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• The information across chapters 27, 32, and 33 is used throughout all the course material.

Ch. 27 Restoring Activities of Daily Living

• ADL observation and analysis is a critical component of evaluation.
• Occupational therapists evaluate ADL performance through self-reports or performance-based assessments.
• It's important to first assess client factors and skills like ROM, strength, sensation, balance, and cognition.
• ADL performance should ideally be assessed in environments where they typically occur, or simulated natural environments.
• ADL tasks should range from simple to complex, based on referral information, chart review, and occupational profile.
• Standardized ADL assessments include:
  • Functional Independence Measure (FIM)
  • Klein-Bell Activities of Daily Living Scale
  • Katz Index of Independence in Activities of Daily Living
  • Performance Assessment of Self-Care Skills (PASS)
  • Disabilities of the Arm, Shoulder, and Head (DASH) Assessment
  • Barthel ADL Index
• Nonstandardized measures include ADL checklists.
• Standardized assessments can re-evaluate to measure outcomes and goals.
• Consider contextual and environmental factors affecting client performance.
• Physical factors like clutter, access barriers, rugs, steps, or stairways should be addressed.
• Cultural and social factors impact ADL performance and should be included in evaluations and interventions.
• Determine whether clients desire family and caregivers to be present.
• Comply with Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations.
• In acute or intensive care, therapists must factor in the client's medical complexity.
• Therapists should understand and monitor:
  • Lab values
  • Vital signs
  • Code status
  • Documented precautions
• Therapists should be familiar with equipment like electrocardiogram (EKG) monitors, ventilators, lines, catheters, tubes, dialysis equipment, pacemakers, mechanical circulatory devices, and respiratory care equipment.
• Isolation precautions should be reviewed and followed.
• Information can be found in client charts and posted on hospital room doors.
• Activities of daily living (ADLs) are activities oriented toward taking care of one's body.
• ADLs include bathing and showering, toileting and toilet hygiene, dressing, swallowing and eating, functional mobility, personal device care, personal hygiene and grooming, and sexual activity.
• ADLs are also known as personal activities of daily living (PADLs) or basic activities of daily living (BADLs).
• Adaptive equipment includes devices, tools, or products that assist individuals with disabilities in occupations.
• Adaptive equipment is also referred to as assistive technology, assistive devices, or adaptive devices.
• A client-centered approach includes respect for and collaboration with clients, involving clients in decision-making, advocating with them and recognizing their experience and knowledge.
• Durable medical equipment (DME) provides therapeutic benefit to clients with medical conditions or illnesses.
• DME must be:
  • Prescribed by authorized physicians or healthcare providers
  • Reusable
  • Primarily used in the home
• Occupational profile provides information about clients':
  • Occupational histories
  • Experiences
  • Daily living patterns
  • Interests
  • Values
  • Needs
  • Reasons for seeking services
  • Concerns related to occupational performance and disruption
• Occupations are meaningful activities that individuals, groups, or populations engage in.
• Occupations include activities of daily living, instrumental activities of daily living, rest and sleep, education, work, play, leisure, and social participation.
• Bed Mobility is the ability to bridge in bed, roll from supine to side-lying, scoot up and down in bed, move from supine to sitting and sitting to supine, and sit at the edge of the bed.
• After screening, therapists complete occupational profiles to gain information about client factors, performance skills and patterns, contexts, and occupations.
• Occupational profiles help therapists understand client abilities, capacities, interests, values, roles, habits, routines, environments, and needs related to occupational engagement.
• Important questions include:
  • What is the client's current lifestyle?
  • What was the client's ADL status prior to injury, disease, or illness?
  • What are the client's current occupational challenges?
  • What comprises the client's typical day-to-day routines?
  • What occupations are meaningful to the client?
  • In what environments does the client currently navigate to complete occupations?

Levels of Independence

• Independent: Clients can perform the activity independently without modifications or assistive devices, within a reasonable time frame.
• Modified independence: Clients require assistive devices or more time, or there are safety considerations.
• Supervision (standby assistance): Clients need a therapist for safety and verbal cues.
• Contact guard: Therapists provide balance with one or two hands but do not assist in task performance.
• Minimal assistance: Therapists provide 25% of assistance (physical or verbal) and clients can perform 75% or more of the activity.
• Moderate assistance: Therapists provide 50% of assistance (physical or verbal) and clients can perform 50% to 74% of the activity.
• Maximal assistance: Therapists provide 75% of assistance (physical or verbal) and clients can perform 25% to 49% of the activity.
• Dependent: Therapist provides more than 75% of assistance (physical or verbal) and clients can perform less than 25% of the activity.

