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what is the OT process?
referral
screening
evaluation
intervention planning
intervention implementation
intervention review
outcomes
initiates the OT process
its a request (either oral or written) from physician or other qualified individual
may be required before initiation of service
referral
brief and does not cover all areas of occupation
determines whether further OT evaluation is warranted
screening
process of obtaining and interpreting data
use of assessments
two parts
generation of occupational profile
analysis of occupational performance
evaluation
prevent disability
promote health
establish or restore a skill or ability
adapt or compensate
maintain current functional abilities
intervention planning
therapeutic use of self
therapeutic use of occupations and activities
preparatory methods and tasks
group interventions
education and training
advocacy
intervention implementation
evaluation of the intervention plan
completed on regular basis to determine whether client’s goals are being met
may include re-evaluation of client’s status
intervention review
focuses on many factors to include:
occupational performance
client’s perceptions of goals/process of meeting goals
well-being of caregiver
outcomes
used in the intervention process
five basic types of reasoning
procedural
interactive
conditional
narrative
pragmatic
clinical reasoning
what are the five basic types of reasoning?
procedural
interactive
conditional
narrative
pragmatic
concerned with getting things done, with what “has to happen next”
a connection between the problems identified and the interventions provided is sought using this form of reasoning
clinical reasoning (procedural)
concerned with the interchanges between the client and therapist
the therapist uses this form of reasoning to engage with, to understand, and to motivate the client
the therapeutic use of self fits well with this form of clinical reasoning as the therapist uses personal skills and attribures to engage the client in the intervention process
clinical reasoning (interactive)
concerned with the contexts in which interventions occur, the contexts in which the client performs occupations, and the ways in which various factors might affect the outcomes and direction of therapy
using this approach, the therapist imagines possible scenarios for the client
clinical reasoning (conditional)
requires teh understanding of the patient’s life stories
guides the therapist in evaluating the meaning that occupational performance limitations might have for the client
focuses on the person as an occupational being and provides a link between the founding values of the profession and current practice demands
clinical reasoning (narrative)
addresses the world in which occupational therapy occurs
forces the therapist to see things as they really are
clinical reasoning (pragmatic)
theories, models of practice, and frames of reference do what for the occupational therapy profession?
advance the profession
demonstrate evidence-based intervention
support occupation
enable development of effective treatment plans
relationship between concepts or ideas related to the phenomenon of interest (e.g., occupational performance)
suggestions on ways the phenomenon of interest can be changed or controlled, and how these relationships can predict behavior or events
theory
applications of theory of OT to practice
serves as a means to view occupation through the lens of theory
ex.: MOHO, ecology of human performance, PEO model, etc.
model of practice
links theory to intervention strategies
a narrower approach than model of practice
ex.: biomechanical, rehabilitation, sensorimotor
frame of reference
list and describe the three types of practitioners for OT.
OT - autonomous practitioner - providing all OT services
OTA - non-autonomous practitioner - requires verious levels of supervision from OT
OT aides - non-autonomous and requires direct/close supervision from OT practitioner
who do OTs collaborate with
just about everyone! some ex are:
physicians, PTs, SLPs, vocational counselors, psychologists, social workers, orthotists, prosthetists, and vendors of durable medical equipment
if you find yourself in an ethical dilemma, what are some resolution approaches?
review AOTA guidelines
seek guidance from ethics and review boards
approach and engage colleagues/peers/community
five common examples of ethical dilemmas include?
cost containment policies and treatment
inaccurate or inappropriate documentation
improper or inadequate supervision
unneeded provision of services
violation of client confidentiality
list and describe the three typical practice settings.
inpatient settings - client stays overnight
community based settings - client is in natural physical, social, and cultural environments
outpatient settings - hospitals and freestanding clinics
what are some examples of inpatient settings?
acute care inpatient
inpatient rehabilitation
acute rehabilitation
subacute rehabilitation
skilled nursing facilities
what are some examples of community based settings?
home-based settings
community based settings
intermediate care facilities (residential care)
assisted living unites or residence
home health
what are some examples of outpatient settings?
outpatient clinic
day treatment
work site therapy
also referred to as telehealth or teleconferencing
provision of services electronically from a distance
telemedicine
client goes from one setting to the next in sequence (e.g., from acute care to acute rehab to community home healthcare)
sequential
client enters healthcare at any point and does not follow a direct progression through settings
non-sequential
involves the integration of research-based techniques (critical, analytic, scientific thinking, and action processes) into all phases and domains of OT practice
systematically guides practitioners in determining which interventions will be effective at producing desired outcomes
uses:
thinking processes
action processes
evidence
systematic OT practice
involves selecting a theory on which the OT plans the steps needed to assess problems, evaluates intervention, specifies the desired outcomes, and plans a strategy to determine and/or demonstrate which outcomes were met via OT service
thinking processes
specific behaviors involved in implementing thinking processes; behavioral steps
action processes
information used to support a claim
evidence
why is SOTP critical?
