Occupational therapy programs tables of content


Occupational Therapy Intervention



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Occupational Therapy Intervention

The major goals of occupational therapy intervention for individuals with dementing illnesses are (a) to maintain, restore, or improve functional capacity; (b) to promote participation in activities that optimize physical and mental health; and (c) to ease caregiving activities.


Although the biological conditions causing dementia cannot be reversed, functional performance can often be improved by simplifying task requirements and structuring the environment. For example, a patient whose hand strength is weak may benefit from a spoon with an enlarged handle, which provides a larger gripping surface. The occupational therapist recommends assistive devices and adaptive equipment that can be used by patients with reduced capabilities and trains the patient to use them effectively.
Environmental structuring does not always require specialized products. For example, manipulating buttons can be avoided by using pull-on garments. Normal objects of everyday living can also be used as memory aids. For example, although a cognitively impaired man may forget to shave, if handed a shaver, he may shave. By exploring the patient’s reaction to and use of objects, the occupational therapist or certified assistant can help care givers use objects effectively to evoke long-standing habits of daily living. Techniques such as removing environmental clutter and posting pictorial reminders may also be used to maintain skills.
Patterning social interactions is as important for maintaining daily living skills of cognitively impaired individuals as is structuring the physical setting. Taking this factor into consideration, the occupational therapist or certified assistant teaches care givers the skills needed to initiate and sustain functional activities. Often, this teaching involves the use of verbal prompts (e.g., “brush teeth”), or physical prompts (e.g., putting a toothbrush in the patient’s hand and moving the arm in a hand-to-mouth action).
As the disease progresses and the patient becomes more disabled, the occupational therapist or certified assistant looks for other ways to simplify the demands of everyday tasks. Each task is analyzed in terms of its component parts, and each part is then evaluated in terms of the patient’s ability to continue to perform it. If cutting meat is no longer possible, meat can be cut before it is given to the patient. Even though the patient may not complete all aspects of the task, the patient is not deprived of using the abilities that remain. In treating cognitively impaired individuals in groups, the task analysis approach may be combined with a division of labor approach. Each group member may complete only one step of the task, while the group as a whole accomplishes the total task. In making holiday decorations, for example, one member may trace the decorations, another cut them, and a third glue the parts together.
When abilities are compromised and a patient takes too long to do something or can no longer complete the task independently, care givers tend to take over and do things for the patient. As a result, the patient is at risk for becoming sedentary, inactive, and depressed. Continued engagement in activities of daily living through occupational therapy has a reality-orienting influence on the patient’s behavior. Leisure activities such as exercise, games, and crafts are often used to maintain joint mobility, muscular strength, mental alertness, and self-esteem and to prevent the development of excess disabilities such as contractures, fatigue, and depression. Symptomatology such as pacing and wandering can often be converted into purposeful activities such as exercise regiments or transporting items. For individuals with severe cognitive impairment, basic sensory activities involving taste, smell, and rhythm can be used to maintain sensory awareness.
In the advanced stages of a dementing illness, impaired judgment and incoordination of the upper and lower extremities combine to increase the risk of accidents. Occupational therapists play a role in promoting safety by correcting hazards such as throw rugs and unstable chairs, prescribing equipment such as bathtub safety rails and telephone aids for emergency communication, and preventing access to potential dangers such as knives and stairways.
In the final stage of illness, occupational therapy concentrates on assisting care givers with life maintenance functions. How to manage dysphagia (difficulty swallowing); position the head, torso, and extremities correctly; and lift and move patients are examples of skills that are often needed. Dementing illnesses such as Alzheimer’s disease are regarded as family illnesses because of the ramifications of the disease for family members and family life. Occupational therapy has a vital role to play in alleviating some of the care-giving burden through the provision of direct services or by assisting in planning of supportive services, such as adult day care or respite care.
Conclusion

Occupational therapy has a critical contribution to make to patient care at all stages of dementia. The specific type of occupational therapy intervention depends of the stage of illness and the manner in which cognitive impairment is manifested in performance. Individuals with dementing illness may also have other medical and psychiatric diagnoses or age-related impairments that influence therapeutic programming. The occupational therapist or certified assistant works directly with patients as well as with their care givers, who may be family members, friends, or paid personnel. They may also consult with health care providers about treatment approaches and environmental modifications.


