Midterm 2: PNF, NDT, Handling, Sexuality, Taboo Occs, EF, Sensory Exams, Goals

CN I

Olfactory

Sensory

Function: Smell

CN II

Optic

Sensory

Function: Sight (visual acuity and visual fields)

CN III

Oculomotor

Motor

Function: Constrict pupils, accommodates

CN IV

Trochlear

Motor

Function: Move eyes

CN V

Trigeminal

Motor and sensory

Function: Chewing and facial sensations

CN VI

Abducens

Motor

Function: Move eyes

CN VII

Facial

Motor and sensory

Function: Facial expressions, taste, salivation

CN VIII

Vestibulocochlear

Sensory

Function: Hearing (cochlear), balance (vestibular), and equilibrium (vestibular)

Nystagmus can be induced to check CN VIII function

CN IX

Glossopharyngeal

Sensory and motor

Function: Taste, salivation, swallow

CN X

Vagus

Sensory and motor

Function: Taste, swallow, lifts palate

Sensory - sensations felt on skin or muscles (somatic); sensations felt in organs (visceral)

Motor - stimulating muscles in mouth, heart, and involuntary contractions in digestive tract

CN XI

Spinal accessory

Motor

Function: Turn/stabilize head, shrug shoulders

CN XII

Hypoglossal

Motor

Function: Move tongue for protrusion, push tongue from side to side inside the mouth to collect the bolus after chewing

Nystagmus

Involuntary rapid eye movements

Two phases: Slower phase/movement; rapid phase w/ re-fixation back to midline

Can be induced to check CN 8 function:

- Cold caloric: irrigate one ear canal w/ cold water (COWS: Cold opposite, warm same)

Scotoma

Visual field defect that results in partial loss of vision or a blind spot.

Central scotoma is a visual field defect due to a lesion at the macula.

Bitemporal hemianopsia

Damage to the optic chiasm results in the loss of the temporal (outside) half of the vision in each eye due

Homonymous hemianopsia

Visual field defect involving either two right or the two left halves of the visual field of both eyes

Monocular vision loss

Lesion of optic nerve that results in loss of vision in one eye

TBI (traumatic brain injury)

Damage to the brain tissue caused by an external mechanical force with resultant loss of consciousness, posttraumatic amnesia (PTA), and skull fracture or objective neurological findings that can be attributed to the traumatic event by radiological findings, physical, or mental status exams

Proprioceptive Neuromuscular Facilitation (PNF)

A method of promoting response of the neuromuscular mechanism through the stipulation of proprioceptors. Uses the body's proprioceptive system to facilitate or inhibit muscle contraction.

Assumptions of PNF

- The muscles must work synergistically in order for movement to occur

- Muscles need to have the reflexive ability to contract and relax in order to perform basic movements

PNF Philosophy

- All human beings have potentials that have not been fully developed

- The way to bring out the potential is to place a demand on the being. Sensory cues impart a demand on patient that facilitates desired response and challenges patient (Visual and auditory cues, manual contacts, positioning, stretch (proprioceptive), resistance (proprioceptive), timing)

- Treat the whole human being, not a part

- Positive approach: Reinforce what pt. can do on physical and emotional level

- People do not move in straight planes

- Eliciting a max. response is the most effective means of eliciting awareness, strength, and coordination

- Functionally oriented: Goal-directed activities hasten learning

- Treatment initiated at current func. levels and progresses to more complex activities

- Developmental sequence activities are utilized

- Motor Learning: Motor performance is dependent on motor learning

- Repetition = Retention and develop strength and endurance

- Reflex activity: Early motor behavior is dominated by reflexes which become integrated as we mature; but are available to reinforce movement

- Shifts b/w flexors and extensors occur during the course of normal movement; during therapy it is important to attend to both directions of movement

- Motor behavior is expressed in orderly sequence of movement patterns. To max. motor performance, clients should work in a variety of patterns

- Balanced interaction of antagonists

Multisensory approach

Grade the sensory input to foster movement and achieve desired results

Auditory: Key w/ verbal commands; tone and volume are modulated to facilitate movement

Visual: Assists in initiation and coordination of movement; ask client to watch the movement of extremity

Tactile: Manual contacts so client can “feel” movement patterns

PNF Diagonals

Motion is spiral and diagonal.

