MED CON FINAL SG

OT in Mental Health

Importance:
- NIH: 1 in 5 U.S. adults live with a mental disorder.
- WHO: 15% of 10-19-year-olds globally experience a mental health disorder.
- Severity varies, prevalence is high.
- Mental health can fluctuate even without a diagnosis.
- Client's experiences and history are unknown until shared.

Key Behaviors in Addressing Mental Health

Client History:
- Review chart: Use as a guide, may lack details.
  - Older diagnosis may not be applicable.
  - Client may not have disclosed everything to their MD.
- Ask open-ended questions: Build trust, use interactive reasoning skills.
Observe Behaviors:
- Appearance, speech, actions.
- Consider context, avoid assumptions.

Common Mental Health Screeners

PHQ-9: Assesses depression.
SF-36: Assesses mental, physical, and social health; good for major life changes.
GAD-7: Assesses anxiety.
Mood Disorder Questionnaire
Columbia Suicide Severity Risk Scale

Affective Disorders

Abnormal disturbances in emotion or mood.
Bipolar Disorder I:
- 1+ manic or mixed episode.
- Highly recurrent, 4+ manic episodes per year have poor prognosis.
Bipolar Disorder II:
- 1+ major depressive episode and at least 1 hypomanic episode.
- Significant impairment in life functions, usually due to depression.
Cyclothymic Disorder:
- Chronic, 2+ years of fluctuating hypomanic and depressive symptoms.
- Symptoms not severe enough for Bipolar I or II diagnosis.

Types of Depression

Major Depressive Disorder:
- 1+ depressive episodes, sometimes referred to as unipolar depression.
- Specifiers: melancholic, atypical, psychotic, anxious distress, catatonia, peripartum onset, seasonal pattern.
- Diagnosis can occur after one episode or a significant life event.
Persistent Depressive Disorder (Dysthymia):
- Less severe symptoms, chronic, not episodic.
- Irritability, inadequacy, guilt, excessive anger, social withdrawal, reduced activity.
- More chronic and harder to overcome than major depressive disorder.

Anxiety vs Fear

Anxiety: Apprehension caused by perceived danger (internal or external).
- Necessary for survival, ranging from mild to immobilizing.
- Activates defense systems and increases autonomic responses.
Anxiety Disorder:
- Prolonged or inappropriate fear response to the actual threat level.
- Leads to significant distress and personal suffering.
Fear: Immediate response to a real or perceived imminent threat.
Anxiety: Response to the anticipation of a future threat.

Types of Anxiety Disorders

Phobias: Fear or anxiety about a specific object or situation.
- Anxiety persists and is out of proportion to the true risk.
Panic Disorder: Recurrent, unexpected panic attacks.
- Panic Attacks: Abrupt surges of intense fear with physical symptoms.
- Individuals are often limited by fear of subsequent attacks.
Agoraphobia: Marked fear and anxiety in at least 2 of the following 5 situations:
- Using public transportation
- Being in open spaces
- Being in enclosed spaces
- Standing in line or in a crowd
- Being out of their home alone
Social Anxiety: Intense fear or anxiety of social situations with potential judgment or scrutiny.
- Symptoms: sweating, blushing, trembling, stumbling over words.
Generalized Anxiety Disorder: Excessive fear or anxiety about everyday life circumstances that substantially interfere with daily life activities.
- Anxiety present for 6+ months for diagnosis.
Post Traumatic Stress Disorder: Anxiety and/or fear that develop after a real or perceived threatening situation, including the following symptoms for 1+ months:
- At least one re-experiencing symptom
- At least one avoidance symptom
- At least two arousal and reactivity symptoms
- At least two cognition and mood symptoms

Obsessions and Compulsions

Obsessions: Recurrent and persistent intrusive and unwanted thoughts, urges, and/or images.
Compulsions: Repetitive behaviors or mental acts in response to obsessive thoughts/"rules".
- Intended to prevent or reduce anxiety/distress associated with negative thoughts.
- Excessive and not realistically able to prevent obsessive thoughts.

