AOTA's NBCOT Exam Prep - Neurodegenerative Conditions PDF

AOTA’s NBCOT® Exam Prep Neurodegenerative Conditions General Considerations Neurodegenerative diseases are progressive and often chronic conditions that result from damage to the peripheral nervous system, the central nervous system, or both. Amyotrophic lateral sclerosis (ALS), dementia, Guillain-...

AOTA’s NBCOT® Exam Prep Neurodegenerative Conditions General Considerations Neurodegenerative diseases are progressive and often chronic conditions that result from damage to the peripheral nervous system, the central nervous system, or both. Amyotrophic lateral sclerosis (ALS), dementia, Guillain-Barré syndrome (GBS), Huntington’s disease (HD), multiple sclerosis (MS), and Parkinson’s disease (PD) are included in this classification (Pendleton & Schultz-Krohn, 2018). Clients with these conditions are often referred for occupational therapy intervention. I. Common terminology A. Akinesia: impairment of voluntary and spontaneous movement initiation that results in freezing, especially during gait activities B. Bradykinesia: slowed motor movements C. Dysmetria: decreased coordination of movements D. Rigidity: muscle stiffness that impairs movement E. Fasciculation: involuntary muscle contraction and relaxation; observed as a muscle twitch F. Festinating gait: small rapid steps that result from a forward-tilted head and trunk posture G. Paresthesia: numbness and tingling because of sensory nerve changes II. Occupational therapy evaluation (American Occupational Therapy Association [AOTA] 2020, 2021) A. The evaluation process focuses on finding out what the client needs and wants to do 1. Assessment of personal abilities and environments, including areas of motor and praxis, sensory–perceptual skills, emotional regulation, cognition, and communication skills (see Table 1 at the end of this lesson) 2. Development of a complete occupational profile a. Detailed exploration of the client’s roles, occupational performance, daily habits, and routines using standardized assessment(s), non-standardized assessment(s), observation, and interviews. b. The client’s priorities for occupational performance activities to target during the intervention. B. Throughout the evaluation process, the occupational therapist must pay particular attention to 1. How the client is affected by variable symptoms (e.g., during the day, week, and months/seasons) and the progression of the disease. Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 1 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep 2. The client’s understanding of the progressive nature of the disease and their level of acceptance. C. It is the responsibility of the occupational therapist to initiate the evaluation process, but both occupational therapists and occupational therapy assistants contribute to the evaluation. The occupational therapist will analyze and synthesize the information to develop a treatment plan (AOTA, 2020). III. Occupational therapy intervention A. The overarching purpose of an OT intervention should be completed in collaboration with the client and facilitate engagement in occupation (AOTA, 2020). B. OT interventions for neurodegenerative diseases help the client compensate and adapt as function declines (Schultz-Krohn et al., 2018). C. Interventions include cognitive compensatory strategies, energy conservation, environmental modifications and adaptive equipment, exercise, and caregiver training. See Table 2 at the end of this lesson for more information on intervention strategies. Amyotrophic Lateral Sclerosis I. Etiology of ALS (Atchison & Dirette, 2023, p. 468; Schultz-Krohn et al., 2018, Forwell et al., 2021, pp. 800–803) A. ALS is a progressive, degenerative disease in which the motor neurons in the brain, spinal cord, and peripheral system are destroyed and replaced by scar tissue. B. The resulting plaques lead to progressive muscle atrophy. C. The exact cause of ALS is unknown, but evidence suggests a combination of genetic, viral, retroviral, autoimmune, metabolic disorders of glutamate insufficiency, metal toxicity, and neurotoxic factors. D. Men are affected more often than women, at a ratio of 1.7 to 1. E. ALS is also known as Lou Gehrig’s disease, after the professional baseball player who died from the disease in 1941. II. Signs and symptoms of ALS (Schultz-Krohn et al., 2018; Forwell et al., 2021, pp. 800– 803) A. Signs and symptoms are progressive and move distal to proximal. Symptoms depend on the part of the nervous system affected. Those with ALS eventually develop all the symptoms, becoming progressively weak and immobile. B. The most typical initial symptom is weakness of the small muscles of the hand or an asymmetrical foot drop with or without night cramps, usually in the calves. A person may report tripping or stumbling when walking or running, or difficulty fastening clothes. If the bulbar tract is affected, initial symptoms might include difficulty breathing, slurred speech, decreased volume in speech, or impaired swallowing. Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 2 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep C. Lower motor neuron symptoms are focal and multifocal weakness, muscle atrophy (progressing from distal to proximal musculature), and cramping and fasiculations, or twitching of muscles at rest. D. Corticospinal tract symptoms are spasticity (which contributes to muscle pain) and hyperreactive reflexes. E. Corticobulbar tract symptoms are dysphagia (difficulty swallowing) and dysarthria (difficulty speaking). F. Cognition, sensation, vision and hearing, and bowel and bladder control typically are not affected. III. Stages of ALS (Dirette & Gutman, 2020; Forwell et al., 2021, pp. 800–803). A. Stage I: The person can walk, is independent with ADLs, and has some weakness. B. Stage II: The person can walk and has moderate weakness. C. Stage III: The person can walk but has severe weakness. D. Stage IV: The person requires a wheelchair for mobility, needs some assistance with ADLs, and has severe weakness in the legs. E. Stage V: The person requires a wheelchair for mobility, is dependent for ADLs, and has severe weakness in the arms and legs. F. Stage VI: The person is unable to get out of bed and is dependent for ADLs and most self-care tasks. IV. ALS diagnosis A physician or neurologist reviews the person’s clinical symptoms and their progression, electromyogram results, and other tests to rule out other causes to make a definitive diagnosis (Atchison & Dirette, 2023, p. 470). V. ALS disease course and prognosis (Atchison & Dirette, 2023, pp. 470–471) A. ALS often progresses rapidly. 1. After diagnosis, life expectancy ranges from 1 to 5 years, with a mean survival of 3 years. 2. The disease course may be longer for younger people whose symptoms are milder. B. Death usually occurs secondary to respiratory failure. VI. Interdisciplinary team management of clients with ALS A. Medications (Atchison & Dirette, 2023, p. 471; Shultz-Krohn et al., 2018) 1. Medications do not alter the fatality of the disease but help manage the symptoms. 2. Antispasmodics, nonsteroidal anti-inflammatory medications, and antibiotics may be prescribed. 3. Riluzole may help people remain in the earlier, mild stages longer. B. Surgical options to manage symptoms Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 3 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep 1. Gastrostomy, tracheotomy, and noninvasive positive-pressure ventilation improve quality and possibly length of life. 2. Low-dose radiation and botulinum toxin injections into salivary glands sometimes help reduce drooling (Atchison & Dirette, 2023, p. 472). C. Interdisciplinary services (Shultz-Krohn et al., 2018) 1. Respiratory therapists can help clients learn techniques to aid in respiratory management. 