AOTA's NBCOT Exam Prep PDF - Neurologic Conditions

AOTA’s NBCOT® Exam Prep Neurologic Conditions: Traumatic Brain Injury, Stroke, and Spinal Cord Injury General Considerations This lesson focuses on impairments that generally have a sudden onset: traumatic brain injury, stroke, and spinal cord injury. See the Neurodegenerative Conditions lesson for...

AOTA’s NBCOT® Exam Prep Neurologic Conditions: Traumatic Brain Injury, Stroke, and Spinal Cord Injury General Considerations This lesson focuses on impairments that generally have a sudden onset: traumatic brain injury, stroke, and spinal cord injury. See the Neurodegenerative Conditions lesson for information on progressive and often chronic conditions. Traumatic Brain Injury (Lohmann & Vas, 2021, pp. 781–788; Shepherd Center, n.d.-a; Tipton-Burton et al., 2018) I. Definition of traumatic brain injury A. Traumatic brain injury (TBI) is an acquired brain injury caused by an external mechanical or blunt force. B. TBI is accompanied by loss of consciousness, posttraumatic amnesia, skull fracture, or other unfavorable neurological findings attributed to the event. C. Diagnosis of TBI involves neurological testing, computed tomography scan, X-rays, and other physical examination. II. Incidence and causation (Lohmann & Vas, p. 766; Tipton-Burton et al., 2018, pp. 841–843) A. Most common cause of death and disability in young people between ages 16 and 30 B. Results in more than 55,000 deaths and 80,000 severe disabilities per year in the United States C. Leading causes (Centers for Disease Control and Prevention, 2019) 1. Falls (48% of TBI-related emergency department visits) 2. Motor vehicle accidents (20% of TBI-related hospitalizations) 3. Striking or being struck by an object (17% of TBI-related emergency department visits) 4. Intentional self-harm (e.g., gunshot wound to the head; 33% of TBI-related deaths). 5. For acquired/nontraumatic brain injury, causes include toxicity from drug overdose, chronic substance abuse, carbon monoxide poisoning, near-drowning, encephalitis, chronic epilepsy, and degenerative diseases. D. Associated factors 1. Gender: Young and middle-aged men are 4 times more likely than women to experience a TBI. 2. Age: After age 65, the discrepancy between genders is less marked. 3. Substance abuse: More than half of adults diagnosed with TBI report alcohol use near the time of injury. E. Factors in positive outcomes: Copyright © 2024 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or distributed. 1 2nd ed. Jan. 2024  AOTA’s NBCOT® Exam Prep 1. Client’s age 2. Preinjury capabilities 3. Severity of injury 4. Quality of intervention and support. F. Prevention 1. Primary (at moment of impact) TBI can be prevented through safety mechanisms such as safety belts, protective helmets, air bags, and roadside barriers. 2. Secondary (days to weeks after injury) TBI can be prevented through medical interventions involving control of the client’s blood pressure and oxygenation, management of intracranial pressure, nutrition, and seizure prevention. III. Clinical associations and symptoms (Tipton-Burton et al., 2018, pp. 843–844) A. Stages of TBI 1. Primary: at the moment of impact 2. Secondary: several days to many weeks after injury B. Types of TBI 1. Focal brain injury: direct blow to the head resulting from collision with an external object, a fall from standing or sitting, or a penetrating injury. Directly injured area is known as the coup; site of an indirect injury is contrecoup. 2. Multifocal and diffuse brain injury: sudden deceleration of the body and head (e.g., from a motor vehicle, bicycle, or skateboard accident; a fall from a high surface; or being thrown from a horse or bull). C. Clinical manifestations of TBI 1. Abnormal muscle tone and spasticity a. Decorticate rigidity: Upper extremities are in spastic flexed position with internal rotation and adduction. Lower extremities are in spastic extended position, internally rotated, and adducted. b. Decerebrate rigidity: Upper and lower extremities are in spastic extension, adduction, and internal rotation. Wrist and fingers flex, plantar portions of the feet flex and invert, the trunk extends, and the head retracts. 2. Primitive reflexes a. Impaired righting reflexes observed with midbrain damage b. Absence of equilibrium reactions and protective extension with basal ganglia damage 3. Muscle weakness: decrease in muscle strength without the presence of spasticity with peripheral nerve or plexus injury 4. Decreased functional endurance: decreased endurance and vital capacity accompany reduced muscle strength as a result of medical complications (e.g., infection, poor nutrition, bedrest) 5. Ataxia: abnormal movement resulting from damage to the cerebellum 6. Postural deficits resulting in imbalance in muscle tone throughout the body 7. Limitations of joint motion potentially resulting from increased muscle tone, volitional resistance, contractures, heterotopic ossification, fractures or dislocation, and pain 8. Changes in sensation Copyright © 2024 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or distributed. 