455/ST nea Yone reduction
Elevation ZASSI swe {lows
ange factor after setial
Overt Poctiolte
ie vd cogm/pye wweare-
Food management: Ness aefood(n moath ¢ PEGUITES cueing
Puree DT Uses Suck- swallou
Mechanical soft eer les chev es gssisferi | ip |
Chopped/ground pecans serewer tho Cedéa '2 feTary chew
Regular diet J. lS ee ee
eesThin
Semithick |TC assist
OS
ae
an
cap ep —
FIG. 40-8
Case study: dysphagia evaluation and treatment plan. Continued
764 TREATMENT APPLICATIONS

Dysphagia Evaluation and Treatment Plan

Major problems:

O vd cognitn tor attention and awareness of food in mouth 5 cueing.

@ td yaw 4 fecial tone resulting in peor rotary chew:
@ Poot jscleted foxgue movements tor lateralization , humping .
@ tel laryngeal tone tesditing in layed staffed.
© "Pool siting bafanee.

Recommendations/ treatment plan:

(positioning, diet level, environment, techniques)

O Psitioning -apright en solid seating urtace, ght foraard (an.

@ Tone reduction techniques Porjaw, tongye, é larynr before ¢ dating mer/.
@ Diet beve/- pureed ¢ mechan/ca/ soft foods, thekened higards 2x ily & hel Apist only.
GD Therapeanic feeding M MET setting.
© No foodof ligatd Mm Dis. 00m
@ Momter patient for signs of Aspiration.
@ Videot/acrascopy for confirmation
Long-term goals:

O Independent Trank and head copfrel far self feeading.

@ tatention and awareness of feod 1k meth To WPL.
@ ti'soleted motor contro! of facial exptession To WHE:
@ tysoleted motor contro/ ofjaw, Tongue, 4 larWNk fo WL.
® 4 oral intake for sods From pureed 7 leg
lar net tor all meals with family Supervision.
@ f oral intake for hguids trom Thick To thin
@® Calorie and hydration count, wean from gastrostomy.
OC) Family © i swaflowing £ det follow through.

FIG. 40-8—cont’d
Case study: dysphagia evaluation and treatment plan.

REVIEW QUESTIONS
5. Describe what the therapist should look for when
1. List the components of dysphagia. evaluating the trunk and head during the dysphagia
2. List the four stages of swallowing and the character- evaluation.
istics of each. . What information can the therapist gain when as-
. List the physiological functions that occur when the sessing the patient's facial motor control?
swallow response triggers, and explain why these . How does poor tongue control contribute to aspira-
functions are necessary. tion?
. Why is it necessary to assess a patient's mental . Name the components required to protect the
status during a dysphagia evaluation? airway.
 Dysphagia 765

9. What is the safest food sequence to follow for a . Bass N: The neurology of swallowing. In Groher M, editor: Dys-
swallowing evaluation? phagia: diagnosis and management, ed 3, Newton, Mass, 1997, But-
terworth-Heinemann.
10. Describe the finger placement that a therapist can
. Bobath B: Adult hemiplegia: evaluation and treatment, ed 2, London,
use to feel the strength and smoothness of the 1978, William Heinemann Medical Books.
swallow. . Buchholz D, Bosma J, Donner M: Adaption, compensation, and
11. Why should the therapist assess voice quality after a decompensation of the pharyngeal swallow, Gastrointest Radiol
swallow? 10(3):235-239, 1985.
10. Cherney L, Pannell J, Cantieri C: Clinical evaluation of dysphagia.
12. Will a patient who has difficulty handling solids
In Cherney L, editor: Clinical management of dysphagia in adults and
also have difficulty with liquids? children, Gaithersburg, Md, 1994, Aspen Publishers.
13. What options does the occupational therapist have . Community Hospital of Los Gatos, Rehabilitation Services: Dys-
when a patient coughs? phagia protocol, Los Gatos, Calif, 1999.
14. List the indicators of swallowing dysfunction. ips Conklin JL: Control of esophageal motor function, Dysphagia

15. List the acute symptoms of aspiration. 8(4):311-317, 1993.

Lys Coombes K: Swallowing dysfunction in hemiplegia and head injury.
16. When is videofluoroscopy necessary? Course presented by International Clinical Educators, Aug 24-27,
17. List the elements in treatment of the patient with 1986, and Aug 24-28, 1987, Los Gatos, Calif.
dysphagia. 14. Curran J: Nutritional considerations. In Groher M, editor:
18. Describe the position in which a patient should be Dysphagia: diagnosis and management, ed 3, Newton, Mass, 1997,
Butterworth-Heinemann.
treated, and give the rationale for this position.
15. Curtis D, Cruess D, Wilgress E: Normal solid bolus swallowing:
19. What are the indications for placing a patient on a erect position, Dysphagia 1:63, 1986.
nonoral treatment program? 16. Davies P: Steps to follow, New York, 1985, Springer-Verlag.
20. Name five important criteria a patient must meet to Le Farber S: Neurorehabilitation: a multisensory approach, Philadelphia,
participate in an oral feeding program. 1982, WB Saunders.
To Fleming S.: Treatment of mechanical swallowing disorders. In
21. List the properties of food preferred for diets for pa-
Groher M, editor: Dysphagia: diagnosis and management, ed 3,
tients with dysphagia. Newton, Mass, 1997, Butterworth-Heinemann Publishers.
22. Describe the effect that poor hand-to-mouth move- 19): Griggs B: Nursing management of swallowing disorders. In
ments have on the patient's swallow. Groher M, editor: Dysphagia: diagnosis and management, ed 3,
23. Why is it important to involve the patient in the Newton, Mass, 1997, Butterworth-Heinemann Publishers.
20. Groher M: Bolus management and aspiration pneumonia with
eating process?
pseudobulbar dysphagia, Dysphagia 1:215, 1987.
24. What are the symptoms of nutritional deficiency? 2 Groher M: Ethical dilemmas in providing nutrition, Dysphagia
25. Describe two possible treatment techniques used 5(2):102-109, 1990.
for a patient who displays a masked appearance. 22, Groher M: Establishing a swallowing program. In Groher M,
26. Name three treatment techniques the occupational editor: Dysphagia: diagnosis and management, ed 3, Newton, Mass,
1997, Butterworth-Heinemann Publishers.
therapist can use for poor rotary jaw movement and 25) Hendrix TR: Coordination of peristalsis in pharynx and esopha-
increased tone. wey gus, Dysphagia 8(2):74-78, 1993.
27. Describe two ways a therapist can decrease abnor- 24. Hiiemae K, Palmer JB: Food transport and bolus formation during
mally high tone in the tongue. complete feeding sequences on foods of different initial consis-
28. Describe thermal application as a treatment tech- tency, Dysphagia 14(1):31-42, 1999.
205 Hislop H, Montgomery J, Connelly B: Daniels & Worthington’s
nique. For which problem is it used? muscle testing: techniques of manual examination, ed 6, Philadelphia,
29. When is use of the dry swallow technique appro- 1995, WB Saunders.
priate? 26. Kaatzke-McDonald M, Post E, Davis P: The effects of cold , touch
30. How can the therapist facilitate a cough? and chemical stimulation ofthe anterior faucial pillar on human
swallowing, Dysphagia 11(3):198-206, 1996.
ie Kahrilas PJ: Pharyngeal structure and function, Dysphagia 8(4):
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uation protocol, Berkeley, Calif, 1999, the Hospital. and endoscopic examination of pharyngeal swallowing. In
2. American Occupational Therapy Association: AOTA resource guide: Perlman A, Schulze-Delrieu K, editors: Deglutition and its disorders:
feeding and dysphagia, Rockville, Md, 1997, The Association. anatomy, physiology, clinical diagnosis, and management, San Diego,
3. American Occupational Therapy Association: Eating dysfunction: Calif, 1997, Singular Publishing.
position paper, Am J Occup Ther 50(10):846-847, 1996. 2D! Leder S, Sasaki C, Burrell M: Fiberoptic endoscopic evaluation of
4. Avery-Smith W: An occupational therapist coordinated dysphagia dysphagia to identify silent aspiration, Dysphagia 13(1):19-21,
program, Occup Ther Pract 3(10):20-23, 1998. 1998.
5. Avery-Smith W: Management of neurologic disorders: the first 20; Liebman M: Neuroanatomy made easy and understandable, Rockville,
feeding session. In Groher M, editor: Dysphagia: diagnosis and man- Md, 1986, Aspen Publishers.
agement, ed 3, Newton, Mass, 1997, Butterworth-Heinemann. Sale Logemann J: Evaluation and treatment of swallowing disorders,
6. Avery-Smith W, Dellarosa D: Approaches to treating dysphagia Austin, Tex, 1998, Pro-Ed Publishers.
in patients with brain injury, Am J Occup Ther 48(3):235-239, B2e Logemann J: Manual for the videofluorographic study of swallowing,
1994. ed 2, Austin, Tex, 1993, Pro-Ed Publishers.
766 TREATMENT APPLICATIONS

33: Martin BJW: Treatment of dysphagia in adults. In Cherney L, 38. Schulze-Delrieu K, Miller R: Clinical assessment of dysphagia. In
editor: Clinical management of dysphagia in adults and children, Perlman A, Schulze-Delrieu K, editors: Deglutition and its disorders:
Gaithersburg, Md, 1994, Aspen Publishers. anatomy, physiology, clinical diagnosis and management, San Diego,
34. Miller A, Bieger D, Conklin JL: Functional controls of deglutition. Calif, 1997, Singular Publishing.
In Perlman A, Schulze-Delrieu K, editors: Deglutition and its disor- 35: Silverman EH, Elfant IL: Dysphagia: an evaluation and treatment
ders: anatomy, physiology, clinical diagnosis, and management, San program for the adult, Am J Occup Ther 33(6):382-392, 1979.
Diego, Calif, 1997, Singular Publishing. 40. Smith C, Logemann J, Colangelo L, et al: Incidence and patient
35). Miller R: Clinical examination for dysphagia. In Groher M: Dys- characteristics associated with silent aspiration in the acute care
phagia diagnosis and management, ed 3, Newton, Mass, 1997, But- setting, Dysphagia 14(1):1-7, 1999.
terworth-Heinemann Publishers. 41. Stone M, Shawker T: An ultrasound examination of tongue move-
36. Netter FE, Dalley A: Atlas of human anatomy, ed 2, 1998, Ciba-Geigy ment during swallowing, Dysphagia 1(2):78-83, 1986.
Corp. 42. Workman J, Pillsbury H, Hulka G: Surgical interventions in dys-
ST. Rader T, Rende B: Swallowing disorders: what families should know, phagia. In Groher M: Dysphagia: diagnosis and management, ed 3,
Tucson, Ariz, 1993, Communication Skill Builders Publishers. Newton, Mass, 1977, Butterworth-Heinemann Publishers.
 «4d
Spinal Cord Injury

LEARNING OBJECTIVES
Quadriplegia After studying this chapter the student or practitioner
Tetraplegia will be able to do the following:
Paraplegia 1. Understand the difference between complete and
ASIA impairment scale incomplete spinal cord injury and the classification
Neurological classification system used to describe such levels of injury.
Decubitus ulcer 2. Recognize and identify the various spinal cord
Vital capacity injury syndromes.
Hypotension 3. Briefly describe the medical and surgical
Autonomic dysreflexia management of the individual who has experienced
Spasticity a traumatic spinal cord injury.
Heterotopic ossification 4. Identify some of the complications that can limit
Tenodesis optimal functional potential.
Durable medical equipment 5. Describe the changes in sexual functioning in males
Rehabilitation technology supplier and females after spinal cord injury.
6. Identify the specific assessment tools that must be
considered before developing treatment objectives.
~
7. Analyze the critical issues in what to consider when
developing treatment objectives during the acute,
active, and discharge phases of the rehabilitation
process.
8. Identify in detail the functional outcomes, including
equipment considerations and attendant care needs,
that can be reached at each level of complete injury
under optimal circumstances.
9. Analyze how the normal aging process is accelerated
by the effects of spinal cord injury and explain how
functional status may change.

i of the individual with a spinal cord therapists provide their patients with the tools and re-
injury (SCI) is a lifelong process that requires readjust- sources needed to achieve their maximal physical and
ment to nearly every aspect of life. Occupational thera- functional potential.
pists play a significant role in physical and psychosocial Spinal cord injuries have many causes. Trauma is the
restoration and help the individual achieve maximum most common cause. Trauma can result from motor
independence. Through accurate assessment, retraining, vehicle accidents, violent injuries such as gunshot
and adaptive techniques and equipment, occupational and stab wounds, falls, sports accidents, and diving

Ra hi
768 TREATMENT APPLICATIONS

accidents.”!* Normal spinal cord function may also be

disturbed by diseases such as tumors, myelomeningo-
cele, syringomyelia, multiple sclerosis, and amyotrophic Brain
lateral sclerosis. Some of the treatment principles out-
lined in this chapter may have application to these con-
ditions; however, the emphasis is on rehabilitation of
the individual with a traumatic spinal cord injury.
Head
and neck
RESULTS OF SPINAL CORD INJURY Diaphragm
Deltoids, biceps
Spinal cord injury results in quadriplegia (more re- Wrist extensors
cently labeled tetraplegia by the American Spinal Cord Spinal
pret Triceps
Injury Association) or paraplegia. Tetraplegia is any
degree of paralysis of the four limbs and trunk muscula- Hand
ture. There may be partial upper extremity (UE) func-
Chest
tion, depending on the level of the cervical lesion. Para- muscles
plegia is paralysis of the lower extremities (LEs) with
some involvement of the trunk, depending on the level
of the lesion." Abdominal
Spinal cord injuries are referred to in terms of the muscles
regions (cervical, thoracic, and lumbar) of the spinal
cord in which they occur and the numerical order of the
Cauda
neurological segments. The level of spinal cord injury equina
designates the last fully functioning neurological Leg
segment of the cord. For example, C6 refers to the sixth muscles

neurological segment of the cervical region of the

spinal cord as the last fully intact neurological seg-
ment.”’'? Complete lesions result in the absence of
Bowel,
motor or sensory function of the spinal cord below the bladder, sex
level of the injury. Incomplete lesions may involve
several neurological segments, and some spinal cord
function may be partially or completely intact.*’'* For
example, C5-6 refers to C5 as being the last intact neu-
rological level and C6 as having incomplete innervation
of musculature and absence of neurological function FIG. 41-1
Spinal nerves and major areas of body they supply. (From Paulson
below C6.
S, editor: Santa Clara Valley Medical Center spinal cord injury home
care manual, ed 2, San Jose, Calif, 1994, Santa Clara Valley Medical
Complete Versus Incomplete Center.)
Neurological Classifications
The extent of neurological damage depends on the loca- ASIA classification C indicates an incomplete lesion
tion and severity of the injury (Fig. 41-1). In a complete with motor function below the neurological level
injury, total paralysis and loss of sensation result from a and the majority of key muscles below the level
complete interruption of the ascending and descending having a grade less than 3.
nerve tracts below the level of the lesion. In an incom- ASIA classification D indicates an incomplete lesion
plete injury there is some degree of preservation of the with motor function preserved below the neuro-
sensory or motor nerves below the lesion. logical level and the majority of key muscles below
The Frankel classification scale** has been replaced the level having a muscle grade of 3 or greater.
by the American Spinal Injury Association (ASIA) Im- ASIA classification E indicates that motor and sensory
pairment Scale’: functions are normal.’
ASIA impairment scale classification A indicates a com- Incomplete injuries are categorized according to the
plete lesion; there is no motor or sensory function area of damage: central, lateral, anterior, or peripheral.
preserved in the sacral segments S4-5.
ASIA classification B indicates an incomplete lesion in Central Cord Syndrome
which only sensation is present below the neuro- Central cord syndrome occurs when there is more cel-
logical level, including the sacral segments S4-5. lular destruction in the center of the cord than in the
 Spinal Cord Injury 769

periphery. Paralysis and sensory loss are greater in the PROGNOSIS FOR RECOVERY
UEs because these nerve tracts are more centrally The prognosis for substantial recovery of neuromuscu-
located than nerve tracts for the LEs. This syndrome is lar function after spinal cord injury depends on whether
often seen in older people in whom arthritic changes the lesion is complete or incomplete. If there is no sen-
have caused a narrowing of the spinal canal; in such sation or return of motor function below the level of
cases cervical hyperextension without vertebral fracture lesion 24 to 48 hours after the injury in carefully as-
may precipitate central cord damage. sessed complete lesions, motor function is less likely to
return. However, partial to full return of function to one
Brown-Sequard Syndrome (Lateral Damage) spinal nerve root level below the fracture can be gained
Brown-Sequard syndrome results when only one side of and may occur in the first 6 months after injury. In in-
the cord is damaged, as in a stabbing or gunshot injury. complete lesions progressive return of motor function is
Below the level of injury there is motor paralysis and possible, yet it is difficult to determine exactly how
loss of proprioception on the ipsilateral side and loss of much and how quickly return will occur.'” Frequently,
pain, temperature, and touch sensation on the con- the longer it takes for recovery to begin, the less likely it
tralateral side. is that it will occur.

Anterior Spinal Cord Syndrome MEDICAL AND SURGICAL MANAGEMENT

Anterior spinal cord syndrome results from injury that
OF THE PERSON WITH SPINAL
damages the anterior spinal artery or the anterior aspect
of the cord. This syndrome involves paralysis and loss of
CORD INJURY
pain, temperature, and touch sensation. Proprioception After a traumatic event in which spinal cord injury is
is preserved. likely, the conscious victim should be carefully ques-
tioned about cutaneous numbness and skeletal muscle
Cauda Equina (Peripheral) paralysis before being moved. Emergency medical tech-
Cauda equina injuries involve peripheral nerves rather nicians, paramedics, and air transport personnel are
than directly involving the spinal cord. Because periph- trained in spinal cord injury precautions and extrication
eral nerves possess a regenerating capacity that the cord
——-—— techniques for moving a possible SCI victim from an ac-
does not, there is better prognosis for recovery with this cident site. Movement of the spine must be prevented
injury. Patterns of sensory and motor deficits are highly during the transfer procedures. A firm stretcher or board
variable and asymmetrical. to which the victim’s head and back can be strapped
should be procured before moving the victim. After the
After spinal cord injury the victim enters a stage of victim is transferred to the stretcher or board, he or she
spinal shock that may last from 24 hours to 6 weeks. should be strapped to the board or stretcher and care-
This period is one of areflexia, in which reflex activity fully transferred via air or ground transport to the
ceases below the level of the injury.'* The bladder and nearest hospital emergency room. Axial traction on
bowel are atonic or flaccid. Deep tendon reflexes are de- the neck should be maintained and any movement
creased, and sympathetic functions are disturbed. This of the spine and neck-prevented during this process.
disturbance results in decreased constriction of blood Careful examination, stabilization, and transportation
vessels, low blood pressure, a slower heart rate, and no of the patient may prevent a temporary or slight spinal
perspiration below the level of injury.’”'° cord injury from becoming more severe or permanent.
The spinal cord is usually not damaged below the Initial care is directed toward preventing further damage
level of the lesion. Therefore muscles that are inner- to the spinal cord and reversing neurological damage, if
vated by the neurological segments below the level of possible, by stabilization or decompression of the
injury usually develop spasticity, because the mono- injured neurological structures.”'”'* Antiinflamatory
) synaptic reflex arc is intact but separated from higher and steroidal drugs are now being administered imme-
inhibitory influences. Deep tendon reflexes become diately after injury in an effort to minimize the neuro-
hyperactive, and spasticity may be evident. Sensory logical damage, although the significance of their effect
loss continues, and the bladder and bowel usually on neurological recovery is still unclear.
become spastic (“upper motor neuron” bladder) in A careful neurological examination is carried out by
patients whose injuries are above T12. The bladder the examining physician to aid in determining the site
and bowel usually remain flaccid (“lower motor and type of injury. The patient is in a supine position
neuron” bladder) in patients whose lesions are at L1 for this procedure, with the neck and spine immobi-
and below. Sympathetic functions become hyperactive. lized. A catheter is usually placed in the patient's
Spinal reflex activity (mass muscle spasms) usually bladder for drainage of urine. Anteroposterior and
becomes evident in the areas below the level of the lateral x-ray films may be taken, with the patient's head,
lesion.*!3/1° neck, or spine immobilized, to help determine the type
770 TREATMENT APPLICATIONS

of injury. A computed tomography (CT) scan or mag- The benefits of early transport to a spinal cord injury
netic resonance imaging (MRI) may be needed for center have been documented.’ Patients treated initially
further evaluation. In early medical treatment the goals in a spinal cord acute-care unit rather than a general
are to restore normal alignment of the spine, maintain hospital had shorter acute-care lengths of stay. Patients
stabilization of the injured area, and decompress neuro- treated in general hospitals tended to have a higher inci-
logical structures that are under pressure. dence of skin problems and spinal instability. It has
Bony realignment and stabilization are usually been found that patients sent to rehabilitation centers
achieved by placing the patient on a rotating kinetic bed specializing in the treatment of SCI made functional
(Fig. 41-2) that allows skeletal traction and immobiliza- gains with greater efficiency.'® Spinal cord centers are
tion. The bed’s constant rotation allows continuous able to offer a complete, multidisciplinary program exe-
pressure relief, mobilization of respiratory secretions, cuted by an experienced team of professionals who spe-
and easy access to the patient's entire body for bowel, cialize in this unique and demanding disability.
bladder, and hygiene care. Open surgical reduction with
wiring and spinal fusion may be indicated.
The goals of surgery are to decompress the spinal
cord and to achieve spinal stability and normal bony
alignment.” Surgery is not always necessary, and ade-
quate immobilization may allow the patient to heal. As
soon as possible, a means of portable immobilization is
provided, usually a halo vest for cervical injuries (Fig.
41-3, A) and a thoracic brace or body jacket for thoracic
injuries (Fig. 41-3, B). This approach enables the patient
to be transferred to a standard hospital bed and, subse-
quently, to be up in a wheelchair and involved in an
active therapy program in as little as 1 to 2 weeks after
injury. Initiating an upright sitting tolerance program
shortly after injury can substantially reduce the inci-
dence and severity of further medical complications
such as deep vein thrombosis, joint contractures, and
the general deconditioning that can result from pro-
longed bed rest.

FIG. 41-3
FIG. 41-2 A, Halo vest, neck immobilization device for patients with quadri-
Kinetic bed with custom arm positioner. Designed and fabricated plegia and high level paraplegia (T| to T4). B, Body jacket, one type
by the Occupational Therapy Department, Santa Clara Valley of immobilization device for paraplegia. (Courtesy of Luis Gonza-
Medical Center, San Jose, Calif. (Courtesy of Luis Gonzalez, Media lez, Media Resource Department, Santa Clara Valley Medical
Resource Department, Santa Clara Valley Medical Center.) Center.)
 Spinal Cord Injury 771

COMPLICATIONS OF SPINAL be improved by assisted breathing and by vigorous res-

CORD INJURY piratory and physical therapy. Strengthening of the ster-
nocleidomastoids and the diaphragm, manually as-
Skin Breakdown, Pressure Sores,
sisted cough, and deep breathing exercises are essential
or Decubitus Ulcers to maintain optimal vital capacity.'*'”
Sensory loss increases the risk of skin breakdown. The
patient with sensory loss cannot feel the pressure and
shearing of prolonged sitting or lying in one position or Osteoporosis of Disuse
the presence of pain or heat against the body. Pressure Osteoporosis is likely to develop in patients with spinal
causes the loss of blood supply to the area, which can cord injuries because of disuse of long bones, particu-
ultimately result in necrosis. Heat can quickly burn and larly of the lower extremities. Osteoporosis may be suf-
destroy tissues. Shearing can destroy underlying tissue. ficiently advanced for pathological fractures to occur a
Any combination of the above will hasten skin break- year after the injury. Pathological fractures are most
down. The areas most likely to develop skin breakdown common in the supracondylar area of the femur, proxi-
are bony prominences over the sacrum, ischium, mal tibia, and distal tibia, the intertrochanteric area of
trochanters, elbows, and heels; however, other bony the femur, and the neck of the femur. Pathological frac-
prominences such as the iliac crest, scapula, knees, toes, tures are usually not seen in UEs. Daily standing with a
and rib cage are also at risk. standing frame may slow the onset of osteoporosis'*’'”;
It is important for all rehabilitation personnel to be however, this is a controversial method and not em-
aware of the signs of developing skin problems. At first braced in all rehabilitation programs. A standing
the area reddens, yet blanches when pressed. Later, the program must fit into the patient's activities of daily
reddened or abraded area does not blanch, which indi- living (ADL) routine after discharge to be effective on an
cates that necrosis has begun. Finally, a blister or ulcera- ongoing basis. Not all reimbursement sources will cover
tion appears in the area. Often the problem is more the cost of standing equipment.
severe below the level of the skin surface. The visible
sore may only be the tip of the iceberg. If allowed to
progress, a sore can become severe, destroying underly-
Orthostatic Hypotension
ing tissues even as deep as the bone. A lack of muscle tone in the abdomen and LEs leads to
Skin breakdown can be prevented by relieving and pooling of blood in these areas, with a resultant de-
eliminating pressure points and protecting vulnerable crease in blood pressure (hypotension). This problem
areas from excessive shearing, moisture, and _ heat. occurs when the patient moves from a supine to
Turning in bed on a routine basis, specialized mattresses upright position or changes body position too quickly.
and wheelchair seat cushions, protection of bony Symptoms are dizziness, nausea, and loss of conscious-
prominences with various types of padding, and per- ness." The patient must be reclined quickly and, if
forming weight shifts are some of the methods used to sitting in a wheelchair, should be tipped back with legs
prevent pressure sores. elevated until symptoms subside. With time this
The use of hand splints, body jackets, and other or- problem can diminish as sitting tolerance and level of
thoses can also cause skin breakdowns. The therapist activity increase; however, some people continue to
must inspect the skin, and the patient must be taught to have hypotensive episodes. Abdominal binders, leg
examine his or her skin on a consistent, daily basis, wraps, antiembolism stockings, and medications can
using a mirror or caregiver assistance to watch for signs aid in reducing symptoms.
of developing problems. Skin damage can develop
within 30 minutes, so frequent weight shifting, reposi-
tioning, and vigilance are essential if skin breakdown is
Autonomic Dysreflexia
to be prevented.'*!° Autonomic dysreflexia is a phenomenon seen in per-
sons whose injuries are above the T4 to T6 level. It is
caused by reflex action of the autonomic nervous system
Decreased Vital Capacity in response to some stimulus, such as a distended
Decreased vital capacity is a problem in people who bladder, fecal mass, bladder irritation, rectal manipula-
have sustained cervical and high thoracic lesions. Such tion, thermal or pain stimuli, or visceral distention. The
individuals have markedly limited chest expansion and symptoms are immediate pounding headache, anxiety,
decreased ability to cough because of weakness or paral- perspiration, flushing, chills, nasal congestion, paroxys-
ysis of the diaphragm and the intercostal and latissimus mal hypertension, and bradycardia.
dorsi muscles. This can result in a tendency toward res- Autonomic dysreflexia is a medical emergency and life
piratory tract infections. Reduced vital capacity affects threatening. The patient should not be left alone.”’*’"”
the overall endurance level for activity. Endurance can The condition is treated by placing the patient in an
772 TREATMENT APPLICATIONS

SEXUAL FUNCTION
upright position and removing anything restrictive,
such as abdominal binders or elastic stockings, to The sexual drive and the need for physical and emo-
reduce blood pressure. The bladder should be drained tional intimacy are not altered by SCI. However, prob-
or legbag tubing checked for obstruction. Blood pres- lems of mobility, functional dependency, and altered
sure and other symptoms should be monitored until body image, as well as complicating medical problems
they return to normal. The occupational therapist must and the attitudes of partners and society, affect social
be aware of symptoms and treatment because dysre- and sexual roles, access, and interest and satisfaction.
flexia can occur at any time after the injury. Education is essential for the spinal cord-injured in-
dividual and is a critical part of the rehabilitation
process.
Spasticity
Lack of sensation over one part of the body is accom-
Spasticity is a nearly universal complication of spinal panied by increased or altered sensation over other parts
cord injury.’” It is an involuntary muscle contraction of the body. The sexual response of the body after SCI
below the level of injury that results from lack of inhibi- needs to be explored in the same way a person learns
tion from higher centers. Patterns of spasticity change what muscles are working and where he or she can feel.
over the first year, gradually increasing in the first 6 In males, erections and ejaculations are often affected
months and reaching a plateau about 1 year after the by SCI. However, this problem is variable and needs to
injury. A moderate amount of spasticity can be helpful be evaluated individually. Frequently the viability of
in the overall rehabilitation of the patient with a spinal sperm in men with SCI is decreased, even when other
cord injury. It helps to maintain muscle bulk, assists in function is near normal.’ Research is under way to in-
joint range of motion (ROM), and can be used to assist vestigate the possible sources of infertility caused by SCI
during wheelchair and bed transfers and mobility. A and to reverse the problem.
sudden increase in spasticity can alert the patient to In women menstruation usually ceases for an interval
other medical problems, such as bladder infections, of weeks to months after injury. It will usually start
skin breakdown, or fever. again and return to normal in time. There may also be
Severe spasticity can be very frustrating to both the changes in lubrication of the vagina during sexual activ-
patient and the therapist, in that it can interfere with ity. In contrast to males, however, there is no change in
function. It may be treated more aggressively with a female fertility. Females with SCI can conceive and give
variety of medications. In select instances local injec- birth. Special attention must be given to the interaction
tions and surgical procedures that involve cutting or of pregnancy and childbirth with SCI, especially in
lengthening involved muscles may benefit some pa- regard to blood clots, respiratory function, bladder in-
tients. In severe cases neurosurgical procedures such as fections, dysreflexia, and the use of medications during
nerve blocks or rhizotomies (the lesioning of spinal pregnancy and breast feeding.
roots) have been performed.”!*!” To avoid pregnancy, women with SCI must take pre-
cautions, and the type of birth control used must be
considered carefully. Birth control pills are associated
Heterotopic Ossification
with blood clots, especially when combined with
Heterotopic ossification (HO), also called ectopic bone, smoking, and probably should not be used. The in-
is bone that develops in abnormal anatomical loca- trauterine device (IUD) is not recommended, even for
tions.'° It most often occurs in the muscles around the able-bodied females. Diaphragms may be difficult to
hip and knee, but occasionally it can be noted also at position properly when there is loss of sensation in the
the elbow and shoulder. The first symptoms are vagina or decreased hand function. Foams and supposi-
swelling, warmth, and decreased joint ROM. The onset tories are not very effective. The use of condoms by the
of HO is usually 1 to 4 months after injury. Early diag- male partner is probably the safest method.
nosis and initiation of treatment can minimize compli- Individuals with disability quickly sense the attitudes
cations. Treatment consists of medication and the main- of professionals and caregivers toward their sexuality.
tenance of joint ROM during the early stage of active Awareness and acceptance by professionals is increasing,
bone formation, to preserve the functional ROM neces- and sexual counseling and education are a regular part
sary for good wheelchair positioning, symmetrical posi- of many rehabilitation programs for all types of physical
tion of the pelvis, and maximal functional mobility. If disabilities. Some patients lack basic sex education.
HO progresses to the phase of substantially limiting hip Others feel asexual because of their disability and
flexion, pelvic obliquity while in the sitting position is altered self-esteem and are isolated from peers; thus they
likely to occur. This problem contributes to trunk defor- may feel uncomfortable with any type of sexual interac-
mities such as scoliosis and kyphosis, with subsequent tion. For these reasons sexual education and counseling
skin breakdown at the ischial tuberosities, trochanters, must be geared to the needs of the individual patient
and sacrum.”?? and his or her significant other. In some instances, social
 Spinal Cord Injury Lita

interaction skills need improvement before sexual activ- Shoulder pain should be thoroughly assessed and diag-
ity can be considered, and occupational therapists play nosed so that proper treatment can be provided before
an important role in providing information and a forum the onset of chronic discomfort and functional loss.
to deal with these issues. (See Chapter 15 for more in- Accurate assessment of the patient's muscle strength
formation on sexuality with physical dysfunction.) is critical in determining a precise diagnosis of neuro-
logical level and establishing a baseline for physical re-
OCCUPATIONAL THERAPY covery and functional progress. Because the occupa-
INTERVENTION tional therapist's skills with activity analysis greatly
enhance his or her effectiveness in treating the individ-
Evaluation
ual with SCI, a precise working knowledge of muscu-
Assessment of the patient is an ongoing process that loskeletal anatomy and specific manual muscle testing
begins on the day of admission and continues long after techniques is essential. Using accepted muscle testing
discharge on an outpatient follow-up basis. Depending protocols ensures accurate technique while performing
on whether the patient is in an acute inpatient rehabili- this complex evaluation. The muscle test should be re-
tation, outpatient, or home setting, the occupational peated as often as is necessary to provide an ongoing
therapist should continually assess the patient's func- picture of the patient's strength and progress.
tional progress and the appropriateness of treatment Sensation is evaluated for light touch, superficial
and equipment. An accurate and comprehensive formal pain (pinprick), and kinesthesia, which determines
initial evaluation is essential to determine baseline neu- areas of absent, impaired, and intact sensation. These
rological, clinical, and functional status from which findings are useful in establishing the level of injury and
to formulate a treatment program and substantiate determining functional limitations (Fig. 41-4).*
progress. Initial data gathered from the medical chart If the patient is evaluated in the acute stage, spasticity
will provide personal information, a medical diagnosis, is rarely noted, because the patient is still in spinal
and a history of other pertinent medical information. shock. When spinal shock subsides, increased muscle
Input from the multidisciplinary team will enhance the tone may be present in response to stimuli. The thera-
occupational therapist's ability to predict realistic pist should then determine whether the spasticity inter-
optimal outcomes accurately. feres with or enhances function.
Discharge planning begins during the initial evalua- An evaluation of wrist and hand function determines
tion. Therefore the patient's social and vocational the degree to which a patient can manipulate objects.
history, as well as past and expected living situations, are This information is used to suggest the need for equip-
necessary for planning a treatment program that meets ment such as positioning splints or universal cuffs or,
the patient's ongoing needs. Treatment should begin as later, consideration of a tenodesis orthosis (wrist-
soon as possible. It is possible to gather enough informa- driven flexor hinge splint). Gross grasp and pinch mea-
tion quickly to begin addressing high-priority areas such surements indicate functional abilities and may be used
as splinting, positioning, and family training without as an adjunct to manual muscle testing to provide ob-
having to wait for the evaluation to be completed. jective measurements of baseline status and progress for
patients who have active hand musculature.®
Clinical observation is used to assess endurance, oral
Physical Status motor control, head and trunk control, LE functional
Before evaluation of the patient's physical status, very muscle strength, and total body function. More specific
specific medical precautions should be obtained from assessment in any of these areas may be required, de-
the primary and consulting physicians. Skeletal instabil- pending on the individual.
ity and related injuries or medical complications will An increased number of combined spinal cord
affect the way in which the patient is moved and the injury-head injury diagnoses suggests that a specific
active or resistive movements allowed. cognitive and perceptual evaluation may be necessary.”
Passive range of motion (PROM) should be meas- Assessing a patient's ability to initiate tasks, follow di-
ured before specific manual muscle testing to determine rections, carry over learning day to day, and do problem
available pain-free movement. This evaluation also solving contributes to the information base needed for
identifies the presence of or potential for joint contrac- appropriate and realistic goal setting. Understanding
tures, which could suggest the need for preventive or the patient's learning style, coping skills, and communi-
corrective splinting and positioning. cation style is also essential.
Shoulder pain, which ultimately causes decreased
shoulder and scapular ROM, is extremely common in
Functional Status
C4-7 tetraplegics. Among the possible causes are scapu-
lar immobilization resulting from prolonged bed rest Observing the patient performing ADL is an impor-
and nerve root compression subsequent to the injury. tant part of the OT evaluation. The purpose of this
774 TREATMENT APPLICATIONS

STANDARD NEUROLOGICAL CLASSIFICATION OF SPINAL CORD INJURY

LIGHT
TOUCH
PIN
PRICK
SENSORY
aaa KEY MUSCLES ‘ade : tie8 KEY SENSORY POINTS
C2 C2
C3 C3 0 = absent
C4 C4 1 = impaired
C5 Elbow Flexors CS 2 = normal
C6 Wrist Extensors C6 NT = not testable
C7 Elbow Extensors C7
C8 Finger Flexors (distal phalanx of middle finger) C8
1 Finger Abductors (little finger) 1
T2 - Te
T3 0 = total paralysis ; : T3
T4 1 = palpable or visible contraction T4
5 2= active movement, TS
T6 gravity eliminated T6
1 o= active mo vement, 17
T8 against gravity T8
T9 4 = active movement, T9
Tio against some resistance T10
TH 5 = active movement, TH
T1i2 against full resistance T12
u NT = not testable “4
L2 Hip Flexors L2
L3 Knee Extensors L3
L4 Ankle Dorsiflexors L4
L5 Long Toe Extensors LS
S1 Ankle Plantar Flexors S1
S2 $2
$3 S3
S4-5 [tar] Voluntary anal contradction (Yes/No) S4-5

TOTALS |__| PIN PRICK SCORE (max: 112)

TOTALS [_}{_]-[-_] MOTOR SCORE |__| LIGHT TOUCH SCORE (max: 112)
(MAXIMUM) (50) (50) (100) (MAXIMUM) (56) (56) (56) (56)
NEUROLGICAL R L ad ZONE OF PARTIAL R L
COMPLETE OR INCOMPLETE
LEVEL SENSORY Pe (a Incomplete = Any sensory or motor function in S4-S5 PRESERVATION SENSORY [ate] fgesal
the most caudal segment with
MOTOR foyer]pasres| ASIA IMPAIRMENT SCALE
(aah Partially innervated segments MOTOR [iors Hite}
normal function

This farm mav be copied freely but should not be altered without permission from the American Spinal Injury Association Version4p
GHC 1996

FIG. 41-4
Standard neurological classification of spinal cord injury. (Courtesy of American Spinal Injury Asso-
ciation, 1992.)

observation is to determine present and potential levels able assets or limiting factors in determining the outcome
of functional ability. If the patient is cleared of bed rest of rehabilitation. A therapist must carefully observe the
precautions, evaluation and simultaneous treatment patient's status in each of these areas before recommend-
should begin as soon as possible after injury. Light ac- ing the course of treatment.®
tivities such as feeding, light hygiene at the sink, and
object manipulation may be appropriate, depending on
ESTABLISHING TREATMENT OBJECTIVES
the level of injury.
Direct interaction with the patient's family and Establishing treatment objectives in concert with the
friends provides valuable information regarding the patient and with the rehabilitation team is important.
patient's support systems while in the hospital and, The primary objectives of the rehabilitation team may
more important, after discharge. This information is rel- not be those of the patient. Psychosocial factors, cultural
evant to later caregiver training in areas in which the factors, cognitive deficits, environmental limitations,
patient may require the assistance of others to accom- and individual financial considerations must be identi-
plish self-care and mobility tasks. fied and integrated into a treatment program that will
In addition to physical and functional assessments, the meet the unique needs of each individual. Every patient
occupational therapist has the opportunity to observe the is different; therefore a variety of treatment approaches
patient's psychosocial adjustment to the disability and and alternatives may be necessary to address each factor
life in general through the nature ofactivities in which the that may affect goal achievement.’ More participation
patient participates.'* The evaluation phase is important can be expected if the patient's priorities are respected to
for establishing rapport and mutual trust, which will fa- the extent that they are achievable and realistic.
cilitate participation and progress in later and more diffi- The therapist's general objectives for treatment of the
cult phases of rehabilitation. An individual's motivation, person with SCI are as follows:
determination, socioeconomic background, education, 1. To maintain or increase joint ROM and prevent de-
family support, acceptance ofdisability, problem-solving formity via active and passive ROM, splinting, and
abilities, and financial resources can prove to be invalu- positioning
 Spinal Cord Injury 775

2. To increase the strength of all innervated and par- (MP) and proximal interphalangeal (PIP) joints.
tially innervated muscles through the use of enabling Splints should be dorsal rather than ventral in design
and purposeful activities to allow maximal sensory feedback while the patient's
3. To increase physical endurance via functional activi- hand is resting on any surface. If at least F+ (3+)
ties strength of wrist extension is present, a short opponens
4. To maximize independence in all aspects of self-care, splint should be considered to maintain the web space
mobility, and homemaking and parenting skills and support the thumb in opposition. This splint can
. To explore leisure interests and vocational potential be used functionally while the patient is trained to use
Du. To aid in the psychosocial adjustment to disability a tenodesis grasp.
7. To evaluate, recommend, and train the patient in the Active and active-assisted ROM of all joints should be
use and care of necessary durable medical and performed within strength, ability, and tolerance levels.
adaptive equipment Muscle reeducation techniques for wrists and elbows
8. To ensure safe and independent home accessibility should be employed when indicated. Progressive resis-
through home modification recommendations tive exercises for wrists may be carried out. The patient
9. To instruct the patient in the communication skills should be encouraged to engage in self-care activities
necessary for training caregivers to provide safe assis- such as feeding, writing, and hygiene if possible, using
tance simple devices such as a universal cuff or a custom
The patient's length of stay in the inpatient rehabilita- writing splint. Even though the patient may be immobi-
tion program and the ability to participate in outpatient lized in bed, discussion of anticipated durable medical
therapy determine the appropriateness and priority of equipment (DME), home modifications, and caregiver
the just-named activities. training should be initiated to allow sufficient time to
prepare for discharge.
TREATMENT METHODS
Acute Phase Active Phase
During the acute, or immobilized, phase of the rehabil- During the active, or mobilization, phase of the rehabil-
itation program the patient may be in traction or itation program, the patient can sit in a wheelchair and
wearing a stabilization device such as a halo brace or should begin developing upright tolerance. A high pri-
body jacket. Medical precautions must be in force ority at this time is determining a method of relieving
_ during this period. Flexion, extension, and rotary move- sitting pressure for the purpose of preventing decubitus
ments of the spine and neck are contraindicated. ulcers on the ischial, trochanteric, and sacral bony
Evaluation of total body positioning and hand prominences. If the patient has quadriplegia yet has at
splinting needs should be initiated at this time. In pa- least F+ (3+) shoulder and elbow strength bilaterally,
tients with tetraplegia, scapular elevation and elbow pressure can be relieved on the buttocks by leaning
flexion (as well as limited shoulder flexion and abduc- forward over the feet. Simple cotton webbing loops are
tion while on bed rest) cause potentially painful shoul- secured to the back frame of the wheelchair (Fig. 41-5).
ders and ROM limitations. Upper extremities should be
intermittently positioned in 80° of shoulder abduction,
external rotation with scapular depression, and full
elbow extension to assist in alleviating this common
problem. The forearm should be positioned in forearm
pronation, since the patient is at risk for supination
contractures such as at the C5 level. At Santa Clara
Valley Medical Center a device has been designed and
fabricated by the Occupational Therapy Department to
maintain the arm in an appropriate position while the
patient is immobilized on a kinetic bed (Fig. 41-2).
Selection of appropriate splint style and accurate
fabrication and fit of the splint by the occupational
therapist enhance patient acceptance and optimal func-
tional gain. If musculature is not adequate to support
the wrist and hands properly for function or cosmesis,
splints should be fabricated to support the wrist prop- FIG. 41-5
erly in extension and the thumb in opposition and to Forward weight shift using loops attached to wheelchair frame.A
maintain the thumb web space while allowing the patient with C6 quadriplegia with symmetrical grade 4 deltoids
fingers to flex naturally at the metacarpophalangeal and biceps and wrist extensors.
 TREATMENT APPLICATIONS

FIG. 41-6
Tenodesis action. A, Wrist is extended when fingers are passively flexed. B, Wrist is flexed when
fingers are passively extended.

A person with low quadriplegia (C7) or a person with

paraplegia with intact UE musculature can perform a
full depression weight shift off the arms or wheels of the
wheelchair. Weight shifts should be performed every 60
minutes until skin tolerance is determined.
Active and passive ROM exercises should be contin-
ued regularly to prevent undesirable contractures. Splint-
ing or casting of the elbows may be indicated to correct
contractures that are developing. Some patients will have
wrist extension, which will be used to substitute for
absent grasp through tenodesis action of the long finger
flexors. With these patients it is desirable to develop
some tightness in these tendons to give some additional
tension to the tenodesis grasp. The desirable contracture
is developed by ranging finger flexion with the wrist fully
extended and finger extension with the wrist flexed, thus
never allowing the flexors or extensors to be in full
stretch over all ofthe joints that they cross (Fig. 41-6). '°
Elbow contractures should never be allowed to
develop. Full elbow extension is essential for allowing
propping to maintain balance during static sitting and
for assisting in transfers. With zero triceps strength a
person with C6 quadriplegia can maintain forward
sitting balance by shoulder depression and protraction,
external rotation, full elbow extension, and full wrist ex-
tension (Fig. 41-7).
Progressive resistive exercise and resistive activities
can be applied to innervated and partially innervated A
FIG. 41-7
fae
muscles. Shoulder musculature should be exercised so A patient with C6 quadriplegia; forward sitting balance is main-
as to promote proximal stability, with emphasis on the tained (without triceps) by locking elbows. This is a valuable skill
latissimus dorsi (shoulder depressors), deltoids (shoul- for maintaining sitting balance, bed mobility, and transfers. (Cour-
der flexors, abductors, and extensors), and the remain- tesy of Luis Gonzalez, Media Resource Department, Santa Clara
der of the shoulder girdle and scapular muscles. The Valley Medical Center.)
 Spinal Cord Injury

FIG. 41-8

A, Patient with injury at C4-5 typing at keyboard with bilateral overhead slings, bilateral wrist splints,
and typing splints. B, Use of a service dog as a treatment option to facilitate bilateral upper extremity
use. (Courtesy of Luis Gonzalez, Media Resource Department, Santa Clara Valley Medical Center.)

triceps, pectoralis, and latissimus dorsi muscles are The ADL program may be expanded to include inde-
needed for transfers and for shifting weight when in the pendent feeding with devices, oral hygiene and upper-
wheelchair. Wrist extensors should be strengthened to body bathing, bowel and bladder care, such as digital
maximize natural tenodesis function, thereby maximiz- stimulation and application of the urinary collection
ing the necessary prehension pattern in the hand for device, UE dressing, and transfers using the sliding
functional grasp and release. board. Communication skills in writing and using the
The treatment program should be graded to increase telephone, tape recorder, stereo equipment, computer,
the amount of resistance that can be tolerated during and calculator keyboard should be an important part of
activity. As muscle power improves, increasing the the treatment program (Fig. 41-8). Training in the use of
amount of time in wheelchair activities will help the the mobile arm support and overhead slings (see
patient gain upright tolerance and endurance. ~ Chapter 31), wrist-hand orthosis (flexor hinge or ten-
Many assistive devices and equipment items can be odesis splint), and assistive devices is also part of the OT
useful to the person with SCI. However, every attempt program.
should be made to have the patient perform the task The occupational therapist should continue to
with no equipment or with as little as possible. Modi- provide psychological support by allowing and encour-
fied techniques are available that enable an individual aging the patient to express frustration, anger, fears, and
to perform efficiently without the need for expensive or concerns.'* The OT clinic in a spinal cord center can
bulky equipment. provide an atmosphere where patients can establish
When appropriate, the universal cuff for holding support groups with other inpatients and outpatients
eating utensils, toothbrushes, pencils, and paintbrushes who can offer their experiences and problem-solving
is a simple and versatile device that offers increased inde- advice to those in earlier phases of their rehabilitation.
pendence. A wrist cock-up splint to stabilize the wrist The assessment, ordering, and fitting of DME such as
with attachment of the universal cuff may be useful for wheelchairs, seating and positioning equipment, me-
persons with little or no wrist extension. A plate guard, chanical lifts, beds, and bathing equipment are ex-
cup holder, extended straw with straw clip, and nonskid tremely important parts of the rehabilitation program.
table mat can facilitate independent feeding. A wash Such equipment should be specifically evaluated,
mitt, soap holder, or soap-on-a-rope appears to make however, and ordered only when definite goals and ex-
bathing easier; however, the added difficulty of donning pectations are known. Inappropriate equipment can
and doffing such equipment must be considered. Many impair function and cause further medical problems,
people with quadriplegia can use a button hook to fasten such as skin breakdown or trunk deformity; the thera-
clothing. A transfer board is a valuable option for safe pist must take into account all functional, positioning,
transfers. Through treatment, optimal muscle strength environmental, psychological, and financial consid-
and coordination can occur, enabling the patient to erations in evaluating the patient’s equipment needs.
outgrow the use of initially necessary equipment. The desired equipment, especially wheelchairs, seat
778 TREATMENT APPLICATIONS

cushions, back supports, positioning devices and bathing cessibility requirements in the home, as well as those
equipment, should be available for demonstration and required in the workplace by the Americans with Dis-
trial by the patient before final ordering. It is imperative abilities Act of 1990 (ADA) (see Chapter 17).
that the therapist involved in the evaluation and order- Decreases in the time of inpatient rehabilitation have
ing of this costly and highly individualized equipment moved the extended phase of treatment to an outpatient
be familiar with what is currently on the market and be basis or home therapy. Adaptive driving, home manage-
knowledgeable in ordering equipment that will provide ment, leisure activities, or workshop skill assessments
the patient with optimal function and body positioning using hand- or power-based tools are feasible and ap-
on a short- and long-term basis. A good working rela- propriate treatment modalities for evaluating and in-
tionship with an experienced rehabilitation technol- creasing UE strength, coordination, and trunk balance;
ogy supplier (RTS), an equipment supplier specializing however, they may not be a priority during inpatient
in custom rehabilitation equipment, is imperative. Ad- hospitalization. Such activities can improve socializa-
vancements in technology and design have provided a tion skills and can also assess problem-solving skills
wide variety of equipment from which to choose, and and potential work habits.
working with another professional specializing in such OT services can offer valuable evaluation and explo-
equipment will help ensure correct selection and fit. See ration of the vocational potential of persons with SCI.
Chapter 14 for a more detailed discussion of wheel- By the sheer magnitude of the physical disability, voca-
chairs, seating, and positioning equipment. tional possibilities for individuals with high levels of
In addition to enhancing respiratory function by sup- SCI are limited. Many patients must change their voca-
porting the patient in an erect, well-aligned position tion or alter former vocational goals. Low aptitude, poor
that maximizes sitting tolerance and optimizes upper- motivation, loss of health benefits, and lack of persever-
extremity function, wheelchair seating must assist in the ance on the part of many patients make vocational re-
prevention of deformity and pressure sores. An appro- habilitation challenging.
priate and adequate wheelchair cushion helps distribute The occupational therapist can assess the patient's
sitting pressure, assists in the prevention of pressure level of motivation, functional intelligence, aptitudes,
sores, stabilizes the pelvis as necessary for proper trunk attitudes, interests, and personal vocational aspirations
alignment, and provides comfort. Whether it is the oc- during the process of the treatment program and
cupational therapist's or the physical therapist's role to through the use of ADL, mobility, and work simulation
evaluate and order the wheelchair and cushion, both activities. The therapist can observe the patient's atten-
should work closely together to ensure consistent train- tion span, concentration, manual ability with splints
ing and use for the individual needs of each patient. and devices, accuracy, speed, perseverance, work habits,
An increasing number of individuals with high-level and work tolerance level. The therapist can serve as a
SCI, C4 and above, are surviving and participating liaison between the client and the vocational rehabilita-
in active rehabilitation programs. The treatment and tion counselor by offering valuable information from
equipment needs of these individuals are unique and ex- observations during activities. When suitable vocational
tremely specialized, ranging from mouthsticks and en- objectives have been selected, they may be pursued in
vironmental control systems to ventilators and sophisti- an educational setting or in a work setting, usually out
cated electric wheelchairs and drive systems (see Table of the realm of OT.
41-1, levels C1-3 and C3-4, at the end of this chapter).
The use of experienced resources in determining appro-
AGING WITH SPINAL CORD INJURY
priate short- and long-term goals and equipment needs
enhances the quality and functional ability of an indi- Following survival of acute SCI, the primary goal of re-
vidual who otherwise would be quite dependent. Reha- habilitation is independence. Independence as the
bilitation centers specializing in the care of ventilator- measure of quality of life for people with disabilities is
dependent patients should be sought for their expertise an idea accepted and often perpetuated by professionals
in addressing all aspects of care for this unique patient and survivors alike.'*
population. Occupational therapists treating patients with SCI
When place of discharge is determined and the have considerable responsibility in influencing the level
patient can tolerate leaving the hospital for a few hours, of independence, whether in the acute setting, during
a home evaluation should be performed. The therapist, active rehabilitation, or in follow-up care throughout
patient, and family members can then view and attempt the life of aspinal cord-injured individual. Understand-
activities in the home in anticipation of return to a safe ing the aging process in both able-bodied and disabled
and accessible environment. The therapist must be individuals is necessary for providing appropriate
knowledgeable about safety and accessibility options options and fostering attitudes that enhance the quality
for a variety of environments and often must advise ar- of the patient's life at any age.
chitects or contractors to ensure that appropriate modi- Physical aging is a natural, nonpreventable process
fications are made. The therapist must be aware of ac- encountered by all humans. The signs of the process can
 Spinal Cord Injury Oibs)

occur at varying rates for each individual, and aging because of aging. The occupational therapist should
affects most systems of the body. In spinal cord-injured make good trunk alignment and seating a priority from
individuals, aging is usually accelerated by the second- the outset to prevent fixed trunk and pelvic deformities
ary effects of the disability, such as the presence of such as kyphosis and scoliosis, which can lead to con-
muscle imbalance, infections (urinary and respiratory), siderable skin problems and uncorrectable cosmetic de-
deconditioning, pain, and joint degeneration secondary formities years later. In addition, it is necessary to be
to overuse.'* aware of how manual wheelchair propulsion can affect
Twenty years after injury appears to be a point at a weak shoulder complex, as well as the advantage of
which some of the aging problems begin to increase. the cardiopulmonary conditioning that such an activity
Since at least one of four SCI survivors is over 20 years can provide.
postinjury,'* a significant portion of SCI survivors are When SCI is compounded by the increased fatigue
prematurely experiencing the problems of aging. Indi- and weakness often associated with normal aging, the
viduals with SCI onset in their later years have very dif- functional status of the individual affected with SCI
ferent patterns of functional outcomes, program needs, may decline. Occupational therapists may cite this
and financial resources than do those with onset in their change to justify additional services or equipment.
earlier years. For someone who acquired quadriplegia in Many considerations must be weighed to make appro-
his or her 20s, when the majority of spinal cord injuries priate short- and long-term decisions. Contacting expe-
occur, the degenerating conditions of normal aging rienced resources who have a perspective of both acute
become evident prematurely, usually before the 40s.* and long-term injuries and issues can offer valuable
Thus someone who was independent in transfers at insight into treatment decisions.
home and loading a wheelchair in and out of the car
may now require assistance getting in and out of bed;

|
this person may have to trade the car for a van requiring
RESEARCH
costly modifications because his or her shoulders have Research is being conducted in clinical settings and sci-

.
given out. Likewise, someone at a level at which one entific laboratories around the world, focusing on un-
would assume functional independence (e.g., T10 para- derstanding the nature of SCI and defining the nervous
plegia) may, in fact, need personal care assistance system's response to this injury. There is now a sense of

ms

skin care, (4) achieving independent wheelchair mobility on all

plete (ASIA A) spinal cord injury as a result of a fall. H€ also, sus- indoor and outdoor surfaces, (5) receiving appropriate durable
tained facial lacerations and bilateral radial wrist fractures, which medical equipment (DME) to meet both short- and long-term
necessitated casting without internal fixation. Mr S is divorced needs (e.g,, manual and power wheelchair, cushion, and bathing
with no biological children. He is a firefighter and has a back- and toileting equipment), (6) returning to safe and accessible
are
©
MO
|S
a
ont
SS -
ground in auto mechanics. Mr S is very athletic, a triathlete and housing, and (7) being educated in all aspects of care and inde-
marathon runner. Just before his accident, Mr S had moved into a pendently instructing caregivers in assistance needed.
second-story apartment. Mr. S has had a very difficult time accepting the fact that he
Mr. S was referred to OT on the day of his injury and was ini- has a complete spinal cord injury. He could not imagine how he
tially evaluated in the ICU within 24 hours of injury. He was im- could function at work and in his community as a quadriplegic.
mobilized in cervical traction and bilateral wrist casts on a kinetic His college and church community offered a tremendous amount
bed. His specific manual muscle test revealed 3+ to 4 strength in of support, yet he continued to be depressed and angry over his
deltoids, biceps, and triceps. Wrists could not be tested second- loss of mobility and independence. He received regular psycho-
ary to bilateral wrist casts, and finger and thumb flexion and ex- logical counseling and attended a weekly peer support group.
tension was noted to be at least 2—bilaterally. Sensory examina- On discharge from acute rehabilitation, Mr S returned to a
tion was intact to the C7 dermatome. Vital capacity was low newly rented single-story home that required ramps at the front
ha
ee
ASA
eh
ie
secondary to the absence of innervation of intercostal and ab- and back entrances and bathroom modifications. Mr S initially re-
dominal musculature, and Mr. S required respiratory treatments 4 ceived 4 hours of attendant care daily. He required assistance
times per day to mobilize lung secretions. Because of his immobi- only for completion of his daily bath and bowel program, as well
eal
ae
lization, he required assistance for all aspects of his self-care and as for some homemaking tasks. After Mr. S received in-home OT
mobility. for home setup and community transition issues, his need for
na personal care diminished and he now requires only homemaking
OT treatment objectives included (1) maintaining optimal
range of motion (ROM) in all joints for optimal upper extremity assistance. He regularly visits a neighborhood gym to maintain
x «in
function and seated positioning, (2) achieving optimal strength upper extremity strength and endurance, and he will soon be
and endurance in available musculature, (3) achieving optimal in- driving a modified van. His vocational plans are on hold until his
dependence in all self-care skills, including bathing, toileting, and van and driving training are completed.

ee
780 TREATMENT APPLICATIONS

optimism in the scientific community that it will be cludes the ability to breathe with or without me-
possible someday to restore function after SCI. This op- chanical assistance and to adequately clear secre-
timism is based on the combined research efforts of sci- tions. Bowel and bladder function includes the
entists in many different disciplines. It is important for ability to manage elimination, maintain perineal
occupational therapists treating spinal cord injury to be hygiene, and adjust clothing before and after elim-
aware of the scientific and technological advances so as ination. Adapted or facilitated methods of manag-
to better educate patients, while at the same time pro- ing these bodily functions may be required to
viding them with the most realistic and comprehensive attain expected functional outcomes.
rehabilitation interventions for their immediate and @ Bed mobility, bed/wheelchair transfers, wheelchair
long-term needs. propulsion, and positioning/pressure relief. The neuro-
logical effects of spinal cord injury may result in
deficits in the ability of the individual to perform the
SUMMARY
activities required for mobility, locomotion, and
SCI can result in substantial paralysis of the limbs and safety. Adapted or facilitated methods of managing
trunk. The degree of residual motor and sensory dys- these activities may be required to attain expected
function depends on the level of the lesion, whether the functional outcomes in standing and ambulation.
lesion was complete or incomplete, and the area of the @ Standing and ambulation. Spinal cord injury may
spinal cord that was damaged. result in deficits in the ability to stand for exercise
Following a spinal cord injury, bony realignment and or psychological benefit or to ambulate for func-
stabilization are established surgically, via an external tional activities. Adapted or facilitated methods of
immobilization device, or through a combination of management may be outcomes in standing and
both methods. The many possible complications of SCI ambulation.
include skin breakdown, rapid loss of bone density, and m Eating, grooming, dressing, and bathing. The neuro-
spasticity. logical effects of spinal cord injury may result in
OT is concerned with facilitating the patient's deficits in the ability of the individual to perform
achievement of optimal independence and functioning. these ADL. Adapted or facilitated methods of man-
Areas of focus are physical restoration of available mus- aging ADL may be necessary to attain expected
culature, self-care, independent living skills, short- and functional outcomes.
long-term equipment needs, and educational, work, @ Communication (keyboard use, handwriting, and tele-
and leisure activities. The psychosocial adjustment of phone use). The neurological effects of spinal cord
the patient is important, and the occupational therapist injury may result in deficits in the ability of the in-
offers emotional support toward this end in every phase dividual to communicate. Adapted or facilitated
of the rehabilitation program. methods of communication may be required to
Table 41-1 presents expectations of functional per- attain expected functional outcomes.
formance of SCI at 1 year after injury and at each of @ Transportation (driving, attendant-operated vehicle,
eight levels of injury (C1-3, C4, C5, C6, C7-8, T1-9, T10- and public transportation). Transportation activities
L1, L2-S5). The outcomes reflect a level of independence are critical for individuals with SCI to become max-
that can be expected of a person with motor complete imally independent in their community. Adapta-
SCI, given optimal circumstances. tions may be required to help the individual meet
The categories presented reflect expected functional the expected functional outcomes.
outcomes in the areas of mobility, activities of daily = Homemaking (meal planning and preparations and
living, instrumental activities of daily living, and com- home management). Adapted or facilitated methods of
munication skills. The guidelines are based on consen- managing homemaking skills may be required to
sus of clinical experts, available literature on functional attain expected functional outcomes. Individuals
outcomes, and data compiled from Uniform Data with complete SCI at any level will require some
Systems (UDS) and the National Spinal Cord Injury Sta- level of assistance with some homemaking activi-
tistical Center (NSCISC). ties. The hours of assistance with homemaking ac-
Within the functional outcomes for people with SCI tivities are presented in Table 41-1.
listed in Table 41-1, a series of essential daily functions B Assistance required. Table 41-1 lists the number of
and activities, as well as the attendant care likely to be hours that may be required from acaregiver to assist
needed to support the predicted level of independence with personal care and homemaking activities in
at 1 year after injury, have been identified. These the home. Personal care includes hands-on delivery
outcome areas include the following: of all aspects of self-care and mobility, as well as
@ Respiratory, bowel, and bladder function. The neuro- safety interventions. Homemaking assistance is
logical effects of spinal cord injury may result in also included in the recommendation for hours of
deficits in the ability of the individual to perform assistance and includes activities previously pre-
basic body functions. Respiratory function in- sented. The number of hours presented in both the
 Spinal Cord Injury 781

panel recommendations and the self-reported disposable medical products are not included in
CHART data is representative of skilled and un- this document.
skilled and paid and unpaid hours of assistance. FIM. Evidence for the specific levels of independ-
The 24-hour-a-day requirement noted for the C1-3 ence provided in Table 41-1 relies both on expert
and C4 levels includes the expected need for unpaid consensus and on data from FIM in large-scale,
attendant care to provide safety monitoring. prospective, and longitudinal research conducted
Adequate assistance is required to ensure that by NSCISC. FIM is the most widely used disability
the individual with SCI can achieve the outcomes measure in rehabilitation medicine, and although
set forth in Table 41-1. The hours of assis- it may not incorporate all of the characteristics of
tance recommended by the panel do not reflect disability in individuals recovering from SCI, it
changes in assistance required over time as re- captures many basic disability areas.
ported by long-term survivors of SCI° nor do they FIM consists of 13 motor and 5 cognitive items
take into account the wide range of individual that are individually scored from 1 to 7. A score of
variables mentioned throughout this document 1 indicates complete dependence and a score of 7
that may affect the number of hours of assistance indicates complete independence (Table 41-1).
required. The Functional Independence Measure The sum of the 13 FIM motor score items can
(FIM) estimates are widely variable in several of range from 13, indicating complete dependence
the categories. Whether the representative indi- for all items, to 91, indicating complete independ-
viduals with SCI in the individual categories at- ence for all items. FIM is a measure usually com-
tained the expected functional outcomes for their pleted by healthcare professionals; different ob-
specific level of injury is unclear, as is whether servers, including the patient, family members,
there were mitigating circumstances, such as and caregivers, can contribute information to the
age, obesity, or concomitant injuries, that would ratings. Each of these reporters may represent a dif-
account for variability in assistance reported. An ferent type of potential bias.
individualized assessment of needs is required in Although the sample sizes of FIM data for
all cases. certain neurological level groups are quite small,
Equipment requirements. Minimum recommenda- the consistency of the data adds confidence to the
tions for durable medical equipment and adaptive interpretation. Other pertinent data regarding
devices are identified in each of the functional cate- functional independence must be factored into
gories. The most commonly used equipment is outcome analyses, including medical informa-
listed, with the understanding that variations exist tion, patient factors, social role participation,
among SCI rehabilitation programs and that use of quality of life, and environmental factors and
such equipment may be necessary to achieve the supports.
identified functional outcomes. Additional equip- In Table 41-1, FIM data, when available, are re-
ment and devices that are not critical for the major- ported in three areas. First, the expected FIM out-
ity of individuals at a specific level of injury may be comes are documented based on expert clinical
required for some individuals. The equipment de- consensus. The second number reported is the
scriptions are generic to allow for variances in median FIM score, as compiled by NSCISC. The in-
program philosophy and financial resources. Rapid terquartile range for NSCISC FIM data is the third
changes and advances in equipment and technol- set of numbers. In total, the FIM data represent 1-
ogy will be made and therefore must be considered. year postinjury FIM assessments of 405 survivors
Healthcare professionals should keep in mind with complete SCI and a median age of 27 years.
that the recommendations set forth in Table 41-1 The NSCISC sample size for FIM and Assistance
are not intended to be prescriptive, but rather to Data is provided for each level of injury. Different
serve as a guideline. The importance of individual outcome expectations should clearly apply to dif-
functional assessment of people with SCI before ferent patient subgroups and populations. Some
making equipment recommendations cannot be populations are likely to be significantly older
overemphasized. All durable medical equipment than the referenced one. Functional abilities may
and adaptive devices must be thoroughly assessed be limited by advancing age.'”’"”
and tested to determine medical necessity, to Home modifications. To provide the best opportu-
prevent medical complications (e.g., postural devi- nity for individuals with SCI to achieve the identi-
ations, skin breakdown, or pain), and to foster fied functional outcomes, a safe and architecturally
optimal functional performance. Environmental accessible environment is necessary. An accessible
control units and telephone modifications may be environment must take into consideration, but
needed for safety and maximal independence, and not be limited to, entrance and egress, mobility in
each person must be individually evaluated for the the home, and adequate setup to perform personal
need for this equipment. Recommendations for care and homemaking tasks.
Text continued on p. 790
 ected Functional Outcomes
FIM/Assistance
Data
Expected Functional Outcomes Equipment Exp Med IR
Level Cl-3

Functionally relevant muscles innervated: sternocleidomastoid: cervical paraspinal; neck accessories

Movement possible: neck flexion, extension, rotation
Patterns of weakness: total paralysis of trunk, upper extremities, lower extremities; dependent on ventilator
NSCISC sample size: FIM = |5\assist = 12
Respiratory Ventilator dependent Two ventilators (bedside, portable)
Inability to clear secretions Suction equipment or other suction
management device
Generator/battery backup
Bowel Total assist Padded reclining shower/commode chair | |
(if roll-in shower available)
Bladder Total assist | | |
Bed Mobility Total assist Full electric hospital bed with | | |
Trendelenburg feature and side rails

Bed/wheelchair Total assist Transfer board

transfers Power or mechanical lift with sling
Pressure Total assist; may be independent Power recline and/or tilt wheelchair
relief/positioning with equipment Wheelchair pressure-relief cushion
Postural support and head control
devices as indicated
Hand splints may be indicated
Specialty bed or pressure-relief mattress
may be indicated
Eating Total assist | | |
Dressing Total assist © | | |
Grooming Total assist | | |
Bathing Total assist Handheld shower | | |
Shampoo tray
Padded reclining shower/commode chair
(if roll-in shower available)
Wheelchair propulsion Manual: total assist Power recline and/or tilt wheelchair with 6 1-6
Power: independent with head, chin, or breath control and manual
equipment recliner
Vent tray

Standing/ambulation Standing: total assist

Ambulation: not indicated

Communication Total assist to independent, Mouth stick, high-tech computer access,

depending on work station setup environmental control unit
and equipment availability Adaptive devices everywhere as indicated
Transportation Total assist Attendant-operated van (e.g., lift, tie
downs) or accessible public transportation
Homemaking Total assist
Assist required 24-hour attendant care to include a a piel |2-24*
homemaking
Able to instruct in all aspects of care

From Consortium for Spinal Cord Medicine, Paralyzed Veterans of America: Outcomes following traumatic spinal cord injury: clinical practice guidelines for health-care
professionals, Washington, D.C., 1999, The Consortium. (Carole Adler was a member of the guideline development panel.)
FIM/assistance data: Exp, expected FIM score; Med, NSCISC median; IR, NSCISC Interquartile Range.
*Hours per day

782
 FIM/Assistance
Data
Expected Functional Outcomes Equipment
Level C4
_ Functionally relevant muscles innervated: upper trapezius; diaphragm; cervical paraspinal muscles
_ Movement possible: neck flexion, extension, rotation; scapular elevation; inspiration
_ Patterns of weakness: paralysis of trunk, upper extremities, lower extremities; inability to cough, endurance and respiratory reserve low
Pos

_ secondary to paralysis of intercostals

_NSCISC sample size: FIM = 28/assist = 12
_ Respiratory — May be able to breathe without a If not ventilator free, see C|-3 for
ventilator equipment requirements

}
- Bowel Total assist Reclining shower/commode chair
(if roll-in shower available)
Bladder Total assist

_ Bed mobility Total assist Full electric hospital bed with

Trendelenburg feature and side rails
_ Bed/wheelchair Total assist Transfer board
~ transfers Power or mechanical lift with sling
Pressure Total assist; may be independent Power recline and/or tilt wheelchair
relief/positioning with equipment Wheelchair pressure-relief cushion
Postural support and head control
devices as indicated
@
Ve
Hand splints may be indicated
Specialty bed or pressure-relief mattress
ey
may be indicated
Eating Total assist

Dressing Total assist

Grooming Total assist

Bathing Total assist Shampoo tray

Handheld shower
Padded reclining shower/commode chair
(if roll-in shower available)
Wheelchair propulsion Power: independent Power recline and/or tilt wheelchair with
Manual: total assist head, chin, or breath contro! and manual
recliner
Vent tray
Standing/ambulation Standing: total assist Tilt table
Ambulation: not usually indicated Hydraulic standing table
Communication Total assist to independent, Mouth stick, high-tech computer access,
depending on work station setup environmental control unit
and equipment availability

Transportation Total assist Attendant-operated van (e.g,, lift,

tie-downs) or accessible public
transportation

Homemaking Total assist

From Consortium for Spinal Cord Medicine, Paralyzed Veterans of America: Outcomes following traumatic spinal cord injury: clinical practice guidelines for health-care
professionals, Washington, D.C., 1999, The Consortium. (Carole Adler was a member ofthe guideline development panel.)
FIM/assistance data: Exp, expected FIM score; Med, NSCISC median; IR, NSCISC Interquartile Range.
*Hours per day Continued

783
 ional Outcomes
FIM/Assistance
Data a
Expected Functional Outcomes Equipment Exp Med IR i
Assist required 24-hour attendant care to include 24* 24* 16-24"
homemaking
Able to instruct in all aspects of care

Level C5

Functionally relevant muscles innervated: deltoid, biceps, brachialis, brachioradialis, rhomboids, serratus anterior (partially innervated) —
Movement possible: shoulder flexion, abduction, and extension; elbow flexion and supination; scapular adduction and abduction
Patterns of weakness: absence of elbow extension, pronation, all wrist and hand movement; total paralysis of trunk and lower extremities
NSCISC Sample size: FIM = 41/assist = 35

Respiratory Low endurance and vital capacity

caused by paralysis of intercostals;
may require assist to clear secretions

Bowel Total assist Padded shower/commode chair or padded

transfer tub bench with commode cutout

Bladder Total assist Adaptive devices may be indicated

(electric leg bag emptier)

Bed mobility Some assist Full electric hospital bed with

Trendelenburg feature with patient
control
Side rails
Bed/wheelchair Total assist Transfer board
transfers Power or mechanical lift

Pressure Independent with equipment Power recline and/or tilt wheelchair

relief/positioning Wheelchair pressure-relief cushion
Hand splints
Specialty bed or pressure-relief
mattress may be indicated
Postural support devices

Eating Total assist for setup, then Long opponens splint 5 25-55
independent eating with Adaptive devices as indicated
equipment
Dressing Lower extremity: total assist Long opponens splint |-4
Upper extremity: some assist Adaptive devices as indicated

Grooming Some to total assist Long opponens splint [-5

Adaptive devices as indicated
Bathing Total assist Padded tub transfer bench or |-3
shower/commode chair
Handheld shower

Wheelchair propulsion Power: independent Power recline and/or tilt with arm drive 6 5-6
Manual: independent to some control
assist indoors on noncarpeted, level Manual: lightweight rigid or folding
surface; some to total assist outdoors frame with handrim modifications

Standing/ambulation Total assist Hydraulic standing table

From Consortium for Spinal Cord Medicine, Paralyzed Veterans of America: Outcomes following traumatic spinal cord injury: clinical practice guidelines for health-care
professionals, Washington, D.C., 1999, The Consortium. (Carole Adler was a member of the guideline development panel.)
FIM/assistance data: Exp, expected FIM score; Med, NSCISC median; IR, NSCISC Interquartile Range.
*Hours per day

784
 FIM/Assistance
‘ Data
pens Expected Functional Outcomes Equipment “ Exp Med IR
~ Communication __ Independent to some assist after Long opponens splint
ssa: =: setup with equipment Adaptive devices as needed for page
i pe turning, writing, button pushing
_ Transportation Independent with highly specialized Highly specialized modified van with lift
equipment; some assist with
accessible public transportation; total
. assist for attendant-operated vehicle
Homemaking — Total assist
Assist Required Personal care: |0 hours/day Doman es ire
Homecare: 6 hours/day
Able to instruct in all aspects of care

Level C6

Functionally relevant muscles innervated: clavicular pectoralis; supinator; extensor carpi radialis longus and brevis; serratus anterior;
latissimus dorsi
Movement possible: scapular protractor; some horizontal adduction, forearm supination, radial wrist extension
Patterns of weakness: absence of wrist flexion, elbow extension, hand movement; total paralysis of trunk and lower extremities
NSCISC sample size: FIM = 43/assist = 35

Respiratory Low endurance and vital capacity

secondary to paralysis of intercostals;
may require assist to clear secretions

Bowel Some total assist Padded tub bench with commode cutout |-2
or padded shower/commode chair
Other adaptive devices as indicated

Bladder Some total assist with equipment; Adaptive devices as indicated |-2 |
may be independent with leg bag_
emptying

Bed mobility Some assist Full electric hospital bed

Side rails
Full to king standard bed may be indicated

Bed/wheelchair Level: some assist to independent Transfer board 3 |-3

transfers Uneven: some to total assist Mechanical lift

Pressure Independent with equipment and/or — Power recline wheelchair

relief/positioning adapted techniques Wheelchair pressure-relief cushion
Postural support devices
Pressure-relief mattress or overlay may
be indicated

Eating Independent with or without Adaptive devices as indicated (e.g., U- 5-6 5 4-6
~ equipment; except cutting, which is cuff, tendenosis splint, adapted utensils,
total assist plate guard)

Dressing Independent upper extremity; some Adaptive devices as indicated (e.g, |-3 2 1-5
assist to total assist for lower button-hook; loops on zippers, pants;
extremities socks, velcro on shoes)

From Consortium for Spinal Cord Medicine, Paralyzed Veterans of America: Outcomes following traumatic spinal cord injury: clinical practice guidelines for health-care
the guideline development panel.)
professionals, Washington, D.C., 1999, The Consortium. (Carole Adler was a member of
FiM/assistance data: Exp, expected FIM score; Med, NSCISC median; IR, NSCISC Interquartile Range.
*Hours per day Continued

785
 | Outcomes
FIM/Assistance _
Data
Expected Functional Outcomes Equipment Exp Med IR
Grooming Some assist to independent with Adaptive devices as indicated (e.g., U- 3-6 864 2-6
equipment ; cuff, adapted handles)

Bathing Upper body: independent Padded tub transfer bench or |-3

Lower body: some to total assist shower/commode chair
Adaptive devices as needed
Handheld shower

Wheelchair propulsion Power: independent with standard Manual: lightweight rigid or folding frame 6 6 4-6
arm drive on all surfaces with modified rims
Manual: independent indoors; Power: may require power recline or
some total assist outdoors standard upright power wheelchair

Standing/ambulation Standing: total assist Hydraulic standing frame

Ambulation: not indicated

Communication Independent with or without Adaptive devices as indicated (e.g.,

equipment tendenosis splint; writing splint for
keyboard use, button pushing, page turning,
object manipulation)

Transportation Independent driving from Modified van with lift

wheelchair Sensitized hand controls
Tie-downs

Homemaking Some assist with light meal Adaptive devices as indicated

preparation; total assist for all other
homemaking

Assist Required Personal care: 6 hours/day fO* [78< 2 8-245

Homecare: 4 hours/day

Level C7-8

Functionally relevant muscles innervated: latissimus dorsi; sternal pectoralis; triceps; pronator quadratus; extensor carpi ulnaris; flexor
carpi radialis; flexor digitorum profundus and superficialis; extensor communis; pronator/flexor/extensor/abductor pollicis; lumbricals
(partially innervated)
Movement possible: elbow extension; ulnar/wrist extension; wrist flexion; finger flexions and extensions; thumb
flexion/extension/abduction
Patterns of weakness: paralysis of trunk and lower extremities; limited grasp and dexterity secondary to partial intrinsic muscles of the
hand
NSCISC sample size: FIM = 43/assist = 35

Respiratory Low endurance and vital capacity

secondary to paralysis of intercostals;
may require assist to clear secretions

Bowel Some to total assist Padded tub bench with commode cutout |-4 | |-4 .
or shower/commode chair
Adaptive devices as indicated
Bladder Independent to some assist Adaptive devices as indicated 2-6 3 1-6
Bed mobility Independent to some assist Full electric hospital bed or full to king
standard bed

From Consortium for Spinal Cord Medicine, Paralyzed Veterans of America: Outcomes following traumatic spinal cord injury: clinical practice guidelines for health-care
professionals, Washington, D.C., 1999, The Consortium. (Carole Adler was a member ofthe guideline development panel.)
FiM/assistance data: Exp, expected FIM score; Med, NSCISC median; IR, NSCISC Interquartile Range.
*Hours per day

786
 FIM/Assistance
Data
Expected Functional Outcomes Equipment Exp Med
Level: independent With or without transfer board 3-7 4
Uneven: independent to some assist
Independent Wheelchair pressure-relief cushion
Postural support devices as indicated
Pressure-relief mattress or overlay may
be indicated
Independent Adaptive devices as indicated 6-7 6 5-7
Independent in upper extremities; Adaptive devices as indicated ae) 6 4-7
independent to some assist in lower
extremities

Independent Adaptive devices as indicated 6-7 ce

Upper body: independent Padded tub transfer tub bench on 3-6 Aol ae
Lower body: some assist to shower/commode chair
independent Handheld shower
Adaptive devices as needed
e Wheelchair propulsion Manual: independent on all indoor Manual: rigid or folding lightweight or 6 6
surfaces and level outdoor terrain; folding wheelchair with modified rims
VayA some assist with uneven terrain

_Standing/ambulation Standing: independent to some assist Hydraulic or standard standing frame

Ambulation: not indicated

~ Communication Independent Adaptive devices as indicated

Transportation Independent in car if independent Modified vehicle
with transfer and wheelchair loading/- Transfer board
unloading; independent in driving
modified van from captain's seat

Homemaking Independent light meal preparation Adaptive devices as indicated

and homemaking; some to total
assist for complex meal preparation
and heavy housecleaning

Assist required Personal care: 6 hours/day B*

|2* 2-24*
Homecare: 2 hours/day

Level T1-9
Functionally relevant muscles innervated: intrinsics of the hand including thumbs; internal and external intercostals; erector spinae;
lumbricals; flexor/extensor/abductor pollicis
Movement possible: upper extremities fully intact; limited upper trunk stability; endurance increased secondary to innervation of
intercostals
Patterns of weakness: lower trunk paralysis; total paralysis of lower extremities
NSCISC sample size: FIM = |44/assist = 122

Respiratory Compromised vital capacity and

endurance

}
}
Bowel Independent Elevated padded toilet seat or padded tub 6-7 6 4-6
bench with commode cutout

From Consortium for Spinal Cord Medicine, Paralyzed Veterans of America: Outcomes following traumatic spinal cord injury: clinical practice guidelines for health-care
professionals, Washington, D.C., 1999, The Consortium. (Carole Adler was a member of the guideline development panel.)
FIM/assistance data: Exp, expected FIM score; Med, NSCISC median; JR, NSCISC Interquartile Range.
*Hours per day Continued
 d Functional Outcomes =

FIM/Assistance
Data
Expected Functional Outcomes Equipment Med IR
Bladder Independent 6 5-6

Bed mobility Independent Full to king standard bed

Bed/wheelchair Independent May or may not require transfer board 6-7 6 6-7
transfers

Pressure Independent Wheelchair pressure-relief cushion

relief/positioning Postural support devices as indicated
Pressure-relief mattress or overlay may
be indicated

Eating Independent TE if

Dressing Independent i 7

Grooming Independent a ve

Bathing Independent Padded tub transfer bench or 6 5-/

shower/commode chair
Handheld shower

Wheelchair propulsion Independent Manual rigid or folding lightweight 6 6

wheelchair

Standing/ambulation Standing: independent Standing frame

Ambulation: typically not functional

Communication Independent

Transportation Independent in car including Hand controls

loading and unloading wheelchair

Homemaking Independent with complex meal

preparation and light housecleaning;
total to some assist with heavy
housecleaning

Assist Required Homemaking: 3 hours/day 2*

ae 0-|5*

Level T10-L1

Functionally relevant muscles innervated: fully intact intercostals; external obliques; rectus abdominis
Movement Possible: food trunk stability
Patterns of weakness: paralysis of lower extremities
NSCISC Sample Size: FIM = 7|/assist = 57

Respiratory ntact respiratory function

Bowel ndependent Padded standard or raised padded 6-/ 6 6
toilet seat

Bladder ndependent 6 6

Bed mobility ndependent Full to king standard bed

Bed/wheelchair Independent J 6-7

transfers

From Consortium for Spinal Cord Medicine, Paralyzed Veterans of America: Outcomes following traumatic spinal cord injury: clinical practice guidelines for health-care
professionals, Washington, D.C., 1999, The Consortium. (Carole Adler was a member ofthe guideline development panel.)
FIM/assistance data: Exp, expected FIM score; Med, NSCISC median; JR, NSCISC Interquartile Range.
*Hours per day

788
 Expected Functional Outcomes
FIM/Assistance
: Data
3 nee Expected Functional Outcomes Equipment ‘ Exp Med IR
Pressure eae Independent Wheelchair pressure-relief cushion
: relief/positioning Postural support devices as indicated
fo er = Pressure-relief mattress or overlay may
Ra ocr be indicated -

:Eating Independent ¢ z 7
: Dressing ; Independent ib i 7

_ Grooming Independent ii 7 7
_ Bathing Independent Padded transfer tub bench es eee) 6-7
Handheld shower
~ Wheelchair propulsion Independent all indoor and outdoor = Manual rigid or folding lightweight 6 6 6
surfaces wheelchair :

~ Standing/ambulation Standing: independent Standing frame

Ambulation: functional, some assist Forearm crutches or walker
to independent Knee, ankle, foot orthosis (KAFO)

Communication Independent
Transportation Independent in car, including Hand controls
loading and unloading wheelchair
Homemaking Independent with complex meal
prep and light housecleaning; some
assist with heavy housecleaning
Assist required Homemaking: 2 hours/day DE 2e 0-8*

Level L2-S5
a

Functionally relevant muscles innervated: fully intact abdominals and all other trunk muscles; depending on level, some degree of hip
flexors, extensor, abductors; knee flexors, extensors; ankle dorsiflexors, plantar flexors.
Movement possible: good trunk stability; partial to full control of lower extremities.
Patterns of weakness: partial paralysis of lower extremities, hips, knees, ankle, foot
NSCISC sample size: FIM = 20/assist = 16

Respiratory Intact function

Bowel Independent Padded toilet seat 6-7 6-7

Bladder Independent 6 6-7

Bed mobility Independent

Bed/wheelchair Independent Full to king standard bed i

transfers

Pressure Independent Wheelchair pressure-relief cushion

relief/positioning Postural support devices as indicated

Eating Independent
>
Dressing Independent

Grooming Independent y

From Consortium for Spinal Cord Medicine, Paralyzed Veterans of America: Outcomes following traumatic spinal cord injury: clinical practice guidelines for health-care
the guideline development panel.)
professionals, Washington, D.C., 1999, The Consortium. (Carole Adler was a member of
FiM/assistance data: Exp, expected FIM score; Med, NSCISC median; IR, NSCISC Interquartile Range.
Continued
*Hours per day

789
 TREATMENT APPLICATIONS

nctional Outcomes
FIM/Assistance
Data
Expected Functional Outcomes Equipment Exp Med IR
Bathing Independent Padded tub bench i ff 6-7
Handheld shower

Wheelchair propulsion Independent all indoor and outdoor Manual rigid or folding lightweight 6 6 6
surfaces wheelchair

Standing/ambulation Standing: independent Standing frame

Ambulation: functional, independent Knee-ankle-foot orthosis (KAFO) or ankle-
to some assist foot orthosis (AFO)
Forearm crutches or cane as indicated

Communication Independent
‘Transportation Independent in car, including loading Hand controls
and unloading wheelchair

Homemaking Independent with complex meal

preparation and light housecleaning;
some assist with heavy housecleaning

Assist required Homemaking: 0-1 hour/day One ascOs Of

From Consortium for Spinal Cord Medicine, Paralyzed Veterans of America: Outcomes following traumatic spinal cord injury: clinical practice guidelines for health-care
professionals, Washington, D.C., 1999, The Consortium. (Carole Adler was a member ofthe guideline development panel.)
FIM/assistance data: Exp, expected FIM score; Med, NSCISC median; JR, NSCISC Interquartile Range.
*Hours per day

3. Describe the functional and prognostic differences

between complete and incomplete lesions.
ndependence Measure Levels 4 . When reference is made to C5 in quadriplegia, what
is meant in terms of level of injury and functioning
(7) Complete independence (timely, safely) No helper muscle groups?
(6) Modified independence (device) 5. What are the characteristics of spinal shock?
6. What physical changes occur following the spinal
Modified Dependence Helper shock phase?
(5) Supervision 7. What is the prognosis for recovery of motor func-
ere : ‘ te
ey ini asst (eublect = 7596 oF sce) tion in complete lesions and incomplete lesions?
8. What are the purposes of surgery in management of
(3) Moderate assist (subject = 50% to 74%) spinal injury?
9. What are some medical complications, common to
eee pein oe patients with spinal cord injuries, ‘that can limit
Got asset Sic ee! achievement of functional potential?
(1) Total assist (subject = 0%-24%) 10. How should postural hypotension be treated?
11. How should autonomic dysreflexia be treated?
From Guide for the uniform data set for medical rehabilitation (including the FIM
. What is the role of the occupational therapist in the
instrument), Version 5.0, Buffalo, NY, State University of New York at Buffalo
prevention of pressure sores?
13, Why is vital capacity affected in patients with spinal
cord injuries?
14. What effect does reduced vital capacity have on the
REVIEW QUESTIONS
rehabilitation program?
1. List three causes of spinal cord injury. Which is 15; Which level of injury has full innervation of the
most common? rotator cuff musculature, biceps, and extensor carpi
2. Describe the patterns of weakness in quadriplegia radialis and partial innervation of the serratus ante-
and paraplegia. rior, latissimus dorsi, and pectoralis major?
 Spinal Cord Injury 791

16. What additional muscle power does the patient . Bromley I: Tetraplegia and paraplegia: a guide for physiotherapists, ed
with C6 quadriplegia have over the patient with C5 3, New York, 1985, Churchill Livingstone.
. Frankel H and associates: The value of postural reduction in the
quadriplegia? What is the major functional advan-
initial management of closed injuries to the spine with paraplegia
tage of this additional muscle power? and tetraplegia, Paraplegia 7:179, 1969.
7: What are the additional critical muscles that the . Freed MM: Traumatic and congenital lesions of the spinal cord. In
patient with C7 quadriplegia has, as compared with Kottke FJ, Lehmann JE, editors: Krusen’s handbook of physical medi-
the patient with C6 quadriplegia? cine and rehabilitation, Philadelphia, 1990, WB Saunders.
. Gerhart KA, Koziol-McClain J, Lowenstein SR, et al: Quality of life
HEE What additional functional independence can be
following spinal cord injury: knowledge and attitudes of emer-
achieved because of this additional muscle power? gency care providers, Ann Emerg Med 23(4):807-812, 1994.
iD: What is the first spinal cord lesion level that has full . Hanak M, Scott A: An illustrated guide for health care professionals,
innervation of the UE musculature? New York, 1983, Springer-Verlag.
20. Which assessments does the occupational therapist . Heinemann AW et al: Mobility for persons with spinal cord
injury: an evaluation of two systems, Arch Phys Med Rehabil 68(2):
use to evaluate the patient with a spinal cord injury? 90-93, 1987.
What is the purpose of each? . Hill JP, editor: Spinal cord injury, a guide to functional outcomes in oc-
21; List five goals of occupational therapy for the cupational therapy, Rockville, Md, 1986, Aspen.
patient with a spinal cord injury. 10. Institute for Medical Research, Santa Clara Valley Medical Center:
a2: How is wrist extension used to effect grasp by the Severe head trauma, a comprehensive medical approach, Project 13-9-
59156/9, report to National Institute for Handicapped Research,
patient with quadriplegia? Nov 1982.
a How does the patient with C6 quadriplegia substi- . Malick MH, Meyer CMH: Manual on the management of the quadri-
tute for the absence of elbow extensors? plegic upper extremity, Pittsburgh, 1978, Harmarville Rehabilitation
24. What is the contracture that is encouraged in pa- Center.
12. Consortium for Spinal Cord Medicine, Paralyzed Veterans of
tients with spinal cord injuries? Why? How is it de-
America: Outcomes following traumatic spinal cord injury: clinical
veloped? practice guidelines for health-care professionals, Washington, D.C.,
20: What is the splint that allows the C6 quadriplegic to 1999, The Consortium.
achieve functional prehension? . Paulson S, editor: Santa Clara Valley Medical Center spinal cord
26. What are some of the first self-care activities that the injury home care manual, ed 3, San Jose, Calif, 1994, Santa Clara
patient with a C6 spinal cord injury should be ex- Valley Medical Center.
. Pierce DS, Nickel VH: The total care of spinal cord injuries, Boston,
pected to accomplish? 1977, Little, Brown.
Pee List four assistive devices commonly used by . Penrod LE, Hegde SK, Ditunno JF Jr: Age effect on prognosis for
persons with quadriplegia, and tell the purpose of functional recovery in acute traumatic central cord syndrome
each. (CCS), Arch Phys Med Rehabil 71(12):963-968, 1990.
. Spencer EA: Functional restoration. In Hopkins HL, Smith HD,
28. How can ordering an ill-fitting wheelchair affect the
editors: Willard and Spackman’s occupational therapy, ed 8, Philadel-
UE function and skin care of a C6 quadriplegic? phia, 1993, JB Lippincott.
2 Describe the role of occupational therapy in the vo- . Whiteneck G et al, editors: Aging with spinal cord injury, New York,
cational evaluation of a patient with a spinal cord 1993, Demos.
injury. . Wilson DJ, McKenzie MW, Barber LM: Spinal cord injury: a treat-
ment guide for occupational therapists, rev ed, Thorofare, NJ, 1984,
30. What are two considerations when predicting the
Slack.
future functional outcomes for a 25-year-old indi- . Yarkony GM, Roth EJ, Heinemann AW, et al: Spinal cord injury re-
vidual with T4 paraplegia? habilitation outcomes: the impact of age, J Clin Epidemiol 41(2):
gi. Why would a person with paraplegia require home- 173-177, 1988.
making assistance if he is independent in all self- 20. Yarkony GM: Spinal cord injury: medical management and rehabilita-
tion, Gaithersburg, Md, 1994, Aspen.
care and mobility?

