IRAT 7

Factors complicating one-handed ADL retraining after brain injury

Unlike isolated orthopedic weakness, brain injury may also cause impaired sitting/standing balance, sensation, vision, perception, cognition, communication, neglect, or apraxia, which must be assessed prior to selecting teaching methods.

General hemiplegic dressing rule for donning versus doffing

Don clothing on the affected arm or leg first; remove clothing from the stronger/unaffected limb first to reduce the need to force the affected extremity.

Environmental setup for initial one-handed dressing practice

Use a sturdy chair or locked wheelchair, support feet on the floor, place clothing and needed equipment within reach, and maintain an upright midline posture before progressing to more challenging surfaces.

Recommended OT positioning during hemiplegic dressing training

Positioned usually on the affected side, directly in front of the client, or at midline, depending on task demands and safety requirements.

Rationale for avoiding automatic prescription of dressing equipment

The clinician should first determine whether safe compensatory techniques suffice, favoring minimal necessary assistive devices before introducing equipment such as reachers.

Front-opening shirt Method 1: Initial preparation and affected arm

Untwist the shirt; place it inside-up on the lap with the collar toward the chest; enlarge the affected sleeve opening; use the stronger hand to thread the affected hand through and work the sleeve past the elbow until the hand is visible.

Front-opening shirt Method 1: Completing donning

Insert the stronger arm, gather fabric up the back, lean forward and duck head to pass the shirt behind/over the head, smooth shoulders and back, align fronts, and begin buttoning from the bottom.

Front-opening shirt Method 1: Benefit for shoulder pain or limited ROM

It allows the stronger hand to manage garment placement while minimizing difficult or painful shoulder movements of the affected extremity.

Front-opening shirt Method 2: Distinctive strategy

After partly placing the affected arm in its sleeve, reach the stronger arm behind the body, wrap the shirt around the back, insert the stronger arm, and work the affected sleeve above the elbow.

Front-opening shirt Method 3: Distinctive strategy

Pull the affected sleeve entirely to the shoulder first, then grasp the collar on the stronger side and bring the garment around behind the head before inserting the stronger arm.

Sequence for donning a pullover shirt with hemiplegia

Orient the shirt on lap; gather fabric to affected sleeve; insert affected hand and pull sleeve past elbow; insert stronger arm; adjust affected shoulder; gather back fabric, lean forward and pass shirt over head; smooth fabric.

Sequence for removing a pullover shirt with one functional upper extremity

Gather fabric at the upper back, lean forward and duck head to lift it over the head, then remove from the stronger arm before the affected arm.

Garment features that simplify one-handed pants management

Slightly larger trousers, wide ankle openings, and accessible fasteners such as hook-and-loop closures or a button fly; socks are put on before pants and shoes afterward.

Seated pants donning Method 1: Threading the legs

Sit securely with stronger knee flexed; use stronger hand to cross affected leg over it; thread affected foot first below knee; support ankle while uncrossing; then thread stronger leg.

Rationale for supporting the affected leg when uncrossing during pants dressing

Uncontrolled dropping can cause injury to an extremity that has impaired motor control, diminished sensation, or compromised protective reactions.

Completing pants donning after both legs are threaded

Work trousers toward the hips, then pull over hips while standing only if balance is safe (using loops or pockets for stabilization if feasible), and fasten securely.

Pants Method 2 (Seated hip-lift) and its target user

A seated method for clients unable to stand independently: with chair or wheelchair secured, lean back and push through the stronger foot to elevate hips while pulling trousers up.

Contraindications for seated hip-lift pants Method 2

Inability to bridge safely, severe affected-side sensory or perceptual deficits, poor safety judgment, impulsivity, or risk of the wheelchair tipping backward.

Wheelchair setup required for seated hip-lift pants management

Lock wheelchair brakes, swing footrests away, place feet flat on the floor, and ensure anti-tippers are engaged before attempting hip elevation.

Technique for donning pants in bed when seated/standing methods are unsuitable

In a semi-reclined or recumbent position, thread affected leg first then stronger leg, pull to hips, and bridge using foot/shoulder pressure or roll side-to-side with knees flexed to hike pants.

Hemiplegic pants doffing sequence

Unfasten and lower past hips via standing, seated hip-lift, bridging, or rolling; remove clothing from the stronger leg first, followed by the affected leg.

Technique for one-handed bra fastening

Anchor one end at waistband, wrap around waist, fasten in front, rotate closure to the back, thread affected arm through strap before the stronger arm, and adjust.

Role of restorative practice alongside one-handed compensations

Compensations establish immediate functional independence, while high-repetition task-specific practice and active affected-arm engagement (such as CIMT) promote underlying motor recovery.