References

Kiernat, J.M. (1982). Environment: The hidden modality. Physical and Occupational Therapy in Geriatrice, 2, 3-12.


Olin, D. W. (1985). Assessing and assisting the persons with dementia: An occupational behavior perspective. Physical and Occupation Therapy in Geriatrics 3, 25-32.
Skolaski-Pellitteri, T. (1983). Environmental adaptations which compensate for dementia. Physical and Occupational Therapy in Geriatrics 3, 31-44
Skolaski-Pellitteri, T. (1984). Environmental intervention for demented persons. Physical and Occupational Therapy in Geriatrics. 3, 55-59.
Skurla, E. (1984). A Qualitative Study of the Functioning of Patients with Alzheimer’s Disease in Activities of Daily Living. Unpublished master’s theses. University of North Carolina. Chapel Hill. 1984.
Snow, T.L. & Rogers, J.C. (1985). Dysfunctional older adults. In G. Kielhofner (Ed.) A model of human occupation: Theory and application. Baltimore: Williams and Wilkins, 352-370.
Wilson, L.A., Grant, K., Whitney, G.P, & Kerridge, D.F. (1973). Mental status of elderly hospital patients related to occupational therapists’ assessment of activities of daily living. Gerontologica Clinica. 15, 197-202.
Prepared by Joan C. Rogers, PhD. OTR, for the Commission on Practice (Esther Bell, MA, OTR, FAOTA, chair, and Cynthia Epstein, MA, OTR, FAOTA, project coordinator).
Approved by the Representative Assembly April 1986.
Previously published by the American Occupational Therapy Association in 1986 in the American Journal of Occupational Therapy, 40. 822-824.


Physical Agent Modalities

(Position Paper)