REFERENCES
uf Amador J: Contemporarary information regarding male infertility
following spinal cord injury, SCI Nursing 15(3):61-65, 1998.
2 American Spinal Injury Association (ASIA): Standards for neurolog-
ical and functional classification of spinal cord injury, Chicago, 1992,
The Association.
 a)V\\ceyoy-tdenten D)vaubelaeloyel

LEARNING OBJECTIVES
Neurogenic After studying this chapter the student or practitioner
Myopathic will be able to do the following:
Motor unit 1. Describe the characteristics of neurogenic and
Lower motor neuron dysfunction myopathic dysfunctions.
Poliomyelitis 2. Discuss the clinical manifestations of neurogenic
Contracture and myopathic dysfunctions.
Postpolio syndrome 3. Discuss the impact of neurogenic and myopathic
Guillian-Barré syndrome dysfunctions on physical and psychosocial function.
Peripheral nerve injury 4. Identify the goals and treatment techniques for an
Neuropraxia occupational therapy program for the various
Neurotmesis neurogenic and myopathic dysfunctions
Axonotmesis
Atrophy
Regeneration
Paresthesias
Wrinkle test
Causalgia
Peripheral nerve pain syndrome
Nociceptors
Myasthenia gravis
Muscular dystrophy

he symptoms, course, medical treatment, and oc- muscular junction, and the muscle fibers innervated by
cupational therapy (OT) intervention for the neurogenic the neuron.
and myopathic disorders most commonly seen in OT Diseases of the motor unit generally cause muscle
practice are presented in this chapter. Neurogenic and weakness and atrophy of skeletal muscle that may be
myopathic disorders are diseases of the motor unit. The of neurogenic or myopathic origin. Those with a neu-
motor unit is the elementary functional unit in the rogenic basis are the lower motor neuron disorders, af-
motor system. It consists of four elements: the cell body fecting the cell bodies, and peripheral neuropathies,
of the motor neuron in the anterior horn of the spinal affecting peripheral nerves. Those with a myopathic
cord, the axon of the motor neuron which travels via basis affect the neuromuscular junction or the muscle
spinal nerves and peripheral nerves to muscle, the neuro- itself.°4

792
 Neurogenic and Myopathic Dysfunction 793

NEUROGENIC DISORDERS
may also be upper extremity involvement. Marked
The motor neurons in the anterior horn cells of the atrophy may be seen in the involved extremities, and
spinal cord mediate all voluntary movement and re- deep tendon reflexes may be absent. Because po-
flexes that promote motor behavior. Variations in range liomyelitis destroys the anterior horn cells, sensory
of motion, muscle strength, and the characteristics of roots are spared and sensation is intact. Contractures
movement are determined by the pattern and firing fre- can occur early in the course of the disease. In cases of
quency of specific motor units. Therefore muscle con- local paralysis the asymmetry of muscles pulling on
Saw
it
aii
ve
Cas
traction is the output of the motor system. various joints may promote deformities, such as sublux-
The lower motor neuron system includes the cell ation, scoliosis, and contractures. In severe cases osteo-
bodies in the anterior horn of the spinal cord and their porosis (bone atrophy) may weaken the long weight-
axons (which pass by way of the spinal nerves and pe- bearing bones and pathological fractures can occur.7°
ripheral nerves to the neuromuscular junction) and the The medical treatment for poliomyelitis during the
nuclei of cranial nerves III through X (located in the acute phase involves bed rest, positioning, and applica-
brainstem) and their axons.*'° The motor fibers of the tions of warm packs to reduce pain and promote relax-
lower motor neurons are divided into the somatic and ation. Because there is no known cure for poliomyelitis,
autonomic components. The somatic motor compo- the disease must run its course. It has an incubation
nents include the alpha motor neurons, which inner- period of 1 to 3 weeks, and recovery depends on the
vate skeletal muscles (extrafusal fibers), and gamma number of nerve cells destroyed. Paralysis may begin in 1
motor neurons, which innervate muscle spindles (intra- to 7 days after the initial symptoms appear. The medical
fusal fibers). The autonomic component innervates the aspects of rehabilitation include reconstructive surgery,
glands, smooth muscles, and heart musculature.”?° A such as tendon transfer, arthrodesis, and surgical release
lesion to any of these neurological structures results in of fascia, muscles, and tendons. Other medical proce-
neurogenic motor unit disease or a lower motor dures include therapeutic stretching, casts, muscle reedu-
neuron dysfunction.”** cation, orthoses, and bracing for standing or stability.*°
Lesions of lower motor neuron systems may be
located in the anterior horn cells of the spinal cord,
Postpolio Syndrome
spinal nerves, peripheral nerves, and cranial nerves or
their nuclei in the brainstem. Such lesions can result Occupational therapists are seeing more patients with
from nerve root compression; trauma (e.g., bone frac- postpolio syndrome in rehabilitation centers. Persons
tures and dislocations, lacerations, traction, or penetrat- who had polio earlier in life may have the onset of ad-
ing wounds and friction); toxins (e.g., lead, phospho- ditional weakness and other disabling symptoms years
tus, alcohol, benzene, or sulfonamides); infections (e.g., after the initial disease.*”’°* The number of such persons
poliomyelitis or Guillain-Barré syndrome); neoplasms has increased, in part, because of the influx of immi-
(e.g., neuromas and multiple neurofibromatosis); vas- grants from Southeast Asia and Latin America who con-
cular disorders (e.g., arteriosclerosis, diabetes mellitus, tracted the original infection in their native lands.”
peripheral vascular anomalies, and polyarteritis no- The cause of postpolio syndrome is not fully under-
dosa); degenerative diseases of the central nervous stood. Motor unit dysfunction, musculoskeletal over-
systems (e.g., amyotrophic lateral sclerosis); and con- use, and musculoskeletal disuse are three factors,
genital malformations. ''**°°° thought to contribute, singly or in combination, to the
onset of postpolio syndrome.’ Several theories have
been postulated about the cause of postpolio syndrome;
Poliomyelitis however, none has proved to be the explanation for the
The active immunization program (Salk and Sabin vac- syndrome. Postpolio syndrome causes health and func-
cines) in the United States since the mid-1950s has es- tional problems, and patients who are affected are likely
sentially eradicated poliomyelitis in the Western Hemi- to be referred for OT services.””
sphere, and new cases of the disease are rare.*”’”? The primary symptom of postpolio syndrome is pro-
However, some new cases have been identified among gressive weakness.'” Muscles that were thought to be
persons who have not been immunized. spared in the original illness may exhibit slowly progres-
Poliomyelitis is a contagious viral disease that affects sive weakness, as well as previously affected muscles.
the anterior horn cells of the gray matter of the spinal Pain, fatigue, cold intolerance, and new breathing diffi-
cord and the motor nuclei of the brainstem. The cervical culties may accompany the muscle weakness. Such mus-
and lumbar enlargements of the cord are primarily af- culoskeletal problems as joint, limb, or trunk deformities
fected. Poliomyelitis results in a flaccid paralysis that can cause pain, decreased endurance, nerve entrapment,
may be local or widespread. The lower extremities, ac- degenerative arthritis, falls, and unsteady gait.*
cessory muscles of respiration, and muscles that Fatigue is the most debilitating symptom because it
promote swallowing are primarily affected, but there limits activity, yet is not apparent to others. The fatigue
794 TREATMENT APPLICATIONS

may be severe and out of proportion to the apparent the selection of therapeutic modalities. The occupa-
physical demands of the activity and can be overwhelm- tional therapist assesses occupational performance,
ing.’*°? An increase in difficulties with activities of ADL, psychosocial and cognitive status, range of motion
daily living (ADL) accompanies the symptoms. Prob- (ROM), muscle strength, and endurance. Functional ac-
lems with ambulation, transfers, using stairs, home tivities are used in combination with passive and active
management, driving, dressing, eating and swallowing, ROM exercises, muscle reeducation, rest, proper posi-
and bladder and bowel control may occur.”* tioning for function, and training in the use of assistive
Unless there is severe pulmonary or swallowing in- and adaptive devices and mobility aids. In all cases,
volvement in postpolio syndrome, the symptoms are fatigue is carefully monitored and avoided. Treatment
not life threatening. The symptoms can range from very goals should be coordinated with the nurse, physical
mild weakness that is only slightly annoying to pro- therapist, and other members of the interdisciplinary
found weakness that is severely incapacitating, with team for a comprehensive rehabilitation program. Prog-
risks of additional disabling problems such as fractures, nosis depends on the progression of the disorder.
osteoporosis, contractures, and depression. In general,
however, patients who adjust their lifestyles by incor- Poliomyelitis
porating the recommendations that prevent muscle During the acute phase the poliomyelitis virus is infec-
fatigue, improve body mechanics, and conserve energy tious. Therefore all personnel involved in the care of the
will have an improvement of symptoms and stabiliza- patient must carefully follow isolation procedures.
tion of function.” OT has an important role to play in During this phase the patient is confined to bed and re-
achieving these goals.”* ceives symptomatic treatment. Hot packs and position-
ing are used to relieve muscle spasm and to prevent con-
tracture and deformity. The therapist can assist the nurse
Guillain-Barré Syndrome in providing good bed positioning to prevent contrac-
Guillain-Barré syndrome (also known as acute idio- tures and protect weakened muscles. The therapist
pathic neuropathy, infectious polyneuritis, and Landry’s should provide gentle passive ROM at the patient's
syndrome) is an acute inflammatory condition involv- physical tolerance level. Care should be taken not to
ing the spinal nerve roots, peripheral nerves, and in grasp the involved muscle bellies because they will be
some cases selected cranial nerves. Guillain-Barré syn- extremely tender and painful. The muscles may also be
drome often follows a viral illness, immunization, or prone to spasm when stimulated to the point of pain.**
surgery. It produces a hypersensitive response resulting Muscle fatigue, which can result in further weakness,
in patchy demyelination of lower motor neuron path- should be avoided throughout the treatment program.
ways. The axons are generally spared, so recovery often If the patient has bulbar poliomyelitis, which affects the
follows a predictable course. In severe cases, however, muscles of respiration, a respirator may be used or a tra-
wallerian degeneration of the axon results in a slow re- cheostomy performed to provide an airway. If the
covery process. Guillain-Barré syndrome affects both muscles necessary for swallowing are impaired, tube
sexes at any age, Wate Aare aia
feeding may also be prescribed. The therapist should
Guillain-Barré syndrome is characterized by a rapid collaborate with the nursing staff when carrying out
onset. Initially there is no fever, but pain and tenderness treatment to ensure proper functioning of the equip-
of muscles, generalized weakness, and decrease in deep ment necessary for life support.°77?47
tendon reflexes occur. As the disease progresses, it pro- Psychological support for the patient and family is
duces motor weakness or paralysis of the limbs, sensory part of the treatment program. The patient's fears and
loss, and muscle atrophy. The prognosis is varied. In anxieties about the disabling effects of the disease should
severe cases cranial nerves VII, IX, and X may be involved not be underestimated. The patient may need encourage-
and the patient may have difficulty speaking, swallow- ment and positive experiences to promote an optimistic
ing, and breathing. If vital centers in the medulla are af- outlook during the rehabilitation process. The family
fected, the patient may have respiratory failure and may also need assistance in adjusting to the patient's dis-
require tracheostomy or assisted ventilation. In most ability. Psychosocial issues may be addressed by the oc-
cases the patient recovers completely within a few weeks cupational therapist during treatment, with additional
to a few months with relatively few residual effects.'**° support from the psychologist sought as needed.
Assistive devices, splints, and mobile arm supports
may be used to gain independence in daily activities. The
Occupational Therapy Intervention:
long-range rehabilitation program should follow a func-
Common Factors
tional course of action. After the acute medical problems
Although specific strategies may be required for OT in- have subsided, the recovery stage may last as long as 2
tervention for each of the neurogenic disorders, there years.® Because the damage to the anterior horn cells is
are some similarities in both the evaluation process and permanent, the therapist should help the patient make
 Neurogenic and Myopathic Dysfunction 795

the best possible use of whatever muscular function valued occupational roles and obtain an activity profile
remains. Manual muscle tests should be repeated of daily life. Activities that cause pain or fatigue, those
monthly forthe first 4 months and bimonthly for the next that have been curtailed or eliminated because of symp-
4 months. After 8 months of therapeutic exercises the toms, the time and circumstances in which symptoms
average patient has probably responded maximally. '!® are most likely to occur, and the kinds of aids, equip-
For the patient recovering from acute poliomyelitis, ment, and human assistance currently used are identi-
movement proceeds from passive to active ROM de- fied. This information is used to prioritize and select
pending on the patient's level of voluntary control. valued, relevant activities for the patient with postpolio
Muscle reeducation should be preceded by gentle syndrome.
stretching exercises. All active motions should be per- Postpolio muscles may actually function at levels of
formed under careful supervision of the therapist. Com- strength lower than estimated from scores on the
pensatory movement should be avoided. A limited but manual muscle test, and upper extremity strength varies
correct movement is preferred to an ampler but incor- markedly throughout the ROM.”* Joint ROM measure-
rect movement. Active movements should be performed ments are important if the patient has contractures and
in front of a mirror to enable the patient to monitor and muscle imbalances.
correct motions accordingly.7°*??*! The psychosocial assessment will help the therapist
Muscle reeducation is accomplished in a graded select a treatment approach that will facilitate rehabili-
fashion. At first the patient should learn “muscle- tation efforts and the patient's adjustment to new limi-
setting” exercises—that is, alternating contraction and tations. Changes in physical capacities and curtailment
relaxation of muscles without moving the joints. Iso- of valued life skills confront the individual with psycho-
metric exercises and electromyographic (EMG) biofeed- logical issues of coping, adjustment, and adaptation.
back may be beneficial. As the patient progresses, light These changes may be as traumatic as they were at the
resistance can be applied manually by the therapist time of the original illness. Feelings of denial, anger,
before the use of resistance equipment. This approach frustration, and hopelessness must be identified and
allows the therapist to accurately assess the patient's worked through as a part of the OT intervention
physical strengths and weaknesses. program.'?
Weakened muscles must be protected at all times. As a group, persons who originally had polio
Muscles that cannot resist the forces of gravity are sup- assumed that the disease was over, that disability was in
ported during exercise and rest periods. As a rule, resis- the past, and that any residual weakness was static. They
tive exercises are not attempted until the muscle is able worked hard to overcome the effects of the initial paral-
to carry out a complete ROM against gravity. Weakened ysis and often performed well, achieved high levels
or flaccid muscles can be splinted at night to counteract of personal fulfillment, became well integrated into
the forces of gravity or the pull of the stronger antago- society, and so “disappeared” as a disabled group. The
nist muscles. During resistive exercises the therapist onset of new symptoms disrupts the performance and
should stress correct body positioning, joint alignment, lifestyle achieved by years of hard work. Such individu-
and energy conservation. Periods of rest should be in- als must deal with the onset of new limitations, and old
cluded in the exercise program. Functional activities remedies do not work to ameliorate the effects of these
that incorporate the same movements and musculature limitations. It is often difficult for the patient to con-
are encouraged.'* front the reality of these circumstances. Thus, to facili-
The goals for resistive exercises in the rehabilitation tate changes in activity patterns and introduce needed
of the patient who has poliomyelitis are to strengthen equipment, the therapist should introduce these
undamaged muscles and give usefulness to the slightest changes gradually. Small changes may be more accept-
contraction by integrating it into the global movement able than major ones, even if the latter are obviously
that permits the performance of a given activity. If the necessary.”
muscle is unable to contract completely against gravity The patient is confronted for a second time, years
after the 8-month period, it is doubtful that additional after the disability was thought to be stabilized, with the
muscle strength will return. At this point the emphasis notion of being “disabled” and with a limitation of
should be placed on maintenance of existing muscles function and valued life activities. A supportive and re-
and functional ADL. A self-care assessment should be alistic approach and patient education are the keys to
administered to determine a baseline of functioning. lifestyle modification.”*
Assistive devices should be tailored to meet the needs of The benefits of exercise are controversial. Exercise
the patient.*? may aggravate pain. Overwork of muscles that have a
decreased number of motor units may be damaging.
Postpolio Syndrome Muscles weakened by disuse, however, may benefit from
As part of the initial evaluation process, the therapist a nonfatiguing trial of gentle exercises for strengthening
performs an interview with the patient to ascertain purposes. Strength may be maintained by performance
796 TREATMENT APPLICATIONS

of ADL. Muscles being used for ADL should not be not be performed in one session. It is best to test a few
stressed further.’ Patients should be encouraged to be muscles or motions at a time and allow the patient
active within limits of comfort and safety. A regular periods of rest.
routine of activity or nonfatiguing exercise is important Particular attention should be paid to determining
and affords the patient the feeling of doing something residual weakness in the intrinsic muscles of the hands.
positive. Exercise programs must be carefully super- If swallowing or speech is impaired, an assessment of
vised, and long-term strengthening or maintenance ex- cranial nerve functions is indicated (Chapter 40).
ercise is recommended only in muscles that show no Sensory testing, including light touch, pressure, two-
EMG evidence of prior polio involvement. Further point discrimination, pain and temperature, proprio-
weakness, discomfort, pain, muscle spasm, and chronic ception, and stereognosis, should be conducted because
fatigue resulting from exercise are signs of excessive ac- the sensory pathways are often affected.
tivity.'°°° Passive ROM should begin with gentle movement of
Pain can be managed or alleviated by improving the proximal joints and should proceed only to the
body mechanics, supporting weakened muscles, and point of pain. As the patient's tolerance level increases,
promoting lifestyle modification. The occupational active ROM and light exercises may be introduced. The
therapist can teach correct body mechanics in such daily exercise program should stress joint protection, and the
living tasks as work and home management, ambula- therapist should look for muscle imbalance and substi-
tion, and transfers. Orthoses are indicated for the tution patterns. Progressive resistive exercises should be
support of weakened muscles, and lifestyle modifica- used conservatively. Throughout the course of recovery
tion reduces fatigue, stress, and activity that can cause the therapist should guard against fatigue and irritation
overuse of muscles. Weight reduction is necessary for of the inflamed nerves. As the patient's strength and tol-
some patients.'” erance level increase, resistance can be gradually and
Perhaps the most important contribution of the oc- moderately increased.
cupational therapist is the guiding and facilitating of The therapist may also introduce sedentary or table-
lifestyle modifications. Patients must avoid overuse of top activities during the early stages of recovery. As the
muscles. Assessment and retraining in all aspects of ADL patient's strength increases, activities promoting more
are important. Assistive devices for self-care and home resistance can be incorporated into the treatment
management may be indicated. Home and workplace regimen. Grooming, self-care, and other ADL should be
modifications can be important for preventing muscle included as soon as the patient is capable of some inde-
overuse and decreasing fatigue and potential deformity. pendence and should be graded to include more activi-
Energy conservation and work simplification tech- ties as strength and endurance improve. Slings and
niques should be taught. The patient and therapist mobile arm supports may be used to alleviate muscle
should set priorities on occupational role performance. fatigue and promote independence. Activities should be
Energy conservation for the most valued activities may varied between gross and fine and resistive and nonre-
mean allowing less valued ones to be performed by sistive to prevent undue fatigue.
others or with the assistance of equipment such as or- Psychological support is important throughout the
thoses, assistive devices, or ambulation aids.”” treatment program. The therapist should try to facilitate
the feeling of self-worth, a positive attitude, and encour-
Guillian-Barré Syndrome agement throughout the therapeutic process. Because
Rehabilitation is initiated once the patient is medically the prognosis for recovery is good, the activities should
stabilized. The patient may be referred to OT while still be mentally stimulating and purposeful to the patient.
totally paralyzed. During this initial phase of treatment, The therapist should also respect the patient's level of
passive ROM, positioning, and splinting to prevent con- pain tolerance during stretching and ROM exercises.*®
tracture and deformity and protect weak muscles are in-
dicated. Passive activities such as watching television
and light social activities such as visits from friends are
Peripheral Nerve Injuries
encouraged. As improvement occurs and more active General Characteristics
motion is possible, gentle, nonresistive activities and Trauma to the shoulder complex, upper extremity, or
light ADL can be introduced to alleviate joint stiffness hand may result in peripheral nerve injury. Regardless
and muscle atrophy and prevent contractures. The activ- of the origin of the injury, peripheral nerve lesions
ity program is graded according to the patient's physical produce similar clinical manifestations. Specific clinical
tolerance level. Fatigue is avoided, and psychological findings will vary with the underlying cause of the lesion.
support is provided.*7 Peripheral nerve injuries may be placed in three cate-
Since the assessment process itself may be fatiguing, gories: neuropraxia, neurotmesis, and axonotmesis.*”
it is best to spread it over the course of a few days. The Neuropraxia is a nerve lesion that is usually caused
manual muscle test or functional motion test should by orthopedic injuries (e.g., compression, concussion,
 Neurogenic and Myopathic Dysfunction 797

and traction injuries). It results in a block of neuronal depends on the nature of the nerve lesion. If the nerve
transmission, usually in the larger myelinated nerve root has been cleanly severed and surgically repaired,
fibers. Although it produces muscle paralysis, there is the rate of regeneration ranges from ‘4 inch (1.3 cm) to
usually some sparing of sensory modalities and an 1 inch (2.5 cm) per month. Peripheral nerve injuries
absence of peripheral nerve degeneration. In general, caused by burns, sepsis, or crushing will present other
neuropraxia has a good prognosis for recovery if causal complications to the healing process. Age is another
factors are removed.” factor: children usually have a faster rate of regeneration
Neurotmesis is a complete severance of the nerve than adults.””
root or division of all the essential neuronal structures. Proximal lesions regenerate faster than distal lesions,
This injury usually results from such traumatic mecha- and injuries to mixed nerves are slower to recover than
nisms as severe traction forces or open lacerations. single nerves.”’ Early medical treatment may involve
Axonotmesis represents disruption of nerve fibers suturing the nerve and immobilizing the affected ex-
(axons) causing peripheral (wallerian) degeneration. tremity to ensure good apposition of the severed nerves.
Because the epineurium and surrounding connective In the past, full recovery of muscles was not probable
tissues are preserved, spontaneous regeneration is because regenerated fibers lose about 20% of their orig-
likely to occur. Axonotmesis usually follows traction in- inal diameter and conduct impulses at a slower rate.”’*®
juries or closed fractures or dislocations or results from Advancements in microsurgery in recent years have im-
ischemia.***” proved the regenerative process.
The most obvious manifestation of peripheral nerve Because peripheral nerves have the capacity to regen-
injury is muscle weakness or flaccid paralysis, depend- erate, the course of recovery is somewhat predictable.
ing on the extent of the nerve damage. Because of the The clinical signs of regeneration do not always follow a
loss of muscle innervation, atrophy follows, and deep specific sequence. The following clinical signs of nerve
tendon reflexes are absent or depressed. Sensation along regeneration can be expected:
the cutaneous distribution of the nerve is also lost. @ Skin appearance. As the edema subsides and collateral
Trophic changes, such as dry skin, hair loss, cyanosis, blood vessels develop, the circulatory system should
brittle fingernails, painless skin ulcerations, and slow become more normalized. Skin color and texture
wound healing in the area of involvement, may be should improve.
present. @ Primitive protective sensations. The first sign of cuta-
Occasionally, minute muscle contractions called fas- neous sensation is usually the gross recognition of
ciculations may be seen on the surface of the skin overly- crude pain, temperature, pressure, and touch.
ing the denervated muscle belly. As a result of distur- @ Paresthesias (Tinel’s sign). Tapping or percussing from
bances of sympathetic fibers of the autonomic nervous distal to proximal along the course of the damaged
system, ability to sweat above the denervated.skin sur- nerve route can be used to detect recovery. If the
faces is lost. The patient may experience paresthesias— patient feels paresthesias (pins and needles) distal to
that is, such sensations as tingling, numbness, and the presumed site oflesion, regeneration is occurring,
burning or pain (causalgia)—particularly at night. In whereas a painful Tinel’s sign at the lesion may indi-
addition, if the nerve damage was caused by trauma, cate neuroma formation.”'®
edema is a prominent clinical manifestation. EMG ex- @ Scattered points of sweating. As the parasympathetic
aminations may reveal extremely small muscle contrac- fibers of the autonomic nervous system regenerate,
tions called fibrillations.°*"°""'*”" the sweat glands recover their functions.
Extensive peripheral nerve damage may produce de- @ Discriminative sensations. The more refined sensations,
formity if contractures, joint stiffness, and poor posi- such as the ability to identify and localize touch, joint
tioning are allowed to occur. Disfigurement of the position (proprioception), recognition of objects
hands is particularly noticeable and may produce some in the three-dimensional form (stereognosis), move-
psychological complications. Other complications may ment (kinesthesia), and two-point discrimination,
include osteoporosis of bone and epidermal fibrosis of should be returning at this point.
the joints. ™ Muscle tone. Flaccidity decreases and muscle tone
The medical and surgical management of peripheral increases. An important principle is that paralyzed
nerve lesions depends on the type of injury that has muscles must first sense pressure before tone and
occurred. Management may include microsurgery to movement can be realized.
suture the severed nerve, nerve grafts or transplants for @ Voluntary muscle function. The patient is able to move
severe traumatic injuries, and injections of alcohol, the extremity, first in the gravity-lessened plane. As
vitamin B,5, and phenol to alleviate the pain that might strength increases, active movement of the extremity
accompany peripheral neuropathy.°* '* through full ROM may be possible, although full re-
Peripheral nerve regeneration begins about 1 month covery of muscle power is unlikely. At this point
after the injury has occurred. The rate of regeneration graded exercises can begin.
798 TREATMENT APPLICATIONS

For complete laceration of peripheral nerves, the two- Long Thoracic Nerve Injury
point discrimination test and the wrinkle test are good The long thoracic nerve (C5-7) innervates the serratus
methods of monitoring sensory return.*” The two-point anterior muscle, which anchors the apex of the scapula
discrimination test provides a quantitative measure of to the posterior of the rib cage. Although injury to this
sensation. The normal distance to discriminate one nerve is not common, the nerve can be injured by carry-
point from two points on the distal fingertip is 2 to 4 ing heavy weights on the shoulder, neck blows, and axil-
mm. A two-point discrimination of greater than 15 mm lary wounds. The resulting clinical picture involves
denotes tactile agnosia (absent sensation). This test can winging of the scapula, difficulty flexing the out-
be performed with a commercially available two-point stretched arm above shoulder level, and difficulty pro-
discrimination instrument or a high-quality caliper with tracting the shoulder or performing scapula abduction
tips blunted so that the pain sensation is not elicited. and adduction.
Light application of the instrument to the patient's skin Injuries involving the long thoracic nerve are usually
in a random pattern can help the therapist map the cu- treated by stabilizing the shoulder girdle to limit
taneous, topographical areas that are innervated and scapula motion. The therapist must avoid using activi-
denervated. ties that promote shoulder movements. If nerve regen-
Another test that can be clinically significant is the eration is not complete, surgery may be indicated
wrinkle test. This test is performed by immersing the to relieve the excessive mobility of the scapula. After
patient's hand in plain water at 108° FE The hand remains medical treatment the occupational therapist encour-
submerged for about 20 to 30 minutes, until wrinkling ages maximal functional independence during activities
occurs. At this point the patient's hand is dried, graded and teaches the patient to use long-handled devices to
on a scale of 0 to 3, and photographed. The “0” on the compensate for shoulder limitations.
scale represents an absence of wrinkling, whereas “3”
represents normal wrinkling. The wrinkle test appears to Axillary Nerve Injury
provide an objective method of testing innervation of the The axillary nerve is composed of the C5-6 spinal nerves
hand with recent complete and partial peripheral nerve and derived from the posterior region of the brachial
injuries. The actual physiological mechanism that causes plexus. The motor branches of the axillary nerve inner-
the wrinkling is not fully understood, and the test is not vate the superior aspect of the deltoid muscle and the
appropriate for patients with traumatic peripheral nerve teres minor muscle. Although the axillary nerve is rarely
compression injuries.*” Nevertheless, the test can help damaged by itself, it is often damaged along with trau-
determine the rate of sensory regeneration and can matic lesions to the brachial plexus. As a result the
provide a graphic record of denervated areas. patient has weakness or paralysis of the deltoid muscle,
which causes limitations in horizontal abduction and
Brachial Plexus Injury hyperesthesia on the lateral aspect of the shoulder. In
The nerve roots that innervate the upper extremity orig- addition to the loss of muscle power, atrophy of the
inate in the anterior rami between the C4 and T1 spinal deltoid muscle produces asymmetry of the shoulders. If
segments. This network of lower anterior cervical and the nerve damage is permanent, muscle transplantation
upper dorsal spinal nerves is collectively called the may be necessary to provide some abduction of the
arm.°®3
brachial plexus. This important nerve complex can be
palpated just behind the posterior border of the stern- The occupational therapist should maintain ROM to
ocleidomastoid as the head and neck are tilted to the prevent deformity and improve circulation. Passive ab-
opposite side.°’*7°4° duction of the shoulder should be performed daily. The
Lesions to the brachial plexus usually result from a teres minor and deltoid muscles should be protected
variety of traumatic injuries. Most brachial plexus in- from stretch during the passive ROM .activities. The
juries in children are caused by birth trauma. Such in- patient may be taught to use long-handled assistive
juries are called Erb’s palsy and Klumpke’s paralysis. Erb’s devices to compensate for the abduction deficit. If a sur-
palsy is indicative of lesions to the fifth and sixth gical transplant is performed, the therapist should be fa-
brachial plexus roots. Paralysis and atrophy occur in the miliar with the surgical procedure and assist in muscle
deltoid, brachialis, biceps, and brachioradialis muscles. reeducation. An EMG biofeedback machine can be ben-
Clinically the arm hangs limp, the hand rotates inward, eficial in providing the patient with visual and auditory
and functional movement is extremely limited. incentives during muscle reeducation sessions.
Klumpke’s paralysis affects the more distal aspect of The occupational therapist may also assist the patient
the upper extremity. The disorder results from injury to in dressing activities. If the asymmetry of the shoulders
the eighth cervical and first thoracic brachial plexus presents a cosmetic problem when wearing shirts or
roots. Consequently there is paralysis to the distal mus- jackets, a foam rubber or thermoplastic pad can be fab-
culature of the wrist flexors and the intrinsic muscles of ricated to fill in the space that was once occupied by the
the hand.° deltoid muscle. The patient should be encouraged to
 Neurogenic and Myopathic Dysfunction 799

learn self-ranging techniques and to implement an exer- noise.’ Causalgia is also exacerbated by emotional
cise program, to maintain the integrity of the unim- stress. Because of the origin of the pain in the sympa-
paired muscles of the involved extremity. thetic division of the autonomic nervous system, even
Lesions of the radial, median, and ulnar nerves and mood changes alter the pain sensitivity levels.'*
cumulative trauma disorders affecting the hand are dis- Neuromas are incompletely regenerated nerve end-
cussed in Chapter 44. ings and fibers at the site where the peripheral nerve was
damaged. Neuromas are a particular problem in nerve
Volkmann's Contracture endings serving the fingers and in amputated limbs.
A fracture of the lower end of the humerus (supra- Phantom limb pain is often the result of neuroma for-
condylar region) may result in a diminished supply of mation. Neuromas are exquisitely painful and tender
well-oxygenated blood to the muscles of the forearm. when they develop in the extremities that bear weight or
This phenomenon can occur when the fracture has been are easily traumatized. In some cases, surgical resection
tightly cast and bandaged. Edema occurs near the site of is necessary to remove neurons that adhere to fascia and
the injury and shuts down the blood supply to the subcutaneous tissue.
muscle bellies because the site of injury cannot swell
outward. Ischemia deprives tissues of oxygen and
nourishment. The muscle can become necrotic, causing
Occupational Therapy Intervention
atrophy and contractures of the wrist, fingers, and Peripheral Nerve Injuries
forearm. The flexor digitorum profundus and flexor pol- The aim of the treatment of peripheral nerve injuries is
licis longus muscles are severely affected. The median to help the patient regain the maximal level of motor
nerve is often more impaired than the ulnar nerve.*° function and independence in all occupational per-
Shortly after a fracture of the humerus has been im- formance areas. Treatment is directed to the stage of re-
mobilized, the patient may have a cold, distal extremity covery and to remediation and compensation for
with a smooth, glossy, or dusky appearance of the skin. sensory, motor, and performance deficits. The rate of
If the therapist observes these symptoms and cannot return and the residual impairments depend largely on
detect a radial pulse, the physician should be informed the severity of the lesion and the quality of care during
immediately and the cast should be removed. Early de- the rehabilitation process. For treatment to be effective,
tection and prevention of this problem can eliminate a the therapist must know the anatomy and innervation
severe deformity. If, for example, the ischemia-lasts 6 of the affected part and be able to assess the pattern of
hours, some contracture will follow. Ischemia lasting 48 paralysis and its effects on function. Table 42-1 is a
hours or more results in a permanent deformity of the useful summary of the major nerve roots and the clini-
forearm. If mild ischemia has occurred, the physician cal manifestations of their lesions.
may prescribe vigorous, active exercises to increase cir- The occupational therapist may be involved during
culation, activate the musculature, and prevent joint the acute and rehabilitation phases of treatment.
stiffness.° During the acute postoperative phase, treatment is
aimed at preventing deformity. Static splints are used
Peripheral Nerve Pain Syndromes initially to immobilize the extremity and protect the
Pain is a common complication in peripheral nerve in- site of injury. (Chapter 44 provides more information
juries.” For some patients the pain itself becomes an on postoperative management of peripheral nerve
overwhelming disability. The pain syndromes that have repair.*’’*°) During this phase the reduction of edema is
been associated with peripheral nerve injuries are important, and this is achieved by elevating the extrem-
causalgia and neuroma pain.*”’**’”* Causalgia is pain of ity above the level of the heart. This decreases the hy-
great intensity originating from peripheral lesions af- drostatic pressure in the blood vessels and promotes
fecting the fibers of the autonomic nervous system.'* venous and lymphatic drainage.
Causalgia most commonly results from injury to the Manual massage while the extremity is elevated may
brachial plexus or the sciatic, tibial, median, or ulnar also reduce edema. The massage should entail cen-
nerve. Because the sympathetic and parasympathetic tripetal strokes to gently force the excess fluids toward
fibers travel in the walls of blood vessels until they reach the proximal aspects of the body. Care must be taken
their respective organs, the pain can radiate to quad- not to disturb the healing process of the site of injury.
tants of the body served by these major blood External elastic support can also be used to alleviate the
vessels. ‘7/77 edema, and passive ROM will help prevent edema by
In the upper extremity, causalgia is described as an promoting venous return.*”
intense burning sensation so excruciating that the As the patient’s muscle function returns, an appro-
patient holds the affected limb immobile for fear of priate exercise program can be established. Functional
stimulating the pain. The affected limb becomes ex- activities that involve resistance are used in conjunc-
tremely sensitive to temperature change, wind, and even tion with isometric and isotonic exercises when muscle
 TREATMENT APPLICATIONS

tations of Peripheral Nerve Lesions

Spinal Nerves Nerve Roots Motor Distribution Clinical Manifestations
Brachial plexus
C5-7 Long thoracic Shoulder girdle, serratus anterior Winged scapula

C5-6 Dorsal scapular Bh omocd major and minor, levator, scapulae Loss of scapular adduction and elevation

C7-8 Thoracodorsal Latissimus dorsi Loss of arm adduction and extension

C5-6 -Suprascapular Supraspinatus, infraspinatus Weakened lateral rotation of humerus

C5-6 Subscapular Subscapularis, teres major Weakened medial rotation of humerus

C6-8,T | Radial All extensors of forearm, triceps Wrist drop, extensor paralysis

C5-6 Axillary Deltoid, teres minor Loss of arm abduction, weakened lateral
rotation of humerus

C5-6 Musculocutaneous Biceps brachii, brachialis, coracobrachialis Loss of forearm flexion and supination

C6-8,T | Median Flexors of hand and digits, opponens pollicis Ape hand deformity, weakened grip, thenar
atrophy, unopposed thumb

GB iT I Ulnar Flexor of hand and digits, opponens pollicis Claw hand deformity, interosseus atrophy, loss of
thumb adduction

Lumbosacral Plexus
L2-4 Femoral lllopsoas, quadriceps femoris Loss of thigh flexion, leg extension

L2-4 Obturator Adductors of thigh Weakened or loss of thigh adduction

L4-5, S|-3 Sciatic Hamstrings, all musculature below the knee Loss of leg flexion, paralysis of all muscles of leg
and foot

L4-5,S1-2 Common peroneal _ Dorsiflexors of foot Foot drop, steppage gait, loss of eversion

L4-5,S1-3 Tibial Gastrocnemius, soleus, deep plantar flexors Loss of plantar flexion and inversion of foot
of foot

Data from references 3, 4, 6, 8,9, 13,21, 28, 36, 41, 45, 50.

function is adequate. The therapist should not overtax Peripheral Nerve Pain Syndromes
the returning musculature and should protect the Pain is perceived by the conscious mind when painful
weaker muscle groups from stretch and fatigue. The stimuli travel from pain receptors (nociceptors) along
therapist may fabricate splints or slings to protect weak- ascending pathways to the thalamus and.to the cerebral
ened musculature, prevent overstretching, and maintain cortex. Research on pain management has revealed that
functional position. certain activities and noninvasive techniques can modu-
ADL assessment is necessary to identify difficulties late pain perception.****** A better understanding of
with essential performance tasks. One-handed methods pain control mechanisms and the discovery of endoge- ~
of dressing, eating, and hygiene activities may be neces- nous opiate-like substances (e.g., endorphins, enkeph-
sary On a temporary or permanent basis. Assistive alins, and substance P) in the body have provided ther-
devices, such as long-handled reaching aids and one- apists with new techniques for patients with peripheral
nerve painga areas
handed kitchen tools, can be provided to increase inde-
pendence in self-care ADL and IADL skills. Since pain resulting from peripheral nerve injury can
Sensory reeducation is used to help the patient estab- interfere with compliance with therapeutic interven-
lish appropriate responses to sensory stimuli. Sensory tion, it is important for the occupational therapist to be
reeducation for peripheral nerve injuries is discussed in able to participate in and assist the patient with pain
Chapters 25 and 44. management strategies.
 Neurogenic and Myopathic Dysfunction 801

The therapist must first assess the intensity, quality, bodies in the limbic system, which go on to transmit to
and location of pain. This can be done by having the the midbrain.'"7°?’*?
patient mark the point of pain on an anatomical The first cortical modulating system is very respon-
drawing and then estimate pain intensity on a numeri- sive to physical and emotional stress. Consequently,
cal scale. The patient is asked to describe the personal stress increases blood concentrations of catecholamines
perception of pain using terms such as sharp, dull, (dopamine, epinephrine, and norepinephrine) via the
aching, throbbing, sore, or burning. Factors that seem to autonomic nervous system, which triggers the release of
contribute to pain should also be explored during the enkephalins that inhibit transmission of afferent in-
interview. These factors might include specific foods terneurons in the dorsal gray matter. The second cortical
and drinks, positions, and activities.** modulating system, involving the limbic system and
Several intervention techniques can alter pain mes- midbrain, responds by releasing endorphins to inhibit
sages or neuronal transmission within these pathways. pain transmission.'’”*”** The release of these endoge-
Peripheral pain emitting from neuromas can be allevi- nous opiates (enkephalin and endorphins) demon-
ated by increased input to mechanoreceptors in the strates the effectiveness of purposeful activities to mod-
skin. The therapist can increase mechanoreceptor input ulate the perception of pain.
using one or more of the following techniques: By involving the patient in successful and purposeful
1. Graded light, local percussion, and therapeutic vibra- activities, the occupational therapist provides cognitive
tion over neuromas. '’7**? diversion from the pain experience. Engagement in pur-
2. Transcutaneous electrical nerve stimulation (TENS) poseful activities can influence moods and emotions, an
to provide relief from pain related to neuromas, pe- effect that in turn alters the perception of pain intensity
ripheral nerve injuries, residual limb pain, and and ultimately modifies the pain threshold.'%?*?7*?
phantom limb syndromes'”*® The occupational The therapist can also use background music or music
therapist who has been appropriately trained can use delivered via headphones as a therapeutic modality.
TENS when it is prescribed by a physician. With ap- While the patient is engaged in activities, the volume of
propriate training, localized stimulation to acu- the music can be increased or decreased to accommo-
points and trigger points can also be used to modify date pain intensity. This provides a control factor over
neuroma pain.*”’** the pain stimulus because concentration on music
3. Protection of the painful regions of the body. The affects the cortical modulating system through connec-
therapist can fabricate protective devices from splint- tions with the limbic system.*7
ing materials. f Causalgia is related to tension and stress. To decrease
4. Some patients find relief when the extremity is feelings of stress and anxiety, the therapist can instruct
wrapped with a cloth material that has been soaked the patient in such relaxation techniques as deep
in water.” breathing, progressive relaxation, and visualization.”’'*
These approaches work because when the sensory When the relaxation response is elicited, the patient's
neurons transmitting pain messages synapse in the muscles relax, the heart rate and respiration rate de-
dorsal horn of the spinal cord to secondary neurons in crease, and the patient experiences a sense of well-
the dorsal gray matter, substance P, one of the opiate- being. By learning relaxation techniques, the patient can
like neurotransmitters, is released. Increased input to control emotional tension and depression, both con-
the mechanoreceptors in the skin inhibits the release of tributors to causalgia and the perception of pain.”
substance P.*°*?
Pain management for causalgia uses a different ra- DISEASE OF THE NEUROMUSCULAR
tionale and different neurophysiological systems. Caus- JUNCTION
algia arises from the autonomic nervous system. In-
creased activity in the sympathetic division of the Myasthenia Gravis
autonomic nervous system exacerbates causalgia. In Myasthenia gravis is a disease of chemical transmission
addition, the neuronal connections to the limbic at the nerve-muscle synapse or neuromuscular junction.
system suggest that emotions play an important role in It is caused by an autoimmune response in which anti-
Gausalgia,?'?27-7° bodies are produced against nicotinic acetylcholine
The neurophysiological rationale for alleviating (ACh) receptors and interfere with synaptic transmis-
causalgia is complex because it involves at least two dis- sion at the nerve-muscle junction. Because neurotrans-
tinct systems. Both systems originate in areas of the mission is defective, there is weakness of skeletal
cortex. One system is more direct, in that it projects to muscle.** Myasthenia gravis occurs at all ages but pri-
neurons in the reticular formation and to motor path- marily affects younger women and older men.'**°
ways terminating on excitatory and inhibitory neurons A majority of patients with myasthenia gravis have en-
in the dorsal gray matter of the spinal cord. The other larged thymus glands, and some have tumors ofthe thy-
system includes neurons in the cortex projecting to cell mus gland. Removal of the thymus gland (thymectomy)
802 TREATMENT APPLICATIONS

reduces symptoms or causes remission in about 50% of medication. The therapist should also report to the
patients, and this procedure has become standard physician any changes in the patient's physical appear-
therapy. Patients are also treated with anticholinesterase ance, such as ptosis of the eyelids, drooping facial
drugs, glucocorticoids, and other immunosuppressive muscles, or alterations of breathing or swallowing.
pharmacological agents.**’”’ Plasmapheresis, a proce- The therapist should provide gentle, nonresistive ac-
dure that entails filtering the blood to remove the IgG tivities that are intellectually and psychologically stimu-
autoantibodies, is sometimes used for patients with lating. The activities should be graded so they do not
severe disease who have failed to respond to other ther- fatigue the patient. Overexertion must be avoided and
apeutic measures and in seriously ill patients before respiratory problems prevented. The treatment plan
thymectomy.””17'®° should include energy conservation, work simplifica-
Myasthenia gravis is characterized by abnormal tion, and adaptive and assistive devices necessary to
fatigue of voluntary muscle.'* The disease can affect any reduce effort during daily activities. If appropriate,
of the striated skeletal muscles of the body, but it has an electronic communication devices can be installed in
affinity for the muscles of the eyelids and eyes and the patient's home so that contact with community
oropharyngeal muscles. Therefore the muscles most agencies can be maintained. In addition, the therapist
often affected are those that move the eyes, eyelids, may assist with home planning to determine architec-
tongue, jaw, and throat. The limb muscles may also be tural barriers, bathroom adaptations, and furniture re-
affected. The muscles that are used most often fatigue arrangements. Mobile arm supports and splints may be
sooner.'*’**! Therefore the patient may have double used to protect weakened musculature from overstretch-
vision, drooping of the eyelids, and difficulty with ing and aid in positioning for function.**
speech or swallowing as muscles fatigue. Patients with The therapist should assist in educating the patient
myasthenia gravis may experience life-threatening respi- about the disease. The patient should avoid emotional
ratory crises, which require hospitalization and use of a stress, overexertion, fatigue, and excessive heat or cold
ventilator. The incidence of these crises has declined sig- because they may exacerbate the symptoms of the
nificantly in recent years, probably because of increased disease. The therapist should also follow infection
use of thymectomy.**”' The intensity of the disease fluc- control procedures because minor infections can also
tuates, and its course is unpredictable.” exacerbate the symptoms.
Spontaneous remissions occur frequently, but relapse
is usual.® Remissions or a decrease in symptoms and an MYOPATHIC DISORDERS
improvement in strength and function can last for years.
However, exertion, infection, or childbirth may induce Muscular Dystrophies ~
exacerbations of unpredictable severity.** The prognosis The muscular dystrophies are a group of uncommon in-
for myasthenia gravis varies with each individual. For herited conditions. There are four major types of mus-
most people it is a progressively disabling disease, and cular dystrophy (MD).**" They have in common the
the patient may ultimately become confined to bed progressive degeneration of muscle fibers while the neu-
with severe permanent paralysis. Death usually occurs ronal innervation to muscle and sensation remain
as a result of respiratory complications.°*~*? intact. As the number of muscle fibers declines, each
axon innervates fewer and fewer of them, resulting in
Occupational Therapy Intervention progressive weakness.”
The primary role of the occupational therapist is to help
the patient regain muscle power and build endurance. Duchenne’s Muscular Dystrophy
The therapeutic program should not cause fatigue; Duchenne’s MD is inherited as an X-linked recessive
therefore the therapist must be aware of the patient's trait and affects males only. The disease begins at birth
medication regimen and ability to tolerate activity and and is usually diagnosed between the ages of 18 and 36
the time of day that the patient has the most energy. The months. It begins in the muscles of the pelvic girdle and
patient's muscle strength must be monitored on a legs, then spreads to the shoulder girdle. Calf muscles
regular basis; however, the therapist need not assess all appear hypertrophic because of the infiltration of fat
of the muscles during one session because the evalua- cells that accompanies degeneration of muscle fibers.
tion contributes to fatigue. Instead, the therapist can test The child has difficulty walking, has a waddling gait,
the strength of a few muscles during each visit and keep and usually must use a wheelchair by age 12. Ultimately
a running record to note any important changes. the child becomes confined to bed; death usually occurs
If the patient is taking oral cholinergic drugs, optimal by the age of 30.7447!
strength is expected about 1 or 2 hours after the medica-
tion has been ingested.* Therefore the therapist should Facioscapulohumeral Muscular Dystrophy
coordinate muscle testing with the drug treatment Facioscapulohumeral MD has its onset in adolescence
regimen so the test results are not confounded by the and affects primarily the muscles of the face and shoul-
 Neurogenic and Myopathic Dysfunction 803

der girdle—hence its descriptive name. It progresses ments. Deficits in cognitive function and verbal intelli-
slowly, and there is a normal life expectancy for those gence have been reported in some types of MD. Depres-
affected.” The disease is inherited through an autoso- sion and other personality abnormalities may be con-
mal dominant gene and affects males and females comitant problems." Patient and family education is an
equally.** important part of the OT program. A supportive ap-
proach to the patient and family is helpful as function
Myotonic Muscular Dystrophy changes and new mobility aids, assistive devices, and
Myotonic MD not only causes weakness but has another community resources become necessary.**
component, myotonia (tonic spasm of muscles), that
makes relaxation of muscle contraction difficult. It is in-
SUMMARY
herited through an autosomal dominant gene and
affects males and females. Its unique features, besides The motor unit consists of the lower motor neuron,
the myotonia, are that it involves the cranial muscles neuromuscular junction, and muscle. Some motor unit
and that the limb weakness tends to be distal rather dysfunctions are reversible, and others are degenerative.
than proximal. Associated symptoms are cataracts, The role of the occupational therapist is to assess func-
found in almost all patients, and testicular atrophy and tional capabilities in all occupational performance
baldness in men. The disease may be mild or severe and areas. ADL and IADL skills (including self-care, home
can occur at any age.**”*! management, mobility, and work-related tasks), energy
conservation, work simplification, and joint protection
Limb-Girdle Dystrophy techniques are used to restore function. Proper posi-
Limb-girdle MD is a group of disorders that do not fit tioning, exercise programs, and pain management tech-
readily in the other types described. Affected persons niques are used as indicated to facilitate recovery and
differ in age at onset, extent of weakness, and familial increase functional capacity. Orthoses, assistive devices,
inheritance patterns. The disease is inherited as an auto- communication aids, and mobility equipment and
somal recessive gene." training in their use may be necessary. Psychosocial con-
siderations and patient and family education are impor-
OCCUPATIONAL THERAPY INTERVENTION. tant aspects of the OT program.
Because this group of diseases is degenerative, the
decline of muscle function cannot be prevented.
Medical management is largely supportive, and rehabil-
itation measures are vital in delaying deformity and
CASE STUDY 42-1
achieving maximal function within the limits of the Case StuDY—Ms. J.
disease and its debilitating effects. The primary goal of Ms, J. is a 23-year-old, African-American woman who received a
OT is to help the patient attain maximal independence diagnosis of Guillian-Barré syndrome 6 weeks before her admis-
in ADL for as long as possible. Self-care activities and as- sion to rehabilitation. She was admitted to the acute care hospi-
sistive devices for independence and leisure activities tal with progressive weakness of both the upper and lower ex-
are a vital part of the treatment program.** tremities. She reported the presence of flu-like symptoms for |
week prior to the onset of weakness in her hands and feet.
Wheelchair prescription and mobility training in
Ms.J.is unmarried and has two children; one is 7 years old and
either a manual or power wheelchair are included in the
the other is 4 months old. She lives in a two-bedroom apartment
OT program. The wheelchair may require a special that is in a wheelchair accessible building. She and her children
seating system or supports to minimize the develop- are presently living with her parents. Ms.J.worked as a waitress In
ment of scoliosis, hip and knee flexion contractures, a coffee shop near her home. Her leisure interests include
and ankle plantar flexion deformity. A wheelchair lap reading to her children, watching television, shopping, and sewing.
board, suspension slings, or mobile arms supports are She has || years of formal education and was pursuing a general
indicated to facilitate self-feeding, writing, reading, use education development certificate (GED). Ms. J. was referred to
of a computer, and tabletop leisure activities when there occupational therapy for evaluation and treatment. During the
is substantial shoulder girdle and upper limb weakness. initial interview it became apparent that she was having some dif-
Built-up utensils may be helpful when grip strength de- ficulty accepting the loss of physical ability and function. She did
not understand the nature of her disease or its prognosis. Her
clines.*7 Home and workplace modification may be
goals for the rehabilitation program included returning to her
necessary for some patients. " own apartment, caring for her children, returning to work, and
Active exercise may be helpful, but overexertion and continuing to pursue a GED. She stated that her family is involved
fatigue must be avoided. For patients with respiratory and would be willing to provide assistance should she require it.
involvement, exercise for breathing control may be ad- Results of the occupational therapy (OT) evaluation indicated
ministered by the physical therapist.* that Ms.J.is alert, oriented, cooperative, and motivated. Cognition
The occupational therapist also addresses psychoso- is intact. Before her illness she was independent in all areas of
cial problems and educational and vocational require- ADL and IADL. Active and passive range of motion are within
Continued
 TREATMENT APPLICATIONS

5. Describe Guillain-Barré syndrome and the occupa-

CASE STUD’ tional therapy interventions used for patients with
this disorder.
normal limits (WNL) and muscle strength is fair (F or 3) for both
upper extremities (BUE). Lower extremity strength is fair (3). 6. List at least six clinical manifestations of peripheral
Sensation is intact. However, she complains of numbness, tingling nerve injury.
and burning in BUE. Fine motor coordination is impaired, as evi- 7. Describe the sequential signs of recovery following
denced by inability to do clothing fasteners. Dynamic sitting peripheral nerve injury.
balance is minimally impaired because of trunk weakness and de- 8. Describe the occupational therapy treatment strate-
conditioning. Standing balance is severely impaired because of gies, including any contraindications, for peripheral
lower extremity (LE) weakness. Ms. J. is able to roll in bed and nerve injuries.
move from supine to sitting using the bed rails. Transfers to all 9. Differentiate between causalgia and neuroma.
surfaces require moderate assistance because of generalized 10. Describe four noninvasive methods of modulating
weakness and LE pain. Ms. J. is independent in feeding. She re-
pain perception that may be used by the occupa-
quires set up for grooming, minimal assistance with UE dressing,
tional therapist.
and moderate assistance with LE dressing, bathing, and toileting.
She complains of pain and generalized weakness that interfere 11. Discuss the clinical signs of myasthenia gravis.
with performance of activities. Ms. J.is not ambulatory at this time 12. Describe the role of occupational therapy for pa-
because of weakness and deconditioning. tients who have myasthenia gravis.
OT was initiated to improve mobility and transfers; improve 13. What is the primary treatment precaution in myas-
functional performance of ADL and IADL activities; improve thenia gravis?
patient's awareness of the disease process and prognosis for re- 14. Name and differentiate four types of muscular dys-
covery of function; increase muscle strength and coordination in trophy. Which one primarily affects children?
both UEs; decrease pain in LEs. 15. What are the treatment goals for muscular dystro-
OT intervention included transfer training, ADL and IADL
training, patient education related to Guillian-Barré Syndrome,
phy?
energy conservation and work simplification techniques, a thera-
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and UE strength for modified work activities (cashier rather than Saunders.
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 Neurogenic and Myopathic Dysfunction 805

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CHA

KEY TE LEARNING OBJECTIVES

Connective tissue After studying this chapter the student or practitioner
Inflammation will be able to do the following:
Chronic 1. Identify common symptoms and differences
Autoimmune between arthritis, osteoarthritis, and fibromyalgia.
Systemic 2. Identify common joint and hand deformities seen
Synovitis in osteoarthritis and rheumatoid arthritis.
Osteophytes 3. Recognize medications commonly used in the
Crepitation treatment of arthritis and the side effects of the
Joint laxity medications.
4. Recognize surgical interventions commonly
performed on persons with rheumatoid arthritis.
5. Identify the psychological effects of arthritis.
6. Identify important areas to evaluate in patients
with arthritis.
7. Identify treatment objectives of occupational
therapy intervention for persons with arthritis.
8. Identify appropriate preventive, compensatory,
and restorative treatment methods for persons
with arthritis, based on diagnosis, stage of disease,
functional limitations, type of deformity(ies),
and lifestyle.
9. Identify resources helpful to persons with arthritis.
10. Identify treatment precautions.

DESCRIPTION OF MAJOR ARTHRITIC

DISEASES
Ithough arthritis literally means joint inflamma- Rheumatoid Arthritis
tion, the term is used to describe many different condi- Rheumatoid arthritis (RA) is a chronic, systemic au-
tions that cause aching and pain in joints and connective toimmune disorder. In response to the body’s immune
tissues throughout the body. Many of these diseases, system activity, the joint lining becomes inflamed. The
such as osteoarthritis, do not involve inflammation. chronic inflammation causes pain, deterioration of the
Three of the most prevalent forms ofarthritis are rheuma- joint, and limited movement.' The course of the disease
toid arthritis, osteoarthritis, and fibromyalgia.’'® is different for each person. Some people have a single

rolO16)
 Arthritis 807
Osteoarthritis (Degenerative
episode of joint inflammation and a long-lasting remis-
Joint Disease)
sion. The majority of persons with RA have inflamma-
tion of the joints over long periods of time. The disease Osteoarthritis (OA) is a disease that causes the break-
process may progress continuously and slowly or may down of cartilage in joints, leading to joint pain and
consist of series of “flare-ups,” or exacerbations, and stiffness. Unlike RA, OA is not inflammatory or sys-
complete or incomplete remissions. Remissions provide temic, but limits its attack to individual joints. It is often
a period of pain relief, but this does not mean the con- referred to as the “wear and tear” disease, because the
dition has been cured; it may flare up again. In addition, involved joints wear down with age or overuse. Up to
any damage done during an active stage remains. The the age of 45, OA is more common in men; beyond age
patient's functional skills may vary, depending on the 54, it is more common in women.? It is also interesting
course of the disease and the severity of the symp- to note that because rheumatoid arthritis may cause
tams.>"* malalignment or instability of the weight-bearing
The systemic symptoms characteristic of RA include joints, it often results in premature osteoarthritis.’
fatigue, loss of appetite, fever, overall aching or stiffness, In osteoarthritis the breakdown of joint tissue occurs
and weight loss. Morning stiffness, an overall stiffness in several stages. First, the smooth cartilage softens and
that occurs on awakening, is another indicator of sys- loses its elasticity. This allows it to be more easily
temic involvement. The severity of the systemic symp- damaged. Eventually, large sections of the cartilage wear
toms usually matches the severity of joint involvement. away completely and permit the bones to rub together,
As in many chronic diseases, there may also be a result- causing pain. The joint may lose its normal shape. As
ing depression or lack of motivation. In a small percent- the ends of the bone thicken, spurs (bony growths) are
age of persons the blood vessels, heart, lungs, or eyes are formed where the ligaments and capsule attach to the
involved.*’*18 bone (Fig. 43-1). These are also referred to as osteo-
The cause of RA is unknown. It occurs most fre- phytes. Fluid-filled cysts may form in the bone, near the
quently between the ages of 30 and 40, and women joint. Bits of bone or cartilage may float loose in the
are three times more commonly affected than men.*° joint space. The joint becomes stiff or unstable, and
Its outstanding clinical feature is synovitis, or inflam- joint motion becomes restricted and painful. Occasion-
mation of the synovial tissue surrounding the joints. ally the process of osteoarthritis causes irritation of the
The function of the synovial tissue is to produce fluid joint, and local inflammation may occur.”’'®
to lubricate the joint. Joint swelling results from an Osteoarthritis can affect any joint and is most fre-
abundance of synovial fluid, enlargement of thé syn- quently seen in the weight-bearing joints of the hips,
ovium, and thickening of the joint capsule. This knees, and spine and the metatarsophalangeal joint of
weakens the joint capsule, tendons, and ligaments. In- the big toe, producing bunions.~” In the hand, the DIP
flamed joints will be warm, swollen, tender, often red, joints, PIP joints, and the carpometacarpal (CMC)
and difficult or painful to move. The affected person joint at the base of the thumb are most likely to be af-
usually has a loss of range of motion (ROM), strength, fected. Hip and knee involvement causes the most
and endurance. As the inflammation continues, it severe disability and may necessitate surgery for joirt
invades the cartilage, bone, and tendons and secretes replacement.
enzymes that damage them. If the inflammation is not The symptoms of OA usually begin slowly and may
stopped, the cartilage, bone, tendons, and ligaments appear as a minor ache or soreness with movement.
surrounding the involved joint(s) can be destroyed. Pain is most frequently felt in the affected joint(s) after
Scar tissue can form between the bone ends, and the overuse or long periods of inactivity. The joint becomes
joint can become fused, permanently rigid, and im- stiff, although movement is possible. If the joint is not
movable.*"*'® moved, surrounding musculature becomes weak. Coor-
Joint involvement is frequently bilateral.” If one dination and posture may also be impaired.*”
hand is involved, the other one is also. However, the Degenerative joint disease occurs to some degree
disease progression is often different on the two sides. among many people over the age of 60. Although it is
One side may be more involved and have different de- most common in the elderly, other factors such as
formities than the other. The joints most affected by RA obesity, heredity, injury, and overuse ofjoints can aggra-
are the wrist, thumb, and hand. RA is frequently seen in vate the disease process.~””’'®
the proximal interphalangeal (PIP) and metacarpopha-
langeal (MP) joints, while the distal interphalangeal
Fibromyalgia
(DIP) joints are usually spared severe damage. The
elbows, shoulders, neck, jaw, hips, knees, ankles, and The use of the term fibromyalgia and its definition are
feet also may be involved. The spine is usually not di- relatively recent events, although its symptoms have
rectly affected.*””’'® been discussed since the early 1900s.*° In fibromyalgia,
ro}OTe) TREATMENT APPLICATIONS

Early Stage Late Stage

of Disease

BY=Yo(=\al=ye- ele)
of Cartilage

(OFlaileel=

FIG. 43-1
Joint involvement in osteoarthritis. (From ARHP Arthritis Teaching Slide Collection,
American College of Rheumatology.)

widespread pain affects the muscles and attachments to seven criteria or clinical manifestations of the disease
the bones. In addition to pain, symptoms may include for the diagnosis of RA to be made (Table 43-1). One
fatigue, sleep disturbance, depression and anxiety, criterion is the presence of rheumatoid factors in the
headaches, morning stiffness, irritable bowel syndrome, blood. Rheumatoid factors are autoantibodies that
bladder irritability, numbness and tingling in extremi- appear in 75% to 90% of patients with RA. These pa-
ties, circulatory problems, and cold intolerance.”® tients are said to have seropositive RA. The presence of
Some 3.7 million Americans have fibromyalgia, and rheumatoid factors in the blood correlates with in-
the condition affects men, women, and children. It creased severity of symptoms and increased involve-
occurs most often in people between the ages of 20 and ment of systemic symptoms.’°
55 and affects women 10 times more frequently than
men.*° The presence of other rheumatic diseases puts Osteoarthritis
one at greater risk of having fibromyalgia. For example, A thorough physical examination confirms typical
in 20% of those with RA, fibromyalgia develops.** symptoms, and lack of systemic symptoms rules out an
The cause of fibromyalgia is not known. Theories to inflammatory joint disorder. X-ray examination of the
explain the underlying cause include (1) previous affected joint can confirm joint damage. However, the
trauma affecting the central nervous system’s response degree of radiological evidence of joint involvement
to pain, (2) infections, (3) lack of or overuse of exercise, does not necessarily correlate with the amount of pain
and (4) hormonal influences.*® and discomfort experienced by the patient.'® The classi-
fication criteria for osteoarthritis of the hand may be
seen in Box 43-1.'° ;
Diagnosis
Physicians diagnose arthritic diseases based on the Fibromyalgia
overall pattern of symptoms, a medical history, and the Classic symptoms of fibromyalgia include a history of
results of a physical examination, x-ray examinations, widespread pain that is present for at least 3 months
and laboratory tests. Definitive diagnosis may not be pos- on both sides of the body, above and below the waist.
sible at onset because of the large number of connective Another classic symptom is pain in at least 11 of 18
tissue disorders with similar symptoms. In most cases, it “tender point” sites (Box 43-2).*° Tender points are
takes weeks or even months for the constellation of areas of the body that are painful when pressed. The
symptoms to develop and eventually be diagnosed.'*'° most distinctive characteristic of fibromyalgia is the
presence of tender points at the base of the skull,
Rheumatoid Arthritis above and between the shoulder blades, below the
The American College of Rheumatology criteria for clas- elbows, in the lower back, on the hips, and behind the
sification of RA require that the patient show four of knees.
 Arthritis

(@igie-\arWie)eias(-M@EK
iile-tafelamelm svat-lelaarinel(e Pverican College of Rheumatology
Arthritis (GiFash ile-talelem @iain-)a fie)al@kia-torlaualatats
Definition fo)aaa\=¥ msElale!
Morning stiffness in and around the
joints, lasting at least | hour before
maximal improvement Hand pain, aching, or stiffness and three or four of the
following features:
hritis of three At least 3 joint areas simultaneously @ Hard-tissue enlargement of two or more of |0 selected
; have had soft-tissue swelling or fluid joints.
(not bony overgrowth alone) @ Hard-tissue enlargement of two or more DIP joints.
observed by a physician. The |4 ~ Ml Fewer than three swollen MP joints.
possible areas are right or left PIP @ Deformity of at least | of 10 selected joints.
MP. wrist, elbow, knee, ankle, and
MTP joints. From http://www.rheumatology.org/classifi/oshand.html.
_ Arthritis of hand joints — At least | area swollen (as defined The 10 selected joints are the second and third distal interphalangeal (DIP),
the second and third proximal interphalangeal, and the first carpometacarpal
ae ne above) in a wrist, MP or PIP joint.
joints of both hands. This classification method yields a sensitivity of 94% and
Symmetrical arthritis Simultaneous involvement of the a specificity of 87%.
same joint areas (as defined in 2) on MP, Metacarpophalangeal.
both sides of the body (bilateral
involvement of PIPs, MP or MTPs is
acceptable without absolute
symmetry)
common deformities and the associated disease
Rheumatoid nodules Subcutaneous nodules over bony follows.
prominences or extensor surfaces Crepitation is seen in both RA and OA and occurs as
or in juxtaarticular regions, observed the joints degenerate. It is characterized by a grating,
by a physician crunching, or popping sensation (or sound) that occurs
Serum rheumatoid Demonstration of abnormal during joint or tendon motion. When the presence of
factor amounts of serum rheumatoid” crepitus is documented, the location and motion that
factor by any method for which the - caused the sensation should be noted.”'®
result has been positive in more
than 5% of normal control subjects OSTEOARTHRITIS
Radiographic changes Radiographic changes typical of In osteoarthritis, osteophytes may form in the fingers
rheumatoid arthritis on or at the base of the thumb.””'® This indicates that car-
posteroanterior hand and wrist tilage damage has occurred. Osteophytes are hard to the
radiographs that must include touch and generally not painful. They are most com-
erosions or unequivocal bony monly seen at the DIP joint and are called Heberden’s
decalcification localized in or most nodes (Fig. 43-2). If seen at the PIP joint, they are called
marked adjacent to the involved Bouchard's nodes (Fig. 43-2).
joints (osteoarthritis changes alone
Osteoarthritis may also involve the CMC joint at the
do not qualify)
base of the thumb. This joint is highly mobile and is
From Arnett FC, Edworthy SM, Bloch DA, et al: The American Rheumatism subject to significant stress during pinch activities. The
Association |987 revised criteria for the classification of rheumatoid arthritis, most common symptom is pain with motion. Patients
Arthritis Rheum 31:315-324, 1988. may be limited in many activities, since the thumb ac-
MP. Metacarpophalangeal; MTP metatarsophalangeal; PIP proximal interpha- counts for 45% of hand function.'® As the disease
langeal.
process progresses, osteophytes may form; the joint can
subluxate, giving a squared appearance to the joint
(Fig. 43-3).7

RHEUMATOID ARTHRITIS
Description of Common Upper Extremity
The hands are the most severely affected sites of
Joint and Hand Deformities RA.*!® A typical sign of RA is the fusiform (spindle-
The destructive processes seen in arthritis can result in shaped) swelling in the PIP joints (Fig. 43-4). Swan neck
tendon, muscle, and nerve dysfunction and many joint and boutonniere deformities may also result from
deformities. A brief explanation of some of the most muscle and tendon contractures.
 TREATMENT APPLICATIONS

igte-! College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia

|. History of widespread pain. ae

Definition: Pain is considered widespread when all of the following are present: pain in the left side of the body, pain in the right side of
the body, pain above the waist, and pain below the waist. In addition, axial skeletal pain (cervical spine or anterior chest or thoracic —
spine or low back) must be present. In this definition, shoulder and buttock pain is considered as pain for each involved side.""Low
back’ pain is considered lower segment pain. |
2. Pain in || of 18 tender point sites on digital palpation.
Definition: Pain, on digital palpation, must be present in at least || of the following |8 sites:
Occiput: Bilateral, at the suboccipital muscle insertions.
Low cervical: Bilateral, at the anterior aspects of the intertransverse spaces at C5-C7.
Trapezius: Bilateral, at the midpoint of the upper border.
Supraspinatus: Bilateral, at origins, above the scapula spine near the medial border.
Second rib: Bilateral, at the second costochondral junctions, just lateral to the junctions on upper surfaces.
Lateral epicondyle: Bilateral, 2 cm distal to the epicondyles.
Gluteal: Bilateral, in upper outer quadrants of buttocks in anterior fold of muscle.
Greater trochanter: Bilateral, posterior to the trochanteric prominence.
Knee: Bilateral, at the medial fat pad proximal to the joint line.
Digital palpation should be performed with an approximate force of 4 kg.
For a tender point to be considered “‘positive,’ the subject must state that the palpation was painful.
Tender’ is not to be considered as “painful.”

From http://www.rheumatology.org/classifi/fibro.html.
For classification purposes, patients will be said to have fibromyalgia if both criteria are satisfied. Widespread pain must have been present for at least 3 months.
The presence of a second clinical disorder does not exclude the diagnosis of fibromyalgia.

Heberden’s nodes

Bouchard’s nodes

FIG. 43-2
Osteophyte formation in the proximal interphalangeal joints (Bouchard’s nodes) and distal inter-
phalangeal joints (Heberden’s nodes) is characteristic of osteoarthritis.
 Arthritis 811

FIG. 43-5
Swan-neck deformity results in proximal interphalangeal hyperex-
tension and distal interphlangeal flexion.

EDC lateral EDC central

FIG. 43-3
Arthritic changes in the carpometacarpal joint of thumb result in a
squared appearance. (From ARHP Arthritis Teaching Slide Collec-
tion, American College of Rheumatology.)

FIG. 43-6
Swan-neck deformity resulting from rupture of lateral slips of ex-
tensor digitorum communis tendon.
l

FIG. 43-7
Swan-neck deformity as a result of rupture of flexor digitorum
superficialis tendon.

(FDS) tendon (Fig. 43-7).'° Bony spurs producing

tendon erosion may also cause the tendon to rupture.'®
With progression of a swan-neck deformity, the patient
may lose active flexion and will be unable to make a fist
FIG. 43-4 or flex the PIP joint to hold small objects.
Fusiform swelling. The boutonniere deformity may look worse than a
swan-neck deformity, but it generally does not impair
The swan-neck deformity involves a flexion contracture function as much. The deformity is a combination of
of the MP joint, hyperextension of the PIP joint, and PIP flexion and DIP hyperextension (Fig. 43-8). A bou-
flexion of the DIP joint (Fig. 43-5). There are several tonniere deformity can occur when synovitis at the
types of swan-neck deformity, three of which are dis- wrist, MP, or PIP joints weakens or destroys the central
cussed here. One type of swan-neck deformity is caused slip of the extensor tendon, which inserts into the base
by initial involvement at the MP joint and results in in- of the middle phalanx. There is often associated PIP
trinsic muscle tightness.'* Another type of swan- neck joint arthritis. The result is incomplete and weak-to-
deformity is a result of initial involvement at the DIP absent extension at the PIP joint when the lateral slips
joints and rupture of the lateral slips of the extensor of the extensor tendon, which insert into the base of the
tendons (Fig. 43-6).'° A swan-neck deformity with distal phalanx, slip below the axis of the PIP joint, be-
initial involvement at the PIP joint is caused by chronic coming flexors of that joint and hyperextending the DIP
synovitis, which leads to stretching of supporting struc- joint where they insert (Fig. 43-9).*°"'® The central slip
tures or rupture of the flexor digitorum superficialis of the extensor tendon is the major extensor of the
812 TREATMENT APPLICATIONS

FIG. 43-8
Boutonniere deformity results in distal interphalangeal hyperex-
tension and proximal interphalangeal flexion.

EDC central

FIG. 43-9
Boutonniere deformity caused by rupture or lengthening
central slip of extensor digitorum communis tendon.

finger. If the occurrence of these symptoms is recent

(days) and if the physician does not know of it, he or
of

SENS
ey
she should be informed immediately. Invariably a
flexion contracture of the PIP joint and hyperextension
of the DIP joint with loss of flexion range will ensue.
Function of the finger will be seriously compromised
because of an inability to straighten the finger and loss
of flexion at the tip for pinch or making a fist.
Trigger finger is caused by a nodule or thickening ofthe
flexor tendons of the fingers or thumb as they pass a
through the digital pulleys. The nodule on the FDS
tendon or thickening of the synovium blocks or hinders

Z2
the tendon’s gliding motion through its sheath. This
results in a snapping or catching of the finger during active
flexion or extension (Fig. 43-10). If persistent triggering
occurs, it may result in lost ROM or tendon rupture. ”!®
As with the fingers, the MP and CMC joints are the
most common sites ofinflammation in the thumb.*””'®
Thumb deformities are referred to by several names. Many
clinicians use the same terms that are used when de-
scribing the fingers. The revised Nalebuff classification
uses five categories (Fig. 43-11). Type I (Fig. 43-11, A) is
the most commonly seen deformity in RA. It begins FIG. 43-11 O
with chronic synovitis of the MP joint, which leads to Common rheumatoid thumb deformities. A, Type | is the most
stretching of the joint capsule and flexion of the MP common deformity seen in rheumatoid arthritis, followed by C,
joint with hyperextension of the interphalangeal (IP) type Ill. B, Although type Il is seen infrequently in rheumatoid
joint. The type II deformity (Fig. 43-11, B) is rarely seen. arthritis, it is a common sequela of osteoarthritis of the car-
It involves subluxation of the CMC joint and leads to a pometacarpal joint.
 Arthritis ro fe}

FIG. 43-12
Joint laxity, or instability. (From ARHP Arthritis Teaching Slide Col-
lection, American College of Rheumatology.)
FIG. 43-13
A, Subluxation. B, Dislocation.
fixed adduction contracture with hyperextension of the
distal phalanx.'®* The type III deformity (Fig. 43-11, C) is
seen in both RA and OA. It is characterized by MP hy- Se am
perextension and flexion of the DIP joint.'*~ The type
IV looks similar to the type II deformity but does not ini-
volve the CMC joint. The type V deformity is a collapse
and shortening of the phalanges with total instability.*°
Joint laxity is a term that describes ligamentéus in-
stability. Joint laxity is a major cause of loss of hand
function. In the fingers and thumb the collateral liga-
ments support the joint capsule on either side, Chronic
synovitis can result in stretching or lengthening of the
ligaments and abnormal lateral movement. When the
thumb IP joint becomes unstable, the thumb tip can
easily be wiggled by the therapist, but the patient loses FIG. 43-14
the ability to oppose the thumb and manipulate small Flexion subluxation of wrist.

objects (Fig. 43-12).

