Occupational therapy programs tables of content

RESOURCES FOR INSTRUCTION: SEATING
PRINT:
Bergen AF, Presberin J, and Tallman T. Positioning for Function: Wheelchairs and Other Assistive Technologies. Valhalla Rehabilitation Publications, Valhalla, NY 1990.
Hobson DA. Seating and Mobility for the Severely Disabled. In Smith RV and Leslie JH, editors: Rehabilitation Engineering, 1990, Boca Raton, FL, CRC Press.
Post KM. Evaluation and intervention techniques in seating and mobility. In: Technology Review ‘90 Perspectives on Occupational Therapy Practice. Rockville, MD. American Occupational Therapy Association, Inc., 1990.
Zachardow, D: Wheelchair Posture and Pressure Sores. Charles C. Thomas, Springfield, IL, 1984.
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Modifications

Care System

GS Fitting (Pediatrics)

Purposes of positioning.

To increase body alignment, improve postural control normalize tone, normalize tone, prevent contracture, decrease influence of pathological reflexes, increase stability, improve endurance and out of bed tolerance, facilitate components of normal movement.

To improve upper extremity function, increase ROM and decrease tendency toward deformity.

To improve cardio-respiratory function, promote drainage of lung and bronchial secretion, decrease swallowing problems

To promote safety, control edema, prevent skin breakdown and distribute pressure.

To increase orientation to environment, promote sensory stimulation, orientation, and attention, decrease dependency, decrease anxiety and isolation.

To ease nursing care.

Systematic Approach
Pelvis

Lower extremities

Trunk

Shoulder girdle

Head and neck

OCCUPATIONAL/PHYSICAL THERAPY Name:

POSITIONING EVALUATION

Admit Date

DOB:

Room #:

Pertinent Medical History:

Precautions:

Reason for referral:

PRESENT MOBILITY

Ambulatory: Distance: Device: Assist:

Non-ambulatory: Chair: Wheelchair: Geri-chair Recliner Bed:

POSTURE

Pelvis Fixed anterior tilt posterior tilt: lateral tilt rotation Spine kyphosis scoliosis lordosis

Flexible

Left

Right

Comments:

EXTREMITIES:

Upper Extremities Left Supported: Tone: Contractures: Abd/Adduction Flexion Extension

Right

Lower Extremities Left

Right

HEAD/NECK SKIN CONDITION

Midline Flexed Tilted Left Right Rotated Left Right

Edema: Breakdown: Other

ASSESSMENT

RECOMMENDED CHANGES AND EQUIPMENT

Therapist________________________________ Date:__________________

Therapist________________________________ Date:__________________

EQUIPMENT PROVIDED

Therapist________________________________ Date:__________________

Therapist________________________________ Date:__________________

TO REMEMBER..............
Preserve as much movement as possible while facilitating proper alignment
Start with least restrictive position
Be aware of age related skin changes and risks
Team work

PROGRAM: REMEDIATING SENSORY IMPAIRMENT
DESCRIPTION/PURPOSE:
Sensory retraining involves the evaluation and treatment of sensory impairment, primarily as it relates to upper extremity functioning. Sensory dysfunction may accom­pany any disease or trauma affecting the nervous system. The rationale for sensory education following CVA is based on the belief that functional use of a body part is possible with reduced sensation but that, without training, a learned disuse phenomenon occurs that leads to loss of motor abilities. The therapist may alter the cortical map by directing the sensory experiences of the patient, therefore the goal of sensory re-education following CVA is to gain a larger cortical representation for those areas of skin from which sensor feedback is crucial to the performance of daily tasks. Following hand injury recovery is not just a process of reinnervation, but also involves cortical re-education of the interpretation of altered afferent signals from the periphery. Following nerve repair there is an inevitable distortion of the profile of neural impulses reaching the sensory cortex because of the misdirection of regrowth of axons. The effect of this misdirection is that a previously well known stimulus will initiate a different set of neural impulses from that elicited by the same impulse before the injury. The patient is then unable to identify or recognize the stimulus. The purpose of sensory re-education in these patients is to retrain them to recognize the distorted cortical impression.
OBJECTIVES/GOALS:

To evaluate the nature and extent of sensory dysfunction.