Diagonal mass movement patterns that are seen in most daily functional activities. Actions of several joints are coupled together instead of isolated movements.

Patterns combine motions in three planes:

Sagittal (flexion and extension), coronal/frontal (abduction and adduction of limbs; lateral flexion of spine), and transverse (rotation)

D1 flexion

Shoulder flexion - adduction - external rotation, elbow flexed or extended, forearm supination, wrist flexion, finger flexion

Functional activities: Combing hair on opposite side, feeding (hand to mouth), tennis forehand (end of stroke), scratching back

D1 extension

Shoulder extension - abduction - internal rotation, elbow flexed or extended, forearm pronation, wrist extension, fingers extended

Functional activities: Pushing car door open, tennis backhand, pushing up off a chair (bilateral)

D2 flexion

Shoulder flexion - abduction - external rotation, elbow flexed or extended, forearm supination, wrist extension, finger extension

Functional activities: Combing hair on same side, backstroke in swimming, completing motion of taking an overhead shirt off (bilateral), reaching up to put a box on a high shelf (bilateral)

D2 extension

Shoulder extension - adduction - internal rotation, elbow flexion or extension, forearm pronation, wrist flex, finger flex

Functional activities: Button/zip side closure on opposite side of body, pitching baseball, starting to take off a pull over shirt (bilateral)

Bilateral symmetrical

Paired extremities perform same action

Unilateral

Movement of one side in one pattern

Bilateral asymmetrical

Paired extremities perform movements to one side of the both (When both sides of the body are working together but doing different movements e.g., using scissors - one hand cuts, the other holds and moves the paper or writing - one hand holds the paper, the other writes

Bilateral reciprocal

Paired extremities move in opposite directions simultaneously (e.g., walking, riding a bike, marching, crawling) - the ability to use both sides of the body in a coordinated, alternating motion (opposite)

PNF techniques

- Positioning

- Manual contacts

- Quick stretch

- Traction/approximation

- Resistance

- Verbal commands

- Rhythmic initiation

- Reversal of antagonists

- Dynamic reversals

- Stabilizing reversals

- Rhythmic stabilization

- Relaxation

- Rhythmic rotation

PNF technique: Positioning

Developmental positions. Use functional alignment of trunk and extremities

PNF technique: Manual contacts

Placement of therapist's hands

- Proximal or distal on the extremity

- Support to both extremities or only one extremity dependent upon clients control of extremities and neurological condition

- Individuals who sustained a CVA have a more involved and less involved side

- Individuals who sustained a TBI may have both sides involved

PNF technique: Quick stretch

Sensory technique. At initiation of movement to foster action. Opposite direction of intended movement to facilitate muscular contraction

PNF technique: Traction/approximation

Sensory technique. Gentle approximation facilitates joint stability. Gentle traction to increase joint ROM

PNF technique: Resistance

Graded during movements to provide sensory feedback and foster muscular activity (not to stop movement)

PNF technique: Verbal commands

Verbal direction should always be clear and concise. Vocal tone and quality can influence movement

PNF technique: Rhythmic initiation

Rhythmic motion of limb through desired range (passive -> active resisted)

Goals:

- Aids initiation of movement

- Improves coordination and sense of motion

- Normalizes rate of motion

- Teaches motion

Indications:

- Increased tone, decreased initiation, uncoordinated movements

- Incorporates a passive, active assistive, active-resistive pattern and avoids reactive stretching

PNF technique: Reversal of antagonists

Combined concentric, eccentric, and stabilizing contractions of one group of muscles (TYPES: dynamic reversals, stabilizing reversals, rhythmic stabilization)