2. Speech therapists can recommend adaptive techniques to help clients with speech impairments to communicate and manage dysphagia. 3. Physical therapists can help clients maintain their level of function and reduce pain from muscle spasms. 4. The palliative care team can assist with end-of-life issues and hospice. VII. Occupational therapy evaluation (AOTA, 2020; Forwell et al., 2021, pp. 800–803) A. Document specific levels of function and the client’s goals and priorities. 1. Write goals that focus on minimizing the effects of symptoms on occupational performance. 2. As the disease advances, interventions expand from the client’s occupational performance to the physical and social environments. B. Standardized assessments (see Table 1 for relevant assessments) C. Home evaluations and home safety assessments D. Reevaluations as needed as the disease progresses. VIII. Occupational therapy intervention for clients with ALS A. General 1. Treatment approaches should be compensatory and focus on adapting to disability and preventing secondary conditions. 2. Focus on physical performance is limited because physical abilities will continue to decline as a result of the disease. 3. See interventions in Table 1. B. Collaboration with the client and the family and caregivers on many aspects of intervention: 1. Safety, including positioning, transfers, and skin integrity 2. Augmentative communication equipment 3. Assessment and management of dysphagia 4. Social participation 5. Selection of adaptive equipment and technology to support occupational performance a. Wheelchair Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 4 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep i.High backed and reclining; lightweight; small turning radius; and supports the head, trunk, and extremities. ii. As ALS advances, the client may consider a power wheelchair with adaptable controls that is easily maneuvered with tilt or recline and head, trunk, and extremity support. b. Voice-operated or hands-free technology for everyday tasks such as using the computer, making phone calls, or locking doors. c. The ability to drive can be maintained for a while through assistive devices and adaptive equipment such as hand controls, wheelchair lifts, and vehicle tie downs. C. The occupational therapist provides techniques to address dysphagia (Rinaldi et al., 2023). 1. Minimize distractions during mealtime. 2. Adapt food consistency (thicken liquids, downgrade diet to soft foods, in conjunction with the speech-language pathologist). 3. Use manual swallowing techniques. 4. Allow sufficient time for meals. 5. Ensure that nutritional needs are met, and refer to health care provider for alternatives to feeding if issues arise (e.g., feeding tube). Dementia I. Types of Dementia A. Alzheimer’s disease (AD) 1. Pathology: cortical atrophy of the frontal, parietal, and temporal lobes as well as the hippocampal region caused by an accumulation of amyloid-beta senile plaques and tau protein neurofibrillary tangles 2. Clinical features a. Progressive impairment of memory, executive function, attention, language, visual processing, and praxis b. Commonly, behavioral disturbances (Atchison & Dirette, 2023, p. 219–220) 3. Course and prognosis a. Slow and progressive until death: AD will lead to behavior and personality changes; a decline in cognitive abilities, such as decision making and language skills; and problems recognizing family and friends. b. Three stages, generally described as early, middle, and late; various sources describe the stages more specifically with numbering systems (Alzheimer’s Association, n.d.). i. Early stage (mild): Individuals may function largely independently and engage in many occupations of daily life without assistance. Individuals may be aware of having memory lapses or forgetting words. ii. Middle stage (moderate): Individuals experience frequent forgetfulness; mood changes, especially when socially or mentally challenged; poor decision making when selecting Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 5 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep clothing appropriate for the weather or situation; personality changes; disorientation; and risk of wandering or becoming lost. iii. Late stage (severe): Individuals are unable to engage with the environment, cannot carry on conversations, and require significant levels of assistance for daily activities. 4. Medical management a. Supportive care for the client and caregiver b. Medications to slow the progression c. Symptom treatment that targets cognitive decline, psychiatric symptoms, and behavior disturbances d. Pharmacotherapy to manage symptoms such as reduced cognition, depression, delusions and hallucinations, and agitation and aggression e. Behavioral and environmental management to restore the balance between challenges presented and the client’s current level of function B. Vascular dementia 1. Pathology: cerebrovascular disease (often a series of small strokes) that leads to focal lesions on the brain and neurotransmitter disruption 2. Clinical features a. Cognitive decline similar to AD but often less severe memory involvement b. Commonly, gait disturbance c. Abrupt or stepwise (rather than continuous) decline (Atchison & Dirette, 2023, pp. 220– 221) 3. Course and prognosis a. Sudden appearance of symptoms, with a stepwise pattern of increased symptoms b. May also progress slowly, similar to AD 4. Medical management a. Immediate emergency medical treatment necessary b. Treatment of cardiovascular factors (e.g., management of diabetes, high cholesterol, and heart disease) c. Pharmacotherapy to prevent future blood clots d. In some cases, surgery to remove blockages in blood vessels (Atchison & Dirette, 2023) C. Frontotemporal dementia 1. Pathology: neuronal, intranuclear inclusions 2. Clinical features: progressive aphasia, corticobasal syndrome, or symptoms similar to AD or Parkinson’s disease (Atchison & Dirette, 2023, pp. 219–220) 3. Course and prognosis a. Immediate, distinct onset b. Progressive c. Varied symptom patterns among individuals Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 6 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep 4. Medical management a. Future research needed; medications currently in development b. Treatment of some disinhibited behaviors with selective serotonin reuptake inhibitors (Atchison & Dirette, 2023) D. Dementia with Lewy bodies 1. Pathology: Lewy body proteins present in the brain, usually predominant in the limbic or neocortical areas; overall decline in acetylcholine and dopamine levels 2. Clinical features: progressive deficits in attention and executive function, memory impairment, fluctuating cognition, visual hallucinations, parkinsonism, autonomic dysfunction, and falls; rapid eye movement sleep behavior disorder as a possible prodromal symptom (Atchison & Dirette, 2023, p. 220) 3. Course and prognosis a. Gradual and insidious b. Early disease symptoms: problems in executive function, visuospatial abilities, attention, and memory c. Symptoms over time: aphasia, apraxia, and spatial disorientation 4. Medical management a. Similar to that for AD b. Increased family involvement; safety assessment c. Neuroleptics d. Cholinesterase inhibitors: some evidence available of effectiveness (Atchison & Dirette, 2023, p. 225) II. Primary signs and symptoms (Atchison & Dirette, 2023, pp. 226–230) A. Memory impairment: deficits in short term, procedural, episodic, and semantic memory. B. Cognitive deficits 1. Expressive and/or receptive aphasia 2. Apraxia: loss of skilled, purposeful movements; can affect ideation and concept formation as well as programming and planning of movement 3. Agnosia: auditory, visual, and tactile agnosies 4. Disturbance in executive functioning: disruption of the broad band of skills that enable a client to engage in independent, self-directed behavior, including volition, planning, purposeful action, and self-awareness C. Other cognitive or personality symptoms 1. Difficulty with topographic orientation (i.e., orientation of the self within the environment; can cause the person to get lost easily 2. Difficulty with spatial tasks 3. Poor judgment Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 7 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep 4. Anxiety and defensiveness 5. Disinhibited behavior 6. Psychotic symptoms D. Motor deficits: gait disturbances, hyperreflexia, paratonia, and dysphagia E. Symptom severity: sufficient to affect occupational performance and represent a decline from previous functional level. III. Effects of dementia on occupational performance (Atchison & Dirette, 2023, pp. 230–232). A. Early stage 1. During the early stage, ADLs remain intact. 