To teach compensation for loss of impairment of sensation order to prevent injury and to improve motor performance.

To increase tolerance to stimulation of a hypersensitive area.
INDICATIONS:
Any patient who has suffered trauma or disease which might affect any part of the sensory system (from the receptors to the cortex).
CONTRAINDICATIONS:
None

Remediating Sensory Impairment (cont.)

PRECAUTIONS:

Observe the hypersensitive patient’s tolerance for pain and adjust evaluation and treatment techniques accordingly.

Monitor patients with hyposensitivity and anesthesia to prevent injury from prolonged pressure or abnormal positioning.

EQUIPMENT:
Hierarchy of Texture and Vibration Used in Desensitization
Dowel Immersion

Level textures textures Vibration

1	Moleskin	Cotton	83cps near area
2	Felt	Terry Cloth pieces	83 cps near area, 23 cps near area
3	*Quickstick	Dry rice	83 cps near area, 23 cps intermittent contact
4	Velvet	Popcorn	83 cps intermittent contact, 23 cps intermittent contact
5	Semirough cloth	Pinto beans	83 cps intermittent contact, 23 cps continuous contact
6	Velcro loop	Macaroni	83 cps continuous contact, 53 cps intermittent contact
7	Hand T-foam	Plastic wire insulation pieces	100 cps intermittent contact, 53 cps intermittent contact
8	Burlap	Small BB’s or buckshot	100 cps intermittent contact, 53 cps continuous contact
9	Rugback	Large BB’s or buckshot	100 cps continuous contact, 53 cps continuous contact
10	Velcro	Plastic squares	No problem with vibration

Remediating Sensory Impairment (cont.)

ASSESSMENTS:
Semmes-Weinstein Monofilament Test - for testing localization of touch and 2 point discrimination.
OTHER:
Gross sensory evaluation procedures - listed in handouts.
PROCEDURES:

General Instructions

Orient the patient to the purpose and procedure of the sensory evaluation.

Once the patient is relaxed and comfortable, the patient’s vision is occluded. This may be done by asking the patient to keep his eyes closed, by using a blindfold, or by shielding the patient’s vision with a screen. Between each test procedure, allow the patient to open his eyes to prevent disorientation and to maintain attention to the task.

Stimuli is usually applied distally to proximally in order to determine the distribution of loss or impairment.

Stimuli are applied in an unpredictable pattern with variation in timing to assure reliability and accuracy of response. Uninvolved areas of the body are tested both to assure that the patient understands the directions and to establish “normal”.

The recording method is as follows.

Intact: responses were quick and accurate/

Absent: no response obtained.

Impaired: delayed response, sensation inappropriate to stimulus, or variable accuracy of response.

Sensory Modalities

Light touch

Stimulus: lightly touch a small area of the patient’s skin using a fingertip camel’s hair brush, feather or cotton ball. Occasionally ask the patient if he felt the stimulus without actually delivering the stimulus in order to verify the accuracy of the response.

Response: the patient indicates if a stimulus was felt, if it felt unusual and where he was touched. The stimulus-response is repeated so that those surfaces of the patient’s skin which would correlate with the expected distribution of dysfunction according to the diagnosis are tested.

Remediating Sensory Impairment (cont.)

Deep pressure

Stimulus: the therapist uses a finger tip to apply a firm pressure to a small area of the patient’s skin. The pressure must be firm enough to indent the skin to stimulate the deep receptors.

Response: the patient indicated if the stimulus was felt unusual, and where he was touched. The stimulus-response is repeated so that those surfaces of the patient’s skin which would correlate with the expected distribution of dysfunction according to the diagnosis are tested.

Temperature

Stimulus: before testing, be sure that the patient’s skin is of normal temperature. Capped test tubes, one filled with hot water, one filled with cold water are applied in random order to the patient’s skin.

Response: after each presentation of a stimulus, the patient indicates if he felt anything, and if it felt “hot” or “cold”. Again appropriate skin surfaces are tested.