OCD and Hoarding Disorders

Obsessive Compulsive Disorder: Characterized by involuntary and unwanted obsessions and compulsions that cause distress and consume 1+ hours/day.
Hoarding Disorder: Persistent difficulty discarding or parting with possessions, regardless of value.
- Results in clutter and inability to use living spaces correctly.
- Individuals have varying levels of insight into the problem.

Trichotillomania, Excoriation Disorder, Body Dysmorphic Disorder, and Eating Disorders

Trichotillomania: Repetitive pulling out of one’s own hair, resulting in hair loss.
Excoriation Disorder (AKA Dermatillomania or Skin Picking Disorder): Recurrent skin picking, resulting in skin lesions.
Body Dysmorphic Disorder: Preoccupation with perceived flaws or defects in an individual’s physical appearance that are not apparent, or appear only slight, to others.
Eating Disorders: Disturbances in eating habits or behaviors that stem from an intense fear of being overweight and a preoccupation with the perception of one’s own weight and shape.
- Anorexia Nervosa
- Bulimia Nervosa – eating but throwing up later
- Binge Eating Disorder

Substance Use Disorder

SUD: Problematic pattern of using substances that result in impairment in daily life or noticeable distress.
Substances: Alcohol, Cannabis, Phencyclidine (PCP), Other hallucinogens, Inhalants, Opioid, Sedative, hypnotic, or anxiolytic, Stimulant: Amphetamines or cocaine, Tobacco.
OTs play a role in helping someone replace these hobbies with something healthier
Hard to draw the line to understand when it's recreational vs unhealthy so the criteria can help bring insight to people to see if it is affecting their life

Types of Dissociative Disorders

Disconnection or separation of self or state of being
Dissociative Amnesia: Sudden memory loss for significant personal information.
Dissociative Fugue: Combination of amnesia and 'flight' from life.
Dissociative Identity Disorder: Multiple personalities as a defense mechanism.
- Childhood: Victims of horrific sexual and/or physical abuse.
Dissociation often occurs following a trauma, often a way for the brain to try to escape the trauma
Depending on the severity of trauma, it can develop into different states

Personality Disorders

Chronic, inflexible, maladaptive pattern of perceiving, thinking, and behaving.
Cluster A—Odd/Eccentric
- Paranoid Personality Disorder
  - Consistent distrust and suspiciousness about motives of others.
Cluster B—Dramatic/Erratic
- Antisocial Personality Disorders
  - No remorse at violating societal norms and laws.
- Borderline Personality Disorder
  - Unstable moods, frequent threats of suicide.
Cluster C—Anxious/Inhibited
- Obsessive—Compulsive Personality Disorder
  - Perfectionist, need to do everything right, fear of errors (Not OCD).

Schizophrenia

A severe form of psychopathology in which personality seems to disintegrate, thought and perceptions are distorted, and emotions are blunted
Categories of Symptoms
- Positive → Added to normal experience (delusions, hallucinations)
- Negative → Removed from normal experience (alogia, flat affect)
Symptom clusters → represent dimensions of schizophrenia
- Psychotic – hallucinations & delusions
- Disorganized – speech, behavior, inappropriate affect
- Negative – flat affect, avolition, anhedonia, attention impairment
- Affective domains – manic, depressive
Hard to say someone with schizophrenia will have just these symptoms because often clusters overlap
Often shows in early-late adolescence so something to look out for if you are working with pediatrics

OT in Mental Health Case Studies

PTSD
- Severe PTSD → caused by an extremely traumatizing event/s that leads to chronic re-experiencing, avoidance, arousal and reactivity, and cognitive symptoms.
Co-occurring diagnoses
- Substance use disorders → Impact a person’s brain and behavior leading to their inability to control their use of substances.
- Personality disorders → Enduring and inflexible patterns of thinking, feeling, and behaving that significantly deviate from societal expectations.
- Anxiety disorders → Experiencing fear, dread, and other symptoms that are out of proportion to the situation.

Three Focus Areas of the PRRC

3 Areas of Focus: Wellness, Recovery, and Growth
- Each veteran has an individual recovery coach who works with them to identify areas of strength and goals tailored specifically to them.
- Psychoeducational & processing groups are offered Monday through Thursday, and on Fridays, veterans go to our community garden in the morning and have community outings in the afternoon.
- Staff includes social workers, one psychologist, one peer support specialist, and OT!