Ch. 44 Amputations & Prosthetics

• Body-powered (BP) prosthesis: An upper limb device that operates from an individual's proximal motions using muscles of the shoulder, neck, or back.
• Externally powered (EP) prosthesis: An upper limb device that operates through external power.
• Functional envelope: The area of space where a patient can effectively operate an upper extremity prosthesis.
• Heterotrophic ossification: Bone growth in soft tissue where it shouldn't exist often after trauma to the musculoskeletal system, brain, or spinal cord.
• Hybrid prosthesis: A device that combines two prosthetic options, like a transhumeral prosthesis with a BP elbow and EP terminal device.
• Musculoskeletal pain: Discomfort in areas like the back, neck, shoulder, or contralateral limb due to overuse or poor body mechanics.
• Myodesis: Surgical technique that involves directly suturing muscle or tendon to amputated bone for optimal distal muscle stabilization.
• Myoplasty: Suturing muscle to muscle then placing it over the end of the amputated bone before closing the wound; often used in patients with poor vascular health.
• Neuroma: An injured nerve with severed nerve fibers forms a painful, disorganized mass of nerve cells.
• Terminal device (TD): A prosthetic component at the distal end of an upper limb prosthesis used to grasp and release objects, like a hook or hand.
• Major limb amputations: Proximal to the wrist or ankle.
• Minor limb amputations: Distal to the wrist (hand and fingers) or ankle (foot and toes).
• The main causes of amputation are dysvascular disease (54%), trauma (45%), and cancer (less than 2%).
• Lower limb dysvascularity is commonly due to complications from diabetes, arteriosclerosis, or smoking.
• Almost 70% of upper limb amputations are due to trauma in males aged 15 to 45 at work.
• Secondary health effects after amputation may include:
  • Poor nutritional intake
  • Reduced exercise
  • Obesity
  • Tobacco use
  • Hypertension
  • Hypercholesterolemia
  • Skin issues
  • Diabetes
  • Cardiac disease
• Patients can be fitted for a prosthetic once wounds are healed, sutures removed, they are medically cleared, and maximize independence in self-care ADL using adaptive strategies, assistive technology, or DME.
• Rehabilitation phases include perioperative, pre-prosthetic training, and prosthetic training.
• Postoperatively, residual limb management includes:
  • Wound healing
  • Limb protection
  • Edema control
  • Limb shaping
  • Pain management
  • Decreasing hypersensitivity

Ch. 45 Diabetes

• Diabetes distress: Emotional burdens and worries in managing a severe and demanding chronic disease like diabetes.
• Diabetes mellitus: Impaired ability to produce/respond to insulin, resulting in abnormal carbohydrate metabolism and elevated glucose levels.
  • Type 1: Body doesn't produce insulin
  • Type 2: Body doesn't respond to insulin well and later doesn't produce enough.
• Glycated hemoglobin (HbA1c): A glucose molecule is attached to hemoglobin. Hemoglobin A1c (HbA1c) levels increase in diabetes.
• Hyperglycemia: High blood glucose due to the body's inability to properly use or make insulin.
  • Symptoms include increased urination, extreme thirst, and unexplained weight loss.
• Insulin: A protein hormone produced in the pancreas. Lack of this hormone results in diabetes mellitus.
• Nephropathy: Kidney disease affecting waste excretion and water/acid-base balance.
• Neuropathy: Disease of the peripheral nerves causing weakness and numbness.
  • High blood glucose levels over time can damage nerves, especially in the lower limbs.
• Retinopathy: Disease of the retina resulting in impairment or loss of vision, sometimes leading to blindness.
• Self-management: Ability to manage the symptoms, treatment, physical and psychosocial consequences, and lifestyle changes inherent in living with a long-term disorder.
• In type 1 diabetes, the body does not produce insulin.
  • Occurs mostly in children, adolescents, or young adults, representing only 10% of people with diabetes.
  • The exact causes are still unknown, but the body's immune system destroys the beta cells in the pancreas.
  • Hypothesis: related to a genetic predisposition or certain environmental factors.
• Type 2 diabetes is the most common form of diabetes, accounting for 90% of cases.
  • The body either doesn't produce enough insulin or doesn't use it properly, leading to hyperglycemia.
  • Insulin resistance: Pancreas produces extra insulin to compensate, but cannot keep blood glucose levels normal over time resulting in the body not effectively using glucose as an energy source.
  • Chronic hyperglycemia causes long-term microvascular complications affecting the eyes, kidneys, and nerves, as well as an increased risk for cardiovascular disease.
• The American Diabetes Association (ADA) recommends individuals are diagnosed with diabetes when their fasting glucose levels are above 7.0 mmol/L and/or the HbA1c level is 6.5% or higher.
• Prediabetes is when HbA1c levels are between 6.0% and 6.4%. These individuals are at high risk of developing diabetes and related complications.
  • People with this syndrome present with high blood glucose, abdominal obesity, hypertension, dyslipidemia, high triglycerides, and insulin resistance.
• The single strongest risk factor for type 2 diabetes is a high body mass index (BMI), with up to 61% of cases attributed to BMI >25.
  • Physical activity level can also predict the development of type 2 diabetes.
• Complications include:
  • Microvascular: Small blood vessels include retinopathy (eye damage), nephropathy (kidney damage), and neuropathy (nerve damage).
  • Macrovascular: Large blood vessels include stroke, heart attack, and circulatory disease.
  • High level of psychosocial stress with higher rates of anxiety and depression.
• People with diabetes experience difficulties in daily occupations, like performing ADLs, limited community mobility, decreased energy, social isolation, poor time usage, poor daily planning, lack of meaningful leisure activities, and diminished healthy habits.
• Self-management is complex, requiring both medical monitoring and lifestyle management, impacting occupations across the lifespan.
• Self-management recommendations include:
  • Adopting healthy eating habits
  • Monitoring blood glucose levels
  • Doing regular physical activity
  • Taking medication daily
  • Taking care of feet
  • Accessing psychosocial resources and support