Sharp/Dull (pain)

Stimulus: using a pin which provides one sharp and one blunt end, the therapist applies mixed sharp and dull stimuli in a random pattern of presentation to verify accuracy of response.

Response: the patient indicates if he felt something, whether it was sharp or dull, and the location of the touch. Again, all surfaces are tested. The scoring is based only on the accuracy of responses to the sharp stimuli. The dull stimulus is used so that the patient must discriminate.

Proprioception

Stimulus: The therapist holds the part laterally over bony prominenses to reduce tactile input, and places joints into easily describably positions. Test large joints (shoulder, elbow) as well as small joints (fingers).

Response: after each stimulus, the patient describes the position or imitates it with the other side of the body.

Remediating Sensory Impairment (cont.)
Kinesthesa

Stimulus: as when testing fro proprioception, hold the part laterally to reduce tactile input, while moving the joint up or down, large and small ranges of motion are tested on representative large or small joints.

Response: after each stimulus, the patient indicates whether the joint was moved “up” or “down”.

Stereognosis

Stimulus: an early recognizable object is placed in the involved hand. The object is to be identified by touch. Assistance in manipulation of the object may be required in the presence of paralysis. Items commonly used include a coin, key, safety pin, paper clip, or pencil.

Response: the patient names the object or selects it from an array or objects placed in front of him.

Two-point discrimination

Stimulus: two points or one point are applied randomly to an area of the skin. The distance between the two points is decreased in sequential presentation to determine how close together the points can be brought until the stimulus is perceived as one point.

Response: the patient indicates whether he felt one point or two. Two point discrimination is most refined in the finger tips than in more proximal areas of the body.
Interpretation
The location of absent or impaired responses is compared to peripheral nerve and dematomal distributions to determine the extent and nature of the sensory dysfunction.
Peripheral nerve injury - recovery of function proceeds proximal to distal. In the proximal area where the nerve is normal, intact function is expected; where the nerve is recovering, impaired functioning is expected; and where the nerve has not yet recovered, the absence of sensation is expected.

Traumatic spinal cord injury – sensory loss occurs in the dermatomes below the level of lesion. Unless the spinal cord is anatomically or physio­logically transected, or involves more than one dorsal root, the loss of sensation may be hard to detect because areas served by dorsal roots overlap.

Cortical dysfunction - damage in this area results in total or partial loss of discriminative sensations. Because the sensory cortex covers a wide cortical area, a localized lesion usually affects a limited part of the contral­ateral side of the body. The loss is usually distal in either the upper or lower extremity, depending on the site of the lesion.

Remediating Sensory Impairment (cont.)

TREATMENT:

Hyposensitivity
Treatment is primarily aimed at teaching the patient to compensate for loss or impairm­ent of sensation in order to avoid injury and to improve motor performance in order to protect himself from injury, as well as move with some degree of coordination, the patient must compensate visually by watching the movement of his extremities. The patient must constantly attend to situations in order to anticipate potential dangers.
Five mechanisms of damage to insensitive limbs have been described:

Continuous lope pressure which causes necrosis from lack of blood supply. Skin over bony prominences are particularly prone to pressure ulcers because of cutaneous tissue trapped between the unyielding bone and external pressure.

Concentrated high pressure causing cutting or crushing by mechanical violence. Compensatory techniques include: larger handles on suitcases, drawers, cupboards and large key holders. High pressure can result from splint straps that are too narrow and splints that are to tight.

Excessive heat or cold leading to burning or frostbite. Oven mitts, or potholders are necessary when cooking, utensils with wood or plastic handles should be used rather than metal ones. In cold weather, gloves or mittens are necessary protections for insensitive hands.

Repetitive mechanical stress causing inflammation and autolysis which can cause tendonitis or tenosynotivis, if the tendons and tendons sheath are subject to mechanical stress and thus traumatized. Skin trauma can also result from repetitious mechanical force with numerous repetitions of pressure the skin will become inflamed and if repetitive pressure is unrelieved, necrotic. To prevent damage, lower pressure or the number of repetitions. Methods to lower the pressure include: using soft shoe insoles, losing weight, wearing gloves and using enlarged or padded handled tools. Decrease repetitions by walking shorter distances, resting, and using a variety of tools or alternating hands.