Goals:

- Active control of motion

- Coordination

- Strength

- Eccentric control for function

Indications:

Decreased eccentric control, coordination, PROM and AROM

PNF technique: Dynamic reversals

Active resistance switching from agonist to antagonist w/o pause (riding bike, throwing a ball, mopping a floor)

Goals:

- Increase AROM and strength

- Coordination (smooth reversals)

- Improve endurance

- Decrease tone

Indications:

Decreased AROM, weakness of agonist, decreased ability to change direction of motion and endurance, decrease tone

PNF technique: Stabilizing reversals

Alternating isotonic contractions against resistance that allows only small motion

Goals:

- Improve stability and balance

- Increase strength

- Improved coordination b/w agonist and antagonist

Indications:

Decreased stability, weakness, weak isometrics

PNF technique: Rhythmic stabilization

Alternating isometric contractions against resistance, no motion

Goals:

- Increase AROM, PROM

- Increase strength

- Improve stability and balance

- Decrease pain

Indications:

Limited ROM, pain, joint instability, weakness, decrease balance

PNF technique: Relaxation

Used to reduce the effects of spasticity and promote ease of movement, increase ROM

Contract-relax

Relaxation technique of PNF. Resisted isotonic contraction of antagonists followed by relaxation and movement into new increased range

Goals:

- Increase PROM

Indications:

Decreased PROM

PNF technique: Rhythmic rotation

Alternating movements to decrease muscle tone

PNF goals

- Irradiation (overflow of neuronal excitation from stronger motor units to weaker ones) so movement becomes less effortful

- To restore or enhance postural responses or normal patterns of motion in a patient w/ a deficient neuromuscular mechanism

- To enhance stability or mobility

- To strengthen or stretch a muscle group

- To improve posture, balance, and coordination for functional activities

Contraindications for PNF

- Inflammatory arthritis

- Malignancy (undermines bone integrity and results in fractures)

- Bone disease

- Bone fracture (don't want to yank around bones that are fractured)

- Congenital bone deformities (don't want to move bones that are deformed)

- Joint subluxation (joint is not in proper alignment)

PNF OT applications

Using movement principles and facilitation techniques superimposed on the diagonal patterns of movement to enhance motor response and facilitate motor learning

- Engaging client in adjunctive activities (manual contacts, rhythmic initiation, etc.) to facilitate more functional movement

- Using ADL/IADL tasks to promote deficits in movement patterns and foster more functional use of involved extremity

Neurodevelopmental treatment (NDT)

Approach to restore function through identifying and correcting impairments at interfere w/ movement and participation in daily routines. Tailored to unique needs of client by assessing where client lacks control.

Recovery of motor function is possible after UMN lesion (CNS neuroplasticity). Interventions are based on analysis of the components of movement that are present and those missing following the UMN lesion.

Foundational principles of NDT

- Normal movement cannot be superimposed over abnormal alignment. Alignment of body segments is necessary for postural control; and for client to be able to develop active use of involved side

- Appropriate physical handling by the therapist is used to promote use of the involved side

- Clients need to practice - intervention involves management and practice of movement strategies in daily life (repetition!)

- Encouragement of normal movement patterns

- Focus on quality of movement

- Normalization of tone to facilitate active movement

- Positioning and posture in lying, sitting, and standing

- Discouragement of compensatory movements

- Discouragement of muscle strength training

- Promotion of maximum functional recovery to improve quality of independence

NDT and movement disorders

Abnormal movement occurs following UMN lesions

Abnormal movement occurs due to changes in:

- Muscle strength

- Muscle tone

- Muscle activation

- Sensory processing

NDT assessment

- Occupational profile, taking into consideration motor components that limit occupational performance

- NDT addresses quality and efficiency of movement as it relates to occupational performance

- Assessment requires OT to detect errors in movement and identify why those errors occur during occupational performance

Intervention process using NDT principles

- Preparation for movement (arrangement of environment, alignment, posture, mobilization of joint)