Behavioral Change Models

• Self-Regulation Theory: Emphasizes monitoring and adjusting actions based on personal standards, goals, and feedback. Higher self-regulation helps people resist impulses, but competing demands can diminish it.
• Goal Setting and Goal Striving Theory: Goals serve as motivating drivers of behavior. Effective goals should be achievable, moderately challenging, and aligned with personal motivations. Goals should be specific and feasible to encourage continued progress.
• Self-Efficacy Theory: Self-efficacy is the belief in one's ability to succeed in specific tasks.
  • Central to Bandura's Social Learning Theory, affects motivation and behavioral change.
  • Mastery experiences, observing others' success, social encouragement, and self-appraisal all boost self-efficacy, which is critical for successful health behavior change.
  • Key concepts are competence mastery, vicarious learning, social persuasion, and self-appraisal.
• Transtheoretical Model: Outlines stages of change including:
  • Precontemplation (no intention to change)
  • Contemplation (awareness but ambivalence)
  • Preparation (intention to act)
  • Action (modifying behavior)
  • Maintenance (sustaining changes and confidence) People progress through these stages before maintaining long-term behavior change.
• Chronic Care Model: A framework where managing chronic conditions like diabetes, focuses on collaborative care between informed patients and proactive healthcare providers, with emphasis on self-management support, system design, decision support, information technology, sustained and individualized care, and client involvement in goal setting/decision-making.
• Primary Role of OT is to support individuals in engagement in healthy lifestyles to manage diabetes.
• The Resilient, Empowered, Active Living with Diabetes (REAL) intervention is an evidence-based occupational therapy-led diabetes intervention and is an adaptation of Lifestyle Redesign intervention.

Ch 25 (Wheelchair and Seating Selection)

• Manual wheelchair (MWC): A mobility base consisting of a frame, rear wheels, and front casters, for self-propulsion or dependent mobility.
• Power assist add-ons: Placed under and behind a manual wheelchair and are activated to assist in propulsion as needed for longer distances.
• Power assist wheels: Standard wheels on manual wheelchair replaced to increase propulsion stroke force for distance and speed.
• Power-operated vehicle (POV): Scooters; mobility bases that have three or four wheels, a driving tiller, and a consumer-style seat.
• Power wheelchair (PWC): A mobility base consisting of a frame, drive wheels, and casters for independent mobility through a joystick/driving method.
• Pressure injury: Breakdown of the skin and tissues due to pressure with other contributing factors.
• Primary support surfaces: Seat, back, footplates, and arm pads of the wheelchair and seating system.
• Secondary supports:
  • Anterior (e.g., pelvic positioning belt or anterior trunk support)
  • Posterior (e.g., calf strap)
  • Superior (e.g., foot straps)
• Secondary support surfaces:
  • Anterior (e.g., anterior lower leg support aka knee block)
  • Lateral (e.g., lateral trunk support)
  • Posterior (e.g., posterior head support)
  • Medial (i.e., medial knee support)
• Support surfaces designed to keep the client aligned with the primary support surfaces.
• Shear: Forces created as body tissues and seating surfaces move differently
• The Positioning Checklist helps screen if a student needs a formal seating evaluation.
• Wheelchair seating systems: Sling upholstery, captains seat, linear, generic contoured, aggressively contoured, and molded seating.
• Assess seating to identify pressure injury risks, angles of support, and challenges.
• Develop interventions matched to products across seating categories.
• Wheeled Mobility Categories include;
  • Augmented Mobility Devices: Canes, crutches, walkers and gait trainers
  • Dependent Mobility Bases: Adaptive strollers, transport chairs and MWCs
  • Manual Mobility Bases: Standard wheelchair, standard hemi wheelchair, lightweight wheelchair, custom lightweight and ultra lightweight, pediatric wheelchair, bariatric wheelchair, and specialty wheelchair
• Manual Wheelchairs with power assist: Power assist wheels replace standard wheels on MWC, increasing propulsion stroke force for distance and speed
• Power Mobility Bases: Power overated vehicles (scooters) or power wheelchair