The American Occupational Therapy Association, Inc. (AOTA) asserts that “physical agent modalities may be used by occupational therapy practitioners when used as an adjunct to or in preparation for purposeful activity to enhance occupational performance and when applied by a practitioner who has documented evidence of possessing the theoretical background and technical skills for safe and competent integration of the modality into an occupation therapy intervention plan” (AOTA, 1991a.p.1075). The purpose of this paper is to clarify the parameters for the appropriate use of physical agent modalities in occupational therapy. Physical agent modalities are defined as those modalities that produce a response in soft tissue through the use of light, water, temperature, sound, or electricity. Physical agent modalities include, but are not limited to paraffin baths, hot packs, cold packs, Fluidotherapy, contrast baths, ultrasound, whirlpool, and electrical stimulation units (e.g., functional electrical stimulation (FES)/neuromuscular electrical stimulation (NMES) devices, transcutaneous electrical nerve stimulator (TENS) (AOTA, 1991b).
Physical agent modalities can be categorized as “adjunctive methods” (Pedretti & Pasquinelli, 1990 pp 3-4). An adjunctive method is one that is used in conjunction with or in preparation for patient involvement in purposeful activity. Adjunctive methods support and promote the acquisition of the performance components necessary to enable an individual to resume or assume the skills that are a part of his or her daily routine. As such, the exclusive use of physical agent modalities as a treatment method during a treatment session without application to a functional outcome is not considered occupational therapy. Physical agent modalities can be appropriately integrated into an occupational therapy program only when they are used to prepare the patient for better performance and prevention of disability through self-participation in work, self-care, and play and leisure activities (AOTA, 1979).
The safe selection, application, and adjustment of physical agent modalities, however, is not considered entry-level practice. The specialized learning necessary for proper use of these modalities typically requires appropriate post professional education, such as continuing education, in-service training, or graduate education. Documentation of the theoretical and technical education necessary for safe and appropriate use of any physical agent modalities should include, but not be limited to course(s) in human anatomy: principles of chemistry and physics related to specific properties of light, water, temperature, sound, or electricity, as indicated by the selected modality: physiological, neurophysical, and electrophysiological changes that occur as a result of the application of the selected modality: the response of normal and abnormal tissue to the application of the modality; indications and contraindications related to the selection and application of the modality; guidelines for treatment and administration of the modality; guidelines for preparation of the patient, including education about the process and possible outcomes of treatment (i.e., risks and benefits); and safety rules and precautions related to the selected modality. Education should also include methods and long-term effects of treatment and characteristics of the equipment, including safe operation, adjustment, indications of malfunction, and care. Supervised use of the physical agent modality should continue until service competency and professional judgment in selection, modification, and integration into an occupational therapy program are assured (AOTA, 1991b). As with all media, when a registered occupational therapist delegates the use of a physical agent modality to a certified occupational therapy assistant, both shall comply with appropriate supervision requirements and ensure that their use is based on service competency (AOTA, 1991c).
The Occupational Therapy Code of Ethics (AOTA, 1988) supports safe and competent practice in the profession and provides principles that can be applied to physical agent modality use. Principle 2 (Competence) states that “occupational therapy personnel shall actively maintain high standards of professional competence”. (P. 795) and places expectations on practitioners to demonstrate competency by meeting competency-based standards. Principle 2B states that “the individual shall recognize the need for competence and shall participate in continuing professional development” (p. 795), which obliges practitioners to maintain competency by involvement in continuing education. In particular, therapists who choose to use physical agent modalities must say abreast of current research findings regarding the efficacy of physical agent modality use. In addition, Principle 3A states that “the individual shall be acquainted with applicable local, state, federal, and institutional rules and Association policies shall function accordingly” (p. 195), and requires practitioners to comply with all rules, regulations, and laws. All state laws and regulations related to physical agent modality use have precedence over AOTA policies and positions.
References
American Occupational Therapy Association (1979), Policy 1.12. Occupation as the common core of occupational therapy. In Policy Manual of The American Occupational Therapy Association, Inc. Rockville, MD: Author.
American Occupational Therapy Association. (1988). Occupational therapy code of ethics American Journal of Occupational Therapy, 42, 795-796.
American Occupational Therapy Association, (1991a). Official: AOTA statement on physical agent modalities. American Journal of Occupational Therapy. 45 1075.
American Occupational Therapy Association (1991b). Physical Agent Modality Task Force report. Rockville, MD: Author.
American Occupational Therapy Association (1991c). Registered occupational therapists and certified occupational therapy assistants and modalities (Policy 1.25), American Journal of Occupational Therapy, 45, 1112-1113.
Pedretti, L.W. & Pasquinelli, S. (1990). A frame of reference for occupational therapy in physical dysfunction. In L. W. Pedretti & B. Zoltan (Eds.). Occupational therapy practice skills for physical dysfunction. (3rd ed. Pp. 1017). St. Louis: C. V. Mosby.
Author:
Mary Jo McGuire, MS, OTR, for Commission on Practice (Jim Hinojosa, PhD, OTR, FAOTA, Chair)
Approved by the Representative Assembly March 1992.
Previously printed and copyrighted in 1992 by the American Occupational Therapy Association in the American Journal of Occupational Therapy, 46, 1090-1091.


