Midterm Review

Where to start in grading and adapting activities?

1. activity analysis

2. Adaptation vs grading

   1. understand the factors that go into performing tasks

   2. design and implement interventions

Adaptation (compensation)

• Change the occupation or activity for the client to participate or find new occupations to engage in

• Goal is to increase participation and independence within the preferred occupation

Grading (remediating)

• Increase or decrease demands on the client while they are performing an activity

• Providing a “just right” challenge

• Too easy- client can experience boredom

• Too hard- client can lose motivation

Areas of grading activities

• Strength

• ROM

• Endurance/activity tolerance

• Coordination

• Cognition

• Social skills

Strength grading and adapting 

• Increase or decrease in resistance

• Changing plane of movement

• We must restore ROM prior to strengthening

• Example: shoulder flexion

  • Grade up: use of dowel rod 1-2#

  • Grade down: pulleys with 1#

ROM grading and adapting

• Increase or decrease amount of range a client has to complete

• Changing plane of movement

• PROM, AAROM, AROM

• Example: shoulder flexion

  • Grade up: into gravity- rolling a ball up the wall

  • Grade down: gravity eliminated- table slides

Endurance grading and adapting

• Light —> heavy work

• Increase time

• Be cautious of certain medical conditions: MS, Parkinson’s, muscular dystrophy

• Example: dressing

  • Grade up: retrieve clothing items and dress EOB

  • Grade down: therapist retrieves clothes, client sits EOB to dress

Coordination grading and adapting

• Decrease gross resistive movements

• Increasing fine controlled movements

• Increasing speed

• Motor control and motor learning theory

• Example: buttons

  • Grade up: buttoning .5'“ buttons on self

  • Grade down: using button board 1” button. Do we want to time this?

Cognition and Social skills grading and adapting

• Step by step direction (1-step, 2-step, multi-step)

• Environmental stimuli

• Initial social interaction with OT and client

  • Another client in the room —> small groups

  • Example: puzzle

    • grade up: increase number of pieces

    • grade down: provide visual to see what puzzle should look like

Things to consider when grading/adapting activities 

• How does the client feel towards this activity?

• What is the client’s dx?

  • Degenerative

  • PMHx

• How many visits do you have?

• Client’s strengths/weaknesses

• Consider the environment

• Safety!!!

Signs/symptoms of cardiac distress

• angina

• dyspnea

• orthopnea

• nausea/emesis

• diaphoresis

• fatigue

• orthostatic

Cardiac Surgical interventions

• Percutaneous transluminal coronary angioplasty (PTCA)

• Coronary artery bypass graft (CABG)

• Pacemaker

• Cardiac ablation

• Life-sustaining options: ventricular assist devices (VAD), extracorporeal membrane oxygenation (ECMO)

Sternal precautions

• No lifting, pushing or pulling > 5-10 lbs 

• No pushing or pulling with arms 

• Do not bring elbows above shoulders 

• Do not twist the trunk or do deep bending 

• Hug pillow to protect chest when coughing or sneezing 

• Do not drive 4 weeks

• MOVE IN THE TUBE!

Monitoring response to treatment (cardiac pt)

• vitals (HR and BP)

• Borg

• Physiological

17-20 Borg Scale

• 17- very hard, getting uncomfortable

• 18- can no longer converse

• 19- extremely hard, body is screaming

• 20- maximal exertion

13-16 Borg scale

• 13- somewhat hard

• 14- breathing hard but not struggling

• 15- can converse but not full sentences

• 16- hard work

9-12 Borg scale

• 9- very light exertion (comfortable)

• 10- just start to hear breathing 

• 11- conversation is easy

• 12- light exertion 

6-8 Borg scale

• 6- zero exertion

• 7- extremely light

• 8- minimal effort

Metabolic equivalents

a measure of energy

MET levels vary from light to _____ activity

vigorous

General MET level rule, once client tolerates activity with ______ _______ then progression can begin 