2. The first signs of memory loss manifest in IADLs, including financial management, shopping, meal preparation, driving, reading, health management, and sexual activity; leisure activities; and social participation. 3. Dementia affects orientation to place, which impairs community mobility. 4. Work performance is often impaired, and relationships with coworkers and supervisors can be negatively affected. 5. Communication is impaired because of language problems. 6. The person clings to old habits and repetitive routines. 7. Cultural and spiritual context remain intact, but participation declines. B. Middle stage 1. Impairments occur in all areas of occupation. 2. The person can no longer live alone and may no longer attend to ADLs. 3. IADLs are totally neglected or performed out of sequence. The person may be completely dependent on others for IADLs. 4. Eating problems and weight loss occur. 5. Simple home management tasks are difficult but can be completed with assistance. 6. Safety is a major concern; risks include wandering, letting a stranger into the house, or causing a fire. 7. Leisure and social participation is very limited, and work is likely not possible. General roles continue to be lost. 8. Orientation is diminished C. Late stage 1. All areas of occupation are lost. 2. The person is dependent in all ADLs. Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 8 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep 3. The person can no longer ambulate safely. 4. Communication is lost. 5. The person has no understanding of cultural, social, or spiritual contexts (Atchison & Dirette, 2023, p. 232). IV. Assessing a client with dementia A. Table 1 lists relevant assessments for people with dementia. B. In addition to using standardized assessments, the OT should use clinical observation to better understand the cognitive functioning of the client. Examples include ability to stay on task during the assessment process, ability to remember the instructions, and ability to follow multiple-step commands. V. Occupational therapy interventions for dementia (AOTA, 2019) A. General 1. The goal of occupational therapy with people with dementia is to emphasize remaining strengths, maintain physical and mental activity for as long as possible, reduce caregiver stress, and keep the individual in the least restrictive setting for as long as possible (Pendleton & Schultz -Krohn, 2018; Piersol et al., 2018). 2. Key features of interventions addressing cognition include metacognitive and domain-specific strategy instructions, task-specific training, and environmental modifications (AOTA, 2019). 3. There is no single approach to dementia, and practitioners should evaluate current research while prioritizing valued occupations to enhance participation and meaningful engagement (AOTA, in press). B. Behavior management 1. Communication a. Avoid reasoning with the client. b. Listen. c. Maintain a trusting relationship. d. Offer choices when possible. e. Decrease demanding social situations f. Provide visual cues 2. Sundowning behaviors: an increase in activity and often agitation that begins in the late afternoon and extends into the evening or night. Simplify interactions and the environment during sundowning. a. Use adequate lighting; shadows can create confusion. b. Provide a safe area for physical activity during the day. c. Provide reassurance in a calm and caring manner. d. Provide the client with fluids during the day to reduce the cognitive changes brought on by dehydration. e. Reduce noise and clutter. Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 9 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep 3. Anger a. Anticipate problems and stressors. Rephrase negatives as positives. b. Ensure the client isn’t hungry, thirsty, tired, or experiencing pain. c. Simplify tasks and allow time for response. Reduce stimuli in the environment. 4. Wandering a. Assess and address the reason for wandering. b. Provide signs in the environment for cueing (e.g., stop sign). c. Use distraction techniques to interrupt pacing (e.g., familiar pictures on the wall). d. Provide opportunities for activities and movement, walk with client and keep areas uncluttered and safe e. Monitor fatigue, fluid intake. f. Monitor the client’s feet wounds, including cuts, lacerations, bruises. g. Use a Medic Alert identity wristband. h. Provide reassurance, attentiveness, and acceptance. 5. Pillaging, rummaging, and hoarding a. Learn the client’s favorite hiding places. b. Give the client a familiar item to hold. c. Involve the client in valued occupations that involve sorting items. d. Provide the client with rummaging closets or areas. e. Do not scold, tease, or punish the client or respond with anger. f. Modify the environment to be more engaging (e.g., fish tank; AOTA, in press). 6. Activities and occupations a. Focus activity on the client’s interests and abilities, not limitations. b. Provide the client with a sense of belonging. c. Promote appropriate verbal and nonverbal communication and positive behaviors. d. Provide activities that are meaningful, safe, modifiable and adaptable, routine, pleasurable, and dignified. C. Affective functioning 1. Teach relaxation activities. 2. Educate caregiver on appropriate medication intake. 3. Refer to structured and planned socialization (e.g., adult day care center). 4. Encourage structured activities (e.g., leisure interests with family or caregivers). 5. Facilitate movement and exercise, and intergenerational activities. 6. Facilitate spiritual expression activities. D. Sensory–perceptual functioning 1. Assess and integrate sensory functioning and processing abilities (AOTA, in press). 2. Ensure the client has appropriate physical aids (e.g., hearing aids, glasses). Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 10 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep E. Social functioning 1. Refer to structured socialization. 2. Encourage intergenerational activities. 3. Use structured verbal and nonverbal communication techniques. 4. Use reminiscence therapy (AOTA, in press). F. Sleep functioning 1. Promote physical activity during the day, and encourage the client to be outdoors in the sun, as appropriate, to maintain their internal clock. 2. Reinforce appropriate sleep patterns through good sleep hygiene and routines. G. Environmental interventions, used in conjunction with other approaches 1. Sensory–perceptual modifications: appropriate lighting; high-contrast coloring or textured surfaces; objects for stimulation; varied, safe, and tactile objects; visual blocks 2. Memory enhancement: large-print calendars, daily schedules, seasonal decorations, use familiar furniture, photographs, favorite music, notices of current events 3. Structured common areas 4. A consistent and calm environment 5. Inconspicuous locks on cabinets and doors, doorways covered with curtains 6. Safe indoor walking space or garden 7. Monitoring systems. Guillain-Barré Syndrome (George, 2018; Forwell et al., 2021, pp. 803–805) I. Etiology of GBS A. Guillain-Barré syndrome (GBS) is an inflammatory disease that causes demyelination of axons in peripheral nerves. 