Population Considerations Specifically for the veteran population

Stigma.
Decreased independence, self-advocacy, and decision-making power.
Limited access to or awareness of resources.
Lower health literacy.
Suicide risk.
Many of those who entered military service had a history of trauma prior to serving.
Chronic disparities among minority groups (stress-vulnerability model).
Stress vulnerability model – more vulnerable if someone grows up in a non-supportive household, a lower socio-economic household, vs someone with a supportive household, so it is important to understand where they are coming from

OT’s Role in TBI

TBI’s impacts on parts of the brain: Definition and epidemiology of TBI:
- TBI→ a traumatic brain injury refers to a brain injury that is caused by an outside force
- TBI can be caused by a forceful bump, blow, or jolt to the head or body, or from an object entering the brain
  - Nonpenetrating→ closed injury to brain (hit, assaulted)
  - Penetrating→ gunshot wound
- Leading causes: falls, motor vehicle accidents, assaults, sports injuries
Know which populations have the highest TBI death and hospitalization rates!
- Children aged 0-4 and adults aged 75 and older have the highest rates of TBI-related hospitalization and death

Symptoms of TBI

Physical:
- Headaches
- Seizures
- Impaired vision
- Nausea and vomiting
- Clear fluids draining from nose or ears
- Neurological problems (slurred speech, weakness, loss of balance)
Cognitive or behavioral:
- Loss or change in consciousness
- Confusion/disorientation
- Impaired memory
- Decreased concentration/attention
- Impaired decision making
- Changes in sleep patterns
- Frustration or irritability
Perception and sensation:
- Light-headedness, dizziness, vertigo
- Loss of balance/coordination
- Hearing problems
- Unexplained bad taste in mouth
- Sensitivity to light and sound
- Feeling anxious or depressed
- Fatigue or drowsiness; lack of energy
TBI in children
- Changes in eating or nursing habits
- Persistent crying or crankiness with the inability to be consoled
- Changes in ability to pay attention
- Lack of interest in toys
- Changes in their sleep patterns
- Seizures
- Sadness
- Loss of a skill
- Loss of balance or unsteady walking
- Vomiting

Classifications of TBI

Mild TBI
- Clinically identified as a loss of consciousness for <30 minutes
- Ranks between 13 to 15 on the Glasgow scale
- Post traumatic amnesia (PTA) up to 24 hours
- No skull fracture on physical examination
- A non-focal (not one spot that they are able to identify) neurologic examination
- Mild TBI Presentation
  - Headaches
  - Dizziness
  - Nausea
  - Light/noise sensitivity
  - Fatigue
  - Visual disturbances
  - Oculomotor dysfunction
  - Irritability
  - Insomnia
  - Memory/executive functioning difficulties
- Mild TBI/concussion
  - Post concussive syndrome
    - Headache is a cardinal feature (tension, cervicogenic, migraine are all variants)
  - Less than 10% of mild TBI have positive CT findings
  - Less than 1% require neurosurgery
  - Short term memory, concentration, vestibular problems, light sensitivity etc. may be present
- Cognitive and behavioral impairments
  - Attention: sustained, alternating, divided, multi- tasking
  - Memory: immediate or short-term
  - Executive functioning: planning, organizing, self- initiating, sequencing
  - Depression: decreased participation in interests, frustration with current state
- Functional impairments and OT role
  - Mild TBI patients can exhibit difficulty with:
    - IADLs such was living independently, cooking, laundry, care of others
    - Returning to work, school and social interactions
    - Driving (reaction time, ocular motor functioning)
Moderate and severe TBI
- Can be a blow to the head or penetrating injury such as a gunshot and involves direct tissue damage
- Moderate→ unconscious that lasts more than 30 minutes but fewer than 24 hours; GCS rating of 9 to 12 or more; Post Traumatic Amnesia of 1-7 days
- Severe→ unconscious for more than 24 hours; GCS rating of 3 to 8, Post Traumatic Amnesia greater than 7 days
- Moderate to severe TBI presentation
  - Headaches
  - Dizziness
  - Nausea
  - Light/noise sensitivity
  - Fatigue
  - Visual disturbances
  - Chronic pain
  - Impaired attention
  - Lack of impulse control
    - Safety concern with these patients
  - Confusion
  - Memory impairments
  - Anxiety
  - Depression
  - Personality changes
  - Post-traumatic stress