Ch. 32 The Biomechanical Frame of Reference

• Edema: Swelling due to excess fluid.
• Endurance: Ability of muscles to exert effort over time, correlated to occupational performance.
• Functional range of motion: Range required at joints to perform requisite functional tasks.
• Impairment: Reduced quality or function in a physical characteristic, partial or complete.
• Kinematics: Science of describing positions and motions in space.
• Kinetics: Study of forces affecting motion.
• Physical agent modalities (PAMs): Modify client factors limiting performance using energy; modulate pain, modify tissue healing, increase extensibility, modify skin and scar tissue, decrease edema/inflammation, decreased function secondary to musculoskeletal conditions; adjunctive or preparatory to occupation.
• Range of motion (ROM): Pathway of movement at a joint, measured in degrees.
• Strength: Muscle force against resistance, measured in pounds.
• Therapeutic activities: Tasks used to meet functional objectives.
• Therapeutic exercise: Movement used to correct impairment or improve musculoskeletal function; repetitive in nature.
• Biomechanics is the study of mechanical laws relating to the movement or structures of living bodies.
• The FOR is applied to individuals who demonstrate limitations in moving freely, with adequate strength or in motion.

Ch. 33 The Rehabilitation Frame of Reference

• Adaptation: Modifying items, activities, or environments to promote function.
• Assistive technology: Items to promote function, may be commercially available, modified, or customized.
• Compensation: Using techniques to complete an activity in a modified way.
• Compensatory techniques: Intentionally performing activities differently.
• Continuum of care: Range of health-related services across levels of intensity.
• Environmental modification: Changing the physical or human environment.
• Orthotic: A device to stabilize a body part, prevent deformity, or protect against injury.
• Prosthetic: A device to replace the function of a missing body part.
• Remediation: Improving or correcting a deficit.
• The Rehabilitation Frame of Reference aligns with the "modify" approach to intervention, emphasizing compensation and adaptation.
• It focuses on restoring function by addressing impairments in body functions.
• Clinical Question: Whether to focus on remediation, compensation, or adaptation.
• Assumptions underlying the Rehabilitation Frame of Reference include:
  • Individuals can regain independence using compensation when underlying deficits cannot be remediated.
  • Regaining independence is tied to motivation and values, roles, preferences, and sense of purpose.
  • Motivation for independence depends on environmental context, individual previous life, family/social support, and resources/culture.
  • Certain psychosocial/cognitive skills are needed for independence.
  • Therapist clinical reasoning should consider top-down approach.
• Function-dysfunction continua are ADLs, IADLs, work/education, play/leisure, social participation, rest/sleep.
• Function is:
  • Ability to engage in choice activities that are satisfying
  • Ability to complete activities with:
  • Acceptable independence
  • Acceptable safety
  • Acceptable timeliness or efficiency
  • Acceptable performance or accuracy
• Dysfunction when indicators of function are absent or limited.