- Facilitation of movement (guide experience of movement; use manual cues/handling)

- Occupational engagement in functional task

Intervention techniques of NDT

Mobilization of UE

Weight bearing on the involved UE

Progress to open ended activities w/ the involved UE

NDT technique: Mobilization of the UE

- Mobilization of the trunk

- Mobilization of the scapula in supine/sitting

NDT technique: Weight bearing on the involved UE

- Sitting w/ weight bearing on the forearm for support

- Standing and weight bearing on the hand for support

- Weight bearing promotes sensory input, reduces tone and promotes activation of muscles

NDT technique: Progress to open ended activities w/ the involved UE

Reach and release objects w/ the more involved hand

Handling

In NDT, used to promote more efficient movement and improved quality of movement, provides sensorimotor input, improves incorporation and awareness of client's hemiplegic side.

Supports and guides the body part for a functional task. Placement of therapist's hands fosters improved postural alignment and/or efficiency of movement. External support is provided where needed in order for client to better control movement. Support is removed from client ASAP

NDT therapeutic handling

"Essential tool" in both examination and treatment. Allows the therapist to:

- Feel the client's response to changes in posture or movement

- Facilitate postural control and movement synergies broadening the client's options for selecting successful actions

- Provide boundaries for movement that distract from the goals

- Inhibit or constrain those motor patterns that, if practiced, lead to secondary deformities, further disability, or decreased participation

Effectiveness of NDT

Criticism regarding evidence to support the efficacy of NDT over other neurodevelopmental treatments. There are studies that demonstrate effectiveness, but not enough

Facilitation position and client position

Client should be:

- Seated

- Symmetrical posture

- Weight bearing evenly

- Pelvis in neutral postural tilt

- Good base of support

Therapist should be:

- On the affected side providing physical support

Similarities/differences of PNF and NDT

NDT:

- Facilitate normal movement

- CP, CVA, head injury, etc.

- Alignment is key for postural control

- Handling promotes use of involved side

- Practice is vital

- Mobilization

- Weight bearing

- Progress to open-ended activities w/ involved UE

- Handling (touch + motion)

- Gradual removal of assistance

- For UMN lesions:

1. Preparation (environment, joint mobilization, joint alignment, symmetry)

2. Facilitation: Guiding movement (Verbal cues and demo), manual cues and handling

3. Occupational engagement in fx task

PNF:

- Assess and improve movement efficiency and effectiveness

- Normalize movement &/or increase flexibility and ROM

- Demand brings out potential

- Cues are key: verbal, visual, auditory, manual, proprioceptive, timing of action

- Focus on strengths

- Focus on goal-directed activities

- Practice fosters motor learning and motor control

- Timing of movement is impt

- Considers effect of gravity and resistance

- Quick stretch (opp. direction of movement)

- Approximation

- Resistance

- Rhythmic motions (initiation, stabilization, reversals)

- Contractions-relaxation

- Motion is spiral and diagonal (D1 and D2 flexion and extension patterns)

Orientation

Person, place, and time

Oriented x__ means that the person has an awareness of person, place, and/or time

Oriented x1 = Person

Oriented x2 = Person, place

Oriented x3 = Person, place, and time

CN II, III, IV, VI: Visual fields and tracking Sensory Exam

What: Sensory exam that tests for ct.’s ability to track and converge with eyes, but not pupil reactivity (done by optometrist). Consists of identifying color of sticks coming from peripherals, tracking stick in an "H" trace, and bringing stick towards and away from face to test for convergence/divergence.

Testing for: CN II, III, IV, VI

Functional importance: Vision abilities (convergence and visual fields)

CN V: Trigeminal Sensory Exam

What: Sensory exam that tests the ct.’s ability to move the muscles that produce chewing and facial expressions. Exam consists of swiping cotton swab on areas of the face to see if they detect touch. Then, palpate masseter and temporalis muscles by having client clench jaw.