Post-traumatic amnesia and types

Anterograde amnesia→ inability to remember new info but able to remember events prior to injury
Retrograde amnesia→ inability to remember events prior to the injury but able to remember events post-injury. Able to make new memories
Dissociative amnesia→ rare but when the person is unable to remember past or their own identity
- Side note: increase in agitation and confusion. Some might not be able to remember family members and loved ones

Primary and secondary brain injuries

Primary brain injury (actual injury)
- Contusions→ localized areas of bruised brain tissue often seen in focal areas like frontal and temporal lobes
- Intracranial hemorrhages→ bleeding in the skull
- Diffuse axonal injury (DAI) → widespread damage to nerve fibers due to shearing forces; typically white matter tracts
- Skull fractures→ bone fractures in the skull which penetrate brain tissue
Secondary brain injury (what happens after the injury
- Cerebral edema→ swelling of brain tissue which can lead to increased intracranial pressure (craniotomy)
- Hypoxia → reduced oxygen to the brain due to decreased blood flow
- Excitotoxicity→ excessive activation of certain neurotransmitters leading to neuronal damage
- Neuroinflammation→ immune response within the brain that can further tissue damage

Coup contrecoup injury

When a head injury results in damage to 2 sides of the brain – trauma side and opposite side of the brain
The damage comes from not only hitting the side of the skull but also rubbing against the inner ridges

Diffuse axonal injury

When rotational forces are created, it causes the fibers and blood vessels to rotate/twist resulting in damage
The white matter axons are less dense than gray matter causing them to be stretched to the point of breaking
White matter allows the brain to process information. It helps with focus, learning, problem solving, and balance. It connects regions that send and receive signals so when these are damaged, various regions of the brain are not able to communicate as efficiently with one another.

Common OT assessments with TBI

Evaluation process – occupational profile and patient history (identify patient’s goals and caregiver’s goals)
- Assessments:
  - Glasgow Coma Scale
  - Ranchos Los Amigos Scale
  - MVPT–3 (visual perception skills)
  - COPM
  - MOCA (cognition)
  - Adult Vision Questionnaire
  - Dizziness Scale

Glasgow Coma Scale

GCS is a practical and consistent assessment that can be used to monitor TBI patients. It can help with identifying changes in consciousness which can help determine interventions and patient’s potential outcomes.