appropriate response 

MET level 1-2 ADL example

eating, seated, washing face, transfer

MET level 2-3 ADL example

seated sponge bath, dressing/undressing, walking 2-3mph

MET level 3-4 ADL example

standing shower, BM on the toilet

MET level 4-5 ADL example

hot shower, sexual intercourse 

MET level 5-6 ADL example

sexual intercourse, walking up stairs at 30 ft/min

MET level 6-7 ADL example

walking with braces and crutches

Psychosocial

• depression, anxiety, anger, and social isolation are common

• denial- acute phase

• lack of social support

• overal QOL

Interventions for cardiac pt 

• energy conservation

• ADLs/IADLs

• Increase activity tolerance/endurance

• lifestyle modifications

• education

• stress management

• breathing techniques- pursed lips vs diaphragmatic 

Stages of swallowing

1. oral preparatory

2. pharyngeal/laryngeal

3. esophageal

swallowing/eating

• keeping and manipulating food or fluid in the mouth and swallowing it; swallowing is moving food from mouth to the stomach

feeding

setting up, arranging, and bringing food [or fluid] from the plate or cup to the mouth; sometimes called self feeding

oral prep phase 

• involves the tongue, mandible, lips, cheeks and palate all working together to ensure the food is adequately prepared for the future stages

• the tongue is critical in controlling the food for chewing and for moving the food into proper position for swallowing which is at the back of the tongue 

cranial nerves involved in oral prep phase

V, VII, IX

oral prep phase varies in _____

length

in the oral prep phase, food is mixed with saliva and chewed with the aid of the muscles of _______

mastication 

in the oral prep phase, food is “prepared” into a pellet, called a ______ so that it can be easily passed from the front to the back of the mouth, and from there into the oropharynx

bolus

Peristalsis

moves food to the esophageal entrance, the sphincter opens, and food moves into the esophagus

esophageal phase lasts around ____ seconds

8-10

What cranial nerve is involved in esophageal phase?

cranial nerve X - vagus

Safe and efficient swallow

• must have both voluntary and involuntary components in order to have a safe and efficient swallow

• if the swallow response doesn’t occur, the physiological functions don’t either

T/F: Swallowing and feeding are the same thing

FALSE

swallowing and feeding may be evaluated by different _______

disciplines

assessment of swallowing

• bedside nursing swallow screen

• clinical swallow evaluation

• modified barium swallow study (videofluroscopic swallow study)

• fiberoptic endoscopic evaluation of swallowing (FEES) 

Aspiration

passage of liquid or solid material into the lungs

signs and symptoms of aspiration

• coughing

• choking

• wet, gurgley voice

• fever

what are some ethical concerns with feeding/swallowing/eating?

• when the client no longer wants to eat or be fed

• when family wants to/keeps feeding client, in violation of swallowing precautions

• when other health care professionals do not carefully adhere to swallowing precautions

two most common procedures for non-oral feedings

1. nasogastric tube (NG tube)

2. the percutaneous endoscopic gastrostomy (PEG)

dysphagia

difficulty moving solids and liquids from the mouth to the stomach

• problem can occur in the mouth (oral), throat (pharyngeal), or esophagus (esophageal)

who is at risk in feeding/swallowing?

• CVA (stroke)

• TBI

• neurological disease (MS, ALS, Parkinson’s disease, dementia, etc.)

• Chronic obstructive pulmonary disease

• head and neck cancer (radiation tx)

• anyone with a weakening condition

Red flags for dysphagia 

• slurred speech

• throat clearing, coughing, choking 

• drooling

• no voice or hoarse, breathy voice 

• recent unexplained weight loss 

• recurrent pneumonia 

laryngeal penetration

food/liquids enters the upper airway and does not go below the level of vocal folds

aspiration

food/liquids enters the upper airway and goes below the vocal folds into the trachea

aspiration outcomes

• pneumonia

• dehydration

• malnutrition/weight loss

• death

• nothing?

why evaluate swallowing?

to see what the client can SAFELY swallow 

what helps the patient safely swallow?

• positioning

• texture/viscosity

• swallow maneuvers/technique/exercises

Dysphagia diet

3 levels:

level 1. consists of foods that are completely pureed

level 2. also known as “mechanical-soft” or “minced” includes foods that require minimal, easy chewing and are very moist

level 3. is any food that is easy to cut through but is not dry, sticky, or crunchy. advanced.

examples of food is level 1: pureed

• pudding

• pureed oatmeal, breads, meats

• hummus

• pureed fruits and vegetables

examples of food in level 2: mechanical soft 

• scrambled eggs

• meatloaf

• pancakes 

examples of foods in level 3: advanced

• bread slices

• muffins

• moistened cereal

Dysphagia exercises

• effortful swallow

• dynamic shaker

• jaw thrust

• Masako maneuver

• Supraglottic maneuver

• hyoid lift maneuver

Global aphasia

loss of all language skills

individuals with global aphasia may appear to understand _____ than they actually do. why?