Impact of neglect or apraxia on ADL retraining after stroke

Neglect limits spatial and limb awareness while apraxia impairs motor planning and tool use; both require tailored cueing and specialized setups rather than assuming motor capacity permits learning.

Occupational performance (OTPF-4 definition)

Engagement in meaningful, purposeful activities related to habits, routines, and roles, evaluated through actual task participation rather than impairment scores alone.

Three OTPF-4 performance skill categories

Motor skills (moving self or objects), process skills (selecting, sequencing, organizing, and adapting task actions), and social interaction skills (verbal and nonverbal exchanges).

Performance skill versus client factor

A performance skill is an observable, goal-directed action executed during an occupation; a client factor is an internal capacity, characteristic, physiological function, or belief.

Motor and process skill examples during shaving

Motor skills involve grasping and manipulating the razor; process skills involve organizing tools, sequencing strokes, timing, and adapting actions during the occupation.

Categories of client factors in the OTPF-4

Values, beliefs, and spirituality; body functions (physiological and psychological capacities); and body structures (anatomical components).

Spirituality as an OT client factor

The personal meaning, purpose, and significance associated with occupation and life experience; it is not synonymous with religiosity.

Clinical limitation of measuring only ROM and strength in OT

Impairment measures describe bodily capacity but do not demonstrate whether the individual can actually coordinate actions to execute a meaningful functional task.

Recommended combination of client-factor and performance-skill assessment

Measure relevant underlying factors (e.g., AROM, cognition), observe client performance in prioritized occupations, identify real-time barriers and strategies, and compare performance with intended outcomes.

Precaution during informal occupational performance analysis

Specify the intended outcome prior to observation so the clinician can benchmark performance objectively and avoid making isolated client factors the sole basis of therapy.

Distinction between a task and an occupation

A task is a discrete step or component of an activity (such as cutting food), whereas an occupation includes personal identity, contextual relevance, and overarching meaning (such as self-feeding).

Task-Oriented Approach (TOA)

A client-centered, individualized framework addressing functional task performance through dynamic interactions among the person, task, and environment, grounded in motor learning principles.

How the Task-Oriented Approach drives cortical reorganization

Meaningful functional practice involving dynamic person-environment interactions provides multisensory feedback and opportunities for neuroplastic changes that enhance performance skills.

Reactive versus reparative axonal sprouting

Reactive sprouting occurs locally adjacent to damaged CNS tissue with limited recovery; reparative sprouting extends farther across neural pathways and supports functional restitution.

Four components of the Accelerated Skill Acquisition Program (ASAP)

Capacity building, skill acquisition, motivation enhancement, and autonomy support.

ASAP component: Capacity building

Practicing foundational prerequisite movement elements and physical capacities necessary to complete a targeted functional occupation.

ASAP component: Skill acquisition

Collaboratively identifying, practicing, and refining the motor execution needed for real-world tasks, including anticipating and solving performance challenges.

ASAP components: Motivation enhancement versus autonomy support

Motivation enhancement establishes client-selected incremental goals; autonomy support continuously engages the client in judging performance and directing future therapeutic goals.

Relationship between performance skills and occupational roles/routines

Competent observable task skills allow successful ADL execution, which solidifies predictable daily routines and facilitates long-term participation in life roles.

Traumatic Brain Injury (TBI)

An alteration in brain function or other evidence of brain pathology caused by an external mechanical force, manifesting in cognitive, physical, or consciousness changes.

Traumatic versus nontraumatic acquired brain injury

TBI results from external physical mechanical forces; nontraumatic acquired brain injury stems from internal factors such as anoxia, toxins, infection, tumors, or ischemia.

Presentation of concussion regarding loss of consciousness

A concussion does not require loss of consciousness; it can present with headache, dizziness, blurred vision, slowed processing, memory lapses, or altered coordination.

Chronic Traumatic Encephalopathy (CTE)

A progressive neurodegenerative disorder associated with repetitive head impacts (concussive and subconcussive blows), with clinical symptoms often emerging years later.

Primary versus secondary TBI mechanisms

Primary injury occurs at the precise moment of physical impact; secondary injury evolves subsequently due to cellular cascades, cerebral edema, ischemia, hypoxia, and elevated intracranial pressure.

Clinical rationale for preventing secondary brain injury

Secondary complications substantially worsen cerebral damage and long-term functional disability; rapid prevention is critical across acute, intensive, and rehabilitative care.

Focal brain injury

Localized damage confined to specific brain regions resulting from direct impact, penetrating objects, or the brain contacting sharp internal contours of the skull.