1. The cause is uncertain; evidence has disproved genetic vulnerability or vaccinations as a possible cause, but some suggestion exists that previous viral infections, enteritis, respiratory tract infections, and HIV/AIDS may precede GBS. 2. An estimated two-thirds of people who develop GBS symptoms do so days or weeks after diarrhea or a respiratory illness (Centers for Disease Control and Prevention [CDC], 2022). 3. Infection with Campylobacter jejuni bacteria is one of the most common risk factors, but people can develop GBS after having the flu or other infections (e.g., cytomegalovirus, Epstein-Barr virus, COVID-19). 4. Occasionally, people develop GBS shortly after being vaccinated. C. Onset is most often in adults ages 20 to 24 and 70 to 74 years, with men at a slightly higher risk than women. Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 11 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep D. In the United States, approximately 3,000 to 6,000 people develop GBS each year (CDC, 2022). II. Signs and symptoms of GBS (Forwell et al., 2021, pp. 803–805) A. Three phases 1. Onset and acute inflammatory phase: Acute weakness that occurs in at least two extremities advances and reaches its maximum in 2 to 4 weeks; 20% to 30% of people with GBS need mechanical ventilation. Rapid progression of symptoms, typically in a symmetrical ascending pattern of flaccid paralysis that begins in the feet; paralysis may occur in respiratory muscles. 2. Plateau phase: Symptoms are at their most disabling, with little or no change over a few days or weeks. 3. Progressive recovery phase: Remyelination and axonal regeneration occur over a period as long as 2 years. Recovery tends to start at the head and neck and travel distally. Most people experience significant if not complete return of function, with fatigue as the most commonly reported residual symptom. B. Pain, mostly in the lower extremities C. Fatigue D. Absence of deep tendon reflexes E. Initial mild sensory loss in the hands and legs (“glove-and-stocking distribution”); as sensation returns in the recovery phase, patients often report hypersensitivity to touch and other painful sensations. F. Dysfunction of cranial nerves, including possible facial palsy. G. Autonomic nervous system (ANS) involvement can result in postural hypotension (when one rises from a horizontal position, blood pressure may drop to precariously low levels), arrhythmias, facial flushing, diarrhea, impotence, urinary retention, and increased sweating. H. Bladder dysfunction III. GBS diagnosis The physician obtains a detailed history of symptoms and provides a thorough physical and neurological examination, which includes nerve conduction velocity tests and cerebrospinal fluid analysis. IV. GBS course and prognosis A. GBS has no cure, and the rate of recovery is variable. 1. About 80% of clients can walk independently 6 months after diagnosis. 2. About 60% of clients fully recover motor strength 1 year after diagnosis. 3. About 5% to 10% of clients have very delayed and incomplete recovery. B. Fatigue is the most frequently reported symptom in 93% of people with GBS, and Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 12 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep C. Minor cognitive difficulties, such as impaired executive functioning, short-term memory, and decision making, may occur. V. Interdisciplinary team management of clients with GBS A. Medications and medical procedures are indicated to reduce severity and to speed recovery. 1. Intravenous immunoglobulin 2. Plasma exchange (plasmapheresis) 3. Steroids to combat inflammation B. Respiratory therapists may be a part of the team to advise on appropriate breathing treatments and exercises if respiratory muscles have been paralyzed or compromised. C. Speech-language pathologists (SLPs) may be needed if speech production or swallowing impairments exist; speech therapists may train clients to “improve speech patterns or facilitate swallowing” (Falvo, 2009, p. 122). D. Physical therapists address mobility needs, help prevent muscle atrophy, and aid in the prevention of contractures or skin breakdown (Falvo, 2009). VI. Occupational therapy evaluation of clients with GBS (Forwell et al., 2021, p. 804) A. Referrals to occupational therapy commonly occur when GBS is moderate to severe, typically involving 40% of those affected. B. In the plateau phase, screening and evaluation often occur in intensive care because the client is receiving extensive medical care. Assessment covers communication, control of the physical environment, comfort and positioning to prevent skin breakdown, and anxiety management. C. In the recovery phase, evaluation focuses on mobility, self-care and ADLs, communication, leisure, and workplace and community reintegration; it typically occurs in inpatient rehabilitation, outpatient rehabilitation, and home or work settings (Forwell et al., 2021). D. Standardized assessments for GBS: Review Table 1 for relevant assessments. VII. Occupational therapy intervention for GBS (Forwell et al., 2021, pp. 804–805) See interventions listed in Table 2; additional occupational therapy interventions for GBS are as follows: A. In the plateau phase, modifications are deemed temporary. 1. Develop and train the client in the use of communication tools, such as signs or picture boards. 2. Adjust (and train caregivers on) supine and sitting positions that optimize function and comfort and reduce risk of skin breakdown. 3. Position the client for trunk, head, and upper-extremity stability. Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 13 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep 4. Educate the client and family about the health condition and anxiety-reduction techniques (Forwell et al., 2021). B. In the recovery phase, interventions aim to help the client resume occupations and roles, rituals, and routines. 1. Design dynamic splints to help maintain range of motion, especially for the wrist, fingers, and ankle (hinged drop-foot orthosis). 2. Continue to adapt modes of communication on the basis of the client’s priorities (e.g., voice- operated text messaging). Huntington’s Disease I. Overview of HD Huntington’s disease (HD) is a fatal, hereditary neurological disorder that leads to severe physical and mental disabilities. Over time, HD causes progressive loss of nerve cells in the brain, affecting movement, cognition, emotions, and behavior (Schultz-Krohn et al., 2018). II. Primary signs and symptoms of HD (Schultz-Krohn et al., 2018) A. Motor difficulties 1. Involuntary movement patterns, including chorea, akathisia, and dystonia 2. Voluntary movement patterns, including bradykinesia, akinesia, incoordination of movement 3. Difficulties with smaller movements and hand–eye coordination 4. In the middle stages, gait and balance problems, such as wide-based gait pattern and difficulties walking on uneven terrain 5. During later stages, hypertonicity replacing chorea, and large bursts of movement when small movements are intended. B. Deterioration of cognitive and behavioral abilities 1. Forgetfulness 2. Difficulty concentrating 3. Difficulty with mental calculations, sequencing of tasks, and memory 4. In the initial stages, difficulty maintaining work performance 5. In the middle stages, disturbances in memory and decision making 6. In the later stages, compromised pronunciation because of dysarthria 7. Irritability and depression 8. Depression, possibly