Joints may also become subluxated or dislocated physician, this condition should be promptly brought to his or
(Fig. 43-13) because of weakened ligaments. The most her attention for treatment. Untreated median nerve com-
common sites of subluxation are the wrist and MP pression can progress to permanent loss of feeling in the
joints.”’'® Subluxation of the wrist is a volar slippage of hand and weak to lost thumb opposition, which are
the carpal bones on the radius. It is caused by the chronic serious impairments to hand use.
synovitis that weakens the supporting ligaments. Synovial invasion of the wrist may also involve the ex-
Carpal tunnel syndrome is caused by pressure on the tensor tendons, carpal bones, and radioulnar joint. If
median nerve where it passes through the carpal tunnel the extensor tendons are involved, there will be dorsal
of the wrist. The carpal tunnel under the transverse flexor swelling that can lead to tendon weakness or rupture,
carpal ligament is a tightly closed space, and inflamma- resulting in weak to lost extension of the fingers at the
tion can lead to increased pressure and subsequent pain MP, PIP, and DIP joints, flexor contractures, and serious
and sensory disturbances over the median nerve distri- loss of hand function. Synovial invasion of the carpal
bution in the hand. Initial symptoms may be numbness bone results in erosion and destruction of the intercarpal
and tingling in the thumb, index, and middle fingers. ligaments and joints. It can cause progressive loss of
Median nerve motor weakness and atrophy of the oppo- wrist motion, contracture of the wrist in a nonfunc-
nens pollicis and abductor pollicis brevis may result in tional position, or, in flexion, subluxation-dislocation
thenar atrophy. If its presence is not already known by the of the wrist (Fig. 43-14). Radioulnar joint involvement
814 TREATMENT APPLICATIONS

usually results in progressive loss of pronation and The dynamic and static ulnar drift, combined with
supination, particularly if there is associated elbow lifting of the extensor hood by MP synovitis, results in
disease. This can lead to severe functional impairment. dislocation of the extensor tendons from the extensor
A characteristic sign of RA is ulnar drift or deviation of hood over the metacarpal heads into the space between
the MP joint (Fig. 43-15). In the normal hand the MP the heads. This may lead to tendon injury and loss of
ligaments, particularly when the MP joints are flexed at ability to completely extend the MP joints. The lateral
45°, give medial and lateral stability. Both the extensor pinching of the thumb results in radial subluxation and
and flexor tendons of the fingers are bowed to produce deformity of the IP joint of the thumb.”1®
an ulnar drift tendency of the tendons at the MP joints The loss of elbow and shoulder motion as a result of
during normal contraction. Forced contractions and es- weakness, pain, and contractures is also a common oc-
pecially forceful hand grips accentuate this tendency. currence in RA. Secondary conditions such as tendinitis
With MP ligaments weakened, normal forces result in and bursitis are frequent causes of pain. Elbow synovitis
ulnar drift. The fifth MP joint buttresses the remainder may result in the loss of pronation, supination, flexion,
of fingers from static, postural ulnar drift. However, and extension, which may severely limit self-care activi-
when the fifth MP ligament loses stability, ulnar drift ties. Frozen shoulder is a complication of shoulder syn-
can occur with gravity and posture, even at rest. ovitis characterized by very restricted ROM.'® Other
If the MP ligament damage is mild or if the stability commonly seen shoulder problems include bursitis and
of the fifth joint is preserved, the ulnar drift may be less rotator cuff dysfunction.’ Additionally, most patients
evident and may occur only dynamically with finger ex- with RA have muscle weakness as a result of disuse, bed
tension-flexion. This condition gives weak pinch, which rest, and drug effects.1?
may result in thumb adduction and lateral pinch being
substituted for true opposition. If the MP ligament
MEDICAL MANAGEMENT
damage is severe or if the stability of the fifth MP joint is
lost, there will be ulnar drift even at rest (posturally), There is no known cure for arthritis. Treatment is aimed
and impairment of opposition will be severe. toward reducing inflammation, pain, and joint damage.
Treatment methods include medication, exercise, the
use of heat and cold, joint protection techniques,
weight control, surgery (when necessary), and coping

DWG
YY strategies.'**° When making treatment decisions, one
must consider both the benefits and risks (or costs) of
one form of treatment over another.
NN »S

Drug Therapy
Traditionally, the approach to medical management of

co
4 i) RA has followed the pyramid model, with well estab-
lished and less toxic treatment methods forming the
foundation of treatment, or the base of the pyramid
(Fig. 43-16).7° With this approach, all patients with RA
receive treatment described at the base of the pyramid.
These treatment methods include rest, education, and
what are referred to as first-line medications. If these
methods are not effective in preventing disease progres-
sion, treatment progresses up the pyramid to agents that
can be more toxic to the patient. At the apex of the
pyramid are the more experimental and cytotoxic med-
ications, which are generally reserved for patients who
have severe disease not responding to other medication.
Supportive measures such as therapy and cortisone in-
jections form the sides of the pyramid and can be used
throughout treatment.’ More recently, an “inverted
pyramid” approach has been suggested.*’ This ap-
proach calls for more aggressive treatment for patients
FIG. 43-15 with early, active inflammatory disease in an effort to
Metacarpophalangeal joint ulnar drift. prevent severe deformity. '°7
 Arthritis 815

chloroquine, and methotrexate, among others. All of

these medications require careful medical monitoring
because of potentially serious side effects.'* Frequent
blood and urine tests may be needed to rule out adverse
effects. DMARDs and cytotoxic agents are slow acting,
with 2 to 3 months of drug therapy needed before their
full benefit is realized. During this time first-line drugs
to control synovitis and the addition of steroids may
improve the patient's functional status. It is also impor-
Experimental drugs/procedures tant that supportive measures such as joint protection,
other cytotoxics
energy conservation, and splinting be employed until
synovitis is controlled. Side effects include diarrhea,
skin rashes, mouth ulcers, bone marrow suppression,
Penicillamine, methotrexate, azathioprine,
sulfasalazine and possible blindness. Any of these symptoms should
be promptly reported to the physician.
Steroids are effective as antiinflammatory and pain-
reducing agents but have serious side effects, such as
Antimalarials, gold
bone erosion, diabetes, weight gain, emotional prob-
lems, and hypertension. Steroids are used. most fre-
quently on a temporary basis if the disease is not ade-
Education, rest, exercise; social services; salicylates or other NSAIDS quately controlled by other medications alone.*’"®
For OA and fibromyalgia, medication for pain is gen-
FIG. 43-16 erally limited to aspirin, NSAIDS, or acetaminophen.
Treatment pyramid for arthritis. (From Primer on the rheumatic dis-
Additionally, patients with fibromyalgia may benefit
eases, ed 10, Atlanta, 1993,Arthritis Foundation.)
from antidepressants used to promote sleep.7®

Drug therapy is constantly changing, and no single

Surgical Intervention
method is recommended over all other methods.'® Pa-
tients’ needs and reactions change, and each physician Treatment of the patient with long-term RA will often
develops his or her own philosophy and regimen. ‘Allied include operative procedures to repair soft tissue or
health professionals need to be aware of the medical replace joints destroyed by the rheumatoid process.*’'®
protocols used in their facilities and of the specific med- Surgeries are often delayed and are used only when
ications (and the side effects) taken by their patients. more conservative methods fail to control the inflam-
The medications used in the treatment of RA are mation and subsequent soft-tissue damage. Several
divided into two groups. The first group, or first-line different surgical procedures may be of benefit to pa-
drugs, are fast-acting drugs such as nonsteroidal antiin- tients with RA. Synovectomy (removal of the diseased
flammatory drugs (NSAIDs), intraarticular corticos- synovium) and tenosynovectomy (removal of diseased
teroid injections, and aspirin, which can suppress in- tendon sheath) are performed to prevent further com-
flammation but cannot alter the progression of the plications. The removal of the excessive tissue does not
disease. These drugs cannot prevent joint destruction.'® prevent the progression of the disease. The surgeries are
Because they are less toxic, they are often prescribed at performed to relieve symptoms and slow the process of
the initial diagnosis of RA. joint destruction or tendon rupture and to help preserve
In large doses, aspirin is one of the most frequently vascular supply to the joint. A synovectomy may be per-
prescribed medications because it reduces pain and in- formed on the ankle, knee, hip, MP, wrist, elbow, or
flammation with tolerable side effects. Inflammation shoulder.*’"®
can also be reduced with NSAIDs that are used either in- Tendon surgery, including tendon relocation, tendon
dividually or in conjunction with others. Some side repair, tendon transfer, and tendon release, is consid-
effects to be aware of are stomach pain, diarrhea, dizzi- ered a corrective strategy for specific hand impairments.
ness, headache, nausea, ringing in the ears, and dark Tendon surgery is most frequently performed on the ex-
stools caused by bleeding.*’'® tensor tendons of the hand and wrist.*’"®
The second group of drugs include disease-modify- Arthroplasty (joint reconstruction) and arthrodesis
ing antirheumatic drugs (DMARDs). These drugs may (joint fusion) may be done when joint restoration is not
actually have an effect on the course of the disease, al- possible. Both types of surgery may be performed to
though this possibility is still in question. The drugs in relieve pain, provide stability, correct deformity, and
this group include gold salts, penicillamine, hydroxy- improve function. Common sites for these types of
816 TREATMENT APPLICATIONS

surgery are the ankle, knee, hip, first MP, PIP, and identifies general treatment strategies and discusses spe-
wrist.”’'® Patients with OA are often seen by the occu- cific suggestions for each disease when applicable.
pational therapist after total hip or total knee re-
placement surgeries. These surgeries are described in
Evaluation
Chapter 45.
Medical History
An initial intake should include a review of medical
PSYCHOLOGICAL FACTORS
charts or records if they are available. If these are not
Anyone who has a chronic illness must develop coping available, a brief medical history should be taken,
strategies to deal with the disability. This is especially because the therapist must be aware of all health prob-
true of the person with any type of arthritis. The person lems. Current medications should also be noted. The
may have suffered a serious change in physical function patient's report of which joints are currently involved or
and life roles, and even appearance is altered by defor- have been involved in the past, as well as any other
mity and drug side effects. These changes evoke an ad- systems affected, should be recorded.
justment process similar to the grief process after a
death. Because the disease is both unpredictable and Functional Abilities
characterized by pain, it is normal to respond to the dis- The functional abilities of the patient with arthritis must
ability with depression, denial, a need to control the en- be the first consideration in evaluation. Impaired ROM
vironment, and dependence.'’'**® Psychological stres- measurements and the presence of joint deformities do
sors may also result in an exacerbation of the disease.** not necessarily mean that the patient cannot function
Some aspects of the illness that may contribute to the independently. The patient may use substitute motions
psychological state are constant pain and fear of pain; to complete tasks. On the other hand, the patient may
changed body image and perception of self as a sick display no apparent deformities but be severely dis-
person; continuous uncertainty about the course and abled for routine tasks because of pain, fatigue, edema,
prognosis of the disease because of remissions and or joint laxity.”'® It is also important to consider the
flares; sexual dysfunction because of the pain or defor- effect of medication on performance.'®
mity or associated depression; and altered social, voca-
tional, and leisure roles. Interview
Rehabilitation workers need to be aware of the The initial interview should involve such factors as the
patient's response to disability and the adjustment that medical history, joints involved, presence of pain, med-
is in progress. All the factors and the behaviors just cited ication, functional abilities, and current symptoms.’® It
will have an influence on rehabilitation. The interaction is also important to find out how much the patient
of personnel with the patient may facilitate the develop- already knows about the disease and if any treatment
ment of healthy coping mechanisms and acceptance of regimen is being followed. If the patient reports pain,
disability (see also Chapter 28). the practitioner should ask, “Where is it?,” “When does
Family relationships and culture will also influence it occur?,” and “How does it limit your abilities?” The
the patient's response to the disability. OT practitioners patient may also be asked to complete a pain rating on
should work with both the patients and their families to a scale of “O” (no pain) to “10” (greatest pain) at differ-
help them learn all they can about the disease and to ent times of the day or with different activities (see
give them opportunities to share their concerns.”!® The Chapter 29). The patient should be asked if he or she
support groups available through the Arthritis Founda- has morning stiffness. Morning stiffness that lasts less
tion will be helpful for many. (See address at end of than an hour would be more characteristic of OA. With
chapter. ) RA, the stiffness would last for longer than an hour. The
stiffness associated with fibromyalgia is generally worse
OCCUPATIONAL THERAPY in the morning and, although diminished, usually
remains throughout the day.'®
INTERVENTION
The OT practitioner should also ask the patient
Rehabilitation of the patient with arthritis is somewhat about present abilities and attempt to estimate the po-
different from that of a patient with an acute or trau- tential for independence in self-care. The patient's tol-
matic condition.'® Because of the chronic and progres- erance for activity should be included. An example of
sive nature of the disease, rehabilitation intervention an Arthritis Evaluation Checklist for RA may be seen in
may be needed periodically for months or even years, Figure 43-17.
depending on the course of the disease and the individ-
ual patient. Observation
Because many of the treatment principles are similar The occupational therapist should observe the appear-
for patients with RA, OA, and fibromyalgia, this section ance of joints for heat, redness, edema, deformity,
 ARTHRITIS EVALUATION CHECKLIST

Name: Diagnosis:
Referral:

Initial Interview:
Which joints bother you the most?
Pain at rest ___ on movement ___ constant ___—Ss— Description
Do you experience morning stiffness? __ Duration?
What medications are you presently taking?
Since taking the medication have you noticed any of the following? (circle)
headaches nausea itching rash ringing in ears other
Surgeries?
Exercise Program?
Splints?
What do you know about arthritis?
What are your goals?

UPPER EXTREMITY JOINT INVOLVEMENT:

1

|
2 is]Q val

|
| SHOULDER

ELBOW

“al
WRIST

HAND PLACEMENT EVALUATION

KEY: 0 - EASILY 2 - WITH MODERATE DIFFICULTY
1 - WITH MINIMAL DIFFICULTY 3 - UNABLE

COMMENTS

FIG. 43-17
Arthritis evaluation checklist. Continued
 ARTHRITIS EVALUATION CHECKLIST

COMMENTS

[P
(oeconesd
totevey sd
HAND

fopposition
SENSATION:

SOFT TISSUE & HAND DEFORMITIES NOTED: (Include Flexion Contractures, Swan Neck, Boutonniere, Ulnar
Deviation, Subluxation, Edema, Redness, Warmth)

FUNCTIONAL ABILITIES: KEY: Q - EASILY 2 - WITH MODERATE DIFFICULTY

1 - WITH MINIMAL DIFFICULTY 3 - UNABLE
—
COMMENTS

i Grasp Spoon or Fork

y Carry to Mouth

HCut Meat
Drink from Glass/Cup

| BILATERAL ACTIVITIES

| re] ct ct ° =]

| Manipulate

Turn Key in
Coins

Lock

wo rite
= Name

Turn Pages

Use Telephone

Open doors

Open jars

Endurance:

Marital Status: Family Members/Supportive Persons at Home:

Household Responsibilities:

Do you have difficulty in ADL?

Architecture:

Vocational Responsibilities:

RECOMMENDATIONS: Adaptive Equipment (circle): Key Extension Feeding Device Writing Device Telephone Device
Car Door Opener: Dressing Stick Buttonhook Other

Splints:

Joint Protection:

Home Program:

Evaluation Completed By:

FIG. 43-17 cont’d

Arthritis evaluation checklist.

fo Ke)
 Arthritis 819

deforming tendencies on motion, skin quality, and joint photographs of the hands and wrist may be useful. Eval-
enlargement. In the early stages of RA, joints may uation procedures for the previously described deformi-
appear puffy and soft. If the disease is active, joints may ties of the hand and wrist seen in RA and OA are shown
be red and hot. Patients with fibromyalgia may also in Table 43-2.
display swelling of the hands. This is considered “sub-
jective swelling” and may be a type of paresthesia.'* The Sensorimotor Components
therapist should record the location of such observa- The OT evaluation of sensorimotor components may
tions so that later comparisons may be made. Actual take considerable time. If there is discomfort or pain in

Tests for Specific Deformities of the Hand and Wrist

_Deformity Test
~ Synovial thickening Ask the patient if the fingers ever catch or stay closed when attempting to open the hand. Determine whether
~ or nodules (seen in this happens rarely, occasionally, or consistently and whether there is any pain or loss of function because of it.
__ trigger finger) Observe the patient actively move the finger Note any snapping or catching of the finger during motion. Look for
discrepancy between AROM and PROM. If these clinical signs are observed or reported, palpate along the
tendon surface and feel for the presence of a nodule. Flexor nodules are often felt near the distal palmar crease.

Tendon rupture Observed as a detached tendon, and the patient is unable to actively move the joint.

Extrinsic tightness Position the patient's wrist at neutral. Passively flex the MP joint to different positions while simultaneously flexing
the PIP and DIP joints. If the position of the MP joint influences the degree of flexion possible at the distal joints,
the extrinsics are tight..*
_ Intrinsic tightness First perform a test for extrinsic tightness to rule out adhesions of extensor tendons. Passively extend the MP
joint and flex the PIP joint. Repeat the action with the MP joint in flexion. Intrinsic tightness is noted if there Is
more resistance when the MP joint is extended.*

MCP ulnar drift Measure the angle between the PIP and the MP joints during active extension and compare it with the normal
ROM. The index finger normally has 10° to 20° of ulnar deviation during active extension. Ulnar drift is described
as follows: f
SEVERITY INDEX FINGER FINGERS 3-5
Mild DOO 30% Ortos Oe
Moderate @* 30° to 50° LORto 80%
Severe 50° or more 30° or more

MP palmar Palpate over the dorsum ofthe joint when it is at the 0° neutral position. Subluxation is felt if there is a step
subluxation- between the metacarpal and the first phalanx. Subluxation is described as follows:
dislocation Mild: step is felt, full extension is possible
Moderate: the step is both felt and visible, extension Is limited
Severe: gross malalignment and definite limitation of ROM?°

Swan-neck May be observed with intrinsic muscle tightness.

deformity To test if the deformity is caused by initial involvement at the DIP joints and rupture ofthe lateral slips of the
extensor tendons, first test for extrinsic tightness. Then move the MP joint into extension and flex the PIP joint to
prove that there is no intrinsic tightness. Then the patient should extend the finger actively. Ifthere is a rupture of
the lateral slips of the extensor tendon, the DIP joint will drop into flexion because ruptured lateral slips of the
EDC cannot function to extend the joint. The middle slip of the EDC, acting on the PIP joint, pulls too hard and
hyperextends the joint when active extension is attempted, resulting in the swan-neck appearance.

To test if the deformity is caused by stretching of supporting structures or rupture of the FDS tendon, first test
for extrinsic tightness. Move the MP joint into hyperextension, and flex the PIP joint to rule out intrinsic tightness.
The patient is then asked to flex the finger into the palm actively while the examiner holds the adjacent fingers in
extension. If the FDS tendon is ruptured, it will not be possible to flex the PIP joint.

Boutonniere and Observation.

thumb deformities

* Perform all movements gently to avoid causing further damage, including tendon rupture.
AROM, Active range of motion; DIP distal interphalangeal; EDC, extensor digitorum communis; FDS, flexor digitorum superficialis; MF metacarpophalangeal, PIP
proximal interphalangeal; PROM, passive range of motion; ROM, range of motion.
820 TREATMENT APPLICATIONS

the joints, the assessments may have to be performed Screening for lower extremity (LE) involvement may
gradually over two or three treatment sessions. be carried out by the occupational or physical therapist.
Sensory evaluation is indicated if there is potential Specific LE joint problems or problems with the feet
nerve damage or compression caused by swelling. may benefit from physical therapy or orthotic assess-
Modalities that should be tested are senses of touch, ment.” The footwear should be noted so that shoes that
pain, temperature, and epee Paresthesias will provide good support to arthritic feet can be recom-
should be noted. mended.
When performing ROM measurements, the therapist Strength of the LEs can be observed in the patient's
should note whether the joints feel stiff, unstable, or crep- gait pattern and when the patient rises from a chair. If
itant. A major discrepancy between active and passive the patient must use arms and hands to push off, this is
ROM may be caused by pain secondary to inflammation indicative of LE weakness. The patient’s need for assis-
in the joint or soft tissue, as well as by weakness or tive devices and safety in ambulation should also be as-
tendon involvement. sessed. The therapist should observe for any obvious
For patients with RA, manual muscle testing may not joint limitations and weakness in the LEs and should
be possible because of joint instability and alterations have data from specific evaluation of ROM, strength,
in the line of muscle pull. If muscle testing is indicated, and deforming tendencies in the legs. These factors are
the usual procedures will need to be adapted. Resistance important considerations when planning treatment,
should be applied within the patient's pain-free ROM presenting joint protection and energy conservation
rather than at the end of the ROM, as is usual in manual techniques, and positioning to prevent loss of ROM in
muscle testing. It is not unusual for patients with arthri- the LEs.
tis to have pain in the last 30° to 40°of joint motion.
Therefore if resistance is applied within the pain-free Cognitive and Psychosocial Components
range, the inhibition of muscle strength by pain will be Patients with arthritis should be screened for problems
avoided.'® in cognitive and psychosocial components. The associ-
The use of the manual muscle test is controversial ated pain, lack of sleep, and depression may cause
because some physicians prohibit any resistance that deficits in attention span, short-term memory, and
can cause harm to diseased tissue and joints or place problem-solving skills.'® It is also important to under-
deforming forces on the joint.’ Functional muscle or stand how patients manage stress in their lives.
motion testing may be used if resistance is prohibited.
In both the ROM assessment and the muscle strength Occupational Performance
test the therapist should make note of the time of day The evaluation of activities of daily living (ADL) for pa-
and the amount of antiinflammatory or analgesic med- tients with arthritis is similar to ADL evaluations for
ication taken. These medications may influence results other physical disabilities. However, the evaluation
of the evaluation.'® In addition, future reevaluations should consider such factors as morning stiffness, med-
should be performed under the same conditions as the ication schedule, activity tolerance, and proper posi-
initial evaluation. tioning.'® Patients with arthritis may report both “good
Hand function testing is important, but the therapist days” and “bad days.” It is important to find out the rel-
should be careful not to stress the joints during the as- ative percentage of each and how the patient's func-
sessment. For this reason, grip and pinch strength may tional abilities differ on good and bad days. Such in-
be tested with an adapted blood pressure cuff and meas- formation may help the patient learn how to prevent
ured in millimeters of mercury.”'® Specific devices for pain and stress to the joints and to increase functional
measuring grip strength for the arthritic hand are also independence.'®
commercially available. A test of hand function that Evaluations for ADL and work and leisure activities
evaluates grasp and prehension patterns, such as the should consider both psychological and social factors.
Jebsen Test of Hand Function,’” or observation of hand What is the patient's attitude toward the disability?
use with common functional tasks should be done. What specific goals does the patient have? What strate-
Hands that have severe involvement and obvious defor- gies are used to deal with pain and fear? The patient's
mity may, in fact, have very good function. abilities may be determined, in part, by interview. The
The patient's physical endurance should be evaluated actual performance should be observed at the normal
by observation and an assessment of the daily or weekly time each activity is performed because the patient's
schedule. Lack of sleep, chronic pain, weakness, decon- abilities may change at different times of the day.
ditioning, and emotional stress are factors that may lead Ideally, a home evaluation should be done in the
to decreased endurance in patients with arthritis. patient's home. On-site or simulated experiences may
Fatigue may be one of the most disruptive factors in be used to assess job performance. The job tasks can
lifestyle for patients with fibromyalgia.'*° be analyzed, and joint protection principles can be
 Arthritis ra |

applied, if possible. Pacing of work responsibilities may fibromyalgia, which is believed to be related to sleep
help the patient incorporate required rest periods into disturbances.'° Rest and relaxation effectively break the
the working day. In all areas of ADL it is essential to de- vicious circle of pain, stress, and depression by allowing
termine whether the patient is using energy conserva- the body time to heal itself. Rest can take several forms.
tion and joint protection techniques.”’'® The amount of systemic rest needed varies with individ-
uals, from complete bed rest to a short nap during the
day. Localized rest to individual joints may include
Treatment Objectives
wearing a splint to support the involved joint during
Treatment of the patient with arthritis must take into activity or lying in non-weight-bearing positions to
account the chronic and progressive nature of the prevent joint stress. Psychological rest is experienced
disease.’ An overall goal of treatment for patients with when a person takes a short diversion from routine ac-
RA is to decrease pain and inflammation. Patients with tivities or focuses attention on enjoyable, instead of
OA may be seen by the occupational therapist because stressful, events.”’'*
of hand, hip, or knee involvement or as a part of a post-
operative rehabilitation program after total hip or total Positioning
knee replacement surgery (see Chapter 45). Patients Positioning against the patterns of deformity is recom-
with fibromyalgia will benefit from a holistic approach mended to reduce pain and prevent contractures. To
that focuses on the psychological conflicts that create prevent flexion contractures, persons with RA should
stress, as well as on the physical factors. '** not sleep with a pillow under the knees and should use
The general objectives of treatment in occupational only a small pillow under the neck. Prone lying is rec-
therapy are to (1) maintain or increase joint mobility ommended for both the hip and knee joints. Maintain-
and strength; (2) increase physical endurance; (3) pre- ing good postural alignment when standing and sitting
vent, correct, or minimize the effect of deformities; will discourage the development of deformities and
(4) maintain or increase the ability to perform ADL; prevent undue stress on the muscles and joints. Patients
(5) increase knowledge about the disease and the best with both RA and OA may benefit from using chairs
methods of dealing with the physical, psychological, with high seats and armrests, which will make it easier
and functional effects; and (6) assist with stress man- to stand up.’®
agement and adjustment to physical disability.
The treatment plan should be designed for the in- Physical Agent Modalities
dividual patient and be based on the severity of the Physical agent modalities (PAMs) such as heat, transcu-
symptoms and the general health status, lifestyle, and taneous electrical nerve stimulation (TENS), and bio-
personal goals of the patient. The patient should feedback are helpful in relieving pain.'”** Local appli-
be an active participant in the treatment process. Both cations of heat, including paraffin wax treatments and
the patient and significant others need to understand moist or dry heat packs, help to reduce stiffness and in-
the disease process and treatment methods. Rehabili- crease mobility. At home, patients may enjoy the bene-
tation intervention will most likely be intermittent, so fits of heat by taking a warm bath or shower. The appli-
the patient's ability to follow through with the treat- cation of heat should be limited to 20 minutes because
ment methods will greatly influence the success of the longer periods of warmth can cause an increase in in-
treatment.”’'® flammation and edema.'”’’” Ice packs are used both for
pain relief and to decrease edema. Practitioners must be
aware of their state licensure requirements and be
Treatment Methods
trained in the use of PAMs if they plan to use these
Many treatment strategies are used in OT for the man- modalities with their patients.
agement of arthritis. Traditional methods include rest,
positioning, physical agent modalities, exercise, thera- Massage
peutic activity, splinting, and ADL training. The choice Massage is helpful in relieving muscle spasm and in in-
of methods will depend upon the patient's condition creasing blood flow to the area. Patients may purchase
and reaction to the various procedures. When indi- electrical massage devices to assist with self-massage.**
cated, methods for the specific type of arthritis will be
provided. Therapeutic Activity and Exercise
Therapeutic activity and exercise are used to promote
Rest joint function, muscle strength, and endurance. Exercise,
Rest is an important part of treatment and should be in particular, may reduce the morning stiffness associ-
considered an active way of reducing inflammation and ated with RA and fibromyalgia, and exercise also reduces
pain. Frequently, patients with RA and OA will develop the risk of cardiovascular disease and osteoporosis.”®
822 TREATMENT APPLICATIONS

For patients with fibromyalgia, exercise is also helpful in done at the best time of the day for the patient (i.e.,
diminishing pain and improving sleep.** Any func- when the patient feels most limber and has the least
tional program should be coordinated with the physical pain). This might be after a warm shower or a short time
therapy program to avoid overworking the same after receiving pain medication.”’'®
muscles. In the acute stage gentle passive and active ROM exer-
The Arthritis Foundation (see the address at end of cises to the point of pain (without stretch) should be
chapter), in cooperation with the YMCA, sponsors done twice a day. As little as one to two repetitions of
aquatic programs designed to meet the needs of people complete joint range are needed to prevent loss of
with arthritis throughout the United States. These pro- ROM.'® However, several attempts at movement may
grams are run by certified instructors, and pools are be needed before full range is achieved. The patient
maintained at the recommended 83° F water tempera- may perform ROM exercises of the neck, elbows, and
ture. Studies suggest that these programs improve func- hands, but the therapist should passively exercise the
tion and reduce pain. Exercises performed under water shoulder to promote muscle relaxation.'* Isometric exer-
are less stressful to the joints and rarely exacerbate cises without resistance may be attempted to preserve
arthritis-related symptoms.'® For this reason patients strength. The patient should be instructed to tighten each
may also be instructed to perform their exercises while muscle without moving the joint and maintain tension
bathing. for 6 seconds once or twice per day.’ Resistive exercise
and stretching at the end range should be avoided.'®
RHEUMATOID ARTHRITIS. The specific types of Active and passive ROM exercises that include a
activity that might be prescribed for patients with RA gentle passive stretch may be started in the subacute
will depend primarily on the stage of disease the patient stage. Isotonic exercises may be done, provided there is
is experiencing. The stages of the inflammatory process minimal stress to the joints.'* The number of repeti-
have been described as acute, subacute, chronic active, and tions performed may range from three to five and
chronic inactive.'® should be done once or twice per day. The number of
Clinical symptoms seen in the acute stage include repetitions should be decreased if pain or swelling in-
limited movement, pain and tenderness at rest that in- creases.’ Graded isometric exercises may be performed
creases with movement, overall stiffness, weakness, tin- once a day. Patients should exert about three quarters of
gling or numbness, and hot, red joints. In the subacute their maximum strength (or less if pain occurs) and
stage, limited movement and tingling remain. A de- perform one to three repetitions.’
crease in pain and tenderness indicates that inflamma- In the chronic-active and chronic-inactive stages,
tion is subsiding. Stiffness is limited to morning stiff- stretch at the end of the range may be included during
ness, and the joints appear pink and warm. The ROM. Resistive isotonic and isometric exercises may be
chronic-active stage is characterized by less tingling, pain, done as long as they do not overstress the joints.”’® En-
and tenderness and increased activity tolerance, al- durance exercises are most important in this stage to
though endurance remains low. No signs of inflam- improve overall cardiovascular fitness.’
mation are present in the chronic-inactive stage. The There is some controversy over the use of isotonic re-
patient’s low endurance and pain and stiffness at this sistive exercise for patients with RA.'® The occupational
stage result from disuse. Overall functioning may be de- therapist must determine if that patient has stable, inac-
creased as a result of fear of pain and limited ROM, tive joints that would benefit from a strengthening
muscle atrophy, and contractures.’ program without jeopardizing other joints. If pain re-
Any treatment program should begin slowly and sulting from exercise lasts longer than 1 hour, the vigor
gradually increase in intensity, duration, and frequency of the exercise should be reduced.’®
of the various activities.” Splints, braces, and position-
ing devices may be used throughout the stages to pro- OSTEOARTHRITIS. Exercise will not increase ROM
vide joint rest and stability. The patients may perform limited by osteophytes, but it may help decrease gener-
self-care activities as tolerated. alized stiffness. Exercise helps lessen the symptoms of
Preservation of function of the hips, knees, elbows, OA by increasing the strength of the muscles that stabi-
and MP joints is essential in the treatment program. lize the joints.* Low-impact activities such as flexibility
Therefore exercise to other joints must not interfere with and strengthening exercises, brisk walking, biking, and
functions of these joints or be done at their expense. swimming or water aerobics may help to ease the pain
During the acute stage, active assistive exercises and and prevent disability. Patients should avoid exercising
exercises with gravity eliminated may be performed tender, injured, or inflamed joints.
within the limits of pain tolerance. As the patient's abil-
ities improve, the activities will progress to include FIBROMYALGIA. A program of flexibility and en-
active and resistive exercises. The exercises should be durance exercise is the best defense for combating the
 Arthritis 823

pain associated with fibromyalgia.** Some of the bene- need for splinting based on a thorough evaluation and
fits include decreased stiffness, increased strength and consultation with the patient's physician. The inappro-
energy, improved sleep patterns, and decreased depres- priate use of splints can be harmful.'”** The splinting of
sion. Going without exercise can lead to deconditioning one joint may put added stress on the surrounding
and result in increased pain. Low-impact or nonimpact joints. An example of this is the increased stress to the
aerobic exercises such as brisk walking, biking, swim- MP joints when the wrist is splinted.'®
ming, and water aerobics are a few ways to start exercis- Some of the more commonly used splints in the
ing without jarring painful joints.** Aerobic exercise treatment of the arthritic hand include the resting hand
appears to be more beneficial than simple stretching.'° splint, wrist immobilization splint, wrist cock-up splint
It is very important to watch the pace at which patients with MP support, and ulnar drift positioning splint.
advance their exercise, because if performed incorrectly, Specific directions for these and other splints may be
exercise may exacerbate patients’ conditions. Exercise found in several sources.'***? Additionally, several
should begin at low intensity, include stretching, and splints designed for the arthritic hand are available
then progress to more strenuous aerobic exercise.'° commercially.
Whether choosing therapeutic activities or exercise, the The resting hand splint (see Chapter 31) is useful for
therapist should apply the same principles.'® Activities the treatment of acute synovitis of the wrist, fingers, and
should not overstress the joints but should offer enough thumb because it helps to prevent ulnar drift and main-
repetition of movement to help improve ROM and tains the thumb web space. The primary use of this
strength. The activities should be nonresistive and avoid splint is to provide rest to the involved joints, but it may
patterns of deformity. For patients with RA, resistive also help prevent multiple joint contractures from de-
squeezing of the hand should be avoided because it can veloping. Because it prevents movement, it is usually
promote ulnar deviation, MP subluxation, and extensor worn during sleep. If the patient needs resting splints
tendon displacement.'*'® When choosing an activity, the for each hand, each splint should be worn on alternate
therapist should consider how it will affect all joints. Al- nights so the patient has one free hand.'**°
though sandinga piece of wood onan inclined board may A wrist immobilization splint (Fig. 43-18) is used to im-
be helpful in increasing shoulder and elbow range, it mobilize a painful wrist while allowing the hand to
could be harmful forthe hand to grip a piece of sandpaper. remain functional. This splint supports the wrist in ex-
This could be remedied by using a sanding block. tension, which relieves compression of the carpal
Patients with RA should avoid activities that require tunnel.'*?? If the MPs are also involved, a wrist cock-up
the use of the hand in prolonged static contfactions. splint with MP support may be necessary (Fig. 43-19).
However, sometimes the psychological benefits of doing This splint places the MP joints in normal alignment, al-
activities one enjoys may outweigh the risks involved, lowing them 0° to 25° of MP flexion.
especially if the risks can be minimized. According to During pinch and grasp activities, an ulnar drift posi-
Melvin, activities such as knitting and crocheting are tioning splint (Fig. 43-20) may be used to prevent ulnar
contraindicated only if there is active MP synovitis, de- drift. A CMC splint may be used to provide support and
veloping swan-neck deformity, or thumb CMC joint in- reduce stress to the CMC joint. This may help to de-
volvement.'® Problems may be prevented by having the crease pain during activities involving the thumb.
patient wear a hand or thumb splint while performing
the activity. Additionally, frequent rest breaks and
stretching exercises for the intrinsic muscles will help to
limit complications. '*
Other leisure activities may be introduced to patients
as a means of helping them cope with their disabilities.
An interest survey completed by the patient can be ana-
lyzed to determine appropriate activities. The patient
may need help modifying tools or tasks or substituting
similar activities.

Splinting
The goals of splinting are to support the joint in an
optimal position for function and to reduce inflam-
mation by providing rest or support to the joint.’®
Dynamic splints are also used to correct deformity. FIG. 43-18
Splints can be useful for the wrist, fingers, neck, elbows, Wrist immobilization splint. (Courtesy of North Coast Medical,
knees, and ankles. The therapist should determine the Inc, Morgan Hill, Calif.)
824 TREATMENT APPLICATIONS

An important but often neglected aspect of self-care

training is sexual counseling. Patients may approach
any member of the health care team with questions
related to sexual concerns. In addition to open discus-
sion of sexual problems, patients and their partners are
often helped by illustrations of more comfortable posi-
tions for intercourse. Several excellent treatments of this
subject are available.**°? Additional information may be
found in Chapter 15.

ENERGY CONSERVATION. Because patients with

FIG. 43-19
arthritis have a decreased energy supply and may need
Wrist cock-up splint with metacarpophalangeal support.
more energy to do things, they can benefit from using
energy conservation techniques (Box 43-3).'*'® OT practi-
tioners can teach the techniques to their patients and
help the patients apply the principles to daily activities.
Patients may have difficulty fitting the principles into
their lifestyle, which often necessitates a change in life-
long habits. Practice in using the techniques during hos-
pitalization will help with carryover after discharge.

ASSISTIVE DEVICES. Assistive devices should be

used only when necessary and must be selected with the
patient’s needs in mind.”’”'® Patients are less likely to
use equipment that is expensive or difficult to use. Pa-
tients will need to be taught to use some of the assistive
devices (such as those that compensate for loss of ROM)
when they have a flare-up. When the inflammation has
FIG. 43-20 subsided, patients should be encouraged to stop using
Ulnar drift positioning splint. (Courtesy of North Coast Medical, the devices and to begin using their own ROM and
Inc, Morgan Hill, Calif.) muscle power to maintain their strength and mobility.
Table 43-4 describes the principles used in selecting
devices, and examples for each.”’'®
To prevent stiffness from occurring, it is important to
remove splints and other orthoses on a regular basis to JOINT PROTECTION. Joints affected by arthritis are
complete ROM exercises to the involved joints.'®”? at risk for further damage. Joint protection (or joint saver)
Table 43-3 describes specific splinting and treatment techniques are taught to patients in order to minimize
strategies for upper extremity deformities previously their risk of injury during daily activities. These tech-
described.‘ niques are especially helpful for patients with RA or
with OA involving the hands.”””’*°
Occupational Performance 1. Respect pain. Pain is one way the body signals there is
An effective method of minimizing the effects of disuse something wrong. Many patients with arthritis may
and bed rest is to have patients perform ADL through- feel that they can “tough it out,” but ignoring pain
out their hospitalization.”’”'® When the patient's condi- will often lead to more pain. As a rule of thumb, pain
tion is acute, activities may be limited to feeding and that lasts for more than 1 or 2 hours after completion
facial hygiene. As the patient's condition improves, ADL of a task indicates that the activity was too stressful
should be resumed because this will help to maintain and the activity should be changed. This change
muscular tone and improve endurance. Adaptive equip- might include breaking the task into steps or using
ment and methods may be used with bathing, dressing, less effort to complete the task. Activities that put
feeding, work and home management, and leisure activ- strain on an already painful joint should be
ities to promote independence and to prevent pain and avoided.?
47 *2°
further injury to the joints. Therapists working with this 2. Maintain muscle strength and joint ROM. This may be
population should be familiar with adaptive equipment accomplished by using each joint to its maximal
and joint protection and work simplification techniques available ROM and strength during daily activities.
described in this chapter. Additional resources are pro- When ironing, sweeping, or mopping, the patient
vided at end ofthe chapter. should use long, flowing strokes, straightening and
 Arthritis

Treatment for Specific Deformities

Possible Medical Care Treatment Methods Splinting Methods to Avoid
Synovectomy in early Daily PROM and gentle Small, short dynamic Isotonic, isometric and
stages stretching for the DIPs splint for the PIPs during resistive exercise
Daily AROM to each daily activity to prevent Passive or device stretch
finger joint hyperextension to flexion contractures
Active muscle Three-point finger
contraction with stretch splint'® to maintain
for flexion contractures range of PIP flexion
~ Boutonniere Synovectomy for the Daily PROM to all joints Dynamic extension Isotonic, isometric, and
second and third fingers of the involved finger(s) splints'® for second and resistive exercise
third fingers may
improve function and
opposition

| Trigger finger Steroid injections Tendon protection Trigger finger splint'®

Surgery techniques
Heat and ice for mobility
and inflammation

,a
OO MP ulnar drift Synovectomy Daily PROM to MP Dynamic ulnar deviation Isotonic, isometric, and
Tendon replacement joints ifAROM lacks full splints during the day resistive exercise
Joint replacement flexion and extension Static splints with the Positions of deformity
Joint protection MPs in neutral deviation
and 45° of flexion at
night

ee
——
MP palmar subluxation- Joint replacement or PROM and AROM of
dislocation repair the MPs
Joint protection

~ Wrist subluxation Arthroplasty Flexible splint during the

day and rigid splint at
night
=

Elbow synovitis Steroid injections Rest for acute synovitis Splint to provide joint Overuse
Synovectomy and Use of cold rest or for instability
resection of the radial Daily AROM and PROM
head exercises
Arthroplasty Isotonic or isometric
exercise

_ Shoulder synovitis Steroid injections AROM and isotonic Slings

Applicable surgery exercises preceded by
hot packs
Joint protection

AROM, Active range of motion;MP metacarpophalangeal; PIP proximal interphalangeal; PROM, passive range of motion.

bending the arms as much as possible (Fig. 43-21). Holding a knife in the traditional manner puts too
Light items, such as cereal or noodles, can be stored much direct pressure on the fingers. Instead, the
in high cabinets so that full shoulder ROM will be patient should use the knife as if it were a dagger or
used when reaching.*’”’'*7° use a pizza cutter. A vegetable peeler should be held
3. Avoid positions that put stress on involved joints. The parallel to MP joints and not diagonally across the
“normal” way of doing things may need to be palm. A butter knife can be used to open milk
changed so that joints are used in their most stable cartons. The palm of the hand (not just the fingers)
position. Activities involving a tight grip can be should be used when pushing from a chair to stand
avoided by using items with enlarged handles.°”’'**° up (rig. 43-22).°7-+*2°
 TREATMENT APPLICATIONS

‘gy Conservation

Attitudes and Emotions

Remove yourself from stressful situations.
Avoid concentrating on things that make you tense.
Close your eyes and visualize pleasant places and thoughts.

Body Mechanics
When lifting something that is low, bend your knees and lift by straightening your legs. Try to keep your back straight.
Avoid reaching (use reachers). Avoid stretching, bending, carrying, and climbing. If you have to bend, keep your back straight.
Incorporate good posture into your activities.
Sit to work whenever possible.
To get up from a chair slide forward to the edge of the chair With your feet flat on the floor lean forward and push with your palms on
the arms or seat of the chair Stand by straightening your legs.
Before you get tired, stop and rest.

Work Pace
Plan on getting 10 to 12 hours of rest daily (naps and nights).
Work at your own pace.
Spread tedious tasks throughout the week.
Do the tasks that require the most energy at the times you have the most energy.
Alternate easy and difficult activities and take a 10- to |5-minute rest break each hour.

Leisure Time
Devote a portion of your day to an activity that you enjoy and find relaxing.
Check out what's available in the community.

Work Methods
Keep items within easy reach.
Use good light and proper ventilation and room temperature.
Use joint protection techniques.
Work surfaces should be at a correct height.

Organization
Plan ahead; don't rush or push yourself.
Decide which jobs are absolutely necessary.
Share the workload with family and friends.

How to Begin
Plan ahead by charting your daily routine.
Make a list of tasks and spread them out in your schedule.
Include daily rest periods and rest breaks during energy-consuming times.

Other hand positions to avoid are those that To discourage the development of ulnar drift de-
involve tight pinching, squeezing, or twisting formities, patients are taught to turn the hand
motions. A dusting mitt will help keep the fingers ex- toward the thumb when turning doorknobs. Pa-
tended while dusting. Sponges or rags may be wrung tients should use the right hand to open a jar and
out by spreading the hand flat over them or by the left hand to close it. When stirring, the patient
squeezing them between the palms. Several methods should move the spoon counter-clockwise if using
may be used to open a screw-top jar, such as leaning the right hand or clockwise if using the left hand
on the jar with the palm of the hand and turning the (Fig. 43-24). Patients should be discouraged from
lid with shoulder motion (Fig. 43-23), or holding leaning their chins on the hands or fingers and from
the jar in a drawer as the cap is twisted.”’'*° using their fingers to pick up a mug because pressure
 Arthritis

Ss
ae

Bae
hw
iy

Check your schedule for the following factors:

Is there one day longer than another?
Are heavier tasks distributed through the week?
Is there a long task that could be done in several steps?
Will your plan allow for flexibility?
Have you devoted part of your day to a relaxing activity?
Does your plan use the principles of energy conservation?

on the thumb side of the fingers may promote ulnar patient should never begin an activity that cannot be
deviation.”’° stopped immediately if pain or fatigue sets in.”*°
4. Avoid staying in one position for a long time. Staying in . Use the strongest joints and muscles available. Using
the same position for a long time can cause excess the larger joints reduces the stress on the smaller
fatigue and stiffness. Instead, the patient should use joints. One example of this is carrying a purse on the
a book stand to hold a book. When stirring, the shoulder instead of in the hands (backpacks and
patient should place the bowl in a partially opened fanny packs are also helpful). The weight should be
drawer or on a rubber mat to eliminate holding. The either balanced between both shoulders or frequently
 Assistive Devices
Problem Principle Examples
Decreased range of motion Lengthen the handle on objects Reachers, long-handled shoe horn, extended mop handle
Organize objects within easy reach Revolving space saver, pegboards

Impaired grasp Enlarge the circumference of handles Built-up soft handles, large pens, universal cuffs, stocking
aids
Instability Stabilize objects and provide support Nonskid mats, suction brushes, handrails, grab bars
for safety

Decreased energy Facilitate ease of performance Lightweight tools, electrical tools

Zim jar opener

Potential for joint Increase leverage Extended faucet handles, adapted key holder, vegetable
deformities peeler held at metacarpophalangeal joints

Prevent static or prolonged holding Book stand, bow! holder

Decreased strength Modify work heights Raised toilet seats

Raise the height of beds and chairs to
make it easier to stand.

FIG. 43-22
FIG. 43-21 Use of palms to push off chair helps to prevent dislocation of
During ironing, full extension at elbow can be practiced. finger joints.

828
 Arthritis

FIG. 43-23
Jar cap is twisted off, using palm of hand, and opened with right
hand to prevent ulnar drift.

FIG. 43-24
alternated between the two sides. Other examples Mixing bowl is stabilized with forearm. Spoon with soft, built-up
include pushing doors open with the side of the arm handle is held so that pressure is toward radial side of the hand.
instead of the hand; adding cloth loops to drawer
pulls so they can be opened with the forearm; using
palms, instead of fingers, to pick up a coffee mug; realistic treatment options.° It is important for families
and using the stronger leg to go first up the stairs and to understand the patient's abilities and when they
last down the stairs. It is also important to keep should help (or not help) the patient do things.’® They
weight under control to prevent stress on the weight- must be cautioned against medical quackery, which pro-
bearing joints.”’'*7° motes worthless arthritis remedies. Over 30 million
6. Distribute the workload over several joints. The patient Americans have arthritis, helping to make health fraud a
should distribute the workload over several joints. very lucrative business.”
For example, the patient should use the palms of When providing patient education, the occupational
both hands to lift and hold cups, plates, pots, and therapist should pay particular attention to questions
pans instead of grasping them with the fingers. The the patient may ask. Information should be reviewed
patient should also use oven mitts to carry hot dishes even if the patient may have heard it before.” Repetition
and carry heavy loads close to the body, in the arms, and reinforcement are the keys to education. Topics
instead of holding them with the hands. He or she should be approached in a variety of ways, and using ex-
should slide objects along the counter instead of car- amples that relate directly to the patient's interest and
tying them. If necessary, the patient should lift experiences.”
objects by scooping them up with both palms turned Group treatment, such as movement or exercise
upward. Stress may also be reduced by wearing a classes, home management classes, or arthritis educa-
wrist splint.”’'*° tion classes, can provide mutual support and promote
problem solving. Seeing others with similar problems
Discharge Planning may serve as a powerful motivational tool.”"’'® OT
Discharge planning begins as soon as the patient is re- practitioners may lead or participate with other
ferred to OT. Patients must be active participants members of the rehabilitation team in such activity
throughout their treatment program so that they will groups.
follow through with the treatment once discharged.'°'® One group program, designed by an occupational
Patient education helps patients use the many appropri- therapist, is the ROM Dance Program.'* Based on the
ate resources available to them. principles of T’ai-chi ch’uan, this program promotes in-
Education of the patient and family should include volvement in daily exercise and rest. Components
information about the disease process, including signs include the ROM dance itself, relaxation techniques,
of inflammation, the range of potential disability, and group sharing, and health education. Information on
 TREATMENT APPLICATIONS

ARTHRITIS RANGE OF MOTION EXERCISES

The following exercises will help you to maintain your mobility. Do only those
checked by the therapist.

INSTRUCTIONS:
1. Start doing five of each exercise two times per day.
2. Progress to ten of each, two times per day.
3. Do all exercises slowly and while sitting.
4. lf in an active flare up, cut down or eliminate exercises. After the flare,
start at the beginning to build up tolerance.

SHOULDER
Hold your hands on your shoulders and make small to large circles with your
elbows. Go clockwise and then counterclockwise.

With your hands on your shoulders, bring your elbows together in front of you
and then spread elbows apart to the side and as far back as you can reach.

Roll up a newspaper and hold onto the ends of it with each hand facing down.
Rest the paper on your knees. Bend your elbows to bring the paper to your
right shoulder and back to your knees. Bend your elbows to your left shoulder
and back to your knees.

ELBOW

Hold your hands on your shoulders. Bring them out straight in front of you
with your palms up.

With your elbows bent at your side, turn your palms up and down.

WRIST

Hold your hands facing down. Make a fist as you bend your wrist up. Open
your fingers as you bend your wrist down.

Hold your hands together like you’re praying. Keeping your hands together,
and moving only your wrist, point your fingertips away from and toward you.

HANDS
Touch your thumb to each finger.

Make a fist and stretch your fingers open and out.

Please call if you have any questions.

Instructed by: Phone:

eee
FIG. 43-25
Arthritis range of motion exercises.

the ROM Dance Program can be obtained from the be included. An example of a home exercise program
address given at the end of the chapter. for RA can be found in Fig. 43-25. Verbal and written di-
Treatment should include the development of a rections should be geared to the patient's level of under-
home program and training of the patient in its use. A standing. The patient should be made aware of the re-
variety of topics, including energy conservation, joint sources available from the local or national chapter of
protection, and appropriate activities and exercises, may the Arthritis Foundation. The Foundation supports re-
 Arthritis 831

search and offers a variety of publications and classes Analysis of her job tasks revealed that some aspects of her job
designed to improve the quality of life for patients with may contribute to the development of deformity. Cutting and
arthritis. (See the address at the end of the chapter.) twisting floral wire, forcing stems and stem supports into Styro-
foam, and binding wreaths are contraindicated, while wreath
design and layout and fresh flower arrangement are possible al-
_ Treatment Precautions ternatives. Mrs. Js employer is willing to retain her on a part-time
basis to perform these duties.
The following is a list of treatment precautions to be
The evaluation revealed weakness in wrist and finger exten-
used when working with patients with arthritis.'* More sors (F +) and to a lesser degree in flexor groups (G). Mild ROM
specific information on each can be found in the appro- limitations are present in elbows, wrists, and fingers, with some
priate sections in this chapter. MP instability noted (10° ulnar drift). No subluxation or other
1. Avoid fatigue. deformities are noted. Difficulty with fingertip prehension is
. Respect pain. noted, and pinch and grip are good but not normal in strength.
. Avoid static, stressful, or resistive activities. Forceful use of the thumb in opposition enhances ulnar drift and
. Limit the application of heat to 20 minutes. produces MP discomfort. Mrs.J'ssensation is intact. She is intelli-
bh
W
MB. Use resistive exercises with caution and never with gent and motivated.
unstable joints.’ OT was initiated to (1) maintain ROM and strength of af-
fected joints during the acute stage, (2) increase muscle strength
6. Be aware of sensory impairments.
by / grade, (3) prevent potential deformity, and (4) teach the
patient to independently perform ADL, home management, and
SUMMARY work tasks without causing fatigue and stress to involved joints.
The OT program provided instruction and practice in using joint
Three of the more common forms of arthritis are protection techniques and adaptive equipment, graded therapeu-
rheumatoid arthritis, osteoarthritis, and fibromyalgia. tic exercises and activities for the involved joints, education about
Although their causes and symptoms differ, methods rheumatoid arthritis and methods of dealing with its effects, and
for treating the joint involvement are similar. The po- job simulation tasks.
tential for further injury can be reduced by proper Mrs. J. responded well to treatment. Upper extremity ROM
medication, a balance between rest and activity, exer- was maintained and strength was increased by % grade. Mrs. J.was
happy to modify the way she had always done things if it meant
cise, and surgery. In occupational therapy, patients
having less pain and deformity. She was given a home exercise
learn how to protect their joints while performing day-
program and the phone number for the local chapter of the
to-day tasks at work and at home. Successful treatment Arthritis Foundation. She plans to join a PACE (People with
depends on early intervention and ongoing care and Arthritis Can Exercise) class within the month.
reassessment.

REVIEW QUESTIONS
Case StupYy—Mrs. J. 1. What is the outstanding clinical feature that causes
Mrs. J. is a 36-year-old woman with a diagnosis of rheumatoid joint damage in rheumatoid arthritis?
arthritis, with onset 3 years ago. She is a wife and the mother of 2. What are the major differences between osteoarthri-
an 8-year-old girl. She lives with her husband and daughter in a
tis and rheumatoid arthritis?
three-bedroom, single-level tract home. Mrs J's primary role is
3. When is occupational therapy indicated for the
that of homemaker She also holds a part-time job at a florist
shop doing wreath design and construction and flower arranging. treatment of patients with fibromyalgia?
She both enjoys this work and sees her salary as a necessary 4. What are three systemic signs of rheumatoid
adjunct to the family income. arthritis?
Mrs.J.was referred to OT during the acute phase of her most 5. What are the clinical signs of joint inflammation?
recent episode for prevention of deformity and loss of ROM and 6. When is resistive exercise appropriate for persons
maintenance of maximal function. Medical precautions are: no with rheumatoid arthritis?
strenuous activity, no resistive exercise or activity, and avoid- 7. Why are activities such as crocheting and knitting
ance of fatigue. controversial for patients with rheumatoid arthritis?
In the OT evaluation , the therapist found Mrs.J.to be pleas- 8. What adaptive equipment would be useful for pa-
ant, cooperative, and motivated for therapy. During periods of re-
tients with arthritis?
mission, she is independent in light housekeeping, self-care, and
9. Why is it important to know the type and schedule
work. She fatigues after 2 hours of light to moderate activity and
requires a 20-minute rest period. During flare-ups she Is severely of medication the patient is taking?
limited in ADL, tends to withdraw from social situations, leaves 10. Why should patients with rheumatoid arthritis
home management tasks to her family, and is unable to work. She avoid opening doors in the usual method?
also displays limited patience when fatigued and in pain. She 11. What are important areas to evaluate in patients
manages to do only light self-care activities independently. with arthritis?
832 TREATMENT APPLICATIONS

i. Why is grip strength measured with an adapted 23% Schumacher HR, editor: Primer on the rheumatic diseases, ed 10,
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Is Why is rest an important part of treatment for pa- Butterworth Publishers.
tients with arthritis? 25; Sidman JM: Sexual functioning and the physically disabled adult,
14. Identify five principles of joint protection. Am J Occup Ther 31(2):81-85, 1977.
1D: Describe how energy conservation ‘techniques can 26. Slonaker D: Arthritis information: using your joints wisely, Atlanta,
1992, Arthritis Foundation.
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16: Identify five assistive devices and describe why they time has come, J Rheumatol 16(5):565-567, 1989.
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Atlanta, 1997, The Foundation.
29) Ziegler EM: Current concepts in orthotics: a diagnosis-related approach
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 44
Hand and Upper Extremity Injuries

LEARNING OBJECTIVES
Upper quadrant After studying this chapter the student or practitioner
Edema will be able to do the following:
Provocative tests 1; Discuss the incidence and effect of upper extremity
Splinting (UE) injuries in the United States.
Peripheral nerve injuries 2 Identify three upper quarter screening tests, and
Tendon injuries explain their significance in developing a treatment
Complex regional pain syndrome plan.
Cumulative trauma disorders Discuss the importance ofjoint mobility in
Functional capacity evaluation regaining hand function.
Ergonomics . Describe the four categories of tests used to
evaluate peripheral nerve function, and explain
how the results would be used in treatment
planning.
. Compare the standardized tests used to assess
hand function.
. Describe the sensory and motor innervation
patterns of the three major nerves, and differentiate
between the effects of proximal and distal lesions
in each of the nerves.
. Discuss complex regional pain syndrome and
treatment techniques that should be included in
the occupational therapy (OT) program for that
disorder.
. Compare techniques used in the rehabilitation of
tendon injuries.
. Describe the significance of edema on wound
healing and joint mobility.
10. Discuss the role of the occupational therapist in
evaluation and rehabilitation of injured workers.

833
834 TREATMENT APPLICATIONS

junctive or enabling modalities in preparation for func-

tional use. It is within this context that treatment tech-
reatment of the upper extremity (UE) is important niques will be presented in this chapter.
to all occupational therapists who work with physically Treatment of the injured UE is a matter of timing and
disabled persons. The incidence of UE injuries is signifi- judgment. Following trauma or surgery, a healing phase
cant and accounts for about one third of all acute in- must occur in which the body performs its physiologi-
juries. About 63% of the 90,000 work-related repetitive cal function of wound healing. Following the initial
motion injuries per year in the United States involve the healing phase when cellular restoration has been ac-
wrist, hand, and shoulder. Combined, these injuries complished, the wound enters its restorative phase. It is
account for 98 million days of restricted activity. The UEs in this phase that hand therapy is most beneficial. Early
are involved in about one third of work-related farm in- treatment that occurs in this restorative phase is ideal,
juries and one quarter of all disabling injuries. In addi- and in some cases essential for optimal results.
tion, disease and congenital anomalies contribute to UE Although sample timetables may be presented, the
dysfunction, and it is estimated that only about 15% of therapist should always coordinate the application of
those suffering from severe cerebrovascular accident any treatment with the referring physician. Surgical
recover hand function. The total cost of UE disorders in techniques may vary, and inappropriate treatment of
the United States in 1995 was estimated to be almost $19 the patient with hand injury can result in failure of a
billion.”* surgical procedure.
The hand is vital to human function and appearance. Communication between the surgeon, therapist, and
It flexes, extends, opposes, and grasps thousands of patient is especially vital in this setting. A comfortable
times daily, allowing the performance of necessary daily environment in which group interaction is possible may
activities. The hand's sensibility allows feeling without increase patient motivation and cooperation. The pres-
looking and provides protection from injury. The hand ence of the therapist as an instructor and evaluator is es-
touches, gives comfort, and expresses emotions. Loss of sential, but without the patient's cooperation limited
hand function through injury or disease thus affects gains will be achieved. Treating the psychological loss
much more than the mechanical tasks that the hand suffered by the patient with a hand injury is also an in-
performs. Hand injury may jeopardize a family’s liveli- tegral part of the rehabilitative therapy.
hood, and at the least affects every daily activity. The Hand therapy is provided in a number of treatment
occupational therapist with training in physical and settings, ranging from private therapy offices to outpa-
psychological assessment, prosthetic evaluation, fabri- tient rehabilitation clinics and hospitals. Reimburse-
cation of orthoses, assessment and training in the activ- ment for services may come directly from the patient, or
ities of daily living (ADL), and functional restoration is through private medical insurance, workers’ compensa-
uniquely qualified to treat UE disorders. tion insurance, or a variety of managed care programs.
Hand rehabilitation, or hand therapy, has grown as a Changes in reimbursement have driven changes in the
specialty area of both physical therapy and occupational market place and employment patterns. In the future,
therapy (OT). Many of the treatment techniques used OT will be provided in a variety of new settings and OT
with hand-injured patients have evolved from the appli- intervention will continue to evolve.
cation of therapy and knowledge of both specialties to In UE rehabilitation, these changes have been mani-
be used by the hand therapist. It is not the purpose of fested as changes in delivery of services. In some cases
this chapter to instruct the OT student in physical agent therapists are not members of the approved provider
modalities. Rather, treatment techniques that have been panel and are no longer able to treat patients who are
found to be beneficial to hand injury patients are pre- members of a health maintenance organization. Reim-
sented. It is assumed that therapists best trained to bursement patterns have altered the provision of serv-
provide them will provide these techniques. ices by limiting the number of visits authorized. Thera-
As used in this chapter, hand therapy is a term that pists are also being asked to provide outcome data that
includes treatment of the entire upper quadrant, which support the need for services. It is likely that outcome-
includes the scapula, shoulder and arm. Upper quad- based treatment plans with functional goals and analy-
rant and upper extremity are used. interchangeably. UE sis of goal achievement will become the standard for the
rehabilitation requires advanced and specialized train- reimbursement of OT services. In addition, patient satis-
ing by both physical and occupational therapists. A faction and perception of health status have become
practice analysis study of the theory and knowledge that crucial in the delivery of medical care in a consumer-
serves as the underpinning for hand therapy has been based economy. Continuous quality improvement doc-
reported.*'’®’ Treatment techniques, whether thermal umentation is often required for participation in
modalities or specifically designed exercises, are used as managed care programs. With fewer authorized visits
a bridge to reach a further goal of restoring functional the therapist must be more adept at instructing the
performance. Thus some modalities may be used as ad- patient in self-management of the condition being
 Hand and Upper Extremity Injuries 835

treated. Occupational therapists should anticipate a phalangeal (PIP) joint is critical for grasp and is consid-
greater need to justify treatment in the future as part of ered to be the most important small joint. '* Limitations
the national challenge to control medical costs. Aides, in flexion or extension will result in significant func-
certified assistants, and other support personnel will be tional impairment.
used increasingly, but the quality of service provided
- must continue to meet all professional and ethical stan-
Observation and Topographical
dards. This climate of change will present unique op-
Assessment
portunities for the occupational therapist. Clinical spe-
cialists may find new roles as consultants and trainers. The occupational therapist should observe the appear-
Just as OT teaches an individual to adapt to changes in ance of the entire UE. The position of the hand and arm
health status, the profession of OT will need to adapt to at rest and the carrying posture can yield valuable infor-
social and economic changes to remain a leader in mation about the dysfunction. How the patient treats
health management. the disease or injury should be observed. The therapist
should note if the hand and arm is overprotected and
carefully guarded or ignored, and if the patient carries
EXAMINATION AND EVALUATION
the arm close to the body, in an awkward posture, or
When approaching a patient who has a hand injury, even covered.
the therapist must be able to evaluate the nature of the The cervical and shoulder area posture should be ob-
injury and the limitations it has produced. First the served for evidence of abnormalities in cervical and tho-
injured structures must be identified by consulting with racic curvature that may reduce the potential for shoul-
the hand surgeon, reviewing operative reports and x-ray der movement. Muscle atrophy may be observable in
films, and discussing the injury with the patient. Assess- the scapular area if there has been significant long-term
ment of bone, tendon, and nerve function must be as- weakness or if the rotator cuff is torn. The scapula may
certained, using standardized assessment techniques appear asymmetrical or altered if muscle imbalances of
whenever possible. length or strength are present.
The patient's age, occupation, and hand dominance The skin condition of the hand and arm should be
should be taken into account in the initial evaluation. noted. In particular, the therapist should note any lacer-
The type and extent of medical and surgical treatment ations, sutures, or evidence of recent surgery; whether
that has been received and the length of time since such the skin is dry or moist; if scales or crusts are present;
treatment are important in determining a treatment and if the hand appears swollen or has an odor. Palmar
plan. Any further surgery or conservative treatment that skin is less mobile than dorsal skin normally. The thera-
is planned should also be noted. A written treatment pist should determine the degree of mobility and elas-
plan should have the approval of the referring physi- ticity and the adherence of scars. The therapist should
cian. Most physicians welcome observations and évalu- also observe trophic changes in the skin. The vascular
ation-based recommendations from the therapist re- system is assessed by observing the skin color and tem-
garding the patient's care. perature of the hand and evaluating for presence of
The purposes of hand evaluation are to identify! edema. Any contractures of the web spaces should be
physical limitations, such as loss of range of motion noted. The therapist should observe the relationship
(ROM); functional limitations, such as an inability to between hand and arm function as the patient moves
perform daily tasks,’ substitution patterns to compen- about and performs test items or tasks.
sate for loss of sensibility or motor function,* and es- The therapist should ask the patient to perform some
tablished deformities, such as joint contracture. simple bilateral ADL, such as buttoning a button,
The movement of the arm and hand must be coordi- putting on a shirt, opening a jar, and threading a needle,
nated for maximum function. Shoulder motion is es- and observe the amount of spontaneous movement and
sential for positioning the hand and elbow for daily ac- use ofthe affected hand and arm. Similar screening tests
tivities.°° The wrist is the key joint in the position of can be used to determine shoulder mobility, such as
function.'? Skilled hand performance depends on wrist reaching overhead, as well as placing the hand behind
stability. Although a mobile wrist is preferable, function the back and behind the head.
is possible as long as the wrist is positioned to maxi-
mize movement of the fingers. Function also depends
Physical Assessment
on arm and shoulder stability and mobility for fixing or
positioning the hand for activity. The thumb is of A number of standardized tests can be used to deter-
greater importance than any other digit. Effective pinch mine physical limitations in the UE. ROM and manual
is almost impossible without a thumb, and attempts muscle testing are crucial and are described in other
will be made to salvage or reconstruct an injured thumb chapters of this text. Special tests used by the hand ther-
whenever possible. Within the hand the proximal inter- apist are described in a general sense, but the student
836 TREATMENT APPLICATIONS

should consult other textbooks for detailed instructions der are outlined in Table 44-1. Comparing initial re-
in such areas as assessment of adverse neural tension.!° sponses with the results of follow-up evaluation will
help document a positive response to treatment. Pat-
Screening the Cervical Neck and Shoulder terns of impairments in UE ROM and strength, as well
Screening examination of the cervical neck and shoul- as a positive response to provocative testing, should be
der regions should be included in evaluation of hand reported to the referring physician if they would affect
conditions to determine if these areas are contributing the patient's planned treatment or outcome. Therapists
to the patient's symptoms or limitations in function. must not attempt to treat conditions that are beyond
Active movements of the neck should be conducted, their scope of knowledge. Referral to an appropriate
with attention paid to complaints of UE symptoms practitioner should be discussed with the physician if
during cervical extension or lateral flexion to the same indicated.
side. Complaints during these movements may be sug-
gestive of nerve root irritation. Hand symptoms with IMPINGEMENT TESTS. The examiner passively
opposite side bending may be a sign of adverse neural overpressures the patient's arm into end-range eleva-
tension. Few occupational therapists are knowledgeable tion. This movement causes a jamming of the greater
in the treatment of cervical conditions, and care must be tuberosity against the anterior inferior acromial
taken not to aggravate an existing condition. The thera- surface.’® The test is positive if the patient's facial ex-
pist should return the patient to the referring physician pression shows pain. An alternative test is described by
with recommendations for referral to an appropriate Hawkins and Kennedy.** The examiner forward flexes
practitioner if the results of this testing are positive. the arm to 90°, then forcibly internally rotates the arm.
Pain indicates a positive test result.
Assessment of Movement
The effect of trauma or dysfunction on anatomical DROP ARM TEST. The patient's arm is passively ab-
structures is the first consideration in evaluating hand ducted by the examiner to 90° with the patient's palm
function. The joints must be assessed for active and down. The patient is then asked to lower the arm ac-
passive mobility, fixed deformities, and any tendency to tively. Pain or inability to lower the arm smoothly with
assume a position of deformity. The ligaments must be good motor control is considered a positive test
assessed for laxity or contracture and their ability to result.°>’**
maintain joint stability. Tendons must be examined for
integrity, contracture, or overstretching; muscles are Soft-Tissue Tightness
tested for strength and function. Joints may develop dysfunction after trauma, immobi-
lization, or disuse. Mennell emphasizes the importance
Limited Movement in the Shoulder of the small, involuntary motions of the joint, which he
Examples of conditions in the shoulder region leading refers to as “joint play.””* Others°° describe these as “ac-
to reduced strength, reduced ROM, or pain in the shoul- cessory motions.” Joint play or accessory motions are

| :ests
for Specific Dysfunction in the Shoulder
Condition Pattern of Impairment Characteristic Findings/Special Tests
Adhesive capsulitis Loss of active and passive shoulder motion with Capsular end feel to passive motions in restricted
the most pronounced loss in external rotation, planes of movement.
and to a lesser degree abduction and internal
rotation

Subacromial Painful arc of motion between approximately In early stages, muscle tests may be strong and
impingement 80° to!00° elevation and/or at end range of active painless despite positive impingement test.
elevation.

Rotator cuff tendinitis Painful active or resistive rotator cuff muscle use Painful manual muscle test of scapular plane abduction
and/or external rotation
Nonpainful passive motion end ranges
Tenderness at tendons of supraspinatus or
infraspinatus.

Rotator cuff tear Significant substitution of scapula with attempted Positive drop arm test
arm elevation Very weak, less than % abduction and/or external
rotation
 Hand and Upper Extremity Injuries 837

those movements that are involuntary and physiologi- be possible to pull the fingers into complete extension.
cal and can be performed only by someone else.”* Ex- If the wrist is then held in flexion, the IP joints will
amples of accessory motions are joint rotation and joint extend more easily because slack is placed on the flexor
distraction. If accessory motions are limited and tendons.
painful, the active motions of that joint cannot be Tightness of the intrinsic musculature is tested by
normal. Therefore it is necessary to restore joint play passively holding the MP joint in extension and apply-
through the use of joint mobilization techniques before ing pressure just distal to the PIP joint. This action is re-
attempting passive or active ROM.”* peated with the MP joint in flexion. If there is more re-
Joint mobilization may date back to the fourth sistance when the MP joint is extended, intrinsic
century BC, when Hypocrites first described the use of tightness is indicated.*
spinal traction.’* In the 1930s an English physician, If passive motion of the PIP joint remains the same
James Mennell, encouraged physicians to perform ma- whether the MP joint is held in extension or flexion and
nipulation without anesthesia, a practice that is advo- there is limitation of PIP joint flexion in any position,
cated today by James Cyriax,*’ who explored the use of tightness of the joint capsule is indicated. The therapist
manipulation of the intervertebral disks. Current theo- should assess the joint for capsular tightness if this has
rists include Cyriax, Robert Maigne, EM. Kaltenborn, not already been done.
G.D. Maitland, Stanley Paris, and John Mennell, son of Provocative tests that are used to assess ligament,
the late James Mennell. Although physicians originally capsule, and joint instability are summarized in Table
practiced manipulation, therapists have adapted the 44-2. The reader is referred to more comprehensive text-
techniques, which are now called joint mobilization. books for details on the administration of these
The techniques used to assess joint play are also used tests Pi?
in the treatment of joint dysfunction. During assess-
ment the evaluator determines the range of accessory Assessment of Peripheral Nerve Status
motion and the presence of pain by taking up the slack Nerve dysfunction can occur at any point from the nerve
only in the joint. Some practitioners advocate use of a roots through the digital nerves in the fingers. A good
high-velocity, low-amplitude thrust or graded oscilla- understanding of the peripheral nervous system is es-
tion to regain motion and relieve pain.°° sential for appropriate treatment of the UE. Determin-
Guidelines must be followed in applying joint mobi- ing the approximate location of nerve dysfunction can
lization techniques, and the untrained or inexperienced assist in treatment planning.
practitioner should not attempt to use the techniques.
Postgraduate courses are offered in joint mobilization CATEGORIES OF TESTS. A variety of tests may be
of the extremities, and the therapist must be familiar required to assess nerve function adequately. These tests
with the orthokinematics of each joint, as well as with can be divided into four categories’: modality tests for
the techniques used. pain, heat, cold, and touch pressure’; functional tests
Joint mobilization is generally indicated with restric- to assess the quality of sensibility, or what Moberg’°
tion of accessory motions or the presence of pain caused described as “tactile gnosis”’; objective tests that do
by tightness of the joint capsule, meniscus displace- not require active participation by the patient*; and
ment, muscle guarding, ligamentous tightness, or ad- provocative tests that reproduce symptoms.
herence. It is contraindicated in the presence of infec- Examples of functional tests are stationary and
tion, recent fracture, neoplasm, joint inflammation, moving two-point discrimination and the Moberg pick-
theumatoid arthritis, osteoporosis, degenerative joint up test; objective tests include the wrinkle test, the Nin-
disease, and many chronic diseases.”* hydrin sweat test, and nerve-conduction studies.'* Elec-
Limitations in joint motion may also be caused by trodiagnostic testing is the most conclusive and widely
tightness of the extrinsic or intrinsic muscles and accepted method of determining nerve dysfunction.
tendons. If the joint capsule is not tight and accessory Provocative tests are highly suggestive of a nerve
motions are normal, the therapist should test for extrin- lesion if results are positive but not do rule out a
sic and intrinsic tightness. problem if results are negative. Tests of nerve dysfunc-
To test for extrinsic extensor tightness the metacar- tion are summarized in Table 44-3. Instructions for ad-
pophalangeal (MP) joint is passively held in extension ministration of the most common tests are described in
and the PIP joint is moved passively into flexion. Then the following paragraphs.
the MP joint is flexed, and the PIP joint is again pas- ADSON MANEUVER. The examiner palpates the radial
sively flexed. If the PIP joint can be flexed easily when pulse on the arm to be tested. The patient then rotates
the MP joint is extended but not when the MP joint is the head toward the arm being tested. The patient then
flexed, the extrinsic extensors are adherent.* extends the head and holds a deep breath while the arm
If there is extrinsic flexor tightness, the PIP and distal is being laterally rotated and extended. Disappearance
interphalangeal (DIP) joints will be positioned in or slowing of pulse rate is considered a positive test
flexion, with the MP joints held in extension. It will not result. "°°
 TREATMENT APPLICATIONS

specific Dysfunction in the Wrist

SSD

Condition Pattern of Impairment Special Tests Q eae

Thumb ulnar collateral ligament instability Pain and instability of the thumb MP joint Movement greater than 35° when valgus —
(gamekeeper's or skier's thumb) stress is applied to the thumb MP joint —
Instability of the scaphoid Pain in the area of the scaphoid bone Watson Test
(anatomical snuffbox) or “clunking’’ with Pain or sound associated with
movement of the wrist subluxation of the dorsal pole of the
scaphoid while performing test
Instability of the distal radioulnar joint Pain and tenderness in the wrist “Piano Keys’’ Test
Hypermobility and pain
associated with pressure on the |
distal ulna

Lunate dislocation Pain or instability in the central wrist Murphy's sign

The head of the third metacarpal is level
with the second and fourth metacarpals
while making a fist
Lunotriquetral instability Pain or instability in the central or ulnar Lunotriquetral Ballottement Test
wrist Crepitus, laxity or pain with isolated
movement of the lunate

TFCC tear Pain and instability in the ulnar wrist Wrist arthrogram or MRI

' Nerve Dysfunction in the Upper Extremity

Conditio Pattern of Impairment Characteristic Findings/Special Tests
Thoracic outlet syndrome Nonspecific paresthesias or heaviness with sustained positioning Adson test
or activity above shoulder level or behind the plane of the body Roos test

Adverse neural tension Nonspecific pain or paresthesias with reaching in positions Positive upper limb screening test
that places tension on brachial plexus nerves

Carpal tunnel syndrome Pain and numbness, primarily in the thumb, index, and middle Tinel’s sign at the wrist
fingers Phalen’s test
Usually worse at night and may be associated with activity Reverse Phalen’'s test
Carpal compression test
Cubital tunnel syndrome Compression of ulnar nerve at elbow Elbow flexion test

Ulnar nerve paralysis Paralysis of the adductor pollicis muscle Froment's sign
Jeanne's sign
Wartenberg’s sign

Roos Test. In this test the patient maintains a posi- are produced when tension stress is placed on the
tion of bilateral arm abduction to 90°, shoulder exter- brachial plexus. The maneuver described primarily
nal rotation, and elbow flexion to 90° for 3 minutes stresses the median nerve and C5-C7 nerve roots.
while slowly alternating between an open hand and a Adverse neural tension in the ulnar or radial nerves may
clenched fist. Inability to maintain this position for the also be tested. However, we have found that using the
full 3 minutes or onset of symptoms is considered a median nerve test as a screening device establishes a
positive test result.°”’°° marker against which to gauge the success of treatment.
Upper Limp TENSION Test (BRACHIAL PLEXUS TENSION Although some authors recommend using the neural
Test). This test is designed to screen for symptoms that tension tests for treatment as well as assessment, this
 Hand and Upper Extremity Injuries 839

has not been the practice of the authors. This screening Jeanne’s sign. Wartenberg’s sign is positive if the patient
process should be used by the occupational therapist to is unable to adduct the small finger when the hand is
rule out or confirm the involvement of more proximal placed palm down on the table with the fingers pas-
structures. sively abducted.
The patient is positioned supine, and the examiner The radial nerve may be tested by asking the patient
takes the patient's arm into abduction and external rota- to extend the wrist and fingers. Median nerve function is
tion behind the coronal plane at the shoulder. The tested by asking the patient to oppose the thumb to the
shoulder girdle is fixed in depression. The elbow is then fingers and flex the fingers.*”
passively extended with the wrist in extension and the SENSORY MapPiNnG. Detailed sensibility testing can
forearm in supination. Symptoms of stretch or ache in begin with sensory mapping of the entire volar surface
the cubital fossa or tingling in the thumb and first three of the hand.'* The hand must be supported by the ex-
fingers indicates tension on the median nerve. Lateral aminer’s hand or be resting in a medium such as
flexion of the neck to the opposite side will amplify therapy putty. Either the examiner or the patient can
symptoms by increasing tension on the dura mater. draw a probe, usually the eraser end of a pencil, lightly
Elbow extension ROM should be compared with the over the skin from the area of normal sensibility to the
uninvolved side to indicate the degree of restriction.°° area of abnormal sensibility. The patient must imme-
TINEL's SIGN. The test is performed by tapping gently diately report the exact location where the sensation
along the course of the nerve, starting distally and changes. This is done from proximal to distal and
moving proximally to elicit a tingling sensation in the radial and ulnar to medial directions. The areas are care-
fingertip. The point at which tapping begins to elicit a fully marked and transferred to a permanent record.
tingling sensation is noted and indicates the approxi- Mapping should be repeated at monthly intervals
mate location of nerve compression. This test is also during nerve regeneration.
used after nerve repair, to determine the extent of SYMPATHETIC FUNCTION. Recovery of sympathetic re-
sensory axon growth. sponse such as sudomotor (sweating), vasomotor (tem-
PHALEN’S TEST AND REVERSE PHALEN’S Test. Phalen’s perature discrimination), pilomotor (gooseflesh), and
Test is performed by fully flexing the wrists with the trophic (skin texture, nail, and hair growth) may occur
dorsum of the hands pressing against each other. early but does not correlate with functional recovery.””
Reverse Phalen’s is performed by holding the hands in O’Rain”’ observed that denervated skin does not wrinkle.
the “prayer” position for 1 minute. The test results are Therefore nerve function may be tested by immersing the
positive if the patient reports tingling in the median hand in water for 5 minutes and noting the presence or
nerve distribution (thumb, index, middle and radial absence of skin wrinkling. This test may be especially
aspect of ring finger) within 1 minute. helpful in diagnosing a nerve lesion in young children.
CARPAL COMPRESSION Test. The examiner places pres- The ability to sweat is also lost with a nerve lesion. A Nin-
sure over the median nerve in the carpal tunnel for up to hydrin test’° evaluates sweating of the finger.
30 seconds. The test result is positive if tingling occurs The wrinkle test and the Ninhydrin test are objective
in the median nerve distribution. The combination of tests of sympathetic function. Recovery of sweating has
wrist flexion and compression of the median nerve for not been shown to correlate with the recovery of sensa-
20 seconds has been found to be more sensitive than tion, but the absence of sweating correlates with the lack
other provocative tests used alone.” of discriminatory sensation. Other signs of sympathetic
ELBOw FLEXION Test. The elbow flexion test is used to dysfunction are smooth, shiny skin; nail changes; and
screen for cubital tunnel syndrome (compression of the “pencil-pointing” or tapering of the fingers.©”
ulnar nerve in the cubital tunnel). The patient is asked NERVE COMPRESSION AND NERVE REGENERATION. Sensi-
to fully flex the elbows with the wrists fully extended for bility testing is performed to assess the recovery of a
a period of 3 to 5 minutes. The test result is positive if nerve following laceration and repair, as well as to de-
tingling is reported in the ulnar nerve distribution of the termine the presence of a nerve compression syndrome
forearm and hand (ulnar ring finger and small finger).°° and the return of nerve function after surgical decom-
Quick TESTS FOR MOTOR FUNCTION IN THE PERIPHERAL pression, or the efficacy of conservative treatment to
Nerves. The ulnar nerve may be tested by asking the reduce compression. Therefore tests such as vibratory
patient to pinch with the thumb and index finger and tests may be interpreted differently, depending on the
palpating the first dorsal interosseous muscle. Another mechanism of nerve dysfunction. In the following
test for ulnar nerve paralysis involves asking a patient to section, tests will be described and differences drawn as
grasp a piece of paper between the thumb and index appropriate to assist the therapist in selecting the correct
finger. When the examiner pulls away the paper, the tip assessment technique, as well as in planning treatment
of the thumb flexes because of absence of the adductor based on the evaluative measures.
pollicis muscle (Froment’s sign). If the MP joint of the During the first 2 to 4 months after nerve suture,
thumb also extends at the same time, it is known as axons regenerate and travel through the hand at a rate of
840 TREATMENT APPLICATIONS

about 1 mm per day, or 1 inch (2.54 cm) per month. The Semmes-Weinstein monofilaments are the most
Tinel’s sign may be used to follow this regeneration.” accurate instruments for assessing cutaneous pressure
As regeneration occurs, hypesthesias develop. Although thresholds." The testing equipment consists of 20
this hypersensitivity may be uncomfortable to the nylon monofilaments housed in plastic handheld rods.
patient, it is a positive sign of nerve growth. A treatment The diameter of the monofilaments increases, and when
program for desensitization of hypersensitive areas can applied correctly exert a force ranging from 4.5 mg to
be initiated as soon as the skin is healed and can toler- 447 g. Markings on the probes range from 1.65 to 6.65
ate gentle rubbing and immersion in textures. Desensiti- but do not correspond to the grams of force of each rod.
zation is discussed further in the treatment section. Normal fingertip sensibility has been found to corre-
ViBRATION. Dellon was an early advocate of the use spond to the 2.44 and 2.83 probes.
of 30-cycles-per-second (30-cps) and 256-cps tuning The monofilaments must be applied perpendicularly
forks for assessing the return of vibratory sensation after to the skin and are applied just until the monofilament
nerve repair, as regeneration occurs and as a guide- bends. The skin should not blanch when the monofila-
line for initiating a sensory reeducation program.*””! ment is applied. Probes 1.65 through 2.83 are bounced
However, many clinicians found that use of a tuning three times. Probes marked 3.22 to 4.08 are applied three
fork was not discrete enough to detect sensory abnor- times with a bend in the filament, and probes marked
malities. 4.17 to 6.65 are applied once. The larger monofilaments
Lundborg® has described the use of commercial vi- do not bend, and therefore skin color must be observed
brometers to detect abnormal sensation. This method to determine how firmly to apply the probe.
was less subjective and thought to be more reliable. In The examiner should begin with a probe in the
a study of induced median nerve compression, Gelber- normal range and progress through the rods in increas-
man” found that vibration and touch perception as ing diameters to find the patient's threshold for touch
measured by the Semmes-Weinstein monofilaments are throughout the volar surface.'° A grid should be used to
altered before two-point discrimination because they record the responses so that varying areas of touch per-
measure a single nerve fiber innervating a group ofrecep- ception can be demonstrated. Two correct responses out
tor cells. Two-point discrimination is a test of innervation of three applications are necessary for an area to be con-
density that requires overlapping sensory units and corti- sidered as having intact sensibility. It is preferable to
cal integration. Thus two-point discrimination is altered place the monofilaments randomly rather than to con-
after nerve laceration and repair but remains normal ifthe centrate on an area, to allow the nerves recovery time.
nerve is compressed, as long as there are links to the When a filament is placed three times, it should be held
cortex. Bell'® has also found normal two-point values in for a second, rested for a second, and reapplied. Results
the presence of decreased sensory function. can be graded from normal light touch (probes 2.83
Vibration and the Semmes-Weinstein Test are more and above) to loss of protective sensation (probes 4.56
sensitive in picking up a gradual decrease in nerve func- and below). Diminished light touch and diminished
tion in the presence of nerve compression where the protective sensation are in the range reflected by the
nerve circuitry is intact. They also correlate with de- central probes.”
creases in the potential amplitude of sensory nerve TWO-POINT AND MOVING TWO-POINT DISCRIMINATION.
action as measured by nerve conduction studies.” Discrimination, the second level of sensibility assess-
Therefore vibration, Semmes-Weinstein, and electrical ment, requires the subject to distinguish between two
testing are reliable and sensitive tests for early detection direct stimuli. Static or stationary two-point discrimina-
of carpal tunnel syndrome and other nerve compression tion measures the slowly adapting fibers. The two-point
syndromes. Vibration and Semmes-Weinstein can be discrimination test, first described by Weber in 1853,
performed in the clinic with no discomfort to the was modified and popularized by Moberg,’° who was
patient and are excellent screening tools when nerve interested in a tool that would assess the functional
compression is suspected. level of sensation. A variety of deviceshave been pro-
Touch Pressure. Moving touch is tested using the posed to use in measuring two-point discrimination.
eraser end of a pencil. The eraser is placed in an area of The bent paper clip is inexpensive but often has burrs
normal sensibility and, pressing lightly, is moved to the on the metal tip. Other devices include industrial
distal fingertip. The patient notes when the perception calipers* and the Disk-Criminator.'°* A device with par-
of the stimulus changes. Light and heavy stimuli may be allel prongs of variable distance and blunted ends
applied and noted.” should produce replicable results.
Constant touch is tested by pressing with the eraser
end of a pencil, first in an area with normal sensibility
*Central Tool Company of Germany (available from Anthony Prod-
and then moving distally. The patient responds when ucts, Indianapolis, Ind).
the stimulus is altered; again, light and heavy stimuli +Disk-Criminator (available from Smith & Nephew, Germantown,
may be applied.” Wis).
 Hand and Upper Extremity Injuries 841