2 2nd ed. Jan. 2024  AOTA’s NBCOT® Exam Prep a. Signs of absent or diminished sensation including light touch, differentiation between sharp and dull sensations, proprioception, temperature, pain, and kinesthesia b. Diminishment of sense of taste and smell with cranial nerve injury c. Possible hypersensitivity. IV. Levels of consciousness (Lohmann & Vas, 2021, pp 771–772; Tipton-Burton et al., 2018, pp. 845–846) A. Consciousness is a continuum (see Table 1 at the end of this lesson). B. Consciousness is assessed using several methods (see Table 2 at the end of this lesson). V. Occupational therapy evaluation (American Occupational Therapy Association [AOTA], 2021; Lohmann & Vas, 2021, pp. 772–782; Tipton-Burton et al., 2018, pp. 855- 868; Wheeler & Accord-Vira, 2023; Wheeler et al., 2024, pp. 1092–1105) A. Begins with establishing the client’s occupational profile and analyzing his or her occupational performance. Information may need to be gathered from family members, depending on the client’s level of consciousness. B May include standardized or nonstandardized assessment of areas of occupation, performance skills, and client factors in the areas of motor skills, process skills, vision and visual–perceptual skills, cognitive abilities, and self-regulation (AOTA, 2020). C. Context is evaluated for cultural, personal, temporal, and virtual demands; physical and social environment is evaluated. VI. Occupational therapy intervention: Acute phase of TBI A. Initial interventions for severe disorders of consciousness occur in the intensive care and acute care units of hospitals. B. Interventions involve both preventive and restorative approaches. 1. Effective wheelchair positioning: a. Prevents skin breakdown and joint and muscle deformity, inhibits primitive reflexes b. Increases sitting tolerance, improves respiration and swallowing ability, and provides opportunities to interact with the environment. c. Includes a stable base of support at the pelvis, maintenance at the trunk and midline, and facilitation of the head in the upright midline position. 2. Proper bed positioning: a. Necessary to prevent pressure ulcers and facilitate normal muscle tone. b. For clients with abnormal tone or posturing, lying on the side or semiprone is preferred to help normalize tone and provide sensory input. c. Pillows, foam wedges, and splinting may be incorporated to facilitate normal positions and prevent abnormal postures. 3. Passive range of motion (ROM) is completed as a preparatory method to prevent the development of secondary impairments. 4. Splinting and casting are indicated when spasticity interferes with functional movement or ADL performance, when ROM deficiencies are present, and when soft-tissue contractures are possible. Copyright © 2024 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or distributed. 3 2nd ed. Jan. 2024  AOTA’s NBCOT® Exam Prep a. Clients wear a resting (20°–30° wrist extension, thumb abducted, metacarpophalangeal joints at 15°–20° of flexion) or functional position splint when not involved in active movement or functional tasks. The wear schedule includes alternating 2-hour periods. Frequent monitoring for skin breakdown is necessary. b. Cone splints are worn to keep fingers from digging into or damaging the palmar surface. c. Antispasticity splints position the hand and wrist in functional positions and abduct the fingers, decreasing spasticity. d. Elbow casts are used for the loss of PROM in the elbow flexors. 5. Sensory stimulation a. Client’s level of awareness can be monitored by stimulating arousal with controlled sensory input. b. It is not expected that sensory stimulation will improve the client’s level of consciousness; rather, it helps the occupational therapist identify when a client has emerged from a coma. 6. Management of agitation a. Agitation during the medically unstable acute phase is common. b. Behavior management strategies are useful to avoid reinforcing inappropriate behavior while allowing medically necessary treatments to occur. c. Tracking arousal and alertness is important to establish a method of communication. A yes–no system is generally the starting point and is possible using eye blinks, head nods, or discernible motor movements (e.g., thumbs up). 