leading to suicide C. Slowing of saccadic eye movements and ocular pursuits D. Dysphagia Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 14 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep III. HD progression A. HD is a progressive disorder, and the client will require continual evaluation of symptoms and progression. B. Symptoms usually appear in the third or fourth decade of life and progress over a 15- to 20-year period. Client will eventually require long-term care or hospitalization. C. Death results from causes secondary to the disease. IV. Medical management of HD A. No effective course of treatment has been identified; medical management addresses symptoms. B. Intervention to replace deficient neurotransmitters changes the course or rate of progression. C. Tricyclic antidepressants are used to treat depression. D. Haloperidol is used to decrease chorea during performance of functional activities. V. Effects of HD on occupational performance (Schultz-Krohn et al., 2018) A. Deterioration of muscle strength and motor control make occupational performance more difficult B. Deterioration of cognitive abilities may lead to dismissal from employment. C. The client may have difficulty sequencing tasks. D. Loss of function may contribute to depression, depression may decrease desire to do activities. E. Performance of voluntary motor tasks is slowed. F. Initiation of voluntary movements for a task is compromised. G. At the later stage of HD, the client is usually unable to talk, walk, or perform basic ADLs without significant assistance. H. Loss of fine motor control and hand–eye coordination affect ability to use tools and utensils, to write, and to use a keyboard. Loss of oral–motor control causes indistinct speech, drooling, choking, and difficulty eating. I. Weight loss can be a consequence of the movement disorder. VI. Occupational therapy evaluation of clients with HD A. The Unified Huntington’s Disease Rating Scale assesses changes in the areas of motor function, cognitive function, and functional capacity and behavioral abnormalities (Huntington Study Group, 1996; Schultz-Krohn et al., 2018). B. Occupational therapy evaluation should include functional daily living skills; cognitive abilities such as problem solving; motor performance; strength; personal interests; and values. Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 15 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep C. Review Table 1 at the end of this lesson for relevant assessments for people with HD. VII. Occupational therapy intervention for HD (Pendleton & Schultz-Krohn, 2018) A. Treatment approaches should be compensatory, focusing on adaptations for participating in meaningful occupations and quality of life, and preventing secondary complications (Forwell et al., 2021). See interventions listed in Table 2. B. The occupational therapist works with the client and family to select adaptive equipment and technology to support occupational performance. The amount of support will vary based on disease progression. Early on, when motor disturbances are typically limited to fine motor coordination problems, modifications should focus on activities that require fine motor skills, such as fastening zippers, buttons, or hooks. C. Cognitive and emotional disability 1. Use adaptive/compensatory strategies to address cognitive deficits. Examples include using a daily routine, writing down steps to an activity, completing the activity in a quiet environment, and using a checklist 2. Help the client develop verbal strategies and problem-solving skills to employ when completing tasks (Pendleton & Shultz-Krohn, 2018, p. 887). D. Work/Finance 1. Perform a worksite evaluation. 2. Implement work environmental modifications (e.g., label items with their name and function; prioritize and schedule tasks needing completion for the day; take notes during meetings; Schultz-Krohn et al., 2018). 3. Discuss other employment options as the disease progresses, if desired. 4. Refer to mental health services to address stress resulting from HD, such as loss of employment or decreased income. 5. Encourage the client to automate finances or arrange for others to handle finances. E. Community 1. Encourage involvement with support groups, engagement in community activities, and use of online virtual resources. 2. Help the client explore ways to maintain social contacts. 3. Refer the client for a driving evaluation and discuss possibilities for other forms of community mobility. F. Motor disability (Schultz-Krohn et al., 2018) 1. Provide home modifications and adaptive equipment to increase safety and independence in the home (e.g., nonslip mats, shower seat, and grab bars; storing commonly used items in accessible locations). 2. Encourage the client to use ambulatory devices (e.g., walker or wheelchair). 3. Engage the client in oral–motor exercises. Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 16 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep 4. Educate the client and family on proper body positioning during activities to decrease motor disabilities and increase participation in the activities (e.g., distal joint support during feeding or self-care tasks: sit in a sturdy chair as close to the table as possible, wrap legs around the chair legs to stabilize the pelvis, and place the elbows on the table to stabilize the upper trunk). G. Final stages 1. Pay attention to positioning. 2. Use splinting to prevent contractures. 3. Facilitate a smooth transition to tube feedings. 4. Put environmental controls into place as needed and desired. 5. Use consistent daily schedules and routines (Schultz-Krohn et al., 2018). Multiple Sclerosis I. Etiology of MS (Atchison & Dirette, 2023, p. 456; Forwell et al., 2021, pp. 791–797; Schultz-Krohn et al., 2018, pp. 888–890) A. Multiple sclerosis (MS) is a chronic, often progressive, demyelinating disease of the central nervous system; a person’s body attacks the myelin sheath that covers the neurons of the brain and spinal cord. 1. This demyelination produces scar tissue or plaque (sclerosis) on the myelin sheath of nerve fibers that interferes with the axons’ ability to conduct impulses. 2. The result is impaired nerve conduction and inflammation, which causes neurological dysfunction. 3. The specific location of demyelination differs with each person and dictates symptoms. B. MS is the most frequently diagnosed neurological condition that can cause disability in young adults 1. Diagnosis most often occurs between age 15 and 50. 2. MS is 2 to 3 times more likely in women than men. C. Early interventions in functional mobility and ADLs, fatigue management, and role and routine modifications are critical for delaying and preventing onset of disability. D. The exact cause of MS is unknown; current research has suggested that an environmental factor, including decreased exposure to vitamin D, smoking, or viral infection, triggers an autoimmune response in people who are genetically susceptible. II. Signs and symptoms of MS A. Clinical presentation 1. Often diverse and difficult to predict, with various combinations and patterns. 2. Initial complaints: visual disturbances, dizziness, paresthesia, and weakness. Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 17 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep 3. With most types, symptoms at times worsen (exacerbation) and at other times improve (remission). 