Occupational therapy programs tables of content

A note to wheelchair attendants: When assistance to the wheelchair user is required, remember to use good body mechanics. Keep your back straight and bend your knees whenever tilting the chair or traversing curbs, stairs, or other impediments.
Also, be aware of detachable parts such as arms or legrests. These must never be used for hand-hold or lifting supports, as they may be inadvertently released, resulting in possible injury to the user and/or attendant(s).
When learning a new assist technique, have an experienced attendant help you before attempting it alone.
Fold-Down Back Models:

Pull up pins located at the back of rear canes.

Fold rear canes down to back tubes.

To relock back in upright position, simply raise push handles with quick upward motion until cams click into the locked position.

Note: To fold push handles completely down to meet rear canes may require pulling pins up a second time to further disengage locking canes.

Functional Reach from a Wheelchair. The approximate reach-limit values shown in the accompanying graphs were derived on the basis of a sample of 91 male and 36 female subject wheelchair users. Note the difference between the maximum and the comfortable reach limits, a subjective but important consideration in design.
Coping with Everyday Obstacles. Coping with the irritation of everyday obstacles such as curbs and stairs can be alleviated somewhat by learning how to manage your wheelchair. Keep in mind your center of gravity to maintain stability and balance.
Tilting

CAUTION: DO NOT TILT THE CHAIR WITHOUT ASSISTANCE!

When tilting the wheelchair, an attendant should grasp the push handles securely, making sure that the handle grips are firmly attached. Inform the chair occupant before tilting the chair and remind him/her to lean back. Be sure the occupant’s feet and hands are clear of all wheels. Place one foot on the tipping lever and apply a continuous motion until the balance point is achieved. At this point, the attendant will feel a difference in the weight distribution. (This usually occurs at about a 30° angle). Turn the chair in the desired direction if necessary. LOWER the front end, placing one foot on the tipping lever and grasping the push handles to slowly lower the chair in one continuous movement. Do not let the chair drop the last few inches to the ground. This could result in injury to the occupant.

Safety/Handling of Wheelchairs

Percentage of Weight Distribution
Many activities require the wheelchair owner to reach, bend and transfer in and out of the wheelchair. These movements will cause a change to the normal balance, the center of gravity, and the weight distribution of the wheelchair. To determine and establish your particular safety limits described on the following pages, activities involving reaching, bending and transferring SHOULD FIRST BE PRACTICES WITH A QUALIFIED HEALTH PROFESSIONAL PRESENT.

*With added reinforcements and modifications tot he frame, the wheelchair weight distribution will change proportionately.

TILTING: CURBS

METHOD 1 - The attendant should tilt the chair until the front casters clear the curb. Roll the chair forward and lower the front casters to the sidewalk. Push the chair forward until the rear wheels roll up and over the curb.

METHOD 2 - The attendant should stand on the sidewalk and turn the chair so that the rear wheels are against the curb. The chair should be tilted back to the balance point and, in one continuous movement, the rear wheels should be pulled up and over the curb. DO NOT return the front casters to the ground until the chair back has been pulled backward far enough to clear the edge of the curb (Figure 9).
Unless the attendant has exceptional upper body strength, it is recommended that two attendants be utilized when choosing Method 2.
STAIRWAYS
Extreme caution is advised when it is necessary to move an occupied wheelchair up or down the stairs. Invacare recommends using two attendants and making thorough preparations. Make sure to use only secure, non-detachable parts for hand-hold supports. Follow this procedure for climbing stairs:

After the chair has been tilted to the balance point, one attendant (in the rear) backs the chair against the first step, while securely grasping the push handles for leverage.

The second attendant, with a firm hold on a non-detachable part of the front framework, lifts the chair up and over the stair and steadies it as the first attendant places one foot on the next stair and repeats the procedure.

The chair should not be lowered until the last stair has been negotiated and it has been rolled away from the stairway.

Escalators? SORRY! Do not use an escalator to move a wheelchair between floors. Serious bodily injury may occur.

Transferring to and from other seats - This activity may be performed independently provided you have adequate mobility and upper body strength: Position the chair as close as possible along side the seat to which you are transferring, with the front casters pointing toward it. Lock wheels. Shift body weight into seat with transfer.
During independent transfer, little or no seat platform will be beneath you. Use a transfer board if at all possible.