Ranchos Los Amigos scale

The RLAS is a scale of cognitive function
- Describes the cognitive and behavioral patterns found in brain injury patients as they recover from TBI
- 10 levels to RLAS scale
Allows clinicians to develop appropriate intervention strategies and communicate between disciplines
Clinical Presentations
- Low level TBI patients (ranchos level 1-3)
  - Level 1 (no response): patient shows no awareness, does not respond to voice, touch, or light
  - Level 2 (generalized response): patient may have involuntary movements like flinching or withdrawing pain, but no purposeful responses
  - Level 3 (localized response): patient starts to react to specific stimuli, may follow simple commands like “look at me” with eye movements, and can sometimes respond to discomfort by pulling away.
  - Coma: The prolonged period of unconsciousness immediately following a traumatic brain injury and is defined by the absence of arousal, sleep wake cycles, and spontaneous eye opening. Painful stimuli may elicit reflex responses.
  - Arousal: the general state of readiness to respond to the environment and is necessary for selective attention/purposeful responses. Arousal is a function of the reticular activating system.
  - Vegetative state (VS): A state of complete unconsciousness with some eye-opening and periods of wakefulness and sleep
    - Return of a sleep-wake cycle with periods of eye opening and eye closing
    - May moan or make other sounds especially when tight muscles are stretched
    - May cry or smile or make other facial expressions without apparent cause
    - May briefly move eyes toward persons or objects
    - May react to a loud sound with a startle
    - Can’t follow instructions.
    - No speech or other forms of communication
    - No purposeful movement
  - Minimally conscious state (MCS)
    - May follow simple instructions.
    - May indicate yes or no by talking or gesturing.
    - May speak some words or phrases that others can understand.
    - May make automatic movements. These may include scratching their head, crossing their legs, or moving their hair out of their eyes.
    - May respond to people, things, or other events by:
      - Crying, smiling, or laughing
      - Making sounds or gesturing
      - Reaching for objects
      - Trying to hold or use an object
      - Keeping the eyes focused on people or things for a sustained period of time whether they are moving or staying still.
    - Use at least 2 objects correctly
  - Treating RLAS 1-3
    - Primary focus
      - Sensory integration/stimulation, promoting arousal
        Sensory – playing music they like
        Tactile – deep pressure, light touch
    - Motor skills: PROM, managing tone visual tracking, head turning
    - Managing joint mobility and edema
    - Basic ADLs such as brushing teeth, feeding is applicable
    - Turning/positioning in bed to prevent pressure injuries
    - Not actively participating in therapy sessions
- High level TBI patients (ranchos level 4 to 10) – coming out of lower level and having more movement and cognitive awareness
  - Level 4: Confused/Agitated: Highly confused, with frequent inappropriate behavior, short attention span, and may react to stimuli with agitation.
  - Level 5: Confused-Inappropriate: Still confused but less agitated, may follow simple commands with some assistance, and may not be aware of their limitations.
  - Level 6: Confused-Appropriate: Can follow simple directions with moderate assistance, shows some awareness of their situation, and may be able to engage in basic self-care routines.
  - Level 7: Automatic-Appropriate: Can perform familiar routines automatically but needs prompting for new tasks, may have difficulty with problem-solving and complex instructions.
  - Level 8: Purposeful-Appropriate: Can independently complete most daily activities, may still have some memory issues and require occasional cues, and can start to identify and correct errors.
  - Level 9: Purposeful-Appropriate - Modified Independent: Can manage most daily activities independently, can learn new things but may need extra time or strategies, and may still have some difficulty with complex tasks.
  - Level 10: Purposeful-Appropriate - Independent: Can fully participate in all activities of daily living without assistance, can manage complex situations, and demonstrates good awareness of their cognitive limitations

Components of executive functioning

Cognitive impairments
- Impaired attention and concentration
- Impaired memory
- Impaired initiation and termination of activity
- Decreased safety awareness
- Delayed processing information
- Impaired executive functions and abstract thinking
- Generalization

Common behaviors presented with TBIs and appropriate OT treatments

TBI patients can present with:
- Increased irritability
- Difficulty managing emotions
- Sudden mood swings
- Impulsive behavior
- Inappropriate social interactions
- Aggression
- Lack of insight to impairments
- Apathy
Treatment:
- Work with care team to develop a plan for the patient
- Provide safe environment
- Strategies to regulate emotions
- Mindfulness techniques– breathing, journaling
- Practicing social interactions

Decorticate vs decerebrate posturing

Decerebrate posturing/rigidity: neurologic damage at or below the midbrain. Slightly worse posturing.
Decorticate posturing/rigidity: severe neurologic damage in the hemisphere above the midbrain

Flaccidity vs spasticity & appropriate treatments

Flaccidity
- Decreased muscle tone where muscles feel weak and lack resistance to movement
- No active muscle contractions formed by patient
Spasticity
- Increased muscle tone resulting in muscle tightness and stiffness which can lead to contractures, pain, skin breakdown
- Damage to upper motor neurons
Treatment
- PROM, positioning, splinting, botox injections, weightbearing to facilitate proprioceptive input and improves function

Ataxia and OT treatments

Ataxia
- Impaired coordination and balance that affects gross and fine motor movements
- Typical with patients who have cerebellum or sensory pathway damage
- Treatment includes: medication management, environmental modifications, energy conservation, adaptive/DME, exercise program facilitating proprioception

Postural deficits associated with TBI

Deficits can occur due to abnormal tone, ataxia, impaired vision and cognition, decreased postural awareness and absent righting reaction
Position in bed and wheelchair help prevent postural deficits