Ch. 41 Orthopedic Conditions

• Abduction pillow brace: Positions the shoulder 30°-45° of abduction to protect the repaired supraspinatus.
• Codman's pendulum exercises: Standing/sitting, trunk parallel to floor, swinging the arm passively/actively.
• Controlled range of Motion: Active/passive movement within a safe arc.
• Scapular plane: Midpoint between shoulder flexion and abduction.
• Shoulder immobilizer: Elastic band fitting around the waist with straps to position/secure an abducted/internally rotated arm.
• Trendelenburg gait: Ambulation pattern resulting from weakened gluteus medius muscle causing lurching toward injured side, pelvis dropping on unaffected side at heel strike.
• Volkmann's Ischemia: Increased compartment pressure in an extremity area because of fracture/crush injury.
• Occupational therapy in orthopedic rehabilitation aims to maximize musculoskeletal functioning.
• In the acute recovery stage, OT helps relieve pain, decrease swelling/inflammation, assist in wound care, maintain alignment, and restore function.
• UE Fracture healing estimated times:
  • 2-3 weeks callus formation
  • 4-6 weeks union
  • 6-8 weeks consolidation
• Three phases of fracture healing: Inflammation, reparative, and remodeling.
• The shoulder is the most challenging portion of the body to rehabilitate.
• Shoulder impingement compression of structures with shoulder elevation above 90 degrees.
• Bursitis Inflammation of the bursa.
• Neer Impingement sign: Forced forward flexion with the shoulder internally rotated indicating compression and/or inflammation
• Hawkins Test- Shoulder and elbow are flexed to 90° followed by forced internal rotation indicating compression and/or inflammation.
• Jobe's Test (empty can test)- Shoulder elevation to 45° and internal rotation (thumb facing down) weakness or pain indicates tear. 90°position suspects bursitis.
• Drop arm test Patient's arm is positioned in 90° of abduction, slowly lowers arm to the side. Supraspinatus tear if pt drops their arm.
• Biceps Speed's Test: Shoulder flexed with forearm is supinated. Pain indication bicep issues.
• Movement restrictions after hip surgery may include:
  • no hip flexion beyond 90°
  • no hip rotation
  • no adduction

Ch 42 (RA & OA)

• Bouchard nodes: Hard, bony outgrowths at the proximal interphalangeal (PIP) joints due to OA.
• Boutonnière deformity: Joint deformity characterized by flexion of the PIP joint and hyperextension at the distal interphalangeal (DIP) joint.
• Cachexia: Loss of muscle mass as the inflammatory processes affects muscles in RA.
• Chondropenia: Loss of cartilage faster than the rate of repair in the osteoarthritic joint.
• Crepitus: Feeling or sound of crunching coming from the articular surface during range of motion.
• Disease-modifying antirheumatic drugs (DMARDs): Affect the immune response to reduce inflammation.
• Fibrillation: Initial changes in OA, by softening articular cartilage.
• Heberden nodes: Hard, bony outgrowths at the DIP joints caused by OA.
• Joint protection techniques: Application of ergonomic principles to reduce stress on joints and tissues.
• Mallet finger deformity: Deformity resulting from damage to the extensor tendon at the DIP joint.
• Swan-neck deformity: Hyperextension of the PIP joint and flexion at the DIP joint.
• Synovitis: Inflammation of the synovial membrane. Inflammation of the synovial membrane.
• Volumetry: A water displacement measuring volume of hand.
• Z deformity of OA thumb: carpometacarpal (CMC) joint adduction, metacarpophalangeal (MCP) joint hyperextension, and interphalangeal (IP) joint flexion.
• Z deformity of RA thumb: Excessive hyperextension of the IP joint and flexion of the MCP joint of the thumb.
• Rheumatoid arthritis (RA) is an autoimmune, chronic, systemic inflammatory disease affecting the joints, commonly diagnosed in women.
• Pathological changes in joints:
  • Synovitis: Thickening of the synovial membrane from edema stretches nociceptors, causing pain.
  • Pannus: Inflammatory cells release protein-degrading enzymes, leading to cartilage, chondral/subchondral erosions.
  • Joint instability: Swelling stretches/weakens ligaments, disrupts stability.
  • Fatigue: Inflammation results in fatigue.
• RA 3 Distinct Disease Process:
  • Monocyclic- About 20% have an episode within 2 to 5 years of initial diagnosis without any recurrence, Early diagnosis and/or aggressive treatment with disease-modifying antirheumatic drugs (DMARDs) can arrest disease progression.
  • Polycyclic- About 75% experience fluctuating disease activity which can last for years.
  • Progressive- About 5% RA rapidly increases in severity.
• RA Signs and symptoms:
  • polyarticular pain, edema, early-morning stiffness, malaise, and fatigue. Stages of inflammation:
  • Acute-Red, hot swollen with tenderness and stiffness
  • Subacute: associated with moring stiffness but less pain and tenderness;
  • Chronic Active and Chronic Inactive- reduce endurance and endurance.
• With early RA losses are:
  • 20° wrist extension
  • 30° wrist flexion
  • 15° MCP flexion
  • 60% power/pinch grip
• OA - pain, Degenerative changes, causes Disability/Pain. Dynamic process of tissues cartilage, synovium, ligaments and muscle). affects cartilage in thumb joints and weight barring joints!
• OA affects knees and hips hands CMC joints cervical, lumbar spine.
• There is a clinical syndrome linked with joint pain.
• OA affects hips, hands and Cervical/lumbar spine.