The test is performed as follows>”: 2. The test is repeated for the opposite hand with
= . The patient's vision is occluded. vision.
2. An area of normal sensation is tested as a reference, 3. The test is repeated for each hand with vision oc-
using blunt calipers or a bent paper clip. cluded.
3. The calipers are set 10 mm apart and are randomly 4. The patient is asked to identify each object one at a
applied, starting at the fingertip and moving proxi- time, with and then without vision.
mally and longitudinally in line with the digital It is important to observe any substitution patterns
nerves, with one or two points touching. The skin that may be used when the patient cannot see the
should not be blanched by the caliper. objects.
4. The distance is decreased until the patient no longer
feels two distinct points, and that distance is mea- Edema Assessment
sured. Hand volume is measured to assess the presence of ex-
Three to four seconds should be allowed between ap- tracellular or intracellular edema. Volume measurement
plications, and the patient should have four correct re- is generally used to determine the effect of treatment
sponses out of five administrations. Because this test in- and activities. By measuring volume at different times of
dicates sensory function, it is usually administered at the day, the therapist can measure effects of rest versus
the tips of the fingers. It may be used proximally to test activity, as well as the effects of splinting or treatment
nerve regeneration. Normal two-point discrimination at designed to reduce edema.
the fingertip is 6 mm or less. A commercial volumeter~? may be used to assess
Moving two-point discrimination measures the in- hand edema. The volumeter has been shown to be accu-
nervation density of the quickly adapting nerve fibers rate to 10 ml'®* when used in the prescribed manner.
for touch. It is slightly more sensitive than stationary Variables that have been shown to decrease the accuracy
two-point discrimination. The test is performed as of the volumeter include the use of a faucet or hose that
follows’: introduces air into the tank during filling, movement of
1. The patient's vision is occluded. the arm within the tank, inconsistent pressure on the
2. An area of normal sensation is tested as a reference, stop rod, and the use of a volumeter in a variety of
using blunt calipers or a bent paper clip. places. The same level surface should always be used.'”*
3. The fingertip is supported by the examining table or The evaluation is performed as follows (Fig. 44-1):
the examiner's hand. 1. A plastic volumeter is filled and allowed to empty
4. The caliper, separated 5 mm to 8 mm, is moved lon- into a large beaker until the water reaches spout
gitudinally from proximal to distal in a linear level. The beaker is then emptied and dried thor-
fashion along the surface of the fingertip. One and oughly.
two points are randomly alternated. The patient 2. The patient is instructed to immerse the hand in the
must correctly identify the stimulus in seven out of plastic volumeter, being careful to keep the hand in
eight responses before proceeding to a smaller value. the midposition.
The test is repeated down to a separation of 2 mm. 3. The hand is lowered until it rests gently between the
Two-point values increase with age in both sexes, middle and ring fingers on the dowel rod. It is im-
with the smallest values occurring between the ages of portant that the hand not press onto the rod.
10 and 30. Women tend to have smaller values than 4. The hand remains still until no more water drips into
men, and there is no significant difference between the beaker.
dominant and nondominant hands.°” 5. The water is poured into a graduated cylinder. The
MODIFIED MoBerRG Pick-up Test. Recognition of cylinder is placed on a level surface, and a reading is
common objects is the final level of sensory function. made.
Moberg used the phrase tactile gnosis to describe the A method of assessing edema of an individual finger
ability of the hand to perform complex functions by or joint is circumferential measurement using either a
feel. Moberg described the Pick-Up Test in 1958,’° and circumference tape* or jewelers ring-size standards.
it was later modified by Dellon.”” This test is used with Measurements should be made before and after treat-
either a median nerve injury or injury to a combination ment and especially after the application of thermal
of median and ulnar nerves. It takes twice as long to modalities or splinting. Although patients often have
perform the tests with vision occluded as with vision subjective complaints relating to swelling, objective
unimpaired. The test is performed as follows: data of circumference or volume will help the therapist
1. Nine or ten small objects (e.g, coins or paper clips) to assess the response of the tissues to treatment and
are placed on a table, and the patient is asked to
place them, one at a time, in a small container as
quickly as possible, while looking at them. The
patient is timed. *DeRoyal/LMB, DeRoyal Industries, Powell, TN.
 TREATMENT APPLICATIONS

FIG. 44-1
Volumeter is used to measure volume of both hands for compari-
son. Increased volume indicates presence of edema.

activity. Edema control techniques are discussed later in

this chapter. FIG. 44-2
Jamar dynamometer is used to evaluate grip strength in both
Circulation hands.
The Allen Test is used to assess patency in the radial and
ulnar arteries to the hand, which form the superficial
and deep palmar arches. The test is performed by having viation. Three trials are taken of each hand, with the dy-
the patient open and close the hand quickly, then make namometer handle set at the second position.”' The dy-
a tight fist. The examiner applies pressure over both ar- namometer should be lightly held by the examiner to
teries, then releases the pressure on one artery to see if prevent accidental dropping of the instrument. A mean
hand color returns. The test is repeated for the other of the three trials should be reported. The noninjured
artery. 65 hand is used for comparison. Normative data may be
used to compare strength scores.°”’”? Variables such as
age will affect the strength measurements.
Grip and Pinch Strength
Pinch strength should also be tested, using a pinch
UE strength is usually assessed after the healing phase of gauge. The pinch gauge made by B & L Engineering
trauma. Strength testing is not indicated after recent has been found to be the most accurate.” Two-point
trauma or surgery. Testing should not be performed pinch (thumb tip to index fingertip), lateral or key
until the patient has been cleared for full-resistive activ- pinch (thumb pulp to lateral aspect of the middle
ities, usually 8 to 12 weeks after injury. phalanx of the index finger), and three-point pinch
A standard adjustable-handle dynamometer is rec- (thumb tip to tips of index and middle fingers) should
ommended for assessing grip strength (Fig. 44-2). The be evaluated. As with the grip dynamometer, three
subject should be seated with the shoulder adducted successive trials should: be obtained and compared bi-
and neutrally rotated, the elbow flexed at 90°,°° laterally (Fig. 44-3).°?
forearm in the neutral position, and wrist between 0° Manual muscle testing is also used to test UE
and 30° extension and between 0° and 15° of ulnar de- strength. Accurate assessment is especially important
 Hand and Upper Extremity Injuries 843

which test writing a short sentence, turning over 3- X 5-

inch cards, picking up small objects and placing them in
a container, stacking checkers, simulated eating, moving
empty large cans, and moving weighted large cans.
Norms are provided for dominant and nondominant
hands for each subtest and also are divided by sex and
age. Instructions for assembling the test, as well as spe-
cific instructions for administering it, are provided by
the authors.*° This has been found to be a good test for
overall hand function.
The Quantitative Test of Upper Extremity Function
described by Carroll*® was designed to measure ability
to perform general arm and hand activities used in daily
living. It is based on the assumption that complex UE
movements used to perform ordinary ADL can be
FIG. 44-3 reduced to specific patterns of grasp and prehension of
Pinch gauge is used to evaluate pinch strength to variety of pre- the hand, supination and pronation of the forearm,
hension patterns of pinch. flexion and extension of the elbow, and elevation of
the arm.
when the patient is being prepared for tendon transfers The test consists of six parts: grasping and lifting four
or other reconstructive surgery. The student who wishes blocks of graduated sizes to assess grasp; grasping and
to study kinesiology of the UE is referred especially to lifting two pipes of graduated sizes to test cylindrical
Brand's work.'” grip; grasping and placing a ball to test spherical grasp;
Maximum voluntary effort during grip, pinch, or picking up and placing four marbles of graduated sizes
yor
muscle testing will be affected by pain in the hand or ex- to test fingertip prehension or pinch; putting a small
tremity, and the therapist should note if the patient's washer over a nail and putting an iron on a shelf to test
ability to exert full force is limited by subjective com- placing; and pouring water from pitcher to glass and
plaints. Localization of the pain symptoms and consis- glass to glass. In addition, to assess pronation, supina-
tency in noting pain will help the therapist to evaluate tion, and elevation of the arm, the therapist instructs the
the role that pain is playing in the recovery from injury. subject to place his or her hand on top of the head,
Pain problems are discussed in more detail later in this behind the head, and to the mouth, and write his or her
chapter. name. The test uses simple, inexpensive, and easily ac-
quired materials. Details of materials and their arrange-
ment, test procedures, and scoring can be found in the
Functional Assessment
original source.*°
Assessment of hand function or performance is impor- Other tests that are useful in the assessment of hand
tant because the physical assessment does not measure dexterity are the Crawford Small Parts Dexterity Test,**
the patient's ingenuity and ability to compensate for the Bennett Hand Tool Dexterity Test," the Purdue
loss of strength, ROM, or sensation or the presence of Pegboard Test,”’ and the Minnesota Manual Dexterity
deformities.”° Test.’° The VALPAR Corporation* has developed a
The physical assessment should precede the func- number of standardized tests that measure an individ-
tional assessment because awareness of physical dys- ual’s ability to perform work-related tasks. They provide
function can result in a critical analysis of functional information about the test taker’s results, compared
impairment and an understanding of why the patient with industry performance standards. All of these tests
functions as he or she does.’* include comparison with normal subjects working in a
The occupational therapist should observe the effect variety of industrial settings. This information can be
of the hand dysfunction on the use of the hand in ADL. used in predicting the likelihood of successful return to
In addition, some type of a standardized performance a specific job. The tests are especially useful when ad-
test, such as the Jebsen Test of Hand Function*® or the ministering a work capacity evaluation. Tests may be
Carroll Quantitative Test of Upper Extremity Func- purchased and come with instructions for administra-
tion,*° should be administered. tion of the test and the standardized norms. Melvin’
The Jebsen Test of Hand Function*® was developed to lists a variety of additional hand function tests.
provide objective measurements of standardized tasks
with norms for patient comparison. It is a short test that
is assembled by the administrator. It is easy to adminis- *VALPAR Assessment Systems (available from VALPAR International,
ter and inexpensive. The test consists of seven subtests, Tuscon, Ariz).
844 TREATMENT APPLICATIONS

TREATMENT
Fractures
In treating a hand or wrist fracture the surgeon attempts
to achieve good anatomical position through either a
closed (nonoperative) or open (operative) reduction.
Internal fixation with Kirschner wires, metallic plates, or
screws may be used to maintain the desired position.
External fixation may also be used with internal fixa-
tion. The hand is usually immobilized in wrist exten-
sion and MP joint flexion, with extension of the distal
joints whenever the injury allows this position. Trauma
to bone may also involve trauma to tendons and nerves
in the adjacent area. Treatment must be geared toward
the recovery of all injured structures, and this fact may
influence treatment of the fracture.
OT may be initiated during the period of immobi-
lization, which is usually 3 to 5 weeks. Uninvolved FIG. 44-4
fingers of the hand must be kept mobile through the use Velcro “buddy” splint may be used to protect finger following frac-
of active motion. Edema should be carefully monitored, ture or to encourage movement of stiff finger. (Splint available
and elevation is required whenever edema is present. from Smalley and Bates, Inc.)
As soon as there is sufficient bone stability, the
surgeon allows mobilization of the injured part. The
surgeon should provide guidelines for the amount of re- of the distal radius are the most common injury to the
sistance or force that may be applied to the fracture site. wrist'* and may result in limitations in wrist flexion and
Activities that correct poor motor patterns and encour- extension, as well as pronation and supination resulting
age use of the injured hand should be started as soon as from the involvement of the distal radioulnar joint. Ex-
the hand is pain free. Early motion will prevent the ad- ternal fixators, which may be used with or without in-
herence of tendons and reduce edema through stimula- ternal fixation, are now common in the reduction of
tion of the lymphatic and blood vessels. distal radius fractures. The external fixator maintains the
As soon as the brace or cast is removed, the patient's anatomical relationship between the radius and ulna by
hand must be evaluated. If edema remains present, maintaining the length of the radius, often with excel-
edema control techniques can be initiated using tech- lent results. The therapist must carefully instruct the
niques described later in this chapter. A baseline ROM patient in active ROM of the fingers and proper care of
should be established, and the application of appropri- the pin sites while the fixator is in place. Use of splints,
ate splints may begin. A splint may be used to correct a active motion that emphasizes wrist movement, and
deformity that has resulted from immobilization, or it joint mobilization may be beneficial after removal of
may be used to protect the finger from additional the fixator or cast. The weight well may be used to
trauma to the fracture site. An example of this type of provide resistance to wrist motions (Fig. 44-5).
splinting would be the application of a Velcro “buddy” The scaphoid is the second most commonly injured
splint (Fig. 44-4). A dorsal block splint that limits full bone in the wrist’* and is often fractured when the
extension of the finger may be used following a fracture hand is dorsiflexed at the time of injury. Fractures to the
or dislocation of the PIP joint. A dynamic splint may be proximal pole of the scaphoid may result in nonunion
used to achieve full ROM or to prevent the development because of poor blood supply to this area. Scaphoid
of further deformity at 6 to 8 weeks after fracture. fractures require a prolonged period of immobilization,
Intraarticular fractures may result in injury to the car- sometimes up to several months in a cast, with resulting
tilage of the joint, causing additional pain and stiffness. stiffness and pain. Care should be taken to mobilize un-
An x-ray examination will indicate whether the joint involved joints early.
surface has been damaged, which might limit the treat- Trauma to the lunate may result in avascular necrosis
ment of the joint. Joint pain and stiffness after fracture of the lunate or Kienbéck’s disease,'* which may result
without the presence of joint damage should be allevi- from a one-time accident or may be caused by repetitive
ated by a combination of thermal modalities, restoration trauma. Lunate fractures are usually immobilized for 6
of joint play, or joint mobilization and corrective and weeks. Kienbéck’s disease may be treated with a bone
dynamic splinting followed by active use. Resistive exer- graft, removal of the proximal carpal row, or partial
cise can be started when bony healing has been achieved. wrist fusion.
Wrist fractures are common and may present special Stiffness and pain are common complications of
problems for the surgeon and therapist. Colles fractures fractures. The control of edema coupled with early
 Hand and Upper Extremity Injuries 845

Peripheral nerve injuries may occur as a result of

disruption of the nerve by a fractured bone, laceration,
or crush injury. Symptoms of nerve injuries include
weakness or paralysis of muscles that are innervated by
motor branches of the injured nerve and sensory loss to
areas that are innervated by sensory branches of the
injured nerve. Before evaluating the patient for nerve
loss, the therapist must be familiar with the muscles and
areas that are innervated by the three major forearm
nerves. A summary of UE peripheral neuropathic condi-
tions can be found in Table 44-4.

Radial Nerve
The radial nerve innervates the extensor-supinator
group of muscles of the forearm, including the brachio-
a radialis, extensor carpi radialis longus, extensor carpi ra-
dialis brevis, extensor digitorum communis, extensor
digiti minimi, extensor indicis, extensor carpi ulnaris,
supinator, abductor pollicis longus, extensor pollicis
brevis, and extensor pollicis longus. The sensory distri-
bution of the radial nerve is a strip of the posterior
upper arm and the forearm; dorsum of the thumb; and
index and middle fingers and radial half of the ring
finger to the PIP joints. Sensory loss of the radial nerve
does not usually result in dysfunction.
Clinical signs of a high-level radial nerve injury
aes
ee
i
ie (above the supinator) are pronation of the forearm,
wrist flexion, and the thumb held in palmar abduction
FIG. 44-5 resulting from the unopposed action ofthe flexor polli-
Weight well is used for strengthening upper extremity with pro- cis brevis and the abductor pollicis brevis.°? Injury to
' gressive resistance applied to weakened musculature and is also the posterior interosseous nerve spares the extensor
See eaining prehension of pinch and grip. (Photo courtesy carpi radialis longus and brevis. Posterior interosseous
of Karen Schultz Johnson) ; 2 :
nerve syndrome includes normal sensation and wrist
extension with loss of finger and thumb extension.
ve
4a
> Clinical signs of low-level radial nerve injury include in-
motion and good patient instruction and support will complete extension of the MP joints of the fingers and
minimize these complications, however. thumb. The interossei extend the interphalangeal (IP)
joints ofthe fingers, but the MP joints rest in about 30°
Nerve Injuries seen
A dorsal
is aa .
splint that provides wrist extension, MP ex-
Nerve injury may be classified into the following three tension, and thumb extension should be provided to
categories: protect the extensor tendons from overstretching during
1. Neurapraxia is contusion of the nerve without wal- the healing phase and to position the hand for func-
lerian degeneration. The nerve recovers function tional use (Fig. 44-6). A dynamic splint is commonly
without treatment within a few days or weeks. provided.
2. Axonotmesis is an injury in which nerve fibers distal
to the site of injury degenerate, but the internal or- Median Nerve
ganization of the nerve remains intact. No surgical The median nerve innervates the flexors of the forearm
~ treatment is necessary, and recovery usually occurs and hand and is often called the “eyes” of the hands
within 6 months. The length of time may vary, de- because of its importance in sensory innervation of the
pending on the level ofinjury. volar surface of the thumb, index, and middle fingers.
3. Neurotmesis is a complete laceration of both nerve Median nerve loss may result from lacerations, as well
and fibrous tissues. Surgical treatment is required. as from compression syndromes of the wrist, such as
Microsurgical repair of the fascicles is common. carpal tunnel syndrome.
Nerve grafting may be necessary in situations in Motor distribution of the median nerve is to the
which there is a gap between nerve endings. 90 pronator teres, palmaris longus, flexor carpi radialis,
 les of the Upper Extremity
Nerve Location Affected Test
Radial nerve (posterior Upper arm Triceps and all distal motors MMT
cord, fibers from C5, C6, Sensory to SRN Sensory test
C7, C8)

Radial nerve Above elbow Brachioradialis and all distal MMT

motors Sensory
Sensory to SRN

Radial nerve At elbow Supinator, ECRL, ECRB, and MMT

all distal motors Sensory
Sensory to SRN
Posterior interosseous Forearm ECU, ED COM APE EPL Wrist extension—f present,
nerve EPB, EIP indicates PIN rather than high radial
No sensory nerve
Radial nerve at ECRB, Radial tunnel syndrome Weakness of muscles Palpate for pain over extensor mass
radial artery, innervated by PIN Pain with wrist flexion and pronation,
arcade of Frohse, No sensory loss Pain with wrist extension and
origin of supinator supination
Pain with resisted middle finger
extension
Median nerve (lateral from High lesions (elbow and Paralysis/weakness of FCR, PL, MMT
C5, C6, C7, medial cord above) all FDS, FDP | and II Sensory
from C8, T 1) FPL, pronator teres and quad.,
opponens pollicis, APB, FPB
(radial head), lumbricals | and II
Sensory cutaneous branch of
median nerve

Median nerve Low (at wrist) Weakness of thenars only Inability to flex thumb tip and
index fingertip to palm
Inability to oppose thumb
Poor dexterity

Median nerve under Pronator syndrome Weakness in thenars, but not Provocative tests to isolate
fibrous band in PT, beneath muscles innervated by AIN compression site
heads of pronator arch of Sensory in median nerve
FDS, origin of FCR distribution in hand

Median nerve under origin Anterior interosseous Pure motor, no sensory Inability to flex IP joint of thumb
of PT, FDS to middle nerve syndrome Forearm pain precedes paralysis and DIP of index
Weakness of FPL, FDP | and Increased pain with resisted pronation
ll, PQ Pain with forearm pressure

Median nerve at wrist Carpal tunnel syndrome Weakness of medial intrinsics Provocative tests
Sensory Tinel’s
Sensory

Ulnar nerve at elbow Cubital tunnel syndrome Weakness/paralysis of FCU, Pain with elbow flexion and
(branch of medial cord FDP Ill and IV, ulnar intrinsics extension :
from C7, C8,T1) Numbness in palmar cutaneous
and dorsal cutaneous distribution
Loss of grip and & pinch strength

Ulnar nerve at wrist Compression at canal of Weakness and pain in ulnar Reproduced by pressure at site
Guyon intrinsics

AIN, Anterior interosseus nerve; APB, abductor pollicis brevis; APL, abductor pollicis longus; ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus;
ECU, extensor carpi ulnaris; ED, extensor digitorum; EDM, extensor digitorum minimus; EIP, extensor indicis proprius; FDS, flexor digitorum superficialis; EPB, ex-
tensor pollicis brevis; EPL, extensor pollicis longus; FCR, flexor carpi radialis; FDP, flexor digitorum profundus; FPB, flexor pollicis brevis; FPL, flexor pollicis longus;
MMT, manual muscle test; PIN, posterior interosseus nerve; PQ, pronator quadratus; PT, pronator teres; SRN, superficial radial nerve.

846
 Hand and Upper Extremity Injuries

FIG. 44-6
Low-profile radial nerve splint is carefully balanced to pull
metacarpophalangeal (MP) joints into extension when wrist is FIG. 44-7
flexed and allows the MP joints to fall into slight flexion when wrist Thumb stabilization splint may be used with median nerve injury
is extended, thus preserving normal balance between two joints to protect thumb and to improve functioning by placing thumb in
and preserving joint contracture. (Splint courtesy of Judy C position of pinch. Normal pinch cannot be achieved with median
Colditz, Raleigh Hand Rehabilitation Center.) nerve injury because of paralysis of thumb musculature.

flexor digitorum profundus of the index and middle of muscle paralysis. Nevertheless, the weakened or para-
fingers, flexor digitorum superficialis, flexor pollicis lyzed muscles should be protected.
longus, pronator quadratus, abductor pollicis brevis,
opponens pollicis, superficial head of the flexor pollicis Ulnar Nerve
brevis, and first and second lumbricals. The ulnar nerve in the forearm innervates only the
Sensory distribution of the median nerve is to the flexor carpi ulnaris and the median half of the flexor
volar surface of the thumb, index, and middle fingers; digitorum profundus. It travels down the volar forearm
radial half of the ring finger and dorsal surface of the through the canal of Guyon, innervating the intrinsic
index and middle fingers; and radial half of the ring muscles of the hand, including the palmaris brevis, ab-
finger distal to the PIP joints. ductor digiti minimi, opponens digiti minimi, flexor
Clinical signs of a high-level median nerve injury are digiti minimi, dorsal and volar interossei, third and
ulnar flexion of the wrist caused by loss of the flexor fourth lumbricals, and medial head ofthe flexor pollicis
carpi radialis, loss of palmar abduction, and opposition brevis. The sensory distribution of the ulnar nerve is the
of the thumb. Active pronation is absent, but the patient dorsal and volar surfaces of the small finger ray and the
may appear to pronate with the assistance of gravity. In ulnar half of the dorsal and volar surface of the ring
a wrist-level median nerve injury the thenar eminence finger ray.
appears flat and there is a loss of thumb flexion, palmar A high-level ulnar nerve injury results in hyperexten-
abduction, and opposition.*” sion of the MP joints of the ring and small fingers (also
The sensory loss associated with median nerve injury called clawing) resulting from overaction of the exten-
is particularly disabling because there is no sensation to sor digitorum communis that is not held in check by the
the volar aspects of the thumb and index and middle third and fourth lumbricals.** The IP joints of the ring
fingers and the radial side of the ring finger. The patient and small fingers do not demonstrate a great flexion de-
when blindfolded substitutes pinch to the ring and formity because of the paralysis of the flexor digitorum
small fingers to compensate for this loss. An injury in profundus. The hypothenar muscles and interossei are
the forearm that involves the anterior interosseous absent. The wrist assumes a position of radial extension
nerve does not result in sensory loss. Motor loss in- caused by the loss of the flexor carpi ulnaris. In a low-
cludes paralysis of the flexor pollicis longus, the flexor level ulnar nerve injury the ring and small fingers claw
digitorum profundus of the index and middle fingers, at the MP joints, and the IP joints exhibit a greater ten-
and the pronator quadratus. The pronator teres is not dency toward flexion because the flexor digitorum pro-
affected. Pinch is affected. fundus is present. Wrist extension is normal.
Splints that position the thumb in palmar abduction Clinical signs of a high-level ulnar nerve injury may
and slight opposition increase functional use of the include clawhand with a loss of the hypothenar and the
hand (Fig. 44-7). If clawing of the index and middle interosseus muscles. In a low-level ulnar nerve injury
fingers is present, a splint should be fabricated to the flexor digitorum profundus and flexor carpi ulnaris
prevent hyperextension of the MP joints. Patients report are present and unopposed by the intrinsic muscles.
that they avoid use of the hand with a median nerve There is a positive Froment’s sign. Long-standing com-
injury because of lack of sensation rather than because pression ofthe ulnar nerve in the canal of Guyon results
848 TREATMENT APPLICATIONS

in a flattening of the hypothenar area and conspicuous in visual protection of the anesthetic area. ADL should be
atrophy of the first dorsal interosseus muscle.'* assessed, and new methods or devices may be needed for
With a low-level ulnar nerve injury a small splint may independence. Use of the hand in the patient’s work
be provided to prevent hyperextension of the small and should be assessed, and the patient should be returned to
ring fingers without limiting full flexion at the MP employment, with any necessary job modifications or
joints. Stabilization of the MP joints will allow the ex- adaptations of equipment, as soon as possible.
tensor digitorum communis to extend the IP joints fully Careful muscle, sensory, and functional testing
(Fig. 44-8). should be done frequently. As the nerve regenerates,
Sensory loss of the ulnar nerve results in frequent splints may be changed or eliminated. Exercises and ac-
injury to the ulnar side of the hand, especially burns. ° tivities should be revised to reflect the patient's new
Patients must be instructed in visual protection of the gains, and adapted equipment should be discarded as
anesthetic area. soon as possible.
As motor function begins to return to the paralyzed
Postoperative Management After Nerve Repair muscles, a careful program of specific exercises should
After nerve repair the hand is placed in a position that be devised to facilitate the return. Proprioceptive neuro-
minimizes tension on the nerve. For example, after muscular facilitation techniques, such as hold-relax,
repair of the median nerve, the wrist is immobilized in a contract-relax, quick stretch, and icing, may assist a fair-
flexed position. Immobilization usually lasts for 2 to 3 strength muscle and increase ROM. Neuromuscular
weeks, after which protective stretching of the joints electrical stimulation (NMES) can also provide an exter-
may begin. The therapist must exercise great care not to nal stimulus to help strengthen the newly innervated
put excessive traction on the newly repaired nerve. A re- muscle. When the muscle has reached a good rating,
paired digital nerve will also be protected with flexion functional activities should be used to complete the
of the PIP joint. return to normal strength.
Correction of a contracture may take 4 to 6 weeks.
Active exercise is the preferred method of gaining full SENSORY REEDUCATION. Assessment of sensibil-
extension, although a light dynamic splint may be ity is described in some detail earlier in this chapter.
applied with the surgeon’s supervision. Splinting to This information should be used to prepare a program
assist or substitute for weakened musculature may be of sensory reeducation following nerve repair.
necessary for an extended period during nerve regenera- When a nerve is repaired, regeneration is not perfect
tion. Splints should be removed as soon as possible to and results in fewer and smaller nerve fibers and recep-
allow active exercise of the weakened muscles. It is im- tors distal to the repair. The goal of sensory reeducation
portant to instruct the patient in correct patterns of is to maximize the functional level of sensation or
motion, however, so that substitution is minimized. tactile gnosis.
Initially treatment is directed toward the prevention of Parry first described sensory reeducation in 1966,°7
deformity and correction of poor positioning during the and Dellon reported a highly structured sensory reedu-
acute and regenerative stages. Patients must be instructed cation program in 1974.*' Dellon divided his program
into early- and late-phase training, based on vibratory
sensation for early phase and perception of moving and
constant touch sensation for late-phase reeducation. Lo-
calization of stimuli and recognition of objects were
used by both Parry and Dellon. Higher cortical integra-
tion was achieved by focusing attention on the stimuli
through visual clues and by employing memory when
vision was occluded. The patients were taught to com-
pensate for sensory deficits by improving specific skills
and generalizing them to other sensory stimuli. Daily
repetition appears to be a necessary component of reed-
ucation.
Callahan'® has outlined a program of protective
sensory reeducation and discriminative sensory reedu-
cation if protective sensation is present and touch sensa-
FIG. 44-8
tion has returned to the fingertips. Waylett-Rendall'°*
Dynamic ulnar nerve splint blocks hyperextension of metacar- has also described a sensory reeducation program using
pophalangeal (MP) joints that occurs with paralysis of ulnar intrin- crafts and functional activities, as well as desensitization
sic muscles and allows MP flexion, which maintains normal range techniques. All programs emphasize a variety of stimuli
of motion of MP joints. (Splint courtesy of Mary Dimick, Univer- used in a repetitive manner to bombard the sensory re-
sity of California-San Diego Hand Rehabilitation Center.) ceptors. A sequence of eyes-closed, eyes-open, eyes-
 Hand and Upper Extremity Injuries 849

closed is used to provide feedback during the training Primary repair of the flexor tendons within zone 2
process. Sessions are limited in length to avoid fatigue is most frequently attempted after a clean laceration.
and frustration. Objects must not be potentially harm- Several methods of postoperative management have
ful to the insensate areas, to avoid further trauma. A been proposed with the common goals of promoting
home program should be provided to reinforce learning gliding of the tendons and minimizing the formation of
that occurs in the clinical setting. scar adhesions.
Researchers'***''°? have found that sensory reeduca-
tion can result in improved functional sensibility in mo- CONTROLLED MOBILIZATION OF ACUTE
tivated patients. Objective measurement of sensation FLEXOR TENDON INJURIES: LOUISVILLE TECH-
following reeducation must be performed and then ac- NIQUE. Dr. Harold Kleinert of the University of
curately compared with initial testing to assess the Louisville School of Medicine was an early advocate of
success of the program. rubberband traction after repair of flexor tendons in
zone two. This technique is often referred to as the
TENDON TRANSFERS. If after a minimum period Kleinert technique. The doctor and therapist do not ac-
of 1 year after nerve repair, a motor nerve has not rein- tively participate in moving the tendon or finger when
nervated its muscle, the surgeon may consider tendon this protocol is followed as outlined by Kutz.”°
transfers to restore a needed motion. The rules of After surgical repair, rubberbands are attached to the
tendon transfer are to evaluate what is absent, what is nails of the involved fingers, using a suture through the
needed for function, and what is available to transfer.** nail or a hook held in place with cyanoacrylate glue. A
Some muscles, such as the extensor carpi radialis dorsal blocking splint is fabricated of low-temperature
longus and the sublimis to the ring finger, are com- thermoplastic material, with the MP joints held in
monly used for transfers because their motions are about 60° of flexion. The splint is constructed so that
easily substituted by the extensor carpi radialis brevis the IP joints are able to extend fully to the splint. The
and flexor digitorum profundus, respectively, to the ring rubberbands are passed through a safety pin in the palm
finger. The pronator teres is often used to restore wrist and are attached to the distal strap of the splint. The
extension for radial nerve paralysis. The surgeon may rubberbands should be placed in sufficient tension to
request assistance from the therapist in evaluating hold the PIP joints in 40° to 60° of flexion without
motor status to determine the best motor transfer. tension on the rubberbands. The patient must be able to
Therapy before tendon transfer is essential if the motor fully extend the IP joints actively within the splint, or
being used is not of normal strength. A muscle loses a joint contractures will develop (Fig. 44-9).
grade of strength when transferred, and a strengthéning The patient wears the splint 24 hours a day for 3
program of progressive resistive exercises, NMES, and weeks and is instructed to actively extend the fingers
isolated motion will help ensure success of the transfer. several times a day in the splint, allowing the rubber-
There must be full passive ROM of all joints before bands to pull the fingers into flexion. This movement of
tendon transfer can be attempted. the tendon through the tendon sheath and _ pulley
Following transfer, many patients require instruction
to perceive the correct muscle during active use of the
transfer. Use of surface EMG-biofeedback, careful in-
struction, and supervised activity to note any substitu-
tion patterns during active use usually help the patient
to use the transfer correctly. Therapy must be initiated
before the patient has time to develop incorrect use pat-
terns. NMES may be used to isolate the muscle and to
strengthen it postoperatively.

Tendon Injuries
Flexor Tendons
Tendon injuries may be isolated or may occur in con-
junction with other injuries, especially fractures or
crushes. Flexor tendons injured in the area between the
distal palmar crease and the insertion of the flexor digi- FIG. 44-9
torum superficialis are considered the most difficult to Following flexor tendon repair, wrist is placed in 30° flexion with
treat because the tendons lie in their sheaths in this area traction applied from the nail through a safety pin pulley in the
beneath the fibrous pulley system and any scarring palm and attached to proximal strap of splint. Metacarpophalangeal
causes adhesions. This area is often referred to as zone joints should be maintained in about 70° flexion, allowing full
two or “no-man’s-land.” passive interphalangeal joint flexion and active extension.
850 TREATMENT APPLICATIONS

system minimizes scar adhesions, while enhancing

tendon nutrition and blood flow.
The dorsal blocking splint is removed at 3 weeks, and
the rubberband is attached to a wristband, which is worn
for 1 to 5 additional weeks, depending on the judgment
of the surgeon. The primary disadvantage of this tech-
nique is that contractures of the PIP joints frequently
occur as a result of too much tension on the rubberband
or incomplete IP extension within the splint.
Dynamic extension splinting of the PIP joint can be
started at 5 to 6 weeks if a flexion contracture is present.
To be successful, this technique requires a motivated
patient who thoroughly understands the program.

CONTROLLED PASSIVE MOTION: DURAN AND FIG. 44-10

HOUSER TECHNIQUE. Duran and Houser’ sug- Blocking splint can be used to isolate tendon pull-through and
gested the use of controlled passive motion to achieve joint range of motion by blocking out proximal joints. This splint is
optimal results after primary repair, allowing 3 to 5 mm being used to facilitate motion at distal interphalangeal joint fol-
of tendon excursion. They found this amount sufficient lowing repair of flexor digitorum profundus tendon.
to prevent adherence of the repaired tendons. On the
third postoperative day the patient begins a twice-daily
exercise regimen of passive flexion and extension of six
to eight motions for each tendon. Care is taken to keep
the wrist flexed and the MPs in 70° of flexion during
Passive exercise. Between exercise periods the hand is
wrapped in stockinette. At 4'/2 weeks the protective
dorsal splint is removed and the rubberband traction is
attached to a wristband. Active extension and passive
flexion are performed for an additional week and gradu-
ally increased over the next several.weeks.

IMMOBILIZATION TECHNIQUE. A third postoper-

ative program involves complete immobilization for
3'/2 weeks after tendon repair. Good results have not
been consistently achieved with immobilization, and
this technique may lead to a great incidence of tendon
FIG. 44-11
rupture after repair because a tendon gains tensile
Manual blocking of metacarpophalangeal joint during flexion of
strength when submitted to gentle tension at the repair
proximal interphalangeal joint.
site. It is still the preferred method when treating young
children or with a noncompliant patient.”*
As methods of tendon suturing and the suture ma- POSTACUTE FLEXOR TENDON REHABILITA-
terials themselves have evolved, some clinicians have TION. When active flexion is begun out of the splint
begun to prescribe active movement of the repaired after any of the postoperative management techniques
tendon within days of surgery. This technique is described previously, the patient should be instructed in
usually performed only with the most experienced exercises to facilitate differential tendon gliding.'*
surgeons and therapists working closely together. The Wehbe”? recommends three positions—hook, straight
condition of the tendon and the technique of repair fist, and fist—to maximize isolated gliding of the flexor
must be communicated to the therapist, and the digitorum superficialis and the flexor digitorum profun-
patient must be closely monitored. As the rate of dus tendons, as well as stretching of the intrinsic mus-
rupture decreases with more sophisticated repairs, the culature and gliding of the extensor mechanism.
results after tendon injury have improved.?* Many Tendon gliding exercises should be done for 10 repeti-
practitioners have modified the tendon protocols, tions of each position, two or three times a day.
using a combination of passive flexion and active ex- Isolated exercises to assist tendon gliding may also be
tension techniques, based on their clinical experience. performed using a blocking splint (Fig. 44-10)*° or the
Protocols are suggested as guidelines but vary in opposite hand (Fig. 44-11). The MP joints should be
actual practice. held in extension during blocking so that the intrinsic
 Hand and Upper Extremity Injuries

FIG. 44-13
FIG. 44-12
This finger splint is used to increase extension of proximal inter-
Plaster cylindrical splint is used to apply static stretch of proximal
phalangeal joint. Splint available from DeRoyal/LMB, DeRoyal In-
interphalangeal joint contracture. It is not removed by patient and
dustries, Inc, Powell, TN.
must be replaced frequently by therapist with careful monitoring of
skin condition.

muscles that act on it cannot overcome the power of the

repaired flexor tendons. Care should be taken not to hy-
perextend the PIP joints and overstretch the repaired
tendons.
After 6 to 8 weeks passive extension may be started
and splinting may be necessary to correct a flexion con-
tracture at the PIP joint. A cylindrical plaster splint
may be fabricated to apply constant static pressure on
the contracture, as described by Bell (Fig. 44-f2).°
Static splinting may be especially effective with a
flexion contracture greater than 25°. A finger gutter
splint may be made using '/16-inch (0.16-cm) thermo-
plastic material for static extension at night, which will
help maintain extension gains made during the day. FIG. 44-14
Dynamic outrigger splint using spring-steel outriggers with a lum-
Gentle dynamic traction may be applied using a com-
brical block can be used to assist proximal interphalangeal (PIP)
mercial splint such as a spring finger extension assist joint extension, stretch against scar adhesions of extrinsic flexors,
(Fig. 44-13) or one that is fabricated by the therapist or reduce PIP joint contractures. Proper fit and tension of rubber
(Fig. 44-14). Dynamic flexion splinting may be neces- bands must be assessed frequently by therapist.
sary if the patient has difficulty regaining passive
flexion.
At about 8 weeks the patient may begin light resistive
exercises and activities. The hand can now be used for caught in the scar tissue. The therapist should be able
light ADL, but the patient should continue to avoid to determine if a tendon is adhering and causing a
heavy lifting with the affected hand or excessive resist- flexion contracture or if the tendon is free but the joint
ance. Sports activities should be discouraged. Such ac- itself is stiff. Treatment should be based on this type of
tivities as clay work, woodworking, and macramé are evaluation.
excellent, however. Full resistance and normal work ac- ROM, strength, function, and sensibility testing (if
tivities can be started at 3 months following surgery. digital nerves were also injured) should be performed
After a hand that has sustained a tendon injury, frequently, with splints and activities geared to progress.
Passive versus active limitations of joint motion must Although performance of ADL is generally not a prob-
be evaluated. Limitations in active motion may indi- lem, the therapist should ask the patient about any
cate joint stiffness, muscle weakness, or scar adhe- problems he or she may have or anticipate. Disuse and
sions.”* If passive motion is greater than active motion, neglect of a finger, especially the index finger, are
the therapist should consider that tendons may be common and should be prevented.
852 TREATMENT APPLICATIONS

Gains in flexion and extension may continue to be Extensor tendons in zones V, VI, and VII (proximal
recorded for 6 months postoperatively. A finger with to the MP joints) become adherent because they are
limber joints and minimal scarring preoperatively will encased in paratenon and synovial sheaths and respond
function better after repair than one that is stiff and to injury in a way similar to flexor tendons, resulting in
scarred and has trophic skin changes.'* Therefore it is either incomplete extension, also known as extensor
important that all joints, skin, and scars be supple and lag, or incomplete flexion caused by loss of gliding of
movable before reconstructive surgery’is attempted. A the extensor tendon.
functional to excellent result is obtained if the com- Evans*°’*’ studied the normal excursion of the exten-
bined loss of extension is less than 40° in the PIP and sor digitorum communis in zones V, VI, and VII to
DIP joints of the index and middle fingers and less than suggest guidelines for early passive motion of extensor
60° in the ring and small fingers’° and if the finger can tendons. She concluded that 5 mm of tendon glide after
flex to the palm.'* repair was safe and effective in limiting tendon adhe-
sions and designed a postoperative splint that allows
FLEXOR TENDON RECONSTRUCTION. If the slight active flexion while providing passive extension.*’
tendon is damaged as a result of a crush injury or the The splint is worn for 3 weeks, with the initiation of
laceration cannot be cleaned up enough to allow for a active motion between the third and fourth weeks. A re-
primary repair, staged flexor tendon reconstruction may movable volar splint is used between exercise periods to
be performed. At the first operation a Silastic rod is in- protect the tendon for 2 additional weeks. Dynamic
serted beneath the pulley system and attached to the flexion splinting may be started at 6 weeks after surgery
distal phalanx. Other reconstructive procedures, such as to regain flexion if needed.
pulley reconstruction, are performed at the same time. A Injuries to extensor tendons proximal to the MP joint
mesothelial cell-lined pseudosheath is formed about may be immobilized for 3 weeks. After this period the
the rod, and a fluid similar to synovial fluid is formed in finger may be placed in a removable volar splint that is
the postoperative recovery phase.”® The second stage is worn between exercise periods for an additional 2
performed about 4 months later when the digit can be weeks. Progressive ROM is begun at 3 weeks, and if full
moved passively to the palm. A tendon graft is inserted flexion is not regained rapidly, dynamic flexion may be
and the Silastic rod removed. The postoperative started at 6 weeks.
program is carried out in the same manner as for a Extensor tendon injuries that occur distal to the MP
primary tendon repair.*” joint require a longer period of immobilization, usually
Following a two-stage tendon reconstruction or 6 weeks. A progressive exercise program is then initiated
primary repair, a tenolysis may be performed if there is a with dynamic splinting during the day and a static night
substantial difference between the active and passive splint to maintain extension.
motion. Tenolysis is usually not performed for 6 months Dynamic splints may include a PIP-DIP splint, first
to 1 year after tendon repair. At the time of tenolysis described by Hollis and now available commercially
surgery, scar adhesions are removed from the tendon and (Fig. 44-15), a web strap made of lamp wick or elastic,
gliding of the tendons is assessed. Patients are often a fingernail hook with rubber band traction, a traction
asked to move their fingers in the operating room at the glove, or another splint.
time of lysis to determine the extent of scar removal. If a lysis of scar tissue is required because of persist-
Active motion is begun within the first 24 hours using ent scar adhesion, the surgeon may place a thin sheet of
bupivacaine (Marcaine) blocks®” or transcutaneous elec- Silastic between the tendon and bone at the time of
trical nerve stimulation (TENS)’” to control pain. surgery to reduce further scar adherence. The patient
LaSalle and Strickland°® have recommended a system begins exercising within the first 24 hours, and splints
for evaluating the results of tenolysis surgery by compar- are applied as needed. Active exercise is essential, and
ing the preoperative passive IP joint motion with the the patient must be carefully instructed in a home
postoperative IP joint motion. Based on this compari- program. The patient is encouraged to use the hand for
son LaSalle and Strickland found that in one group of all activities except those requiring heavy resistance.
patients undergoing tenolysis, 40% had an improve- After 4 to 6 weeks the Silastic sheet is removed and
ment in motion of 50% or better, compared with their ROM should be maintained.
preoperative status.
Total Active Motion and Total Passive Motion
Extensor Tendons Total active motion (TAM) and total passive motion
Dorsal scar adherence is the most difficult problem after (TPM) are mthods of recording joint ROM that are used
injury to the extensor tendons because of the tendency
of the dorsal extensor hood to become adherent to the
underlying structures and thus limit its normal excur-
sion during flexion and extension. *DeRoyal/LMB, DeRoyal Industries, Powell, Tenn.
 Hand and Upper Extremity Injuries 853

pressed. Pitting may be more pronounced on the dorsal

surface where the venous and lymphatic systems
provide return of fluid to the heart. Active motion is es-
pecially important to produce retrograde venous and
lymphatic flow.
If the swelling continues, a serofibrinous exudate
invades the area. Fibrin is deposited in the spaces sur-
rounding the joints, tendons, and ligaments, resulting
in reduced mobility, flattening of the arches of the
hand, tissue atrophy, and further disuse.°* Normal
gliding of the tissues is eliminated, and a stiff, often
painful hand is the result. Scar adhesions form and
further limit tissue mobility. If untreated, these losses
may become permanent.
FIG. 44-15 Early recognition of persistent edema through obser-
Proximal interphalangeal (PIP)-distal interphalangeal (DIP) splint vation and volume and circumference measurement is
may be used to increase flexion of both PIP and DIP joints. Tension
important. It may be necessary to use several of the sug-
can be adjusted with Velcro closure. Wearing time should be de-
gested edema control techniques.
termined by therapist.

Elevation
to compare tendon excursion (active) and joint mobil- Early elevation with the hand above the heart is essen-
ity (passive). It is the measure of flexion minus extensor tial. Slings tend to reduce blood flow and should be
lag of three joints. TAM and TPM have been recom- avoided. Resting the hand on pillows while seated or
mended for use in reporting joint motion by the Ameri- lying down is effective. Resting the hand on top of the
can Society for Surgery of the Hand.* head or using devices that elevate the hand with the
TAM is computed by adding the sum of the angles elbow in extension has been suggested. Suspension
formed by the MP, PIP, and DIP joints in flexion, minus slings may be purchased or fabricated.
incomplete active extension at each of the three joints. The patient should use the hand for ADL, within the
For example, MP joint flexion is 85° with full extension, limitations of resistance prescribed by the physician.
PIP is 100° and lacks 15° extension, and DIP is 65° Light ADL that can be accomplished while the hand is
with full extension; therefore in the dressing are permitted.
TAM
= 85 + 100
+ 65 — 15 = 235°.
Contrast Baths
TAM should be measured while making a fist. It is Alternating soaks of cold and warm water that is 66°
used for a single digit and should be compared with the and 96° F (18.9° and 35.6° C) have been recom-
same digit of the opposite hand or subsequent measure- mended as a method preferred over warm water soaks
ments of the same digit. It should not be used to or whirlpool baths. The contrast baths can be done for
compute a percentage of loss of impairment. TPM is cal- 20 minutes, alternating the hand between cool water for
culated in the same manner but measures only passive 1 minute and warm water for 1 minute, starting and
motion. ending with cool water. A sponge can be placed in each
tub so that the hand is moved during the soaking
period. The tubs should be placed as high as possible to
Edema
provide elevation of the extremity. The alternating warm
Edema is a normal consequence of trauma but must be and cool water cause vasodilatation and vasoconstric-
quickly and aggressively treated to prevent permanent tion, resulting in a pumping action on the edema. Com-
stiffness and disability. Within hours of trauma, vasodi- bined with elevation and active motion, edema may be
latation and local edema occur, with an increase in reduced and pain is often alleviated by this technique.
white blood cells to the damaged area.°* The inflamma-
tory response to the injury results in a decrease in bacte- Manual Edema Mobilization*
ria to control infection. “Manual edema mobilization (MEM) is a method of
Early control of edema should be achieved through edema reduction based on the role of the lymphatics for
elevation, massage, compression, and active ROM. The moving tissue fluid, protein molecules, and other large
patient is instructed at the time of injury to keep the molecule substances not permeable to the venous
hand elevated, and a compressive dressing is used to
reduce early swelling. Pitting edema is present early and
can be recognized as a bloated swelling that “pits” when *Material used courtesy of Sandra Artzberger, Hartford, Wis.
854 TREATMENT APPLICATIONS

system out of an edematous area. MEM specifically ad-

dresses how to activate lymph uptake and the unique-
ness of the lymphatic system.
“Recent European and Australian studies have given
new insights into lymphatic pathways (routes); pres-
sures which collapse or damage lymphatics preventing
protein absorption; functional anatomical characteris-
tics differentiating lymphatics from the venous system;
the role of stagnant high protein fluid in the intersti-
tium and chronic edema; formation of lymphatics in
scar tissue, etc. These studies plus Manual Lymphatic
Treatment principles associated with post cancer lym-
phedema form the foundation for Manual Edema Mo-
bilization. MEM is a technique used on the patient with
sub acute edema to either prevent edema from moving
into a chronic state or to reduce an existing chronic
TAC)
edema.

PRINCIPLES AND CONCEPTS OF MANUAL

EDEMA MOBILIZATION
Provide light massage, less than 40 mm Hg pressure
to prevent collapse of the lymphatic pathways.
Incorporate exercise before and after massage in a
specific sequence when possible.
Massage, done in segments, is proximal to distal, then
distal to proximal, always following movement of the
therapist’s hand in proximal direction.
Massage follows the flow of lymphatic pathways. FIG. 44-16
Massage reroutes around the incision area. One-inch Coban is wrapped with minimal pressure from distal end
Method does not cause additional inflammation. to proximal crease of digit. Patient is instructed to be aware of vas-
Include a patient home self-massage program. cular compression or tingling. Coban may be worn several hours a
Guide treatment to avoid increased edema from other day to reduce edema. Product available from Medical Products Di-
treatment techniques. vision/3M, St. Paul, Minn.
Incorporate low stretch compression bandaging and
warmth to soften hardened tissues, especially at night.

Active Range Of Motion

Normal blood flow is dependent on muscle activity.
Active motion does not mean wiggling the fingers, but
rather maximum available ROM, performed firmly. Casts
and splints must allow mobility of uninjured parts while
protecting newly injured structures. The shoulder and
elbow should be moved several times a day. The impor-
tance of active ROM for edema control, tendon gliding,
and tissue nutrition cannot be overemphasized.

Compression
Light compression using Coban wraps* of the affected
area (Fig. 44-16) or light compressive garments such as
those made by Arist or Jobst*’ (Fig. 44-17) will help to
control swelling, especially at night.
FIG. 44-17
Custom-fit Jobst garment may be used to reduce edema and to
*Coban (available from Smith & Nephew, Inc, Germantown, Wis). reduce and prevent hypertrophic scar formation after burns or
TAris Isotoner gloves (available from North Coast Medical, Morgan trauma. Inserts may be used with garment to increase pressure
Hill, Calif). over natural curves, such as dorsum of wrist.
 Hand and Upper Extremity Injuries 855

Wound Healing and Scar Remodeling

ing the three wound types help the therapist choose the
The basis of hand therapy is the histology of wound proper method of cleansing and dressing wounds. The
healing. Acute treatment must be planned using the foun- reader is encouraged to review this material before treat-
dation of tissue healing as a guide. Bones, tendons, nerves, ing open wounds.
and skin follow a progression of healing phases. Treat- Topical treatment such as antimicrobials, may be
ment must respect healing tissue to promote recovery and used to control bacteria. There are a variety of dressings
prevent further damage. The therapist must take care to do that can be placed on a wound, including gauze that has
no harm, and that can be accomplished only with a thor- been impregnated with petroleum, such as Xeroform
ough understanding of the physiology of healing. gauze or Adaptic. Ointments such as Polysporin are also
The first phase of wound healing, the acute inflam- commonly applied. N-Terface* is a dry mesh fabric that
matory phase, is initiated within hours, when the tissues looks and feels like the interfacing used in sewing.
are disrupted through injury or surgery, causing vasodi- Because it is nonadherent, it can be used directly over
latation, local edema, and migration of white blood wounds and will not stick to them. Sterile dressings can
cells and phagocytic cells to the area. The phagocytes be applied directly over the N-Terface without oint-
remove tissue fragments and foreign bodies and are crit- ments or gels. The selection of materials depends on the
ical to healing. The inflammatory process can subside or amount of exudate and the goal of the dressing (which
persist indefinitely, depending on the degree of bacterial may include removing debris, absorbing exudate, or
contamination.’ protecting new cells).
Fibroblasts in combination with associated capillaries Spenco Second Skin* is an inert gel sheeting made
begin to invade the wound within the first 72 hours and from 96% water and 4% polyethylene oxide. It removes
gradually replace the phagocytes, leading to the second friction between two moving surfaces and is said to
phase: the collagen or granulation phase, between the clean wounds by absorbing secretions. It comes in
fifth and fourteenth days. Collagen fiber formation sterile and nonsterile packs and is encased in a light
follows the invasion by fibroblasts, so that by the end of plastic covering. It is especially effective with abrasions
the second week the wound is rich with fibroblasts, a cap- or areas of skin loss because it is cool and reduces
illary network, and early collagen fibers. This increased itching. It can be used after burns.
vascularization results in the erythema of the new scar. Spenco Dermal Pads* are artificial fat pads that can
During the third to sixth weeks fibroblasts are slowly be used to prevent pressure sores or can be cut to size to
replaced with scar collagen fibers, and the wound use around an existing pressure sore or wound to allow
becomes stronger and more able to withstand progres- it to heal. Dermal pads are '/s inch thick (0.32 cm) and
sive stresses, leading to the last phase of scar matura- will adhere to the skin when the protective film is
tion. Tissue strength continues to increase for 3 months removed. The pad can be held in place with a dressing
or longer. The collagen metabolizes and synthesizes or with a pressure garment. It also can be washed
during this period, so that new collagen replaces old without reducing its adherence. Dermal pads can be cut
while the wound remains relatively stable. Covalent and placed around a healing wound to protect it under
bonding between collagen molecules leads to dense scar a splint or dressing. They are generally not needed after
adhesions and the formation of whorl-like patterns of the wound is healed.
collagen deposits, which may be altered as the scar ar- The wound can be cleaned with a solution of hydro-
chitecture and collagen fiber organization within the gen peroxide and sterile saline, with dead tissue then
wound change over time.” being gently removed with sterile swabs. Sterile saline
Myofibroblasts, which are fibroblasts with properties solution can be used to soak off adherent bandages
similar to smooth muscle cells, are contractile and cause rather than pulling them off the patient. The therapist
a shortening of the wound. should pour a very small amount of saline on the area
Tissues that have restored gliding have different scar that is sticking, wait a few moments, and gently pry the
architecture from those that do not develop the ability dressing off. Dead skin can be debrided using iris scis-
to glide. With gliding, the scar resembles the state of sors and pickups. Betadine-impregnated scrub sponges
the tissues before injury, whereas the nongliding scar may be used for cleaning and desensitization of the
remains fixed on surrounding structures. Controlled wound once it is healed and the stitches have been
tension on the scar has been shown to facilitate remod- removed. The patient also can do this procedure at
eling. Scar formation is also influenced by age and the home. Sterile whirlpool may be used for debridement,
quantity of scar deposited.°* especially if the wound is infected.

Wound Care and Dressings

Wounds may be described using a “three-color concept” *N-Terface, made by Winfield Laboratories (available from North
of red, yellow, or black wounds.’® This system simplifies Coast Medical, Morgan Hill, Calif).
wound description and treatment. Guidelines for treat- *Spenco Medical Corp, Waco, Tex.
856 TREATMENT APPLICATIONS

Pain Syndromes
Pressure
A hypertrophic scar or a scar that is randomly laid down Pain is the subjective manifestation of trauma transmit-
and thickened is reduced by the application of pressure, ted by the sympathetic nervous system, which may in-
often by means of pressure garments.**’ Use of an terfere with normal functioning. Because pain leads to
insert of neoprenet fabric or molds made from Silastic overprotection of the affected part and disuse of the ex-
elastomert°’ under the pressure garment increases the tremity, it should be treated early.
conformity of the garment. Pressure should be applied
for most of the 24-hour period, and with a hypertrophic Desensitization
burn scar this treatment should continue for 6 months Stimulation of the large afferent A nerve fibers leads
to 1 year after the injury. Silicone Gel Sheets§ have been to a reduction of pain by decreasing summation in
found to reduce hypertrophic scarring when worn on a the slowly adapting, small, unmyelineated C fibers,
regular basis for up 12 to 24 hours a day. which carry pain sensation. The A-axons can be stimu-
lated mechanically with pressure, rubbing, vibration,
Massage TENS, percussion, and active motion. Desensitization
Gentle to firm massage of the scarred area using a thick techniques are based on the amplification of inhibitory
ointment rapidly softens scar tissue and should be fol- mechanisms.
lowed immediately with active hand use so that Yerxa'”” has described a desensitization program that
tendons glide against the softened scar.*’ Vibration to “employs short periods of contact with three sensory
the area with a small, low-intensity vibrator will have a modalities: dowel textures, immersion or contact parti-
similar effect.*® Active exercise, using facilitation tech- cles, and vibration.” This program allows the patient to
niques and against resistance, or functional activity, rank 10 dowel textures and 10 immersion textures on
should follow vibration. Massage and vibration may be the degree of irritation produced by the stimulus. Treat-
started 4 weeks after injury. ment begins with a stimulus that is irritating but tolera-
Thermal heat in the form of paraffin dips, hot packs, ble. The stimulus is applied for 10 minutes, three or four
or fluidotherapy, immediately followed by stretching times a day. The vibration hierarchy is predetermined
while the tissue cools, provides stretch to the scar tissue. and is based on cycles per second of vibration, the
Wrapping the scarred or stiff digit into flexion with placement of the vibrator, and the duration of the
Coban during the application of heat often increases treatment. Complete instructions for assembling the
mobility in the area. Heat should not be used with in- Downey Hand Center desensitization kit can be found
sensate areas or if swelling persists.*” in the literature in the references. The Downey Hand
Center Hand Sensitivity Test can be used to establish a
Active Range of Motion and Electrical desensitization treatment program and to measure
Stimulation progress in decreasing hypersensitivity."
Active ROM provides an internal stretch against resistant
scar, and its use cannot be overemphasized. If the patient Neuromas
is unable to achieve active motion because of scar adhe- Neuromas are a complication of nerve suture or amputa-
sions or weakness, use ofa battery-operated NMES may tion. A traumatic neuroma is an unorganized mass of
augment the motion.'”” Stimulation may be performed nerve fibers that results from accidental or surgical cutting
by the patient for several hours at home and has been of the nerve. A neuroma in continuity occurs on a nerve
shown to increase ROM and tendon excursion.’’ that is intact.”° Neuromas may be clinically identified bya
Many hand therapists use high-voltage direct current specific, sharp pain. Stimulation of a neuroma usually
as a treatment to increase motor activity, and it may be causes the patient to pull the hand away quickly; many pa-
used for scar remodeling.* Ultrasound treatments are tients report a burning pain that radiates up the forearm.
often prescribed but may be more effective if done Neuromas are disabling because any stimulation causes
within the first few months after trauma. A continuous intense pain and the patient avoids the sensitive area.
passive motion (CPM) device may be used at home to A generalized desensitization program may not work
maintain passive ROM and promote tendon gliding. It because the patient never develops a tolerance for stim-
should be used for several hours a day for maximum ulation of the neuroma. Injection of cortisone acetate
benefit. may help break up the neuroma, making desensitiza-
tion techniques more effective. Surgically excising the
neuroma or burying the nerve endings deeper may be
*Bio-Concepts, Phoenix, Ariz. necessary.
TtNeoprene (available from Benik Corp, Silverdale, Wash).
+ Silicone elastomers (available from Smith & Nephew, Germantown,
Wis).
Complex Regional Pain Syndrome
§Cica-Care Silicone Gel Sheets (available from Smith & Nephew, Ger- Complex regional pain syndrome (CRPS) is the new
mantown, Wis). term that replaces “reflex sympathetic dystrophy (RSD)”
 Hand and Upper Extremity Injuries 857

to describe a group of disorders that “involve pain and CRPS is treated by decreasing sympathetic stimula-
dysfunction of severity or duration out of proportion to tion. It is most responsive in stage I. The first goal of
those expected from the initiating event.”'°° treatment is reduction of the pain and hypersensitivity
“Complex” denotes the complex nature of the pain to light touch. This goal may be accomplished with ap-
response, which may include inflammation, auto- plication of warm (not hot), moist heat, fluidotherapy,
nomic, cutaneous, motor and dystrophic changes. “Re- gentle handling of the hand, acupressure, desensitiza-
gional” refers to the wide distribution of symptoms tion, and TENS before active ROM. Treatment that in-
beyond the area of the original lesion. “Pain” is the creases pain (such as passive ROM) should be avoided.
primary characteristic of this syndrome. It includes Many patients respond well to gentle manual edema
spontaneous pain, thermal changes, and at times mobilization,® which reduces the edema and reintro-
burning pain. CRPS, type I, corresponds to RSD. Type II duces touching of the hand. Stellate ganglion blocks to
corresponds to causalgia, a severe, burning pain first de- eliminate the pain are effective early. They should be co-
scribed during the Civil War. ordinated with therapy so that the patient can perform
Diagnostic criteria for CRPS must include sponta- active ROM and functional activities during the pain-
neous pain beyond the territory of a single peripheral free period after the blocks. Active ROM is crucial.
nerve and disproportionate to the inciting event. There Gravity-eliminated exercise either in water or on a table-
is generally edema, skin blood-flow abnormality, or ab- top may be easier for the patient to tolerate.
normal sudomotor activity in the area of the pain. The A variety of drugs may be used, including sympa-
diagnosis is excluded by existence of conditions that tholytic drugs’’ that reduce the vasoconstrictive action
would otherwise account for the pain. The hallmarks of of the peripheral vessels. Neurontin is often effective in
CRPS are pain; edema; blotchy-looking, shiny skin; and reducing pain and increasing temperature in the extrem-
coolness of the extremity. Sensory changes may occur. ity. Calcium channel blockers are also effective. Care-
There may be excessive sweating or dryness if there is as- fully monitored use of narcotics may interrupt the pain
sociated sympathetic dysfunction. The degree of trauma cycle and allow active use of the hand. A stress-loading
does not correlate with the severity of the pain and may program that has been used effectively to reduce symp-
occur after any injury. CRPS, Type I may be triggered by toms of RSD (CRPS, type I) has been described." It can
a cycle of vasospasm and vasodilatation after an injury. easily be adapted for home use.
Abnormal edema and constrictive dressings or casts Edema control techniques should be started immedi-
may be a factor in initiating the vasospasm. A va- ately. Elevation, manual edema mobilization, contrast
sospasm “causes tissue anoxia and edema and therefore baths, and high-voltage direct current in water have
more pain, which continues the abnormal cycle.””” Cir- been’ found to be effective. Surface EMG-biofeedback
culation is decreased, which causes the extremity to training for relaxation may help muscle spasms and in-
become cool and pale. crease blood flow, in addition to reducing anxiety.
Fibrosis after tissue anoxia and the presence of CRPS frequently triggers shoulder pain and stiffness,
protein-rich exudates result in joint stiffness. The resulting in shoulder-hand syndrome or adhesive cap-
patient may cradle the hand and prefers to keep it sulitis of the shoulder (“frozen shoulder”). Therefore
wrapped. There may be an exaggerated reaction to active ROM and functional activities should include the
touch, especially light touch. Osteoporosis may be ap- entire upper quadrant. Use of skateboard exercises is
parent on x-ray films by 8 weeks after trauma after active helpful in the early stages for active-assisted exercise of
use of the hand. Burning pain associated with causalgia the shoulder. Splints that reduce joint stiffness should
(CRPS, type II) is a symptom that may be alleviated by be used as tolerated. Splints must not be painful or in-
interruption of the sympathetic nerve pathways. crease swelling. Reliance on immobilization splinting
There are three stages of CRPS. Stage I (traumatic should be avoided because patients with CRPS prefer
stage) may last up to 3 months; it is characterized by not to move the affected part, which ultimately makes
pain, pitting edema, and discoloration. Stage II (dys- their symptoms worse.
trophic stage) may last an additional 6 to 9 months. A tendency to develop CRPS should be suspected in
Pain, brawny edema, stiffness, redness, heat, and bony any patient who seems to complain excessively about
demineralization are usually found in this stage. The pain, appears anxious, and complains of profuse sweat-
hand usually has a glossy appearance. Stage III (atrophic ing and temperature changes in the hand. Some patients
stage) may last up to several years or indefinitely. Pain report nausea associated with touching the hand. Pa-
usually peaks in Stage II and decreases in stage III. tients tend to overprotect the hand. Early intervention
Thickening around the joints occurs, and fixed contrac- with a structured therapy program of functional activi-
tures may be present. If there is swelling, it is hard and ties, group interaction, and exercises that include the
not responsive to techniques such as elevation. The hand and shoulder may prevent the occurrence of a fully
hand may be pale, dry, and cool. There may be substan- developed CRPS. This problem is best recognized early
tial dysfunction of the limb. and treated with tempered aggressiveness and empathy.
858 TREATMENT APPLICATIONS

Transcutaneous Electrical Nerve Stimulation ated with cumulative trauma usually fall into one of
TENS is a treatment technique that is thought to stimu- three categories: tendinitis (such as lateral epicondylitis
late the afferent A nerve fibers in the high-frequency or de Quervain’s tenosynovitis), nerve compression syn-
mode and stimulate the release of morphinelike neural dromes (such as carpal tunnel syndrome or cubital
hormones, the enkephalins, in the low-frequency mode. tunnel syndrome), or myofascial pain.
Its efficacy as a treatment for pain control is well docu- Cumulative trauma occurs when force is applied to
mented in medical literature. As with other electrical the same muscle or muscle group, causing an inflamma-
modalities that may be used by hand therapists, TENS tory response in the tendon or muscle.®° Muscle fatigue
should be correlated with functional use of the hand. is an important aspect of cumulative trauma. Excessive
TENS should be used for treatment periods not to use of the muscle or body system (overuse or overexer-
exceed 60 minutes at a time to achieve pain control.”' A tion) is experienced as a muscle cramp. Acute overuse is
TENS diary should be used to record the level of pain on relieved by rest, but chronic fatigue is not relieved by
a scale of 1 to 10 before and after treatment, as well as rest. The amount of fatigue is related to the amount of
activities that exacerbate the pain. To prevent overuse, force and the duration of force application.
TENS may be tapered as the pain-free periods increase. Fatigue occurs more quickly with high force. If force
Treatment can be continued as long as necessary to is maintained, repetitions must be reduced to allow re-
provide pain control. covery. Therefore if the force is decreased while repeti-
tions are maintained and recovery time is adequate,
harm is less likely to occur. The combination of repeti-
Joint Stiffness
tions without adequate recovery time and high force es-
Joint stiffness has been discussed in other sections ofthis tablishes an environment that is likely to lead to injury.
chapter because it is seen after almost any hand trauma Byl'’ has found that repetitive hand opening and
or disease. In the acute phase it may also result from “in- closing may lead to motor control problems and the de-
ternal splinting” done unconsciously by the patient to velopment of focal hand dystonias through a degrada-
avoid pain. It may be prevented by early mobilization, tion of the cortical representation. Applying this re-
pain control, reduction of edema, active and passive search may help therapists develop more effective
ROM, use of a continuous passive motion device, and treatment programs for cumulative trauma and chronic
appropriate splinting techniques. Grade I and II joint pain.
mobilization are especially helpful in preparing for Treatment may be divided into phases. Acute-phase
passive and active motion and for pain relief. treatment is geared toward decreasing the inflammation
Treatment of established joint stiffness is more diffi- through dynamic rest. Splints are used for immobiliza-
cult. Thermal modalities, joint mobilization, ultra- tion. Splinting alone may relieve symptoms; splinting is
sound and electrical stimulation, dynamic splinting, often combined with cortisone injections to reduce in-
serial casting, and active and passive motion in prepara- flammation. Icing, contrast baths, ultrasound phono-
tion for functional use should all be included in the phoresis, iontophoresis, and interferential and high-
treatment regimen. voltage electrical stimulation have all been found to be
effective in reducing pain and decreasing inflammation.
Nonsteroidal antiinflammatory drugs are also fre-
Cumulative Trauma Disorders
quently used. Newer medications such as Celebrex and
A number ofterms are used throughout the world to de- Vioxx seem to be more effective clinically in reducing
scribe injuries to the musculoskeletal system, including symptoms than previous antiinflammatory drugs.
overuse syndromes, repetitive strain injuries, cervical- When splints are used, they should be removed three
brachial disorders, repetitive motion injuries, and in the times a day for stretching of the affected musculature
United States, cumulative trauma disorders (CTDs). (e.g., the extensor group with lateral epicondylitis) to
The incidence of CTDs in the United States is on the maintain or increase muscle length and to prevent joint
rise, with 281,800 cases reported in private industry in stiffness. Painful activities should be avoided during
1992.°° Between 1981 and 1992, CTDs increased from the dynamic rest phase. Vibration is contraindicated
18% to 62% ofall worker's compensation claims filed.”! because vibration may contribute to inflammatory
Women account for about two thirds of work-related problems.
repetitive motion injuries. As the acute symptoms decrease, the patient begins
The term “cumulative trauma disorder” should be the exercise phase of treatment. After warmup of the
viewed as a description of the mechanism of injury muscles by slow stretching, the patient begins con-
and not a diagnosis. Even when the presenting symp- trolled progressive exercise. Resistance should be given
toms are confusing, attempts to define a specific diagno- at the end of range when progressive resistive exercise is
sis are necessary because “each disorder has a different performed. A tennis-elbow armband can be worn over
cause, treatment, and prognosis.”*’ Diagnoses associ- the extensor muscle bellies to limit full excursion of the
 Hand and Upper Extremity Injuries 859

muscle during active use of the arm. Resistance should be crotrauma, swelling, pain, and limitations in movement
increased slowly and should not cause an increase in pain. is followed by rest, disuse, and weakness. Normal activ-
Patients are instructed to continue stretching three ity is resumed, and the cycle begins again.
times a day, especially before activity, for an indefinite Patients usually have a combination of localized
time. Proper body mechanics are critical in the long- pain, swelling, pain with resisted motion of the af-
term control of inflammatory problems, so patients fected musculotendinis unit, limitations in motion,
must become aware of what triggers their symptoms weakness, and crepitation of the tendons. Symptoms
and learn early intervention if symptoms reappear. are reproduced with activity or work simulation. Using
Icing, splints, stretching, and modified activities com- functional grades to describe the associated symptoms
bined with correct body mechanics are usually effective. assists in evaluation, as well as monitoring of improve-
The key is that the patients learn self-management tech- ment (Table 44-5).°° Although isometric grip strength
niques and take an active role in their treatment. may be normal, wrist and forearm strength are often de-
Work-related risk factors for CTDs include the follow- creased and out of balance. Dynamic grip strength may
ing”: be more limited because tendon gliding is more likely
m@ Repetition to increase inflammation and pain. Muscle imbalance
@ High force leads to positioning and substitution patterns that may
@ Awkward joint posture result in worsening or spreading of symptoms.
@ Direct pressure Nerve compression syndromes, especially carpal
@ Vibration tunnel syndrome, are frequently seen.®' Carpal tunnel
m@ Prolonged static positioning syndrome is caused by pressure on the median nerve as
An assessment of the job site, tools used, and hand it travels beneath the transverse carpal ligament at the
position during work activities may be indicated with volar surface of the wrist.*° The syndrome is associated
the patient whose symptoms are related to job demands. with increased pressure in the carpal canal because of
Modification of the equipment used and strengthening trauma, edema, retention of fluids as a result of preg-
of the dominant muscle groups and their antagonist nancy, flexor tenosynovitis, repetitive wrist motions, or
muscles may permit continued employment and con- static loading of the wrist.
trol the inflammatory problem. Symptoms are night pain that is severe enough to
Tendinitis and tenosynovitis are frequently seen in waken the patient; tingling in the thumb and index and
cumulative trauma. The cycle of overuse leading to mi- middle fingers; and, if advanced, wasting of the thenar

Functional Grading of Cumulative Trauma Disorders

Grade | Pain after activity; resolves quickly with rest
No decrease in amount or speed of work
Objective findings usually absent.

Grade ll Pain in one site while working

Pain is consistent while working, but resolves when activity stops
Productivity may be mildly affected
May have objective findings

Grade III Pain in one or more sites while working

Pain persists after activity is stopped
Productivity affected and multiple breaks may be necessary to continue working
May affect other activities away from work
May have weakness, loss of control and dexterity, tingling, numbness, and other objective findings
May have latent or active trigger points

Grade IV All common uses of hand/upper extremity cause pain, which is present 50% to 75% of the time
May be unable to work or works in limited capacity
May have weakness, loss of control and dexterity, tingling, numbness, trigger points, and other objective findings

Grade V Loss of capacity to use upper extremities because of chronic, unrelenting pain
Usually unable to work
Symptoms may persist indefinitely.

From Kasch MC: Therapist's evaluation and treatment of upper extremity trauma disorders. In Hunter JM et al, editors: Rehabilitation of the hand, ed 4, St Louis,
1995, Mosby.
860 TREATMENT APPLICATIONS

musculature caused by pressure on the motor branch of own armamentarium of strengthening exercises and
the nerve. Early carpal tunnel syndrome may be recog- media, only a few suggestions are provided here.
nized during a thorough nerve evaluation.
Conservative treatment is usually attempted first and Computerized Evaluation and Exercise
includes splinting of the wrist in no more than 20° ex- Equipment
tension, contrast baths to reduce edema, wearing of Iso- Baltimore Therapeutic Equipment (BITE) has made
toner gloves, and activity analysis. A semiflexible or neo- available the BITE Work Simulator (Fig. 44-18),7° an
prene splint rather than a completely rigid splint may be electromechanical device that has more than 20 inter-
used to provide support while allowing a small amount changeable tool handles and can be used for both work
of flexion and extension for greater functional use in evaluation and UE strengthening. Resistance can vary
carpal tunnel syndrome. from no resistance to complete static resistance, with
Ultrasound phonophoresis and iontophoresis may tool height and angle also adjustable. When the device
be used to reduce inflammation, and icing techniques is used for strengthening, the resistance is usually set
are beneficial. Specific strengthening exercises of the low and gradually increased. Length of exercise is in-
wrist, fingers, and thumb should be given when the creased when a base level of strength has been achieved.
pain and inflammation have been controlled. The BTE Work Simulator allows for close simulation of
In 1988, 35,000 carpal tunnel releases were per- real-world tasks that are easily translatable into physical
formed in the United States. In 1993, this number demands common to manual work.
climbed to over 250,000 releases.°’ Most patients report Other computerized evaluation equipment allows
a relief of numbness, but many have persistent pain. the therapist to record the results of assessment and
Therapy is often provided after surgical release and may print a report. Percentage of impairment can also be de-
include a combination of ultrasound to the scar, termined electronically. Portable systems are being
massage, manual edema mobilization, desensitization, developed that allow the therapist to record daily treat-
dexterity activities, and strengthening. ment and download the information into a computer-
Myofascial pain and fibrositis are also conditions of
pain elicited by activation of trigger points within the
muscles and resulting in pain referred to a distal area;
these are frequently encountered conditions. Travell?®
has studied myofascial pain and mapped out the tradi-
tional trigger points and their referral patterns. Poor
posture and positioning of the body out of normal
alignment are often the mechanisms of injury in myo-
fascial pain, so careful examination of the patient and
his or her normal daily activities is indicated. The thera-
pist should observe the patient performing the activity
rather than rely on a verbal description.
Myofascial pain should be considered if direct treat-
ment of the painful area does not relieve the pain. Eval-
uation for trigger points must be done meticulously,
and mapping of the trigger points and the referral areas
must be documented. Because the pain is referred, the
trigger point must be treated, not the referral area. The
treatments used for other inflammatory problems, such
as ice and ultrasound phonophoresis, can be used. In
addition, there are specific treatments for the trigger
points, such as friction massage and TENS, that may
relieve the pain. Activity analysis is an essential part of
treatment to relieve the stresses on the affected tissues.

Strengthening Activities
FIG. 44-18
Acute care is followed by a gradual return of motion, BTE Work Simulator is electromechanical device used to simulate
sensibility, and preparation to return to normal ADL. real-life tasks for upper extremity evaluation and strengthening.
The patient usually cannot strengthen the injured Patient’s progress is monitored through computerized print-out,
and neglected extremity at home because of the fear of and program can be modified to increase resistance and en-
further injury and pain. Because every hand clinic has its durance.
 Hand and Upper Extremity Injuries 861

ized network. Outcome data from many sources can Imaginative use of common objects should present a
then be compared. The advancement of technology in challenge to the hand therapist.
rehabilitation will allow the therapist to be more effi-
cient and also capture important information that is not
Functional Activities
available through traditional means.
Functional activities are an integral part of rehabilitation
Weight Well of the hand. Functional activities may include crafts,
The Weight Well’ was developed at the Downey Com- games, dexterity activities, ADL, and work samples. Many
munity Hospital Hand Center in Downey, California, of the treatment techniques described previously are
and is available commercially.* Rods with a variety of used to condition the hand for normal use.
handle shapes are placed through holes in the box and Activities should be started as soon as possible at
have weights suspended. The rods are turned against re- whatever level the patient can perform them with adap-
sistance throughout the ROM to encourage full grasp tations to compensate for limited ROM and strength.
and release of the injured hand, wrist flexion and exten- They should be used in conjunction with other treat-
sion, pinch, and pronation and supination patterns. ments. The occupational therapist must continually
The Weight Well can be graded for resistance and repeti- assess the patient's functional capacities and initiate
tions and is an excellent tool for progressive resistive changes in the treatment program to incorporate activi-
exercise. ties as soon as possible in the restorative phase.
Vocational and leisure goals should be established at
Theraband the time of initial evaluation and taken into account
Therabandt is a 6-inch (15.2-cm) wide rubber sheet when planning treatment. The needs of a brick mason
that is available by the yard and is color coded by may be quite different from those of a mother with
degrees of resistance. It can be cut into any length re- small children, and the environmental needs of the
quired and used for resistive exercise for the UE. Use of patient must not be neglected.
Theraband is limited only by the therapist's imagina- Crafts should be graded from light resistance to heavy
tion, and it can be adapted to diagonal patterns of resistance and from gross dexterity to fine dexterity.
motion, wrist exercises, follow-up treatment of tennis Crafts that have been found to work extremely well with
elbow, and other uses. The Theraband can be combined hand injuries include macramé, Turkish knot weaving,
with dowel rods and other equipment to provide resist- clay, leather, and woodworking. All of these crafts can be
ance throughout the ROM. It is inexpensive and easy to adapted and graded to the patient's capabilities and have
incorporate into a home treatment program. beer found to have a high level of patient acceptance.
When integrated into a program of total hand rehabilita-
Hand-Strengthening Equipment tion, they are viewed as another milestone of achieve-
Hand grips of graded resistance are available from reha- ment and not as a diversion to fill up empty hours. For
bilitation supply companies and sporting goods stores. example, the pride of accomplishment for a patient who
They can be purchased with various resistance levels sustained a Volkmann's contracture caused by ischemia
and can be used for progressive resistive hand exercises. and who completed her first project in nearly 4 years is
The therapist is cautioned against using overly resis- evidence that crafts belong in hand rehabilitation.
tive spring-loaded grippers often sold in sporting goods Activities that do not have an end product but
stores. These devices may be beneficial to the seasoned provide practice in dexterity and ADL skills also fit into
athlete but are usually too resistive for the recently the category of functional activities. Developmental
injured. games and activities that require pinch or grasp and
Therapy putty can be purchased in bulk, and the release may be graded and timed to increase difficulty.
amount given to the patient is geared to hand size and ADL boards that have a variety of opening and closing
strength. Putty is also available in grades of resistance, devices provide practice for use of the hand at home
and some provide chips that can be added to progres- and increase self-confidence. String and finger games are
sively increase resistance. It can be adapted to most challenging coordination activities that can be done in
finger motions and is easily incorporated into a home pairs and are fun to do.
program. Many times a hobby can be adapted for use in the
Household items such as spring-type clothespins clinic. Fly-tying is a difficult dexterity activity but one
have been used to increase strength of grasp and pinch. that will be enjoyed by an avid fisherman. Golf clubs
and fishing poles can be adapted in the clinic to allow
early return to a favorite form of relaxation.
*Upper Extremity Technology Weight Well (available from Upper Ex-
Humor and interaction with the therapists and the
tremity Technology, Glenwood Springs, Colo). other patients are vital but intangible benefits of treat-
TTheraband (available from Smith & Nephew, Germantown, Wis). ment. Treatment should be planned to promote both.
862 TREATMENT APPLICATIONS

FUNCTIONAL CAPACITY EVALUATION

Job analysis may also be provided by a rehabilitation
The ultimate goal of therapy for an injured worker is to counselor, and through information provided by the
return to full employment. Many weeks or months may patient. The therapist should consult the Dictionary of Oc-
have elapsed between the time of the injury and the cupational Titles (DOT)? to obtain information about the
point at which the physician feels a return to work is ap- worker traits required forthe expected job. This dictionary
propriate from a medical standpoint. Despite the fact contains 12,900 job descriptions and 20,000 job titles. If
that x-ray examinations may show full’ healing and re- sufficient information about the job is not available
stored ROM, many patients do not feel they have the through these methods, an on-site job analysis by the
strength, dexterity, or endurance to return to their therapist may be necessary. Once the physical demand
former jobs. Pain may continue to be a limiting factor, characteristics of work have been documented, it is pos-
especially with heavy activities. Light duty or part-time sible to evaluate the patient's ability to perform them.
positions may not be available, and the physician, ther- Schultz-Johnson”’ described a functional capacity
apist, industrial insurance carrier, and most of all the evaluation adapted for UE injuries based on the physi-
patient are frustrated by the lack of an objective method cal demands established by the U.S. Department of
of evaluating an individual’s physical capacity for work. Labor. After evaluation, the therapist may recommend a
Occupational therapists with training in evaluation, ki- work therapy program.”° Work therapy can include sim-
nesiology, and adaptation of environmental factors ulated job tasks to increase job performance.
coupled with a functional approach to the patient may Matheson®®*®? has written several manuals and arti-
play a key role in functional capacity evaluation. cles that describe work capacity evaluation (WCE). This
A renewed interest in evaluation of prevocational 8- to 10-day work assessment includes evaluation of the
factors has brought the profession of OT full circle (see patient's feasibility for employment (worker characteris-
Chapter 16). Although one of the cornerstones of the tics, such as safety and dependability), employability,
profession in its early years, prevocational evaluation work tolerances (such as strength, endurance, and the
has been neglected in many centers during the last two effect of pain on work performance), the physical
decades. Since the early 1980s, however, occupational demand characteristics of the job, and the worker's
therapists have rediscovered a need that the profession ability to “dependably sustain performance in response
is in a unique position to provide. The term “prevoca- to broadly defined work demands.”*”
tional evaluation” ambiguously implied that occupa- Tests with well-accepted reliability, such as the
tional therapists were involved in assessing the vo- Purdue Pegboard Test,’ the Crawford Small Parts Dex-
cational needs of patients they: treated. The terms terity Test,** the Minnesota Manual Dexterity Test,”
functional capacity evaluation (FCE) and work toler- and the Jebsen Hand Dexterity Test,*° may be adminis-
ance screening (WTS), however, more clearly describe tered as a screening process. These tests will give the
the process of measuring an individual's ability to therapist valuable information through observation,
perform the physical demands of work. whether the normal tables are used or the test is adapted
The results of the functional capacity evaluation to an individual worker.
allow the therapist, worker, physician, and vocational Many assessments and job simulation devices are
counselor to establish a specific, attainable employment available and should be reviewed before a physical ca-
goal using reliable data. This approach relieves the pacity evaluation program is established. To choose ap-
physician of the responsibility of returning the patient propriate work samples the therapist should determine
to work without objective information about the the job market in a specific area. This can be done by
patient's ability to do a job. It also allows the patient to consulting with vocational schools, rehabilitation coun-
test his or her own abilities and may result in increased selors, and employment agencies in the area.
self-confidence about returning to work. Work samples, available through Jewish Employ-
Many techniques for performing a functional capac- ment and Vocational Service,'°° Singer, *VALPAR,+ and
ity evaluation have been proposed.***°*°°° Some Work Evaluation Systems Technology (WEST),# may be
basic steps may be followed regardless of the specific used to test specific skills. The therapist may also
technique adopted. The patient should be evaluated for develop job samples by using information on jobs in
grip and pinch strength, sensation, and ROM. Edema the local area. Discarded electronic assembly boards, a
and pain must also be assessed and reassessed during lawn mower motor, an automobile engine, or other
the course of the evaluation. items from the local hardware store may provide valu-
The GULHEMP (general physique, UE, lower extrem- able information about the worker's ability.
ity, hearing, eyesight, mentality, and personality) Work
Capacity Evaluation Worksheet®® may be used as a
*Singer Education Division, Career Systems, Rochester, NY.
general method of determining functional abilities. The +VALPAR Assessment Systems (available from VALPAR International,
GULHEMP Physical Development Analysis Worksheet®® Tuscon, Ariz).
may be used to evaluate the job. +Work Evaluation Systems Technology, Fort Bragg, Calif.
 Hand and Upper Extremity Injuries 863

Work simulation using job samples or the BTE Work sources available to therapists interested in establishing
Simulator assesses the worker's specific physical capaci- work capacity evaluation, work tolerance screening, or
ties, as well as endurance and symptoms that become work hardening services. A publications and equipment
cumulative with prolonged use of the injured part list is available on request.
(called symptom response to activity, or SRA). Monitor- FCE and work hardening are adjuncts to the voca-
ing the client's SRA may prevent loss of time and money tional rehabilitation process. Occupational therapists
expended in training for an inappropriate vocational are trained to observe behavior and have the skills nec-
goal. King” has written about the analysis of test results essary to translate that observation into useful data. FCE
to determine the consistency of effort and veracity of and work hardening should not be a process that is in
evaluation findings, which assists in identifying patients competition with the work of rehabilitation or voca-
who may be magnifying their symptoms. tional counselors, but rather one that provides critical
A combination of “normed” tests, job samples, job information about a worker's physical functioning and
simulation, and work capacity evaluation devices may may serve as a program to foster reentry into the job
provide the therapist with the best information about a market.
worker's physical capacity. For more information about
vocational evaluation and rehabilitation, the therapist
should write to the Materials Development Center at
CONSULTATION WITH INDUSTRY
the University of Wisconsin-Stout in Menomonie, Wis- Occupational therapists may be asked to visit the job
consin.* site to make recommendations for ergonomic adapta-
tions, including tool modification, ergonomic furniture
and accessories, and training of workers in proper posi-
Work Hardening
tioning to reduce the incidence of CTDs. Prevention
Work hardening is the progressive use of simulated substantially reduces the costs to industry, which pres-
work samples to increase endurance, strength, produc- ents occupational therapists with a unique opportunity
tivity, and often feasibility. Work hardening may be per- to apply their training in activity analysis and adapta-
formed for a period of weeks, and the progressive tion of the environment in a new setting. The Americans
ongoing nature of the work usually results in improve- with Disabilities Act (ADA) mandates reasonable ac-
ments in physical capacity. It is an important contribu- commodations for workers with disabilities (see Chap-
tion to return to work. ter 17). Many occupational therapists have become
Because FCE is also performed over time, it may be active in helping companies comply with the require-
difficult to identify the difference between FCE and ments of the ADA. The American Occupational Therapy
work hardening. An FCE is generally done when the Association is an excellent resource for information
patient has stopped improving with traditional therapy about how therapists can be involved in these efforts in
methods and may have been released from acute their communities.”
medical care. The patient may be unable to return to his
or her former employment, or it may be questionable if
SUMMARY
the patient would be able to do the former work. An
FCE may be initiated by a physician, rehabilitation This chapter provides an overview of treatment of the
counselor, insurance adjustor, or attorney. UE. Evaluation procedures are discussed, as well as the
Work hardening or work conditioning may be initi- basic treatment techniques. Management of both acute
ated earlier in the rehabilitation process, perhaps by the injuries and cumulative trauma is included, as well as
treating physician or therapist who recognizes that an information on strengthening and programs for in-
individual may have difficulty returning to the former dustrial injuries. References for additional study are
employment. It is performed before the end of medical provided.
care and may serve as a final checkout before discontin- Most occupational therapists should be familiar
uing treatment. with the basic treatment approaches because they work
Standards for work hardening services have been de- with patients who have some limitation in the UEs.
veloped by the Commission on Accreditation of Reha- Specialization in hand therapy requires both academic
bilitation Facilities (CARF)** to ensure that injured study and clinical experience. Therapists who have
workers are offered high-quality programs that are max- specialized in this area of practice and who meet
imally effective in returning them to gainful employ- minimum requirements may choose to take the Hand
ment. The Employment and Rehabilitation Institute of Therapy Certification Examination and become a Certi-
California (ERIC)** has many publications and re- fied Hand Therapist (CHT). Both levels of expertise are
needed in the profession. For more information on be-
*Materials Development Center, Stout Vocational Rehabilitation Insti- coming a CHT, contact the Hand Therapy Certification
tute, University of Wisconsin-Stout, Menomonie, Wis. Commission.**
864 TREATMENT APPLICATIONS

CASE STUDY 44
Case Stupy—Ms. L.
Ms. L. is a 42-year-old, right-handed administrative manager for finger The scar was sensitive to touch, and she had difficulty
an insurance company. She has had numbness and pain in both wearing long-sleeved blouses.
hands for about 2 years. She first consulted a physician about a OT was initiated to increase wrist and shoulder range of
year ago. Nerve conduction studies were positive for carpal motion, reduce edema, decrease pain and hypersensitivity, soften
tunnel syndrome in both hands, right greater than left. She had the scar, and improve her tolerance for use of the hand. The OT
a right carpal tunnel release, open technique, 2 months ago and program included active range of motion of the shoulder and
a left carpal tunnel release 10 days ago. She had therapy follow- wrist, tendon gliding exercises, edema reduction techniques, de-
ing the first surgery until the second hand was operated on. She sensitization techniques, scar massage, and kinetic activities to
has been referred for postoperative management of the left improve strength and endurance.
hand. Ms. L. responded well to treatment. As the swelling decreased,
Ms. L. is divorced and lives alone. Her interests are gardening, her hand and wrist felt less stiff. After doing pendulum and pulley
needlework, and reading. She has had difficulty using the right exercises for two weeks she was able to reach to the cereal shelf
hand since surgery, since she still had residual weakness from the in her kitchen without difficulty. She worked on simulated activi-
first surgery. She has been sitting at home watching television ties on the BTE Work Simulator, and once she was able to “open
since the most recent surgery and has not moved her arm. She a jar’ on the BTE, she was able to do it at home.As her strength
expressed fear that she will not be able to return to work reached a functional level, she was able to build endurance. She
because she uses a computer for about six hours a day. She is began to spend 30 minutes of each therapy session working on a
having difficulty cooking for herself, and she has not been able to computer. Her employer asked the therapist to perform an er-
garden for two months. She stated that she cries frequently. gonomic assessment of her workstation before she returned to
It was observed that Ms. L. was holding the left arm close to work. It was decided to provide her with an ergonomic keyboard
her body and not initiating movement with the arm. There were and wrist rest with an adjustable keyboard tray. She was given a
limitations in active range of motion of the left shoulder and trackball to use instead of a mouse. The employer was investigat-
wrist. Ms. L. was able to make a full fist, but she stated that her ing use of voice activation software for some of her work tasks
fingers felt stiff and sore. Volume measurements revealed that the so she would not have to type the entire day. She returned to
left hand was 15% larger than before surgery, indicating significant work four hours a day six weeks after surgery. She continued in
swelling. She reported that her numbness was nearly gone, al- therapy for conditioning. Within a month she had resumed full-
though she had occasional shooting pain to the tip of the middle time work, and therapy was discontinued.