Heterotopic ossification

HO is a diverse pathologic process, defined as the formation of extraskeletal bone in muscle and soft tissues. HO can be conceptualized as a tissue repair process gone awry and is a common complication of trauma

Definitions of proprioception, kinesthesia, and graphesthesia

Proprioception→ perception or awareness of the position and movement of the body
Kinesthesia→ perception of body movements and changes in body position
Graphesthesia→ ability to recognize writing on the skin purely by sensation of touch

Common visual deficits

Field cuts
Visual spatial disorder
Nystagmus
Diplopia
Light sensitivity
Visual hallucinations
Dry eye

Terms regarding visual perception

Possible impairments in the following areas:
- Visual agnosia: the total or partial loss of the ability to recognize and identify familiar objects and/or people by sight.
- Impaired right/left discrimination
- Impaired figure-ground
- Impaired topographical orientation
- Impaired depth perception
- Tactile agnosia
- Impaired body scheme
- Neglect
- Apraxia

Neuroplasticity

The brain’s ability to make adaptive changes based on behaviors.
Repetition with activity allows the brain to reorganize the neural circuitry and allows the brain to adapt and strengthen the new connections.

Assistive and technological options for TBIs

Electrical Stimulation Devices– Bioness, NMES
Blaze Pods
Dynavision
Virtual Reality
Augmentative and Alternative Communication (AAC) – can be used for vision, tracking

OT’s Role in ALS and PD

What is ALS? → Amyotrophic Lateral Sclerosis
- Neurodegenerative disorder characterized by progressive muscle weakness that impacts physical function (can affect bulbar, limb & respiratory muscles)
- Results in both UPPER MOTOR & LOWER MOTOR DYSFUNCTION
- Progressive degeneration of motor neurons → When motor neurons die, the ability of the brain to initiate and control muscle movement is lost.
- Called Lou Gehrig's Disease after baseball player
- A type of motor neuron disease that causes nerve cells to gradually break down and die.
- We don't know why ALS occurs. A small number of cases are inherited.

ALS Symptoms

~Progressive muscle weakness/paralysis~
Falling and tripping
Abnormal fatigue in arms and/or legs
Drooling
Difficulty holding head upright
Slurred speech (dysarthria)
Muscle cramps and twitches (spasms)
Dropping things (Ataxia)
Uncontrollable periods of laughing or crying (lability)
Typical client presentation:
Life Expectancy following diagnosis of ALS:

Upper VS Lower motor neurons diseases and presentations:

ALS is an UPPER (brain) & LOWER (brainstem & spinal cord) MOTOR NEURON DISEASE
NOTE: ALS is difficult to diagnose, and is normally diagnosed by ruling out other diseases

Common testing that helps to identify ALS:

No single diagnostic test that can confirm or entirely exclude the diagnosis of motor neuron disease

Electrodiagnostic tests including electromyography (EMG) and nerve conduction velocity (NCV)
Blood and urine studies including high resolution serum protein electrophoresis, thyroid and parathyroid hormone levels and 24-hour urine collection for heavy metals
Spinal tap
X-rays, including magnetic resonance imaging (MRI)
Myelogram of cervical spine
Muscle and/or nerve biopsy
Neurological Examination:
- Presence of upper & lower motor neuron signs
- Progressive spread of signs within a region or to other regions.
- Cannot be explained by other diagnosis (Rule out others)

Primary areas impacted by ALS:

Biggest impact: ORAL, RESPIRATORY, MUSCULAR
Impacts ability to walk/functional mobility
IADLs: driving, work, avocational interests
Basic ADLs: dressing, toileting, grooming/hygiene, ect
Fine Motor – including writing and manipulation of objects
Speech
Swallowing
Breathing

Leading cause of death for ALS:

Leading cause of death → respiratory insufficiency
- Either can not take in enough O2 or not enough O2 through blood

ALS: Motor – Clinical Presentations

Bulbar involvement: → impacts the fluidity of movements
- mixture of spastic and flaccid components may characterize speech, resulting in a dysarthria with severe disintegration and slowness of articulation (25% initial presentation)
Pseudobulbar symptoms:
- consist of exaggerated, involuntary emotional responses.
- The response may be of one type (laughter or crying)
Lower motor neuron (LMN) involvement:
- fasciculations (tiny muscle spasms) occur early on in the disease, particularly in the tongue and limbs.
Upper motor neuron (UMN) involvement:
- altered muscle tone & presence of spasticity
Preserved functions:
- include extraocular movements and bowel & bladder control
- With progressive disease, patients may develop problems with urge incontinence and constipation because of weak abdominal musculature.