7. Family and caregiver education begins immediately because the family can assist with sensory regulation, positioning, and ROM needs. VII. Occupational therapy intervention: Inpatient rehabilitation phase of TBI A. Intensive rehabilitation for clients who are able to demonstrate stimulus-specific responses. B. Clients are generally at Rancho Level V and higher. C. Intervention goals: 1. Optimize motor function a. Intervention focuses on motor learning, skill acquisition, and exercise, generally beginning with gross motor functions. b. Occupation-based activities that include motor skill performance may be more effective than motor practice activities alone. c. Current evidence does not support the use of neurodevelopmental treatment, Rood techniques, and proprioceptive neuromuscular techniques. d. Ataxia may be treated through intervention focused on compensatory strategies for control, including weighting of body parts or use of weighted utensils and cups. e. Apraxia may be treated with hand-over-hand exercise to repair damaged neural pathways. The client may also compensate by following steps depicted in pictures or written on a card. 2. Optimize visual abilities: Intervention can involve environmental adaptation, vision correction (with an optometrist or ophthalmologist), and introduction of compensatory strategies (e.g., contrasting colors, textured tapes, sunglasses; Below & Lewis, pp. 101–116). 3. Optimize visual–perceptual function: Intervention can involve compensatory and rehabilitative strategies (Below & Lewis, pp. 101–116). Copyright © 2024 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or distributed. 4 2nd ed. Jan. 2024  AOTA’s NBCOT® Exam Prep a. Neglect may be treated by encouraging the client to use the neglected side during functional activities. b. Environmental adaptation may necessitate interaction with the neglected side, such as moving the television or meal tray. c. The client may also compensate by placing all objects in the field of vision to maximize success. 4. Optimize cognitive function: a. Intervention emphasizes self-awareness of deficits, attention, memory, and executive function through participation in functional activities as much as possible. b. Engagement in ADLs and IADLs allows the client to develop problem solving, planning, organization, concentration, frustration tolerance, sequencing, and categorization skills. c. Compensatory approaches to address memory impairment have the most supporting evidence. 5. Optimize voice and speech function: a. Expressive aphasia may be treated with conversation exercises, with occupational therapists recognizing client errors and asking the client to verbalize the words the client meant to say. b. Compensation through communication devices, pictures, or charts may be used if significant gains are not found from treatment. 6. Restore competence in self-maintenance tasks: a. Dysphagia and feeding i. Feeding instruction may begin in an isolated and quiet area to prevent distraction and then be graded to include social situations. ii. Adaptive equipment may include a rocker knife, plate guard, and nonspill mug. iii. Impulsivity may be controlled by requiring the client to place the fork down after each bite to ensure that a full chew-and-swallow routine is completed. b. Bed mobility: Training in bed mobility skills progresses from scooting up and down in bed to rolling, bridging, and moving from and to supine and from and to sitting and standing positions. c. Wheelchair management: Ensure proper pelvic and trunk alignment; educate on wheelchair parts and train client on correct wheelchair propulsion. d. Functional ambulation: High-level activities are provided, including those involving both lower and upper extremities such as advanced IADLs (e.g., sweeping, raking, interaction with children). Compensatory devices include walkers with bags and baskets, canes, and reachers. e. Community mobility: i. The ability to negotiate the community environment is client dependent. ii. Electric scooters or wheelchairs may be recommended to assist clients with extended mobility requirements. iii. Determine the client’s safety with mobility devices via clinical practice before they are issued to the client. f. Transfers: Memory impairments and carryover difficulties necessitate consistent transfer training among all care providers, including family members. g. Home management: The degree of assistance required is client dependent. Some clients can prepare simple meals in a microwave, and others are able to perform higher-level activities including meal planning and budgeting. Copyright © 2024 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or distributed. 5 2nd ed. Jan. 2024  AOTA’s NBCOT® Exam Prep h. Community reintegration: Reintegration can be accomplished through community trips to practice IADLs in natural environments. 7. Behavioral and emotional adaptation: Interventions focus on decreasing or mediating problem behaviors: a. Environmental interventions: Agitated clients should be provided a quiet, isolated room without a roommate (if possible). Environmental cues are also useful in orienting the client to place and time. b. Interactive interventions: Interventionists’ speech should be calm, concise, and deliberate. Behavioral management programs may be necessary to promote appropriate behavior. 