WARNING - BEFORE attempting to transfer in or out of the wheelchair, every precaution should be taken to reduce the gap distance. Also be certain the wheel locks are engaged against the large wheels to help prevent the wheels from moving (turn both casters toward the object you are transferring into).

CAUTION: Do not attempt to lift wheelchair by lifting on the armrests or legrests of a wheelchair equipped with removable (detachable) armrests or legrests. Lifting by means of the armrests or legrests of a wheelchair designed with removable features may result in injury to the user or damage to the wheelchair.

Reaching, Bending - FORWARD - Position the front casters so that they are extended as far forward as possible and activate wheel locks. DO NOT LEAN FORWARD OF THE ARMRESTS.
Reaching, Leaning, and Bending - When reaching, leaning, or bending, it is important to use the front casters as a tool to maintain stability and balance. Proper positioning is essential for your safety.

WARNING: DO NOT attempt to reach objects if (1) you have to move forward in the seat or (2) if you have to pick them up from the floor by reaching down between your knees.

Reaching, bending - BACKWARDS - Position wheelchair as close as possible to the desired object.
Point front casters forward to create the longest possible wheelbase.
Reach back only as far as your arm will extend without changing your sitting position.

WARNING: DO NOT activate the wheel locks – It is better to roll backwards than tip over. DO NOT lean over the top of the back upholstery. This will change your center of gravity and may cause you to tip over.

Anatomical Body

PLANES
ANATOMICAL POSITION - For the purpose of study, the human body has a reference point: a standard body position that remains consistent. The anatomical position is the position in which the body is standing erect, facing the observe, with feet together and parallel, the arms at the sides with palms directed forward.

PLANES - To locate the parts of the body in a relative position, the body is sectioned by specific planes:

Median plane - a vertical plane that would divide the body by a mid-line into right and left

halves. (Also referred to as the midsagittal plane).

Sagittal plane - a vertical plane parallel to the median plane, that would cut the body into

longitudinal slices of any thickness, but it must be parallel tot he median plane.

Frontal or Coronal plane - a vertical plane, at right angles to the median plane. It cuts

the body into anterior (front) and posterior (back) positions. These sections are not

referred to as halves.

Transverse plane - a horizontal plane, at right angles to both median and frontal planes,

that would cut the body into superior (upper) and inferior (lower) portions.

Terms of

MOVEMENT
The body and its extremities are capable of movements in many directions. Range of Motion is the ability of a part of the body to perform any single movement throughout an established normal pattern. Following injury, the residual ROM of a given part is compared to normal, then progress in rehabilitation may be recorded as this ROM improves.
Flexion - To bend or decrease the angle between two parts, as the action taking place at an articulation or joint.
Extension - To straighten or increase the angle between two parts of the body.
Abduction - To move laterally, away from the midline of the body.


Terms of

POSITION
All terms are relative to the body studies in the anatomical position.

Anterior (or Ventral) - the front or belly side.

Side

Posterior (or Dorsal) – the back side.

Superior – nearer the head end.

Inferior – farther from the head end.

Superficial – nearer the surface.

Deep – farther from the surface.

Medial – nearer the midline of the body.

Lateral – farther from the midline of the body.

Body

Proximal – used in reference to the extremities and meaning nearer the attached end (to the body)

Distal – opposite of the above term and meaning farther from the attached end.

Body Subdivision

Regions of the Body and their Subdivisions

Head: Divided into cranium and face.

Neck:

Trunk: Divided into thorax, abdomen, and pelvis.

Upper extremity: Divided into arm, forearm, wrist and hand.

Lower extremity: Divided into thigh, leg, ankle and foot.

WEIGHT LIMITATION

INVACARE recommends that only heavy duty constructed wheelchairs should be used for individuals weighing more than 250 pounds. On children’s models, the weight limitation is 160 pounds.
Further, the activity level of the individual wheelchair user is important. For instance, a 170-pound active wheelchair user could subject the wheelchair to more stress than a 250-pound passive user. The Manufacturer recommends therefore, that very active users consider the use of heavy duty construction.