Testing for: CN V

Functional importance: Facial expressions and chewing abilities

Sharp/Dull Sensory Exam

What: Sensory exam that tests for ct.’s ability to detect sharp/dull sensations. Another component of it would be distinguishing b/w hot/cold sensations. Exam consists of client occluding eyes and therapist applying sharp/dull stimulus along dermatomes in hands and arms. Client identifies if they feel sharp/dull.

Testing for: Spinothalamic pathways (determine if pathways can convey painful information to higher centers for recognition)

Functional importance: Safety, pain/temperature detection, affects ability to safely perform ADLs/IADLs like cooking, bathing, etc.

Proprioception Sensory Exam

What: Sensory exam that test the ct.’s ability to know the position in space of your body and limbs when at rest. For client w/ movement in both arms, client mirrors movement done on one body part. If ct. doesn't have movement on affected side, move ct.'s unaffected arm and have them identify movement.

Testing for: Dorsal columns or posterior columns; fasciculus gracilis (legs) and fasciculus cuneatus (arms). Dorsal columns carry info about conscious proprioception, discriminative light touch, and vibration

Functional importance: Safety, affects ability to safely participate in occupations (e.g., if cooking, you want to control and be aware of where your arm is in relation to the hot stove)

Light Touch Sensory Exam

What: Sensory exam that tests the ct.’s ability to detect light touch. Consists of occluding eyes of ct. and swiping cotton tip on different areas of dermatomes on hand and arm. Ct. opens eyes and identifies location of light touch.

Testing for: Spinothalamic and dorsal columns system.

Functional importance: Safety, affects ability to safely participate in occupations or detect stimuli that makes contact w/ you through light touch (e.g., swipe bug off skin, feel leaf move across arm).

Pressure Touch Sensory Exam

What: Sensory exam that tests the ct.’s ability to detect pressured touch. Consists of occluding ct. eyes and applying pressure on their skin. Ct. indicates where they were touched.

Testing for: Pressure receptors in subcutaneous or deeper skin.

Functional importance: Safety, ability to participate in occupations safely

Stereognosis Sensory Exam

What: Sensory exam that tests the ct.’s ability to perceive and recognize the form of an object in the absence of visual and auditory information, by using tactile information to provide cues from texture, size, spatial properties, and temperature, etc. Consists of client identifying common and relevant objects placed in their hand w/ eyes occluded. If client has expressive aphasia, have second set of items to point at. If client has movement limitations in hand, have OT place item in hand and move fingers over object.

Testing for: Dorsal column

Functional importance: Safety, ability to identify objects w/o seeing it (e.g., rummaging through purse for keys, moving around a dark room by tracing a wall, etc.).

Two Point/One Point Discrimination Sensory Exam

What: Sensory exam that detects ct.’s ability to distinguish touch w/ one point or two points. Occlude vision and have client identify if they were touched from one/two points

Testing for: Dorsal columns

Functional importance: Distinguishing if touch is from one/two points.

Tips for sensory testing

- Refer to written instructions

- Explain the procedure and ask for permission

- Clean items in view of ct.

- Demonstrate on yourself

- Demonstrate on ct. w/ their eyes open

- Ask how they want their vision occluded

- Vary the timing

- Don't give clues

- Make modifications as necessary

- Go over results w/ ct.

Role of OT in sexuality

Provide education about:

- Appropriate vs. inappropriate sexual behaviors (when and where to act, under what circumstances)

- Safety and awareness (to prevent harm towards the client and towards their sexual interest)

- Preparing family members for when sexual interest/behaviors will arise

Sexuality is listed as an ADL, so it is w/in our scope of practice. Specifically for TAY, sexuality is first experienced and questioned during adolescence, around when puberty occurs