the location of service delivery and the time allowed for service delivery are in flux
OTPs can provide evidence-based rationale for treatment to consumers, other professionals, insurers, and policy makers
systematic inquiry provides a common forum and language for cross-disciplinary communication
what are the types of reasoning for SOTP?
inductive
abductive
deductive
approaches the combine abduction and/or induction with deduction constitute what?
mixed methods of research
thinking process in which a person begins with seemingly unrelated data and then links these data by discovering relationships and principles within the data set
inductive
data is analyzed for patterns and concepts (which in some cases may relate to available theories and in other cases may not)
abductive
begins a theory and reduces the theory to its parts, which are then verified or discounted through examination
deductive
what are the steps of systematic OT practice (SOTP)?
identification and clarification of the problem to be addressed by the intervention
understanding of need - what is needed to resolve all or part of the problem?
setting of goals and objectives to address the need
reflexive intervention to achieve the goals and objectives
outcome assessment
a specific claim of what is not desired or of what should be changed
problem mapping may help identify/clarify the problem statement
upstream (what caused the problem)
downstream (what are the consequences of the problem)
problem statement
a systematic, evidence-based claim, linked to all or part of a problem, that specifies what conditions and actions are necessary to resolve the part of the problem to be addressed
need statement
criterion referenced
credible, especially as an outcome measure
client-perceived problems in area of self-care, productivity, and leisure
Canadian Occupational Performance Measure (COPM)
statements developed by clients and relevant others identifying the client’s desired outcome of the service
goals
statements about how to reach a goal and how to determine whether all or part of the goal has been reached
objectives
list and describe the two types of objectives
process - define concrete steps necessary to attain the goal
outcome - define the criteria used to determine whether all or part of the goal has been reached
systematic thinking does not stop during the implementation of interventions
the OT systematically monitors the client, the collaboration, the professional practice, setting-based resources, the therapeutic use of self, and other internal and external influences
reflexive intervention
a set of thinking and action processes conducted to ascertain and document treatment outcomes
assessed by using quantitative, naturalistic techniques and mixed methods, and by applying systematic inquiry to examine whether objectives have been attained
outcome assessment
what are the three types of arthritic conditions?
rheumatoid arthritis
osteoarthritis
gouty arthritis
chronic, systemic, inflammatory, autoimmune D/O'; inflammation of the joints; between ages 40-60, women are 2-3 times more commonly affected by men
rheumatoid arthritis
what are some common signs/symptoms of rheumatoid arthritis?
fatigue, weight loss, loss of appetite, overall ache or stiffness, low-grade fever
give a few examples of the common sites of rheumatoid arthritis
PIPs, MCP, and thumb joints of the hand
wrists, elbows, ankles, MTP, and TMJ joints
hips, knees, shoulders, and cervical spine
flexion of the MCP, hyperextension of PIP, and flexion of DIP
swan-neck deformity
(hyper)extension of MCP, PIP flexion, DIP hyperextension
boutonniere deformity
caused by a nodule or thickening of the tendon at the entrance of the tendon sheath
trigger finger
what is a characteristic of RA?
ulnar drift or deviation of MCPs
what are the most common sites of subluxation in RA?
wrist and MCPs
is there a cure for rheumatoid arthritis?
no
what are some ways to manage RA?
reducing pain, swelling, and fatigue
improving joint function and minimizing joint damage and deformity
preventing disability and disease-related morbidity
maintaining physical, social, and emotional function while minimizing long-term toxicity from medications (NSAIDs, corticosteroids, and DMARDs)
list and describe some of the surgical management strategies for RA?
synovectomy - surgical removal of the disease synovium
tenosynovectomy - surgical removal of the diseased tendon sheath
tendon surgery
tendon transfers and peripheral nerve decompression
what is another name for osteoarthritis?
degenerative joint disease (DJD)
caused by breakdown of cartilage in joints leading to joint pain, stiffness, tenderness, and limited ROM
non-inflammatory
wear and tear disease due to age and overuse
more common in men before the age of 50 years; beyond the age of 50, more common in women
osteoarthritis/ DJD
what is the breakdown of joint tissue in OA?
smooth cartilage softens and loses its elasticity
large sections of cartilage wear away completely
joint loses its normal shape
ends of bones hypertrophy, spurs (osteophytes) are formed where the ligaments and capsule attach to the bone
joints become stiff or unstable and motion becomes restricted and painful
OA can affect any joint but its most frequently seen where?
weight-bering joints such as the hips, knees, and spine
MTP joint of the big toe
DIP, PIP of hand and CMC of thumb
heberden’s node is located where?
