Unit 6E - Functional Activities & Rehabilitation

Text Sources: O&S pp. 316 & 325
TERMINOLOGY (Box 8.1)
- Independent
  • Performs skill safely & consistently with no assistance or cueing
- Supervision
  • Therapist within arm’s reach as precaution; low probability of needed help
- Close Guarding
  • Therapist hands raised, no contact; fair probability of assistance
- Contact Guarding
  • Hands on patient, no lifting; high probability of assistance
- Assistance Levels
  • Minimum Assist – patient completes majority of task
  • Moderate Assist – patient completes part of task
  • Maximum Assist – patient unable to help
Alternative order used for Transfers/Ambulation (adds Close & Contact Guarding between Supervision and Min-Assist)
FIM (Functional Independence Measure)
- 18 items → 7-point scale based on % patient effort
- Scoring
  7 Complete Independence (timely/safe)
  6 Modified Independence (device)
  5 Supervision/Set-up (patient = $100\%$ )
  4 Minimal Assist (patient ≥ $75\%$ )
  3 Moderate Assist (patient ≥ $50\%$ )
  2 Maximal Assist (patient ≥ $25\%$ )
  1 Total Assist or NT (patient < $25\%$ )
- Domains: Self-Care, Sphincter Control, Transfers, Locomotion, Communication, Social Cognition

Rolling Techniques (M&K p.374-375, O&S p.691 tactile cues)
- Bend both knees → therapist assists at pelvis & scapula (key points of control)
- Alternate if weak LE non-functional: cross stronger leg over weaker to achieve hook-lying → roll ("last resort")
- Single-leg strategy: flex only one leg prior to roll
- Assistance can vary from max → min → tactile cues
Supine ↔ Side-Lying imagery (hook-lying, UE’s clasped) reinforces symmetrical movement & trunk dissociation
Moving Up / Scooting in Bed
- Bridge, advance shoulders/hips sequentially (practice!)
Supine-to-Sit (diagonal pattern emphasized)
- Sequence: roll → drop LEs → push up with UE → therapist cues at trunk/hips
- PNF diagonal (M&K 11-17, 11-18) useful; strong abdominals critical
Activity Analysis
- Identify weak components (balance, approximation for UE weight-bearing, side-sitting prop on elbow, etc.)

Scooting to Edge of Chair (prep for Sit-to-Stand / Stand-Pivot)
- Demonstrate to patient/caregiver; focus on problematic parts (e.g., pivot phase)
Stand-Pivot Transfer (SPT) vs. Sliding-Board Transfer (SBT)
- Choose SBT for safety or limited standing tolerance
- Therapist must block weak LE
Sit-Pivot Dependent Transfer (NDT)
- Key points: flex trunk forward, therapist knees against pt’s, hands under trochanters, maintain head support
- Progression: include car transfers prior to d/c

Propulsion
- One-arm/foot pattern
- Hemi-chair vs. One-Arm-Drive (see YouTube link)
Management
- "Lead-ups" (locking brakes, removing armrest/footrest, positioning)
- Vigilance for involved extremities (subluxed shoulder, foot drag)

Wheelchair Push-Ups → ↑ UE/LE strength & coordination (both arms engaged)
Lateral Weight-Shift on Mat (NDT)
Assisted Stand (therapist at scapulae, knees blocked)
NDT Standing – “Prayer/Antennae” arms; apply graded resistance at head/trunk; tactile cues at pelvis
Weight-Bear on Affected LE
- Knee stabilization strategies (manual block, knee brace, DF wedge)
Protect involved UE (avoid traction, subluxation)
Facilitate hip extension, ankle alignment as needed
Maintain Stand: Static & Dynamic balance drills (reach, perturbations)

Pre-gait (Table 11-8) → weight-shift, marching, step taps
Parallel Bars Progression → lowering UE support, tandem weight-shift, step-through
Alternatives: bedside table walker, shopping cart for community practice
Surfaces: mats, carpet, gravel, ramps
Anticipate gait deviations section for problem-solving

Ascending with hemiplegia
- Emphasize pelvic elevation, trunk alignment; clinician assists at axilla & distal femur to cue hip/knee flexion
Descending
- Control trunk extension; prevent adduction “falling” to involved side
Wheelchair Elevation Drills for ramp negotiation & curb drops
ADA Ramp Education (Box 13-11)
- Maximum slope $1:12$ (rise:run)
- Level landings top & bottom; max single run rise $30\text{ in}$
- Minimum clear width $36\text{ in}$
- Handrails both sides if rise > $6\text{ in}$ or run > $72\text{ in}$ , height 34$–$38\text{ in}
- Surface: firm, stable, slip-resistant; landings drain water
- Example: one 7″ step ⇒ run $=84\text{ in}$ ; three steps ⇒ $7\text{ in} \times 3 = 21\text{ in rise},\; 84\text{ in} \times 3 = 252\text{ in run} = 21\text{ ft}$

Dressing & toileting strategies (see course guide)
Functional assessment tools critical for reimbursement (FIM, Barthel, Katz, etc.)

Ethical: Ensure patient safety while promoting maximum independence; use evidence-based FIM scoring for fair reimbursement.
Philosophical: Foster autonomy through graded assistance → empowerment.
Practical: ADA compliance vital for community reintegration; caregiver education reduces readmission risk.