Secondary sexual characteristics

Physical signs of sexual maturation that do not directly involve sex organs

- Hormonal changes

- Potential emotional irregularity

- Changes in physical size and body shape

- Changes in sexual function

Social expectations surrounding sexuality

- Identifying healthy relationship characteristics

- Expectations from peers vs. adults

- Dating - finding appropriate partner, identifying when dating is appropriate

Issues of sexuality w/ a client who has ASD

- Differentiating b/w a public and private environment

- Socially appropriate expression of interest

- Accurately identifying and interpreting sexual advances from others (both welcome and unwelcome)

- Collaborate w/ family to identify helpful strategies

Issues of sexuality w/ a client who has an intellectual disability (ID)

- Typical sexual interests - Individuals w/ ID have normal sexual interests and exploration

- Vulnerable - At greater risk for sexual predators and have a higher rate of sexual abuse; work on consent, identifying how/when to say "yes" and "no", and assessing interest and motivation when approached w/ sexual advances

- Private vs. public environments

Issues of sexuality w/ a client who has TBI

- Poor impulse control and decision-making skills

Strategies for approaching sexuality issues

- Differentiate b/w personal sexual behavior and sexual behaviors w/ others

(Personal sexual behaviors - private vs. public and timing

Sexual behaviors w/ others - Basic health protection w/ sexual partners, ID/awareness of danger, understanding social expectations/boundaries, healthy relationships)

- Normalization of sexuality/counter stigma or prejudice (acknowledging biases/stigmas and countering it as a therapist)

- Support for families

- PLISSIT model

PLISSIT model

Provides guidelines and a progressive approach for supporting the level of intervention appropriate to a healthcare professional’s knowledge and qualifications.

Permission - allowing the client to feel and express thoughts pertaining to sexuality

Limited Information - explaining the effect the disability can have on sexuality (general info)

Specific Suggestions - provide specific solutions for specific problems related to a certain disability. Highest level of input for the OT w/ basic training

Intensive Therapy - reserved for client when extensive counseling is needed for serious issues or abnormal coping patterns are present (provided by a health professional w/ advanced training)

How OT should approach sexual exploration and identity

- Create a safe place for client to present concerns or questions

- Know resources ahead of time

- Be aware that you may have clients who make advances towards you due to your client-centered approach

- Provide clear limits

- Clients may "try out" a sexual behavior on you b/c you are perceived as "safe"- identify appropriate settings/people and establish boundaries

OT in rehabilitation settings

- Various settings for youth who have sustained injuries/illnesses

- Not a clear progression through each type of institution/service

- Depends on condition and prognosis

General settings:

- ICU/CCU

- Acute rehab

- Subacute rehab

- Skilled Nursing Facilities (SNF)

- Outpatient rehab settings

Acute care hospitalization

Client not stable, still in ICU. Prior to acute rehab

Dx: Acute illness/injury compromising vital signs

Focus of intervention: ADLs, typically eating, feeding, swallowing, oral hygiene, hygiene, possibly dressing - depending on status of client

Frequency of services: Daily

Duration of stay (length of stay - LOS): Days to possibly 1 week

Acute rehab setting - hospital setting

Client relatively medically stable but still needs medical care. Severity of illness/symptoms has slightly diminished

Dx: Neurological and medical issues/infections/degenerative conditions

Focus of intervention: ADLs, IADLs, planning for d/c

Frequency of services: Daily, often several times per day

LOS: 1-3 weeks

Subacute rehab setting

Client medically stable. Client may go directly to either SNF or outpatient rehab services instead of subacute rehab

Dx: Neurological and medical issues/infections/degenerative conditions

Focus of intervention: ADLs, IADLs, planning for community re-entry, finalize d/c plans and follow-up care services needed

Frequency of services: Daily

LOS: 1-3 weeks

Skilled nursing facility (SNF)

Client needs medical monitoring/skilled nursing. May have stable vitals but specific compromises such as wounds

Dx: Neurological and medical issues/infections/degenerative conditions

Focus of intervention: ADLs, IADLs, determination if community re-entry is possible or residential care will be needed

Frequency of services: Initially daily but quickly change to weekly services

LOS: Varies substantially (based on needs and how quickly they are progressing)

Outpatient rehab setting

Client medically stable. Living at home or in community

Dx: Neurological and medical issues/infections/degenerative conditions

Focus of intervention: ADLs, IADLs, community re-entry, access to community; identify and address needs w/in their current environment.