4. MS progresses over time and is eventually irreversible. B. Motor symptoms 1. Impaired balance and coordination (ataxia) 2. Partial or complete paralysis of a part of the body; muscle spasticity, especially in lower extremities 3. Muscle weakness 4. Fatigue: the most common complaint and debilitating symptom 5. Intention tremors, which occur when a person attempts to engage in meaningful activity, such as reaching for an object 6. Dysphagia C. Sensory symptoms 1. Paresthesia: numbness or tingling a. Impaired vibratory, proprioceptive, pain, touch, superficial and temperature sensations b. Impaired sensation may affect perceptual skills such as stereognosis, kinesthesia, or body scheme 2. Vertigo 3. Pain (typically the result of musculoskeletal causes) D. Visual symptoms 1. Diplopia (double vision) or blurred or dimmed vision, with or without ocular pain 2. Optic neuritis, which causes sudden loss of vision with pain in or behind the eye, with symptoms possibly subsiding after 3 to 6 weeks without residual impairments a. Scotoma (partial loss of vision) b. Nystagmus c. Loss of visual acuity in 80% of people with MS (Atchinson & Dirette, 2023) E. Communication symptoms 1. Dysarthria 2. Scanning speech, or slow enunciation with frequent hesitations at the beginnings of words or syllables F. Bladder and bowel symptoms 1. Incontinence or urinary retention (failure to empty the bladder; Atchison & Dirette, 2023, p. 459) 2. Increased urgency or frequency, as well as constipation (Cooper, 2007, p. 473) G. Sexual symptoms (Forwell et al., 2021) Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 18 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep 1. Men: erectile dysfunction 2. Women: decreased libido, lubrication difficulty, and inorgasmia; ability to conceive and carry pregnancy to term remains intact. H. Cognitive symptoms 1. Short-term memory loss 2. Attention deficits 3. Decreased processing speed 4. Impairment in visuospatial ability 5. Impaired executive functioning and judgment 6 “Difficulty with attention, conceptualization, memory, or new learning... difficulty with abstract reasoning and problem solving as well as difficulty with tasks that require either rapid or precise motor responses” (Falvo, 2014, p. 111). I. Emotional symptoms 1. Depression (whether it is a manifestation of the neurological condition or a reaction to the disease is uncertain) 2. Inappropriate euphoria 3. Mood swings, irritability, or pseudobulbar affect. III. Diagnosis of MS A. To make a definitive diagnosis of MS, physicians consider client history, laboratory studies, and neurological examination. B. Diagnostic tests may include cerebrospinal fluid analysis, nerve conduction studies, and brain imaging (e.g., MRI, CT scans; Forwell et al., 2021). C. The results of these procedures help contribute to a diagnosis, but the person must have “episodes of exacerbation and remission and slow or step-by-step progression over 6 months; there must also be evidence of lesions in more than one site in the white matter and no other neurological explanation for the clinical picture” (Atchinson & Dirette, 2023, p. 460). IV. MS disease course and prognosis A. MS is not a fatal diagnosis, and most people can have a normal life expectancy. Treatments can reduce the number and severity of relapses and delay the long-term progression of the disease. B. MS has four types, defined by the disease course (National Multiple Sclerosis Society, n.d.): 1. Clinically isolated syndrome: the first episode of MS symptoms. Not everyone at this stage develops MS, but those with brain lesions at this stage have a high likelihood of developing relapsing-remitting MS. Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 19 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep 2. Relapsing-remitting MS: the most common type of MS, characterized by active (often worsening) and nonactive (stable) stages. 3. Secondary progressive MS: follows the course of relapsing-remitting MS, but in some people neurologic function worsens progressively. 4. Primary progressive MS: neurologic function worsens progressively as soon as symptoms appear, with no remissions. V. Interdisciplinary team management of clients with MS A. Medications (Atchison & Dirette, 2023; Forwell et al., 2021) 1. Disease-modifying medications can slow progression of the disease, reduce the number of lesions, and reduce the frequency and severity of relapses. Medications include interferon beta- 1a (Avonex), interferon beta-1B (Betaseron), interferon beta-1b (Extavia), glatiramer acetate (Copaxone), and interferon beta-1a (Rebif). 2. Medications to treat symptoms of MS include antispasmodics (including Baclofen, tizanidine, and botulinum toxin), muscle relaxants, and anticonvulsants. 3. Neurofunctional modifiers target underlying pathophysiology and can decrease symptoms as a result. Dalfampridine has been shown to improve walking with all types of MS (Forwell et al., 2021). 4. Corticosteroids shorten acute attacks, reduce inflammation, and ease symptoms. B. Physical therapy focuses on mobility, muscle strength and tone, and physical fitness. C. Speech therapy focuses on dysphagia and swallowing difficulties, dysarthria or dysphasia symptoms, and cognition. D. Strong evidence supports mental health counseling and emotional regulation, specifically group therapy and cognitive–behavioral therapy (Cunningham et al., 2022). VI. Occupational therapy evaluation of clients with MS (Cunningham et al., 2022; Forwell et al., 2021) A. Initial evaluation and occupational profile 1. Elicit client’s goals and history of symptoms and treatments 2. Assess pain 3. Review medications from the medical records 4. Screen for cognitive deficits during questioning. 5. Ask about dizziness, sensation, fine motor skills, incontinence, fatigue patterns, sleep patterns, muscle cramping, falls, and balance issues. Assess further, as needed (see Table 1). B. Gather information about occupational performance during times of fatigue. C. Endurance and strength vary throughout the day, depending on participation in occupations and timing of medications; therapy should be scheduled for when the client reports feeling most energized. Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 20 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep D. Goals should address both the exacerbation and remission stages and should be compensatory because of the progressive nature of MS. VII. Occupational therapy interventions for MS (Forwell et al., 2021) Begin by reviewing interventions in Table 2. Additional interventions for MS not included in Table 2 are as follows: A. Vision 1. Perform home safety assessment; make recommendations to reduce risk of falls and improve occupational performance. 2. Adaptive equipment may include optical devices, large-print reading material, large-button technology, talking watches, raised-dot markings for technology, and audiobooks. 3. Refer the client to a low vision specialist, ophthalmologist, or optometrist, as indicated. B. Sensory disturbances 1. Provide sensory reeducation. 2. Introduce compensatory strategies (e.g., relying on visual feedback to observe a desensitized limb; testing water temperature for dishwashing or bathing using an unaffected body part). C. Urinary incontinence 1. Provide bladder training and instruction in self-catheterization or use of sanitary pads or absorbent underwear to avoid embarrassment with accidents. 2. Monitor times of day when fluids are consumed to ensure availability of bathrooms to minimize risk of incontinence. D. Muscle weakness and other motor difficulties 1. Monitor body mechanics to avoid stressing joints and increasing musculoskeletal pain. 2. Consider use of therapeutic exercise. 3. Provide recommendations for adaptive equipment/home modifications to improve occupational performance. E. Pain (from spasticity) 1. Maintain hips at 90° or more of flexion to reduce extensor tone in the lower extremities. 