REVIEW QUESTIONS
10. List five tests used to assess joint integrity in the
1. A patient is seen for a hand problem and found to hand.
have limited or painful ROM of the shoulder. List 11. List three objectives of splinting as they relate to
three tests that should be performed. injury of the radial, median, and ulnar nerves.
2. Discuss three approaches to postoperative care of 12. What are the characteristics of complex regional
flexor tendon injuries, and compare how the differ- pain syndrome, type I? What are the treatment
ences between the methods would influence the goals?
initiation of OT. 13. Define “work hardening.” How can work hardening
3. To what does joint dysfunction refer? What are its be incorporated into OT?
causes? 14. How is the presence of edema evaluated? List three
4. Discuss the three classifications of nerve injury. methods used to reduce edema.
5. Define the area referred to as “no-man’s land.” 15. What are the primary work-related risk factors asso-
What distinguishes injury to this area? ciated with cumulative trauma? How can the occu-~
6. What techniques are used to evaluate the physical pational therapist intervene to prevent the develop-
demand characteristics of work? ment of cumulative trauma?
7. List three methods of applying pressure to a hyper-
trophic scar.
8. Which functional activities could be used for REFERENCES
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 Hand and Upper Extremity Injuries re]o}e)

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 R45
Hip be ues and Lower Extremity
: Joint Replacement

LEARNING OBJECTIVES
Spica cast After studying this chapter the student or practitioner
Osteoporosis will be able to do the following:
Open reduction and internal fixation 1. Describe the etiology of hip fractures and joint
Weight-bearing restrictions replacements.
Arthroplasty 2. Describe the medical management for these
Anterolateral approach conditions.
Posterolateral approach 3. Identify occupational therapy treatment goals.
Hip precautions 4. Identify the medical precautions associated with hip
Knee immobilizer fractures and joint replacements.
Critical pathway 5. Identify and discuss areas of intervention for
Leg lifter occupational therapy.
Abduction wedge 6. Discuss appropriate treatment techniques to address
daily occupations and functional mobility.
7. Discuss the impact of hip fractures and joint
replacement on occupational performance.

H ip fractures and lower extremity (LE) joint re- ular, develop osteoporosis to a greater degree than men
placements are two orthopedic conditions occurring and thus tend to have more hip fractures when they fall.
with more frequency now than in years past. This is in Mobility is compromised in the elderly population
part a result of extended life spans. Older individuals are because of decreased flexibility, diminished strength,
more likely to have orthopedic problems such as osteo- reduced vision, slowed reaction time, and the use of as-
porosis and degenerative joint changes. Medical ad- sistive ambulatory aids such as canes and walkers. Many
vances have also made the treatment of hip fractures and elderly people become more cautious when moving
LE joint problems safer and easier to manage. LE joint about and are fearful of falling. In some cases individu-
problems can lead to temporary or more long-lasting als trip over a cane or walker, which causes a fall. Not
disability. In both hip and knee conditions a large seeing a step or threshold is also a common cause for
weight-bearing joint is unstable for a period of time, falling.
which limits an individual's mobility and ability to com- Individuals with a history of arthritis or other joint
plete meaningful daily occupations. disease are the primary candidates for LE joint replace-
The elderly population is most at risk for hip frac- ment. Individuals who elect to have this surgical proce-
tures. Reduced mobility and the presence of osteoporo- dure performed usually have been living with increasing
sis are two specific risk factors. Elderly women, in partic- pain in their joints for many months or years and are

867
868 TREATMENT APPLICATIONS

already limited in their ability to perform daily tasks. thereby fragile, the affected bones are prone to fracture
They hope, by having the painful joint replaced, to during a fall or other traumatic event. A pathological
return to a more active lifestyle that is more satisfying to fracture can occur in a bone weakened by disease or
them. tumor, as in the cases of osteomyelitis and cancers that
Occupational therapy (OT) plays a key role in identi- have metastasized to the bone.®
fying and remediating the many functional problems
imposed by these acute and chronic orthopedic condi-
Medical Management
tions, thus sharing in the goal of returning the orthope-
dic patient to optimal performance of safe, independ- The goals of fracture treatment are to relieve pain, main-
ent, and meaningful occupations. tain good position of the bone, allow fracture healing,
This chapter discusses hip fractures and LE joint re- and restore optimal function to the patient.’”
placements, their medical and surgical management, Reduction of a fracture refers to restoring the bone frag-
the psychological implications of hospitalization and ments to normal alignment.® This can be done by a
disability, and the health care team approach in acute closed procedure (manipulation) or by an open proce-
hospital and rehabilitation settings. dure (surgery). The physician performs a closed reduc-
tion by applying force to the displaced bone, opposite
GENERAL MEDICAL MANAGEMENT to the force that produced the fracture. Depending on
the nature of the fracture, the reduction is maintained in
OF FRACTURES
a cast, brace, traction, or skeletal fixation.”
It is important for the occupational therapist working With open reduction the fracture site is exposed sur-
with orthopedic patients to have a good understanding gically so that the bone fragments can be aligned. The
of the site, type, and cause of the fracture before starting fragments are held in place with internal fixation by
treatment. A basic understanding of fracture healing pins, screws, a plate, nails, or a rod. Further immobiliza-
and medical management is also necessary to appreci- tion by a cast or a brace may be necessary. Usually an
ate risks, precautions, and complications involved. The open reduction and internal fixation (ORIF) must be
occupational therapist is advised to consult an orthope- protected from excessive forces, so weight-bearing re-
dic manual for specific information regarding the frac- strictions are indicated."
ture healing process. There are several levels of weight-bearing restric-
In general, a fracture occurs when the bone’s ability tions. The physician indicates at which level the
to absorb tension, compression, or shearing forces is ex- patient should be placed and changes the restrictions
ceeded.® The healing process begins after the fracture. as the fracture site heals and becomes stronger. The
Osteoblasts, which are cells that form bone, multiply to levels of weight-bearing restrictions are listed in Box
mend the fractured area. A good blood supply is neces- 45-1."
sary to supply the cells with oxygen for proper healing.
The fracture site is protected during the healing process
by pins, plates, and wires. In some cases in which extra
protection is needed, a spica cast may be used for the
hip. A spica cast extends around the pelvis and down ht-Bearing Restrictions
the thigh of the fractured hip. Other types of casts may
be used for fractures at other parts of the LE. Several
NWB (non—weight bearing) indicates that no weight at all
months may be needed for a bone fracture to heal com- can be placed on the extremity involved.
pletely. The time needed varies with the age and health TTWEB (toe-touch weight bearing) indicates that only the toe
of the patient, site and configuration of the fracture, can be placed on the ground to provide some balance
initial displacement of the bone, and the blood supply while standing—90% of the weight is still on the unaffected
to the fragments. leg. In toe-touch weight bearing, patients are instructed to
imagine that an egg is under their foot. :
PWEB (partial weight bearing) indicates that only 50% of the
Etiology of Fractures person's body weight can be placed on the affected leg.
Trauma is the major cause of fractures. In most cases the WBAT (weight bearing at tolerance) indicates that patients
are allowed to judge how much weight they are able to put
trauma occurs from falling. Poor lighting, throw rugs,
on the affected leg without causing too much pain.
and unmarked steps are particular hazards that can lead FWB (full weight bearing) indicates that patients should be
to a fall. Osteoporosis is a common bone disease af- able to put 100% of their weight on the affected leg without
fecting people over 65 years of age. It results in de- causing damage to the fracture site.
creased bone density, most commonly in the vertebral
bodies, the neck of the femur, humerus, and distal end From Early MB: Physical dysfunction: practical skills for the OT assistant,
of the radius. Because the bone becomes porous and St Louis, 1998, Mosby.
 Hip Fractures and Lower Extremity Joint Replacement 869

HIP FRACTURES
Femoral Neck Fractures
Types of Hip Fractures and Medical
Femoral neck fractures, which include subcapital, trans-
Management
cervical, and basilar fractures, are common in adults
Knowledge of hip anatomy is necessary for understand- over 60 years old and occur more frequently in women.
ing medical management of hip fractures. An anatomy If the bone is osteoporotic, fracture may result from
-and physiology reference should be consulted for even a slight trauma or rotational force.’ Treatment of a
details. See Fig. 45-1 for an illustration of the normal displaced fracture in this area is complicated by poor
hip joint. blood supply, osteoporotic bone that is not suited to
The typical levels of fracture lines are shown in Fig. hold metallic fixation, and a thin periosteum. The type
45-2. The names of the fractures generally reflect the site of surgical treatment used is based on the amount of
and severity of injury and may signal which medical displacement and the circulation in the femoral head.
treatment will be used. For example, a femoral neck The age and health of the patient are considered in
fracture will be treated with femoral neck stabiliza- deciding on the surgical procedure. Generally, hip
tion.” pinning (application of acompression screw and plate)
is used when displacement is minimal to moderate and
blood supply is intact. With a physician's approval, a
patient is usually able to begin limited out-of-bed activ-
ities 1 to 3 days after surgery. Per physician’s orders,
weight-bearing restrictions may need to be observed

FIG. 45-1
Normal hip anatomy. |, Acetabulum. 2, Femur. 3a, Greater
trochanter. 3b, Lesser trochanter. 4, Ligamentum teres. 5, In- FIG. 45-2
tertrochanteric crest. (Modified from Croch JE: Functional human Levels of femoral fracture. A, Subcapital. B, Transcervical. C,
anatomy, ed 3, Philadelphia, 1978, Lea & Febiger; Grant LC: Grant's Basilar. D, Intertrochanteric. E, Subtrochanteric. (Modified from
atlas of anatomy, ed 6, Baltimore, 1972,Williams & Wilkins.) Crow |: Fracture of the hip:a self study, ONA J 5:12, 1978.)
WAY) TREATMENT APPLICATIONS

with the aid of crutches or a walker for at least 6 to 8 spontaneously in middle age and progress as the
weeks while the fracture is healing. Weight bearing may normal aging process of joints is accelerated. Degenera-
be limited beyond this time if precautions are not ob- tive changes may also develop as the result of trauma,
served or if delayed union occurs." congenital deformity, or a disease that damages articular
With severe displacement or in the case of a femoral cartilage. Weight-bearing joints such as the hip, knee,
head with poor blood supply (avascular) or nonunion and lumbar spine are usually affected. In the hip there is
(a poorly healing fracture site where new bone does not a loss of cartilage centrally on the joint surface and for-
form) and degenerative joint disease, the femoral head mation of osteophytes on the periphery of the acetabu-
is surgically removed and replaced by an endoprosthe- lum, producing joint incongruity. Pain originates from
sis. This joint replacement is referred to as a hemipolar the bone, synovial membrane, or fibrous capsule and
or bipolar arthroplasty.'°Several types of metal prosthe- from muscle spasm. When movement of the hip causes
ses can be used; each has its own shape and advantages. pain and limited mobility, the muscles shorten, which
Weight-bearing restrictions are sometimes indicated. can result in a hip position of flexion, adduction, and
Because of the surgical procedure used, precautions for internal rotation that causes a painful limp.'?
positioning the hip must be observed to prevent dislo- Rheumatoid arthritis (see Chapter 43) may involve
cation. Patients who have had a prosthesis implanted the hip joint. Surgery is often performed early in the
can usually begin limited out-of-bed activity, with a disease process to limit fibrotic damage to joint and
physician’s approval, about 1 to 3 days after surgery.” tendon structures.'? Other disease processes (such as
lupus and cancer) and some medications (e.g., pred-
Intertrochanteric Fractures nisone) can compromise the blood flow to the hip joint
Fractures between the greater and lesser trochanter are and lead to avascular necrosis (AVN, a condition in
extracapsular, or outside the articular capsule of the hip which bone cells die because of poor blood supply)
joint, and the blood supply is not affected. Like femoral or osteoporosis; either condition results in a painful
neck fractures, intertrochanteric fractures occur mostly hip.”
in women but in a slightly older age group. The fracture
is usually caused by direct trauma or force over the Medical Management
trochanter, as in a fall. The preferred treatment for these When other forms of treatment for the pain and de-
fractures is ORIF. A nail or compression screw with a creased mobility have not been successful, a total joint
sideplate is used. Weight-bearing restrictions must be replacement is considered to restore an individual’s
observed for up to 4 to 6 months‘during ambulation. ability to perform daily occupations. The total joint re-
The patient is allowed out of bed 1 to 3 days after placement is not considered for persons who will not
surgery, pending the physician’s approval." comply with a rehabilitation program or who will not
experience significant improvement in functional
Subtrochanteric Fractures ability.° There are two mechanical components to a
Subtrochanteric fractures 1 to 2 inches below the lesser “total hip.” A high-density polyethylene socket is fitted
trochanter usually occur because of direct trauma, as in into the acetabulum, and a metallic prosthesis replaces
falls, motor vehicle accidents, or any other situation in the femoral head and neck. Methylmethacrylate or
which there is a direct blow to the hip area. These frac- acrylic cement fixes the components to the bone. Var-
tures are most often seen in persons less than 60 years ious surgical approaches are used, according to the
old. Skeletal traction followed by ORIF is the usual surgical skill or technique of the orthopedist, severity of
treatment. A nail with a long sideplate or an in- the joint involvement, and history of past surgery to the
tramedullary rod is used. An intramedullary rod is a rod hip. With an anterolateral approach the patient will be
inserted through the central part of the shaft of bone to unstable in external rotation, adduction, and extension
help maintain proper alignment for bone healing.” of the operated hip and usually must observe precau-
In all types of hip fractures the practitioner should be tions to prevent these movements for 6 to 12 weeks. If a
aware of the soft-tissue trauma, edema, and bruising posterolateral approach is used, the patient must be
that occur around the fracture site.'° cautioned not to move the operated hip past specific
ranges of flexion (usually 60° to 90°) and not to inter-
HIP JOINT REPLACEMENT nally rotate or adduct the leg. Failure to maintain these
hip precautions during muscle and soft-tissue healing
Etiology
may result in hip dislocation (Box 45-2).
Restoration of joint motion and treatment of pain by Most surgeons do not restrict weight bearing postop-
total hip replacement, or arthroplasty, is sometimes in- eratively when cement fixation is used. However, one of
dicated, primarily in osteoarthritis and rheumatoid the major problems with total hip replacement is the loss
arthritis and occasionally in other disease processes. Os- of fixation at the prothesis interface. The most recent
teoarthritis or degenerative joint disease may develop development is the use of biological fixation. Bony
 Posterolateral approach
® No hip flexion greater than 90°
@ No internal rotation
@ No adduction (crossing legs or feet)

Anterolateral approach
@ No external rotation
M@ No adduction (crossing legs or feet)
@ No extension

From Early MB: Physical dysfunction: practical skills for the OT assistant,
St Louis, 1998, Mosby,

FIG. 45-3
Modular total hip prosthesis designed for bony ingrowth. (From
Kottke FJ: Krusen’s handbook of physical medicine and rehabilitation,
FIG. 45-4
ed 4, Philadelphia, 1990, WB Saunders.
Porous-coated total knee prosthesis. Note resurfacing features of
components and beaded surfaces for biological fixation. (From
Kottke FJ: Krusen’s handbook of physical medicine and rehabilitation,
ed 4, Philadelphia, 1990, VB Saunders.)
ingrowth, instead of cement, secures the prosthesis. In
other words, new bone grows into openings in the pros-
thesis, and this secures the prosthesis to the bone (Fig.
45-3). The precautions following the surgery are those KNEE JOINT REPLACEMENT
of the anterior or posterior hip replacements with an
additional restriction on weight bearing for 6 to 8
Etiology and Medical Management
weeks. The restrictions on weight bearing will vary in The reason for a total knee replacement is similar to
terms of amount of pressure and length of time. A that for the total hip replacement, except that the de-
walking aid, usually a walker or crutches, is necessary generative changes occur in the knee joint. Total knee
for at least the first month while the hip is healing and replacement, or total knee arthroplasty (TKA), is de-
muscles are becoming stronger. Patients with total joint signed to alleviate pain, increase motion, and maintain
replacements usually begin out-of-bed activity 1 to 3 alignment and stability of the knee joint. The process
days after surgery.‘7 involves cutting away the damaged bone (as little
Total joint surface replacements, which are rarely bone as possible) and attaching a prosthesis for the
used, are a variation of the total hip replacement.” The new joint. There are various types of prostheses. The
surface of the femur is capped by a metallic shell, and type used depends on the severity of joint damage
the acetabular cavity receives a plastic cup. Both are held (Figs. 45-4 and 45-5). The prosthesis can be cemented to
in place by methylmethacrylate. This technique pre- the bone or not cemented. With a cemented prosthesis,
serves the femoral head and neck. With this technique patients are usually able to bear weight at tolerance on
no weight-bearing restrictions apply.'* the operated leg. With a noncemented prosthesis,
872 TREATMENT APPLICATIONS

FIG. 45-5
Total knee replacement. The metal aspects of the prosthesis cover
the distal portion of the femur and the end of the tibia. There is a
polyethylene plastic-bearing surface (plastic) between the metallic
aspects of the two surfaces. The patella is replaced by a polyethyl-
ene button. The medial collateral ligament (MCL), lateral collateral
ligament (LCL), and cruciate ligaments (CL) are retained. (From
Early MB: Physical dysfunction: practical skills for the OT assistant, St
Louis, 1998, Mosby; modified from Calliet R: Knee pain and instabil-
ity, ed 3, Philadelphia, 1992, FA Davis.)

weight bearing is usually avoided initially. Patients may

start out-of-bed activities 1 to 3°days after surgery,
pending the physician’s orders. Patients may use a knee
immobilizer (Fig. 45-6) when moving in and out of FIG. 45-6
the bed and ambulating to provide support to the A knee immobilizer is used to support and stabilize the knee joint
knee. The patient should avoid any rotation at the knee during mobility. (Courtesy DeRoyal, Powell, Tenn.)
up to 12 weeks after surgery. There is usually no restric-
tion on bending the knee. In fact, it is important to
maintain the mobility of the knee to ensure good mo- using a spica cast to immobilize the hip joint for indi-
bility as it heals.*'® viduals at high risk for a dislocation.’
Emphasis in rehabilitation is on maintaining or in-
creasing joint motion, slowly increasing the strength of
GENERAL CONSIDERATIONS FOR LOWER
surrounding musculature, decreasing swelling, and in-
EXTREMITY JOINT REPLACEMENTS
creasing independence in activities of daily living
Individuals with joint changes that result in increasing (ADL). The occupational therapist's role in this process
pain may have multiple joint involvement (i.e., both is primarily in educating the patient who has undergone
knees or hips). Some patients opt to have both joints re- joint replacement about adaptive techniques for ADL
placed during the same hospitalization, with proce- with limited mobility.
dures usually 1 week apart. This can complicate the re-
habilitation process, since the patient will not have a
stronger leg to rely on for walking and performing daily
PSYCHOLOGICAL FACTORS
occupations. Psychological issues are critical in the overall treatment
It is important to be aware of complications or of the orthopedic patient. A large number of patients in
special procedures that occurred during surgery and this population are faced with a chronic disability (such
to inquire about additional precautions and _ risks. as rheumatoid arthritis), a life-threatening disease (such
Common complications include dislocation, wearing as cancer), or the aging process. The loss or potential
out of parts, fracture of bone next to implanted parts, loss of mobility and physical ability is a major concern
and loosening of parts. A special procedure involves for most of these patients. Adjusting to loss is stressful,
 Hip Fractures and Lower Extremity Joint Replacement 873

requiring an enormous amount of physical and emo- ask personal questions. The therapist can do this by
tional energy.'* An awareness of and a sensitivity being open minded and realizing that sexual activity is
toward the orthopedic patient are critical for the deliv- an important and meaningful occupation. The therapist
ery of optimal patient care. may need to suggest ways for the patient to position the
Patients with a chronic orthopedic disability often operated leg during sexual activity to maintain precau-
experience one or all of the following: disease of a body tions. Side-lying on the nonoperated side is one option.
part, fear, anxiety, change in body image, decreased Abduction precautions can be maintained via pillows
functional ability, deformity, and pain. Treatment of a between the knees. To prevent excessive external rotation
patient with a chronic orthopedic disability must at the hips while in the supine position, the patient can
address these issues and provide the support needed for place pillows under the knees. Patients with weight-
the grieving process to take place. Without an opportu- bearing precautions should avoid kneeling.° Written in-
nity to confront these issues, the patient is likely to formation with diagrams can be helpful when address-
become depressed, filled with guilt and anxiety, and ing such a personal issue. The patient can read it privately
paralyzed with fear. These emotions inhibit the patient's or with his or her partner at another time.
progress and further damage the self-image. Clinicians
can help patients acknowledge and experience some of
REHABILITATION
these feelings, ultimately enhancing the treatment
process. One way to ease anxiety and fear is to make Good communication and clear role delineation
sure the patient understands the treatment and proce- among members of the health care team are essential
dures he or she is receiving. Taking time to answer ques- for an efficient and smooth therapy program. The
tions and provide additional information can be crucial health care team usually consists of a primary physician,
for successful adjustment. nursing staff, a physical therapist, an occupational ther-
The elderly patient experiencing disability deals with apist or assistant, a nutritionist, a pharmacist, and a case
additional issues specific to the aging process: fear of de- coordinator. Many facilities have a protocol or critical
pendence and relocation trauma.* With the onset of a pathway that outlines each team member's responsibil-
disability late in life the patient may be forced to let go ities and a time frame for accomplishing assigned tasks
of independence and self-sufficiency.'* For some this related to the patient's rehabilitation. Regular team
can be a devastating experience, requiring prolonged meetings to discuss each patient's ongoing treatment,
grieving before adjustment. Others may use dependence progress, and discharge plans are necessary for coordi-
for secondary gain, remaining in the hospital for extra nating individual treatment programs. Members from
attention or manipulating their support systems to each service usually attend each meeting to provide in-
avoid taking responsibility for themselves and others. formation and consultation.
Relocation may result in confusion, disorientation, and The role of the physician is to inform the team of the
emotional lability when individuals are removed from patient’s medical status. This includes information re-
their familiar environment. Decorating the person’s garding previous medical history, diagnosis of the present
room with familiar items and using a calendar can be problem, and a complete account of the surgical proce-
helpful in reducing this traumatic event. dure performed. Information provided may include the
Learning to cope and adjust to the changes resulting type of appliance inserted, the anatomical approach, and
from chronic disability or the aging process is a critical any movement or weight-bearing precautions that could
aspect of recovery. Practitioners must realize that a great endanger the patient. The physician is also responsible
deal of a patient's functional independence has been for ordering specific medications and therapies. Any
relinquished as a result of disease or disability. The change or progression in therapy or change in the
psychosocial issues resulting from this loss must be patient's medication regimen should be approved by the
addressed while focusing on increasing a patient's func- physician.
tional level of independence.'* The nursing staff is responsible for the physical care
An important area of ADL that is often overlooked is of the patient during hospitalization. The orthopedic
sexual activity. Persons with a hip fracture or LE joint re- nurse must have a thorough understanding ofthe surgi-
placement will have difficulty performing sexual activi- cal procedures and movement precautions for each
ties in their usual manner. (See Chapter 15 for a further patient. Proper positioning using pillows and wedges is
discussion of sexuality.) It is recommended that persons carried out by the nurse, especially in the first few days
not engage in sexual activity for 6 weeks so that they after surgery. As the patient's therapy program pro-
maintain the movement precautions applicable to their gresses, the patient starts to take more responsibility for
condition.° Patients of all ages and both genders may proper positioning and physical care. The nurse works
have questions regarding the level of sexual activity that closely with the physical and occupational therapists to
is allowed. The occupational therapist will need to create carry through self-care skills that the patient has already
an environment in which the patient feels permitted to learned in therapy.'*
874 TREATMENT APPLICATIONS

Evaluation and Treatment Planning

The physical therapist is responsible for evaluation
and treatment in the areas of musculoskeletal status, The role of the occupational therapist and occupational
sensation, pain, skin integrity, and mobility (especially therapy assistant can be clearly defined with cases of
gait). In many cases involving total joint replacement total joint replacement and hip fractures. The occupa-
and surgical repair of hip fracture, physical therapy is tional therapist is responsible for performing any evalu-
initiated on the first day after surgery. The physical ther- ations that are needed. In addition to an occupational
apist obtains baseline information, including range of history, a baseline physical evaluation is necessary for
motion (ROM), strength of all extremities, muscle tone, determining whether any physical limitations not
mental status, and mobility, adhering to the prescribed related to surgery might prevent functional independ-
precautions of protocol. A treatment program that in- ence. Upper extremity (UE) ROM, muscle strength, sen-
cludes therapeutic exercises, ROM activities, transfer sation, coordination, and mental status are assessed
training, and progressive gait activities is established. before a functional evaluation is made. The certified oc-
The physical therapist is responsible for recommending cupational therapy assistant can participate in the ADL
the appropriate assistive device to be used during ambu- evaluation. During evaluation it is also important to
lation. As the patient’s ambulation status advances, in- observe any signs of pain and fear at rest or during
struction in stair climbing, managing curbs, and outside movement.'~’'°
ambulation is given.'~’'° OT involves a progression of functional activities that
The nutritionist consults with each patient to ensure simulate a normal, daily regimen of occupation that is
that adequate and appropriate nutrition is received to in accordance with all the movement precautions.'*!°
aid the healing process. The pharmacist monitors the This is also referred to as ADL training. The therapist in-
patient's drug therapy and provides information and as- troduces and trains patients in the use of assistive
sistance with pain management.'* devices, proper transfer techniques, and ADL techniques,
The role of the case coordinator is to ensure that each while maintaining hip precautions. Specific training
patient is being discharged to the appropriate living sit- techniques are discussed later in the chapter. An OT as-
uation or facility. Usually the case coordinator is a regis- sistant may play a large role in this training. Both the
tered nurse or social worker with a thorough knowledge occupational therapist and the OT assistant are involved
of available community resources and nursing care fa- in treatment planning, documentation, and discharge
cilities. With input from the health care team the case planning (including recommending equipment and
coordinator makes the arrangements for ongoing home exercise programs).
therapy after hospitalization, for admission to a rehabil-
itation facility for further intensive therapy, or for
Patient Education
nursing home care if necessary. The case coordinator
works closely with the health care team and is instru- Although hip fractures are never a planned occurrence,
mental in coordinating the program after the patient's total joint replacements are usually preplanned and
discharge from the hospital.'*'° scheduled to be performed on a specific date. Occupa-
tional therapists provide education classes for individu-
als at risk for fractures and those planning joint replace-
ROLE OF OCCUPATIONAL THERAPY
ment. For the person who may be at risk for falling,
After a total joint replacement or surgical repair of a attending a class on fall prevention may be a wise rec-
fractured hip, OT typically begins when the patient is ommendation. Topics may include home modifications
ready to start getting out of bed, usually 1 to 3 days (such as removing throw rugs, telephone cords, and
after surgery. The actual time varies, depending on the clutter), safe transfer techniques, use of public trans-
age and general health of the patient and on surgical portation, and community mobility tips. The person
events or medical complications involved. Before any who is having an elective total joint replacement may
physical assessment it is important for the therapy benefit from a class offered before surgery that explains
practitioner to introduce and explain the role of OT the procedures, introduces assistive devices, and de-
and gather any pertinent information regarding the scribes therapy procedures.
patient’s occupational history, including prior func-
tional status, home environment, and living situation.
Specific Training Techniques
The goal of OT is for the patient to maximize inde-
pendence in daily occupations, with all movement pre- Some common assistive devices are useful for many
cautions observed during activities. The role of the oc- people with hip fractures or joint replacements (Fig.
cupational therapist and assistant is to teach the patient 45-7). Helpful assistive devices or adaptive aides in-
ways and means of performing daily occupations clude a dressing stick, sock aid, long-handled sponge,
safely.'*"1° long-handled shoe horn, reacher, elastic shoe laces,
 Hip Fractures and Lower Extremity Joint Replacement 875

FIG. 45-7
Assistive devices for ADL. A, Sock aid. B, Reacher. C, Dressing stick. D, Leg lifter. E, Long-handled
sponge. F, Walker bag. G, Elastic shoe laces. H, Long-handled shoe horn. (From Early MB: Physical
dysfunction: practical skills for the OT assistant, St Louis, 1998, Mosby.)

elevated toilet seat or commode seat, leg lifter, and mine the type and height of the patient's bed at home.
shower chair or bench. Walker bags are helpful for When getting in and out of bed initially, the patient may
people using walkers who need to carry small items use a leg lifter to help the operated leg move from one
from one place to another. The OT clinic should have surface to another. Some patients have an overhead
samples of these devices and should be able to issue trapeze placed on the bed to assist with bed mobility. It
them to patients for use during the training process. is important to wean the patient away from using this
device because he or she will most likely not have one at
home.
Hip
The training procedures outlined below apply to both Transfers
types of hip joint replacement (posterolateral and .an- It is always helpful for the patient to observe the proper
terolateral) unless otherwise noted. The positions of hip technique for transfers first, before attempting the
instability for both types of surgical procedures are im- movement.
portant to remember. For the posterolateral approach,
positions of instability include adduction, internal ro- CHAIR. A firmly based chair with armrests is recom-
tation, and flexion greater than precautions. For the an- mended. The patient is instructed to extend the oper-
terolateral approach, positions of instability include ated leg forward, reach back for the armrests, and sit
adduction, external rotation, and excessive hyperexten- slowly. For the person with a posterolateral approach,
sion. care should be taken not to lean forward when sitting
down (Fig. 45-8). To stand, the patient extends the op-
Bed Mobility erated leg and pushes off from the armrests. Because of
The supine position with the appropriate wedge or the hip flexion precaution for the posterolateral ap-
pillow in place is recommended. If a patient sleeps in proach, the patient should sit on the front part of the
the side-lying position, sleeping on the operated side is chair and lean back (Fig. 45-8, C). Firm cushions or
recommended if tolerable. When sleeping on the non- blankets may be used to increase the height of chairs
operated side, the patient must keep the legs abducted and especially may be needed if the patient is tall. Low
with the wedge or larger pillows and the operated leg chairs, soft chairs, reclining chairs, and rocking chairs
supported to prevent rotation. The patient is instructed should be avoided.
in getting out of bed on both sides, although initially it
may be easier to observe precautions by moving toward COMMODE CHAIR. Three-in-one commode chairs
the nonoperated leg. Careful instruction is given to with armrests can be used in the hospital and at home.
avoid adduction past midline. It is important to deter- For the person with a posterolateral approach, the
FIG. 45-8
Chair transfer technique. A, Patient extends operated leg and reaches
for armrests. B and C, Bearing some weight on arms, the patient sits
down slowly, maintaining some extension of the operated leg.
 Hip Fractures and Lower Extremity Joint Replacement 877

height and angle can be adjusted so that the front legs tain hip precautions, the patient uses a reacher or dress-
are one notch lower than the back legs; thus with the ing stick to don and remove pants and shoes. For pants,
patient seated, the precautionary hip angle of flexion is the operated leg is dressed first by using the reacher or
not exceeded. A person with an anterolateral approach dressing stick to bring the pants over the foot and up to
may have enough hip mobility to use a standard toilet the knee. A sock aid is used to don socks or knee-high
seat safely at the time of discharge. All patients should nylons, and a reacher or dressing stick is used to doff
wipe between the legs in a sitting position or from them. A reacher, elastic laces, and a long-handled shoe-
behind in a standing position and use caution to avoid horn can also be provided.
rotation of the hip. The patient is to stand up and step
to turn to face the toilet to flush. Lower Body Bathing
The section on transfers describes the proper method of
SHOWER STALL. Nonskid strips or stickers are rec- getting in and out of the shower or tub. Sponge bathing
ommended in all shower stalls and tubs. When the at the sink is indicated until the patient is approved by
patient is entering, the walker or crutches go first, then the physician to shower. A long-handled bath sponge or
the operated leg, followed by the nonoperated leg. A back brush is used to reach the lower legs and feet
shower chair with adjustable legs or a stool and grab safely. Soap-on-a-rope is used to prevent the soap from
bars should be installed if balance is a problem or if dropping, and a towel is wrapped on a reacher to dry
weight-bearing precautions are present. the lower legs.

SHOWER-OVER-TUB (WITHOUT SHOWER Hair Shampoo

DOORS). The patient is instructed to stand parallel to Until able to shower, the patient is instructed to obtain
the tub facing the shower fixtures. Using the walker or assistance for shampooing hair. If unable to obtain any
crutches, the patient is to transfer in sideways by assistance, the patient may shampoo the hair while
bending at the knees, not at the hips. For patients with standing or sitting on a stool at the kitchen or bathroom
weight-bearing precautions or poor balance, purchase sink, observing hip precautions at all times.
of a tub bench may be considered, allowing the patient
to sit on the edge of the bench and then swing the legs Homemaking
over the tub while observing flexion precautions. Heavy housework, such as vacuuming, lifting, and bed
Sponge bathing at the sink is an alternative activity. making, should be avoided initially. Kitchen activities
are practiced, with suggestions made to keep commonly
CAR. Bucket seats in small cars should be avoided. used items at countertop level. The patient can carry
Bench-type seats are recommended. The patient is in- items by using an apron with large pockets, sliding
structed to back up to the front passenger seat, hold items along the counter top, using a utility cart, attach-
onto a stable part of the car, extend the operated leg, ing a small basket or bag to a walker, or wearing a fanny
and slowly sit in the car. Remembering to lean back, the pack around the waist. Reachers are provided to grasp
patient then slides the buttocks toward the driver's seat. items in low cupboards or to pick up items from the
The upper body and LEs move as one unit to turn to face floor.
the forward direction. It is helpful to have the seat
moved back and reclined to accommodate the hip Family Orientation
flexion precaution. Pillows in the seat may be necessary A family member or friend should be present for at least
to increase the height of the seat. Prolonged sitting in one OT treatment session so that any questions may be
the car should be avoided. If transferring to the front answered. Appropriate supervision recommendations
Passenger seat is a problem, transferring to the back seat and instruction regarding activity precautions are given
of a four-door car is an alternative. The patient backs to at this time. Instructional booklets on hip fractures and
the seat, extends the operated leg, and slowly sits in the total hip and knee surgery may be purchased from the
car. Then he or she slides back so that the operated leg is American Occupational Therapy Association to supple-
resting on the seat fully supported. ment training.'~’'°

Lower Body Dressing

Total Knee Replacement
The patient is instructed to sit in a chair with arms or on
the edge of the bed for dressing activities. The patient is Procedures for ADL training for persons with total knee
instructed to avoid adduction and rotation or crossing replacement are provided in the following paragraphs.
the legs to dress. The patient must avoid crossing the op- Many of the techniques used with a hip replacement
erated extremity over the nonoperated extremity at can be used for someone with a knee replacement. Posi-
either the ankles or knees. Assistive devices may be nec- tions of knee instability include internal and external
essary for observing precautions (Fig. 45-7). To main- rotation and flexion greater than ROM permits.
878 TREATMENT APPLICATIONS

Bed Mobility the patient to observe necessary hip flexion precau-

The supine position is recommended, with the entire tions.
leg slightly elevated via balanced suspension or pillows, Sequential compression devices (SCDs): SCDs are used
with or without a knee immobilizer. This will help to postoperatively to reduce the risk of deep vein
reduce edema and prevent knee flexion contractures. It thrombosis. They are inflatable, external leggings
is recommended that a person not sleep on the oper- that provide intermittent pneumatic compression
ated side. As in hip replacement, a pillow or wedge can of the legs.'7
be placed between the legs if this is necessary for side- Antiembolus hose: These are thigh-high hosiery that
lying and the person lies on the nonoperated side. are worn 24 hours a day and removed only during
bathing. Their purpose is to assist circulation,
Transfers prevent edema, and thus reduce the risk of deep-
In general, the patient can bend at the hip as much as he vein thrombosis.'
or she is able. Because of decreased knee flexion, the Patient-controlled administration (PCA) IV: The
patient may need to use the same techniques for amount of medication is predetermined and pro-
commode and car transfers as have been described for grammed by the physician and nursing staff to
hip replacements. Grab bars or a shower chair or bench allow the patient to self-administer pain medica-
is recommended, especially for transferring to the tion by pushing a button.
shower over the tub, as well as for the individual with Incentive spirometer: This portable breathing appara-
decreased standing endurance or inability to bend the tus is used to encourage deep breathing and
knee enough to sit on the bottom of the tub. prevent the development of postoperative pneu-
monia.
Lower Extremity Dressing
This presents a problem only if the patient is unable to
SUMMARY
reach his or her toes. In such a case, techniques described
for the hip replacement can be used. The patient should Hip fractures and LE joint replacement are orthopedic
practice donning and doffing the knee immobilizer. conditions in which OT intervention may speed the
Homemaking and family training are as for hip re- patient's return to functional independence safely and
placement. comfortably. The protocol for OT is determined by the
surgical procedure performed and by the precautions
prescribed by the physician. Patients who have weight-
Special Equipment
bearing precautions must be trained to observe these
The OT practitioner should be familiar with the follow- during all ADL. A simulation of the home environ-
ing equipment that is commonly used in the treatment ment or a home assessment is helpful in preparing
of hip fracture and total hip replacement. the patient for potential problems that may arise after
Hemovac: During surgery a plastic drainage tube is in- discharge. Areas to assess include the entry, stairs,
serted at the surgical site to assist with drainage of bathroom, bedroom, sitting surfaces, and kitchen. Rec-
blood postoperatively. It has an area for collection ommendations to remove throw rugs and slippery
of drainage and may be connected to a portable floor coverings and obstacles are made, since the
suction machine. The unit should not be discon- patient will most likely be going home using an assis-
nected for any activity, since this may create a tive device for ambulation. A kitchen stool or utility
blockage in the system. The Hemovac is usually left cart may be indicated. It is important to assess and in-
in place for 2 days after surgery. struct the patient and caregiver in ADL with adaptive
Abduction wedge: Large and small triangular wedges equipment, as well as in observing: any movement
are used when the patient is supine to maintain precautions.’” Home therapy may be indicated after a
the LEs in the abducted position. hospital stay to ensure safety and independence in
Balanced suspension: This is fabricated and set up by daily occupations if these goals were not met during
an orthopedic technician and can be used for hospitalization.
about 3 days after surgery. Its purpose is to support Preoperative teaching programs are invaluable in
the affected LE in the first few postoperative days. aiding patient adjustment. The class orients and famil-
The patient's leg can be taken out of the device for iarizes the patient with the hospital, nursing, physical
exercise only.'® therapy, OT, respiratory therapy, and discharge plan-
Reclining wheelchair: A wheelchair with an adjustable ning. Procedures and equipment, concerns regarding
backrest that allows a reclining position is used for the hospitalization and discharge, and therapy are ad-
patients who have hip flexion precautions while dressed. Participation in this type of class has been
sitting. shown to relieve anxiety and fear, empower the patient
Commode chairs: The use of a commode chair instead during the hospitalization, and decrease the hospital
ofthe regular toilet aids in safe transfers and allows length of stay.
 Hip Fractures and Lower Extremity Joint Replacement 879

Case StupY—Mrs. T.
Mrs.T. is a 75-year-old woman who sustained a left hip fracture as durance is poor, and she is experiencing a great deal of pain in
a result of a fall on ice in front of her home. A hemiarthroplasty her left hip because of the surgery. She is independent with setup
was performed to repair the fracture. Currently, she is PW/B on for UE grooming, hygiene, dressing, and eating. She requires
the LLE and has ROM precautions for the left hip. She was ad- MOD assistance for LE dressing and continues to need supervi-
mitted to the subacute rehabilitation unit 3 days after surgery. sion for transfers and ambulation while using the walker, second-
Before the accident, Mrs.T.was independent in ADL and very ary to her inability to follow weight-bearing precautions.
light housekeeping. She lives in an assisted-living apartment build- OT intervention areas include the following: (1) increase level
ing on the third floor The building has an elevator and ramp access of independence in ADL, particularly in LE dressing, bathing, and
to the front door. Heavy house cleaning and one meal per day are toileting; (2) education on hip and weight-bearing precautions;
provided by the center Mrs. T’s daily occupations included per- (3) train in use of adaptive equipment; (4) make recommenda-
forming morning ADL, preparing breakfast, watching television, tions to increase safety in her home; and (5) increase UE strength
knitting, or getting together with friends or other residents for and endurance.
shopping (van service provided), a movie, orjust to socialize in the At discharge, Mrs. T. achieved independence in ADL with
recreation room. Mrs.T. has a daughter and two grandchildren in adaptive equipment. She responded well to treatment after
the area whom she sees every weekend. Mrs.T.was able to main- having many opportunities to practice ADL skills and build her
tain her independence in ADL and light IADL with the use of a confidence. She was trained in the use of a reacher, sock aid, and
straight cane for ambulation and a shower seat in the bathtub. long-handled sponge. The occupational therapist assisted the
Results of the OT evaluation reveal that Mrs.T. is anxious patient's daughter in obtaining an elevated toilet seat. Suggestions
about her ability to return home at the same level of independ- were given to the patient and her daughter to improve accessi-
ence. She is cooperative in general but has difficulty following bility and safety in her home. Home therapy was recommended
weight-bearing precautions. Her UE function is WFL, although for a few visits to do more ADL training in the patient's own
she reports joint pain and stiffness in her hands at times. Her en- home environment.

REVIEW QUESTIONS
11. Compare rehabilitation techniques between pa-
1. Explain the difference in precautions for the antero- tients with a hip replacement and patients with a
lateral and posterolateral approaches for_a hip re- knee replacement.
placement. . 12. What are the benefits of conducting patient educa-
2. When transferring from one surface to another, tion preoperative classes for persons who are at
what is the general procedure to follow to ensure tisk for falls or who are planning a joint replace-
safety and protection of the involved side? ment?
3. List the most common items of adaptive equip- 13. How might a person’s rehabilitation program be af-
ment used during rehabilitation of hip fractures fected by bilateral joint replacements?
and LE joint replacements, and describe their
purpose.
4. Describe how the case coordinator and occupa- REFERENCES
1. American Occupational Therapy Association: Daily activities after
tional therapist can work together on similar issues.
your hip surgery, rev ed, Rockville, Md, 1990, the Association.
5. List two specific suggestions for performing sexual 2. Butler RN: The life review: an interpretation of reminiscence in
activities for someone with a hip replacement. the aged. In Kastenbaum R, editor: New thoughts on old age, New
6. When reviewing the patient's medical and occupa- York, 1964, Springer.
tional history, what information should be ob- 3. Butler RN: Aging and mental health, ed 3, St Louis, 1982, Mosby.
4. Calliet R: Knee pain and disability, ed 3, Philadelphia, 1992, FA
tained?
Davis.
“Ni. Identify two factors that affect fracture healing. 5. Crow I: Fractures ofthe hip: a self study, ONA J 5:12, 1978.
8. What is the difference between closed and open re- 6. Delisa J, Gans B: Rehabilitation medicine: principles and practice,
duction procedures? ed 2, Philadelphia, 1993, JB Lippincott.
9. Why are weight-bearing precautions observed with 7. Ehrlich G: Rehabilitation of rheumatic conditions, ed 2, Baltimore,
1986, William & Wilkins.
an ORIF? 8. Garland JJ: Fundamentals of orthopedics, Philadelphia, 1979, WB
10. In which diagnoses, other than fractures, is there Saunders.
frequent indication for a total joint replacement? 9. Goodgold J: Rehabilitation medicine, St Louis, 1988, Mosby.
What are the goals of this surgical approach? 10. Gray H: Gray's anatomy, Philadelphia, 1974, Running Press
880 TREATMENT APPLICATIONS

i Hogshead HP: Orthopaedics for the therapist, Gainesville, Fla, 1973, 16. Morawski D: The total hip replacement protocol and hip fracture proto-
University of Florida (Unpublished). col, Los Gatos, Calif, 1990, Community Hospital & Rehabilitation
2s Jones M, Lieberman S, Sitko S, et al: The total hip replacement proto- Center of Los Gatos Saratoga, Department of Occupational
col, Stanford, Calif, 1986 and 1982, Stanford University Hospital, Therapy (Unpublished).
Department of Physical and Occupational Therapy (Unpub- Les Opitz J: Reconstructive surgery of the extremities. In Kottle FE
lished). Lehmann J, editors: Krusen’s handbook of physical medicine and reha-
13. After total hip replacement and after hip fracture, Daly City, Calif, bilitation, ed 4, Philadelphia, 1990, WB Saunders.
1989, Krames Communications. a 18. Richardson JK, Iglarsh ZA: Clinical orthopaedic physical therapy,
14. Lewis SC: The mature years: a geriatric occupational therapy text, Tho- Philadelphia, 1994, WB Saunders.
rofare, NJ, 1979, Charles B Slack. . Salter RB: Textbook of disorders and injuries of the musculoskeletal —
itoy, Melvin J: Rheumatic disease: OT and rehabilitation, ed 2, Philadel- system, Baltimore, 1970, Williams & Wilkins.
phia, 1982, FA Davis.
 LEARNING OBJECTIVES
Role blurring After studying this chapter, the student or practitioner
Structural weakness will be able to do the following:
Cognitive distraction 1. Discuss how low back pain (LBP) disrupts role
Self-report function.
Energy conservation 2. Identify similarities and differences in acute and
Pacing chronic LBP.
Diagnostic tests 3. Identify appropriate body mechanics for home
Depression maintenance and dressing activities.
Social isolation 4. Recognize the inherent structural weakness of the
“Flare-up” plan intervertebral disks and ligaments of the lumbar
spine.
5. Anticipate role blurring between occupational
therapy (OT) and physical therapy (PT) in the
rehabilitation of LBP.
6. Demonstrate an understanding of diagnostic tests
used for determining diagnosis of LBP.
7. Recognize the psychosocial effects of LBP.

be back pain (LBP) is a complex, multifaceted Many authors discuss the neuropsychological aspect
medical problem that represents an exciting challenge to of the pain experience and how it is compounded by
the occupational therapist. The frequently sudden onset emotional response.”'~’'® Engel uses the definition of
with severe symptoms can be overwhelming to the the International Association of the Study of Pain and
patient. It is often seen as a narcissistic injury and inher- includes a discussion of acute pain and of numerous
ently subjective. LBP affects the physical, psychological, differentiations of chronic pain.” A practitioner special-
emotional, financial, and social aspects of a person’s izing in orthopedics or pain management should
life." The occupational therapist well trained in the explore these and other references, in addition to the
psychosocial and physical aspects of rehabilitation is an basic information presented here.
important member of the health care team. Diagnosis of LBP is difficult and presents an obstacle
In the United States approximately 79 billion dollars to successful treatment." Other obstacles include fre-
is spent each year on the direct and indirect costs of quent recurrence, wide variation in patient responses to
LBP.’ “Back pain is the second-leading reason that specific pathological findings, and multiple possible
Americans visit their doctors.”'° “LBP primarily affects causes of LBP in a patient.'* LBP is often not the result
25- to 55-year-old adults, which places a significant of one single injury or event, but instead results from
burden on the work force.”* (1) participation in activities that are stressful to the
882 TREATMENT APPLICATIONS

joints of the spine, and (2) habitual use of physical po- Posterior
sitions over several hours, months, or even years that
Spinous Process
involve inappropriate use of body mechanics. These ac-
tivities and positions include prolonged static postures Vertebral Foramen
such as slouched sitting and forward bending, as well as
repetitive tasks like pushing, pulling, lifting, and carry- Articular Processes
ing. The goals in managing LBP are the prevention of
prolonged disability and a speedy return to previous
function.
The occupational therapist's role in the rehabilitation
of the LBP patient may vary, depending on the division
of responsibility at the particular health care facility.
Patient education and training in maintaining normal Vertebral Body
spinal alignment while performing functional activities
are critical parts of the rehabilitation program. Whether
Anterior
pain is acute or chronic, patients with LBP will respond
best to medical professionals who are knowledgeable, FIG. 46-1
positive, and willing to work with them and with each Vertebral body and arch. (From Callahan P et al: Stanford back
other toward a successful outcome. school manual, Stanford, Calif, 1984, Dept. of OT-PT, Stanford Uni-
versity Hospital.)

SPINAL ANATOMY
To help the therapist understand the medical and reha- vertebrae form the intervertebral foramen, where the
bilitation management of LBP, a brief review of lumbar spinal nerves exit.
anatomy is presented. A more in-depth study of spinal
anatomy is recommended for those who will treat this
Ligaments
population.
Spinal ligaments function to restrain or align the verte-
brae. The anterior longitudinal ligament (ALL), a thick,
Vertebrae
strong band of fibers, runs along the anterior surface of
The spine is composed of 33 stacked spinal vertebrae, the vertebral bodies, firmly attaching to the bodies and
24 of which are movable (7 cervical, 12 thoracic, and 5 the intervertebral disks. The ALL limits extension of the
lumbar). Below those are five that are fused together to vertebral column. The posterior longitudinal ligament
form the sacrum, and four rudimentary fused vertebrae (PLL) runs along the posterior aspect of the vertebral
that form the coccyx. The vertebrae are arranged in an S- bodies anterior to the spinal cord. In the lumbar region
curve balanced around the line of gravity. The lumbar it narrows considerably, contributing to the inherent
vertebrae are the largest, reflecting the increasing load structural weakness at the lower lumbar levels, where
from head to pelvis. Each vertebra is made up of two there is the greatest amount of spinal movement. The
parts: the vertebral body anteriorly and the vertebral PLL functions to limit spinal flexion.
arch posteriorly. The vertebral bodies are kidney shaped The ligamenta flava connect the laminae of adjacent
and separated by intervertebral disks.’ The vertebral vertebrae and lie posterior to the spinal cord. These liga-
arch is made up of the pedicles, laminae, and seven ments limit flexion of the spinal column, and their
bony transverse and articular processes. elastic quality helps the spine return to upright from a
The vertebral body and arch (Fig. 46-1) form an ir- flexed posture.®
regular ring called the vertebral foramen. The vertebral
foramina of adjacent vertebrae form the spinal canal
INTERVERTEBRAL DISKS
that encloses the spinal cord and its blood vessels. Facet
joints made from the four articular processes above and Disorders of the intervertebral disks are common causes
below the transverse process guide and restrict the of LBP. The disks, interposed between adjacent surfaces
movements of the spine: flexion, extension, lateral of the vertebral bodies, are composed of two parts. The
flexion, and some rotation. The orientation of these central portion, or nucleus pulposus, is a gelatinous
facet joints allows considerable movement in trunk substance and is surrounded by the annulus fibrosus,
flexion and extension but limits lateral flexion and rota- made up of concentric and oblique fibers that encase
tion. The transverse processes serve as the attachments the nucleus. The nucleus is held under pressure in this
for muscles and ligaments. At the junction of the verte- casing. During vertebral column movements the
bral body and arch, the vertebral notches of adjacent nucleus moves posteriorly with flexion, anteriorly with
 Low Back Pain 883

extension, and to the opposite side with lateral flexion. tion and motor control to and from the lower extremi-
Rotation substantially increases disk pressure and ties (LEs). The three major nerves innervating LE muscu-
stretches the annular fibers. Static or repetitive flexion lature are the femoral, obturator, and sciatic nerves. The
forces the nucleus posteriorly, and it can more easily close relationship of the disks, ligaments, and facet
rupture through the annulus. The combination move- joints to the nerves complicates the diagnosis of LBP.
ment of flexion and rotation is even more stressful to Patients with LBP who develop LE symptoms should
the disk.” seek medical attention. When pain and symptoms
The lumbar disks are the widest but suffer a substan- move distally, the spinal nerve root may be compro-
tial loss of height in the aging process; hence the loss of mised, as in sciatica.
spinal flexibility and height with advancing age. The
nucleus pulposus sits more posteriorly in the lumbar
Muscles
spine. The annulus is therefore narrower and offers less
support. These anatomical factors make the lumbar The muscles of the spine function to move the vertebral
disks more vulnerable to injury, which contributes to column but do little to keep it erect. Erect spinal posture
the high incidence of LBP. Once a load on the disk is is achieved by the hip and thigh muscles, primarily
removed, it regains its normal height. This process re- through the strong ligamentous support of the spine.®
quires a finite amount of time and depends on the The muscles of the lower back are divided into three
health and age of the disk. If the disk is loaded again groups: the postvertebral, prevertebral, and lateral trunk
without time to regain its height, premature aging and muscles. The postvertebral muscles act to extend the
potential derangement can result.” spinal column and limit flexion of the trunk, and they
When the disk is young and healthy and there is vio- accentuate the lumbar lordosis. The postvertebral
lence to the spine, the bones give way first. After age 25, muscles are categorized as deep, intermediate, and su-
degenerative changes occur in the annulus fibrosus, and perficial muscles. The deeper they lie, the shorter is their
the structure is weakened. Under these conditions, a course. The deep muscles include the transversospinalis,
minor strain can cause internal derangement of the interspinalis, spinalis, longissimus, and iliocostalis. At
disk, which causes severe pain and muscle spasm. A the intermediate level is only one muscle, the serratus
study by Nachemson’” demonstrated stress to the L3 posterior inferior. The superficial muscle is the latis-
disk in various positions and postures (Fig. 46-2), simus dorsi. The paravertebral muscles are known as the
which correlates well with the common histories of pa- abdominal muscles and include the rectus abdominis,
tients with LBP and the anatomical considerations de- internal and external obliques, and the transversus ab-
scribed previously. dominis. These muscles flex the spine, flatten the lumbar
lordosis, and assist in rotating the spine. The lateral
muscles of the trunk are the quadratus lumborum and
Nerves
the psoas. They flex the spine ipsilaterally and rotate it
The lumbar nerves exit at the intervertebral foramen at contralaterally, as well as accentuate the lumbar lordosis
the levels of their respective vertebrae, conveying sensa- and flex the vertebral column when the pelvis is fixed.”
In summary, the spine is composed of a network of
structures: the vertebrae, disks, ligaments, nerves, and
muscles. The lumbar spine is subjected to the greatest
kinetic strain and, because of the inherent structural
weakness of the intervertebral disks and ligaments, is
most vulnerable to injury.

REHABILITATION OF THE PATIENT

WITH LOW BACK PAIN
Conservative Approach
The past 10 years have brought dramatic changes in
health care delivery systems in the United States. In
health maintenance organizations and managed care
systems the primary care physician (PCP) must screen
all patients first. Insurance companies require prior au-
thorization for medical care, including occupational
FIG. 46-2
Relative change in pressure in third lumbar disk with various pos- therapy (OT) and physical therapy (PT). Visits are
tures and movements. (Adapted from Nachemson A: The lumbar limited, and therapists must evaluate, plan treatment
spine: an orthopedic challenge, Spine |[1]:59, 1976.) regimens, and establish functional outcomes in a
884 TREATMENT APPLICATIONS

limited time. Patients must demonstrate consistent 8. Prior level of function in self-care, work, and leisure
compliance and motivation and take full responsibility activities
for their medical care. They must understand that with An objective examination includes analysis of the fol-
either acute LBP or chronic LBP, the therapist cannot lowing items:
“fix” them or their pain. 1. Static and dynamic posture
The PCP (e.g., an internist or general practitioner) Gait
sees patients first. The initial evaluation will vary. The Active range of motion (ROM) of the spine
examination should include a thorough medical his- . Active ROM of all extremities
tory, both past and present; a review of the symptoms Pelvic asymmetry
and functional limitations; observation of posture, gait, . Tension signs
trunk mobility, strength, reflexes, and sensation; and Strength, reflexes, and sensation
palpation of the spine and surrounding soft tissues. A . LE muscle flexibility and symmetry
diagnosis is made, and medication (usually a nonste- VaONANAWH
Passive movement testing of the spinal segments
roidal antiinflammatory drug, or NSAID) is prescribed, —_S . Palpation of soft tissue restrictions along the spine

along with rest and restrictions on activities. and surrounding areas

Unfortunately, pamphlets with instructions for exer- Special tests are performed to help with the differen-
cise are sometimes given without additional direction. tial diagnosis, especially to identify sacroiliac dysfunc-
If substantial relief is not achieved in about a week, the tion and hip pathology.
physician who is knowledgeable about rehabilitation An analysis of the data will yield a treatment plan,
will prescribe a course of PT and OT. which may include the following components: (1) posi-
Role functions for rehabilitation specialists in pain tioning for relief of muscle spasm and pain; (2) mobi-
management vary according to the rehabilitation setting. lization techniques to improve mobility of specific
Many factors influence how roles are defined. Therapists joints and soft tissues and relieve muscle spasm and
may acquire additional skills as a result of interest and pain; (3) muscle stretching to gain symmetry to all mus-
studies; the distribution of these skills among practition- culature, especially the LEs; and (4) training in posture,
ers may influence whether an occupational therapist ora body mechanics, strengthening, conditioning, and re-
physical therapist teaches the skill. A physical therapist turning to recreational sports and activities. Training ina
who has movement training may be more skilled in teach- home program includes first-aid tips for pain and muscle
ing moving from sit to stand and from floor to stand. Sim- spasm telief, flexibility, mobility, symptom control, pos-
ilarly, an occupational therapist with stress management ture correction, strengthening, and general conditioning
training will be qualified to teach diaphragmatic breath- for optimal health and return to the preinjury level of
ing, visualization, and other techniques of cognitive dis- function. The overall goals of PT are to provide symptom
traction to help the patient modulate the experience of relief, to normalize joint and soft-tissue mobility, and to
pain. Open communication and flexibility among practi- establish an effective exercise regimen to achieve the
tioners promote effective role function. In rural settings highest functional level for the patient.
there may be only one therapist for hundreds of miles. By
necessity the isolated therapist may perform most of the Occupational Therapy
functions that follow in this chapter. The Stanford Health Services Rehabilitation Services
questionnaire (Fig. 46-3) generates information the
physical therapist might share with the occupational
Evaluation
therapist (this is generally a more efficient use of practi-
Physical Therapy tioner time than having both disciplines collect similar
Often the patient is referred first to PT to address pain, information). However, the occupational therapist may
muscle spasm, limited joint mobility, and postural prefer to ask the patient some of these questions (1 to
defects. The PT evaluation may include a subjective 13) directly. These questions could form a “self-report”
history, including the following information: questionnaire, with the patient asked to fill out the in-
1. Mechanism of the injury formation in the presence of the occupational therapist.
. Progression of symptoms Patient performance of this task affords the therapist an
. Recent treatment and results opportunity to assess comprehension of written mate-
. The patient's medical history rial (important if the patient is to follow a home exer-
WN
Me. Sleep disturbances, including sleep surface, posi- cise program). This could be graded with answers
tions, and use of pillows that best reflect present ability. Concurrently, the thera-
. Work postures pist can observe the patient's sitting tolerance and pain
ND. Activities of daily living (ADL) postures and the be- behaviors.
havior of the symptoms during these postures and A functional assessment of the patient's ADL is
activities (Fig. 46-3) important. Actual observation of each task enables the
 STANFORD HEALTH SERVICES
REHABILITATION SERVICES QUESTIONNAIRE

Name: Age: Date:

‘ain B Began :
1. Pain ae = How? 2

2. Please draw a picture of your pain today. 3. Rate your pain:

O = Painfree 10 = Severe/Disabling

A. Medications:

5. Does rest help decrease your pain?

yeseta er no

6. Please check if you have (or have had):

____ High blood pressure ____ Bowell /Bladder
_____ Respiratory ____ Pregnancy
_____ Heart disease ____ Allergies
____ Diabetes ____ Skin Disorders
____ Arthritis
Fractures (where? )
Cancer (where? SS ate)
Neurological disease

8. Please list surgeries/dates:

"hePlease check if have had:

10. A. What is your occupation?

B. Are you currently working? Yes No Last day worked:
C. What percentage of your day do you sit? Stande

11. Please check if you have difficulty performing the following activities:
Dressing Childcare Gardening Housekeeping
___ Toileting Cooking Home or car repair Public transportation
Bathing Laundry Shopping Keyboard/typing
Eating Walking Telephone Driving car
Writing Other:
Continued
FIG. 46-3
Rehabilitation services questionnaire. (Courtesy ofJ Smithline, Stanford Health Services, Depart-
ment of Rehabilitation Services, Stanford, Calif.)
885
12. [My pain is... BETTER WORSE
Sue
ANNES
utah alge tare
ial
ad She
Lying onnny. bockinit eee eeeenanie
Pilying oniyside Sa cin setiepenceieneeuae
Walking. c8s aceasta s ees
|Standing. S.'iiecuaien se aie er ee
Climbing stairs PAE
(ace
Coughing or sneezing aaa Ad
Putting on my shoes
oe siti eetre
ene oie |
BLO erie noe
Middle of the da ieee
Before bedtime ore kwh pad

13. | wake up at night because of pain 0, 1-2, 3 or more times a night.

14. Please check all treatments for pain that you have received and circle those that have helped the most.

TREATMENT J TREATMENT
Pew Medications: SS SSC Aes 2 io oe eee Tos
|Bedrest | Acupressiro 1
|Hospitalization, butno surgery || Acupuncture | ae
Pinjections | Other, Describe: fe
Back manipulations — Bose
Corset or brace
Physical therap Sone
Name of P.T. or clinic:

15. If you have had physical therapy, what did your treatment include? Please check all that apply:

TREATMENT TREATMENT
Ultrasound
¥6

| Massage
Beepacks
|__| Range ofmotion exercises |_| _TENS (transcutaneous nerve stimulator gets a

peed Strengthening exercises Bacan Training in posture, body mechanics

|__| Spinal mobilization |__| Conditioning program et ge
|__| Electrical stimulation |_| Home exercise program. Since.
|__| Traction (Sitting) |_| Other. Describe:
|__| Traction (Lying)

16. Are you performing a home exercise program? Yes No How often? x week.

17. What are your leisure activities now?

18. What activities (vocational, functional, recreational) do you want to return to?

19. If we could do one thing for you, what would it be?

FIG. 46-3—cont’d
Rehabilitation services questionnaire. (Courtesy of J Smithline, Stanford Health Services, Depart-
ment of Rehabilitation Services, Stanford, Calif.)

886
 Low Back Pain 887

occupational therapist to evaluate faulty postures and

body mechanics. Often patients can verbalize the gen-
eral principles for minimizing stress to the spine but
are not aware that they do not observe these principles
in ADL. A kitchen, bedroom, and work simulation area
greatly expand the occupational therapist's contexts
for evaluation. Activities including dressing, toileting,
hygiene and self-care, bed mobility, transfers (from the
bed, sofa, chair, bath, and shower), loading and unload-
ing the dishwasher, meal preparation, oven use, refriger-
ator use, carrying and lifting from various heights, reach-
ing, and simulated work activities can be observed and
problems identified. The organization of the kitchen,
home, work environment, and frequently used objects
can be discussed and modified to minimize spinal stress.
During the evaluation the occupational therapist ob-
serves spontaneous movements, such as scratching the
foot, posture when sitting, and sequence of movements
in rising from a chair. These can be compared to move-
ments performed when the patient knows he or she is 5.
being observed. Pain behaviors such as facial grimacing
and grunts are noted. Specific lifting and carrying evalu- FIG. 46-4
ations may be conducted, using work evaluation Positions for rest using pillows and towel rolls to support body
contours, allowing muscles to relax. (From Smithline J: First aid tips
systems (see Chapter 16) or simulations created by the
for back pain, Stanford, Calif, 1993, Stanford Health Services, De-
therapist to mimic a patient's individual occupational
partment of Rehabilitation Services.)
demands. Throughout the evaluation the therapist
notes the patient's spinal posture, keeping in mind the
anatomical constraints of the spinal structures. the upright position, lying down most of the day is in-
Depending on the extent or availability of informa- dicated. Pain relief should occur in 1 to 3 days.
tion from the physical therapist, a physical evaluation Bed mobility techniques and skills could be taught
including strength, extremity and trunk mobility, by either the occupational or physical therapist, but
general posture, and ambulation may be performed. collaboration is critical to ensure that sequential learn-
Finally, the occupational therapist quantifies the infor- ing is taking place. Incorrect performance in bed mo-
mation collected, establishing a baseline from which bility can contribute to LBP; the patient must learn to
progress can be measured. Probably the greatest advan- eliminate torsion and flexion of the lumbar spine
tage of this format for evaluation is that a natural dia- (Fig. 46-5). Lying down on the bed using a prone ap-
logue will ensue, which will provide an opportunity to proach is also helpful. To do this, the patient touches
begin establishing rapport. At the completion of the the bed with his or her hands while the leg closest to
above the therapist can discuss the difficulties the the bed is elevated to mattress level. The trunk is
patient has defined as goals for treatment in OT. slowly lowered to the bed surface and the supporting
leg is then lifted onto the bed. Spinal alignment must
be maintained during this maneuver. Ice (or heat) can
Treatment
be used at home to relieve pain and decrease abnor-
Physical Therapy mal muscle tone while resting. Home remedies for ice
Finding pain-free positions for rest is the first concern of or heat pack are detailed in Box 46-1. The side-lying
the physical therapist. Each person is different, but posi- and prone positions are most favored and allow ease
tions of comfort can be found in prone, supine, and in using ice or heat pack applications. Supine lying is
side-lying positions by using pillows and towel rolls to least favored because of the direct pressure on the
support the natural contours of the body. This will lumbar spine and the stress placed on the anatomical
allow muscles to relax (Fig. 46-4). Resting should be structures when the spine flattens to meet the support-
performed as an exercise. Initially lying down for 10 to ing surface. Sitting, especially if prolonged, often ag-
20 minutes three or more times a day can decrease the gravates LBP. In addition to using correct posture, pa-
stress to the spine from sitting, standing, and walking tients must learn to use lumbar supports. These can
and provide considerable pain relief. Bed rest is rarely be created by rolling up a towel to fit the lumbar
prescribed because of the threat of decreased muscle curve (Fig. 46-6). Patients are cautioned against sitting
tone. Nonetheless, if an individual is unable to tolerate in hot tubs or saunas.
888 TREATMENT APPLICATIONS

: OF of Ice or Heat to Reduce Muscle Spasm

Use ice or heat

Ice or heat, or both, can be helpful in reducing pain and muscle
spasm. Ice is usually more effective than heat. Sometimes
using heat for |0 minutes, then ice for 10 minutes works
well. Below are some preparation techniques.

Remember
|, Use ice or heat when resting, not when sleeping or sitting.
2. Use no longer than 20 minutes.
3. Repeat three to five times per day as pain indicates.

Ice pack preparation

FIG. 46-5
Method for getting up from bed or couch to reduce stress on low Method |
back. A, Roll to side. B, Bend knees forward to bring feet off bed Place an unopened bag of frozen peas wrapped in a damp
and push up to sitting, using arms and keeping back straight with towel on the back. Use as directed above. Return peas to
normal curve. (From Smithline J:First aid tips for back pain, Stanford, the freezer Use again and again. DO NOT EAT PEAS.
Calif, 1993, Stanford Health Services, Department of Rehabilitation
Services.) Method 2
Place cracked ice cubes in a zipperlocking bag, Place on a
damp towel on the back. Use as directed above. Return to
the freezer Recrack ice before next application.

Heat pack preparation

Method |
Place damp towel in microwave to heat. Test temperature,
ly then place on back. Use as directed above.
eS
Method 2
Use heating pad set on LOW. Do not sleep on the heating
pad. Do not sit in chair with heating pad. Use as directed
above.

A B
FIG. 46-6
Sitting postures. Most important is keeping normal curves in back,
preferably by ensuring proper support, especially for low back.
(From Callahan P et al: Stanford Back School Manual, Stanford, Calif, The physical therapist will perform a variety of
1984, Stanford Health Services, Department of Rehabilitation manual therapy techniques, including (1) joint mobi-
Services.) lization to provide pain relief and reestablish normal
physiological and accessory ROM to the lumbar spinal
Patients with LBP should not exercise because this ac- segments; (2) soft-tissue mobilization, including my-
tivity can aggravate the symptoms and prolong the dis- ofascial and massage techniques to alter soft-tissue re-
ability. Once pain is controlled, exercise can be initi- strictions that contribute to pain and mobility limita-
ated. Exercise must be designed for the specific tions; and (3) muscle stretching to achieve symmetry
individual and should be performed slowly, gently, and and normal length to LE muscles that directly affect
progressively, as the symptoms allow. Exercise must be spinal function. These muscles include the hamstrings,
performed free of pain. If the pain and muscle spasm psoas, tensor fasciae latae, piriformis, rectus femoris,
continue, the therapist may use modalities such as ultra- gastrocnemius, and soleus.
sound or electrical stimulation to normalize muscle Once pain relief is achieved and symptoms are under
tone and decrease pain. Pelvic traction can be helpful in control, aerobic and strength training can begin, but the
relieving LE radicular symptoms, pain, and paresthesias training must be very conservative and graded very
radiating into one or both LEs. gently. Recurrence of LBP is frequent and often the
 Low Back Pain 889

result of advancing too rapidly with exercise or activity. 2. Progressive, repetitive tasks to build strength and en-
Pool exercise is an excellent treatment alternative for pa- durance for specific activities, minimizing spinal stress
tients in the acute stage. The buoyancy of the water and 3. Discussion of faulty body mechanics and poor pos-
elimination of gravity on the weight-bearing joints tures, with specific education and practice in correct
allows ease of movement and enables pain-free exercise. techniques during functional activities
‘Walking and specific exercise are more easily tolerated 4. Training in the use of assistive devices to increase in-
in water, and patient compliance is very good. Pool tem- dependence in ADL despite pain and limitation and
peratures for ambulation and exercise should be 88° to to minimize recurrence of symptoms
92° F Swimming laps, if tolerated, can also be benefi- 5. Training in simulated work tasks to minimize spinal
cial. Using aqua vests or flotation devices may allow the stress and grade tolerance of these tasks
patient to perform vigorous aerobic activity without 6. Simulation of body mechanics for play and leisure
loading the spine vertically. activities to determine if the activities are appropriate
Teaching and modifying a home program will be during the rehabilitation phase. The overall goal of
ongoing during the course of treatment. With health in- OT in treatment of patients with LBP is to achieve the
surance limitations, PT visits may be extended over time highest level of functional independence in all tasks
to allow musculoskeletal changes to take place, allowing of role function, including self-care, play and leisure,
for changes in the program with each visit. An average of and work activities.
three to six visits is commonly authorized by health OT can begin as soon as the patient can tolerate ac-
maintenance organizations and managed care programs. tivity in the upright position. Communication with the
Some insurance benefits limit the duration of treatment physical therapist is critical for ensuring that (1) both
to 60 days. These time constraints often make comple- therapists teach posture and body mechanics with
tion of a PT program and the return to work with previ- similar principles and (2) suggestions for spinal align-
ous activity expectations difficult for the patient. ment are coordinated. The occupational therapist also
addresses self-care, including hygiene, dressing, and
Occupational Therapy meal preparation. Assistive devices are considered.
The occupational therapist designs a specific treatment Functional training and practice with techniques will
plan that could include the following: be more successful than just discussing them with the
1. Education in energy conservation and pacing patient. Examples include sitting, lifting (Fig. 46-7), car-
skills to be used for symptom control with all self- rying, and standing. These activities are monitored
maintenance, work, and play and leisure tasks to quantify progress. Work simplification and energy

Method 1 Method 2

FIG. 46-7
Lifting methods that protect lumbar spine from injury. (From Callahan P et al: Stanford back school
manual, Stanford, Calif, 1984, Stanford Health Services, Department of Rehabilitation Services.)
890 TREATMENT APPLICATIONS

conservation skills are taught and applied to all func- to return. This problem identification and problem-
tional activities. The occupational therapist can perform solving approach helps prevent exacerbation of symp-
functional capacity or work tolerance assessment using toms and reinjury. This approach is reinforced as a
work assessment systems or simulations created in the technique the patients must use after rehabilitation to
OT setting. This information is vital to the physician, “problem solve” each “flare-up” in the future. A work
patient, and employer and is the foundation for the de- hardening program can be initiated and job simulation
velopment of reasonable, achievable goals. Returning tasks can be practiced and timed (see Chapter 16).
to work may mean part-time employment or activity-
restricted work. The appropriate activity level can be de- Body Mechanics Training
termined by the occupational therapist through assess- Activities of daily living (ADL) must be scrutinized to
ment and observation of simulated work tasks. observe stresses on the lumbar spine. Keeping in mind
Helping patients define potential difficulties they the anatomical weakness in the lumbar disk and PLL,
may encounter at work is necessary before they attempt the occupational therapist must observe patients in all

Forward bending places increased stress on the structures in the back and neck.

Balanced Balanced

If you are goin to work over the bathroom reaps: one hand on the counter to support your weight and bend at the hips,
not the back. Elevate one foot and keep your hea up and your back in a balanced position.
You can also try performing some of your sink activities in the kneeling position to reduce the temptation to bend forward. Use
the counter for support when you come to standing.

Using a hand-held mirror eliminates the need to bend over the sink.
During an acute episode of ead al you can minimize stress when using the toilet by facing the back of the toilet. This will
prevent you from bending forward and will provide you with support when you come to standing.
Additional a aga Purchasing an accordion-mounted mirror for shaving and applying make-up allows you to avoid the
temptation to ean over the sink. Purchase a good shower caddy and place razor, toothbrush, toothpaste, and face cloth in the
shower. Use a tub mirror (not glass) to avoid activities over a low sink.

FIG. 46-8
Bathroom activities. (From Melnick M, Saunders R, Saunders HD: Managing back pain: daily activities
guide for back pain patients, Minneapolis, Minn, Educational Opportunities.)
 Low Back Pain 891

daily tasks, especially those that were reported to aggra- (2) a good shower caddy can hold razor, toothbrush,
vate symptoms in the subjective assessment. toothpaste, and face cloth in the shower; (3) a tub
The following information is adapted from Managing mirror (not glass) can help the patient avoid activities
Back Pain.'* Numerous everyday activities are evaluated, over a low sink; and (4) a tub bar will promote safety if
and faulty body mechanics are described as “unbal- balance is poor or if patient is elderly.
anced.” Stressful positions include prolonged static pos-
tures with a flexed lumbar spine, repetitive bending Bed Making
with a flexed spine, and lifting and carrying when the When making the bed, the patient should not stand on
normal lumbar curve is not maintained. It is very im- one side and reach across the bed. The temptation to
portant to avoid tasks or positions that do not allow a bend forward may be reduced by kneeling or climbing
balanced posture. The patient is taught to visualize onto the bed, which encourages keeping the back in a
making the movement necessary to perform the activity balanced position. To complete the task the patient
before attempting to initiate the activity. should walk around the bed to finish the far side. Using
a lightweight comforter instead of a heavy bedspread
Bathroom Activities decreases spinal stress (Fig. 46-9).
Forward bending places increased stress on structures in
the back and neck. To work over the bathroom sink, the Kitchen Activities
patient should place one hand on the counter to Commonly used items can be arranged between waist
support weight and bend at the hips, not the back. The and shoulder height to reduce the need to bend over. To
patient should elevate one foot and keep the head up reach something from a lower level, the patient can
and the back in a balanced position. The patient can drop down onto one knee, take the object, put the
also try performing some of the sink activities in the object on the counter, and then use the support of a
kneeling position to reduce the temptation to bend table, chair, or counter to assist in coming to standing.
forward. The counter can be used for support when This support helps maintain the normal curves in the
coming to standing. Using a handheld mirror elimi- spine (Fig. 46-10). If support is not available, the patient
nates the need to bend over the sink. During an acute can place the hands on the thighs and push off with the
episode of back pain the patient minimizes stress when arms.
using the toilet by facing the back of the toilet to prevent To load the dishwasher, the patient should place the
bending forward and to provide support when coming rinsed dishes on the counter near the dishwasher, go to
to standing (Fig. 46-8). one knee, and load the dishwasher from this position.
Additional suggestions include the following: (1) an This method helps avoid prolonged or repetitive
accordion-mounted mirror for shaving and applying forward bending and twisting movements. The process
make-up reduces the temptation to lean over-the sink; is reversed to unload the dishwasher. The patient should

eal

Unbalanced Balanced |

When making the bed, do not stand on one side and reach. The temptation to bend forward can be reduced by kneeling or
climbing onto the bed. This will encourage you to keep your back in a balanced position. If you are going to perform the task
while standing, walk around the bed to complete the far side.
Additional suggestions: Use a lightweight comforter instead of a heavy bedspread to decrease spinal stress.

FIG. 46-9
Making a bed. (From Melnick M, Saunders R, Saunders HD: Managing back pain: daily activities guide for
back pain patients, Minneapolis, Minn, Educational Opportunities.)
892 TREATMENT APPLICATIONS

It is very important to avoid tasks or positions which do not allow a balanced posture. Take a few seconds to approach each
task in a way which will minimize the stress to your back.

é
é bi

F ee r wage ip

7 : ; t 3 3

a a ee ~* me
f

Balanced | Balanced

Arrange commonly used items between waist and shoulder height to reduce the need to bend over. If you need to reach
something from a lower level, drop down onto one knee, grab the object, put the object on the counter and then use the
support of a table, chair or counter to assist you while you come to standing. This support will fa you maintain the normal
curves in your spine. If you do not have support available, place your hands on your thighs and push off with your arms.

— % oneal:

Unbalanced |, . Balanced |) Balanced |

To load the dishwasher, place the rinsed dishes on the counter near the dishwasher. Go to one knee and load the dishwasher
from this position. This helps you avoid prolonged or repetitive forward bending and twisting movements. Reverse the process
to unload the dishwasher. Use support when you come to standing.

Additional suggestions: Remove silverware basket before loading and place it on the counter. Fill with silverware while
standing, then return the basket to the dishwasher. Use top tray only to decrease bending.

FIG. 46-10
Kitchen activities. (From Melnick M, Saunders R, Saunders HD: Managing back pain: daily activities
guide for back pain patients, Minneapolis, Minn, Educational Opportunities.)

use support when coming to standing. Additional sug- loading a front-loading washer or dryer, the patient
gestions are to (1) remove the silverware basket before should drop to one knee to avoid any forward bending
loading and place it on the counter, fill it with silver- and twisting and should use support when coming to
ware while standing, then return the basket to the dish- standing (Fig. 46-11).
washer and (2) use only the top tray to decrease the
need for bending (Fig. 46-10). Home Maintenance
Participation in vacuuming, car maintenance, mowing,
Laundry and shoveling is not recommended during the early stages
When the patient does laundry, loads should be kept of recovery. Once the condition has stabilized, the
small and manageable. Several small loads place less patient may be taught methods for preventing a recur-
stress on the back than one or two large ones. The rence of symptoms. Sweeping and vacuuming can be
patient should avoid bending forward into the ma- performed as if the vacuum or broom were attached
chines and should not try to handle large bundles of to the body. The patient should move the feet and
clothes, particularly if they are wet. When loading or un- legs rather than reaching or bending forward and
 Low Back Pain 893

Keep loads small and manageable. Several small loads will place less stress on your back than one or two large ones.

mys
Bah

Unbalanced iis : sii bas i Balanced

Avoid ie forward into the machines. Do not try to handle large bundles of clothes, particularly if they are wet. When
loading or unloading a front-loading washer or dryer, drop to one knee to avoid any forward bending and twisting. Use
support when coming to standing

FIG. 46-11
Doing laundry. (From Melnick M, Saunders R, Saunders HD: Managing back pain: daily activities guide
for back pain patients, Minneapolis, Minn, Educational Opportunities.)

NOTE: Participation in the following activities (vacuuming, car maintenance, mowing and shoveling) is not recommended
during the early stages of recovery. These activities are presented to offer methods for preventing a recurrence of your
symptoms once your condition has stabilized.

Unbalanced | =, Balanced

Perform the tasks as if the vacuum or broom were attached to your body. Move your feet and legs rather than reaching or
bending forward. Avoid twisting. If you must vacuum or sweep under a table or chair, bend at your hips and knees and keep
your back in a balanced position.
Additional suggestions: Lightweight electric brooms make the job much easier. Beware of self-powered vacuum cleaners. They
are very heavy!