8. Support family caregivers: Professional support is essential to help family members understand recovery and rehabilitation processes. The family is also important to consult in discharge planning. VIII. Occupational therapy intervention: Postacute rehabilitation phase of TBI A. Rehabilitation transitions from an inpatient setting to one of a variety of postacute rehabilitation settings, including home-based therapy, a residential program, a day treatment program, or an outpatient community reentry program. B. The client’s family often will need to provide long-term assistance, depending on the severity of the TBI. C. General intervention goals: 1. Optimize cognitive function a. Residual cognitive deficits remain in the postacute rehabilitation phase, including memory problems and executive function deficits. b. The more stable and consistent environment of the postacute rehabilitation phase often allows for more emphasis on changing the physical and social contexts and environment to compensate for cognitive deficits. c. Increasing the client’s self-awareness is also important in this phase. 2. Optimize visual and visual–perceptual function: Interventions focus on environmental adaptations and strategies to compensate for deficits that remain (Below & Lewis, pp. 101– 116). 3. Maximize ADL and IADL skills a. Interventions continue to focus on self-care and homemaking tasks if those skills have not been fully acquired in the inpatient phase of rehabilitation. b. Emphasis is on behavioral intervention with repetitive practice through errorless learning, fading cues, and positive encouragement. c. Strategies from the inpatient setting may need to be adapted for the community setting. 4. Leisure and social participation a. Intervention should focus on guiding the client in identifying leisure activities that are within the client’s abilities and are important for the individual. b. Social skills training groups can be used to focus on social interaction and ability to develop relationships. c. Specific techniques include behavior contracts, role-playing, self-reflection through video feedback, and role modeling. 5. Work Copyright © 2024 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or distributed. 6 2nd ed. Jan. 2024  AOTA’s NBCOT® Exam Prep a. Intervention should focus on appropriate job identification, including appropriate skill development that matches the demands of the desired job. b. Vocational rehabilitation is useful in this skill development and in identifying appropriate work or volunteer settings. 6. Behavioral and emotional adaptation: Interventions aim to increase self-awareness and coping skills. Stroke (Gillen, 2018; Nilsen & Gillen, 2021a) I. Definition of stroke A. Stroke is a nontraumatic acquired brain injury resulting in neurological dysfunction caused by a lesion in the brain. B. Stroke is also called cerebrovascular accident (CVA). II. Pathophysiology (Gillen, 2018, pp. 810–811; Nilsen & Gillen, 2021a, pp. 736–742) A. Ischemia may result from a brain embolism from cardiac or arterial sources. B. Hemorrhage results from subarachnoid and intracerebral hemorrhages in 13% of strokes. C. Cerebral anoxia and aneurysm may result from hemorrhage and have similar treatment strategies. D. Transient ischemic attacks (TIAs) may result from vascular disease in the brain and may cause mild, either single or repetitive, neurological symptoms. TIAs are sometimes referred to as ministrokes. E. Prognosis for recovery: Functional outcome largely depends on which artery supplying the brain was involved. III. Neurological impairments and functional limitations (Gillen, 2018, pp. 821–830; Nilsen & Gillen, 2021a, pp. 736–742) A. Motor dysfunction, as evidenced by hemiplegia or hemiparesis (ranging from mild weakness to complete paralysis) on the side of the body opposite the lesion. 1. A lesion on the left side of the brain may produce right hemiplegia. 2. A lesion on the right side of the brain may produce left hemiplegia. B. Impairment in trunk and postural control that increases risk for falls, limits functional activity, and decreases independence in ADLs C. Impairment in standing activity that affects weight bearing, weight shifting, and stepping and increases risk for falls D. Communication impairments, which can mildly to severely limit speech, reception of speech, or both. 1. Impairments are most often, but not always, caused by damage to the left hemisphere of the brain. 2. Aphasia: neurological language disorder. Copyright © 2024 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or distributed. 7 2nd ed. Jan. 2024  AOTA’s NBCOT® Exam Prep a. Global aphasia: loss of all language ability b. Broca’s aphasia: broken speech; slow, labored speech with frequent mispronunciations c. Wernicke’s aphasia or receptive aphasia: impaired auditory reception; speech may be fluent but is often meaningless or nonsensical d. Anomic aphasia: difficulty finding words. 