more and they can be sensitive to gestures, vocal inflections, and facial expressions

Broca’s aphasia

• poor speech production

• slow, labored speech, incorrectly pronouncing words and sounds

• good auditory comprehension

• reading comprehension and writing can be impacted severely

• difficulty with monetary concepts and calculations

global aphasia usually involves ____ of dominant cerebral hemisphere

MCA

Wernicke’s aphasia

• impaired auditory comprehension and feedback

• fluent speech with word substitution errors

• meaningless sequence of words

• reading and writing often limited

• mathematical skills can be impaired

Autonomic aphasia 

• difficulty with word retrieval- primary or only symptom 

• have fluent and grammatically correct speech, but difficulty finding words

• hesitant or slow speech

• can see mild- severe deficits in reading comprehension and written expression

• mild deficits in mathematical skills 

when working with clients with aphasia….

• use concise language/sentences

• 1 person talking at a time

• give extra time for client to respond

• phrase yes/no questions

• use visual cues or gestures to help with understanding

Driving and community mobility

planning and moving around in the community using public or private transportation, such as driving, walking, bicycling, or accessing and riding in buses, taxi cabs, rideshares, or other transportation systems

1

2

What are components with feeding?

• Setting up

• Bringing food to mouth

• Beverage management

What are components with grooming?

• Oral hygiene

• Hair care

• Deodorant

• Washing face

What are components with upper body dressing?

• Threading RUE

• Threading LUE

• Pulling over head

• Pulling down over back

• Fastener management

What are components with lower body dressing?

• Threading RLE

• Threading LLE

• Pulling over hips

• Donning/doffing socks

• Shoes

• Fasteners

• Underwear, adult briefs, orthotics/braces

Components of meal prep/cleanup

• Planning meals

• Preparing meals

• Serving meals

• Cleaning up meals

Components of shopping

• Preparing lists

• Purchasing (method of payment)

• Transporting items (item retrieval)

• Internet shopping (Insta cart, Walmart pickup)

MMT grade 5

Normal, holds test position against maximal resistance

MMT grade 4+

Good+, holds test position against moderate to strong pressure

MMT grade 4

Good, holds test position against moderate resistance 

MMT grade 4-

Good-, holds test position against slight to moderate pressure 

MMT grade 3+

Fair+, holds test position against slight resistance

MMT grade 3

Fair, holds test position against gravity

MMT grade 3-

Fair-, gradual release from test position

MMT grade 2+

Poor +, moves through partial ROM against gravity OR moves through complete ROM gravity eliminated and holds against pressure 

MMT grade 2

Poor, able to move through full ROM gravity eliminated

MMT grade 2-

Poor-, moves through partial ROM gravity eliminated

MMT grade 1

Trace, no visible movement; palpable or observable tendon prominence/flicker contraction 

MMT grade 0

No palpable or observable muscle contraction

examples of ADLs

• feeding

• grooming

• upper body dressing

• lower body dressing 

• bathing 

• toileting

• sexual activity 

examples of IADLs

• meal prep and cleanup

• driving and community mobility

• shopping

• caring for others

• caring for pets

• home safety

• home management

• communication management 

• money management

• religious and spiritual expression

Priorities of home safety

• identifying safety risks

• reduce hazards 

What are some basic types of documentation?

• Evals

• Treatment notes/daily notes/intervention notes/visit notes

• Progress notes

• Re-evals

• Discharge summaries

Who reads documentation?

• Patient care managers

• Physicians

• Interdisciplinary team

• Reimbursement entities (insurance)

• The legal system

• Quality improvement

• Research

• Accreditation bodies

• Education

• Public health

• Utilization management

In OT treatment, problems must have a ________ component

functional

Use ______ language in objective session

skilled

What are some common mistakes in the O section?

• Using ONLY assist levels (why Min A)

• Focusing on media

• Not being specific enough about assist levels

• Using too many words

T/F: It is okay to introduce new information into the A section

FALSE

It is important to de-emphasize the _______ media

treatment 

Types of transfers

• stand-pivot

• squat-pivot

• lateral transfer (scooting)

• slide board transfer

• ambulatory transfer

• Hoyer lift transfer

• toilet transfer

• shower/tub transfer

• car transfer

• floor transfer