FIG. 46-12
Sweeping and vacuuming. (From Melnick M, Saunders R, Saunders HD: Managing back pain: daily ac-
tivities guide for back pain patients, Minneapolis, Minn, Educational Opportunities.)

should avoid twisting. If it is necessary to vacuum or Gardening may evoke LBP because many people at-
sweep under a table or chair, the patient should bend tempt it on the first warm day, after months of sedentary
at the hips and knees and keep the back in a balanced activity indoors. Patients with LBP must learn to pre-
position (Fig. 46-12). Lightweight electric brooms pare by using stretching and conditioning exercises be-
make the job much easier. fore undertaking extensive gardening. Most gardening
894 TREATMENT APPLICATIONS

catalogues have functional tools such as long-handled people without complaints of LBP had abnormal find-
rakes, kneeling pads, and knee pads. Some shovels ings at one or more vertebral levels.'°
come with hand-controlled jaws to capture and hold
the soil. Lightweight gardening stools allow patients to Computed Tomography
sit while bending forward at the hips to remove dead Computed tomography (CT) uses cross-sectional x-ray
flowers and perform other similar tasks. Sitting rather films to define bony and soft-tissue abnormalities. This
than standing helps to conserve energy. procedure is used less often for spinal problems now
The home can be arranged to meet the needs of the because the MRI is superior at visualizing soft-tissue
patient with LBP. The following are some suggestions abnormalities.
for this arrangement:
1. Place all frequently used items on shelves at waist to Diskogram
chest level. In a diskogram, contrast material is injected into the in-
2. Store refrigerator or freezer items most frequently tervertebral disk to see whether symptoms are repro-
used on the top shelves of the compartment. duced and clinical impressions are confirmed.
3. Keep a kneeling pad in the kitchen and use it when
using the oven, dishwasher, lower shelves of the re- Myelogram
frigerator or freezer, and floor-level cupboards. In a myelogram, iodinated contrast material is injected
4. Have a wheeled cart available to conserve energy and into the dural sac in order to outline spinal structures
avoid unnecessary lifting and carrying. on x-ray film. Use of this procedure has declined with
5. Ask packing clerks in the stores to pack bags lightly the advent of the MRI and CT.
and ask for carry-out assistance or delivery service.
6. Line the bottom of the car trunk with boxes, crates, or Bone Scan
other means to raise the level of the floor, which will In a bone scan, radioactive material is injected intra-
reduce the necessity to lean farinto the trunk to place or venously and the body is scanned after several hours,
remove packages. Alternately, use the back seat to hold making it possible to identify infections or tumors in
groceries. (Transporting grocery bags is an awkward the skeletal system.
activity and should be practiced with supervision.)
7. Shop in stores that offer waist-high, shallow grocery Nerve Conduction Velocity
carts. and Electromyography
8. If pain suddenly increases because of a stressful phys- Nerve conduction velocity and electromyography use
ical position, stand upright and realign the spine to electric current to provide physiological data about nerve
its normal curves and perform stretching exercises root dysfunction and peripheral neuropathic conditions,
(as instructed by therapist) before resuming the same often caused by disk herniation. '’
activity.

INVASIVE, NONSURGICAL PROCEDURES

MEDICAL MANAGEMENT
OF LOW BACK PAIN Epidural corticosteroid injection is an option before sur-
gery. This outpatient procedure can be performed in
Diagnostic Tests the hospital with local anesthesia. Relief can occur up
If management of acute LBP is not successful with med- to 1 week later, and the corticosteroid medication lasts
ication, rest, and rehabilitation, further diagnostic test- up to 3 months. By then the patient has resumed activ-
ing may be indicated. The PCP then refers the patient to ities and often continues to be functional. If partial
a specialist, usually an orthopedist or neurosurgeon. Di- relief is obtained, another injection may be performed
agnostic tests are often ordered. These may include the from 1 to 4 weeks later.° The patient who feels much
following. better must be cautioned to continue self-pacing and
performing exercises recommended by the physical
X-Ray Examination therapist.
Radiographic evaluation (an x-ray examination) is used Another outpatient procedure performed with local
to rule out fractures, degenerative disease, possible anesthesia is the percutaneous diskectomy. Specialized
metastatic disease, and structural abnormalities. instrumentation is introduced that suctions out the
damaged disk material. Very specific criteria are used to
Magnetic Resonance Imaging determine candidates for this procedure.°
Magnetic resonance imaging (MRI) visualizes bones
and tissues using a magnetic field and radio waves. The
technique is used to localize a problem area and
SURGICAL PROCEDURES
confirm clinical impressions such as herniated disks or Indications for surgery include bowel, bladder, and
spinal stenosis. A study using MRI showed that 66% of sexual dysfunction, saddle anesthesia, muscle weak-
 Low Back Pain 895

ness with progressive neurological deficits, and signifi- programs usually include standing and bed exercises to
cant pain with the presence of structural deformities. improve extremity ROM and strength.
Common procedures include laminotomy and _diskec- Both the occupational therapist and physical thera-
tomy, in which part of the lamina is excised to expose pist must determine the need for further rehabilitation
the nerve root and disk. The extruded material is after discharge. Recommendations for home care and
removed along with the fragmented part of the outpatient follow-up are made.
nucleus.°
In a foraminotomy small pieces of bone around the in-
tervertebral foramen are excised to allow more room for CHRONIC LOW BACK PAIN
the spinal nerve. This procedure is usually done in con- The literature reflects that the treatment of chronic pain
junction with a laminotomy. A decompressive laminec- must be separated from that of acute pain and is most
tomy is the removal of the entire lamina and therefore effectively approached by a team of medical and behav-
the spinous process, to decompress the spinal canal. It is ioral specialists. The optimum treatment setting is inpa-
usually performed in patients with spinal stenosis. A tient hospitalization, where all services are coordi-
posterolateral fusion is performed when there is evidence nated.'® Although chronic is defined as more than 3 to
of spinal instability. Autogenous iliac crest bone graft is 6 months’ duration, it is functionally determined by
used to stabilize the lumbar segments.° disruption of all the patient's chosen life roles. In a
Surgery for herniated disk(s) is controversial. Long- center that treats chronic pain, a history of LBP from 3
term outcome relative to pain and function is similar to months to 50 years with multiple surgeries and fusions
that achieved with conservative care.’ Surgery forms scar is not uncommon.
tissue, which can be equally painful and inhibiting. As the intrusiveness and corrosiveness of chronic
pain lead to inactivity and a general decline in physical
fitness, depression and social isolation become promi-
REHABILITATION MANAGEMENT
nent. Frequently, patients dealing with these problems
OF THE POSTSURGICAL PATIENT
abuse narcotic analgesics, alcohol, and street drugs. To
The OT-PT team initiates treatment on the first postop- counteract this decline in function, patients in a pain
erative day. Pain is often well controlled through the management program are expected to be out of bed,
use of a patient-controlled analgesic device(PCA). This dressed, and actively involved in their daily rehabilita-
allows the patient to self-administer pain medication in tion program.'® Many phases of acute LBP rehabilita-
premeasured doses, thus avoiding overdose. Postopera- tion can be prescribed to all patients (as in exercises and
tive bandages and surgical tape cover the sutures and education in the use of proper body mechanics), but the
help prevent soft-tissue stretching and unwanted occupational therapist's evaluation is, by necessity, in
pulling on the surgical site. greater depth. Of continuing concern is the individual's
The goal of inpatient care is to achieve a safe dis- physical function, time management, ability to pace ac-
charge to home with or without supervision from a tivities, and cognitive functioning. Additional emphasis
family member or health care attendant. OT focuses on is placed on behavioral, cultural, familial, and spiritual
functional training in bed mobility, self-care, transfers, aspects of the patent's life.°
standing tolerance, dressing, and other daily tasks. With An interview will yield needed information about the
little time for rehabilitation, adaptive equipment such patient's functioning. Even with an interview, a self-
as a commode and shower seat need to be rented in report form should be given to the patient, for reasons
time for discharge to home. Education and training in discussed previously. It may be difficult for the patient to
posture and body mechanics are reviewed and prac- complete such a form because issues such as the abuse of
ticed. The emphasis is on maintaining normal spinal narcotic analgesics, alcoholism, depression, anxiety, and
alignment during self-care (sitting and standing) to head trauma can depress cognitive function. The practi-
minimize stress on the spine. tioner must be aware that in some cases there may be
The length of stay in the hospital continues to be many associated problems that may or may not have
shortened. Patients with single-level laminotomies are been previously diagnosed. (See Chapter 27 on cognitive
often discharged in 3 days. Patients with multilevel pro- components and Chapter 28 on the psychological and
cedures and fusions may stay 5 or 6 days because exter- psychosocial experience of disability.)
nal stabilization devices sometimes need to be ordered Engel discusses the need for accurate, multidimen-
and fitted before discharge. sional evaluations, using instruments that have been
PT focuses on strengthening, mobility, and ambula- validated and are reliable, to establish the effect of treat-
tion activities, as well as evaluation for ambulation aids ment. Several methods for pain evaluation have been
such as a walker, cane, or other equipment for neurolog- used to measure clinical pain. Engel discusses overt and
ical deficits that are not resolved after surgery. Func- covert behavioral approaches, as well as physiological
tional training is also practiced, and written exercise pain responses used in the behavioral evaluations of
programs are reviewed and practiced. Home exercise pain.” (See Chapter 29 on pain management.)
896 TREATMENT APPLICATIONS

All of the evaluation findings are relayed to the pain tional stress and the accumulation of physical stress to
team. The findings may be indicators for further exami- the lumbar spine lead to another episode of pain. This
nation, such as neuropsychological testing. All of this is often referred to as a “flare-up.” Patients are told that
information helps the occupational therapist to struc- because of human nature, this will probably happen.
ture the patient's experience and thus help maximize ac- Patients design a “flare-up plan” for themselves in OT
ceptance of information and integration of educational and PT before discharge. Developing this plan rein-
experience. forces their ability, after education, for self-treatment.
Occupational therapists have many modalities avail- Maintaining a positive attitude, planning realistic
able for individuals with chronic LBP, Engel? lists phys- goals, and taking increasing responsibility for them-
ical activity, communication of pain, relaxation train- selves and their own rehabilitation are key ingredients
ing, biofeedback, cognitive restructuring, distraction, of the ability of LBP patients to decrease pain and pain
social support, and cutaneous stimulation modalities. complaints.
Many practitioners see the empowerment of assertive
behaviors as a skill critical to management of pain and
depression.'°
One of the major functions of both OT and PT is
evaluation of the musculoskeletal system and of the
CASE STUD
functional capacities of the individual. In addition, the Case Stupy—MnkR. C.
occupational therapist and physical therapist evaluate Mr. C. is 29 years old. He lives in a two-bedroom, single-story
previous rehabilitation experiences, treatment, and out- house with his wife and 6-year-old daughter He worked as a
comes in order to advise the pain management team picture framer but was injured at work 3 months ago while lifting
about present limitations and the prognosis for positive a 50-pound box. He complains of pain in his right low back and
change with further rehabilitation. of an inability to function in normal activities. He appears de-
The physical therapist evaluates asymmetries in pressed and admits to becoming more isolated socially since the
muscle length, tone, and strength, as well as joint mo- injury. He states that he would like to return to work but is cur-
bility, asymmetry, or changes in soft tissue. Overall rently unable to work. He is unable to help his wife with house-
function, especially gait and general fitness, are also work, as he once did. He enjoys fishing, skiing, and basketball and
would like to do these activities again. His condition is diagnosed
evaluated. From these findings the physical therapist
as low back strain. He was referred to OT for restoration to
designs a treatment program that emphasizes muscle
maximal functional independence and for instruction in proper
stretching and joint mobility to correct or reduce the body mechanics for self-care, work, and leisure.
severe joint restrictions seen in individuals with The initial evaluation included functional activities such as
chronic pain. Often a patient is seen in a “back school” lifting and carrying, work with LE weights, UE weights, treadmill,
setting for additional education. If movement therapy and stationary bicycle, and functional analysis of performance of
is available, this is used as an adjunct. The goal of PT is tasks. Tasks evaluated included dressing, housework, and mobility,
to help the patient return to the highest level of physi- such as from lying down to standing and sitting to standing. The
cal function possible. patient's chief complaint of burning pain in the right lower back
interfered with the performance of dressing, particularly the
donning of socks and shoes. The patient demonstrated poor
SUMMARY body mechanics when sweeping, vacuuming, and lifting and
reaching, as well as in sitting to standing and lying to standing. De-
The patient with acute or chronic LBP is a challenge to
creased ROM and poor flexibility were noted in all trunk
the rehabilitation team of the occupational therapist, motions and in hip flexion. The patient's habitual posture showed
physical therapist, physician, psychiatrist, psychologist, a flattened lumbar curve with forward head. The patient admit-
nurse, social worker, and vocational rehabilitation ted to watching television all day; he had lost contact with friends
counselor. All members of the team must communicate and spent much time alone.
often and realistically with each other, as well as with The treatment plan focused on the goals of management of
the patient and family, to facilitate positive change in all pain and stress, increased ROM, flexibility, strength, and en-
aspects of the patient's life. durance, and the consistent use of appropriate body mechanics.”
Understanding the anatomical weaknesses of the Principles of body mechanics were explained and demonstrated;
lumbar spine, especially with respect to disks and liga- the occupational therapist observed Mr. C. and corrected his
posture and body mechanics in the context of activities such as
ments, enables the occupational therapist to educate pa-
dressing, home maintenance, play and leisure, and work. Simu-
tients in ways of moving that minimize spinal stress.
lated tasks of lifting and other functions related to Mr C's job as
This knowledge must become a way of life and must be a picture framer were practiced on the Baltimore Therapeutic
incorporated into the individual's daily activities now Equipment simulator Tasks were graded for resistance, and time
and in the future. was increased as tolerated. Deep breathing and stress manage-
Exacerbation of chronic LBP is common. Patients ment techniques were taught in a group, and Mr C. developed
often disregard safe techniques, only to find that emo- friendships with two of the group members.
 Low Back Pain 897

After 4 weeks of treatment, Mr C. was able to return to work. REFERENCES

He occasionally experiences flare-ups but manages his response Alf Bowman JM: The meaning of chronic low back pain, AAOHN J
by reflecting on what activities or positions might have con- 39(8):381-384, 1991.
tributed to the flare-up, by reducing activity level and pacing . Callahan P et al: Stanford back school manual, Stanford, Calif, 1984,
himself, and by practicing visualization and deep breathing. His Stanford Health Services Department of Rehabilitation Services.
. Davis G, Onik G, Helms C: Automated percutaneous diskectomy,
employer has accommodated the intermittent LBP by hiring a
Spine 16(3):359-363, 1991.
=
=
ry
high-school student to help with lifting heavy frames and by al- . DeGirolamo G: Epidemiology and social costs of low back pain
lowing Mr. C. to store frequently used materials so that they are and fibromyalgia, Clin J Pain (suppl 1):S1-S7, 1991 (abstract).
accessible without awkward reaching or lifting. Mr. C. once again . Engel JM: Treatment for psychosocial components: pain manage-
helps his wife with the housework, and the family is planning a ment. In Willard, Spackman, editors: Occupational therapy, ed 9,
fishing and camping trip for the coming summer Mr. C. says he is New York 1998, JB Lippincott.
worried about getting into a tent and a sleeping bag, and he is . Franklin TD: Personal communication, Dec 10, 1994.
considering renting a cabin instead. . Frymoyer JW: Back pain and sciatica, N Engl J Med 318(5):291-
300, 1988.
. Gardener W, Osborn W: Structure of the human body, Philadelphia,
1967, WB Saunders.
. Kapandji IA: The physiology of the joints. Vol 3. The trunk and verte-
bral column, New York, 1979, Churchill Livingstone.
REVIEW QUESTIONS . Kolata G: Diagnosis of backache might need more spine, San Jose
Mercury News, July 14, 1994.
1. List three causes of LBP.
. Long DM: Failed back surgery syndrome, Neurosurg Clin North Am
2. Name the major components of the spine. 2(4):899-919, 1991.
3. Explain the movements of an intervertebral disk . McCormack GL, Pedretti LW: Motor unit dysfunction. In Pedretti
with spine flexion, extension, and lateral flexion. LW, editor: Practice skills for physical dysfunction, ed 4, St Louis,
4. List the five areas of physical assessment the thera- 1996, Mosby.
sip Melnick MS, Saunders R, Saunders DH: Managing back pain: daily
pist evaluates in an individual with LBP.
activities guide for back pain patients, Minneapolis, 1989, Educa-
5. What potential psychosocial stressors may become tional Opportunities.
evident during the evaluation? . Moore S, Garg A: Ergonomics: low back pain and carpal tunnel
6. What emotional responses may a patient demon- and upper extremity disorder in the workplace, Occupational Med-
strate as a result of LBP? icine, State of the Art Reviews 7(4):593-594, 1992.
. Nachemsom AL: The lumbar spine: an orthopedic challenge,
7. What are some of the physical problems a person
Spine 1(1):59, 1976.
with chronic LBP encounters? . Snow BR, Lefkowitz M, Lebovits AH, editors: Hospitalization of
8. List the major goals of postsurgical rehabilitation of chronic pain patient. In A practical approach to pain management,
the patient with LBP. New York, 1997, Little, Brown.
9. Describe the progression of treatment for the . Tollison C, Kriegel M: Interdisciplinary rehabilitation of low back
pain, Baltimore, 1989, Williams & Wilkins.
patient with LBP. . Warwick P, Williams R: Gray's anatomy, ed 35 (British), Philadel-
10. What is the foundation for good body mechanics? phia, 1973, WB Saunders.
11. List the general principles of proper body mechan-
ics for ADL.
12. In a team environment, what other disciplines
might see or treat the person with LBP?
 Rehabilitation

LEARNING OBJECTIVES
Epidermis After studying this chapter the student or practitioner
Dermis will be able to do the following:
Superficial partial-thickness burn 1. Recognize and understand the characteristics of the
Deep partial-thickness burn different depths of burn injury.
Full-thickness burn 2. Describe the phases of recovery and focus of
Hypertrophic scar occupational therapy (OT) intervention for each
Donor site phase.
Ischemia 3. Identify factors that increase potential for scar
Escharotomy hypertrophy and contractures.
Autograft 4. Comprehend the impact of ongoing patient and
Split-thickness skin graft caregiver education on long-term compliance with
Erythema treatment.
Keloid scar 5. Understand the rationale for early involvement of
Scar maturation burn patients in their own self-care as a step toward
Boutonniere deformity role resumption.
Boutonniere precautions 6. Acknowledge and anticipate complications
Total active motion characteristic of a severe burn.
Heterotopic ossification 7. Appreciate the impact that a severe burn has on the
Ectropion life roles, self-image, and values of the patient.

t has been estimated that each year 2 million people tional, and psychosocial problems that are encountered
in the United States sustain a burn injury, approximately during recovery.
300,000 are burned seriously, and more than 6000 die
from burn injuries.**”°’ Since the early 1970s, advances
SKIN’S FUNCTION
in the medical, surgical, and rehabilitative management
of burn victims have expanded the focus of burn care The skin is the largest organ of the body and serves pri-
professionals from patient survival to include regaining marily as an environmental barrier. Included in its func-
the quality of life after a burn injury. Although func- tions are sensation, temperature regulation, protection
tional recovery may be a long and arduous process, most from chemical or bacterial invasion and ultraviolet rays,
burn survivors can expect to resume roles and function and prevention of loss of body fluids. Anatomically the
comparatively close to their preinjury level of independ- skin consists primarily of two layers. The epidermis is
ence. However, from the date of injury through the out- the nonvascular surface layer made up of epidermal
patient phase ofcare, a multidisciplinary team approach cells. The dermis, or corium, contains a network of cap-
is necessary to effectively manage the medical, func- illaries, sweat glands, sebaceous glands, nerve endings,

898
 Burns and Burn Rehabilitation 899

superficial partial-thickness, deep partial-thickness, or

full-thickness injury (Table 47-1). Superficial and deep
partial-thickness burns usually heal without surgical in-
Stratum Corneum tervention. However, once healed they tend to be exces-
‘== (other epidermal layers)
sively dry, itchy, and subsequently susceptible to excoria-
Stratum Germinativum
tion by shear forces produced during rubbing or
Sweat Gland
scratching. These shear forces can cause blisters and
compromised long-term skin integrity caused by re-
Corium (dermis) peated reopening of the wound. Partial-thickness and
full-thickness burns usually lead to uneven pigmenta-
Subcutaneous Tissue tion of the healed scar. Deep partial- and full-thickness
Hair Root Sebaceous Gland
burns have a greater potential for thick, hypertrophic
FIG. 47-1 scar and contracture formation because of the pro-
Cross section of skin. (From Iles RL: Wound care: the skin, 1988, longed period for healing. This is especially true ifa burn
Marion Laboratories.) converts from partial-thickness to full-thickness because
of infection or repeated trauma. Most full-thickness
wounds necessitate surgical intervention or skin grafting
and hair follicles (Fig. 47-1).'’ When the skin is dam- for wound closure. Skin graft donor sites usually heal in
aged, various systemic, physiological, and functional the same manner that superficial partial-thickness burns
problems can occur. A burn injury causes a destruction heal, with less scarring but uneven pigmentation.
of the environmental barrier. Because of this, a large
burn injury is one of the most painful forms of trauma
PERCENT TOTAL BODY SURFACE
and is life threatening in severe cases.
AREA INVOLVED
After a burn injury many factors must be taken into
consideration in determining the severity of injury, The extent of a burn is classified as a percentage of the
functional recovery potential, and treatment needs. total body surface area (Y%TBSA) burned. The two most
Primary considerations are the mechanism of injury, the common methods for estimating %TBSA are the “rule
depth and extent of the burn, specific body areas of nines” and the Lund and Browder chart.”° The rule of
burned, the individual's age, medical history, and prein- nines is simple and quick, but relatively inaccurate (Fig.
jury health, and other associated or concurrent injuries 47-2). It divides the body surface into areas comprising
such as an inhalation injury or fractures. 9%, or multiples of 9%, with the perineum making up
the final 1%. The head and neck area is 9%, each upper
extremity (UE) is 9%, each leg is 18%, and the front and
MECHANISM OF INJURY
back of the trunk are each 18%. However, the rule of
Burns can be thermal, chemical, or electrical in nature nines applies only to adults. Body proportions vary with
and can be caused by flame, steam, hot liquids, hot children, depending on their age, especially in the head
metals, radiation, or extreme cold.'” The severity of the and legs.’ The Lund and Browder chart*° provides a
injury depends on the area of the body exposed and the more accurate estimate of the total body surface area
duration and intensity of thermal exposure. Superficial and is used in most burn centers. This chart assigns a
partial-thickness burns can be caused by prolonged percent of surface area to body segments (Fig. 47-3),
sun exposure or a brief contact with hot liquids or with adjusted calculations for different age groups. For
flames. Deep partial-thickness burns are caused by smaller %TBSA injuries the therapist can get a quick,
longer exposure to intense heat, such as with hot water rough estimate using the size of the patient's palm
immersion scalds or contact of the skin with flaming (hand excluding the fingers) to equal approximately 1%
materials. Full-thickness burns usually result from pro- of the individual's total body surface area.
longed immersion scalds, contact with flaming or high-
temperature materials such as hot tar, extended expo-
SEVERITY OF INJURY
sure to chemical agents, and contact with electrical
current. The %TBSA and depth of burn are primary indicators of
the severity of injury. A 20% or greater burned surface
area is often the determining criterion for admission to a
BURN DEPTH burn intensive care unit. However, depending on the pa-
The depth of a burn is estimated from clinical observa- tient’s age and preinjury health, partial- or full-thickness
tion of the appearance, sensitivity, and pliability of the burn wounds less than 20% TBSA can still be consid-
wound.” A burn injury was traditionally classified as ered serious enough to warrant admission. A person with
first, second, and third degree but now is described as deep partial- and full-thickness burns of greater than
 TREATMENT APPLICATIONS

Characteristics
Burn Common
Depth Causes Tissue Depth Clinical Findings Healing Time Scar Potential
Superficial Sunburn, brief flash Superficial epidermis Erythema, dry, no 3-7 days No potential for
(first degree) burns, brief blisters; moderate hypertrophic scar or —
exposure to hot pain contractures :
liquids or chemicals
Superficial partial Severe sunburn or Epidermis, upper Erythema, wet, Less than 2 weeks Minimal potential
thickness radiation burns, dermis blisters; significant for hypertrophy or
(superficial second prolonged exposure pain contractures if no
degree) and donor to hot liquids, brief secondary infection
sites contact with hot or iftrauma does
metal objects not delay healing

Deep partial Flames; firm or Epidermis and much Erythema; larger Greater than 2 High potential for
thickness (deep prolonged contact of dermis nonviable, usually broken weeks, may convert hypertrophic
second degree) with hot metal but skin appendages blisters; on palms to full thickness with scarring and
objects; prolonged survive from which and soles of feet, onset of infection contractures across
contact with hot, skin may regenerate large, possibly intact joints, web spaces,
viscous liquids blisters over beefy and facial contours;
red dermis; severe high risk for
pain to even light boutonniere
touch deformities if dorsal
fingers involved
Full thickness Extreme heat or Epidermis and Pale, nonblanching, Larger areas require Extremely high
(third degree) prolonged exposure dermis: skin dry, coagulated surgical intervention potential for
to heat, hot objects appendages and capillaries may be for wound closure; hypertrophic
or chemicals for nerve endings are seen; no sensation smaller areas may scarring or
extended periods nonviable to light touch heal in from borders contractures
except at deep over extended depending on the
partial-thickness period oftime method used for
borders wound closure
Subdermal Electrical burns and Full-thickness burn Nonviable surface, Requires surgical Similar to full-
severe long-duration with damage to may be charred or intervention for thickness except
burns (e.g., house underlying tissues with exposed fat, wound closure; may where amputation
fires, motor vehicle tendons, muscles; require amputation removes the burn
accidents with a electrical injuries or significant site
passenger trapped may have small reconstruction
in a burning vehicle external wounds
or under hot but significant
exhaust systems, secondary sub-
and smoking in bed dermal tissue loss
or alcohol-related and peripheral
burns) nerve damage

INITIAL MEDICAL MANAGEMENT

30% TBSA has a severe burn that usually requires a pro-
longed period to achieve wound closure and intensive re- Immediately after a burn injury the permeability of
habilitation for functional recovery. Burn involvement of blood vessels increases, causing rapid leakage of
certain body areas is also used to classify injury severity, protein-rich intravascular fluid into surrounding ex-
although the %TBSA burn may be limited. For example, travascular tissues.*° In larger burns, hypovolemia or
deep partial- or full-thickness burns involving the burn shock can occur because of decreased plasma and
hands, face, or perineum are considered severe burns.°? blood volumes with reduced cardiac output, all results
 Burns and Burn Rehabilitation 901

RIGHT UPPER ARM

LEFT UPPER ARM

FIG. 47-3
Chart for calculating %TBSA. (Adaptation of Lund and Browder chart, from
Burn Center at Washington Hospital Center.)

FIG. 47-2
Rule of nines.

of extensive intravascular fluid loss.” Fluid resuscitation

with an intravenous fluid such as lactated Ringer's solu-
tion is essential for promptly replacing venous fluid and
electrolytes. The fluid volume required is determined by
various formulas, such as the Parkland and modified
Brook formulas,* and is based on the extent ofthe burn
and the weight of the patient. The rate of fluid infusion
is determined by monitoring pulse rate, central venous
pressure, hematocrit, and urinary output.
The lymphatic system, which normally carries away
excess tissue fluid, often becomes overloaded, causing
subcutaneous edema. With circumferential full-thickness
burns, loss of burned skin elasticity combined with in-
creased edema can cause interstitial pressure severe
enough to compress vessels. This impairs circulation to
the distal extremity and causes limb ischemia.'’ Es- FIG. 47-4
charotomy, or incision through the necrotic burned Escharotomies on the dorsum of the hand with full-thickness burn
tissue, is performed to release the binding effect of the injury.
tight eschar, relieve the interstitial pressure, and restore
distal circulation (Fig. 47-4). In deeper wounds an inci-
sion down to and through the fascia, or fasciotomy, may
be needed for adequate pressure relief.
A smoke inhalation injury is a common secondary
diagnosis with thermal injury and can significantly in- examinations are used to confirm the diagnosis. Intuba-
crease mortality in burn patients. When the face is tion and ventilatory support may be required along with
burned, if the burn occurred in a closed space, or when vigorous respiratory therapy. A tracheostomy is per-
there is other objective evidence of a possible inhalation formed if the airway is difficult to maintain or ventila-
injury, bronchoscopy, arterial blood gas, and chest x-ray tory support is prolonged.°°
902 TREATMENT APPLICATIONS

WOUND CARE patient is unable to meet individual requirements

After a patent airway and fluid resuscitation have been through the diet, high-protein and calorie supplements
established, attention is directed to wound care. Hy- are given either orally or through a nasogastric or gastric
drotherapy is performed at least once a day via tanking tube. Intravenous hyperalimentation is frequently nec-
or showering to provide a thorough cleansing of both essary with severe burns of extensive %TBSA. As wound
the wound and uninvolved areas. Various topical agents closure is achieved, nutritional demands decrease and
are applied to delay colonization of organisms and the individual’s normal eating habits must be normal-
reduce bacterial counts in the burn wounds.” ized to prevent excessive weight gains.
Burn wound colonization begins at the moment of
injury, with gram-negative organisms replacing normal ASSOCIATED PROBLEMS
bacterial flora. Wound cultures and biopsies are per-
Scar Formation
formed to monitor this growth when there are signs of
possible serious infection. A severe infection could After initial healing, most burn wounds have an ery-
cause septic shock, which is a state of circulatory col- themic, flat appearance. As the healing process contin-
lapse and a cardiovascular response to bacterial by- ues, the wound’s appearance may worsen as a result of
products or endotoxins. Septic shock can be character- scar hypertrophy or contraction. The long-term quality
ized by ischemia, diminished urine output, tachycardia, of a mature burn scar can be affected by numerous
hypotension, tachypnea, hypothermia, disorientation, factors, some of which occur during the early phases of
or coma. burn care.*”*’ The amount of time needed to achieve
Although all burn wounds are treated with some type wound closure is a strong determinant. Bacterial infec-
of topical antibacterial agent, when the depth and tions in the wound increase the inflammatory response
extent of the wound require 3 or more weeks for that can delay wound healing and contribute to scar for-
healing, surgical intervention is indicated to decrease mation.*’ However, any factor that delays healing will
burn morbidity and mortality. Surgical treatment for increase the potential for scarring.
burns usually consists of excision of the nonviable Hypertrophic scars are thick, rigid, red scars that
burned tissue, or eschar, and placement of biological or become apparent 6 to 8 weeks after wound closure. 'His-
synthetic skin grafts. tologically, these immature scars have increased vascu-
There are essentially three types of biological grafts. A larity, fibroblasts, myofibroblasts, mast cells, and colla-
xenograft, or heterograft, is processed pigskin. A homo- gen fibers arranged in whorls or nodules.°*°
graft, or allograft, is processed cadaver skin. These are Biochemical investigations of hypertrophic scars have
used as biological dressings to provide temporary disclosed increased synthesis of collagen fibers and con-
wound coverage and pain relief. An autograft is a per- nective tissue. As hypertrophic scars mature, capillaries,
manent surgical transplantation of the upper layers or fibroblasts, and myofibroblasts decrease significantly,
split-thickness skin graft of the person’s own skin from with the collagen relaxing into parallel bands and the
an unburned donor site. The graft is applied to the scar becoming flatter and more pliable. The time needed
clean, excised tissues of the burn wound graft site. Now for scars to mature differs markedly among individuals.
that the size of a survivable burn has increased, the The race and age of the patient, as well as the location
amount of available donor sites for autografting has and depth of the burn wound, have been reported anec-
conversely decreased. For this reason, alternatives to au- dotally to influence hypertrophic scarring.'°°’ Superfi-
tografts are being developed. Examples of such alterna- cial burns that heal in less than 2 weeks generally will not
tives are epidermal cultured skin substitutes*? and cul- form hypertrophic scar. Deeper burns that take greater
tured epidermal autograft (CEA).”’* A wound may be than 2 weeks to heal have a greater potential to form hy-
limited in size, but the defect may be so deep that bone pertrophic scars. Hypertrophic scars may take from 12 to
or tendon survival is at risk. In these instances split- 24 months to mature.°’ Excessive scar formation, such as
thickness skin graft adherence is difficult to obtain, and a keloid scar, may take up to 3 years to mature.
a full-thickness skin graft or microvascular skin flap may All scars initially have an increased vascularity and
be indicated. red appearance. Scars that remain erythemic for more
Adequate nutrition is essential during wound healing than 2 months are more likely to develop into hyper-
because the metabolic rate of the burn patient greatly trophic scars. They become progressively firmer and
increases with corresponding increases in protein, thicker, rising above the original surface level of the
vitamin, mineral, and calorie needs.*"”** Protein is espe- skin. There is a marked increase in production of fibrob-
cially important for wound healing and must be pro- lasts, myofibroblasts, collagen, and interstitial material,
vided in substantial amounts. Nutritional requirements all with contractile properties that help to draw together
are calculated based on the %TBSA and patient's admis- the borders of a wound but can also cause scar tightness.
sion weight. Calorie counts and the patient's weight are Pain and skin tightness cause most patients to become
closely monitored to ensure adequate nutrition. If the less active. These patients prefer to rest in a flexed, ad-
 Burns and Burn Rehabilitation 903

ducted position for comfort. This allows the new colla- the patient for self-feeding, or just reinforcing the im-
gen fibers in the wound to link and fuse together. The portance of active motion. The long-term goals of occu-
fibers become progressively more compact, coiling up pational therapy (OT) are quite similar to the long-term
in whorls and nodules and giving the scar surface a tex- goals of the burn team. Although specific goals may be
tured appearance that can lead to disfigurement. If the the responsibility of various team members, everyone is
scar extends over one or more joints, the progressive focused on the same outcome. Treatment goals should
tightness leads to a scar contracture and loss of active be presented to the patient and family as goals of the
motion. Fortunately, collagen linkage is less stable in entire rehabilitation team. Inherent in this concept are
new scars, and an immature hypertrophic scar contrac- the close communication and cooperation of all burn
ture can be influenced by such sustained mechanical team members. Role delineation between occupational
forces as proper positioning, exercise, and splinting. and physical therapy differs by burn care facility and
may be determined by insurance reimbursement rather
than by traditional roles or the specialized skills of
Psychosocial Factors
either individual therapist. Therefore it is especially im-
During hospitalization the patient is often subject to portant that these two disciplines work closely together
isolation, dependency, and pain. Because burn injuries with ongoing communication, so that patients benefit
and treatment procedures are usually painful, narcotic from the skills and viewpoints of both disciplines. Many
analgesia is often liberally used.** Relaxation and occupational and physical therapists who specialize in
imagery techniques can also be employed to reduce burn rehabilitation increasingly use cotreatments that
stress and anxiety, which in turn increases the effective- promote independence with both mobility and activi-
ness of the pain medications. The amount of narcotic ties of daily living (ADL).
analgesia given is gradually decreased as the wound
heals, and patients usually require minimal pain med-
Phases of Recovery
ication on discharge.
After a burn injury there is a potential for psycholog- Rehabilitation management of burn victims can be
ical reactions, including depression, withdrawal reac- divided into three overlapping phases to aid in catego-
tions because of disfigurement, behavioral regression, rizing and determining effective treatment goals. These
and anxiety over the ability to resume work, family, phases of recovery are acute care, surgical and postoper-
community, and leisure roles.'* Providing emotional ative, and inpatient and outpatient rehabilitation.*”
support and education and helping the patient to The acute care phase is usually the first 72 hours after
develop coping mechanisms and self-direction can help a major burn injury. However, if the burn is superficial
with the psychological adjustment of the burn patient. partial thickness and heals spontaneously in less than 2
However, a severe burn injury may also result in such weeks without surgical intervention, the time from
positive changes as reassessment of personal values and injury until epithelial healing is also considered as an
relationships and a renewed appreciation of life. To help acute care phase.”
determine how people will adjust psychologically to a The surgical and postoperative phase follows the
severe burn injury, the complex interaction between acute phase and continues for varying lengths of time,
premorbid personality style, extent of injury, and social depending on the size of the burn injury and presence
and environmental contexts should be considered.** of associated medical complications. During this pe-
riod, vulnerability to wound infection, sepsis, and septic
BURN REHABILITATION shock is especially great, and medical treatment is fo-
cused on promoting healing and minimizing infection.
The Team
The rehabilitation phase covers both inpatient and
Successful care and rehabilitation of burn victims outpatient care and can extend for an indeterminate
require a multidisciplinary team approach that begins length of time. This phase is the postgrafting period,
immediately on the patient's admission to the hospital when the patient is medically stable and is affected by
and continues through and beyond hospitalization.” the quality of wound healing, scar formation, and need
Ideally, the burn care team includes physicians, nurses, for rehabilitation. It is the most challenging phase for
physical and occupational therapists, dietitians, social burn patients, their families, and their therapists.
workers, respiratory therapists, recreational therapists,
clergy, and vocational counselors.*”””* Acute Care Phase
During the acute care phase, medical management is of
utmost importance for survival of the patient, and the
Goals of Rehabilitation goal of OT is primarily preventive. As the patient recov-
The entire burn team is involved in some aspect of burn ers and wound closure progresses, the nature of the ac-
rehabilitation, whether for verbal support, setting up tivities with the patient also changes, with treatment
904 TREATMENT APPLICATIONS

being directed at restoring function. Initially, however, Wound maturation usually takes from 12 to 18
when the wounds are partial or full thickness, the acute months following injury; however, it is important to re-
care rehabilitation goals are as follows: member that each patient heals differently. Some
. Reduce edema. wounds mature in less than a year, whereas others may
. Prevent loss of joint and skin mobility. take over 2 years.*' The therapist's goals for this phase
. Prevent loss of strength and endurance. are exhaustive, but understandably so, considering the
. Promote independence and self-care skills. potentially disabling effects of burn scar.*”
Re
WN
MB . Provide orientation and begin patient and caregiver Goals for the rehabilitation phase are as follows:
education regarding the rehabilitation process. 1. Teach independent self-care skills.
2. Provide education and practice of home care activi-
Surgical and Postoperative Phase ties, including appropriate exercise, positioning,
Rehabilitation goals during the surgical and postop- and skin care.
erative phase are aimed at preserving or assisting func- 3. Restore muscle strength, activity tolerance, and
tion while supporting surgical objectives. Excision and endurance.
grafting procedures usually require periods of immobi- 4. Improve joint mobility and coordination.
lization of the areas treated. The preferred position and 5. Fit splints, compression and vascular support gar-
length of immobilization will vary by physician pre- ments, and pressure adapters for edema and man-
rogative and burn center protocol, with the average agement of scar maturation.*”
period of immobilization being between 2 and 7 6. Support reacquisition of social and vocational
dayseier se?
skills.
During this phase the goals of therapy are as follows: 7. Provide instruction regarding scar and skin care
1. Protect and preserve graft and donor sites by fabricat- techniques, including potential changes in sensa-
ing splints and establishing positioning techniques tion and appearance.
that support the surgeon's postoperative care orders. 8. Control edema and minimize scar hypertrophy,
2. Increase self-care by providing or fabricating adap- contractures, and disfigurement.
tive equipment as needed. 9. Teach compensation techniques for limiting expo-
3. Promote cognitive awareness by providing orienta- sure to ultraviolet light, chemical irritants, friction,
tion activities when necessary. and extremes of weather and temperature.
4. Prevent muscular atrophy and loss of endurance and 10. Guide the implementation of a postdischarge plan
reduce thrombophlebitis risk by providing exercise that supports resumption of school, work, and
for areas not immobilized. leisure roles.
5. Educate and reassure the patient and family regard-
ing this phase of recovery.
OCCUPATIONAL THERAPY EVALUATION
Rehabilitation Phase Although medical issues are a primary concern during
The third phase of recovery is the rehabilitation phase, acute care, whenever possible the occupational therapist
which begins as wound closure occurs. Individuals with should complete an initial evaluation within the first 24
large %TBSA burns frequently enter this phase needing to 48 hours after hospital admission. Burn cause,
further surgery; however, the majority of their wounds medical history, and any secondary diagnoses are ob-
are closed and wound maturation is commencing. The tained from the medical record. The wounds are visually
focus of care during this phase is on maximizing self- assessed to determine the extent and depth of injury,
care, promoting physical and emotional independence, and any critical areas involved are noted. Patient and
and controlling scar maturation to prevent deformity family interviews are used to establish rapport and to
and contracture formation. Patient and family educa- obtain specific information such as hand dominance,
tion is especially important for developing competence previous functional performance and limitations, prein-
with wound care and therapy programs in preparation jury daily routine and activities including job, school,
for discharge. and home responsibilities, and pretrauma psychologi-
The rehabilitation phase extends past hospital dis- cal status. In the case of a severe burn requiring patient
charge and continues until maturation of both burn intubation, this information must be obtained from
wounds and surgical sites is complete. Before discharge family members to verify and supplement what the
from the hospital, emphasis is on independence and patient may relay nonverbally.
education. Once the individual is home, emotional Preserving function of the body areas involved is of
support and intervention are often needed to help primary concern; however, a baseline of overall physical
restore the self-confidence and motivation needed to function should be established before treatment plan-
cope with the physical, social, and emotional conse- ning.’ Involved and uninvolved areas should be evalu-
quences of a severe burn injury. ated for joint mobility, strength, sensation, and func-
 Burns and Burn Rehabilitation bo]Ole)

tional use. Before starting, the therapist should explain Manual muscle testing of major muscle groups is indi-
the purpose of OT and what to expect during the assess- cated if the burn was an electrical contact injury, severe
ment, including the potential for discomfort. edema is present causing a possible compartment syn-
Ideally, the initial OT assessment should take place drome, or other musculoskeletal or neurological injuries
during a dressing change, when the depth and exact lo- are suspected.°° If the hand is not burned or the burn is
cation of the burns can be viewed directly and carefully superficial partial thickness, a dynamometer and pinch
documented. Distinctions should be made between su- gauge are used to measure grip and pinch strength.
perficial and deep partial-thickness burns, as well as full- A gross sensory screening including all sensory distri-
thickness burns, by appearance and presence of sensa- bution areas should be performed. This is especially im-
tion. The therapist must view the wounds as soon as portant in the case of electrical injury or long-standing
possible postinjury, before the development of burn diabetes in which peripheral neuropathies may be
eschar. Eschar causes deep partial-thickness burns to re- present.
semble full-thickness burns closely, and makes accurate Assessment of activities of daily living (ADL) is initi-
evaluation of depth difficult. Attention should also be ated by interviewing the patient or the family to estab-
directed to burned joint surface areas and the presence lish preinjury level of functional independence. When
of any circumferential burns. An active or active assistive the burn injury is severe, an ADL assessment may be in-
range of motion (ROM) assessment should be per- appropriate and should be postponed until the patient
formed without dressings, to evaluate joint mobility and is medically stable and able to participate with therapy.
general strength before significant edema develops or re- Individuals with less severe burns and who are not intu-
strictive dressings are applied. The dorsum of the hands bated should be assessed for basic ADL skills, such as
should be checked for deep burns over the proximal in- the ability to feed self, basic grooming skills, and
terphalangeal joints that could indicate the need to initi- donning and doffing of hospital gowns. Any compensa-
ate boutonniere deformity precautions or hand splints. tory actions or awkward movements used to complete
When possible, a goniometer should be used for as- the activity should be noted. Any abnormal patterns
sessing ROM to accurately document baseline deficits should be investigated and discussed to determine if
and future changes in recorded measurements. Ongoing they were present before the burn injury.
instruction and continuous encouragement help reas- After completion of an initial evaluation (Table 47-2),
sure patients and decrease anxiety, allowing patients to short- and long-term goals should be established with
perform at their best. Instructing the patient regarding the patient's collaboration. The patient's personal goals,
the types of movements and the number of repetitions priorities, and previous lifestyle should be taken into
expected while gently guiding the individual through account when establishing these goals. After this is
the specific motion can help ensure achievement of full done, the treatment plan can be formulated. The OT
range. If pain, edema, tight eschar, or bulky dressings treatment plan should be practical and should comple-
limit full ROM, this fact should also be documented. ment and support the goals of the other team members.
Preexisting conditions that may alter expected active Two fundamental principles should be kept in mind
ROM should be investigated during the patient and when working in burn rehabilitation. First, the main
family interview. Although active ROM is preferred, factor that can hinder postburn functional recovery is
passive ROM should be measured if a patient is unre- the formation of scar contractures and hypertrophic
sponsive or unable to move the extremity. When using scarring. Second, severe scars and contractures are often
Passive ROM, care must be taken not to apply excessive preventable with prompt therapeutic intervention.*®
force, especially with older patients with degenerative Therefore most burn rehabilitation treatment tech-
joint disease or small children with hypermobile joints. niques and objectives are directed at prevention, as well
With deeper partial or full-thickness dorsal hand burns, as restoration.
boutonniere precautions should be initiated until the
integrity of the hand’s extensor hood mechanisms can OCCUPATIONAL THERAPY
be verified. Composite active or passive flexion of the INTERVENTION
fingers should be avoided; instead, isolated metacar-
Acute Care Phase
pophalangeal (MP) flexion is combined with interpha-
langeal (IP) joint extension to avoid stress and possible The purpose of proper positioning is to reduce edema
damage to a compromised extensor tendon mechanism. and to maintain involved extremities in an antideformity
All passive proximal interphalangeal (PIP) flexion is position. Proper positioning is critical because the posi-
avoided, and protective splinting is promptly initiated. tion of greatest comfort for the patient is usually the po-
If the individual had normal functional muscle sition of contracture.*”’*’ The typical position of comfort
strength before injury, an initial test of gross muscle consists of adduction and flexion of the upper extremi-
strength may not be needed if the ROM assessment ties, flexion of the hips and knees, and plantar flexion of
revealed adequate strength to work against gravity. the ankles. Hands are held in a dysfunctional position
 TREATMENT APPLICATIONS

Rehabilitation Evaluation Components

Initial Inpatient Rehabilitation Outpatient Rehabilitation
Burn cause Graft adherence

%TBSA, depth of burn Skin or scar condition Skin or scar condition

Area(s) involved Contracture concerns Compression garment fit

Age, hand dominance Edema (if present) Volumetrics if needed

Functional status ADL performance level ADL performance level

Occupation Work skills Work skills

ROM and strength Active and passive ROM, TAM Active and passive ROM, TAM

Mobility and endurance Strength and endurance Strength and endurance

Developmental level (child) Developmental level (child) Developmental level (child)

Psychological status Psychological status Psychological status

Social support Social support Social support

Leisure activities Leisure activities Leisure activities

Compression garment needs Compression garment needs

Home management Home management

Home care understanding

Return to work.capacity

Return to school potential and need for reentry program

ADL, Activities of daily living; ROM, range of motion; TAM, total active motion; TBSA, total body surface area.

consisting of wrist flexion, metacarpophalangeal exten-

sion, interphalangeal flexion, and thumb adduction.
This position is often called the “claw hand” position.
During the initial wound assessment, positioning
needs are determined by evaluating the surface areas
burned and the presence of edema, considering the
posture the individual tends to assume, and determin-
ing if that posture would limit function if allowed. For
example, if the burn injury involves the shoulder, chest,
and axillae, the patient's upper extremities should be el-
evated and positioned in approximately 90° of shoul-
der abduction, 45° of external rotation, and 60° ofhor-
izontal adduction, using pillow inclines, arm boards, or
overhead traction (Fig. 47-5). Achieving full shoulder
abduction with frequent exercise and activity is critical
to preventing axilla web contractures and subsequent FIG. 47-5
loss of abduction as wound healing progresses. Once Shoulder positioning using overhead traction and felt slings.
positioning needs are determined, illustrated guidelines
should be posted at bedside and the nursing depart- tremity slightly above heart level can reduce the severity
ment should be advised to ensure ongoing correct posi- of distal edema formation, especially when paired with
tioning (Fig. 47-6). active ROM exercises. As wound closure progresses, at-
During acute care, positioning is instituted primarily tention should be directed to more proximal body posi-
to limit edema formation.*’ Elevation of the entire ex- tioning concerns (Table 47-3).*’
 Burns and Burn Rehabilitation 907

Splinting is initiated to provide positioning assis-

tance and protect compromised tissues. It is not neces-
sary for splints to be worn at all times to prevent con-
tractures. When a splint is used during the acute phase,
it is generally static in design and applied when at rest,
with activity and exercise emphasized during the day.
Volar hand splints are indicated if a burned hand has
significant edema, active motion is limited, or unsuper-
vised movement is contraindicated because of deep
dorsal burns or other traumatic injury. The typical volar
burn hand splint provides approximately 30° wrist ex-
tension, 50° to 70° MP joint flexion, full IP joint ex-
tension, and the thumb abducted and extended (Fig.
47-7).°’ Elbows or knees should be splinted at 0° to 5°
of flexion to avoid joint hyperextension.
When splints are fitted any possible pressure points
should be considered and correct positioning ensured.
Splints fabricated shortly after injury require daily as-
sessment and possible alterations to accommodate any
significant changes in edema. Hand splints are secured
in place with a figure-eight wrap of gauze bandage and
disposable elastic wraps. Folded 4-by-4 inch gauze
sponges are used over the proximal phalanges and
under the wrap to keep the fingers extended and secured
in the splint. Detachable straps, although convenient
for later use, may be inappropriate for use on acute burn
splints because of infection control concerns and the
potential for constriction during fluctuations in distal
edema.
When there is a partial- or full-thickness burn to the
FIG. 47-6 external ear, protection is required to prevent further
Highly visible posters are beneficial as reminders to patient and damage caused by pressure from pillows, dressings, or
staff regarding positioning, exercises, and splinting schedules. endotracheal tube straps. An ear protection splint

Antideformity Positioning for Specific Body Areas Following Burn Injury

_ Body Area Antideformity Position Equipment and Technique
Neck Neutral to slight extension No pillow; soft collar neck conformer or triple-component
i neck splint

Chest and Trunk extension, shoulder retraction Lower top of bed, towel roll beneath thoracic spine,
abdomen clavicle straps
Axilla Shoulder abduction 90° to 100° Armboards, airplane splint, clavicle straps, overhead traction
Elbow and forearm Elbow extension, forearm neutral Pillows, armboards, conformer splints, dynamic splints

Wrist and hand * Wrist extension 30°, thumb abducted and Elevate with pillows, volar burn hand splint
extended, MP flexion 50° to 70°, IP extension
Hip and thigh Neutral extension, hips 10° to 15° abduction Trochanter rolls, pillow between knees, wedges

_ Knee and lower leg Knee extension; anterior burn: slight flexion Knee conformer, casts, elevate when sitting, dynamic splints

Ankle and foot Neutral to 0° to 5° dorsiflexion Custom splint, cast, ankle-foot orthosis (AFO)

Ears and face Prevent pressure No pillows; headgear’?

IP, interphalangeal; MP, metacarpophalangeal.

 TREATMENT APPLICATIONS

In addition to functional activities, active exercise is a

primary component in every burn treatment plan. Exer-
cise techniques used during acute care are not unique to
the injury.’’ Active, active-assisted, or passive exercises
are used, depending on the patient's condition. The focus
of exercise in acute care is to preserve ROM and func-
tional strength, build endurance, and decrease edema.
Strength and endurance activities are introduced
into the acute care treatment program as the patient's
condition allows. These activities range from simple
active movement to resistive activities, as tolerated. The
purpose of resistive exercise is to counteract the decon-
FIG. 47-7 ditioning effects of hospitalization.*” Exercise after a
Postburn hand splint. Note wrapping approach for thumb. severe burn injury was once thought to overstress an
already hypermetabolic patient. However, research and
experience have shown that graded, progressive exercise
should be fitted at the earliest opportunity and worn is not deleterious in acute burn recovery.*®
until the external ear burns have healed. The splint can Although patient education is the responsibility of
be fabricated of two thermoplastic ear cups or semirigid all burn team members, OT program success depends
oxygen masks secured in place by a three-point stabiliz- on patients’ understanding of their long-term needs and
ing elastic strapping technique.'”** responsibilities. Initial educational objectives should
A patient's ability to perform self-care is often limited focus on developing an understanding of stages of burn
during the acute care phase because of individual recovery, the need for and importance of independent
medical needs. The need for artificial ventilation, multi- activity and motion, and pain and stress management
ple lines, catheters, and other supportive equipment in- techniques. Meeting these goals promotes the motiva-
terferes with independence with ADL, and patients are tion and compliance so essential for successful treat-
dependent on nursing for their self-care. When the ment outcomes.'?
patient is extubated and medically cleared to take fluid
or food by mouth, the occupational therapist, working
Surgical and Postoperative Phase
in concert with the speech pathologist, should assess
self-feeding abilities. Dressings and edema may inter- Excision and grafting procedures usually require a
fere with self-feeding motions. Temporary use of adap- period of postoperative immobilization to allow adher-
tive equipment may be needed and may include built- ence and vascularization of the grafts.’” It is advanta-
up and extended handles on utensils and a plate guard geous for the occupational therapist to discuss postop-
or a travel mug with a lid and a straw. Grooming is erative positioning needs with the surgeon before
another self-care activity that can be encouraged. Tem- surgery so that splints and positioning devices can be
porary adaptations to environment setup, equipment, applied in the operating room immediately after the
or the patient's usual technique may be indicated to surgical procedure. A wide variety of materials and pro-
support independence. Withdrawing adaptations as tocols are available. All have the common purposes of
soon as possible should be a goal of therapy and pre- immobilizing the grafted area, preventing edema, and
sented to the patient as a sign of progress. The therapist assisting wound healing needs.””
must convey to the patient that the goal is to be inde- Postoperative positioning may use standard posi-
pendent with all ADL, using normal movement patterns tioning techniques or may be unique, designed only for
performed within a normal length of time. the specific surgical procedure. Although standard burn
Sitting tolerance and ambulation are initiated as splints position the extremity in the antideformity posi-
soon as the patient is medically cleared to get out of bed tion, preoperative or postoperative splints should hold
and bear weight on his or her lower extremities. If the the extremity in the position that promotes the greatest
patient has lower extremity burns, elastic wraps should surface area for graft placement. For dorsal hand grafts,
be applied before the patient sits up and the feet become the wrist is positioned in neutral, the MP joints in
dependent. A figure-eight pattern should be used, from flexion, and the thumb in abduction to maximize the
the base of the toes, over and including the heel, to at dorsal grafted surface area. Another example is that in
least the knees, and up to the groin as needed. When the which an axillary advancement flap is performed; the
patient is sitting in a chair, the lower extremities should shoulder is abducted only 45°. Gaining prior knowl-
be kept elevated. Time spent dangling the feet or static edge of the surgical procedure and determining poten-
standing should be limited to discourage lower extrem- tial postoperative complications enable the therapist to
ity swelling and prevent unnecessary discomfort. establish effective positioning procedures.
 Burns and Burn Rehabilitation

exercise of a body area with a donor site is generally per-

mitted after 2 to 3 days if there is no excessive bleeding.
Lower extremity donor sites are treated similarly to
lower extremity burns; therefore elevation and wrap-
ping with elastic bandage are standard treatment.
Ambulation following lower extremity excision and
grafting is usually not resumed until 5 to 7 days after
surgery. With the physician’s consent the patient is then
encouraged and assisted to ambulate for short distances
and then slowly increase the distance. Before ambula-
tion, double elastic bandage wraps are applied over a
a
fluff gauze dressing to prevent graft shearing or vascular
pooling. Wrapping with an elastic bandage, elevation,
and avoidance of static stance are particularly important
for protecting lower extremity grafts. When the individ-
FIG. 47-8 ual is able to walk, exercise on a stationary cycle er-
Thermoplastic total-contact ankle dorsiflexion splint. gometer is beneficial for increasing endurance.
Environmental stimulation, self-care, and leisure ac-
tivities should be continued and increased commensu-
rate with the patient's physical abilities and tolerance
Although postoperative immobilization is frequently level. Self-care is often difficult during this phase
achieved through the use of bulky restrictive dressings because of the immobilization positions necessary to
and standard positioning equipment, splints are often ensure graft adherence. Creative ADL adaptations are
needed to secure the position. Most splints are regularly frequently needed to allow patients some involvement
*T
‘>
made using plaster bandages or thermoplastics (Fig. in their care and control over their environment during
47-8). If a wet dressing will cover the graft site, a perfo- this time. Although only temporary, simple techniques
rated or open-weave splinting material may be preferred such as prism glasses for those supine in bed, universal
to permit continuous drainage and prevent graft macer- cuffs over splints, or extended handle utensils help pre-
ation.'° In some instances movement of adjacent joints serve current level of independence and foster contin-
may disrupt graft adherence even though the graft does ued feelings of self-actualization and confidence. Con-
not cover the joint surface. In these cases the splint tinued emotional support and burn care education are
design should incorporate immobilization of those also essential.
joints in a functional position. A postoperative thermo-
plastic splint generally can be made by using a drape
Rehabilitation Phase
and trim technique.'” Most postoperative splints are for
temporary use and are discontinued once graft adher- During the inpatient rehabilitation phase, OT evalua-
ence is ensured. If made of thermoplastics, they can tion should emphasize a thorough assessment of per-
later be remolded into the antideformity position. formance skills and performance components. Active
Throughout the postoperative phase of care, active and passive goniometric measurements should be taken
and resistive exercise to the uninvolved extremities to document any limitations caused by joint restrictions
should be continued when possible, to maintain ROM or scar tightness. Individual measurements can be used
and strength. Immediately after excision and grafting to document individual joint restriction, but total
procedures, exercises for adjacent body areas are usually active motion (TAM) measurements should be used if
discontinued for a short time. Although the time varies skin tightness affects several joints in the same extrem-
among burn centers, the average is 3 to 5 days, with 7 to ity. Muscle strength can be measured with the manual
10 days for cultured epithelium grafts.”'”*’ Exercises muscle test (MMT). However, when the MMT is used,
can be resumed as soon as graft adherence is confirmed. caution is needed when the therapist applies resistance,
Before resuming exercises, the occupational therapist so as not to shear newly healed skin. Other components
should view the grafts and adjacent areas to determine of the evaluation should include: muscular and car-
graft integrity and whether there are any exposed diorespiratory endurance, performance of self-care and
tendons or compromised subcutaneous tissues. home management activities, skin and scar condition,
Gentle active ROM is the treatment choice to avoid presence of edema, and the need for compression gar-
shearing of the new grafts. If the patient exhibited ments (Table 47-2).
normal ROM before surgery and was immobilized for Treatment goals during inpatient rehabilitation are
only 3 to 5 days, baseline ROM should be expected to increase ROM, strength, and endurance, to achieve
within 3 days following resumption of activity. Active independence with self-care, to familiarize the patient
910 TREATMENT APPLICATIONS

with the care necessary for discharge from the hospital, tially tolerate. The garment or bandage is changed as
to aid psychological adjustment, to begin skin condi- tolerance gradually increases. The type of interim com-
tioning, and to provide patient and caregiver education. pression bandage or garments chosen should be based
Although these goals are continued and progressively on the amount and consistency of pressure it applies, the
increased during the outpatient rehabilitation phase, ease of application, and the potential for shear forces
many other goals are added as the individual prepares exerted during application.® Elastic bandage wraps, self-
for reintegration into the home and community. adherent elastic wraps, tubular elastic support bandages,
The rehabilitation phase generally begins when a se- presized elastic pressure garments, and spandex gar-
verely burned patient no longer needs the intensive care ments custom made by the therapist are all commonly
provided on the burn unit. Most of the wounds are now employed (Fig. 47-9).”** Tubular elastic bandages, pre-
closed, and the patient may move to a step-down unit sized elastic garments, and custom-made spandex gloves
or transfer to a rehabilitation setting. Here patients are can be worn over minimal dressings and are routinely
expected to assume a more active role in establishing applied 5 to 7 days after removal of the postoperative
treatment goals, demonstrate more independence in dressing. When patients have small open areas requiring
their care, and fully participate in their therapy. Specific minimal dressings, a woman’s nylon stocking can be
discussions regarding work, recreation, and self-care used over the dressing before the donning of tubular
skills are necessary to help focus patients on resuming bandages, to reduce shearing forces and preserve correct
previous roles, returning to normal daily activity rou- dressing placement. Intermediate garments are worn
tines, and anticipating potential roadblocks to commu- consistently day and night, taken off only for bathing
nity reentry. An upgraded exercise program, a variety of and skin care. Independent donning and doffing of
self-help and rehabilitation equipment, and new tech- interim garments are incorporated into the patient's ADL
niques are introduced to help increase ROM, strength, training.
endurance, and independence with ADL. Newly healed skin tends to blister with shearing
Scar formation begins as wound closure occurs, and forces or splint with overstretching, especially when the
consequently patients frequently report increased tight- skin is dry. Every therapy session should therefore
ness in joint movements or an inability to perform begin with massage to the scars using a moisturizing
certain functional activities. Numerous treatment tech- lotion to prepare the dry or tight skin for increased
niques are advocated to counteract the effects of scar motion. Patients should learn to perform their own
maturation. Examples are skin conditioning, scar mas- skin care independently before their scheduled therapy.
sage, compression therapy, and therapeutic exercise pre- Once the scars are lubricated, stretching is performed to
ceded by slow, sustained stretching. increase flexibility and fluidity of movement.*® Stretch
Skin-conditioning techniques are used to improve should be slow and sustained, and forceful dynamic
scar integrity and durability against minor trauma stretch should be avoided, with attention given to
caused by pressure or shearing forces of garments, to de- the position of adjacent joints during the stretching
crease hypersensitivity, and to moisturize dry, newly motion. Massage with additional moisturizers during
healed skin. These activities are recommended for any stretch exercises helps relieve itching and discomfort.
individual whose burns or surgical sites took longer Stretching in front of a mirror provides positive feed-
than 2 weeks to heal. Lubrication and massage with a back for the patient and is helpful for correcting abnor-
water-based cream or lotion should be performed three mal posturing.
to four times a day or whenever the skin feels exception- Active ROM, strengthening, and endurance activities
ally dry, tight, or itchy. This action provides needed lu- should follow stretching exercises. During the rehabili-
brication for skin that is dry because of damaged sweat tation phase more complex motions must be empha-
and sebaceous glands. Massage is essential for desensi- sized. Flexibility exercises are complex motions that
tizing hypersensitive grafted or healed scars and soften- require movement of several joints simultaneously.
ing tight scar bands during sustained stretching exer- Most ADL that require complex motions and exercise
cises. When massaging a scar band, the therapist should programs should emphasize not just individual joint
be sure the scar is in full stretch and premoisturized to ROM but combined joint mobility in functional pat-
prevent splitting of immature and often unstable, prob- terns of movement (Fig. 47-10). An activity that requires
lematic scar tissue. Massage should be performed using hand manipulation skills while reaching overhead is an
a circular motion, with more pressure applied gradually, example of a complex motion for a burn injury that in-
as tolerated over time. volves the shoulder, elbow, and hand.
Intermediate pressure garments are beneficial for de- For individuals recovering from severe hand burns,
sensitization, general skin conditioning, edema control, treatment activities may involve use of exercise putty,
and early scar compression. The type of interim garment hand manipulation boards, the BTE Work Simulator,*
or compression bandage applied depends on how much Valpar Work Samples,°° crafts, and other fine motor ac-
pressure and shear force the individual’s skin can ini- tivities. Strengthening activities may involve the use of
 Burns and Burn Rehabilitation

FIG. 47-9
Early compression techniques: tubular elastic dressings, ready-made gloves and chin strap, custom
fabricated foam collar, and padded clavicular strap to preserve neck and axillae contours.

cuff weights or dumbbells, the WEST II,°* or the BTE half-turn on each digit and continuing in this manner
Work Simulator.’ The Valpar Full Body ROM Sample pro- across the hand and onto the wrist. Strips are also
vides full body range, as well as finger manipulation.°° applied to each web space (Fig. 47-12). The wrapped
Following severe hand burns, edema may occur hand should then be used for ADL and other functional
because of decreased function, dependent positioning motions and elevated just above heart level when the
without adequate external compression, or circumferen- patient is resting. For lower extremity edema, wearing a
tial scarring to the upper extremity with associated poor double layer of elastic wraps when ambulating, eleva-
lymphatic damage. Dependent edema is also frequently tion when resting, active ankle exercises (e.g., pumping),
observed in the lower extremities following healing of and avoidance of static standing are recommended.
full-thickness burns. When edema is present, motion is Coban can also be used for treatment of toe edema. In-
limited and painful, and if allowed to remain, it may termittent compression pump therapy is often used to
lead to fibrosis.*”Self-adherent elastic bandage material treat chronic edema of the distal extremities.
(Coban or Cowrap) is often used as compression dress- As patients near discharge from the hospital, stress-
ing to the digits and hand. When self-adherent wrap is ing independent self-care is extremely important.
applied, before-and-after circumferential or volumetric Eating, dressing, grooming, and bathing skills should be
measurements are recommended to monitor treatment emphasized as part of the normal daily routine. When
effect (Fig. 47-11). problems occur, the therapist must determine if the dys-
To treat hand edema, elevation, progressive compres- function originates from a physical limitation, scar con-
sion, and activity are recommended. A compression tracture, pain, edema, or an assumed abnormal postural
wrap, using a self-adherent bandage (Coban), is applied reaction. Early identification of abnormal movements
in a spiral fashion, overlapping the previous turn by one helps patients understand their needs and allows an
 FIG. 47-10
Combined motions in functional patterns of movement help obtain the greatest total active motion.

opportunity for relearning normal movement patterns. problem areas, or to assist function (Fig. 47-13). Static
Practicing ADL with personal care items and supplies splints, dynamic splints, and casting’”*~*? may be used,
from home can foster a positive attitude toward hospital depending on the need. Regardless of the purpose of the
discharge and feelings about personal abilities. Major splint, every effort should be made to ensure that its
burn injuries may require adaptations to support inde- purpose is easily understood and that it is simple to
pendence initially. Assessing the need for adaptive self- apply. Nighttime splinting is preferred because it allows
care should differentiate between a scar limitation that functional use of the extremity during the day and pro-
can be rehabilitated and a more permanent disabling vides treatment of contractures while at rest.
result. Patient and caregiver education becomes increasingly
In addition to self-care, instrumental ADL (IADL), important during this phase to aid the transition from
such as home management tasks, should be practiced hospital to home. Increased understanding is needed in
before discharge. Experience has proven that fears of hot the areas of wound healing, the effect of scar contrac--
water, the stove, or an iron can hinder functional recov- ture, the importance of preserving independence in
ery. For individuals injured during a home activity, ADL and IADL, the need for continued activity and ex-
counseling, support, and practice of the skills or activity ercise, and scar management techniques and principles.
in the clinic should be organized. Prevention tech- Before discharge from the hospital the patient and
niques taught as part of the inpatient treatment family should receive comprehensive home care educa-
program, should also be part of the home program.°° tion (Table 47-4).°°°** To reinforce learning, informa-
Splinting at this stage is used to limit or reverse po- tion should be presented in a variety of ways, such as
tentially disabling or disfiguring contracture forma- orally, in writing, as a demonstration, and by video.
tions, to increase ROM, to distribute pressure over However, opportunities should be provided for the
 FIG. 47-12
Self-adherent elastic wrap (Coban) applied to hand to provide ex-
ternal compression for treatment of edema.

FIG. 47-11
Comparison of sequential volumetric measurements of hand
edema substantiates treatment effect.

FIG. 47-13
Bivalved dynamic metacarpophalangeal flexion splint. Presized intermediate glove is worn for skin
conditioning and edema control.

913
 TREATMENT APPLICATIONS

more pliable, and smoother. The time since injury is

one evaluation measurement. A rating scale has been
Jome Program Outline designed that allows serial assessment of scar pigment,
Item Information Needed vascularity, pliability, and height.°* Although the ratings
Wound care, positioning Dressing change technique, are somewhat subjective, the scale is a useful clinical
precautions, elevation tool. Use of high-quality Polaroid photography expe-
dites objective reassessment.
Skin and scar care Lubricant frequency, sun
During outpatient rehabilitation, patients may un-
protection and trauma
precautions
dergo numerous physical and emotional changes. Once
discharged from the hospital, they are faced with the
Self-care (ADL) Techniques and equipment overwhelming task of becoming responsible and self-
needed reliant while dealing with the aggravation of developing
Splints and orthotics Donning techniques, schedule, scars. They may not participate fully with therapy or ad-
precautions equately follow through with home care activities
because of the physical and emotional effects of the
Pressure garments Purpose, washing, reordering,
injury.’ Noncompliance, apathy, avoidance of pain,
donning techniques
scar tightness, and hyperssensitivity all contribute to
Exercises Frequency, techniques for specific dysfunction after injury.
areas
In addition to standard treatments such as counsel-
ing, support, and relaxation techniques, attending a
burn support group can help with adjustment. Experi-
ence has shown that burn patients at different stages of
patient and caregivers to actually practice wound care, recovery tend to provide positive support to each other.
garment and splint application, and all exercises under Group discussions can facilitate understanding of what
staff supervision. Only with a detailed understanding of they have been through and what they have to do.”
home care techniques and potential outcomes can pa- Wearing intermediate pressure garments prepares the
tients be expected to assume responsibility for their own skin for the fitting of custom-made compression gar-
care and recovery.°° ments. Compression garment use is indicated for all
donor sites, graft sites, and burn wounds that take more
than 2 to 3 weeks to heal spontaneously. '”'**° The oc-
Outpatient Rehabilitation | cupational therapist is often responsible for the mea-
The list of assessment procedures expands during burn surement, ordering, fitting, and sometimes adjustments
recovery. ROM, strength, endurance, ADL, and skin and of the custom-made garments. All custom-made gar-
scar status must be assessed frequently to ensure early ments need to be measured and ordered following the
identification of specific problem areas. In addition to special instructions of each company.*
these physical components, the effectiveness of com- Ideally, patients should be fitted with custom-made
pression garments, the fit and need for certain splints, compression garments no later than 3 weeks after
home care activities, emotional responses, and coping wound healing; otherwise, the wearing of interim gar-
skills should be constantly monitored. ments is continued until custom garments can be
Physical tolerance and work skills assessment are in- applied. Garments may need to be ordered “piecemeal”
dicated when patients are ready for return to school, since different areas of the patient may be ready for
work, or vocational rehabilitation. Driving evaluation treating with compression at different points in time.
and prevocational assessment, using simulated work ac- Custom-made compression garments are constructed to
tivities or work sample testing, may also be needed for provide gradient pressure, starting with 35 mm Hg pres-
the more severely injured burn survivor. Vocational sure distally. They must be worn 23 hours a day, being
counseling and exploration should be undertaken in removed only for bathing, massage, or changing into a
the later stages of recovery if residual dysfunction neces- clean garment (Fig. 47-14). Face masks and gloves also
sitates a change in vocational role. need to be removed for meals. Most patients employed
An underlying objective of most burn rehabilitation inside are able to return to work and previous activities
techniques is the prevention or treatment of hyper- without interference from the garments. Patients who
trophic scars and scar contractures. For effective treat- work outside may find compression garments too hot in
ment of scar problems, scar characteristics must be
monitored to recognize when maturation occurs. Active
* Custom-made garments are available from Jobst Institute, Charlotte,
scars have been described as erythemic, raised, and NC (800) 221-7573; Barton Carey, Perrysburg, OH (800) 421-0444;
rigid.*° As they mature, their color, contour, and texture Bio-Concepts, Phoenix, AZ (800) 421-5647; Medical-Z, Seattle, WA
improve, and the scar becomes less vascular in color, (800) 368-7478.
 Burns and Burn Rehabilitation

a
——————

FIG. 47-14 FIG. 47-15

Fit of custom-made compression garments must be frequently as- Example of scar contracture of antecubital skin of elbow. Note
sessed to ensure adequate compression for scar management. taut, shortened skin when elbow is extended.

summer months and may need to change their work Pressure inserts were originally made from thermo-
setting. Because of damaged or lost skin pigment, burn plastics, but inflexibility and skin reactions limited their
patients are at a greater risk for sun burning and must use. Inserts and conformers are now made from a
use sunblock and avoid prolonged sun exposure. variety of materials; the choice is based on the area to be
Compression therapy should be applied to the treated and need for flexibility when applied. When one
burned area for approximately 12 to 18 months or is applied, its fit should be monitored at regular inter-
until scar maturation is complete. Donor sites may also vals. During the early phases of healing when scar re-
need compression garments, depending on the thick- modeling is possible, conformers need to be replaced
ness of the donor skin and whether healing occurred in frequently to maintain exact contouring. Silicone gel,
less than 2 weeks. Once proper fit is established, it is Silastic elastomer, Otoform-K, Plastazote, and Velfoam
recommended that the patient possess a minimum of are used for hand scars. One-sixteenth-inch Aquaplast
two sets of garments at any one time, to allow for both and Silastic elastomer are used on face scars; closed cell
around-the-clock compression therapy and laundering. foams, prosthetic foam elastomer, Elastogel pads, Plas-
Because of the resilient construction of the fabric, pa- tazote, and Velfoam are used for other body areas. *
tients should be instructed to hand wash the garments In addition to skin care and scar management, the
with mild soap and allow them to air-dry. Washing outpatient treatment plan should be directed at increas-
machines, dryers, direct heat, strong detergents, or ing independence with home care while also emphasiz-
bleach should not be used, to prolong the life of the ing resumption of past life roles. This includes return-
garments. If they are properly cared for, the garments ing to previous work, school, and leisure activities.
will last approximately 2 months before a new set is Because scar contracture is often the primary cause of
needed. Some individuals who have returned to work dysfunction (Fig. 47-15), activities performed in ther-
may need more than two sets of garments at a time; apy should emphasize strength, endurance, and func-
children may need replacements more frequently as a tional ROM to counteract the effects of scarring and
result of their growth and active lifestyle. Toddlers un- preserve independence.
dergoing toilet training and incontinent adults will Inpatient rehabilitation techniques, equipment, and
need extra garments and design options that allow in- therapeutic activities are also appropriate for outpatient
dependent toileting. therapy. However, progressive grading of exercise and ac-
To be effective, compression garments must exert tivity frequency, intensity, and duration is necessary to
equal pressure over the entire area. Because of body successfully regain or improve an individual's strength,
contours, bony prominences, and postural adjustments, endurance, and functional skills. Sequencing the order of
flexible inserts or pressure-adapting conformers are treatment activities is necessary to prevent injury and to
usually needed under the garment to distribute the pres- minimize patient discomfort. Skin lubrication, massage,
sure more evenly. Areas commonly requiring pressure
adapters are the supraclavicular region of the chest,
*Vendors of materials for pressure inserts include the following:
between and under the breasts on women, the na- Alimed, Dedham, MA (800) 225-2610; North Coast Medical, Inc.,
solabial folds, upper and lower lip areas, and the web Morgan Hill, CA (800) 235-7054; Smith & Nephew, Menomonee
spaces of the hands and feet. Falls, WI (800) 558-8633.
916 TREATMENT APPLICATIONS

and stretching should precede progressive strengthening

exercises and activities.*® As soon as possible, outpa-
tients should learn how to prepare for exercise and activ-
ity by doing their own skin lubrication, massage, and
stretching. This approach will maximize actual therapy
time and may develop habits that will improve compli-
ance with home activities.
Return to school or work becomes a primary objec-
tive during outpatient rehabilitation. Many recovering
burn survivors are capable of resuming normal daily
routines before their wound maturation is complete.
Most burn patients will still be wearing compression
garments and inserts, having to avoid prolonged sun ex-
posure and needing to perform skin care while they are
in school or at work.
Return to school and association with friends can be
an especially difficult process for children who have cos-
metic disfigurement or functional loss or restrictions.
Many burn centers have developed school reentry pro-
grams to educate teachers and students about burn in-
juries and what the child has been through, and to
explain the purpose of compression garments, splints,
exercise, and skin care precautions. The goal of a reentry
program is to reduce restrictions to the child’s activities
and ease the transition of returning to school.”* Summer
camps for burned children can help the children adjust
by placing them in social settings where all of their peers
are also burned. Many such camps are sponsored by
local firefighter organizations.
Preparing a burn patient for return to work does not FIG. 47-16
Combined range of motion (ROM) and skin conditioning activity.
have to be a long-term process. Burn rehabilitation and
Use of Valpar Whole Body ROM for upper extremity exercise
work skills training have many similarities; therefore it while wearing compression garments.
is possible to design treatment activities that simulate
not only functional activities but also various work
skills. Strength, endurance, and flexibility, often identi-
fied as work tolerances, are obvious goals of burn reha- ment, program progression, or return to work or school
bilitation.*° Physical demands of jobs, as described in status should be changed.** When patients have
the Dictionary of Occupational Titles, are also compo- resumed their preinjury activities, outpatient therapy
nents of functional skills; lifting, stooping, pushing, may be discontinued. Because burn scar maturation
pulling, handling, and manipulating are a few exam- may take up to 18 months after injury, some schedule of
ples. A job analysis interview, as part of the activity follow-up care, every 2 to 3 months, is needed until the
needs analysis, will provide the type of information wearing of compression garments is discontinued.
needed to integrate activities into the treatment plan
that should not only improve functional ability but also BURN-RELATED COMPLICATIONS
provide beginning work conditioning.
Preparing an individual for return to work after burn
Heterotopic Ossification
injury also requires attention to two other types of toler- Heterotopic ossification (HO) is new bone formation
ance, skin and temperature. Skin-conditioning activities in tissues that normally do not ossify.°' Although HO is
and exercises performed while wearing garments will frequently found in the posterior aspect of the elbow, it
improve skin tolerance for friction and shear force may occur in other joint areas, such as the shoulder,
demands (Fig. 47-16). Education about the body’s re- wrist, hand, hip, knee, and ankle. It may occur in either
sponse to temperature variations and precautions for extremity or bilaterally, even if both extremities were
dealing with extremes of temperature is the only way to not burned. It develops either in the soft tissue around
address temperature tolerance abnormalities. the joint or in the joint capsule and ligaments, and
The outpatient therapy program should be reevalu- often forms a bony bridge across the joint.° Signs that
ated periodically to determine if the frequency of treat- HO may be present usually appear during the latter
 Burns and Burn Rehabilitation 917

stages of hospitalization, with the patient experiencing eye contact because of social rejection and loss of self-
increased pain at a certain point in the joint’s ROM. The esteem.
pain is fairly localized and severe and ROM losses are Two main compression therapy methods are used
usually rapid. Inflammatory signs, such as redness or to prevent or manage hypertrophic facial scars. An
swelling, are not easily discernible within healing burn elastic face mask can be worn with underlying flexible
wounds. Once HO has been detected, frequent active conformers. The other option is a rigid, total-contact
ROM exercise to the joint should be carried out within transparent facial orthosis.°” Each has advantages and
the pain-free range to maintain joint motion.'* Use of disadvantages.
dynamic splints or forceful passive stretching to the in- Because face masks of elastic fabric usually enclose
volved joint should be discontinued. The condition the entire head and use flexible conformers, they
may resolve itself with time, or eventual surgical inter- provide more uniform compression during movement
vention may be required to release fused joints. or changes in position. However, because they occlude
the face, they are cosmetically and socially less accept-
able and must be removed before entering facilities
Neuromuscular Complications
such as banks or convenience stores where the patient is
Peripheral neuropathic conditions are the most com- not known. Effectiveness of the compression is based
mon neurological disorder observed in burn patients. on subjective feedback from the patient and observa-
They usually occur in high-voltage electrical burns or tions made by the fabricator between therapy visits.
burns of greater than 20% TBSA.** Peripheral nerve Most types of underlying conformers are easy to modify
damage may be caused by infections, metabolic abnor- or replace as needed to provide effective pressure distri-
malities, or neurotoxicities. A peripheral neuropathic bution over facial concavities and contours.
condition is generally demonstrated with symmetrical Fabrication of the transparent, rigid orthosis is an in-
distal weakness, with or without sensory symptoms. volved and often expensive process. Fabrication in-
Most conditions improve with time; however, patients volves taking a negative impression of the patient's face
often complain of fatigue and decreased endurance that and making a positive plaster mold of the impression.
may last for months.”? Thermoplastic is heated and stretched over the mold.
In addition to peripheral neuropathic conditions, lo- The edges are finished, elastic straps are applied, and the
calized compression or stretch injuries to nerves are en- orthosis is fitted to the patient.*' The therapist can ob-
countered during burn recovery. Causes of localized jectively evaluate the amount ofpressure exerted on the
nerve injury include improper or prolonged positioning scars by noting the presence of scar blanching under the
in bed or on the operating room table, tourniquet clear mask and make precise adjustments as needed.
injury, and extreme edema. Common injury sites are the With either method, frequent alterations are neces-
brachial plexus and ulnar and peroneal nerves. Pro- sary to achieve and maintain adequate compression of
longed frog-leg positioning can cause a stretch injury, all facial scars (Fig. 47-17). The choice of which method
whereas prolonged side lying can cause a compression to use is based on patient and physician preference.
injury to the peroneal nerve.”* The ulnar nerve is subject However, a combination of both is most advantageous
to a compression injury if resting on a firm surface with with a clear rigid facemask for social settings and the
the elbows flexed and forearms pronated. The brachial fabric mask with conformers at nighttime or when at
plexus is subject to stretch or compression injury if in- home.
appropriate shoulder positioning techniques are used. Appropriate skin care education is also important.
Therapists should be aware of the causes for various Massage with lotion twice a day will aid scar desen-
nerve injuries, to implement more effective prevention sitization and provide necessary lubrication. Facial
and intervention techniques. massage and exercises are performed at least twice a day
to stretch tight facial skin, maintain eyelid and mouth
flexibility, and maintain nostril openings. Just as with
Facial Disfigurement any compression therapy technique, patient compliance
Facial scars can be devastating, both functionally and is essential to the effectiveness of the treatment. The pa-
psychologically. Hypertrophic scarring not only distorts tient is instructed to wear the face mask(s) at all times,
the smooth contours of the cheeks and forehead, but except while eating or bathing. Individuals wearing
also can flatten the nasal contours, evert eyelids and either type of mask often report feelings of self-con-
lips, and constrict optic and oral commissures. This dis- sciousness, acute awareness of being stared at, and a fear
figurement is damaging to an individual’s self-image of going out in public. To successfully manage these so-
and inhibits social interactions. A considerable amount cial and personal issues, supportive intervention is
of communication depends on nonverbal facial expres- needed from the family, therapist, and social worker.
sions and eye contact. Severe facial burn scars not only Compliance is especially critical in controlling facial
distort the face and restrict expression, but also inhibit scar and disfigurement. The therapist must provide
FIG. 47-17
Close-up view of transparent rigid facial orthosis. Mask contours and
straps are adjusted to increase pressure over scarred areas (note
blanching of lower lip and lateral chin).
 Burns and Burn Rehabilitation 919

encouragement and continual support to ensure perse- compression techniques, patient and family education,
verance with wearing a facial orthosis, despite the social and emotional support.
barrier it can cause. Once the scars are mature and com- Advancements in medical and surgical burn care
pression therapy is no longer needed, the patient should have made it possible to expect not only self-care inde-
be instructed in the use of special camouflaging cosmetics pendence, but also early return to school, work, and
such as Covermark that will cover minor texture flaws leisure and social activities. Even when functional recov-
and correct uneven pigmentation. * ery is possible, pain, disfigurement, and adverse psycho-
logical reactions (noncompliance, apathy, and depres-
sion) can contribute to postinjury dysfunction. In
ee
ayer
——
*Covermark Cosmetics, Veterans Dr., Suite D, Northvale, NJ 07647, addition to progressive physical rehabilitation, ongoing
(800)524-1120157, http://www.covermark.com/. patient education is crucial. A comprehensive patient
education program should be initiated early and incor-
porate information about the physical, psychological,
and social components of burn injury to facilitate the
SUMMARY
patient's cooperation and adjustment to the injury. Fre-
A thermal injury can be one of the most devastating quent reassessment of the patient's physical abilities,
physical and psychological injuries a person can suffer, emotional status, and social needs is also needed to
especially if appropriate treatment is not received in a ensure effective treatment programming.
timely and comprehensive manner. Successful burn A basic OT concept that should be observed in all
care requires a coordinated, multidisciplinary team ap- burn care is treatment of the “whole” person. Although
proach from the date of the patient's admission to the this concept is apparent with large, severe burn injuries,
hospital until wound maturation is complete. The occu- it is also important to remember when treating small
pational therapist is an integral member of the burn (less than 20% TBSA) burn injuries. A saying in the
,er
team, providing treatment that promotes recovery of burn care field that makes this point is, “There is no
functional skills. Treatment activities include position- such thing as a small burn, unless it is on someone
ing, exercise, ADL, splints, skin conditioning, external else.”

Sze = = £ Ee
es Ses

CASE STUDY—S.T.