Pressure on infected tissue that results in the spread of infection. Individ­uals with absent sensation often do not give infected tissue a chance to rest, hindering the healing process. Pain perception is not present to prevent over-use. Splinting, bedrest or other means of total immobilization may be necessary. Other techniques that compensate for absence sensation include reliance on other senses, e.g., vision may be used to prevent contact with sharp objects. Using a body part with intact sensation to test water temperature before emersion of any part without sensat­ion is recommended. Auditory cues may also be helpful in preventing injury.

Remediating Sensory Impairment (cont.)
Other recommendations include:

using an insulated coffee cup and using extreme care when smoking

avoiding exposure to extreme temperature

becoming aware of using only as much force as necessary in grasping objects and avoiding small handles that concentrate forces on a small area and skin

applying lotion or oil daily for good skin hydration

applying a splint to active but insensate injured areas (because these areas lack the natural splint of pain) or splinting to prevent injury in patients who cannot recognize dangerous situations or cannot remember to avoid them.

Anesthesia
Absence of sensation, especially of a large area of the body occurs in spinal cord injury, for example, is a particularly serious problem. The patient is neither aware of the discomfort of remaining in the same position for a long time, nor due to accompanying paralysis, is he easily able to change his position to relieve pressure. If unnoticed, continued pressure in susceptible areas causes loss of blood supply and tissue breakdown resulting in a decubitus ulcer. Patients can be trained to recognize potentially dangerous amounts of pressure concentrated in small areas and to take the responsibility for maintaining the integrity of their own skin.
A variety of wheelchair cushions are available to assist and distribute the pressure during sitting. Appropriately prescribed wheelchair cushions must be accompanied by proper skin care and position changed to prevent problems. The individual should change body position frequently, skin needs to be visually inspected daily. If a reddened area is noted and the time for skin to recover to its normal color exceeds 20 minutes, the cause of the skin irritation, it is essential to discover the cause. Modification of orthotic equipment schedule, physician and/or procedure is necessary.
Hypersensitivity
Hypersensitivity is a state in which stimuli that do not cause pain in normal tissues, do cause pain in the affected region. Individuals with hypersensitivity will typically hold the affected part in a protective manner. Hypersensitivity can lead to disability through nonuse of the involved body part. Desensitization is based on the belief that progressive stimulation will allow progressive tolerance. Through desensitization patient learns to filter out unpleasant sensations to permit accurate perception of sensory input. Materials are graded from soft to hard to rough, force is graded from touch to rub to tap. Due to the patient’s anticipation of pain a program of desensitization is best carried out by the patient himself under the direction of the therapist.
Remediating Sensory Impairment (cont.)
Hierarchy of Texture and Vibration Used in Desensitization
Dowel Immersion

Level textures textures Vibration

1	Moleskin	Cotton	83cps near area
2	Felt	Terry Cloth pieces	83 cps near area, 23 cps near area
3	*Quickstick	Dry rice	83 cps near area, 23 cps intermittent contact
4	Velvet	Popcorn	83 cps intermittent contact, 23 cps intermittent contact
5	Semirough cloth	Pinto beans	83 cps intermittent contact, 23 cps continuous contact
6	Velcro loop	Macaroni	83 cps continuous contact, 53 cps intermittent contact
7	Hand T-foam	Plastic wire insulation pieces	100 cps intermittent contact, 53 cps intermittent contact
8	Burlap	Small BB’s or buckshot	100 cps intermittent contact, 53 cps continuous contact
9	Rugback	Large BB’s or buckshot	100 cps continuous contact, 53 cps continuous contact
10	Velcro	Plastic squares	No problem with vibration

Other activities to decrease hypersensitivity include:

continuous pressure and isotoner gloves, or weight bearing pressure

massage

transcutaneous electrical stimulation

fluidotherapy

typing

washing hair

macrame

leather link belts

other activities that encourage use of the hypersensitive part
HANDOUTS:

Upper Extremity Gross Sensory Evaluation Procedures

Desensitization Evaluation Procedures
RESOURCES:

Trombly, Catherin A.

Pedretti L.W.