Non-medication interventions for ALS

Peg Tube
- Important consideration for persons having trouble with swallowing & at risk for aspiration (can eat orally and have feeding tube)
Ventilation
- Beneficial effects of non-invasive ventilation, in which the patient uses a mask ventilator system (usually bilateral positive airway pressure) overnight during sleep.
- Machines are small & portable w/ various face masks.
- May be used in later stages using a small nasal mask.
Antioxidant treatment
- Has been great interest in trialing antioxidant treatments
- Results have been disappointing

ALS: Supportive Interventions

Nutrition and Feeding: Malnutrition, Dysphagia, Peg Tube Placement
Multidisciplinary Care: Neurologist, PT, OT, ST, nursing, social worker, dietitian, respiratory and palliative care.
End of Life Care: Advanced Directives, Hospice Care, Intubation, Respiratory Distress
Medications to address comfort & symptom relief
Future Treatments: Neuronal Stem Cells

Know examples of compensatory strategies and assistive equipment for ADLs

Adaptations for basic ADLs
- EATING: built-up handles, foam tubing, large handled cup suitable for hot and cold liquids, dycem, long straws (rigid or flexible)
- DRESSING: Velcro closures on clothes & shoes, knit shirts, pull-on pants, fewer closure, elastic thread for cuff buttons, large-handed buttonhook, stretchy shoelaces, long handled shoe horn
- ADLs: baby wipes for toileting, toilet attachments for cleansing, foam tubing on toothbrush, electric toothbrush with rotary brush, hand-held shower hose, plunger soap dispenser, long- handled sponge
- GROOMING: wall-mounted hair dryer, foam tubing on comb/brush, lightweight + long handled comb/brush, nail brush with suction cups, stabilizing platform/board, electric shaver
- OTHER: key holder, door handle levers, touch light switches, offset hinges for doors (widens doorway without reconstruction)
Functional Mobility
- WALKING AIDS: canes, walker, mobile walkers, platform walkers (limited due to UE use)
- TRANSFERS: gait belt, beasy board, sliding board, mechanical lifts, hydraulic lifts, hoyer lift, ceiling fans, recliner chair lifts
- Hospital Beds/Pressure Relieving Mattress: Manual to fully electric bed systems with bed rails, interface with environmental controls, low air loss, alternating pressure mattress
- Bathing/Toileting: Padded tub bench, shower w/c, tilt in space shower w/c, bedside commodes, sliding transfer board/bench, grab bars, hand held shower
- Home Modifications: ECU with door openers, stair lifts, porch lifts, entry and exits , door widening, ramps, accessibility
Wheelchair Selection
- May require a manual (back up w/c) for transport purposes
- Will require a device which compliments/interfaces with AAC (alternative augmentative communication) and ECU (electronic control unit)
- Will need power wheelchair (PWC), which is modifiable as client regresses:
  - joystick
  - head array
  - eye gaze, etc.
- PWC features for positioning, pressure relief and comfort:
  - tilt-in-space
  - recline
  - power elevating legs
  - seat elevation
- Pressure Relieving Cushion: Roho(air pockets-best), gel, foam.
Orthotics
- AFO–ankle-foot orthosis
- Neck supports: soft cervical collar, headmaster, buddy pillow
- Resting Hand Splint: soft
- LE Edema: Ted Hose, Compression Hose
- Pressure Relieving Foot Protection: bunny boots

Parameters of exercise for ALS clients

People w/ ALS CAN exercise
- Not harmful to exercise (moderate intensity)
- May slow down progression
- Very individualized & functional based
- Is it an important occupation for the client??
Types of Exercise
- Stretching/flexibility exercises ** important for passive stretching as disease progresses**
- Aerobic