History twice-a-day dressing changes using silver sulfadiazine cream to

S.T. is a 38-year-old man who received 25% TBSA battery acid the torso and arms, antibiotic ointment to the face, and Sul-
burns in a rollover automobile accident in which he was pinned famylon to the ears. On 8/4 he underwent a tracheostomy to
under his vehicle. He had superficial-, deep-, and full-thickness ensure a patent airway. On 8/8 he underwent tangential excision
burns to his upper chest, midback, dorsal right hand and forearm, and STSG to the right upper extremity and face with donor
right circumferential upper arm, and right anterior axillary fold, as sites from his anterior thighs and lower chest. On 8/I5 he re-
well as deep partial- and full-thickness burns to his neck, face and ceived tangential excision and grafting again to his face and
dorsal right index finger. Other trauma-related injuries included scalp. His respiratory status improved and he was extubated on
skin lacerations to his forehead, fracture to his coccyx, right 8/20. Initially the patient was incoherent, but by 8/2! his mental
elbow sprain, chest trauma resulting in a lacerated spleen, and a status had cleared and he was allowed liquid diet by mouth on
collapsed upper lobe of his right lung. Medical history includes 8/21. His tracheostomy was removed on 8/27. He was dis-
sleep apnea and psoriasis to both lower legs. His right hand is charged on 8/29/97 to home, 28 days after injury. At discharge
dominant. the patient was eating a regular diet but still had unhealed areas
S.T. lives alone in a mobile home but shares custody of his on his face and lips.
3-year-old son, who stays with him on alternate weekends. He
completed high school and had been employed for |8 years as a Evaluation and Goals

truck driver for a transportation company until the time of his An OT evaluation was performed on 8/2. Current. status,
accident. Leisure interests included fishing, working out at the medical history, and preevaluation background information was
gym, and competitive power lifting. His previous level of function- obtained from the medical record, family, and nonverbal com-
ing was independent in all ADL and IADL. munication from the patient. Areas of assessment included loca-
S.T. was admitted to the regional burn intensive care unit on tion and depth of burned surface areas; communication abilities;
8/1/97. He had not received a significant smoke inhalation injury, cognitive and emotional status; active ROM, general strength,
but was intubated because of facial swelling, pharyngeal edema, and coordination; presence and degree of edema; and screening
and subsequent airway compromise. Initial nursing care included for changes in neurological function or sensation.The patient's
enna
mnemeeceneimeemeeememmezemees mummies a eee
 TREATMENT APPLICATIONS

"CASE STUDY
CASE STUDY—S.T.—cont’d Treatment interventions begun in the postoperative phase
functional performance was initially impaired by acute edema of |. A right postoperative elbow extension splint was fabri-
the face and bilateral upper extremities and an acute decline in cated and applied, to be worn over dressings full time post-
mental status. Several weeks later, as S.J. became more alert operatively for 5 days and then part time at night until full
and able to participate in treatment, it was noted that he also active ROM (AROM) was regained.
had peripheral nerve damage to his right-median nerve with Treatment interventions initiated during the rehabilitation —
subsequent decrease in his right hand strength and sensation. phase
Goals were initially reviewed and discussed with the family and |. After the patient was orally extubated, he was measured
again later with the patient after he became alert and fully and fitted with a Microstomia Prevention Appliance (MPA)
cognizant. mouth splint that he wore initially when sleeping, but later
Acute phase treatment goals were to: MPA use was increased to include daytime periods because
|. Reduce facial and extremity edema of increased oral tightness. The patient was measured for a
2, Improve cognitive awareness manufactured elastic face mask, chin strap, and sleeve. A
3. Preserve functional mobility, strength and coordination of temporary right compressive sleeve was fabricated and
the neck, and both upper extremities applied. Fabrication of a clear acrylic face mask was initiated
4, Regain independence with basic activities of daily living before discharge and applied on an outpatient basis. After
A goal was added during the postoperative phase: discharge, the patient continued to receive OT for right
|. Protect and immobilize surgical graft sites to maximize upper extremity exercise program, scar management, and
graft take monitoring the fit of compression garments. As his scars
Goals of increased focus in the rehabilitation phase were: continued to contract, the tight anterior axilla was treated
|. Minimize hypertrophic scarring and disfigurement. Pre- with moist heat and slow sustained stretch. Facial exercises
serve facial function. were intensified with emphasis on patient participation.
2, Regain independence with activities of daily living and in- Horizontal stretch exercises to the healed eyelids and
crease activity tolerance. midface were performed by the patient using skin traction.
3. Develop coping strategies for dealing with pain and facial Oral stretch exercises that were initiated by the therapist in
disfigurement (added later after irreversible facial scarring the acute phase using plastic thermometer covers, in this
occurred), phase were performed more aggressively using acrylic
The long-term goal of treatment was to return S.T. to his straws (horizontal) and tongue depressor stacks (vertical).”°
preinjury level of independence by four, months after injury. 2, Practice of ADL was continued, progressing with perform-
ing self-care tasks, sitting on the edge of the bed and later
Treatment Approaches standing at the sink in order to increase general strength
Treatment interventions initiated in the acute care phase and activity tolerance while becoming more independent
|. Positioning guidelines were established with the head of with self-care tasks.
the patient's bed elevated 20° or more; bilateral upper ex- 3. Relaxation techniques were taught to help S.T. cope with
tremities elevated on pillow inclines with right upper ex- discomfort during therapy, emotional support was pro-
tremity abducted to 90°. Illustrated positioning recom- vided, and S.T. was referred for professional counseling
mendations were posted bedside. As wounds healed, while still an inpatient.
retrograde massage was provided to assist with edema re-
duction in the hands. Outcomes
2, Orientation activities were incorporated into the patient's In spite of compression therapy, mouth splinting, and facial exer-
exercise and activity treatment sessions. cises, S.T’s facial scars, which were caused by acid burns, contin-
3. Passive ROM was provided when the patient was not alert ued to contract, causing eye, nasal, and oral constriction, lip ever-
enough to participate. Later, as the patient became more sion, eye ectropion, and flattening of his facial features. About
cognizant, an active assistive exercise program was pro- 2 months after discharge, S.T. abandoned the use of the acrylic
vided to promote edema reduction and return of func- face mask because the frequent long-distance trips for adjust-
tional use of the extremities and face. The patient's exer- ments to the mask could not keep pace with the rapidly changing
cise program was posted bedside. Therapeutic activities of facial contours. Instead, S.T. preferred using the elastic fabric face-
interest were encouraged to increase motivation, activity masks and flexible conformers. S.T. continued nighttime use ofhis”
tolerance, endurance, and fine motor coordination. The MPA for approximately | year after discharge to prevent further
patient particularly enjoyed working out on the stationary constriction of his mouth, but continued to have webbing at each
bicycle. oral commissure. S.T’s right arm graft sites and burn scars re-
4, After the patient was fully cognizant, extubated, and sponded well to exercise and the consistent use of elastic com-
allowed food by mouth, the patient began to practice basic pression sleeves, with resulting full active ROM, a supple, flat-
oral and facial ADL, sitting supported in bed or in a tened texture, and acceptable appearance. The scars on his
bedside chair Sponge handles were initially applied to his upper shoulders did not receive compression therapy because of
eating utensils and toothbrush and removed after his right his preference to use a sleeve rather a full vest, but these scars,
grip strength improved. while having a slightly raised texture, were also acceptable to him.
 Burns and Burn Rehabilitation

ae
sai
iia

_
a

CASE STUDY—S.T.—cont’d stances led to physical altercations. S.T. and his small son had
Two years later, S.T. has had 10 surgical revisions for treat- maintained contact by telephone throughout his hospitalization.
\
ment of recurrent facial contractures caused by the severe acid Before discharge, the child had been gradually introduced to
burn scarring and an extended period to obtain facial scar mat- S.T’s changed facial features, first with photos, then with the face
=.
Soe
uration. He has regained right hand strength but still lacks sen- mask in place, and later without either mask. He was and con-
sation in his thumb and forefinger and continues to experience tinues to remain fully accepting of his father, regardless of his
chronic low back pain. He is currently scheduled for a series of altered appearance.
surgical reconstruction procedures to establish patent nasal pas-
sages and relieve facial tightness. Although improving with multi- Patient’s Personal Long-Term Goals
ple surgical procedures and the use of facial compression “Because of my eyes I'll never be able to work as a truck driver
therapy, the patient's facial appearance is still unacceptable by again, and because of my back | can’t power lift anymore, but I'd
social standards. Because of limited field of vision caused by dis- like to build up my lawn service into a business with a small crew.
torted eyelids and right eye blurring, S.T. has not been em- Emotionally, I'm doing okay, | have my ups and downs. | won't go
ployed as a truck driver since his accident. He is currently self- out to eat at a restaurant anymore. Sometimes my appearance
employed part-time, providing lawn care services for local startles people. What I'd really like is to look halfway normal so
businesses. His attempts to reenter previous social circles have that | don't always stand out.”
resulted in mixed responses from individuals, and in some in-

REVIEW QUESTIONS
16. Why are skin conditioning activities used in burn
1. Name the two layers of the skin. In which layer are rehabilitation? What are examples of skin condi-
the nerves and sebaceous glands? tioning techniques?
2. Which factors are considered in determining burn 17. What is the average length of time required for scar
severity? maturation?
3. What is an escharotomy, and why is it performed? 18. What are possible causes of limitations in ADL
4. Describe two factors that affect the quality of burn during the rehabilitation phase?
wound healing and promote excessive scar forma- 19. Which points should be covered in a home
tion. he program?
5. During the acute care phase, which factors may 20. What is the primary cause of dysfunction following
limit full ROM? a burn injury?
6. What is a boutonniere deformity, and what are bou-
tonniere precautions?
7. What are the two basic principles underlying most
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12. Why may a patient need temporary adaptations for
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ADDITIONAL INFORMATION
American Burn Association
~—
a
http://ameriburn.org/home.htm
 - ienekjestagtes

KEY TER LEARNING OBJECTIVES

SECTION 1 After studying each section, the student or practitioner will be able to do the
General Considerations following:
Preprosthetic Section 1
Residual limb . List the common causes of amputation.
Postprosthetic . Discuss the occupational therapist's role in rehabilitation after amputation.
Socket . List the goals of amputation surgery.
Neuroma Name two types of surgical procedures.
Phantom limb Name four factors that can interfere with prosthetic training.
Phantom pain Define neuroma, phantom limb, and phantom pain.
. Describe typical psychological consequences of amputation surgery.
SECTION 2
. Describe how the occupational therapist facilitates adjustment to
Upper Extremity Amputations
amputation.
Body-powered prosthesis
Section 2
Passive prosthesis
i Describe the role of the occupational therapist in the rehabilitation of
Terminal device
the individual with an upper extremity (UE) amputation.
Hook
. Discuss the impact of the residual limb status on the success of fitting
Prepositioning
and operating a UE prosthesis.
Wrist flexion unit
Name the five components common to all body-powered prostheses.
Forequarter amputation
List the motions used to operate the body-powered prosthesis.
Myoelectric prosthesis
Describe at least two techniques for donningthe body-powered prosthesis.
Muscle site
Describe the importance of prepositioning the terminal device.
Greifer
List the two phases of training a person to use an UE prosthesis.
Pull sock
Appreciate the need to introduce postprosthetic training into three levels.
Control training
ie Understand basic operation of an electric prosthesis.
tage
PA
NISAD
RE
als
Pressure control
10. Recognize the primary function of any prosthesis in different daily tasks.
SECTION 3 Section 3
Lower Extremity Amputations — List two major causes of LE amputation.
Hemipelvectomy List postsurgical problems that affect prosthetic fitting and rehabilitation.
Above-knee amputation Discuss problems that can occur in postprosthetic rehabilitation.
Below-knee amputation Identify levels of LE amputation and functional losses associated with each.
Symes amputation Name and describe at least three types of LE prostheses.
Pylon List the goals of occupational therapy for the person with LE amputation.
Ischial weight-bearing prosthesis Name the members of the rehabilitation team and their respective roles.
SACH foot Describe some treatment strategies used by the occupational therapist.
Rigid removal dressing Yranld Discuss activities of daily living addressed in the rehabilitation program.
gae:
RIT
RIS
Sep
ge’
se
ay© Identify typical psychosocial factors affecting the adjustment and
rehabilitation program after amputation.
 Amputations and Prosthetics 925

ee
SECTION 1 variously reported as between 7% and 13% and is
usually associated with other medical problems such as
General Considerations of Upper and cardiac disease and strokes.”’'*''*
Lower Extremity Amputations The second leading cause of LE amputation is
trauma, usually from motor vehicle accidents or gun-
‘DENISE D. KEENAN shots. Individuals with traumatic amputations are
PATRICIA ANN MORRIS
usually young adults and more frequently men.*'? Im-
proved imaging techniques, more effective chemother-
Limb loss can result from disease, injury, or congenital apy, and better limb salvage procedures have reduced
causes. Individuals born with congenital limb deficien- the incidence of amputation from osteogenic sarcoma.
cies or whose amputations occur early in life usually Tumor resection followed by limb reconstruction fre-
grow and develop sensorimotor skills and self-images quently provides as functional an extremity as a pros-
without the limb. The individual who has an amputa- thesis and does not appear to affect the 5-year survival
rate 15,20,30,34,39
tion in adolescence or adulthood is confronted with the
task of adjusting to the loss of a well-integrated part of
the body scheme and self-image. These two types of
SURGICAL MANAGEMENT
patient populations present different problems for the
rehabilitation worker.**** The surgeon is an important team member. Before surgery
The occupational therapist's primary responsibility the surgeon should consult with the health care team to
in the rehabilitation program is the formulation and ex- maximize the functional outcome. The surgeon attempts
ecution of the preprosthetic program and prosthetic to preserve as much length as possible and provide a
training. During the preprosthetic phase the treatment residual limb that has good skin coverage and vascular-
plan involves preparing the limb for a prosthesis; during ization. Conservation of residual limb length and un-
the prosthetic phase, treatment involves increasing pros- complicated wound healing are important. During and
thesis wearing tolerance and functional use. The reha- after surgery the primary goal is to form a residual limb
bilitation program involves an individualized treatment that maintains maximal function of the remaining tissue
plan that helps the person with the physical and psy- and allows maximal use of the prosthesis.''”*?
chological adjustments. This program is designed so Blood vessels and nerves are severed and allowed to
that the individual may learn to accept the new body retract so that residual limb pain is minimized during
image and function as independently as possible.'**”** prosthetic use. Bone beveling is a surgical procedure
that smoothes the rough edges and prevents spur devel-
opment of the remaining bone. Muscles are sutured to
CAUSES AND INCIDENCE
the bones distally by a surgical process called myodesis.
OF AMPUTATION z
The muscles involved in the function of the amputated
The majority of amputations result from trauma, pe- limb are correspondingly affected by the loss.7’
ripheral vascular disease (PVD), peripheral vasospastic Surgical techniques vary with the level and cause of am-
diseases, chronic infections, chemical, thermal, or elec- putation.*'’*? A closed or open surgical procedure may be
trical injuries, and malignant tumors. Elective upper ex- performed. The open method allows drainage and mini-
tremity (UE) amputations may occur as a result of a mizes the possibility of infection. The closed method
severe or complete brachial plexus injury.’ reduces the period of hospitalization but also reduces free
Each year an estimated 40,000 Americans lose a drainage and increases the risk of infection.°*” The specific
limb. Approximately 4000 to 5500 lose a hand or arm. type of amputation performed is at the discretion of the
The incidence of amputation remains fairly constant surgeon and is often determined by the status of the ex-
between the ages of 1 and 15. From 15 to 54 years of tremity at the time of amputation. In either case the
age, however, there is a gradual increase in incidence surgeon must remove the part of the limb that has to
because of work-related injuries and highway accidents. be eliminated, allow for primary or secondary wound
Approximately 75% of UE amputations in adults are healing, and construct a residual limb (also called a
caused by trauma.'”’?* stump) for optimum prosthetic fitting and function. The
The major cause of lower extremity (LE) amputation residual limb that results should be strong and resilient.”
is PVD, often associated with smoking and dia-
betes.'*7"*? Despite major improvements in noninva- POSTSURGICAL FACTORS
sive diagnosis, revascularization, and wound-healing
AND PROBLEMS
techniques, 2% to 5% of individuals without diabetes
but with PVD, and 6% to 25% of those with PVD and Several factors and potential problems can affect the
diabetes, undergo amputation.'*'****”*? Periopera- outcome of rehabilitation. Length of the residual limb,
tive mortality of persons with LE amputation has been skin integrity, edema, sensation, the time for healing,
926 TREATMENT APPLICATIONS

infections, and allergic reactions to the prosthesis are function, is lost. Residual limb hyperesthesia, neuro-
among the physical factors that affect rehabilitation mas, and phantom sensation or pain are problems that
potential.'? may interfere with the functional use of the limb either
with or without the prosthesis.
Residual limb hyperesthesia, or an overly sensitive
Skin
limb, limits functional use and causes discomfort. De-
Skin complications account for most postsurgical prob- sensitization consists of tapping and massage, which
lems. These complications occur in either the prepros- helps decrease the discomfort.’ Sympathetic nerve
thetic or postprosthetic phase. Delayed healing and blocks may be used to manage residual limb hypersen-
extensive skin grafting are complications in the pre- sitivity medically.**
prosthetic phase. Skin breakdown, ulcers, infected seba- The residual limb may have areas of absent or im-
ceous cysts, and allergic reactions can occur in the post- paired sensation that require special attention and edu-
prosthetic phase. Residual limb edema can occur in cation when the prosthesis is worn. The person must
either phase. Delayed healing of the incision site is one rely on visual and proprioceptive feedback because sen-
of the earliest preprosthetic complications resulting sation is functionally lost when the prosthesis is on the
in postponed prosthetic fitting. Necrotic areas may residual limb. The person must adjust to new sensa-
develop, requiring surgical intervention.” tions, such as the pressure of the residual limb inside
To achieve a residual limb length suitable for pros- the socket and the feel of the harness system, if used.**
thetic use, the surgeon may perform extensive skin
grafting. If the skin graft adheres to bone, the area may Neuromas
ulcerate and require medical attention.* Daily gentle Severed peripheral nerves form neuromas in the residual
massages by the person or therapist decreases the like- limb.*!’*4 A neuroma is a small ball of nerve tissue that
lihood of skin graft adherence to bone and the atten- develops when growing axons attempt to reach the distal
dant complications. end of the residual limb. As the axons grow, they turn
Immediately after surgery the residual limb is nor- back on themselves, producing a ball of nerve tissue. If
mally edematous as a result of fluid that collects within the neuroma adheres to scar tissue or skin subject to
the soft tissues, especially in its distal portion. Compres- repetitive pressure, it can be painful when pressed. Diag-
sion wrapping or a rigid dressing helps decrease the nosis is made by palpating the neuroma.’ Most neuro-
edema.*1%""” mas occur | to 2 inches (2.5 to 5 cm) proximal to the end
During the postprosthetic phase an ill-fitting socket of the residual limb and are not troublesome.”
or wrinkles in the prosthetic sock may cause skin break- So that pain will not interfere with prosthetic wear,
down or scar adhesions." Residual limb ulceration is as- the neuroma must be well surrounded by soft tissue.
sociated with ischemia and pressure exerted by the pros- During surgery the surgeon identifies the major nerves,
thesis on the limb. The physician should see the patient pulls them down under some tension, cuts them clearly
in this case, and the prosthesis should not be worn until and sharply, and allows them to retract into soft tissue
the area heals. The prosthetist should also examine the of the residual limb. Neuromas that form close to scar
prosthesis to determine if the socket should be adjusted. tissue or bone generally cause pain.*!’**
If these problems persist, surgical revision of the limb Treatment involves local anesthetic injections or ul-
may be needed before rehabilitation can continue.*’ trasound. Both treatments should be followed by
The torque forces between the socket and the residual massage and stretching. Surgical intervention may
limb cause a predisposition to the development of seba- be necessary. In addition, the residual limb socket
ceous cysts. Treatment involves the application of moist may be fabricated or modified to accommodate the
heat. When the cyst becomes infected, drainage ensues neuroma.!?778
and enucleation of the cyst wall may be required.”
The development of residual limb edema during the Phantom Limb
postprosthetic phase is usually indicative of an ill-fitting The majority of patients who have had an amputation ex-
socket. Proximal tightness of the socket may result in perience phantom limb. In its simplest form the
distal edema, which may require a new, well-fitted phantom is the sensation of the limb that is no longer
socket.” there. The phantom, which usually occurs initially imme-
diately after surgery, is often described as a tingling, pres-
sure sensation, or sometimes as numbness. The distal part
Sensory Problems
of the extremity is most frequently felt, although some-
The loss of sensory feedback from the amputated limb times the person feels the whole extremity. The sensation
is a major problem that confronts the person. This is es- is influenced by external stimuli such as bandaging or
pecially significant for the person with UE amputation, rigid dressing. It may dissipate over time, or the person
since sensory feedback from the hand, so essential for may have the phantom sensation throughout life.
 Amputations and Prosthetics 927

Phantom sensation is painless and usually does not in- Many factors may affect normal wound healing. Post-
terfere with prosthetic rehabilitation. The patient should operative infection from external or internal sources is a
be assured that the feeling is quite normal.*!** major concern. Patients with wounds contaminated
Desensitization, supportive counseling, and early use from injury, infected foot ulcers, or other causes are
of the residual limb with a temporary or permanent at greater risk for infection. Research indicates that
prosthesis are effective measures for dealing with smoking is a major deterrent to wound healing. One
phantom sensations.** In many cases it is best not to study reported that cigarette smokers had a 2.5% higher
dwell on the discussion of phantom sensation but rate of infection and reamputation than nonsmokers.”
rather to focus on prosthetic training and the return to a There is some indication that failure of limb revascular-
former lifestyle. ization may negatively influence healing at below-knee
levels. Other factors that influence wound healing are
Phantom Pain the severity of the vascular problems, diabetes, renal
Phantom pain is different from phantom limb sensa- disease, and other medical conditions such as cardiac
tion in that it is usually characterized as either a cramp- disease.?’713>/3°
ing Or squeezing sensation, a shooting pain, or a
burning pain. Some patients report all three. The pain
PSYCHOLOGICAL REACTIONS
can be localized or diffuse. It may be continuous or in-
TO AMPUTATION
termittent and can be triggered by external stimuli. It
may diminish over time or may become a permanent Profound psychological shock and disbelief are likely to
and often disabling condition. In the first 6 months fol- accompany amputation, particularly for those who ex-
lowing surgery, phantom pain is related to preoperative perience a sudden trauma that causes or necessitates
limb pain in location and intensity.”' amputation.*''®'” Seeing the residual limb for the first
No strict treatment protocol has been established for time can cause shock, panic, despair, self-pity, suicidal
phantom pain. Isometric exercises begun 5 to 7 days fol- impulses, and even rage.*° Subsequently there can be
lowing the amputation and performed several times feelings of hopelessness, despondency, bitterness, and
throughout the day may help control phantom pain. anger. Some individuals may mourn the possible loss of
Biofeedback, transcutaneous electrical nerve stimula- a job or ability to participate in favorite sports or activi-
tion (TENS), ultrasound, progressive relaxation exer- ties, as well as the lost limb.
cises, and controlled breathing exercises may reduce The person may feel lonely, isolated, and an object
phantom pain. Activities such as rubbing, tapping, and of pity. Concerns about the future, body image and
applying pressure and heat may be beneficial. The function, the responses of family and friends, and em-
physician may treat the pain by prescribing amitripty- ployment all affect the person’s emotional status.*°
line (Elavil) at bedtime by injecting anesthetics:into the Reactions to amputation may be less severe in individ-
tender area or by performing sympathetic nerve blocks. uals who have had a chance to adjust before the
Surgical revision of the residual limb is sometimes surgery.”'°'’ Older persons may demonstrate postop-
necessary to alleviate the pain.'’”’ The appearance of erative confusion, whereas younger persons may have a
phantom pain or excessive concern with phantom sen- sense of mutilation, emasculation, or castration.*’°
sation requires the intervention of the team. The thera- The person's personality, age, cultural background,
pist can allay the patient's fears about these phenomena and psychological, social, economic, and vocational
by offering support, information, reassurance, and resources influence the reaction to amputation. Ulti-
contact with other prosthesis wearers. mately, the individual must come to terms with the
consequences of limb loss and perceived diminished
attractiveness. The person confronts discomfort, incon-
Bone Problems venience, economic expense and loss of function, in-
The formation of bone spurs is another complication creased energy expenditure, and possible curtailment of
that may occur during the preprosthetic phase. Because favorite activities. He or she may need to change occu-
most bone spurs are not palpable, an x-ray examination pations, deal with social discrimination, and cope with
is needed to confirm their presence or absence. Bone resultant medical problems.°
spurs that cause pain or result in persistent drainage Cultural factors are important in the reaction to am-
require surgical excision. putation. In some social, cultural, or religious groups
the amputation may be considered a means of punish-
ment or atonement. Such beliefs and society's aversion
Delayed Wound Healing and Infection to amputation can cause the person to adopt the same
For the person with LE amputation, delayed wound viewpoint. Such attitudes can result in self-hatred and
healing and excessive skin grafting are potential compli- self-deprecation, which may affect the person's reac-
cations during the preprosthetic phase. tions and adjustment to the disability.°
928 TREATMENT APPLICATIONS

Depression and a sense of futility are considered a Long-term adjustment depends on the person's basic
normal part of the adjustment process.° If depression is personality structure, sense of accomplishment, and
severe and prolonged, psychological or psychiatric refer- place in the family, community, and world. Generally,
ral is indicated. Medication may be necessary to reduce individuals who have had an amputation may dream of
depression.° The preexisting personality of the patient themselves as not being amputated. This image may be
determines the severity and duration of the reactions so vivid that persons with LE amputation fall as they
and ultimately the adjustment to the amputation and to get up at night and attempt to walk to the bathroom
prosthetic use.*” without a prosthesis.7°
The rehabilitation team members can help the
patient understand the importance of the prosthetic
Psychosocial Adjustment to Amputation
training program. The use of new prosthetic technology
An individual’s psychosocial adjustment depends on that addresses different lifestyles and enhances normal
various factors: the individual's character and inner
strength, the quality of the social support systems avail-
able, and sociocultural reactions to amputation and the . Forequarter
team’s management of the rehabilitation.® \
\
The process of adjustment to amputations is analo- \
gous to the grieving process. The patient experiences \ Shoulder
identifiable stages of denial, anger, depression, coping, \ aoe Kee disarticulation
and acceptance.° Some patients progress through these
;\ 7
stages and ultimately adapt to the loss. The cause of the 7
\ /
amputation may contribute significantly to the patient's le
1 4
response.
In any phase the person may have hostile reactions ' Short above
directed toward self and the medical team. Often, overt elbow
solicitousness and friendliness may mask such hostility.
Caregivers should not react with hostility but should
make allowances for such behavior. Positive reinforce-
ment through involvement in the rehabilitation process
and contact with people having similar amputations
aids in solving the problems of returning to former life
roles.°
The person may have fear about returning to family,
social, vocational, and sexual roles. Frequent discus- Long above
sions of fears and solutions to real or imagined prob- elbow
lems, if possible with a similar, successfully rehabili-
Elbow
tated person, are important for facilitating adjustment.°
disarticulation
After a mourning period, the person may minimize
the significance of the amputation and actually joke
about it. When this phase of adjustment has subsided, Short below
\
the person begins seriously to consider the future. At elbow

VL.
this point the therapist can discuss social, vocational,
and educational plans with the individual.°
Loss of a body part necessitates a revision and accept-
Ry, Long
elbow
below
ance of the body image. Problems with the acceptance
of the change in body image may cause difficulties in
prosthetic training.**°* Fostering acceptance of the
prosthesis is a primary way to promote the person’s ad-
justment. Establishing a training program that presents
the prosthesis in a manner that meets the person’s
needs and goals has a beneficial effect in integrating the
ai \\ disarticulation
prosthesis into the body scheme. The prosthesis must
become part of the self before it can be used most effec- Transmetacarpal
tively. The prosthesis contributes to a normal appear-
ance, helping the person identify with able-bodied indi- FIG. 48-1
viduals.°?773 Levels of upper extremity amputation.
 Amputations and Prosthetics 929,

appearance should be stressed. The patient needs to and desire for a prosthesis are important factors in
receive reassurance and understanding from the entire making the decision.®
rehabilitation team.*°
LEVELS OF AMPUTATION AND
ee FUNCTIONAL LOSSES IN
SECTION 2
THE UPPER EXTREMITY
Upper Extremity Amputations
The higher the level of amputation, the greater the func-
I. Body-Powered Prostheses tional loss of the arm. Greater functional loss necessi-
DENISE D. KEENAN tates a more complex prosthesis and more extensive
LYNDA M. ROCK training in operation and use of the prosthesis (Fig.
48-1).'? Table 48-1 provides an outline of progressively
higher UE amputations, associated loss of function, and
CANDIDATES FOR PROSTHESES
appropriate components required for a functional body-
Information regarding prostheses and the rehabilitation powered prosthesis.”’'*
program should be provided before the amputation, if
possible, because afterward pain medication and COMPONENT PARTS OF THE UPPER
anxiety may interfere with the person’s ability to process EXTREMITY BODY-POWERED
new information. Team discussion that includes the
PROSTHESIS
patient is vital for determining whether to generate a
prosthetic prescription and, if so, which components to Various prosthetic components are available for each
include, or, alternatively, whether a prosthesis is inap- level of amputation (Fig. 48-2). Each prosthesis is pre-
propriate. The person's age, medical status, amputation scribed according to the patient's needs and lifestyle and
level, skin coverage, skin condition, cognitive status, is custom made and individually fitted. The prosthesis

Amputation Levels, Functional Losses, and Suggested Prosthetic Components

Level ofAmputation Loss of Function Suggested Functional Prosthetic Components
Partial hand Some or all grip functions Dependent on cosmesis and functional loss

~ Wrist disarticulation Hand and wrist function; about 50% of Harness, control cable, socket, flexible elbow
pronation and supination hinges

Long below elbow Hand and wrist function; most pronation and Same as for wrist disarticulation but circular wrist
supination unit

- Short below elbow Hand and wrist function; all pronation and Harness, control cable, socket, rigid elbow hinges,
supination; impaired elbow flexion and extension and biceps half cuff, wrist unit, and terminal device

Elbow disarticulation Hand and wrist function; all pronation and Harness, dual-control cables, socket, externally
supination; elbow flexion and extension locking elbow, forearm shell, wrist unit, and
terminal device

Long above elbow Hand and wrist function; all pronation and Harness, dual-control cables, socket, internally
supination; elbow flexion and extension locking elbow, lift assist, turntable, forearm shell,
wrist unit, and terminal device

Short above elbow All of the above; shoulder internal and external Same as for long above elbow, but socket may
rotation partially cover shoulder, restricting its function

Shoulder disarticulation Loss of all arm and hand functions Same as for long above elbow, but socket covers
shoulder; chest strap; shoulder unit; upper arm
shell; chin-operated nudge control for elbow unit

_ Forequarter Loss of all arm and hand functions; partial or May be same as above but with lightweight
complete loss of clavicle and scapula materials; when minimal function is attainable,
endoskeletal cosmetic prosthesis may be preferred

Bilateral amputation Dependent on levels of amputation Appropriate to level of amputation, plus wrist
flexion unit and cable-operated wrist rotator
 TREATMENT APPLICATIONS

I>
[>

Cable for
locking elbow

Turntable

Internal
elbow

Terminal
device
cable

FIG. 48-3
Prosthetic sock worn under the prosthesis.

Terminal Socket
device
The socket is the fundamental component to which the
remaining components are attached. A cast molding of
FIG. 48-2 the residual limb is used to construct the socket to opti-
Component parts of standard above-elbow prosthesis. (Adapted mize fit, comfort, and function. It fits snugly over the
from Santschi W, editor: Manual of upper extremity prosthetics, ed 2, limb and extends as far as the wrist unit on a below-
Los Angeles, 1958, University of California Press.) elbow (BE) prosthesis, or to the elbow unit on an
above-elbow (AE) prosthesis. It should cover enough of
the residual limb to be stable, but not so much that it
can be either a functional prosthesis or a passive pros- unnecessarily restricts movement. Uneven pressure dis-
thesis. Passive does not mean nonfunctional; the pros- tribution may lead to skin problems.'”’?
thesis provides postural balance and can act as an assist The length of the residual limb determines whether a
to secure items for the functional limb. socket is of single- or double-wall construction. Most
The first five prosthetic components described below sockets have a double wall. The outer wall provides a
are common to all body-powered prostheses prescribed structurally cosmetic surface. The inner wall maintains
for wrist disarticulation and higher levels. They are the total contact with the residual limb’s skin surface to dis-
socket, harness, cable, terminal device (TD), and wrist tribute the socket pressure evenly. Recently, flexible
unit. Many people with UE amputations weara prosthetic frame-type sockets have been favored. The inner socket
sock between the residual limb and the prosthesis.'” is flexible and is covered with a rigid outer frame that
carries the hardware. This type of socket allows for
volume and contour changes that occur when muscles _
Prosthetic Sock
contract and relax. Wearers report that this type of
A prosthetic sock of knit wool, cotton, or Orlon-Lycra is socket is cooler than more conventional alternatives.77
worn between the prosthesis and the limb (Fig. 48-3). The Utah Dynamic Socket is a unique socket design that
Silipos makes a Silo-Line that assists in minimizing hy- provides mediolateral and rotational stability through
pertrophic scarring and may be worn as the prosthetic shaping of the shoulder region.”
sock or covered with a sock. The function of the pros-
thetic sock is to absorb perspiration and protect against
Harness and Control System
irritation that could result from direct contact of the
skin with the socket. The sock compensates for volume The prosthetic control system functions through the in-
change in the residual limb and contributes to fit and teraction of a Dacron harness and stainless steel cable.
comfort in the socket.'”"* The figure-eight harness is commonly used, although
 Amputations and Prosthetics

others are available. The harness is worn across the

back and shoulders or around the chest and fastens to
the socket to secure the prosthesis. The higher the level
of amputation, the more complex the harnessing
system.
Loss of muscle power and range of motion (ROM)
may necessitate variations in the harness design. A prop-
erly fitted harness is important for both comfort and
function.""'°
A flexible stainless-steel cable, contained in a Teflon
housing, attaches to the harness on one end via a T-
bar or hanger fitting and attaches to a functional com-
ponent of the prosthesis on the other end. Spectra
fiber, an ultra strong material, has been used recently FIG. 48-4
The Hosmer-Dorrance hook terminal devices are available in a
instead of the stainless steel cable because it glides
variety of materials, shapes, and sizes that can be matched to the
through the housing with less friction. A BE prosthesis
particular functional needs of a child or adult. (Courtesy of
uses one cable to operate the TD, connected by a ball Hosmer-Dorrance Corp. From Hunter JM, Mackin EJ, Callahan AD:
swivel. An AE prosthesis uses a second cable to lock Rehabilitation of the hand: surgery and therapy, St Louis, 1995, Mosby.)
and unlock the elbow unit. Specific upper body move-
ments create tension on the cables, thereby operating
the prosthesis. A properly fitted control system maxi- neoprene lining increases the holding friction and mini-
mizes prosthetic control while minimizing body mizes damage when holding objects. Neoprene is a high-
movements and exertion. '’"""!* density rubber that wears out faster than the stainless
steel-grid and disintegrates if it comes in excessive
contact with some chemical solutions. The TD must be
Terminal Device
sent back to the manufacturer for neoprene replacement.
The TD, the most distal component, functions to grasp A variation of the standard VO TD is the heavy-duty
and hold an object. When choosing the most appropri- model. This model is made of stainless steel and has a
ate TD for a prosthesis, team members consider the serrated grid between its fingers. The heavy-duty model
_ person’s age and life roles. is designed to hold tools, nails, and such long-handled
Two styles of TDs are commonly prescribed: the instruments as a broom or shovel.
hook and the hand. Many TDs and prosthetic hands A prosthetic hand is also available as a TD. It attaches
have the same shaft size at their base, which allows to the wrist unit and is either passive or cable operated.
them to be interchangeable. Hooks are of two basic The passive hand has cosmetic and lightweight appeal,
designs: canted or lyre shaped.° They may be either vol- but it is also functional because it is used to push, pull,
untary opening (VO) or voluntary closing (VC).” and stabilize objects. The same control cable that oper-
The VO TD opens when the wearer exerts tension on ates the hook activates the functional prosthetic hand. It
the control cable that connects to the “thumb” of the comes in VO and VC styles. Like the hook style TD, the
TD. When tension is released, rubber bands or springs VO hand is preferred and prescribed more often than the
close the fingers of the TD. The number of rubber bands VC hand. A flesh-colored rubber glove fits over the pros-
or springs determines the holding force of the TD. thetic hand for protection and a cosmetic appearance. '*
VC TDs close by tension applied to the control cable. The person’s lifestyle and activities determine the
The tension may also lock the TD and maintain the most appropriate TDs. It is important to provide the
grasp on the object. The VC TD automatically opens by wearer with certain information regarding the differ-
spring operation when the cable is relaxed. The VO TD ences between hook- and hand-style TDs. The hook TD
was most commonly prescribed in the past. Since World is lighter and provides better visibility when grasping
War II, more modern alternatives have become available objects. It is more durable and functional than pros-
(Fig. 48-4).""*° thetic hands. The hook VO TDs are mechanically
VO TDs have several options to better suit the simpler than both the VC TDs and functional prosthetic
wearer's lifestyle. The option chosen depends on the hands. Prosthetic hands provide a more cosmetic ap-
desired durability, weight, or grip of the TD. pearance than the prosthetic hook TDs. However, the
Stainless-steel TDs are prescribed for activities requir- cosmetic glove that covers the hand is easily stained,
ing a durable TD, such as yard work or construction. Alu- wears out quickly, and disintegrates if it comes in
minum TDs are recommended for lighter work and to contact with certain cleaning solutions and chemicals.
reduce the total weight of the prosthesis for a person with Many persons with amputations choose an interchange-
a higher-level amputation. Most TDs have either a neo- able hand for social occasions in addition to a hook TD
prene lining or a serrated grid between their fingers. The for manual work.°
932 TREATMENT APPLICATIONS

Wrist Unit
The wrist unit connects the TD to the forearm socket
and serves as the unit to interchange and to pronate and
supinate the TD for prepositioning purposes. An indi-
vidual rotates the TD by turning it with the sound hand,
by pushing the TD against an object or a surface, or by
stabilizing the TD between the knees and using the arm
to rotate it. With bilateral amputations, TD rotation in
the wrist unit may be accomplished by cable operation.
There are five basic types of wrist units selected accord-
ing to their ability to meet the person’s needs in daily
living and vocational activities: the friction-held unit,
the locking unit, the wrist flexion unit, the oval unit,
and the ball-and-socket unit.
The friction-held wrist units hold the TD in place by
friction provided by a rubber washer or set-screws.
Tightening the washer or screws increases the friction.
There is sufficient friction to hold the TD against mod- FIG. 48-5
erate loads. The friction-held units are mechanically Ball-and-socket wrist unit. (Courtesy of Otto Bock Orthopedic In-
simple but not as strong as the locking unit. dustry, Inc, Minneapolis. From Bowker JH, Michael JW: Atlas oflimb
The locking wrist unit allows the TD to be manually prosthetics: surgical, prosthetic, and rehabilitation principles, St Louis,
1992, Mosby.)
positioned and locked into place. The quick-disconnect
locking wrist unit is most common. An adapter is per-
manently attached to the base of the TD. The unit has a and align the BE prosthesis on the residual limb. When
button on its side that locks, unlocks, and ejects the TD. properly aligned, the hinges help distribute the stress of
Inserting the TD into the wrist unit locks it into place. the prosthesis on the limb.
Another style of TD with the same adapter type on its Two hinge styles, flexible and rigid, are available fora
base may be locked into place. The friction and locking BE prosthesis. Flexible hinges are used on wrist amputa-
wrist units allow the TD to be rotated up and down, but tion and long BE prostheses. They are usually made of
not deviated in toward the body. Dacron and connect the socket to a triceps pad posi-
The wrist flexion unit allows the TD to be manually tioned over the triceps muscle. The flexibility permits
flexed and locked into position. It is generally used on some forearm rotation, decreasing the need to rotate the
the dominant side of a person with bilateral amputa- TD manually in the wrist.
tions for facilitating midline activities close to the body, Medium to short BE prostheses have a socket that
such as dressing and toileting.'"'7'4 covers most of the residual limb below the elbow and
The oval unit, which conforms to the shape of the rigid hinges to provide stability. Rigid hinges are usually
wrist, is used on the wrist disarticulation prosthesis. It is steel and attach to a laminated Dacron biceps half-cuff
thinner than the other wrist units, so the prosthesis may positioned behind the arm, which is sturdier and pro-
more closely match the length of the sound arm. vides more support than the triceps pad. Team members
A ball-and-socket wrist unit is also available (Fig. consider the amount of residual function and the limb’s
48-5). The unique aspect of this unit is that it allows length when choosing the appropriate style hinge for
prepositioning in multiple wrist positions. It has con- the BE prosthesis.”
stant friction, and the magnitude of the loading is ad-
justable.° Elbow Units for Above-Elbow Prostheses
The socket, harness, control system, terminal device, A prosthetic elbow unit is prescribed for the person who
and wrist unit are components common to all body- has had an amputation through the level of the elbow or
powered prostheses. The remaining body-powered pros- higher. The elbow unit allows 5° to 135° of elbow
thetic components maximize function at specific levels flexion and locks in various positions. The two main
of amputation. These components are the elbow hinges types of elbow units are the internally and externally
for BE prostheses, elbow units for AE prostheses, and locking units. The more durable internally locking unit is
shoulder units designed for shoulder prostheses. prescribed for a person who has had an amputation 2
inches or more above the elbow. The unit connects the AE
Below-Elbow Hinges socket to the prosthetic forearm. The locking mechanism
A BE prosthesis employs two hinges, one on each side of is contained within the unit and attaches to a control
the elbow, that attach to the socket below the elbow and cable. A lift assist, which consists of a tightly coiled spring
to a pad or cuff above the elbow. The hinges stabilize attached to the elbow unit and forearm shell, helps
 Amputations and Prosthetics 933.

FIG. 48-6
A, Lateral side of above-elbow prosthesis: a, elbow unit; b, turntable; c, control cable; d, adjustable
axilla loop; e, harness ring; f, figure-of-eight harness; g, elbow lock cable; h, terminal device (TD)
thumb; i, hook TD;j,wrist flexion unit. B, Medial side of AE prosthesis: a, wrist unit; b, hook TD; c,
forearm; d, harness; e, harness ring;f,control cable;g,baseplate and retainer; h, socket; i, turntable;j,
spring-loading device.

reduce the amount of energy required to lift the forearm

shell. The lift assist also allows a slight bounce in the
forearm when walking with the elbow unlocked, which
increases the appearance of a natural arm swing.
A friction-held turntable positioned on top of the
elbow unit allows the prosthetic forearm to be rotated
manually toward or away from the body. The lateral
and medial aspects of an AE prosthesis are shown in Fig.
48-6. The internally locking unit is 2 inches long, and
therefore does not fit on a person who has had an am-
putation close to the elbow.
Correspondingly, the externally locking elbow unit is
prescribed for a person who has an elbow disarticula-
tion or an amputation within 2 inches above the elbow.
This unit, which consists of a pair of hinges positioned
on either side of the prosthesis, attaches the socket to
the forearm. The cable attaches to one of the hinges,
which locks and unlocks the unit.

Shoulder Units FIG. 48-7

Hosmer-Dorrance “Flexion/Abduction Shoulder Joint,’ shown at-
A person with an amputation at the shoulder requires a
tached to a shoulder disarticulation-type prosthesis, provides
prosthesis with a shoulder unit in addition to the TD,
passive mechanical range of motion in flexion to 90° and abduction
wrist unit, forearm shell, elbow unit, socket, harness,
to 135°. An extension stop is provided to restrict extension.
and cables. Because of the high level of amputation, (From Hunter JM, Mackin EJ, Callahan AD: Rehabilitation of the hand:
however, shoulder and back movements are not suffi- surgery and therapy, St Louis, 1995, Mosby.)
cient to use a cable-operated shoulder unit. Thus most
shoulder units are manually operated and friction held.
The TD and elbow units may still be cable operated. unit allows the prosthesis to be locked in various
Two shoulder unit styles that are often prescribed are degrees of shoulder flexion. This feature is helpful
the flexion-abduction unit and the locking shoulder because the prosthesis is heavy and the friction style
joint. The flexion-abduction (or double-axis) unit pro- may not be strong enough.
vides manual prosthetic positioning in flexion and ab- In a forequarter amputation, all or a portion of the
duction and is friction held (Fig. 48-7).° The locking scapula and clavicle is removed with the arm. If standard
934 TREATMENT APPLICATIONS

prosthetic components were used, the prosthesis might m@ Improving ILS status
be too heavy for practical use. Therefore an endoskeletal ® Education regarding prosthetic components and
prosthesis made from lightweight materials such as alu- prosthetic prescription
minum and dense foam is often prescribed to decrease Depending on the level of amputation, medical con-
its weight. The system provides its own style of pros- dition, and ILS status, the decision is made whether to
thetic joints, which will not withstand heavy-duty complete the preprosthetic program on an inpatient or
usage. Many of the TDs discussed earlier may be used on outpatient basis. In most cases in which the person has
the endoskeletal system. had a unilateral amputation, therapy may be completed
on an outpatient basis. A person with bilateral amputa-
UPPER-EXTREMITY PREPROSTHETIC tions may need to be admitted to the facility because of
the amount of therapy and assistance he or she will
PROGRAM
require. The team closely monitors the residual limb
The preprosthetic program begins when the decision to and reports problems to the physician. If the person is
perform an amputation is made or when a person is followed on an outpatient basis, frequent clinic visits
evaluated after a traumatic amputation.® Education re- are necessary to monitor progress.
garding prostheses, relaxation techniques, and general
strengthening may in some cases begin before the surgi- Wound Healing
cal amputation. During the period between the amputa- When the surgical dressing is removed, the residual
tion and the fitting of the prosthesis, the individual par- limb is massaged to discourage scar adhesions, increase
ticipates in a program designed to prepare the residual circulation, aid in desensitization, and reduce swelling.
limb for a prosthesis, facilitate adjustment to the loss, Massage of the limb also helps the person overcome
and achieve maximal independence in self-care.'”'? It is fear of handling the residual limb. Massage over the in-
important for the team to assist the person in securing cision site begins after the incision has healed.* Initially,
the financial resources necessary to complete rehabilita- deep massage over healed areas is performed, followed
tion and obtain a prosthesis if desired. by lighter pressures as tolerated by the person. If skin
grafts have been used, the therapist must communicate
with the surgeon to determine the status before per-
Preprosthetic Evaluation
forming scar massage.
To establish an individualized treatment plan, the ther-
apist must complete a thorough evaluation. The eval- Desensitization
uation includes assessment of the patient’s medical The residual limb may be hypersensitive after surgery
history, assessment of family, work, and leisure activities and require a technique known as desensitization. Mas-
history, and assessment of independent living skills sage is one method of desensitization. Other methods
(ILS) status. are tapping, vibration, constant pressure, and the appli-
A statement of the person’s goals is important for ori- cation of various textures to the limb, such as terry cloth
enting the treatment toward meeting the goals and for and cotton. When the therapist performs the tech-
determining the person’s understanding of the program niques, he or she teaches them to the person and family
and the prosthesis.* members or caregivers to perform on a home program
A tape measure is used to record residual limb length basis.*””
and circumference. Care must be taken to measure the
limb’s circumference at the same place each time. A Wrapping
drawing of the residual limb, with the different levels Shrinking and shaping the residual limb are necessary
that were measured marked off in inches or centimeters, to form a tapered limb that will tolerate a prosthesis.
will help the therapist chart progress. Compression using an elastic Ace bandage, a tubular
bandage, or a shrinker sock applied to the residual limb
aids in the shrinking and shaping process. When an
Preprosthetic Treatment
elastic bandage is applied to the limb, a figure-eight
The treatment plan is based on evaluation results. Most method (Fig. 48-8) is used, not a circumferential
plans include the following: method in which the bandage is wrapped around the
® Wound care limb spirally. Care must be taken to apply the bandage
@ Desensitization techniques smoothly, evenly, and not too tightly from the distal to
@ Wrapping the residual limb to shrink and shape it, the proximal end of the residual limb. Care must also be
and document circumference changes taken to avoid wrapping skin-grafted areas too tightly or
® Education regarding proper skin hygiene without an inner nonadherent dressing applied, so that
# Education regarding care of insensate skin the graft is not compromised. A limb that is wrapped in-
® Maintaining passive and active ROM correctly may not be able to be fitted with a prosthesis
@ Increasing upper body strength and endurance or may take longer to shrink and shape. A BE limb
gana
Amputations and Prosthetics 935

eta Back view

B
FIG. 48-8
Residual limb bandaging. A, Step-by-step procedure. B, Bandaging in progress.

should be wrapped up to or above the elbow. An AE should be washed often with a mild soap, rinsed well,
limb should be wrapped up to or above the shoulder. and allowed to dry thoroughly lying flat. For longer life,
Short AE amputations must usually be wrapped around the bandages should not be wrung out after washing.*
the chest to help stabilize the wrap.'*!* The elastic Shrinker socks have become more favorable than Ace
bandage should be changed several times a day and the bandage wrapping because the individual with the am-
skin checked between wrappings. Several bandages are putation can more independently don the sock and
required so that the limb can be wrapped in a clean because changing the sock is much quicker than chang:
bandage at all times, except when bathing. The wraps ing the wrap. Compressogrip tubing with a knot tied in
936 TREATMENT APPLICATIONS

one end is commonly used. The tubing may be attached strengthen the movements required to operate the pros-
to a chest strap if necessary. thesis. The therapist manually positions and holds the
residual limb in the desired posture and asks the person
Circumference Measurements to resist the hold. In the case of a BE amputation, it is
The residual limb’s circumference measurements are important to strengthen the muscles of the shoulder,
taken often and in the same area to determine when the elbow, and scapula. Pronation and supination move-
person is ready to be casted for a prosthesis. The thera- ments are also important for long BE amputations. AE
pist uses a tape measure to establish baseline and subse- amputation strengthening includes a movement com-
quent measurements (Fig. 48-9). When the edema is bining shoulder depression, extension, and abduction.
gone and the circumference measurements have stabi- Isometric exercises are important and enable the indi-
lized, the limb is ready to be casted. vidual to engage in a strengthening program without
equipment. Exercises may be completed with rubber
Skin Hygiene tubing, elastic band, or strap-on weights. Chest expan-
Instruction in proper residual limb hygiene is an impor- sion is important for higher-level amputations and
tant aspect of the preprosthetic program. The limb when the harness wraps around the chest. A tape
should be washed daily using a mild soap, rinsed thor- measure positioned around the chest helps document
oughly, and patted dry. The limb should dry completely increased chest expansion.
before the wrap or sock is reapplied.* A home program should be provided that contains
exercises for general strengthening, as well as the spe-
Insensate Skin cific movements taught during therapy (Fig. 48-10).
The person with a UE amputation requires instruction
regarding the care and safety of a residual limb that Independent Living Skills Status
lacks all or partial sensation. The person should learn to During the preprosthetic period the person with a uni-
inspect the limb when removing the wrap and washing lateral amputation should be encouraged to use the
the limb. Problems should be reported to the therapist
or physician. The person should also learn to track a ; =e
sensory-impaired limb when completing activities, and
not to use the limb for sensory input, such as by testing

\
water temperature.

Upper Extremity Range of Motion, Strength,

and Endurance
Following medical approval, the person begins exercises
designed to encourage residual limb usage, maintain
|
ROM, and strengthen upper body muscles. Depending
on the level of amputation, the therapist instructs the
person to complete specific exercises that mimic and

FIG. 48-10
FIG. 48-9 Home program of upper extremity strengthening to prepare arm
Measuring residual limb circumference. for prosthesis. Thera-tubing is being used for resistive exercise.
 Amputations and Prosthetics 937

sound arm to perform ILS. If the dominant arm was am- more like an assist or helper than an arm. If the pros-
putated, training may be required for the nondominant thesis is presented in this manner, the wearer may have
limb to assume the dominant role. Practice in writing an easier time accepting it.
and activities requiring dexterity and coordination may The prosthesis training program begins after the
be helpful in the retraining process.'”!7'!> Most individ- final fitting of the prosthesis. Although a treatment
uals change dominance to the sound extremity auto- plan focuses on the wearer's prosthetic goals, some in-
matically. formation and initial training points are common to
In the case of a bilateral amputation, adaptive equip- all prosthesis training programs. These include the fol-
ment should be introduced as soon as possible to in- lowing:
crease the person’s level of independence. The equip- ™ Residual limb and prosthetic sock hygiene
ment may include a utensil cuff secured by elastic or Prosthesis terminology and function
Velcro to the residual limb to aid in eating, writing, and Care of the prosthesis
hygiene; a dressing tree to improve dressing skills; and Prosthesis wearing schedule
loops added to items such as socks and towels. The Prosthesis checkout
person with a bilateral amputation can also learn to Controls training
complete activities using foot skills. Use training
Functional training
Driving
PROSTHETIC INFORMATION
Home program
AND PRESCRIPTION
Follow-up appointments
During the preprosthetic period the person should The prosthesis checkout, controls training, and func-
receive information about the prosthesis and its benefits tional training are individualized according to the level
and limitations. The therapist must be aware of what of amputation.
the amputation and the prosthesis may mean to the
person. In selecting prosthetic components and present-
Residual Limb and Prosthetic
ing the prosthesis, the therapist must consider whether
the person’s primary need is function or cosmesis. There
Sock Hygiene
are several ways to introduce prosthetic components to The person is instructed in residual limb hygiene and
the person: an introduction to a person with a similar care of the prosthetic sock in the early phase of prosthe-
amputation, slides, video, showing a prosthesis, and sis training. The residual limb and armpit should be in-
scheduling a trip together to the prosthetist. spected, washed, and patted dry, and deodorant should
be applied daily. If the person chooses to wear a pros-
thetic sock, he or she should own several, so that a clean
PROSTHETIC PROGRAM
one may be worn daily to decrease chances of skin prob-
The amount of training each person needs depends on lems. The socks should be washed, gently squeezed, and
how fast he or she is able to understand the body me- placed on a flat surface to dry in their original dimen-
chanics required to operate the prosthesis, the person’s sions. Wearing an undergarment under the harness is
problem-solving skills and motivation, the carryover often recommended because it will absorb perspiration
between activities, and the cueing needed to include and protect the axillae and back from irritation. Pros-
the prosthesis in an activity. When a long period has thetic socks and undergarments may need to be
elapsed between the amputation and receiving the changed twice a day in hot weather.'*"*
prosthesis, the person may require more cueing because
he or she has become adept at one-handed activities.
Prosthesis Terminology and Function
Some individuals arrive at therapy already able to op-
erate the prosthesis, whereas others require extensive The wearer should learn the terminology and function of
training. each prosthetic component. This task is important so
The prosthetist and therapist should coordinate the that the person can communicate with the rehabilitation
final fitting of the prosthesis and the initial training team, using terminology understood by all, regarding
session. The therapist may arrange to be present for the difficulties with or repairs needed to the prosthesis.*’'*"*
final fitting. Communication between the wearer, thera-
pist, and prosthetist is essential to ensure that the prosthe-
Care of the Prosthesis
sis fits and functions optimally. The therapist should be
aware of a possible need for prosthesis adjustment and Instructions regarding care of the prosthesis are pro-
consult with the prosthetist if this need becomes evident. vided and reviewed. The socket should be cleaned daily
The prosthesis will not be as functional as a normal with a soft cloth and mild soap and rinsed thoroughly
arm, and training should stress that the prosthesis is with warm water. Cleaning at night is recommended to
938 TREATMENT APPLICATIONS

allow the prosthesis to dry completely. Wearing the more than 10°, except if there are joint or muscle limi-
prosthesis when the socket is wet may lead to skin prob- tations. Pronation and supination of a wrist disarticula-
lems. Components should be cleaned and maintained tion or long BE residual limb with the prosthesis on
according to the manufacturer's or prosthetist’s specifi- should not be less than 50% of the rotation possible
cations. Daily inspection of the prosthesis will help without the prosthesis.
prevent unnecessary problems.* With the elbow flexed at 90° the person should be
able to open the TD fully. The TD is also opened near
the mouth (elbow fully flexed), and again near the fly of
Prosthesis Wearing Schedule the trousers (elbow extended). From 70% to 100% of
A prosthesis wearing schedule is provided and reviewed TD opening should be achieved in these two positions.
during the first training session. Initially the person
wears the prosthesis 15 to 30 minutes, three times a day. Checkout of Above-Elbow
The skin must be closely monitored, and wearing time is and Shoulder Prosthesis
advanced only if the skin remains in good condition. If With the AE prosthesis on and the elbow locked, the
there are no skin problems, the three scheduled wearing person is instructed to move the residual limb
periods may be increased by 30 minutes each day. By the (humerus) into shoulder flexion, extension, abduction,
end of the first week the person should be wearing the and internal and external rotation. The ROM of each of
prosthesis all day. If skin problems occur, the therapist, these is measured. Minimal standards for shoulder
prosthetist, or physician must be notified. The prosthesis ROM with the prosthesis on are as follows: 90° flexion,
should not be worn until the skin problem has cleared. 30° extension, 90° abduction, and 45° rotation. The
Restarting the initial wearing schedule may be necessary previous part of the checkout is not applicable for the
to decrease the chance of more skin problems.” shoulder prosthesis.
As the person’s wearing tolerance increases, the With the elbow unlocked, the individual is instructed
number of rubber bands on the TD can be increased. to flex the shoulder slowly, which flexes the mechanical
Each rubber band added to the TD increases the pinch elbow. The elbow ROM should be about 10° to 135°. The
force by approximately 1 pound. It is best to wait several therapist measures the amount of shoulder flexion, which
days after adding one rubber band before adding should not exceed 45°, required to fully flex the mechani-
another, to allow the residual limb’s skin and strength to cal elbow. The individual should also be able to abduct
acclimate. If adding a rubber band substantially in- the prosthesis to 60° without locking of the elbow.
creases limb pain or skin irritation; it should be removed The individual flexes the elbow to 90°, locks the
until the pain diminishes and skin tolerance increases. elbow, and then activates the TD. Full TD opening
should be attained in this position. The TD is then
opened in full elbow flexion with elbow locked (TD at
Checkout of the Prosthesis
mouth, Fig. 48-11) and extension with elbow locked
When the prosthesis is received, team members check it (TD at fly of trousers). At least 50% of full TD opening
to ensure that it meets prescription requirements, is should be obtained.
functioning efficiently, and is mechanically sound. The With the elbow unlocked, the individual is asked to
prosthesis is checked for fit and function against specific walk and practice swinging the prosthesis without
mechanical standards developed from actual tests on locking the elbow. This action mimics a normal arm
prostheses worn by individuals. Tests performed are swing during gait.
comparative ROM with the prosthesis on and off; The individual flexes the elbow to 90°, locks the
control system function and efficiency; TD opening in elbow, abducts the residual limb to 60°, and then
various positions; amount of socket slippage on the rotates the humerus. The person should be able to
residual limb under various degrees of load or tension; control the prosthesis during this motion. The socket
compression fit and comfort; and force required to flex should not slip around the residual limb, and the indi-
the forearm.'’"’’'*? Communication between the wearer, vidual should not feel pain or discomfort during these
therapist, and prosthetist is essential to ensure an effi- maneuvers. When the prosthesis is removed, the resid-
ciently operating and comfortable prosthesis. The fol- ual limb should not appear discolored or irritated.
lowing methods and standards for the prosthesis The prosthesis checkout also includes a technical in-
checkout were adapted primarily from Wellerson.'* spection of the prosthesis to determine correct length,
Step-by-step instructions for the prosthetic checkout are fit, and mechanical function of all parts. Various forms
available in Wellerson'® and Santschi." have been devised to record all information for the
complete checkout of the prosthesis. The initial check-
Checkout of Below-Elbow Prosthesis out is performed before prosthetic training begins, and
The therapist measures elbow flexion with the prosthe- the final checkout is done after prosthetic revisions and
sis on and off the wearer. The ROM should not differ by adjustments and either during or after training."
 Amputations and Prosthetics

FIG. 48-12
Controls training in front of mirror.

thesis is removed, it should be placed on a surface ready

FIG. 48-11 for the person to don again.
Above-elbow prosthesis checkout: opening terminal device at
mouth with elbow locked in full flexion. Coat Method
The coat method is similar to placing one arm in the
coat sleeve and manipulating the coat to a position
where the other arm can reach the sleeve. The coat
Controls Training
method has two variants. In the first method the person
Controls training is best accomplished in front of a places the prosthesis on a table or bed and pushes the
mirror to help the person learn the minimal motions residual limb between the control cable and the Y-strap
necessary to operate the prosthesis while maintaining from the medial side into the socket. By raising the
proper body mechanics (Fig. 48-12). residual limb or leaning sideways, the individual places
Acquiring skill in the operation of the prosthesis is the harness across the shoulder on the amputated side
emphasized in controls training. The therapist educates and dangles the harness down the back. The sound
the wearer in the importance of the practice drills that hand reaches around the back and slips into the axilla
will ensure more successful function with the prosthesis loop. The person then slips into the harness as if putting
in daily activities. Joint protection, energy conservation, on a coat. The shoulders are shrugged to shift the
and work simplification principles and techniques harness forward and into the correct position.
should be stressed during this phase of training. Each The second method works by placing the axilla loop
prosthetic component should be reviewed separately of the harness on the sound arm first. For example, if
and understood before the components are combined the person has an AE amputation, it may be easier to
into functional activities. Such movements as elbow lock the elbow at 90°, position the axilla loop on the
flexion and TD opening are cable operated. Other sound arm above the elbow, grasp the prosthetic
movements, such as TD or elbow rotation, are passively forearm, and raise the prosthesis over the head, allow-
positioned using the sound hand or an item in the envi- ing the harness to position itself across the back. By
ronment, such as a table. Emphasizing external assists raising the residual limb, the individual positions it in
from the environment is an important part of this train- the socket (Fig. 48-13).
ing process. To remove the prosthesis, the individual uses the TD
to slip the axilla loop off the sound side and then slips
Donning and Doffing the Prosthesis the shoulder strap off the amputated side. The harness is
The two common methods of donning and doffing the then slipped off like a coat.'""""°
prosthesis are the coat method and the sweater method. The person with bilateral amputations can use the
Either method can be used with unilateral or bilateral coat method by placing the prostheses face up on a
amputations. The method used depends on which is surface, placing the longer residual limb into the
easier for the wearer. Whichever the method, the socket, and elevating the prosthesis, allowing the other
harness and cables must not be kinked or twisted prosthesis to hang across the back. The person then
around the prosthesis before starting. When the pros- leans to the side and places the shorter limb in the
940 TREATMENT APPLICATIONS

prosthesis.
'’'* To remove the prosthesis, the individual Sweater Method
shrugs the harness off the shoulders and removes the The sweater method (Fig. 48-14) is equivalent to enter-
prosthesis from the shorter side first. Before removing ing both sleeves at the same time and then raising both
the prosthesis on the longer side, the person should arms up and out to don the sweater. To apply a unilat-
position the prostheses somewhere convenient for the eral prosthesis using the sweater method, the person
next donning. places the prosthesis on a surface face up, positions the
residual limb in the socket under the Y-strap, and places
the opposite arm in the harness. The person then raises
both arms above the head, allowing the axilla loop to
slide down to the axilla and the harness to be properly
positioned across the back and on the shoulders. To
remove the prosthesis, the person raises both arms
above the head and grasps and removes the prosthesis
with the sound arm, while allowing the axilla loop to
slide off the arm."
A person with a bilateral amputation dons the pros-
theses using the sweater method by placing the pros-
theses on a surface, face up. With the longer limb sta-
bilizing the socket, the shorter residual limb is then
positioned under the harness and in the socket. The
longer limb is then positioned similarly under the
harness in the socket, and the arms are raised, allowing
the harness to flip over the head and across the back
and shoulders. The individual removes the prostheses
by shrugging the shoulders to bring the harness up,
grasping it with the TD, and pulling it over the head
while allowing the residual limbs to come out of their
FIG. 48-13 sockets.
Coat method of donning prosthesis.

FIG. 48-14
Sweater method of donning prosthesis.
 Amputations and Prosthetics 941

Controls Training for the Unilateral that allows internal and external forearm rotation. The
Below-Elbow Prosthesis person operates the turntable, first with the elbow at
TERMINAL DEVICE CONTROL. Scapula abduction 90° by manually rotating the forearm medially (toward
and glenohumeral flexion are the motions necessary to the body) or laterally (away from the body).
open and close the TD. The person is instructed to
operate the TD first, by flexing the humerus on the am- ELBOW FLEXION AND EXTENSION. Flexion and
putated side, then by scapula abduction while the extension of the mechanical elbow are the next steps in
humerus remains at the body’s side. The therapist in- the training process. The therapist should protect the
structs the person to operate the TD with the arm in person’s face when teaching elbow flexion control. This
various positions in space, such as overhead and leaning precaution is important because initially the person
over toward the floor. '* may have poor control over elbow flexion, which could
cause the TD to hit the face.’
PRONATION AND SUPINATION. If the residual The therapist makes sure that the elbow unit is un-
limb is long enough for flexible hinges to be prescribed locked. Then the therapist asks the person to flex the
on the prosthesis, pronation and supination should be humerus slowly and abduct the scapula to accomplish
practiced. The therapist asks the person to stabilize the elbow flexion and slowly extend the shoulder to achieve
elbow at 90° and to pronate and supinate the forearm. elbow extension. This movement is repeated until the
If rigid hinges were prescribed, the TD is manually person gains sufficient control to accomplish elbow
rotated in the wrist unit to achieve pronation and flexion and extension smoothly and easily.'’'*
supination. Using the opposite hand or stabilizing the
TD between the knees and turning the forearm or shoul- ELBOW LOCKING. The elbow unit operation has an
der accomplishes manual TD rotation. audible two-click cycle. Both clicks must be heard each
time the unit is locked or unlocked. The same body move-
EXCHANGING TERMINAL DEVICES. The person ment both locks and unlocks the unit. The person is in-
learns to exchange the TD in the wrist unit if more than structed to operate the elbow unit by moving the shoulder
one TD is prescribed. Cable slack is needed to release into a combination of hyperextension, abduction, and
the cable from the TD. To obtain enough slack in the scapula depression. This movement places tension on the
cable, it may be necessary to place an item between the cable that attaches the harness to the elbow unit and may
fingers of the hook or hand. The TD is then removed ac- be difficult to master. The reminder, “Down, out, and
cording to the wrist unit prescribed. When the TD has away” may be repeated until the person develops a propri-
been removed, another TD style may then be positioned oceptive memory. The person is then asked to practice
in the wrist unit and the cable attached to it. locking and unlocking the elbow in various ranges of
To complete BE controls training, the therapist in- elbow flexion and extension (Fig. 48-15).'°""*
structs the person to repeat the motions required to po-
sition and operate the TD, until they are performed in
one continuous smooth and natural sequence in both
sitting and standing positions.'* Once controls training
is completed, functional training may begin to improve
the person’s bilateral and ILS activities.

Controls Training for the Unilateral

Above-Elbow Prosthesis
Most AE prostheses operate through the use of a dual-
control cable system. When tension is applied on the
cable attached to the elbow unit, it locks and unlocks.
When the elbow unit is unlocked, tension on the second
cable attached to the TD raises the prosthetic forearm
(flexes the elbow). A spring assist helps reduce the
amount of effort required to raise the forearm, and gravity
assists in lowering it. When the elbow unit is locked,
tension on the second cable is used to operate the TD. The
person learns to operate each component separately.

INTERNAL AND EXTERNAL ROTATION. Many in-

ternally locking elbow units have a manually operated FIG. 48-15
turntable located between the elbow unit and the socket “Down, out, and away” movement used to unlock the elbow unit.
942 TREATMENT APPLICATIONS

TERMINAL DEVICE CONTROL. The same motions cable. Shoulder flexion and scapula abduction on the
of shoulder flexion and scapula abduction that flex the opposite side also assist in TD operation. Wrist opera-
forearm with the elbow unlocked also control the TD tion is the same as explained for the BE prosthesis.
when the elbow is locked. The person is instructed to
lock the elbow, first at 90°, and perform the motions to Controls Training for Bilateral Prostheses
operate the TD. Care must be taken not to unlock the A person with bilateral amputations usually receives
elbow by placing tension on the cable that operates the two prostheses that are attached to one harness (Fig.
elbow unit. The sequence of elbow positioning, elbow 48-17). Operating one of the prostheses may transmit
locking, TD operation, elbow unlocking, elbow reposi- tension through the harness to the other prosthesis,
tioning, and locking is repeated at various points in the causing it to operate also. The person must learn to
elbow ROM from full extension to full flexion.'’** operate each prosthetic component without affecting
The person then learns how to rotate the TD manu- the components on either side. This skill is called sepa-
ally in the wrist unit and to exchange TDs in the same ration of controls, and the individual may need extensive
manner as described previously for the BE prosthesis. practice to master it. Each prosthesis operates according
Once the AE prosthesis controls are performed in a to the level of amputation as described in the previous
smooth manner, functional training begins. sections, with special attention given to relaxing the op-
posite side (Fig. 48-18).
Controls Training for the Shoulder Two components not generally used on unilateral
Disarticulation Prosthesis prostheses may be prescribed on bilateral prostheses to
A prosthesis prescribed for a person with a shoulder improve the person’s independence. These components
disarticulation may have different components and are the wrist flexion unit and a cable-operated wrist ro-
methods of operation than the AE prosthesis. The pros- tation unit. The wrist flexion unit assists completion of
thesis may have a manually operated, friction-held midline activities and is prescribed either for both pros-
shoulder unit that the person prepositions using the theses or for the dominant side. The ability to achieve
sound arm or a table’s edge. A chin-operated nudge midline is important for completing many activities
control may be used to operate the elbow unit because such as dressing, grooming, and eating. Depressing the
the person does not have the shoulder movements unit's control button and creating tension on the TD
needed to lock and unlock the elbow (Fig. 48-16). A cable operate the flexion unit. The opposite TD, a
cable connects the nudge control to the elbow unit. The surface edge, the knee, or other surface can depress the
person still learns the two-click cycle and dual-cable button. The TD cable must be medial to the flexion axis
system of operation described previously for the AE of the unit to pull the TD into flexion. A spring in the
prosthesis. The elbow turntable is also available for a flexion unit repositions the TD in extension when the
shoulder prosthesis. button is depressed and slack is provided in the TD
A chest harness may be needed to secure the prosthe- cable.
sis on the person. It can also assist TD operation by There are several ways to achieve wrist rotation. One
using chest expansion to increase tension on the TD is by using the wrist units mentioned earlier and rotat-

FIG. 48-16
Nudge control used to operate the elbow unit for shoulder disar- FIG. 48-17
ticulation prosthesis. Single harness for bilateral prostheses.
 Amputations and Prosthetics 943

plish an activity. With an AE prosthesis, the person

flexes and locks the elbow and rotates the turntable
before prepositioning the TD. The person with a shoul-
der disarticulation prepositions the shoulder unit
before the elbow and wrist components. The person
with bilateral prostheses must still preposition all com-
ponents in the same fashion. The goal of prepositioning
eee
eS
is to allow the person to approach the object or activity
as one would with a normal hand and thereby avoid
awkward body movements used to compensate for poor
prepositioning."

Prehension Training
The prosthesis should be regarded as an assistive device
and not as the dominant arm. '* Training objects are used
to allow the wearer to practice TD control. The person
should first use large, hard objects such as blocks, cans,
and jars, and progress to soft, then to crushable objects,
such as rubber balls, sponges, paper boxes, cones, and
paper cups. These objects should be placed in positions
that require elbow and TD prepositioning and TD opera-
tion at various heights. The hook TD has a nonmovable
and a movable finger. Ifa hook is used to pick up objects,
FIG. 48-18
the person is taught to stabilize the item with the non-
Passing a pen from one prosthesis to the other to practice separa-
| tion of controls. movable finger and then release the tension on the
movable finger to secure the object. Prehension training
should be completed using all prescribed TDs.'*’"*
ing the TD by placing it between the knees or by pulling
on the thumb of one hook with the other. Another
Use Training for Bilateral Prostheses
-method is use of a button on the medial side of the
forearm, which controls a cable attached inside the After the person understands how the components
forearm to a wrist-locking device. The wrist is locked operate, he or she gains control of the prostheses by
and unlocked by pressing the button against the side of practicing passing such items as a ruler or a piece of
the body. When the wrist is unlocked, tension on the paper back and forth between the TDs without drop-
TD cable rotates the TD to the desired position. ping them (Fig. 48-18). Another activity that helps the
person learn separation of controls is holding an object
in one prosthesis without dropping it while completing
USE TRAINING
an activity with the other prosthesis.
Use training begins after the person understands how to
operate and control the prosthetic components. This
FUNCTIONAL TRAINING
training applies the mechanics of operation to repetitive
activities. Repetition is important for the wearer to gain Functional training applies concepts of control and use
an understanding of how to preposition the prosthesis training to functional activities. The prosthesis wearer is
and the objects and how to use the environment to help now introduced to completion of specific tasks impor-
preposition them. Along with prepositioning, prehen- tant to him or her. Prehension training and methods
sion training begins. to complete ILS, including prevocational, leisure, and
driving skills, are addressed in this phase. The key to
successful functional training is teaching the wearer a
_ Prepositioning problem-solving approach with respect to the activity
Prepositioning involves moving the prosthetic units in being performed.
their optimum position to grasp an object or perform a
given activity. All prosthetic components must be
Prehension Training
prepositioned in a proximal-to-distal order. Thus the
person with the BE prosthesis rotates the TD into the Prehension training trains the person to use all TDs pre-
desired degree of pronation or supination to accom- scribed in a meaningful manner, such as using the
944 TREATMENT APPLICATIONS

heavy-duty TD with tools and the hand to eat. Such

items as a pencil sharpener, lock and key, jar and lid,
and bottle opener should be used to challenge the
person. '’'* However, initially there are only two or three
rubber bands on the TD, which limit its grip strength. In
bilateral activities the person should be encouraged to
determine the best position and appropriate use for the
prosthesis and the sound arm. For details the therapist
is referred to Santschi’s work on prosthetic training."
Movements become less cognitive and more automatic
during this phase, and prepositioning occurs naturally.

Independent Living Skills

Functional training should progress to the performance FIG. 48-19
of necessary ILS. Activities should be introduced in a Steering ring used for driving with a prosthesis.
simple-to-complex order. The therapist should also ask
the person what areas are important for him or her to be
able to accomplish. The person is encouraged to analyze of modifications will vary, depending on the level of
and perform the activities of personal hygiene and amputation.
grooming, dressing, feeding, home management, com- The occupational therapist is responsible for assess-
munication, and leisure and vocational activities as in- ing predriving skills. A predriving evaluation may
dependently as possible. The therapist may help the consist of an assessment of visual acuity, traffic signal
person analyze and accomplish a task or help achieve it recognition, color vision, glare recovery, night vision,
by means of adaptive equipment or by encouraging rep- peripheral vision, depth perception, reaction time, and
etitious practice to reach maximum speed and skill. The UE function. When necessary, additional cognitive,
sound arm or longer prosthesis should complete most visual, and perceptual skills are evaluated. See Chapter
of the work while the opposite side acts as a stabilizer.'* 14, Section 3, for more information on driving.
Home management skills and child care should be in- Upon completion of the predriving evaluation, the
cluded as part of the person’s assessment when appro- therapist is responsible for making driving recommen-
priate.'* dations. These may include treatment for deficits, refer-
ral to a driver education center for training, and installa-
tion of assistive devices. The therapist's evaluation
Work-Related Activities
should include a statement regarding the person’s
Prevocational evaluation may be included in the reha- potential for safe driving. If the person is unable to
bilitation program. The therapist assesses the person's drive, alternative methods of transportation should be
potential for returning to a former occupation or a pos- explored.
sible change of vocation. A visit to the work site may be In some states people are required to report any
necessary to make recommendations that will enable change in physical health status to the motor vehicle de-
the person to return to work in a safe and efficient envi- partment and to their insurance company. Failure to do
ronment. It may also be necessary to restrict work activ- so may result in a loss of automobile insurance.
ities, such as restricting the amount ofweight the person
may lift and carry or restricting work on ladders. Ini-
Leisure Activities
tially the person may be able to work only part time, im-
proving work endurance gradually. Training and educa- The rehabilitation program should include information
tion for new jobs may be necessary (see Chapter 16). and training regarding leisure interests. With the
person’s and the rehabilitation team’s joint effort and
motivation, the person should be able to return to a
Driver Training
meaningful and productive life. A wide variety of spe-
The ability to drive increases independence and may cialized prosthetic devices are available for all kinds of
enhance vocational opportunities. The person should sports and recreational hobbies. Therapeutic Recre-
be referred to an adaptive driving program where he or ational Systems (TRS)* provides a catalog of prosthetic
she can be evaluated and trained in using assistive devices designed to improve the person’s ability to par-
devices such as a driving ring or a steering knob (Fig.
48-19). The controls of the car, such as the ignition
switch and turn signals, can be modified to improve * 2450 Central Ave., Unit D, Boulder, CO 80301-2844 // (800) 279-
safety and comfort. The amount of training and extent 1865.
 Amputations and Prosthetics 1 Bo)

ticipate in such activities as photography, ball games, II. Electric-Powered Prostheses

and skiing.’ DENISE D. KEENAN
DIANE J. ATKINS

Duration of Training
Externally powered electric upper extremity (UE) pros-
The average adult with a unilateral BE amputation who theses have opened a new world of freedom and function
is otherwise healthy and well adjusted will require ap- for persons with UE amputations. The advent of elec-
proximately 5 hours of training (five to eight treatment tronic microminiaturization has allowed the develop-
sessions) to master control and use of the prosthesis for ment of prosthetic devices with totally self-contained
daily living. The person with a unilateral AE amputation services of power, motor units, and electrodes.° Powered
under the same conditions will require approximately prostheses have existed for decades, but it was not until
10 hours of training. About 12 hours will be required the 1960s that myoelectrically controlled prostheses
for bilateral BE prosthetic training, whereas about 20 were clinically introduced. The activities of the Otto Bock
hours is required for bilateral AE prosthetic training. Company in Duderstadt, Germany, began this process,
The initial training session should be about 1 hour by aiming for the development of an electromechani-
long, and subsequent sessions may be more brief, in- cally driven prosthetic hand that would match both the
creasing in duration commensurate with the wearer's technical and cosmetic demands of ahuman hand.*®
increased prosthesis tolerance and_ physical en- The clinical use of the electric devices began in
durance.*’*'* Europe because of government-supported health care
systems and a large patient population of persons with
congenital (postthalidomide) amputations. By the late
SUMMARY
1970s and early 1980s North America had an increasing
Acquired UE amputations can occur as a result of but limited experience with myoelectric prostheses.’
trauma, infections, neoplasms, and vascular diseases. When funding permits, hundreds of myoelectric pros-
Occupational therapists play an essential role in the re- theses are prescribed for children and adults throughout
habilitation process by addressing residual limb condi- the United States.
tioning and care, preprosthesis exercise, and prosthesis The term myoelectric prosthesis is often used inter-
training. The desired outcomes of OT intervention are changeably with electric prosthesis. A myoelectric pros-
the independent management of ILS and resumption of thesis uses muscle surface electricity to control the pros-
work and leisure roles. thetic hand function. The muscle membrane generates
Working with an individual who has an amputation an electric potential at the time of contraction. The my-
can be a real challenge. Careful assessment of the oelectric signal is sensed, amplified, and processed by a
person’s needs, a creative approach to therapeutic inter- control unit that generates a motor, which in turn drives
vention, and close communication with the team can a terminal device.” This terminal device is often an
make the challenge rewarding and successful. electromechanical hand (Fig. 48-20).* The myoelectric

Electric hand

Motor

Battery
EMG amplifier

EMG electrodes

FIG. 48-20
A typical electric-powered myoelectrically controlled, below-elbow prosthesis with an electro-
mechanical hand terminal device activated by electromyographic potentials. (From Billock JN: Upper
limb prosthetic terminal devices: hands versus hooks, Clin Prosthet Orthot 10[2]:59, 1986.)
 TREATMENT APPLICATIONS

\dvantages and Disadvantages

f Myoelectric Prosthesis

Advantages
|. lmproved cosmesis
2. Increased grip force (approximately 25 Ib in an adult
myoelectric hand)
3, Minimal or no harnessing
4. Ability to use overhead
5. Minimal effort needed to control
6. Control more closely corresponding to human physiological
control

FIG. 48-21 Disadvantages

Surface electrodes, recessed within wall of myoelectric socket, |. Cost of prosthesis
detect muscle contractions. 2. Frequency of maintenance and repair
3. Fragile nature of glove and frequent replacements necessary
4. Lack of sensory feedback (a body-powered prosthesis has
control can be a digital control or a proportional some sense of proprioceptive feedback)
control. Digital systems are operated at only one speed, 5. Slowness in responsiveness of electric hand
allowing them to either turn on or turn off. Propor- 6, Increased weight
tional control means that the myoelectric signal
(power) to the hand is proportional to the level of
muscle signal the wearer generates, so the wearer's effort
directly conrols the speed of the hand.' of prescriptions for myoelectric prostheses for higher-
Myoelectric controls require minimal physical effort level amputees because there functional possibilities are
for operation and rarely require adjustment. The muscle greater.’
groups in the below-elbow (BE) area are used according The task of training a patient with an above-elbow
to their physiological function; that is, the wrist exten- (AE) amputation or shoulder disarticulation to operate
sor muscles are used for hand opening and the wrist and function with a body-powered prosthesis is sub-
flexor muscles for hand closing. Surface electrodes re- stantially more challenging than training with an elec-
cessed within the wall of the prosthetic socket (Fig. tric-powered prosthesis.
48-21) detect muscular contractions. Before a myoelectric prosthesis is prescribed, the
patient should have adequate strength and an ability to
contract muscles independently. A minimum signal of 5
CANDIDATES FOR ELECTRIC-POWERED
microvolts will operate the most sensitive system. The
PROSTHESES
candidate with this minimum signal should be capable
An electric prosthesis might be chosen because of the of developing stronger signals for longer-term prosthe-
combination of a natural appearance and the functions sis use. Independent contraction of each muscle is im-
of high pinch force without a high level of effort. Also, a portant to produce a smooth and controllable pros-
myoelectric prosthesis requires no cables for control, so thetic function. As a general guideline, the prosthesis
the harnessing can be much more comfortable. The can be operated with a 10-microvolt difference, but the
patient's work, home, and recreational needs and activi- wearer will use the prosthesis more easily if a 20- to 30-
ties must all be considered. Previous experience with microvolt difference can be controlled. The surface elec-
other prostheses may also be relevant. tric signals are amplified by a miniature electrode and
In the past, the BE amputation has been the most led to the relay system. The relay is responsible for the
common condition for which these prostheses were energy supply to the battery-operated motor in the elec-
prescribed. For amputation levels above the elbow, the tric hand. When the alternating contractions of extensor
complexity of function and the power level required to and flexor muscles take place, the direction of the
accomplish functional movement increases consider- current changes in the electric motor and the hand
ably. At the same time, the capability of the patient to opens and closes accordingly.®
operate a prosthesis by harnessing body movement via Some rehabilitation professionals who work with pa-
straps and cables, in the traditional body-powered tients who have UE amputation believe that electric
manner, decreases considerably.'° More recently, with components may be the only appropriate alternative for
the advances in technology, there are a greater number high-level unilateral or high-level bilateral amputations.
 Amputations and Prosthetics 947

Conversely, some rehabilitation professionals believe and hook TD with an electric wrist rotator. For bilateral
that body-powered prostheses are the most functional amputees a powered elbow combined with a cable-
and appropriate type of prosthesis for the majority of hook TD offers a very quick elbow and less overall bulk
patients, despite the level of amputation. There are of the prosthesis and dedicates all excursion of the cable
many schools of thought regarding the advantages and to the TD. A hybrid prosthesis can decrease the overall
disadvantages of myoelectric prostheses. The list in Box weight of a prosthesis. It can be less expensive and
48-1 describes some of the points that differentiate complex. All excursion of the existing cable is dedicated
the myoelectric prosthesis from a body-powered, cable- to one component, as opposed to multiple compo-
controlled, hook-type terminal device. nents. This feature requires less overall force on the part
of the amputee for operating the prosthesis.
Training an individual with bilateral limb loss re-
HYBRID PROSTHESES
quires extensive rehabilitation experience, and it is not
A hybrid prosthesis is one that combines body power recommended for the therapist with little or no previ-
with electrical power. These designs have been created ous exposure to the rehabilitation of patients with am-
and used more and more in the past several years. putations. “Centers of excellence,” where rehabilitation
Hybrid prostheses, using various components and of persons with amputations is a specialty area of treat-
control methods from various systems, can in many ment, may be the best rehabilitation choice for the indi-
cases result in a prosthesis that is more functional and vidual with high-level bilateral limb loss.
more acceptable to the individual.* The improved tech-
nology of electric hands has increased the cost of myo-
PREPROSTHETIC THERAPY
electric prostheses. The hybrid design decreases overall
cost of the prosthesis. Some hybrid designs eliminate Awareness of postoperative and subsequent prepros-
the cable and harness, therefore eliminating pressure on thetic principles of care is crucial for the successful man-
the sound side when the prosthesis is operated. One agement ofthe individual who has sustained traumatic
hybrid design involves the use of a body-powered elbow limb loss. The patient has little control over what is hap-
flexion device with a myoelectric hand (Fig. 48-22).* pening and must depend on the health care team to
Another configuration might be the use of a cable elbow provide the best treatment possible.*
The rehabilitation team, which should include the
physician, nurse, occupational or physical therapist,
social worker, and patient, addresses the following goals:
Promote wound healing
Control incision pain
Control residual limb shrinkage and shaping
Maximize joint ROM
Increase strength
Increase ILS independence
Explore patient's and family’s feelings about change
in body
Orient to prosthetic options
Identify or test potential muscle sites for prosthesis
control
= Improve muscle site control and strength (once iden-
tified)
m Explore the patient's goals regarding the future
@ Obtain adequate financial sponsorship for the pros-
thesis and training’
When the sutures are removed, the preprosthetic
program can begin. Most of this program has been ex-
FIG. 48-22 tensively discussed in Section 1 of this chapter. For the
This “hybrid” above-elbow prosthesis uses a thoracic suspension patient receiving a myoelectric prosthesis, the following
and control harness for total suspension of the prosthesis and ac-
paragraphs will clarify the last five goals.
tuation of the Bowden cable-controlled mechanical elbow and
locking mechanism. The batteries and electronic components for
myoelectric control of the hand are self-contained within the Identify Potential Muscle Sites
upper arm of the prosthesis. (From Hunter JM, Mackin EJ, Callahan
AD: Rehabilitation of the hand: surgery and therapy, St Louis, 1995, A myoelectric prosthesis functions by detecting elec-
Mosby.) tromyographic (EMG) signals produced by muscles
948 TREATMENT APPLICATIONS

Locating appropriate muscle sites superficially is the minimum signal required for operating the myoelectric
most important aspect of the successful operation of a system chosen for the patient.”
myoelectric prosthesis. Physical examination of the
forearm can often detect sufficient strength in natural
Muscle Site Control Training
agonist-antagonist pairs, such as the wrist extensor and
wrist flexor contractions in the person with a BE ampu- The more proximal the level of amputation is, the more
tation and biceps and triceps contractions in the person difficult it becomes for the prosthetist to fit the individ-
with an AE amputation. Shoulder amputees often have ual and for the therapist to train that individual. For the
a pectoralis or deltoid site anteriorly and an infraspina- patient to understand the desired muscle contraction,
tus or trapezius site posteriorly. It is difficult to identify the therapist instructs the patient to imitate the desired
proximal muscle sites that both are adequate in signal contraction or movement with both arms. The therapist
and allow the prosthetist to position the electrodes should ask the patient to raise the sound hand at the
within the socket and hold them securely against the wrist (wrist extension) and imagine this motion with
skin. On occasion, trauma or nerve injuries do not the phantom hand on the amputated side (Fig. 48-24).
allow the choice of a natural pair. If a particular site Often a therapist can palpate the wrist flexors and exten-
could cause tissue breakdown under the pressure for an sors on the residual limb during this exercise. The
electrode, avoid it. Often, healed skin or muscle grafts patient is instructed to contract and relax each muscle
can tolerate such pressure very well. Consult the physi- group separately and on command. For this step a myo-
cian when dealing with repaired tissue. If the best electric tester is particularly useful because it indicates
muscle site signals are weak, the therapist and pros- the magnitude of the EMG signal as the patient con-
thetist require a biofeedback system or myotester (Fig. tracts the muscle.
48-23). When surface potentials are being measured The myoelectric tester can be used to train the mus-
with the electrodes and a myotester, it is important that cles with both visual and auditory feedback. Various
all electrodes have good contact with the skin and be models are available to therapists. The goals of training
aligned along the general direction of the muscle fibers. at this point are to increase muscle strength and to
Moistening the skin slightly with water may improve isolate muscle contractions. As confidence and accuracy
the EMG signal by lowering skin resistance. EMG testing improve, the visual or auditory feedback should be
is begun with the most distal portion of the remnant removed. Practicing muscle contractions without feed-
muscles. back teaches the patient to internalize the feeling of
The goal of this testing is to identify two adequate each control movement. The advantage of creating this
muscle sites with the strongest difference between them, internalized awareness of proper muscle control is that
not necessarily the two strongest muscle site signals. The control and strengthening practice can be continued
selection can be considered complete when the patient between treatment sessions without the feedback equip-
can tolerate a 1-hour training session and is consistently ment.” The therapist needs to recognize muscle fatigue,
generating sufficient signals to operate the prosthesis in which is frequently a side effect in this process, and time
such basic functions as opening and closing of the TD. must be given to allow that muscle to relax during the
The therapist should check with the prosthetist for the treatment session.