2. Apply focal heat modalities on muscle trigger points (Forwell et al., 2021). F. Fatigue 1. Educate clients on types of fatigue; after the type is identified, client-centered interventions emerge. a. Primary MS fatigue as a direct result of the MS disease process b. Fatigue secondary to sleep disturbances (because of spasticity, depression, or bowel and bladder issues) Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 21 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep c. Fatigue secondary to depression or mood changes d. Nerve fiber or motor fatigue, likely the result of poor nerve conduction e. Fatigue from muscle weakness or spasticity f. Fatigue related to medication side effects or infection (Forwell et al., 2021) 2. Reduce extended periods of standing or mobility by adapting tasks and using power mobility when appropriate. 3. Instruct the client in the use of cooling techniques, such as taking cold showers, wearing ice packs or a liquid cooling vest, and drinking iced beverages; use ice as a modality in therapy (Forwell et al., 2021). G. Ataxia 1. Encourage proximal stabilization for improved distal movements. 2. Modify tasks by promoting hand-over-hand techniques for fine motor tasks (e.g., using the unaffected extremity over the hand with tremor when dialing a phone; Forwell et al., 2021). 3. Use orthoses (Forwell et al., 2021). a. Cervical collar to reduce the travel of the head and neck b. Wrist orthoses to minimize travel and number of joints in motion in the presence of a tremor H. Dysphagia and dysarthria 1. Collaborate with an SLP to enhance intervention strategies and maximize carryover. 2. Routinely screen for signs of choking, aspiration, or swallowing dysfunction; videofluoroscopy has shown that most people with MS who are asymptomatic have underlying impairments (Forwell et al., 2021). I. Cognitive and emotional disturbances (Cunningham et al., 2022) 1. Consider cognitive retraining, memory enhancement programs, cognitive–behavioral therapy, visual compensation strategies, or group therapy. 2. Advise the client to allow for increased time, delegation, and repetition when learning new ideas and to perform difficult mental tasks earlier in the day. 3. Teach stress management and relaxation techniques; emotional and physical stress can temporarily worsen symptoms. 4. Explain coping strategies that can help in handling exacerbations (Forwell et al., 2021). Parkinson’s Disease (Forwell et al., 2021, pp. 797–808) I. Etiology of PD A. Parkinson’s disease (PD) is a progressive, variable condition that occurs most frequently in later adulthood, with a mean onset age of 55 to 60 years. 1. Major degenerative changes occur in the basal ganglia, the gray matter that contributes to complex movements. Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 22 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep 2. The substantia nigra becomes depigmented, affecting the production of dopamine, a neurotransmitter that influences the speed and accuracy of motor skills, postural stability, cognition, and affect and expression. 3. The loss or reduction of dopamine leads to disabling symptoms. B. The exact cause of PD is unknown; it has been attributed to both heredity and environmental factors. II. Signs and symptoms of PD A. Primary symptoms are resting tremor, muscle rigidity, bradykinesia, and postural instability. 1. Tremor a. Resting tremor: affects one side, described as a “pill rolling” movement of the hand b. Typically disappear when the person is asleep or calm, increases with stress or cognitive tasks c. Often absent with voluntary movement. 2. Muscle rigidity or stiffness a. Tone is increased, adversely affecting movement b. Cogwheel motions: jerky, sometimes painful movements with joint mobility, most commonly in the upper extremities c. Fatigue: caused by the increased effort needed to produce voluntary movement; becomes a barrier to occupational performance. 3. Bradykinesia a. Extreme slowness when the person initiates or performs volitional movements. b. Examples: shuffling gait, difficulty moving from sitting to standing, freezing, and increased time required for fine motor tasks such as shaving or fastening clothes. 4. Postural instability a. Stooped posture, with a lack of arm swing during mobility and loss of postural reflexes b. Increased fall risk, especially when balance is challenged. B. Myriad secondary symptoms are common, although their number and severity differ among people with PD. 1. Gait dysfunction (e.g., festinating gait, or shuffling steps with limited or no arm swing) that leads to balance issues 2. Fine motor and bimanual impairments 3. Freezing (inability to initiate or continue movement) or overshooting a target, such as taking five or six small steps past the goal 4. Cognitive deficits: impaired executive functioning, memory loss, and visuospatial deficits; in later stages of PD, dementia Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 23 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep 5. Communication difficulties: smaller and smaller handwriting (micrographia), reduced volume of speech (hypophonia), muffled speech, lack of verbal inflection, and reduced facial expression or flat affect (e.g., infrequent eye blinking) that affects nonverbal communication 6. Sensory loss, including bowel and bladder as well as sexual dysfunction 7. Dysphagia that causes an increase in saliva and subsequent drooling, slower and more intentional eating, and episodes of coughing and choking 8. Mood and behavior disturbances: depression, apathy, lack of initiative, disinterest, social isolation, and withdrawal (Schultz-Krohn et al., 2018). III. PD diagnosis (Atchison & Dirette, 2023, pp. 465–466) A. People with initial symptoms such as resting tremor are often referred to a neurologist, who observes the current symptoms, eliminates other diseases that may contribute to the symptoms, and assesses the person’s response to PD-related medications. B. At least one primary symptom must be present. C. CT scans, MRI, and electroencephalography help eliminate the possibility of other neurological causes. D. An autopsy confirms the diagnosis of PD. IV. PD course and prognosis A. PD has no cure. 1. Symptoms may take years to develop, but people with PD gradually experience a loss of function and increasing disability. 2. Disease progression is not always linear; functioning may fluctuate and even show occasional improvement. 3. Life expectancy is rarely affected by a diagnosis of PD, but quality of life often is. B. PD has five clinical stages. 1. Stage 1: Unilateral symptoms; function is maintained 2. Stage 2: Bilateral symptoms; balance is not affected 3. Stage 3: Bilateral symptoms, balance is impaired, mild to moderate impairments in function 4. Stage 4: Significantly decreased function, impaired mobility, need for assistance with ADLs, poor fine motor and dexterity 5. Stage 5: Total dependence for mobility and ADLs (Atchison & Dirette, 2023, p. 466). V. Interdisciplinary team management (Schultz-Krohn et al., 2018) A. Medications 1. Levodopa (L-dopa, carbidopa) can decrease symptoms by increasing the amounts of dopamine in the brain. Side effects are nausea and dyskinesia. Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 24 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep 2. Other medications are dopamine replacement medications, acetylcholine inhibitors, and antiviral compounds. 3. Antidepressants may also be prescribed B. Surgery, if symptoms are not well controlled with medications 1. Thalamotomy: Application of heat to destroy part of the thalamus to reduce tremors. Effects last more than 10 years. 2. Pallidotomy: Application of heat radiosurgery to destroy part of the globus pallidus to reduce tremors, shuffling gait, flat affect, rigidity, and bradykinesia. Effects last about 5 years. 