POSITION PAPER: OCCUPATIONAL THERAPY AND ASSISTIVE TECHNOLOGY

The American Occupational Therapy Association asserts that occupational therapy services are important in the application of technology to habilitation and rehabilitation. Occupational therapy, uses low technology assistive devices (i.e., devices without electronic components, such as reachers, key guards, and positioning systems) and high-technology assistive devices (i.e., devices with more complex electronic components, such as microprocessor-controlled wheelchairs, environmental control units, and augmentative communication systems) to ensure maximum independence in activities of daily living, work/school activities, and play/leisure activities. In this document, the term assistive technology devices means “any item, piece of equipment, or product system, whether acquired commercially, off the shelf, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities” (Technology-Related Assistance for Individuals With Disabilities Act of 1988 (Public Law 100-407). This paper addresses the use of assistive technology devices with persons who have sensorimotor and cognitive dysfunction.
Historically, occupational therapy has used technology devices in the provision of assessment and intervention services. The Association recognizes that continuing technological advances have significant impact on the use of these devices in occupational therapy practice. Professional and technical education prepares the occupational therapy practitioner to assess the individual’s need for technological assistance. However, the rapid change in the availability and complexity of technological devices necessitates that practitioners pursue continuing education so that they can apply new technology and new devices to the needs of persons with disabilities.
The occupational therapist assesses a person’s sensorimotor, cognitive, and psychosocial abilities to determine the assistive technology that will enable him or her to safely perform activities of daily living, work/school activities, and play/leisure activities. During the assessment process, the therapist also considers the person’s environmental constraints and life-style to ensure a useful and appropriate application of technology. The occupational therapist’s unique ability to analyze the person’s capabilities, the task, and the environment ensures compatibility between the person and the assistive technology used to meet that person’s needs.
The occupational therapy practitioner provides a broad range of services in the applications of technology, including identification, evaluation, recommendation, procurement, fit, modification, training and follow-up. The occupational therapy assistant works under the supervision of the occupational therapist in specified service provision tasks. The occupational therapy practitioner’s understanding of the disabled person’s everyday functional needs and abilities enables the practitioner to provide input into the design, development, and clinical application of new technological devices.
It is important that information and knowledge from many areas be coordinated in the application of technology. The occupational therapy practitioner routinely collaborates with individual team members (e.g., rehabilitation engineer, rehabilitation technologist, speech-language pathologist, teacher) to assess each person’s unique needs and to apply the appropriate technology. The occupational therapist’s orientation toward the provision of adaptive solutions, coupled with an understanding of the person’s impairments and the task’s demands, places the occupational therapist in the unique position of coordinating the application of technology services. Training and follow-up are coordinated with the person, the family or caregiver, and other professionals involved in the person’s care.
Decisions regarding technological assistance are guided by ethical considerations such as the person’s values and needs, long-range cost-effectiveness, and usefulness. The application of technology is not an end in itself, but is part of an ongoing therapeutic process. Technology and the new tools it offers to simplify work and extend human performance serve occupational therapy in its most traditional and enduring dimension–helping humans toward independence by assisting them in the process of adaptation.
Reference
Technology-Related Assistance for Individuals With Disabilities Act of 1988 (Public Law 100-407), 29 U.S.C. § 2202.
Prepared by Cheryl Deterding, MA, OTR, Mary Jane Youngstrom, MS, OTR, and Winnie Dunn, PhD, OTR, FAOTA, for the Commission on Practice (Jim Hinojosa, PhD, OTR, FAOTA, Chair).
Approved by the Representative Assembly June 1991.
Previously published and copyrighted by the American Occupational Therapy Association in 1991 in the American Journal of Occupational Therapy, 45, 1076.




Occupational Therapy in the Promotion of Health and the

Prevention of Disease and Disability (Position Paper)


The American Occupational Therapy Association supports the expansion of occupational therapy research and practice in activities that will document achievement in health, well-being, and wellness through disease prevention and health promotion. Promoting health and wellness is the basis of prevention efforts and should be the cornerstone of all therapeutic intervention. Health promotion, therapeutic intervention, and disease and disability prevention are interdependent activities.
Wellness is a life-style one designs to achieve one’s highest potential for well-being. It is a way of life a person chooses, even in the presence of disabling condition or illness (Ryan & Travis, 1983). Illness and wellness are separate dimensions rather than polar opposites (Reed & Sanderson, 1983). Occupational therapy’s emphasis on occupational performance, purposeful activity, balance within systems, and the interaction between the environment and the individual is congruent with the ideal of wellness as a context for living (Johnson, 1986).
Health promotion is the practice of informing, educating, facilitating behavioral change, and using cultural supports so people can assume responsibility for living a life-style that is centered on optimal well-being. Prevention of disease and disability is any activity intended to keep specific diseases or disabling conditions form occurring or worsening. Occupational therapy practitioners anticipate and prevent the onset of disease or disability by, for example, educating parents of high-risk infants, teaching safely procedures in industrial and home settings, and teaching coping techniques to reduce stress.
The promotion of health and wellness is compatible with the fundamental beliefs and theoretical foundations of occupational therapy. Occupational therapy practitioners can effectively promote wellness for persons of all ages and all socioeconomic environments by applying their knowledge of human growth and development, disease processes, disabling conditions, and theories of purposeful activity and human performance. Occupational therapy practitioners promote health and well-being within interdisciplinary teams and in independent practice. Through the use of purposeful activity, occupational therapy practitioners assist in the promotion of health and the prevention of disease and disability in community settings, including school systems and the home, health facilities, and the workplace. Documentation of successful occupational therapy efforts in health promotion and in disease prevention can demonstrate the central role of occupational therapists as health promoters in this important health care movement.
References
Johnson, J.A. (1986). Wellness: A context for living. Thorofare, NJ: Slack.
Reed, K.L., & Sanderson, S.R. (1983). Concepts of occupational therapy (2nd ed.) Baltimore: Williams and Wilkins.
Ryan, R., & Travis, J. (1983). Wellness workbook. Berkely, CA: Ten Speed Press.
Related Readings
Dunn, H.E. (1977). High level wellness. Thorofare, NJ: Slack.
Dwore, R. B. & Kreuter, M.W. (1980). Update: Reinforcing the case for health promotion.  Family and Community Health 2, 103-113.
Opatz, J.P. (1985). A primer of health promotion: Creating healthy organizational cultures. Washington, DC: Oryn Publicaitons
Public Health Service, (1979). Healthy people: The surgeon general’s report on health promotion and disease prevention. (DHEW Publication No. 79.55071). Washington, DC: US Government Printing Office.
Prepared by Barbara A. Rider, MS, OTR, FAOTA, Chair, Karen E. Maurer, OTS, Cindee Q. Peterson, MS, OTR, Dean R. Tyndall, MS, OTR, FAOTA, Virginia K. White, PhD, OTR, FAOTA, with consultation from Els R. Nieuwenhuijsen, Mph, OTR for the Commission on Practice (L. Randy Strickland, EdD, OTR, FAOTA, Chair).
Approved by the Representative Assembly April 1989.
This document replaces the 1978 AOTA Roles and Functions Paper: The Role of Occupational Therapist in the Promotion of Health and Prevention of Disabilities, which was rescinded by the Representative Assembly in April 1989.
Previously published and copyrighted by the American Occupational Therapy Association in 1989 in the American Journal of Occupational Therapy, 43, 806.