FIG. 48-23 FIG. 48-24

Otto Bock myotester determines magnitude of muscle contrac- Therapist instructs patient to imitate desired muscle contraction
tion. on both sides.
 Amputations and Prosthetics 949

Ideally the individual with an amputation receives fully charged. Some rechargers require 12 hours of
adequate training and practice in initiating these muscle charging time, whereas others may take as long as 24
contractions before receiving the completed myoelectric hours (Fig. 48-25). A fast charger, requiring only 1 or 2
prosthesis from the prosthetist. Prosthetists commonly hours of charging time, may be available. For best
engage a patient in muscle site training with the results, the batteries should be just about completely
preparatory socket and prosthesis. This. occurs as they drained before recharging. The prosthesis will begin to
strive for optimum electrode placement and socket fit. operate more slowly when the battery is low, and some
This training is not adequate for the majority of patients. unexpected control problems could occur. This is why
Anxiety and frustration often accompany training to use the first troubleshooting step is always, “Make certain
a myoelectric prosthesis, and the development of a team you have installed a fresh battery.””
approach to training by the therapist and prosthetist can Although the myoelectric hand is the most com-
minimize these responses. The patient's success and ef- monly prescribed electric terminal device, a specially
fectiveness in using the prosthesis are closely related to designed gripping device, or Greifer, is also recom-
the quality of the preprosthetic training. mended at times. The Greifer, designed by the Otto
Bock Company, is a universal working tool designed
to handle various specialized tasks. It can be used for
PROSTHETIC PROGRAM
heavy work in industry or farming and provides quick
Orientation of the patient to what the prosthesis realis- handling and precise manipulation of small objects.
tically can and cannot do is an important aspect of a Features of the Greifer include a 38-lb grasp, as well as
prosthetic training program. If the individual has an un- parallel gripping surfaces and a flexion joint for dorsal
realistic expectation about the usefulness of the prosthe- and volar flexion (Fig. 48-26). ®
sis as a replacement arm, he or she may be dissatisfied Instruction manuals from the manufacturer for the
with the ultimate functioning of the prosthesis and battery charger and the prosthesis are often provided for
may reject it altogether. It is imperative that the thera- the individual's reference, and they are excellent tools to
pist be honest and positive about the function of the use for review and education.
prosthesis. If he or she believes in and understands the
functional potential and limitations of the prosthesis, Independence in Donning and Doffing
success can be more realistically achieved.* the Prosthesis
The individual should be able to put on and remove the
prosthesis independently. With proper instruction and
Orientation and Education
the help of the prosthetist in suspension design, the
Training with a prosthesis should begin as soon as the patient should be able to do this. Donning the prosthesis
prosthesis is received, preferably the same day.-An excel- should be performed with the electronics in the off posi-
lent resource in the training process of a patient with a tion to prevent any uncontrolled movements. A person
myoelectric hand is in the text Comprehensive Manage- with a BE amputation usually has the great advantage
ment of the Upper Limb Amputee.* of not needing a harness and control cables because a
Important areas to review during the initial visits are
orientation to prosthesis terminology and operation,
independence in donning and doffing the prosthesis,
orientation to a prosthesis wearing schedule, and care of
the residual limb and prosthesis.

Orientation to Prosthesis Terminology

Considering that the prosthesis is a natural extension of
the individual’s body, it is particularly important to
know the function and names of the major parts such as
the electrodes, battery, glove, and electric hand. The
initial visit is an appropriate time to review the battery-
charging procedure with the patient.
The batteries are energy-storing devices, and most are
rechargeable. Some prosthesis control systems use a 9-
volt disposable battery. The prosthetist supplying the
prosthesis will instruct the patient in proper installation
and recharging. Rechargers are plugged into a standard FIG. 48-25
electrical outlet. Most manufacturers’ rechargers have Battery of myoelectric arm is inserted in battery charger and
some indicator to alert the patient when the battery is charged overnight.
 TREATMENT APPLICATIONS

and lukewarm water. It should be rinsed thoroughly

and dried using patting motions with a towel, so as not
to irritate sensitive or scar tissue.
The prosthesis may be cleaned with soap and water
by using a damp cloth. Rubbing alcohol may be used to
clean the inside of the socket if an odor develops. The
cosmetic glove stains easily; special attention should be
paid to avoiding ink, newsprint, mustard, grease, and
dirt. Wiping with soap and water or a glove cleansing
cream obtained from the prosthetist will remove
general soil but not stains. The average life of a glove
is approximately 6 months. Polyvinylchloride (PVC)
plastic gloves are the least expensive, most flexible, and
toughest. Silicone gloves are being used more frequently
because the new silicone formulas are tougher and min-
FIG. 48-26 imize the yellowing and brittleness that frequently sets
Myoelectric Greifer is designed as universal working tool with par-
in with age, and allow the greatest cosmesis.* The pros-
allel gripping force of up to 38 pounds.
thesis itself should never be immersed in water because
this will seriously damage the internal electronic com-
ponents. Additionally, it is important to advise myoelec-
supercondylar suspension at the elbow is often used. The tric wearers against excess vibration, sand, dirt, and the
wearer can slip the arm directly into the socket. extremes of heat and cold. These, too, can seriously
Suspension designs for the person with an AE ampu- impair the electronic components.
tation frequently require a pull sock for donning the The prosthesis should be checked occasionally for
prosthesis. This provides close contact with the limb, loose screws and harness attachments, and these should
particularly for very short residual limbs. The wearer be brought to the attention of the prosthetist. The covers
must be sure not to start with the stocking too high on of the prosthesis should not be opened unless the pros-
the residual limb because this will increase friction thetist instructs the wearer or therapist to do so.
during pull and make it harder to pull the sock out of
the bottom of the socket. It may be necessary to experi-
Control Training
ment with different sock materials, powder on the skin,
and donning techniques until the most successful mate- The first function to master is opening and closing the
rials and techniques are identified. hand. The individual now understands the muscle
Good electrical contact is achieved after approxi- contractions required to perform these actions. Simple
mately 1 minute of donning. A wearer can also moisten opening and closing of the hand are practiced. The
the skin at the electrode sites to eliminate the waiting muscles should contract as independently as possible.
period for perspiration to occur. The prosthetic arm Next, the patient practices opening the hand halfway,
should be stored in the off position with the batteries then stopping and relaxing so the hand does not
removed. The hand should be fully opened when move. If a proportional control system is used, the
stored, to keep the thumb web space stretched. patient can also practice opening and closing quickly
and slowly.
Orientation to a Prosthesis Wearing Schedule
Initial wearing periods should be no longer that 15 to
Use Training
30 minutes. This limit is particularly important if scar-
ring Or insensate areas are present on the residual limb. Repetitive grasp and release of objects are introduced
If redness persists for more than 20 minutes in a pattic- after control training. Simple approach, grasp, and
ular area after prosthesis removal, the patient should release activities are practiced with objects of various
return to the prosthetist for adjustments. If no skin shapes, sizes, and densities. It is important for the indi-
problems exist, the wearing periods can be increased in vidual first to visualize how the object should be ap-
30-minute increments two to three times a day. By the proached and grasped, and then to preposition the my-
end of a week, full-time wearing should be achieved. oelectric hand. Prepositioning involves placing the
terminal device in the optimum position for a specific
Care of the Residual Limb and Prosthesis activity. In approaching a glass, the hand should face in
Appropriate care of the skin is vitally important. The toward the midline to grasp the glass as a normal hand
residual limb should be washed daily with mild soap would (Fig. 48-27). The fingers of the hand should not
 Amputations and Prosthetics 951

be positioned downward because a normal hand does in the patient with a BE amputation. This response
not approach a glass in this position. should become automatic if there has been good pre-
Working on approach, grasp, and release in multiple prosthetic training of the muscles.
positions follows practice with more simple activities. Eventually the ability to perform specific movements
The patient with an AE amputation who uses a body- will take less cognitive effort and the movements
powered or electric elbow should make certain the become. automatic. The wearer now has muscle en-
angle of elbow flexion is appropriate to complete the durance and prosthesis tolerance for 1-hour therapy ses-
grasp in a natural manner. Often the patient adjusts the sions. Next, functional use activities are introduced into
body using compensatory body motions rather than the therapy program.
adjusting the elbow position or prepositioning the
hand first. It is important to avoid this because it looks
Functional Training
unnatural, becomes habitual, and may lead to second-
ary musculoskeletal problems in the neck, shoulder, or The prosthesis is used as a functional assist in the ma-
trunk. A mirror can help the patient see the way the jority of bilateral activities. Therefore most activities of
body is positioned and visualize how the sound arm daily living (ADL) will be accomplished with the un-
would approach a particular object or activity. It is involved arm and hand. Other than perhaps for prac-
often necessary to remind the patient to maintain an tice, it is not appropriate to train a person with a uni-
upright posture and avoid extraneous body move- lateral amputation to eat holding a spoon, write, or
ments. brush his teeth using the myoelectric hand. In almost
Another important goal of training an individual to all cases the sound hand becomes the dominant ex-
grasp an object is mastering pressure control or the tremity and performs these tasks. Occasionally, if the
gripping force of the terminal device. This skill involves right arm was dominant and is amputated and the in-
close visual attention to grade the muscle contraction dividual is fitted with a myoelectric hand in a timely
for a specific result in the myoelectric hand. Foam pack- manner, he or she may prefer to use the myoelectric
aging bubbles, paper cups, and ping-pong balls work hand for some of these activities. The critically im-
well for developing this skill. The individual must learn portant component of sensory feedback is often the
how to pick up the object without crushing it. Too determining factor in deciding which hand to use. A
strong a grasp crushes the object being held (Fig. 48-28). person with an amputation almost always chooses to
Good grasp control through training with foam, cotton
balls, or wet sponges will help develop the control
needed to handle paper cups, eggs, potato chips, and
sandwiches or even to hold someone's hand."
Release is accomplished by visualizing a wrist exten-
sion contraction, or a quick “hand up” or “hand.open”

FIG. 48-27 FIG. 48-28

When approaching glass, hand is prepositioned in midline to grasp Above-elbow amputee demonstrates how excessive grasp crushes
glass as normal hand. object (plastic cup) being held.
 TREATMENT APPLICATIONS

of Myoelectric Hand and Sound Hand in Bilateral Activities of Daily Living

Activity Myoelectric Hand Sound Hand
Cutting meat Hold fork with prongs facing downward; Hold knife
hold knife as grip strength increases Hold fork

Opening a jar (Fig. 48-29) Hold the jar Turn the lid

Opening a tube of toothpaste Hold the tube Turn the cap

Stirring something in a bowl Hold the bowl with a strong grip Hold the mixing spoon or fork
Cutting fruit or vegetables Hold the fruit or vegetable firmly Hold the knife to cut
(Fig. 48-30)
Using scissors to cut paper Hold the paper to be cut Use scissors in normal fashion

Buckling a belt Hold the buckle end of belt to keep stable Manipulate long end of belt into buckle
Zipping a jacket from bottom up Hold anchor tab Manipulate pull tab at base and pull upward
Applying socks Hold one side of socks Hold other side of socks and pull upward

Opening an umbrella (Fig. 48-31 ) Hold base knob of umbrella Open as normal

perform activities with a hand that has feeling. A my-

oelectric hand lacks this sensory feedback. Feedback is
provided more proximally with the action of muscle
contraction, yet responding to this is difficult for the
wearer.
The therapist should review a list of bilateral ADL
tasks with the patient to determine which tasks are most
important to accomplish. These are the activities to
focus on in training, stressing throughout that the myo-
electric hand is used as an assist and stabilizer. If unilat-
eral tasks are presented to the patient, his or her need to
operate the prosthesis is minimized or absent. These
tasks should be avoided. The bilateral activities listed on
Table 48-2 are good examples to review and practice.
With practice, these activities and many others will
be easier and automatic to perform. It is important to
reinforce and emphasize the fact that bathing, groom-
ing, and hygiene skills involving water must be done
without a myoelectric hand because of the damaging
effects of water on the electric motor and battery.

Vocational and Leisure Activities

As training proceeds and a sense of self-acceptance and
comfort with the amputation is achieved, a therapist
should broach the subject of return to work. Ideally the
therapist makes an on-site visit. If possible, the various
job requirements can be discussed and then practiced
in a simulated, step-by-step process. If changes and ad-
justments to the work environment are necessary, the
therapist could advise in these modifications. FIG. 48-29
Recreational activities are also critically important to Opening jar is accomplished with myoelectric hand holding jar and
discuss at this time because these activities contribute not sound hand turning lid.
FIG. 48-30
Cutting apple is accomplished with myoelectric hand holding apple
while sound hand holds knife to cut. FIG. 48-32
Amputee Golf Grip is high-performance prosthetic golf accessory
that allows smooth swings and complete follow-through.

FIG. 48-33
FIG. 48-31 Super Sports terminal device is highly flexible, strong, prosthetic
Opening umbrella is accomplished by holding base knob of um- sports accessory for volleyball, soccer, football, floor exercise gym-
brella with myoelectric hand and using sound hand to open as nastics,or any activity in which shock absorption, safety, and bilat-
normal. eral control are important.

953
954 TREATMENT APPLICATIONS

only to physical well-being but also to psychological well- of AE, shoulder disarticulation, and bilateral limb loss,
being. The terminal devices for recreational activities are significant training and expertise on the part of the ther-
not myoelectric. As discussed in Section I, Therapeutic apist are essential.
Recreation Systems (TRS) has some excellent TD adapta- The potential of individuals with amputation is
tion components, including an Amputee Golf Grip (Fig. limitless, and often they are able to accomplish activi-
48-32) anda Super Sports terminal device (Fig. 48-33). ties one never would have predicted. The success of
rehabilitation does not rest solely on the quality of
Home Instructions training in the use of the prosthesis. Rather, success
At the conclusion of training, home instructions that depends on such complex factors as the quality of
include a wearing schedule, care instructions, and addi- medical management, the type and fit of the prosthe-
tional tasks to practice should be shared with the sis, the patient's interest in learning the use of the
patient and his family. A follow-up appointment should prosthesis, and the conscientious follow-up of the in-
be made at this time, as well as a list of the rehabilita- dividual once the rehabilitation phase is complete.
tion team members and their telephone numbers, to Follow-up. is critically important and often over-
enable the patient to contact the appropriate person looked. Perhaps the most important aspect of a suc-
when problems arise. cessful rehabilitation program is the motivation and
the desire of the person with amputation to become
more independent. As a team member, this aspect is a
SUMMARY
pivotal ingredient to cultivate and reinforce. The effect
The rehabilitation process of a person with upper limb a therapist has during this important process will
loss can be challenging and rewarding. In the instances remain with the patient for life.

CASE STUDY 48-1

Case StubYy—Mnp. K.
Mr. K. is 41 years old. He has lived in poverty all his life. He ts in- to strengthen the control movements were initiated. The names
tellectually limited. Mr K. recently sustained an above-elbow and functions of all parts of the prosthesis were reviewed, and
AE) amputation of the nondominant left upper extremity (UE) Mr K. practiced putting on and removing the prosthesis
as the result of a traumatic injury. The residual limb is well smoothly and efficiently. Control training included practice in
healed with good shrinkage. There is no pain in the residual elbow flexion, elbow locking, elbow and wrist rotation, and ter-
imb. There are no medical complications. Mr. K. is performing minal device opening and closing in sequence. Training in grasp
most self-care activities independently, using the sound right and release of objects of various weights, textures, sizes, and
arm, except for bilateral activities such as cutting meat, button- shapes in a variety of positions (cans, wood cylinders, pencils,
ing the shirt, applying deodorant, carrying large objects, and cabinet handles, doorknobs) was completed. ADL bilateral activ-
tying shoes. He needs some assistance in analyzing methods for ities addressed included fastening trousers, handling a wallet,
one-handed performance. tying shoes, cleaning fingernails, applying deodorant, tying a
Mr. K. is receiving state aid, and a prosthesis and vocational necktie, buttoning a shirt, using the phone, cutting food, planting
training have been authorized for him. He has worked as a janitor seeds in a pot, and playing cards. Work simulation activities in-
and as a field hand picking vegetables in the past. He reads the cluded cleaning the floor, emptying trash, assembling electronic
basic vocabulary necessary for everyday life at home and in the parts, and using hand tools.
street (e.g., signs and newspaper headlines). When employed, Mr Mr. K. tolerates the prosthesis throughout full daytime hours.
K. is a steady and hard worker He is married and has four chil- He has worn it for 100% of his community and social outings.
dren, all living at home. His interests are watching television, He is incorporating tt automatically into 75% of his bilateral
playing cards, and gardening. ADL tasks. The shoulder muscles have increased in strength to
Mr. K. is accepting the prosthesis and is no longer depressed grade 4+/5, but he does fatigue with constant use longer than
about the loss of his arm. He appears to be well motivated for 2 hours, requiring a brief respite from use. Mr K. is pleased with
the prosthesis and for return to employment. He was referred to the simple household maintenance activities he has been able to
occupational therapy for prosthetic training and vocational evalu- perform with the help of the prosthesis. He is anxious to return
ation. to gainful employment and has met with the vocational coun-
Progressive resistive exercises to increase the strength of the selor two times, with a third visit for prevocational testing
shoulder rotators and adductors and manual resistive exercises scheduled.
 Amputations and Prosthetics 955
{
——_——————————— middle, and lower third indicate the distance below the
SECTION 3 ischium for AKAs and the distance below the tibial
Lower Extremity Amputations plateau for BKAs.*° The Symes amputation is equiva-
t —_ lent to an ankle disarticulation with loss of ankle and
t PATRICIA ANN MORRIS foot function. In a transmetatarsal amputation the foot
' . is severed through the metatarsal bones and ankle func-
: LEVELS OF AMPUTATION AND tion remains intact. Loss of the small toes does not
: FUNCTIONAL LOSSES IN THE result in any significant functional impairment. Loss of
: LOWER EXTREMITY the great toe, however, prevents toe-off during ambula-
tion.
The higher levels of lower extremity (LE) amputation
result in more functional loss and a greater need for a TYPES OF PROSTHESES
prostheses for function and cosmesis. They require
more complex and extensive prostheses. Levels of am- The pylon, a temporary prosthesis, serves as a working
putation are shown in Fig. 48-34. prosthesis. It allows the patient to use the proximal
Hemipelvectomy and hip disarticulation amputa- musculature of the residual limb and maintains joint
tions result in loss of the entire LE; hip, knee, ankle, and ROM, and it provides the sense of pressure, motion, and
foot functions are lost.* Above-knee amputation (AKA) weight that is similar to that of the actual prosthesis
and knee disarticulation amputations result in loss of (Fig. 48-35).°° The immediate postoperative ischial
knee, ankle, and foot motion. The residual limb length weight-bearing prosthesis (IWBP) (Fig. 48-36), de-
of the AKA varies from 10 to 12 inches (5.4 to 30.5 cm) signed by Dr. Madan Telikicherla, is an early fitting pros-
below the greater trochanter.””*° thesis that is fabricated and adjustable to an individual's
Below-knee amputations (BKA) result in a residual
limb that is approximately 4 to 6 inches (10.1 to 15.2
cm) in length from the tibial plateau.*°*° Other systems
classify the levels of amputation into thirds: upper,

Complete Complete
hip hip
Complete
thigh

Upper 1/3
ial : Above
ie Middle 1/3 pe
Lower 1/3

Complete Knee

lower leg disarticulation

Upper 1/3

Partial ; Slow
leg Middle 1/3 casa

Lower 1/3

Complete tarsal syme's . i Ga

Partial tarsal a « 4
Complete phalange

FIG. 48-34 FIG. 48-35

Levels of amputation and functional losses in the lower extremity. A typical pylon.
 TREATMENT APPLICATIONS

FIG. 48-37
Canadian prosthesis used for the hemipelvectomy and hip disartic-
FIG. 48-36 ulation amputations.
Immediate postoperative ischial weight-bearing prosthesis.

height and weight.*® It can be fitted to persons with The Canadian-type hip disarticulation prosthesis
BKA, AKA, and knee disarticulation amputation as early meets the needs of patients who have had a hemipelvec-
as the first postoperative day. Previous methods of early tomy or hip disarticulation (Fig. 48-37). This prosthesis
weight bearing and ambulation have been associated is suspended from the pelvis by straps and equipped
with such complications as separation of the layers of with hip and knee joints and a solid ankle, cushioned
surgical wound (wound dehiscence). The unique heel-type foot (SACH foot). Pelvic movements activate
design of the IWBP bypasses weight bearing through the prosthesis.”’
the residual limb, thus protecting the surgical wound The patient with an AKA benefits from either a
and preventing the pain usually associated with early suction socket or a conventional above-knee prosthesis.
weight bearing. Use of the IWBP under the super- The conventional socket prosthesis is held in place by
vision of a physician, an occupational therapist, a phys- a silesian bandage or pelvic belt."’*'’?? As its name
ical therapist, and a prosthetist enables the patient to implies, the suction socket is held in place by negative
achieve functional ambulation and independent mobil- air pressure or suction. Both these prostheses have a
ity. Within a week of surgery, and almost a full month quadrilateral socket, a knee joint that permits flexion
before the patient can be fitted for a regular prosthesis, and extension, a shank, and a SACH foot.
stairs and uneven terrain can be negotiated. This early Patients with BKA use either the patella tendon-
independence results in increased self-esteem and bearing (PTB) prosthesis or the standard BK prosthesis.
dignity and enhances the patient’s quality of life. Fur- The PTB prosthesis has a-soft socket for the BK residual
thermore, early mobility can potentially reduce the re- limb. It is composed of a strap around the thigh, just
habilitation stay and the risk of medical complications above the patella,"’’*' for suspension, a shank, and the
associated with immobility.7® ankle-foot assembly.'* The standard BK prosthesis con-
 Amputations and Prosthetics 957

i
}
The physician is responsible for coordinating the
{
t
team’s efforts, making decisions on the patient's general
medical condition, and ordering appliances.””
The occupational therapist assesses occupational per-
formance areas and performance components. Based on
the evaluation, the therapist designs a treatment
program, in concert with the patient and the family, to
facilitate achievement of maximum independence. In-
cluded are recommendations for adaptive devices and
durable medical equipment designed to enhance the
person’s independence and safety for reentry into the
community.
The physical therapist evaluates and treats the physical
problems (e.g., strength, ROM, coordination, balance,
and gait) of patients from the preprosthetic through
prosthetic phases of the treatment program. The physical
therapist recommends whether to fit the patient with a
prosthesis. If a prosthesis is recommended, the physical
therapist recommends the prosthetic components. The
physical therapist may also act as clinical coordinator of
the treatment team.
The prosthetist fabricates and modifies the prosthe-
sis, recommends prosthetic components, and shares
data on new prosthetic developments.
The social worker is the financial counselor and coor-
dinator. The social worker acts as liaison with third-
party payers and community agencies and helps the
family cope with social and financial problems.
The dietitian consults with any patients needing
ey,
dietary guidance, especially those with diabetes.
FIG. 48-38 The vocational counselor assesses the patient's em-
Plastic Syme prosthesis. ployment potential and helps with education, training,
and job placement.
The nursing staff is responsible for administering
medications, monitoring vital signs, and caring for the
sists of a thigh corset, lateral hinges for a knee joint, a wound. The nursing staff is also responsible for daily
shin piece, and the ankle-foot assembly. dressing changes, inspection of the surgical site, and
The person who has had a Syme’s amputation uses helping with prevention of contractures and decubiti.'*
the Canadian-type Syme prosthesis or a plastic Syme As the patient continues to progress, the nurse encour-
(Fig. 48-38). This prosthesis consists of a total con- ages performance of activities that have been learned in
tact plastic socket and SACH foot; there is no ankle physical and occupational therapy.
joint.?’
Transmetatarsal and toe or multiple toe amputations OCCUPATIONAL THERAPY
do not require prostheses. A shoe-toe-filler is all that is INTERVENTION
needed.”'*’
The occupational therapist begins the assessment to de-
termine the patient's functional status in the occupa-
REHABILITATION TEAM tional performance areas, performance components,
Rehabilitation of the patient with LE amputation is best and performance contexts.’’** Before the initial assess-
accomplished with a team approach.”’*’'® The rehabili- ment the occupational therapist reviews the patient's
tation team consists of a physician, occupational thera- medical record. The chart contains important medical
pist, physical therapist, prosthetist, social worker, voca- history such as date and level of amputation, surgical
tional counselor, and of course, the patient. Other procedure performed, etiology, disease processes that
health professionals who often contribute to the team may be associated with the amputation, presence of am-
are the nurse, dietitian, psychologist, and possibly an putation-associated symptoms, medications, and medi-
administrative coordinator. cal history.
958 TREATMENT APPLICATIONS

The goals of OT for the patient with lower extremity rest of the rehabilitation team. Positions encouraging
amputation are as follows: knee and hip flexion, such as prolonged sitting in a bed
1. Decrease edema or chair, are avoided. In supine or sitting positions,
. Prevent contractures pillows should not be placed under the knee in a BKA,
. Maintain or increase ROM under the residual limb in an AKA, or between the legs,
. Increase strength and endurance because these positions encourage knee flexion, hip
. Improve posture flexion, and hip external rotation, respectively.®
. Decrease pain The patient with BKA benefits from the use of a
. Increase mobility support for the residual limb in the wheelchair. The
WN
SP
MN
ANA. Educate the patient and family about limb care and wheelchair padded extension (also called a stump
prosthesis care and wear board) allows the patient to be up and reduces the
9. Provide adaptive devices and durable medical chances of increased edema by not allowing the de-
equipment pendent posture of the residual limb (Fig. 48-39).
10. Assess the home for accessibility To prevent decubiti, the patient is instructed to
The occupational therapist must be mindful of the perform pressure relief and daily skin inspection tech-
importance of eliciting the cooperation and acceptance niques. The wheelchair-bound patient should relieve
of the family in order to achieve treatment goals. pressure every 15 minutes. Pressure relief can be ac-
Proper positioning, edema reduction techniques, complished by weight-shift relief techniques or wheel-
therapeutic exercise and activity, pain desensitization chair push-ups. When the patient is in bed, prone-
techniques, mobility and transfer training, and support lying, side-lying, and supine positions are alternated
groups with similar patients are some of the methods every 2 hours. Skin inspection techniques, using a long-
used to achieve these goals. handled mirror, are conducted once or twice a day.

Treatment of Occupational Edema Reduction

Some edema is a normal postsurgical occurrence. An
Performance Components
early rehabilitation goal is to reduce edema. If edema
Soft Tissue Integrity persists, it can cause such secondary complications as
The prevention of soft tissue contractures is an immedi- pain, contractures, and soft-tissue adhesions. After sur-
ate postoperative concern.’ Positioning techniques are gery, elevation is commonly used to reduce edema.*”
used to prevent abduction, flexion, and external rota- Another method used to control edema is a rigid
tion of the hip and flexion of the knee."’*"*’ To prevent removal dressing, developed in the early 1960s by or-
hip flexion contractures, patients are instructed in lying thopedic surgeons in Europe. The residual limb is fitted
prone and are encouraged to sleep and rest in the prone with a plaster of Paris socket in the configuration of the
position. A positioning schedule is established in col- final prosthesis (Fig. 48-40). It greatly limits the devel-
laboration with the patient and is communicated to the opment of postoperative edema in the residual limb,

FIG. 48-39 FIG. 48-40

Wheelchair with support for residual limb. Rigid removal dressing.
 Amputations and Prosthetics 959

thereby reducing postoperative pain and enhancing the cardiovascular system, and increase endurance for
wound healing.* The cast is changed approximately performing functional activities. The scapula depres-
every 10 days, or more often if the cast becomes loose, sors, elbow extensors, and wrist extensors are required
until the residual limb is healed and ready for a perma- for transfers and ambulation. Trunk exercises are incor-
nent prosthesis. porated into the program to facilitate mobility and
The cast is held in position with a canvas band and transfers when performing self-care activities such as
secured with a Velcro strap.* The occupational therapist hygiene and LE dressing at bed or wheelchair levels. All
can also incorporate Ace bandage wrapping techniques patients, especially older patients, require close moni-
or the use of a shrinker sock into the patient program. toring for signs of fatigue and shortness of breath when
There are several methods of wrapping the limb. Most exercising.
methods are based on similar principles. These include Some methods to improve the patient's endurance
diagonal bandaging and application of firm, even pres- include increasing the number of repetitions of an exer-
sure distally. The pressure decreases as the bandage is cise or activity within the same time allotment, increas-
applied proximally. The bandage is reapplied as ordered. ing the total time the patient performs the activity, or in-
The advantages of wrapping are that it allows for the creasing the distance the patient propels a wheelchair.
patient's contouring and frequent checking of the Wheelchair mobility can be graded from level surfaces
wound. The disadvantages are that improper wrapping to uneven surfaces to ramps. It provides UE exercise and
may result in a poorly shaped residual limb and impair- endurance, as well as wheelchair mobility training.
ment of blood supply to its distal portion.*”
Because of the disadvantages of wrapping, the clini- Postural Control
cian may recommend a shrinker sock.*” The primary The center of gravity changes in patients with either AKA
advantage of the shrinker sock is that it is easily applied or BKA. The seating system should be considered when
and removed. The shrinker sock is donned as follows: the wheelchair is used for mobility before the final
1. The sock is turned so that the bulky seam at the end prosthetic fitting. The standard wheelchair has a
is on the outside. hammock-type seat, which causes poor postural align-
2. The top is turned so that it is folded back on itself ment, unequal distribution of weight, decreased
about two thirds of the way. balance, and instability for the patient who sits in the
3. The end of the sock is stretched so that it fits wheelchair for long periods. A solid seating system is
smoothly on the end of the residual limb. recommended to maintain good postural alignment,
4. The sock is gently pulled up over the limb.* weight distribution, balance, and stability.
The therapist instructs the patient to don and doff Patients with total hip disarticulation and hemi-
the sock and periodically to check its fit. There are two pelvectomy benefit from a hemipelvectomy cushion in
reasons to check the sock: to prevent sock wrinkles and the wheelchair. The cushion is made of molded, vis-
to prevent the top rim ofthe sock from rolling over onto coelastic foam with a polyurethane foam bottom layer
an elastic band. The latter impairs circulation and and has a contoured seating surface. It provides light
causes distal edema; the former may irritate the skin and pressure relief. These features provide superior weight
cause skin breakdown. The major disadvantage of the distribution and pressure relief and improve overall po-
shrinker sock is that it is available in only a limited sitioning and support.*’’” For the patient with a BK am-
number of sizes. putation, proper positioning of the residual limb will
In addition to controlling edema, both wrapping require a support system to prevent knee flexion con-
and shrinker socks prevent hemorrhage, promote limb tractures and help control edema.
shaping, provide a sense of security, assist in desensiti- For patients with bilateral AK amputation, the center
zation, and aid in venous return. Ace bandages and of gravity is affected because ofthe significant change in
shrinker socks should be washed frequently, rinsed body weight distribution. The wheelchair must be de-
thoroughly, and dried on a flat surface. Over time, both signed to accommodate the poor posterior alignment
Ace bandages and socks lose their elasticity and must be and uneven weight distribution. These factors can lead
replaced.” to posterior pelvic tilt and balance problems that can
cause the wheelchair to tip over more easily during
Physical Endurance and Strength weight shifts. Antitipping devices address the weight
At initial evaluation the patient's overall strength distribution problems of bilateral AKA. These are placed
usually ranges from good to normal. As the result of a on the rear of the wheelchair to accommodate the
long hospitalization, the patient may lose some muscle change in the center of gravity. The wheelchair’s large
strength and a therapeutic exercise program may be wheels are placed further back than those on a standard
indicated. wheelchair to accommodate the change in the patient's
The goals of the exercise program are to maintain or center of gravity. It is important for the occupational
regain strength in the remaining extremities, condition therapist to have a good working relationship with the
960 TREATMENT APPLICATIONS

wheelchair specialist. It is essential for the patient to

achieve good dynamic sitting and standing balance for
the safe performance of activities of daily living.'*

Pain Management
Pain management is a team approach. The physical
evaluation will include inspection of the‘amputated site
for poor healing, neuromas, bone fragments, edema,
abscesses, and infection. The occupational therapist ad-
dresses the physical and psychosocial aspects of pain in
the initial evaluation.
Psychosocial issues regarding patient and family
customs, emotional support, education, legal issues,
and concerns of health care delivery can affect pain
status. Phantom pain is an ongoing concern that differs
with each person.* The physician can consider such FIG. 48-41
various treatment approaches as injection of anesthetics Bridging to perform pushing up in bed and to don lower extremity.
into tender areas, sympathetic nerve blocks, pain med-
ications, positioning, edema reduction techniques, and
desensitization techniques. Many patients have found
that desensitization techniques such as tapping, rub- creases independence when transferring in more re-
bing, applying pressure, and heat and cold decrease strictive environments—for example, in a bedroom or
pain. Biofeedback has been effective in decreasing pain. bathroom.
The effectiveness of a technique varies from patient to Sliding board transfers may be taught to the patient
patient. The rehabilitation team is concerned with de- whose remaining limb is very weak or to the patient
termining the best approaches to pain management.'* with bilateral amputations. Such patients may benefit
from a wheelchair with a zippered or removable back.
This allows posterior and anterior transfers by sliding
Occupational Performance Areas
backward to a surface, such as the toilet, and by sliding
Activities of Daily Living forward to return to the wheelchair.
BED MOBILITY. The patient is taught bed mobility, As the patient progresses, and in collaboration with
without using bed rails or an overhead trapeze bar, to the physical therapist, ambulation training is incorpo-
promote independence. The movements that are prac- rated with transfer training. The patient is trained to
ticed during bed mobility training are rolling from side place hands on the armrests of the chair, scoot forward,
to side, bridging with knee and hip flexion, using the re- place the existing foot backward to avoid several ad-
maining sound limb for pushing up and down in bed justments, and then to stand. Standing pivot and
(supine to short sitting and short sitting to supine), and lateral transfers are practiced to and from bed, toilet,
static and dynamic balance training at the bed edge (Fig. and tub. A tub bench and grab bar are used for the tub
48-41). transfer.

WHEELCHAIR MOBILITY AND PARTS MANAGE- RESIDUAL LIMB HYGEINE. Once the wound is
MENT. After surgery the wheelchair will be the patient's healed and sutures are removed, the residual limb
main source of mobility. Wheelchair training consists of should be washed daily with warm water and dried with
propulsion on various surfaces (eg., even, uneven, a towel. The patient should be instructed in daily skin
smooth, and carpeted) and training in wheelchair navi- inspection, using a long-handled inspection mirror to
gation (e.g., moving in and around tight spaces, through see all surfaces of the limb. The use oflotions or alcohol
doorways, and up ramps and curbs). The patient with should be avoided to prevent softening of the residual
unilateral LE amputation uses the arms and sound leg limb before prosthetic use.'”
to propel the wheelchair. Patients who have bilateral
amputations use only the upper extremities. BATHING. Bathing is a self-care activity that requires
dressing and undressing, transferring to and from
TRANSFER TRAINING. The patient with a unilat- shower chair or tub transfer bench, balancing, and man-
eral lower extremity amputation generally uses a stand- aging body parts while operating the water controls
ing pivot transfer (90° pivot), transferring toward the (faucets). Adaptive devices such as the long-handled
sound side when possible. Having the patient practice bath brush, flexible shower hose, and tub transfer bench
transfers toward the amputated side or 180° pivots in- are helpful for independence and safety.
 Amputations and Prosthetics 961

DRESSING. Most patients with LE amputation are only 15 discussed sexuality with a health care profes-
independent in UE dressing but require assistance for sional. The authors of the study concluded that there is
LE dressing. LE dressing is graded from performing in a risk of sexual dysfunction after amputation and that
bed, to sitting, and then to standing. Socks and shoes sexual counseling should be included in the rehabilita-
should be donned while sitting. A sock aid and elastic tion process.** The patient needs the reassurance and
shoelaces may ease donning for the person with loss of understanding of the entire rehabilitation team.
flexibility, poor dynamic sitting balance, or impaired
vision. A footstool may also be used. Using the prosthe- Work and Productive Activities
sis effectively also involves being able to don it correctly HOME MANAGEMENT. The person with a new am-
and developing good balance and coordination for putation usually expresses no interest in performing in-
walking. strumental activities of daily living (IADL). The occupa-
Patients with AKA can don the prosthesis in a stand- tional therapist can make it possible for the patient to
ing position. The residual limb is pushed into the socket observe other patients who are successfully performing
while the prosthesis is steadied against a firm object. IADL. Performance of such light household tasks as
The adductor longus tendon fits into the adductor cleaning the tabletop and countertops, stripping the
longus tendon groove, and the ischial tuberosity rests bed, preparing light meals, folding laundry, putting per-
on the ischial shelf. The patient must exert weight into sonal things in the closet, and reading recipes while
the prosthesis while fastening the suspension apparatus sitting in the wheelchair or kitchen chair is good prepa-
to prevent hip internal rotation and a concomitant gait ration for doing more complex and physically demand-
deviation.* If the patient has difficulty with sock wrin- ing daily activities later.
kling, the sock may be placed in the socket before the
prosthesis is donned. ENERGY CONSERVATION AND WORK SIMPLIFI-
The patient with a BKA dons the prosthesis while CATION. ADL can be performed while sitting or stand-
sitting. Initially the leg is flexed at the knee. After the ing. The therapist should provide rest periods and teach
limb enters the socket, the knee is extended. To align the graded energy-conserving techniques to increase the
limb and socket properly, the patient stands and exerts patient's productivity and safety. More energy is ex-
weight on the prosthesis. pended by persons with amputation during ADL than
by other individuals of the same sex, age, and stature.”
TRANSPORTATION. The ability to resume driving Energy expenditure increases with age and obesity.'*
increases mobility and independence. State laws vary re- Studies suggest a statistically significant correlation
garding driving after LE amputation. The occupational between residual limb length and energy demands.*
therapist should know the law before recommending Therefore patients with LE amputation benefit from in-
that the individual resume driving. When appropriate, struction in work simplification and energy conserva-
the patient should be referred to a driver safety special- tion techniques.
ist for a driving evaluation. However, the occupational
therapist can perform a predriving assessment that PREVOCATIONAL AND VOCATIONAL ACTIVI-
includes visual acuity, reaction time, recognition of TIES. The vocational evaluator should determine
common traffic signs, color vision, glare recovery, night whether the client is able to return to the previous
vision, peripheral vision, depth perception, and trans- job. The vocational evaluation includes psychological
ferring to and from the car and wheelchair. Chapter 14, testing, interests, achievement, and work history. The
Section 3, provides a further discussion of this issue. vocational evaluator establishes an initial vocational
plan and may provide counseling. Assessing architec-
SEXUAL EXPRESSION. There is a lack of literature tural barriers in the work environment, providing driver
on sexuality of patients after LE amputation. In a brief education and vehicle modification as needed, commu-
interview with a middle-aged woman who lost the left nicating with state vocational rehabilitation agencies,
LE as the result of poor circulation, the woman spoke of insurance companies, and other sponsors, and imple-
having to “cope” with her new body image and felt that menting job analysis and modifications are also roles of
her spouse would be unwilling to resume a sexual rela- the vocational evaluator. Follow-up care is an important
tionship because of her limb loss. aspect of the vocational rehabilitation program.
One study found a statistically significant decrease in
frequency of sexual intercourse following amputation. Recreation and Leisure Activities
The decrease was greater for males than for females. Recreation and the constructive use of leisure time
Men cited less interest as the reason for decreased fre- enhance the quality of life. Many individuals may view
quency, and women reported fear of injury. None of the mobility limitations as obstacles to returning to previ-
respondents cited uncomfortable position as a reason ous leisure activities. Thus the rehabilitation program
for the decline in frequency. Of the 60 respondents, should include using community recreational resources,
962 TREATMENT APPLICATIONS

learning new leisure skills, making adaptations for per- tion are focused on proper positioning to prevent con-
formance of previous leisure skills and interests, and re- tractures, on basic ADL training, and on improving
fining functional abilities related to specific leisure ac- ROM, strength, and endurance in the residual limb. UE
tivities. Community groups feature both discussion and strength and endurance training is also important for
reentry trips to develop the skills necessary to take an the performance of essential occupational performance
active role in community recreational opportunities. tasks. In later stages of rehabilitation the occupational
Special LE prostheses are available for golf, swimming, therapist can aid in the evaluation of the feasibility of
running, driving a car, and engaging in sports.'” future employment and explore appropriate leisure ac-
tivities with the client.
Community Reintegration Facilitating psychological adjustment is another im-
Ultimately, the person with an LE amputation must portant goal of all the clinical specialists who work
gain independence in and accessibility to the commu- with the client and the family. To help the client
nity. Management of mobility for curbs, ramps, and in- achieve the maximum possible independence and
clines, stair climbing, walking on uneven surfaces, and function, ongoing collaboration of the rehabilitation
getting on and off public transportation and elevators is team is essential.
essential. The individual should be encouraged to solve
problems encountered with specific architectural and
community barriers.
CASE STUD
Discharge Planning Case StuDYy—Mnkr. B.
Discharge planning includes educating the family, pro- Mr. B. is a 49-year-old African-American man who sustained a left
viding home exercise programs, and securing necessary above-knee amputation as the result of a traumatic injury. He is
durable medical equipment (DME). A home visit may married and has two small children living in the home. He works
be completed as discharge is anticipated. as a telephone line man, a job that requires climbing telephone
poles. His leisure interests are fishing, camping, traveling with the
Family Education family to visit parents in Georgia, watching television, gardening,
During family education the occupational therapist and occasionally reading. Mr. B. lives in a single-family home with
four steps up to the front entrance, but there is no railing. The in-
demonstrates transfers and encourages the family to
terior of the home is wheelchair accessible.
practice using recommended DME with the client. The
Mr. B. seems to be accepting the loss of his left leg and is
therapist observes how the family and patient perform looking forward to returning to the community. He was referred
the activities and corrects any unsafe practices. Exercise to occupational therapy (OT) for evaluation and treatment.
programs are reviewed with the family in clear and un- During the initial interview Mr. B.talked freely about the auto ac-
derstandable language, and written instructions are pro- cident that caused his amputation. He also expressed doubts
vided. DME and resources for equipment in the com- about returning to work with a prosthesis and concerns about
munity are discussed. To ensure accessibility in and out the need to find new employment.
of the home and tight spaces, a home visit is an essential Results of the OT evaluation indicate that Mr B. is pleasant,
part of the rehabilitation program before discharge. cooperative, and motivated for therapy. Before admission he
was independent in activities of daily living. He has normal
muscle strength in the upper extremities and the sound right
PATIENTS WITH MULTIPLE leg. The patient is independent in grooming, hygiene, and dress-
DIAGNOSES AND AGING ing. He requires minimal assistance for transfers and can use
hopping, with a standard walk-aid in tight spaces such as the
In the geriatric population the LE amputation is often bathroom. He is motivated to return to independent living and
complicated by other medical problems such as hyper- employment.
tension, diabetes, congestive heart failure, coronary OT was initiated to increase activity tolerance and physical
artery disease, osteoarthritis, cerebrovascular accident endurance, decrease pain and edema in the left residual limb, and
(stroke), cognitive deficits (e.g., dementia), and periph- improve mobility and transfers. The initial OT program included
eral vascular disease.” All or even one of these addi- edema reduction techniques, desensitization techniques, thera-
tional medical problems can cause the geriatric patient peutic exercise for the upper extremities and residual limb, and
additional problems in adjustment to the amputation, wheelchair mobility training.
Mr. B. responded well to treatment. Pain was decreased and
and reduce the potential for prosthetic wear and use.
the edema was eliminated in the residual limb. He became inde-
pendent in wheelchair mobility and chairto-bed and chairto-
SUMMARY toilet transfers. He managed tub transfers using a tub bench and
stand-by assistance. Upper extremity strength was maintained at
The rehabilitation of an individual who has had an LE normal and strength ofthe residual limb was increased from F+
amputation requires the skills of many health care spe- to G.The patient was fitted for a prosthesis and referred to phys-
cialists. OT evaluation and training in early rehabilita- ical therapy for ambulation training.
 Amputations and Prosthetics 963

11. What is a hybrid prosthesis?

12. What does muscle site control training mean?
13. Describe the relative roles of a prosthesis and a
Case Stupy—Mnr. B.—cont’d
Additional surgery because of venous insufficiency in the left
sound arm and hand in the following activities:
lower extremity interrupted the ambulation training. The vascular cutting meat; opening a jar; using scissors; buckling
problem was corrected, and prosthetic training was resumed a belt; using an eggbeater; hammering a nail.
with an ischial weight-bearing prosthesis. After healing of the left
residual limb there was a final fitting of the prosthesis and plans Section 3: Lower Extremity Amputations
were made for Mr. B. to return to physical therapy as an outpa- 1. Define AKA, BKA, PVD, and IWBP.
tient for more intense prosthesis training. 2. Which leg functions are lost after AKA?
In OT, Mr B. practiced activities of daily living and functional 3. Which leg functions are lost after a Symes amputa-
ambulation within his pain tolerance. He was also referred to vo- tion?
cational rehabilitation for retraining, since he will not be able to 4. What are the function and purpose of the rigid
return to his former job.
dressing?
5. Name three types of prostheses.
6. Which prosthesis allows the AKA and BKA to be
trained for transfers?
7. What is included in the initial OT evaluation?
REVIEW QUESTIONS
8. Name three additional areas the occupational ther-
Section |: General Considerations for Upper and apist addresses in the rehabilitation program of the
Lower Extremity Amputations patient with LE amputation.
1. List six causes of amputation. 9. How is residual limb supported in the wheelchair?
2. What is the most common cause of LE amputation? 10. Identify all members of the rehabilitation team and
3. What is the second most common cause of LE their roles.
amputation? 11. Describe a method to decrease edema.
PN . What are the primary goals of amputation surgery? 12. What type of wheelchair is needed when there are
5. Name the two types of surgical procedures that can bilateral LE amputations?
be performed, and list the advantages of each. 13. Which adaptive devices are helpful for ADL?
6. Name at least four postsurgical factors that can in- 14. Which pieces of durable medical equipment are
terfere with prosthetic training and rehabilitation. often recommended by the occupational therapist
How is each solved? at the time of discharge?
7. Define neuroma. How does it affect the wearing of a 15. Why is family education an important part of the
prosthesis? 5 rehabilitation program?
8. What is the difference between phantom limb and 16. List the immediate postoperative concerns. How
phantom pain? does OT address these concerns?
9. What are some of the typical and expected psy- 17. Which areas are assessed in bed mobility?
chosocial consequences of limb loss? 18. Which prosthesis is used as a training prosthesis?
10. How can members of the rehabilitation team facili-
tate adjustment to amputation and prosthesis wear?
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Comprehensive rehabilitation of burns, Baltimore, 1984, Williams & tremity amputees: a survey, Arch Phys Med Rehabil 61(6):258-264,
Wilkins. 1980.
. Nader M, Ing EH: The artificial substitution of missing hands with 16. Knighton DR, Fylling CP, Fiegel VD, et al: Amputation prevention
myoelectric prostheses, Clin Orthop 258:9-17, 1990. in an independently reviewed at risk diabetic population using a
NovaCare: Motion control: training the client with an electric arm comprehensive wound care protocol, Am J Surg 160(5):466-471,
prosthesis, King of Prussia, Pa, 1997, NovaCare (videotape). 1990.
10. Scott RN, Parker PA: Myoelectric prostheses: state of the art, JMed Ye. Larson CB, Gould M: Orthopedic nursing, ed 8, St Louis, 1974,
Eng Technol 12(4):143-151, 1988. Mosby.
al Spiegal SR: Adult myoelectric upper-limb prosthetic training. In 18. May BJ: A statewide amputee rehabilitation programme, Prosthet
Atkins DJ, Meier RH, editors: Comprehensive management of the Orthot Int 2(1):24-26, 1978.
upper-limb amputee, New York, 1989, Springer-Verlag. HOR Metro Medical Seating Systems: Wheelchair catalog, Livonia, Mich,
1993:
20. O'Sullivan S, Cullen K, Schmitz T: Physical rehabilitation: evaluation
el
ee ee ee ee
and treatment procedures, Philadelphia, 1981, FA Davis.
SECTION 3 PA be Palmer MI, Toms JE: Manual for functional training, ed 3, Philadel-
he American Occupational Therapy Association: Uniform terminol- phia, 1992, FA Davis.
ogy for occupational therapy, ed 3, Am J Occup Ther 48(11):1047- 22, Raney RR, Brashear H: Shands’ handbook of orthopaedic surgery, ed 8,
1054, 1994. St Louis, 1971, Mosby.
. Banerjee SJ: Rehabilitation management of amputees, Baltimore, 285 Reed KL, Sanderson SN: Concepts of occupational therapy, ed 3, Bal-
1982, Williams & Wilkins. timore, 1972, Williams & Wilkins.
. Borcich D, Beukma L, Olives T: Amputee care: a handout for patients 24. Reinstein L, Ashley J, Miller KH: Sexual adjustment after lower ex-
with below knee amputations, Stanford, Calif, 1986, Department of tremity amputation, Arch Phys Med Rehabil 59(11):501-504, No-
Physical and Occupational Therapy, Stanford University Hospital vember, 1978.
(Unpublished). 2D Rusk H, Taylor E: Rehabilitation medicine: a textbook of physical med-
. Burgess EM: Amputation of the lower extremities. In Nickel VL, icine and rehabilitation, ed 2, St Louis, 1964, Mosby.
editor: Orthopedic rehabilitation, New York, 1982, Churchill- 26. Spencer EA: Amputations. In Hopkins HL, Smith HD, editors:
Livingstone. Willard & Spackman's occupational therapy, ed 5, Philadelphia,
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ise
 10nary Diseases

MAUREEN MICHEL

KEY TERMS LEARNING OBJECTIVES

Heart rate Study of this chapter will allow the student or
Blood pressure practitioner to do the following:
Ischemic heart disease ihe Briefly describe the cardiovascular system and its
Myocardial infarction function.
Cardiac risk factors 2. Identify the significance of ischemic heart disease
Cardiac rehabilitation and valvular diseases of the heart.
Signs and symptoms of cardiopulmonary distress Differentiate between modifiable and
Rate of perceived exertion nonmodifiable risk factors.
Rate pressure product Identify signs and symptoms of cardiac distress.
Chronic obstructive pulmonary disease Describe the course of action one should take if
Package year history signs and symptoms of cardiac distress are present.
Signs and symptoms of respiratory distress List the psychosocial considerations for persons
Pulmonary rehabilitation with cardiovascular or pulmonary disease.
Dyspnea control postures Describe methods for taking heart rate and blood
Pursed-lip breathing pressure.
Diaphragmatic breathing Determine rate pressure product, given heart rate
Cardiovascular response to activity and blood pressure.
Basal metabolic equivalent Give a brief overview of the respiratory system and
Energy conservation identify its primary function.
10. Define chronic obstructive pulmonary disease
(COPD).
LL Identify pulmonary risk factors and psychosocial
considerations.
WX Describe dyspnea control postures, pursed-lip
breathing, and diaphragmatic breathing.
Ne Describe a relaxation technique and explain its
purpose.
14. List interview questions that will help the clinician
know what the patient understands about
treatment.
15; List the principles of energy conservation.
16. Explain the significance of an MET chart in the
progression of activity, and describe how to use it.

966
 Cardiac and Pulmonary Diseases 967

Aorta

.. with disorders of the cardiovascular or

Superior
pulmonary system may be severely limited in endurance vena cava
and performance of activities of daily living (ADL). Oc-
-cupational therapy (OT) services may benefit such indi-
viduals and are available throughout the continuum of
health care. An understanding of the normal function Pulmonary veins
of the cardiopulmonary system, the pathology of car- Left atrium
diopulmonary disease, common risk factors, clinical ter-
Aortic valve
minology, medical interventions, precautions, and stan-
dard treatment techniques will guide the occupational Mitral valve
therapist in providing effective care and promoting re- Pulmonary valve
covery of function in persons with compromised cardio- Papillary muscle
vascular or pulmonary systems.
Every living cell of the body has three major require-
ments for life: (1) a constant supply of nutrients and 4 Left ventricle

oxygen, (2) continual removal of carbon dioxide and

other waste products, and (3) a relatively constant tem- intanee Right ventricle
perature. The cardiovascular and pulmonary systems vena cava
play key roles in meeting these requirements. Tricuspid valve

CARDIOVASCULAR SYSTEM”’'*’'? FIG. 49-1

: - Anatomy of the heart. (Modified from Guyton AC: Textbook of
ety and Circulation medical physiology, ed 8, 1991, WB Saunders.)
The heart and blood vessels work together to maintain a
constant flow of blood throughout the body. The heart,
located between the lungs, is pear shaped and about the are named for their location on the myocardium (Fig.
size of a fist. It functions as a two-sided pump. The right 49-2). Cardiologists generally refer to these arteries by
side pumps blood from the body to the lungs; simulta- abbreviations, such as “LAD” for “left anterior descend-
neously the left side pumps blood from the lungs to the ing” and “RCA” for “right coronary artery.” The LAD is
body. Each side of the heart has two chambers, an upper on the left, anterior portion of the heart and runs in a
atrium and a lower ventricle. downward direction, supplying part of the left ventricle.
Blood flows to the heart from the venous system. The A blockage of this coronary artery will interrupt the
blood enters the right atrium, which contracts and blood supply to the left ventricle. Because the left ventri-
squeezes the blood into the right ventricle. Next, the cle supplies the body and brain with blood, a heart
right ventricle contracts and ejects the blood into the attack caused by LAD blockage can have serious conse-
lungs, where carbon dioxide is exchanged for oxygen. quences.
Oxygen-rich blood flows from the lungs to the left
atrium. As the left atrium contracts, it forces blood into TUNA Causes the teart to Contract?
the left ventricle, which then contracts and ejects its con-
tents into the aorta for systemic circulation (Fig. 49-1). In addition to the ordinary muscle tissue of the heart,
Blood travels from the aorta to the arteries and through the myocardium is composed of two other types of
progressively smaller blood vessels to networks of very tissue, nodal and Purkinje. These tissues are part of a spe-
tiny capillaries. In the capillaries, blood cells exchange cialized electrical conduction system that causes the
their oxygen for carbon dioxide. heart to contract and relax (Fig. 49-2). An electrical
Each of the ventricles has two valves, an input valve impulse usually originates in the right atrium at a site
and an output valve. The valves open and close as the called the sinoatrial (SA) node. The impulse travels along
heart muscle (myocardium) contracts and relaxes. These internodal pathways to the atrioventricular (AV) node,
valves control the direction and flow of blood. The through the bundle of His, to the left and right bundle
input valves are the mitral and tricuspid, and the output branches, and then to the Purkinje fibers. Nerve im-
valves are the aortic and pulmonary. pulses normally travel this pathway 60 to 100 times
The heart is living tissue and requires a blood supply every minute, first causing both atria to contract,
(through an arterial and venous system of its own), or it pushing blood into the ventricles, and then provoking
will die. Coronary arteries cross over the myocardium to the ventricles to contract. The electrical impulse created
supply it with oxygen-rich blood. The coronary arteries by the heart's conduction system can easily be studied.
968 TREATMENT APPLICATIONS

Ascending aorta
Pulmonary artery SA node Bachmann bundle

Superior vena cava Ny

Left main Internodal left bundle branch
KZLA. artery pathways
Right atrial appendage BS

Right coronary
None Circumflex artery
Posteroinferior fascicle
of left bundle branch
artery AV node
Left anterior
x descending artery AV bundle of His
N Great
Anterior cardiac veins A cardiac vein Anterosuperior fascicle
a) Right bundle branch of left bundle branch
y

Septum
Inferior vena cava

Purkinje fibers
Small cardiac vein Mé y. —-
Marginal FIG. 49-3
branch
Cardiac conduction. (Modified from Andreoli KG et al: Comprehen-
FIG. 49-2 sive cardiac care: a text for nurses, physicians, and other health practi-
Coronary circulation. (From Underhill SL et al, editors: Cardiac tioners, St Louis, 1983, Mosby.)
nursing, Philadelphia, 1982,JB Lippincott.)

monary in the right and aortic in the left) open and the
diastolic BP is attained.
Electrodes placed on a person's limbs and chest can pick The ventricles continue to contract, squeezing blood
up the heart's electrical impulse, which can be trans- under greater and greater pressure into the pulmonary
lated to paper via an electrocardiogram (EKG). The re- and body circulation. Systolic BP is attained when pres-
sulting EKG tracing is frequently used to help diagnose sures in the emptying ventricles fall below pressure in the
cardiac disease. blood vessels beyond, causing the output valves to close.
The SA node responds to vagal and sympathetic
nervous system input.* This is why heart rate (HR) in- PATHOLOGY OF CARDIAC DISEASE
creases in response to exercise and anxiety and decreases
Ischemic Heart Disease
in response to relaxation techniques, such as deep
breathing and meditation. Each cell within the electrical Ischemic heart disease (ischemia) occurs when a part
conduction system of the heart can respond to, conduct, of the body is temporarily deprived of sufficient oxygen
resist for a brief period, and generate an electrical to meet its demand. The most common cause of cardiac
impulse. Because of this, electrical impulses causing the ischemia is coronary artery disease (CAD). CAD usually
heart muscle to contract can be generated from any- develops over a period of many years without causing
where along the electrical conduction system. This is de- symptoms. The internal wall of an artery can become
sirable when part of the conduction system has been injured by years of cigarette smoking or high BP. Once
damaged and is unable do its job, but it is undesirable the wall is damaged, it becomes irregular in shape and
when life-threatening conduction irregularities develop. more prone to collect plaque (fatty deposits like choles-
terol). Platelets also gather along the arterial wall and
clog the artery, creating a lesion in the same manner in
Cardiac Cycle
which rust can clog a pipe. The artery gradually narrows,
The amount of blood ejected by the heart each minute allowing a smaller volume of blood to pass through it.
(cardiac output) is controlled by both HR and the This disease process is called atherosclerosis.
blood pressure (BP). The cardiac cycle occurs in two If a coronary artery is partially or completely blocked,
phases, input (diastole) and output (systole). the part of the heart supplied by that artery may not
During the input phase, blood flows through the receive sufficient oxygen to meet its needs. Persons with
atria and into the ventricles. The atria contract, pushing partial blockage of a coronary artery may be free of
more blood into the ventricles. Once the pressure inside symptoms at rest but have angina, a type of chest pain,
the ventricles is equal to the pressure in the atria, the with eating, exercise, exertion, or exposure to cold.
input valves (tricuspid in the right ventricle and mitral Angina varies from individual to individual and has
in the left ventricle) close. The ventricles then contract, been described as squeezing, tightness, fullness, pres-
resulting in rapidly increasing ventricular pressure. sure, or a sharp pain in the chest. The pain may also
When the pressure inside the ventricles exceeds the pres- radiate to other parts of the body, usually the arm, back,
sure in the blood vessels beyond, the output valves (pul- neck, or jaw. Angina has also been confused with indi-
 Cardiac and Pulmonary Diseases

gestion. Rest, medication, or both will frequently relieve

angina. Usually no permanent heart damage will result.
Angina is a warning sign that should not be ignored. mela(eale)sy-le Girl siile-ta(o) alte)Mm
@rlael-lonD)KX=-14-1
Coronary artery disease is present; the individual may
Class | Patients have cardiac disease but no limitation
be a candidate for a heart attack. Chest pain that is not of physical activity,
_telieved by rest or nitroglycerin is indicative of a myo-
cardial infarction (MI), or heart attack. The patient Class2 Patients have cardiac disease resulting in slight
who has this type of pain should be evaluated promptly limitation of physical activity. Patients are
by a physician. comfortable at rest. Ordinary physical activity
results in fatigue, palpitation, dyspnea, or anginal
A myocardial infarction is significant because part of
pain.
the heart muscle dies as a result of lack of oxygen. If a
substantial section of the heart is damaged, it will stop Class 3 Patients have cardiac disease resulting in marked
pumping (cardiac arrest). Activity restrictions are pre- limitation of physical activity. Patients are
scribed for the first 6 weeks after a heart attack, because comfortable at rest. Less than ordinary physical
activity causes fatigue, palpitation, dyspnea, or
newly damaged heart muscle, like any injured body
anginal pain.
tissue, is easily reinjured. During the heart attack, meta-
bolic waste products accumulate in the damaged myo- Class 4 Patients have cardiac disease resulting in inability to
cardium, making it irritable and prone to electrical ir- carry on any physical activity without discomfort.
regularities such as premature ventricular contractions Symptoms of cardiac insufficiency or of the anginal
(PVCs). A delicate balance of rest and activity must be syndrome may be present even at rest. If any
physical activity is undertaken, discomfort is
maintained to allow the damaged area of myocardium
increased.
to heal while also maintaining the strength of the
healthy part of the heart. To guide the patient toward a From New York Heart Association: Nomenclature and criteria for diagnosis of
safe level of activity during this acute period of recovery, diseases of the heart and great vessels, ed 8, Boston, 1979, The Association.
OT may be recommended.
At about 6 weeks after an MI, scar tissue forms and Table 49-1 delineates the four functional classifica-
the risk of extending the MI decreases. The scarred part tions of heart disease. OT can be of great benefit to
of the heart muscle is not elastic and does not contract persons with stage 3 and 4 disease.
with each heartbeat. Therefore the heart does not pump
as well. A graded exercise program will help strengthen
Valvular Disease
the healthy part of the myocardium and improve
cardiac output, the amount of blood ejected by the The heart valves, which are responsible for controlling
heart in 1 minute. the direction and flow of the blood through the heart,
Congestive heart failure (CHF) occurs when the heart may become damaged through disease or infection. Two
is unable to pump effectively, causing fluid to back up complications result from valvular disease: volume over-
into the lungs or the body. Fluid overload is serious load and pressure overload. A fibrous mitral valve will
because it puts a greater workload on the heart as the fail to close properly. Blood will be regurgitated back to
heart strains while attempting to clear the excess fluid. the atria when the left ventricle contracts. Volume over-
This may result in further congestion. Heart size is often load results when fluid accumulates in the lungs, causing
enlarged in persons with CHF because the heart muscle shortness of breath. Volume overload increases the po-
thickens (hypertrophy) from working so hard. Diuretics tential for atrial fibrillation, which causes irregular and
can be prescribed for persons with CHF to promote ineffective contractions in both atria. Blood flow
fluid loss through the urinary system. Low-sodium diets through the heart slows, and blood clots (emboli) may
and fluid restrictions reduce the overall amount of fluid develop in the ventricles. Many cerebrovascular acci-
in the body. Usually CHF can be controlled with diet, dents are caused when emboli ejected from the left ven-
medications, and rest. tricle enter the circulatory system of the brain.
Once an acute exacerbation of CHF is controlled, a If the aortic valve fails to close properly (aortic insuf-
gradual resumption of activity will promote improved ficiency), CHF or ischemia may result. Another disorder
function. If activity is resumed too quickly, another of the aortic valve is aortic stenosis (narrowing), which
acute episode may follow. Patients who have difficulty results in pressure overload. The left ventricle, which
resuming their former level of activity may self-limit must work harder to open the sticky valve, becomes
their recovery. OT can guide persons with acute CHF enlarged, and cardiac output decreases. Ventricular
toward an optimal level of function through graded self- arrhythmia, cerebral insufficiency, confusion, syncope
care tasks. Some individuals ultimately eliminate their (fainting), and even sudden death may result from
tendency to develop CHF altogether, whereas others aortic stenosis. Surgery to repair or replace the damaged
develop severe heart failure. valves is frequently recommended.
970 TREATMENT APPLICATIONS

Cardiac Risk Factors

proving coronary circulation. Strict compliance with
There have been many scientific studies to determine postsurgical precautions is necessary to avert serious
the causes of heart disease. The most famous of these consequences.
studies, the Framingham study,® helped identify many When the heart’s pumping ability has become too
factors that put an individual at risk for atherosclerosis. compromised by CHF or cardiomyopathy, a heart trans-
Risk factors are divided into three major categories: plant or heart-lung transplant may be considered.
those that cannot be changed (heredity, male gender, Healthy tissue of a recently deceased person is har-
and age); those that can be changed (high blood pres- vested; the diseased organ(s) of the patient are removed,
sure, cigarette smoking, cholesterol levels, and an inac- and the harvested tissue is transplanted into the
tive lifestyle); and contributing factors (diabetes, stress, patient’s body. Transplant patients are typically main-
and obesity). The more risk factors an individual has, tained on special medication to decrease the risk of
the greater is the individual's risk of CAD. All team organ rejection. If the surgery is successful, the patient
members should support the patient's attempts to can generally be rehabilitated to a level of function sig-
reduce risk factors. nificantly higher than in the months before surgery.

Cardiac Medications
Medical Management
Knowledge of the purpose and side effects of cardiac
Persons who have a heart attack are initially managed in medication promotes understanding of the patient's re-
a coronary care unit, where they are closely observed for sponse to activity. Table 49-2 lists common cardiac
complications. Ninety percent of persons who have medications.
had an MI will have arrhythmia.” Heart failure, the de-
velopment of blood clots (thrombosis and emboli), Psychosocial Considerations
aneurysms, ruptures of part of the heart muscle, inflam- Persons who have had an MI pass through a number of
mation of the sac around the heart (pericarditis), and phases of adjustment to disability. Fear and anxiety
even death are potential outcomes of an MI. Close develop initially as patients confront their mortality.
medical management is imperative. Sedatives may be prescribed to reduce stress and allow
Generally patients are managed for 2 to 3 days after rest so that the cardiovascular system can begin to heal.
MI in an intensive care unit. Once their condition is sta- Once stabilized, patients must confront the reality of
bilized, they graduate to a monitored hospital bed. Pa- their physical limitations. Education and supportive
tients stay 4 to 6 days in the hospital after an acute MI. communication will do much to reduce anxiety.'”
Vital signs are closely monitored while activity is gradu- As patients begin to resume more normal activities,
ally increased. OT personnel may be called on to mon- such as self-care and walking around the ward, feelings
itor the patient's response to activity and educate the of helplessness may begin to subside. Patients feel more
patient about the disease process, risk factors, and secure when familiar coping mechanisms allow them to
lifestyle modification. respond to the stress, but some former coping mecha-
Should the patient not respond well to increased ac- nisms (e.g., smoking, drinking, or consuming fatty
tivity, surgical intervention may be necessary. Various foods) are harmful and should be discouraged.
surgical procedures can correct circulatory problems Denial is common among patients with cardiac
associated with CAD. Balloon angioplasty, also called disease. Patients in denial must be closely monitored
percutaneous transluminal coronary angioplasty during the acute phase of recovery. Persons in denial
(PTCA), and coronary artery bypass graft (CABG) are may ignore all precautions and could stress and further
most common. damage their cardiovascular systems.
In a PTCA a catheter is inserted into the femoral Depression is common in the third to sixth day after
artery and guided through the circulatory system into an MI and may last many months.* Forced inactivity
the coronary arteries. Radioactive dye is ejected into the during the recovery phase can compromise coping for a
arteries, and the site of the lesion is pinpointed. A person who has previously dealt with stress by exercis-
balloon is then inflated at the site of the lesion to push ing until exhaustion. The patient’s family must be in-
plaque against the arterial wall. When the balloon is de- cluded in the education so that their misconceptions
flated and the catheter removed, improved circulation and anxieties do not compound the patient's fears.
to the myocardium usually results. Eight hours of bed
rest after the PTCA helps prevent hemorrhaging from Cardiac Rehabilitation
the femoral artery. During the first 1 to 3 days after an MI, stabilization of
Ifa lesion is too diffuse or an artery reoccludes after a the cardiac patient's medical condition is usually at-
PTCA, a CABG may be performed. The diseased section tained. This acute phase is followed by a period of early
of the coronary arteries is bypassed with healthy blood mobilization. Phase one of treatment, inpatient cardiac
vessels (taken from other parts of the body), thus im- rehabilitation, includes monitored low-level physical
 Cardiac and Pulmonary Diseases

(@oynnlanvelam @r-lnel rom 4 (-velle-talelats

Common Names Purpose and Uses
D Lasix (Furosemide) Lowers BP Orthostatic HTN
a. Dyazide Decreases edema Dehydration
ea HCTZ Muscle spasms
—
: as dilators Hydralazine Lowers BP Palpitations
ie Captopril Controls CHF Tachycardia
uel Orthostatic HTN
ts Cardiac glycosides Digoxin Lowers heart rate Anorexia
pase Lanoxin Controls ventricular Nausea
‘ heart rate Arrhythmia
or Heart block
_ Anticoagulants Coumadin (Warfarin) Prevents blood clots Hemorrhage
Heparin Nausea and vomiting
Aspirin Abdominal cramps
Persantine
: Antiarrhythmic Procainamide Controls heart rhythm Can aggravate ventricular arrhythmias
Quinidine Bradycardia
Inderal
——— Lidocaine
Beta blockers Atenolol (Tenormin) To manage angina, CHF
Propranolol (Inderal) hypertension, and Worsening of peripheral vascular disease
Other drugs ending in “olol” arrhythmia Increased dyspnea

Calcium channel Verapamil To manage angina, coronary Orthostatic HTN

ee
———
blockers Diltiazem artery spasms, and Bradycardia
Nifedipine arrhythmia

Nitrates NTG sublingual To manage angina Orthostatic HTN

Nitropaste and CHF Headache
lsordil
BP Blood pressure; CHF congestive heart failure; HCTZ, hydrochlorothiazide; NTG, nitroglycerin; HTN, hypotension.

activity, including self-care; reinforcement of cardiac had cardiac rehabilitation after an acute MI.** Cardiac
and postsurgical precautions; instruction in energy rehabilitation has also been found to benefit patients
conservation and graded activity; and establishment of with left ventricular dysfunction by improving physical
guidelines for appropriate activity levels at discharge. work capacity."*
Via monitored activity, the ill effects of prolonged inac- Early and accurate identification of the signs and
tivity can be averted, while medical problems, poor re- symptoms of cardiac distress and modification oftreat-
sponses to medications, and atypical chest pain can be ment to remedy distress are imperative to the well-being
addressed. ofthe patient. If the clinician observes any ofthe signs of
Phase two of treatment, outpatient cardiac rehabili- cardiac distress (Table 49-3) during treatment, the
tation, usually begins at discharge. During this phase proper response is to stop the activity, allow the patient
exercise can be advanced while the patient is closely to rest, seek emergency medical help if the symptoms do
monitored on an outpatient basis. Community-based not resolve, report the symptoms to the team, and
exercise programs follow in phase three. Some individu- modify future activity to decrease the workload on the
als require treatment in their place of residence because heart.
they are not strong enough to tolerate outpatient Table 49-4, the Borg Rate of Perceived Exertion Scale,
therapy. is a tool used to measure the perceived exertion. The
Health care costs can be significantly reduced and patient is shown the scale before an activity and in-
positive health effects can result from comprehensive structed that a rating of “6” means no exertion at all and
cardiac rehabilitation.'’ Additional research indicates a “19” indicates extremely strenuous activity, equal
reduced mortality among selected patients who have to the most strenuous activity the patient has ever
 TREATMENT APPLICATIONS

performed. After the activity has been completed the

patient is asked to appraise his or her feelings of exer-
igns and Symptoms of Cardiac Distress tion as accurately as possible and give a rating to the
activity.
Sign/Symptom What to Look For
Angina Look for chest pain that may be squeezing,
tightness, aching, burning, or choking in
Monitoring Response to Activity
nature. Pain is generally substernal and may When the patient's response to an activity is being as-
radiate to the arms, jaw, neck. or back. sessed, symptoms provide one indication that the
More intense or longer-lasting pain patient is or is not tolerating the activity. HR, BP, rate
forewarns of greater ischemia. pressure product (RPP), and EKG readings are other
measures that may be used to evaluate the cardiovascu-
Dyspnea Look for shortness of breath with activity
or at rest. Note the activity that brought on lar system’s response to work.
the dyspnea and the amount of time that it
takes to resolve. Dyspnea at rest, and with HEART RATE (HR). Heart rate (HR), the number of
resting respiratory rate over 30 breaths per beats per minute, can be monitored by feeling the
minute, is a sign of acute CHF. The patient patient's pulse at the radial, brachial, or carotid sites.
may need emergency medical help. The radial pulse is located on the volar surface of the
Orthopnea Look for dyspnea brought on by lying wrist, just lateral to the head of the radius. The brachial
supine. Count the number of pillows the pulse is found in the antecubital fossa, slightly medial
patient sleeps on to breathe comfortably to the midline of the forearm. The carotid pulse, located
(1, 2, 3, or 4 pillows of orthopnea). on the neck lateral to the Adam's apple, should be pal-
pated gently; if overstimulated, it can cause the HR to
Nausea/emesis Look for vomiting or signs that the patient
feels sick to the stomach.
drop below 60 beats per minute (bradycardia). To deter-
mine the HR, the clinician applies the second and third
Diaphoresis Look for a cold, clammy sweat. fingers (flat, not with the tips) to the pulse site. If the
Fatigue Look for a generalized feeling of pulse is even (regular), the clinician counts the number
exhaustion. The Borg rate of perceived of beats in 10 seconds and multiplies the finding by six.
exertion (RPE) scale is a tool used to grade The thumb should never be used to take a pulse because
fatigue (Table 49-4). it has its own pulse.
All clinicians who take the HR, as well as patients,
Cerebral signs Ataxia, dizziness, confusion, and fainting
(syncope) are all signs that the brain is not should be able to note the evenness (regularity) of the
getting enough oxygen. heartbeat. HRs can be regular or irregular. Although an
irregular heart rate is not normal, many persons func-
Orthostatic Look for a drop in systolic blood pressure
tion quite well with an irregular rate. Clinicians should
hypotension of greater than 10 mm Hg with change of
note the normal rate pattern for the individual, as well
position from supine to sitting or sitting to
standing.
as any variations. A sudden change in HR from regular
to irregular should be reported to the physician. An EKG
or other diagnostic test may be ordered based on such
findings. When the HR is irregular, the number of beats
should be counted for a full minute. Patients can be
taught to take their own pulse and monitor the response
of their HR to activity. As a general rule of thumb, HR
eived Exertion should rise in response to activity.
6 14
BLOOD PRESSURE. BP is the pressure that the
Vy Very, very light 5 Hard blood exerts against the walls of any vessel as the heart
8 6 beats. It is highest in the left ventricle during systole and
decreases in the arterial system with distance from the
9 Very light 7 Very hard
heart.*° A stethoscope and BP cuff (sphygmomanome-
10 8 ter) are used to indirectly determine the BP. The BP cuff
is placed snugly (but not tightly) around the patient's
|| Fairly light 9 Very, very hard
upper arm just above the elbow, with the bladder of the
12 20 cuff centered above the brachial artery. The examiner
13 Somewhat hard inflates the cuff while palpating the brachial artery to
20 mm Hg above the point at which the brachial pulse
From Borg et al: Med Sci Sports Exerc |4:376, 1982. is last felt. With the earpieces of the stethoscope angled
 Cardiac and Pulmonary Diseases 973

forward in the examiner's ears, the dome of the stetho- voice box. From there the air continues downward into
scope is placed over the patient's brachial artery. Sup- the lungs by way of the trachea or windpipe. The trachea
porting the patient's arm in extension with the pulse consists of a ribbed cartilage approximately 10 cm long.
point of the brachial artery and the gauge of the stetho- The cartilage is lined with a mucous layer and cilia to
scope at the patient’s heart level, the examiner deflates help to filter out dust. When the trachea or pharynx
_ the cuff at a rate of approximately 2 mm Hg per second. becomes blocked, a small incision may be made into
Listening is imperative when taking BP. The first two the trachea to allow air to pass freely into the lungs. This
sounds heard correspond to the systolic BP. The exam- procedure is called a tracheotomy.
iner continues to listen until the last pulse is heard and Two main bronchi branch off from the trachea, carry-
the diastolic BP is attained. ing air into the left and right lungs. The bronchi con-
Physicians usually indicate treatment parameters for tinue to branch off into smaller tubes, called bronchioles.
the HR and BP of patients in medical facilities. Parame- Bronchioles are segmented into smaller passages called
ters are frequently written in abbreviations, such as, the alveolar ducts. Each alveolar duct is divided and leads
“Call HO (house office, or physician on call) if SBP > into three or more alveolar sacs. The entire respiratory
150 < 90; DBP > 90 < 60; HR> 120 < 60” (systolic BP passageway from bronchi to alveolar ducts is often re-
greater than 150 or less than 90; diastolic BP greater than ferred to as the pulmonary tree because its structure is
90 or less than 60; HR greater than 120 or less than 60). much like an upside-down tree with the alveolar sacs as
HR and BP will fluctuate in response to activity; its leaves.
cardiac output is affected by both HR and BP. Rate pres- Each alveolar sac contains more than 10 alveoli. A
sure product (RPP) measurement can give a more accu- very fine, semipermeable membrane separates the alveo-
rate indication of how well the heart is pumping. RPP is lus from the capillary network. Across this membrane,
the product of HR and systolic BP (RPP = HR X SBP). It oxygen is transported and exchanged for carbon di-
is usually a five-digit number but is reported in three oxide. Carbon dioxide is exhaled into the air after travel-
digits by dropping the last two digits (for example, HR ing upward through the “pulmonary tree” (Fig. 49-4).
100 X SBP 120 = 12000 = RPP 120). During any activ- The musculature of the thorax is responsible for in-
ity RPP should rise at peak and return to baseline in spiration and expiration. Inspiration, the muscle power
recovery. for breathing air into the lungs, is provided primarily by
EKG reading and interpretation is a skill that requires the diaphragm. Originating from the sternum, ribs,
hours of learning and practice for proficiency. Electro- lumbar vertebrae, and the lumbocostal arches, the di-
cardiography is not available in most nonacute settings. aphragm forms the inferior border of the thorax. The
The reader is referred to Dubin’s Rapid Interpretation_of muscle fibers of the diaphragm insert into a central
EKG,” which is an excellent resource for persons unfa- tendon. Innervated by the left and right phrenic nerves,
miliar with the subject. the diaphragm contracts and domes downward when it
There are many similarities in the evaluation and is stimulated. This downward doming of the diaphragm
treatment of persons with cardiac disease and those enlarges the volume of the thorax and causes a drop in
with pulmonary dysfunction. A review of the pul- pressure in the lungs relative to the air in the environ-
monary system and its disease processes follows. ment. Air then enters the lungs to equalize inside and
outside pressures. Accessory muscles, the intercostals
PULMONARY SYSTEM and scalenes, are also active during inspiration. The in-
tercostals maintain the alignment of the ribs, and the
Anatomy and Physiology scalene helps elevate the rib cage.
of Respiration”’ At rest, expiration is primarily a passive relaxation
While the heart provides oxygen-rich blood to the body of the inspiratory musculature. The lungs help to draw
and transports carbon dioxide and other waste products the thorax inward as the inspiratory muscles relax.
to the lungs, the respiratory system exchanges oxygen Forced expiration requires active contraction of the ab-
for carbon dioxide. The cardiac and pulmonary systems dominal muscles to compress the viscera and squeeze
are interdependent. If no oxygen were delivered to the the diaphragm upward in the thorax. Expiration can be
bloodstream, the heart would soon stop functioning for further forced by flexing the torso forward and press-
lack of oxygen; conversely, if the heart were to stop ing with the arms on the chest or abdomen. As the
pumping, the lungs would cease functioning for lack of volume of the thorax decreases, air is forced out of the
a blood supply. All body tissues depend on the car- lungs.
diopulmonary system for their nutrients.
The respiratory system supplies oxygen to the blood Innervation of the Respiratory System
and removes waste products, primarily carbon dioxide,
from the blood. Air enters the body via the nose and Breathing is mostly involuntary. A person does not have
mouth and travels through the larynx to the pharynx or to think to take a breath. The autonomic nervous system
974 TREATMENT APPLICATIONS

Superior nasal concha

Middle nasal concha

Frontal sinus

Inferior
Sphenoid sinus nasal concha
Nostril
Nasopharynx Soft palate
Oral cavity
Oropharynx Fogler

Laryngopharynx Thyroid cartilage

Esophagus Cricoid cartilage

Trachea

Left primary
ronchus
Right upper lobe

Carina Hilum

Left
Right middle secondary
lobe bronchus

Bronchiole

Right lower Alveolus

lobe

FIG. 49-4
Major structures of the respiratory system. (From Respiratory support, Springhouse, Pa, 1991, Spring-