INSERT SAFETY INSPECTION CHECKLIST

MAINTENANCE AND ADJUSTMENTS FOR WHEELCHAIRS

ETC. HERE!

OCCUPATIONAL THERAPY

PROGRAMS

Section 24

PROGRAM: WORK SIMPLIFICATION AND ENERGY CONSERVATION
DESCRIPTION/PURPOSE:
Energy conservation and work simplification are the use of adaptive techniques and devices to reduce the energy necessary to complete functional activities, the two terms are used interchangeably and are most often applied to modification of ADL’s and management of chronic cardio-respiratory conditions such as COPD.
OBJECTIVES/GOALS: 

Instruction in techniques to reserve personal energy.

Modify environment to maximize efficiency.

Teaching adaptive techniques to conserve energy.

Help residents understand and adapt to new limitations on energy level.

Instruction in decision making and problem solving for homemaking situations.

Assessment and provisions of assistive or adaptive devices.

INDICATIONS:

Resident whose clinical diagnosis or condition decreased energy and increased levels of fatigue.

Residents adapting to new physical limitations.

Residents requiring equipment adaptations to either conserve energy or prevent further progression of disease process.
CONTRAINDICATIONS:

Unstable medical condition
PRECAUTIONS:

Level of exertion used must be closely monitored.

Monitor any shortness of breath, changes in respiratory rate, change in heart rate and blood pressure, change in appearance and notify nursing/physician and modify activity accordingly.

Work Simplification and Energy Conservation (cont.)
EQUIPMENT:

Appropriate adaptive and assistive equipment.

Blood pressure cuff, stethoscope.

PROCEDURE:

Assess the resident’s overall physical, cognitive and psychosocial condition. Determine if modification in work habits will enhance task performance.

Observe resident during functional tasks to assess his/her ability to problem solve and set a realistic pace without over exertion.

Instruct resident in the following principles/techniques:

Set up proper working condition.

Set up work at heights appropriate for job.

Collect tools and equipment before starting.

Place appliances within easy reach.

Store frequently used tools and supplies in convenient location.

Reduce clutter–throw away things that are no longer used.

Organize storage–keep equipment in appropriate locations, such as duplicate bathroom cleansers in both bathrooms. Utilize Lazy Susans, peg boards and pull-out shelves.

Select proper equipment to fit the job. Utilize electric appliances such as electric can opener, dishwasher, garbage disposal to conserve personal energy.

Lay out work stations within arm’s reach to eliminate extra steps.

Create working conditions to make the job more pleasant and less tiring. Good lighting, proper ventilation, comfortable clothing and pleasing colors set the stage for work without strain.

Avoid unnecessary motions.

Eliminate step of a job or whole jobs. For example, wear permanent press clothing to eliminate ironing. Allow dishes to air dry.

Slide objects rather than lifting. Utilize continuous counterspace between stove, refrigerator and sink. Use a wheeled service cart if possible.

Use two hands in symmetrical, smooth, motions when possible. Use the larger proximal muscles and joints rather than the smaller more distal joints and muscles.

Avoid holding. Use stabilizers when possible. Dycem mats, suction cup bases, and heavy post are all ways to stabilize.

Work Simplification and Energy Conservation (cont.)
Conserve physical energy.

Set to work whenever possible. Sit to iron, work at the sink, and prepare foods.

Allow time for rest periods between tasks. Stop working and rest to avoid exhaustion.

Use a slow, relaxed pace. Work to music if necessary.

Get help for heavy work.

Alternate strenuous work with lighter activity.

Avoid stooping, bending and reaching. Open and close lower cabinets while seated.

Consider weather conditions. Work load should be decreased on a hot, humid day versus a cool one.

Utilize proper body mechanics by using strongest available muscles for the task.

Lifting to reach the floor.

Bending at the knees rather than at the waist.

Use legs to lift.

Use a chair or other sturdy object for assistance if needed.

Keep object being lifted close to body.

Pushing/pulling

Bend at hips and knees to better use the legs for power.

Keep elbows in and slightly bent.

Exhale while pushing.

Use wheels under objects whenever possible.

Stair climbing.

Walk on whole foot.

Use hand rail for support.

Pause between each step.

Use proper breathing techniques while climbing.