DIP joint
Bouchard’s node is located where?
PIP joint
is there a known cure for osteoarthritis?
no
what are some ways to manage OA?
relieve symptoms
Improve function
limit disability
avoid drug toxicity (analgesics, NSAIDs, corticosteroids, DMARDs)
what are some surgical management techniques for OA?
arthroscopic joint debridement
bone grafts
joint fusion
joint replacement
metabolic disease marked by uric acid deposits in joints and tissue that causes recurrent episodes of arthritis; occurs in middle-aged men (40-50 y/o), exact cause is unknown, causes severe inflammation, acute onset is very rapid, inflamed joints will display: extreme heat, pain, redness, and swelling within hours
gout
where does gout usually affect?
typically the big toe
seen in both RA and OA; occurs as the joints degenerates
crepitation
what are the psychological factors seen in arthritic conditions?
depression, denial, anxiety
what are some OT intervention techniques for arthritic conditions?
energy conservation techniques, joint protection principles are essential in all areas of ADLs
what are the treatment objectives for arthritic conditions?
maintain or increase joint mobility and strength
increase physical endurance
prevent, correct, or minimize the effect of deformities
maintain or increase ability to perform ADLs
increase knowledge about the disease and best methods of dealing with the physical, psychological, and functional effects
assist with stress management and adjustment
what are some treatment methods for arthritic conditions?
sleep/rest, positioning, PAMs, TA and TE, splinting, energy conservation, adaptive equipment, assistive devices, joint protection, client/family education, communication resources
when should discharge planning occur for arthritic conditions?
as soon as the patient is referred to OT
effective way of reducing inflammation
rest
position against patterns of deformity to prevent contractures
positioning
heat, TENs, biofeedback
physical agent modalities
promote joint function, muscle, strength, and endurance
therapeutic activity and exercise
limited movement, pain, and tenderness at rest, weakness, tingling or numbness and hot, red joints
acute stage
when and what kind of exercise should be done for a patient in the acute stage?
active assistive exercises and exercises with gravity eliminated may be performed within the limits of pain tolerance. exercise should be performed at the ebst time of day for the patient
gentle PROM and AROM to the joint in the acute stage should be done how many times a day?
2x a day
limited movement and tingling remains, decrease in pain and tenderness indicates inflammation is subsiding, stiffness is limited to morning stiffness and. joints appear pink and warm
subacute stage
AROM and PROM exercises during the subacute stage include what?
a gentle passive stretch, isotonic exercises and graded isometric exercises may be done with minimal stress to joints
reduced tingling, pain, and tenderness, increased activity tolerance, endurance remains low
chronic-active stage
during ROM exercises in the chronic-active stage, what may be included?
stretch at the end of the range as well as isotonic and isometric exercises may be done as long as they do not overstress the joints
support joint in optimal position for function and reduce inflammation by providing rest or support to the joint, dynamic ___________ are used to correct deformity
splinting
instruct in techniques to help patient complete daily actviities
energy conservation
use only when necessary, use when there is a flare up; when flare up has subsided, return to own ROM and muscle power
assistive devices
joints affected by arthritis have increased potential for potential damage, __________________ teaches patients to minimize their risk of injury during daily activities
joint protection
what are some joint protection techniques?
respect pain
maintain muscle strength and joint ROM
avoid positions that put stress on involved joints
avoid staying in one position for a long time
use strongest joints and muscles available
distribute workload over several joints
if pain lasts more than 1-2 hours after completing a task, what would you deem most appropriate to tell the patient?
respect pain
using each joint to maximum available ROM and strength during daily activities; use long movement with arms
maintain muscle strength and joint ROM
avoiding hand positions that involve tight pinching, squeezing, or twisting motions; open objects toward thumb to avoid ulnar drift
avoid positions that put stress on involved joints
causes excess fatigue and stiffness; never begin an activity than cannot be stopped if pain or fatigue sets in
avoid staying in one position for a long time
using the larger joint reduces stress on smaller joints; keep weight under control to avoid stress on weight-bearing joints
use the strongest joint available for the job
use two hands to lift a mug; carrying heavy loads close to body in arms instead of holding them with your hands
distribute workload over several joints
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