Occupational Therapy and Eating Dysfunction

(Position Paper)


The American Occupational Therapy Association (AOTA) asserts that occupational therapy is an essential service for the comprehensive management of eating dysfunction. Eating is a significant performance area of daily living skills throughout a person’s life. The Uniform Terminology System for Reporting Occupational Therapy Services refers to eating/feeding as “the skill and performance of sequentially feeding oneself, including sucking, chewing, swallowing, and the manipulation of appropriate utensils” (AOTA, 1986. P. VIII 13). Many problem areas within the person’s environment affect eh eating/feeding process, including deficits caused by sensorimotor, perceptual, neurological, cognitive, or psychosocial factors. Feeding is the process of getting food to the mouth, while eating is the process of moving food from the mouth to the stomach. Although occupational therapy has a critical role in the treatment of psychosocial eating disorders and related behavior problems, that role will not be addressed in this paper.
The ability to feed oneself independently in order to meet nutritional needs is assessed and treated by the occupational therapist. Aspects of the physical and social environment that affect feeding performance are addressed. Reinstitution of oral feeding in persons nourished by prolonged nonoral methods (e.g., central venous nutrition, nasogastric feeding, gastostomy) is facilitated. Occupational therapists differentiate eating difficulties intrinsic to the patient, such as dysphagia, from those that involve the caregiver’s knowledge and skill.
Eating functions are complex and require comprehensive assessment and treatment. Advanced education and clinical practice are essential prerequisites for using specialized evaluations such as videofluoroscopy and techniques such as complex oral motor facilitation. Occupational therapy assessment and treatment focuses on the following areas:


Treating impairments of tone, strength, coordination, and movement patterns of the muscles of the face, lips, jaw, tongue, and pharynx to attain the oral-motor control necessary to manipulate and swallow various textured foods and liquids.

Initiating treatment to normalize impairments in oral facial sensitivity.

Inhibiting abnormal oral-motor and/or postural reflexes and facilitating age-appropriate responses to promote function.

Introducing compensatory techniques to minimize the effects of visual-perceptual problems that affect eating performance.

Using developmentally appropriate activities to facilitate the dynamic and static postural control necessary for eating.

Addressing cognitive issues to ensure that safe eating practices are followed.

Encouraging socially appropriate eating behaviors and activities.

Using specialized seating and orthoses to achieve appropriate positioning, providing functional equipment or utensils to assist with self-feeding, and devising adaptations for patient dependent on life-support systems or environmental controls.


Occupational therapy is a qualified and valued service in the management of eating dysfunction. Through collaboration with other professionals, occupational therapists promote maximal independence in all components of eating.
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