Avoid carrying objects in hands by using pocket or a shoulder carrying bag.

Proper breathing techniques.

Pursed lip breathing, slowly down the rate of breathing to fully expel trapped air from lungs when exhaling.

Breath in through nose with mouth closed.

Breath out slowly through pursed lips (as when whistling), taking twice as long to exhale as inhale. For example, when climbing steps, breathe in one step, breathe out through pursed lips during two steps.

Do not blow out hard as this may increase wheezing in lungs.

Do not hold your breath during exertion, such as sitting down, standing up, lifting, pushing, and pulling.

Work Simplification and Energy Conservation (cont.)

Abdominal breathing–using stronger abdominal muscles to aid the diaphragm and conserve energy used for breathing.

Let abdomen rise while breathing in.

Contract abdominal muscles while exhaling through pursed lips. This compresses the abdominal contents, pushing them up against the diaphragm and the base of the lungs, helping to push the air out.

Instruct resident to place hands below the rib cage to feel abdomen rise and fall while inhaling/exhaling until the technique becomes more natural.

DOCUMENTATION:
Documentation must reflect the need for skilled therapy, support the skilled nature of the Work Simplification/Energy Conservation program, present objects and measurable progress and the resident’s improvement as related to functional abilities. Also include the resident’s response and tolerance to the treatment procedure; to active/training provided to family/staff, and post therapy recommendations.
RESOURCES:
Furst, G.P., Gerber, L.H., and Smith C.B. (1985) Rehabilitation Through Learning: Energy Conservation and Joint Protection. A Workbook for Persons with Rheumatoid Arthritis. (Publications No. 017-045-001OT). Wash. DC: US Government Printing Office.
Reed, K.L. and Saunderson, S.N. (1992). Concepts of Occupational Therapy. Baltimore: Williams and Wilkins.
Trombly, C.A. (1995). Occupational Therapy for Physical Dysfunction. Baltimore: Williams and Wilkins.

WORK SIMPLIFICATION

RESIDENT HANDOUT

Slide rather than lift when possible
Eliminate unnecessary motions and processes, use both hands and arms at once. Encourage team work.
Avoid holding, use pans that rest firmly so both hands are free.
Use gravity, i.e., laundry chute, gravity feed flour canister.
Plan ahead and pre-position tools.
Place appliance controls in easy reach.
Sit to work whenever possible.
Stop working and rest before exhaustion.
Get help with heavy work.
Alternate strenuous work with lighter activity and take a rest period between jobs.
Avoid stooping, bending and reaching (use seat for closing and opening cabinets).
Store tools and supplies where first used.
Throw away things to don’t use (unclutter).
Make work easier with correct counter height and normal work areas.

Correct counter height for standing should be 2" below the height from the floor to your bent elbow.

To find the proper height for your work chair, measure the distance from your elbows to the floor while you stand and also when you sit. The distance from the floor to elbow when you stand, minus the distance from the floor to elbow when you sit, equals the amount to be added to the present height of the chair. You should be able to work without bending or raising your hand above your elbow. Moderate exercise is good for everyone. A person’s physical capacity depends on many things – age, health, body build, etc. Capacity to work is also affected by such factors as experience, weather, and state of mind. The following are some factors which you should consider in coping with your particular problems.


OCCUPATIONAL THERAPY

PROGRAMS

Section 25

MAKING FUNCTIONAL TRAINING MORE EFFECTIVE FOR THE ELDERLY
Maureen E. Neistadt, ScD, OTR/L, FAOTA

Assistant Professor

Occupational Therapy Department

University of New Hampshire

Durham, NH 03824

Definition of Function
Self-care, work, and leisure activities that are meaningful to people, that help them to fulfill their roles (e.g., spouse, parent, volunteer, worker, pet owner) and stay connected to other people.

Self-care

Personal care (eating, bathing, dressing, toileting)

Functional mobility (bed mobility, transfers, ambulation)

Community management (budgeting, shopping, transportation)

Work/Productivity

Paid/Unpaid work

Household management (cleaning, cooking, laundry)

Play/School

Leisure

Quiet recreation

Active recreation

Socialization

Before we engage in functional training, we need to know what functional activities are meaningful to any given elderly person.