3. Deep brain stimulation: Delivery of electrical impulses to areas of the brain through an implanted device similar to a pacemaker to reduce tremors; the electrode is tunneled under the skin to an external switch that the person with PD can turn on or off. The generator must be replaced every 3 to 5 years. C. Speech therapy: To address dysphagia, communication, and cognitive deficits D. Physical therapy: To prevent complications or postural abnormalities of the trunk and extremities via passive stretching, muscle massage, resistive exercise, techniques to maintain normal gait, and assistive device training. VI. Occupational therapy evaluation of clients with PD A. Occupational therapists become essential interdisciplinary team members as the disease progresses. 1. Occupational therapists review interests, roles, and routines and set goals to help the client maintain participation in life activities. 2. Evaluation and occupational profile a. Client interview to obtain a brief history and information on occupations or preferred activities that have been altered or eliminated b. Observation of how symptoms such as rigidity, bradykinesia, tremors, and postural instability impair areas of occupational performance. B. Clients with PD may experience fluctuating energy levels during the day; symptoms tend to increase just before the next medication dose. 1. Evaluating a person with PD at only one time of day may not provide an accurate picture of strengths and deficits. 2. Using a tool such as the Canadian Occupational Performance Measure (Law et al., 2019) to establish client-centered goals empowers clients and minimizes their stress. 3. Further cognitive screening also may be warranted (Schultz-Krohn et al., 2018). C. Table 1 lists relevant assessments for people with PD. VII. Occupational therapy interventions for clients with PD Begin by reviewing interventions in Table 2. Additional interventions for PD not included in Table 2 are as follows (Wood et al., 2022): Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 25 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep A. Safety considerations for functional mobility 1. Provide instruction to manage freezing, such as avoiding crowds, tight spaces, and turns or corners; reducing distractions and avoiding multitasking; eliminating clutter in pathways; and avoiding rushing to answer the phone or door. 2. Instruct the client in the use of assistive devices such as a walker or cane. If a wheelchair is required, evaluate for proper positioning and train the client and family in its use, transport, and maintenance. 3. Use of a single auditory cue can help the person produce quicker and smoother movements. The rhythm of counting out loud and singing also helps clients fine-tune movements (Schultz- Krohn et al., 2018). B. Feeding adaptations 1. Encourage the client to use adaptive equipment such as built-up or weighted utensils, cups with lids, plate guards, and nonslip surfaces. 2. Educate the client and caregiver to allow increased time for feeding and ADLs; stress from rushing increases symptoms. 3. Use distal wrist weights if effective in decreasing tremors. 4. Instruct the client to work on feeding and other activities as close to the body as possible and, when appropriate, with upper-extremity support on a table. Using proximal muscles can help stabilize distal joints and muscles, which may reduce tremors. C. Movement: LSVT BIG 1. The movements of people living with PD often become smaller and slower, and LSVT BIG helps people learn to use bigger movements again. 2. Practitioners certified in LSVT BIG can use it with clients to improve movements for both fine motor activities (e.g., buttoning a shirt) or gross motor activities (e.g., getting up from a chair or maintaining balance). D. Communication adaptations 1. Use larger paper and large felt-tip pens; rest before writing 2. Pay bills and perform other IADL tasks online, including through cell phone apps. Clients with sufficient cash flow can set up autopay options. 3. Use speed dial or voice-controlled telephones, speech-to-text programs, and voice- and other remote-control systems for electronics. 4. Use a mirror to increase the client’s awareness of facial expression and how it might affect communication. 5. Instruct the client in articulation and speech volume and in breaking up sentences; advise the family to phrase questions in a way that elicits shorter responses (Forwell et al., 2021). Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 26 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep E. Sexual routine 1. Educate the client to engage in sex after resting and voiding bowel and bladder, and when symptoms are best controlled with medications. 2. Screen for depression if passivity, lack of interest, or general apathy is a factor (Schultz-Krohn et al., 2018). F. Bowel and bladder 1. Assist the client in creating a voiding schedule. 2. Instruct the client to wear absorbent underwear as needed (Forwell et al., 2021). G. Cognition 1. Train the client to use external or visual cues during daily tasks. Use rhythmic cues and music, and practice with repetition. 2. Instruct the client in ways to reduce environmental distractions during cognitively demanding activities. 3. Educate caregivers to speak slowly and clearly with simple, one-step instructions and to introduce new concepts one at a time (Forwell et al., 2021). H. Stress reduction 1. Stress tends to exacerbate symptoms. 2. Incorporate relaxation techniques such as visualization, meditation, imagery, deep breathing, or yoga. I. Address rigidity and associated pain. 1. The masklike facial expression of people with PD makes it imperative to diligently monitor pain during all exercise and stretching (Cooper, 2007, p. 477). 2. Use moist heat, stretching, and gentle ROM. 3. For clients with contractures, an antispasticity orthotic or a dynamic or static progressive splint gives a low-intensity stretch against the contraction of the antagonist muscles (Hock & DeMott, 2021). Advise the client on a wearing schedule and skin integrity checks to prevent breakdown. 4. Help the client advocate for better control over the environment; family or coworkers may prefer a cool home or work environment, but colder temperatures increase muscle stiffness (Cooper, 2007, p. 477; Falvo, 2009, p. 117). J. Provide intervention to enable clients to maintain employment. 1. A sedentary job that requires minimal verbal communication is a good fit for a person with PD over the long term. 2. Jobs to be avoided are those that require extensive gross motor movements, such as walking, reaching, or bending (because of balance and gait deficits), and that entail high stress levels. Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 27 2nd ed. December 2023  AOTA’s NBCOT® Exam Prep K. Provide interventions to improve driving; refer to a driving specialist who will do the following (Wood et al., 2022): 1. Perform screens of vision, motor, and cognitive function related to fitness to drive. 2. Refer for an on-road evaluation in a car that is equipped with a passenger-side brake for safety 3. Provide driving recommendations to the client and physician. 4. With a therapy driving rehabilitation specialist, provide driving rehabilitation services which may include education, coordination of guided home programs to build driving skills, and in-car training. References Allen, C. K., Blue, T., & Earhart, C. A. (1995). Understanding cognitive performance modes (4th ed., Version 14). Allen Conferences. Alzheimer’s Association. (n.d.). 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Psychopharmacology Bulletin, 24, 709–711. Additional Resource Mahle, A. J., & Ward, A. L. (2019). Adult physical conditions: Intervention strategies for occupational therapy assistants. F. A. Davis. Copyright © 2023 by the American Occupational Therapy Association. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 30 2nd ed. December 2023