Coup versus contrecoup injury

A coup injury is localized directly at the site of cranial impact; a contrecoup injury occurs at an indirect location, typically opposite the impact, due to brain deceleration rebound.

Epidural hematoma pathophysiology and clinical hallmark

Arterial hemorrhage (often the middle meningeal artery) between the skull and dura mater; characteristically presents with an initial lucid interval followed by rapid neurological decline.

Subdural hematoma

Venous bleeding accumulating between the dura and arachnoid membranes, commonly caused by torn bridging veins, which typically develops more gradually than arterial hematomas.

Subdural hematoma clinical timeline classification

Acute: symptoms develop within 48 hours; subacute: symptoms appear between 2 and 14 days; chronic: symptoms manifest after 2 weeks post-injury.

Mechanism causing diffuse or multifocal axonal brain injury

High-velocity acceleration and deceleration forces that produce rotational shearing and tensile deformation throughout deep and superficial neural pathways.

Anatomical sites vulnerable to microhemorrhage in deceleration TBI

The gray-white matter junction, corpus callosum, basal ganglia, brainstem/midbrain, and cerebellum.

Complication resulting from a large intraventricular hemorrhage

Mechanical obstruction of cerebrospinal fluid circulation pathways, leading to acute obstructive hydrocephalus and rapid intracranial hypertension.

Rancho Los Amigos Levels of Cognitive Functioning Scale

A standardized descriptive scale outlining levels of awareness, cognitive processing, behavioral control, and environmental interaction after brain injury to frame assessment and therapy.

Core occupational deficits at low Rancho levels (Case of Maria)

Complete dependence for self-care and mobility, absent sitting balance, left upper extremity spasticity with contracture risk, and inability to communicate verbally.

Early OT rehabilitation priorities for low Rancho level TBI

Manage tone/spasticity, preserve joint ROM, encourage midline head and trunk control, facilitate supported transfers, provide sensory stimulation, and address low-level feeding/communication.

Impact of low Rancho cognitive level on OT assessment selection

Severe deficits in arousal, cognition, and behavioral consistency preclude standardized functional tests; clinicians must use direct behavioral observation and basic sensory/motor screening.

Core evaluation domains in intermediate to higher-level TBI

Physical capacity, swallowing, cognitive processing, vision, perception, basic and instrumental ADLs, vocational readiness, and psychosocial adjustment.

Core intervention domains for intermediate to higher-level TBI

Neuromuscular re-education, ataxia intervention, cognitive/perceptual training, behavioral management, home management (IADLs), community mobility, and psychosocial skills.

Key prognostic factors influencing recovery trajectory following TBI

Chronological age, preinjury cognitive/functional baseline, injury severity/duration of coma, quality of rehabilitation, and the presence of stable family/community support systems.

Importance of caregiver education throughout the TBI continuum

Caregivers reinforce safety strategies, help prevent secondary physical/behavioral complications, assist with daily compensatory routines, and sustain long-term community participation.

Rationale for assessing visual, perceptual, and cognitive status before ADL training

Deficits in these areas compromise comprehension, safe sequencing, tool manipulation, and strategy generalization even when isolated limb strength is completely intact.

Clinical scenario: Intact grip strength with failure to sequence shaving steps

Indicates a deficit in occupational process skills (e.g., apraxia or executive dysfunction); treatment must emphasize task organization, cueing, and sequencing rather than motor strengthening.

Clinical scenario: Pants donning strategy for a client who cannot stand but can bridge

Implement a seated hip-lift (or supine bridging) method, verifying wheelchair locks, foot placement, anti-tippers, and balance stability prior to execution.

Clinical scenario: Pants management for a client in bed unable to bridge

Position the bed flat with knees flexed as tolerated and have the client roll side-to-side, hiking the trousers over one hip at a time.

Clinical scenario: Shirt doffing sequence in left hemiplegia

Remove the sleeve from the unaffected/stronger right arm first, and doff from the affected left arm last.

Clinical scenario: Task-Oriented Approach for improving kitchen independence

Engage the client in practicing meaningful meal-preparation activities within contextual environments while modifying task demands, rather than relying on isolated muscle exercises.

Clinical scenario: Rapid neurological deterioration following an initial lucid interval

Classic clinical presentation of an expanding epidural hematoma; requires immediate emergency neurosurgical evaluation rather than therapeutic intervention.

Clinical scenario: Varied ADL outcomes in two individuals with identical joint ROM

Underlying differences in cognitive-process skills, perception, sensation, postural control, compensatory strategies, motivation, and environmental supports dictate functional success.