Collaboration & Cooperation

Canadian Occupational Performance Measure (COPM)

Introduction of COPM

COPM examples.

Information Processing Approach to Functional Training.
“Functional training” implies that we expect clients to learn/Definition of learning.

Learning as information processing

Input via Central Nervous System Processing Motor Output

Sensory º (New interpretation/Old concepts; º

System Decision about response; plan for

Movement)
Errors in this information processing system lead to error in functional activity performance.

Nature of functional activity training depends on the type of information processing errors evident in functional activity performance.

Sensory detection errors - Augment sensory input

Central processing errors - Simplify task to decrease processing demands

Motor execution errors - increase muscle strength, endurance, dexterity.
Types of information processing errors due to deficits common in elderly persons.

Sensory detection

Visual deficits lead to errors in taking in visual information

Decreased acuity

Changes in optic lens (thickening, yellowing, and decreased elasticity)

Changes in iris (decreased ability to change width)

Changes in pupils (remain small in both dim and bright light)

Cataracts

Decreased visual fields

Decreased pupil size

Decreased retinal metabolism

Relaxation of upper eyelid and loss of retrobulbar fat (eyes sink more deeply into sockets)

Glaucoma

Macular degeneration

Stroke

Decreased color discrimination

Blue-greens

Retinal changes

Decreased ability to handle glare

Thickening of lens

Weakness of muscles that control pupil dilation

Decreased ability to handle contrast

Depth perception

Lens thickening and yellowing

Decreased ability to accommodate to light changes (pupillary muscle weakness)

Hearing deficits lead to errors in taking in auditory information.

Decreased detection of higher frequencies

Presbycusis

Death of nerve and sensory cells of inner ear

Decreased discrimination of sounds (presbycusis)

Muffled sounds (obstructions in inner ear)

Slowed processing (neuron loss in superior temporal lobe)

Proprioceptive deficits lead to errors in movement

Tactile deficits lead to delayed recognition of noxious stimuli (e.g., stone in shoe)

Changes in Meissner’s corpuscles

Soles of feet and palms of hands

Central Nervous System (CNS) Processing

Slowed CNS processing leads to errors in performance of timed tasks.

Difficulty learning new information leads to errors in performing adapted versions of functional tasks.

Association learning

Representational learning

Abstract learning

Misinterpretations of incoming sensory data leads to perceptual errors.

Over-reliance on previously learned concepts leads to poor decisions about capabilities and unsafe task performance

Decreased memory leads to errors in task sequencing and timing

Decreased motor planning ability leads to unsafe movements

Motor execution

ALL LEAD TO UNSAFE MOVEMENTS:

Muscle weakness

Decreased flexibility

Tremors

Abnormal muscle tone

Decreased coordination

Decreased endurance

Decreased postural stability

Information processing evaluation of functional activity performance

Observe functional performance; Note errors and quality of errors.

Hypothesize category of errors

Sensory detection

CNS Processing

Motor execution

Verify error categories and identify specific errors within those categories via client interview

Identify learning capabilities via variation of functional tasks

No learning

Association learning/Near transfer

Representational learning/Intermediate transfer

Abstract learning/Far and Very Far transfer

Suggest appropriate treatment strategies based on information processing errors and levels of learning

No learning - adapt environment for safety

Associated learning - consistent task set-ups and schedules; repetition; vary by no more than one surface characteristic

Representational learning - can very 3-6 surface characteristics

Abstract learning - vary tasks by more than 6 surface characteristics

Information processing functional skills training

Establish goals in collaboration with client.

Establish learning environment

Physical environment

Approximate discharge situation as much as possible

Include sensory augmentation as needed (see tables 1-3)

Include CNS processing aids as needed (see table 4)

People environment

Sensory augmented communication as needed (see table 2)

Complexity of cues

Speed of cues

Provide training to facilitate learning

Task skill training

Imparting knowledge

Supervised practice

Promotion self-assessment

Opportunities for skill generalization, as appropriate

Integrating skills into daily living habits

Habit training

Maintaining mobility and personal care routines

Engaging in meaningful activities during non-therapy time

Create opportunities for clients to initiate and sustain activities on own

Re-establish routines needed for discharge situation