Frequency of services: Initially daily but quickly change to weekly services

LOS: 1-3 weeks

Therapeutic handling

- Influences quality of motor responses

- Matched to client's abilities

Includes client's ability to use sensory information and adapt - movements

- Involves neuromuscular facilitation, inhibition, and a combination of the two

Considerations and safety - body mechanics

- Hold loads close to your body

- Use a broad base of support

- Move as one unit (shoulders to hips)

- Lift w/ your legs, not your back

- Avoid twisting and bending

- Avoid quick or jerky movements

Considerations and safety - lifts and transfers

- Never lift more than you can comfortably handle

- Let the person do as much as they are capable of during the lift or transfer. If person cannot assist w/ the transfer at all, you may require special training and/or adaptive equipment for lifts/transfers

- Work at person's level and speed and check for pain

- Avoid sudden jerking motions

- Never pull on the person's arms or shoulders

- Have the person wear shoes w/ good treads or sturdy slippers

- Create a base of support by standing w/ your feet shoulder width apart w/ one foot a half-step in front of the other

- Let your legs do the lifting, not your back

- Avoid letting the person put their arms around your neck or grab you. If the person is fearful, have them clasp their hands close to their chest during the lift or transfer

- Breathe deeply and keep shoulders relaxed

Body alignment

Achieved by placing one body part in line w/ another body part in a vertical or horizontal align.

Correct alignment contributes to body balance and decreases strain on muscle-skeletal structures. W/o this balance, the risks of falls and injuries increase

Center of gravity

The center of the weight of an object or person.

A lower center of gravity increases stability. This can be achieved by bending the knees and bringing the center of gravity closer to the base of support, keeping the back straight.

A wide base of support is the foundation for stability

Wide base of support

Achieved by placing feet a comfortable, shoulder width distance apart.

When a vertical line falls from the center of gravity through the wide base of support, body balance is achieved. If the vertical line of gravity moves outside the base of support, the body will lose balance

Preparation for handling

- Observation (visual, auditory, kinesthetic and proprioceptive)

- Environment (lighting, noise, temp., characteristics of materials, space for movement and privacy, social milieu)

- Client context considerations (culture, age, gender identity and expression, sexual orientation, history of trauma)

Hand use

Tension, position, placement, and movement can facilitate feelings of warmth, acceptance, and respect or decrease them.

We touch through our hands as well as with our hands. It’s a privilege to touch and be touched by someone - don’t take it lightly

Influence of tactile input through handling

- CNS (changing NS through touch)

- Muscle tone (temp. change; enable client to engage in functional activities)

- Behavior (new neurological pathways -> change behavior)

- Neuro organization

- Autonomic, reticular, limbic systems (avoid activating symp. response; reticular system - circadian rhythm, sleep cycles, homeostasis; limbic system - client's emotions and psychological comfort)

Eyes before hands

- Approach client from the front at about 45 degrees of angle

- Give their attention visually and/or verbally

- Clients may or may not be able to see you, but you want them to be aware of your presence before you touch them

- Avoid approaching from behind

- Avoid startling the client w/ unexpected touch

- Move slowly, let the client know what you are doing using a calm and confident tone of voice

General guidelines for therapeutic handling

- "Soft hands"

- Hands that mold to body

- Awareness of skin temp., fingernail length, client pain, client discomfort/embarrassment

- Avoid digging/gripping

Feedback and modification during therapeutic handling

- Touch, pressure, and movement tolerance

- Client skin integrity

- Client pain or discomfort

- Effect of the handling (and act accordingly to modify and revise what we are doing)

Grading input - consider hyper and hypo responsiveness to tactile input, pain, movement (vestibular/musculoskeletal), deep pressure and changes in body position (proprioceptive)