3. Dysarthria: articulation disorder resulting from paralysis of the organs of speech. E. Cognitive and perceptual impairment 1. Spatial relations and positioning: difficulty perceiving distance and object placement 2. Spatial neglect: inability to recognize stimuli in a particular area of the environment, generally on the contralateral side of the body 3. Body neglect: spatial neglect of the client’s own body, generally on the contralateral side 4. Motor apraxia: difficulty completing planned movements 5. Ideational apraxia: difficulty conceptualizing planned, multistep movements 6. Organization and sequencing: difficulty completing steps of a meaningful action in the necessary order 7. Attention: difficulty maintaining focus on a topic or activity 8. Figure–ground: difficulty differentiating an object from its natural background 9. Initiation: difficulty beginning an activity or movement 10. Visual agnosia: difficulty recognizing objects 11. Problem solving: difficulty solving problems. F. Upper-extremity impairment 1. Subluxation in the glenohumeral (shoulder) joint caused by the humeral head moving downward from the joint because paralyzed muscles generally remain in place 2. Abnormal skeletal muscle involving an inability to recruit and maintain muscular strength on the affected side; results in the following: a. Edema b. Overstretching and damage of joint capsules and antagonist muscles that keep joints in place c. Shortening of muscle d. Damage to joints and soft tissue because of lack of control and sensation. G. Visual impairments 1. Occurrence and extent depend on the site of the lesion 2. May result in visual dysfunction, including visual field deficits such as homonymous hemianopsia and hemi-inattention or neglect (Warren, 2018). H. Psychosocial adjustment 1. Psychosocial adjustment is an essential component of recovery following stroke. 2. The incidence of depression after stroke is reported at 35%, with the highest incidence occurring in acute and rehabilitation hospitals (Gillen, 2018, p. 834). 3. Other psychological symptoms include anxiety, mania, lability, and personality changes. 4. The occupational therapist should work closely with the client and the family and caregivers to gradually increase awareness of the deficits that may remain. Copyright © 2024 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or distributed. 8 2nd ed. Jan. 2024  AOTA’s NBCOT® Exam Prep IV. Occupational therapy evaluation (Gillen, 2018, pp. 815–820; Hildebrand et al., 2023; Nilsen & Gillen, 2021a, pp. 745–756; Nilsen & Gillen, 2021b, pp. 311–326) A. Phases of recovery and intervention 1. Acute phase (immediately after the stroke) 2. Rehabilitation phase 3. Community reintegration phase. B. Evaluation 1. Begin with client-centered assessments using a top-down approach focusing on the client’s roles and the occupational performance related to those roles. Emphasis is placed on roles, current ability in roles, and goals related to role engagement. 2. Self-care and ADLs a. Assessing self-care, such as by observing a client donning a shirt, allows the occupational therapist to evaluate many performance skills and client factors. b. The occupational therapist must determine whether informal observation or the use of a standardized assessment is most appropriate given the client’s current level of ability and the setting. c. The American Heart Association and American Stroke Association rehabilitation guidelines recommend use of several measures of ADL disability, most recently adding the Patient- Reported Outcomes Measurement Information System and the NIH Toolbox (Weinstein et al., 2016). The following assessments are also commonly used: i. Barthel Index (Mahoney & Bartel, 1965) ii. Canadian Occupational Performance Measure (Law et al., 2019) iii. Assessment of Motor and Process Skills (AMPS) (Fisher, 2006) iv. Stroke Impact Scale (Duncan et al., 2003) v. Árnadóttir OT–ADL Neurobehavioral Evaluation (A–ONE) (Árnadóttir, 1990) vi. Section GG Self Care and Mobility Items (CMS, n.d.). 3. Performance skills and client factors a. Often require further assessment after occupational performance has been observed. b. Visual function, speech and language, motor planning, cognition, and psychosocial function all integrate to influence client performance. c. The National Institutes of Health Stroke Scale is a multidisciplinary team assessment that addresses several client factors (Brott et al., 1989). Assessments may include informal observations or standardized assessments and should measure the following areas: i. Postural adaptation: best observed through functional task performance. Other assessments not within the context of functional task performance include the Berg Balance Scale (Berg et al., 1989) and the Functional Reach Test (Duncan et al., 1990). ii. Upper-extremity function: includes assessment of sensory function, ROM, joint alignment, muscle tone, pain, motor control for ability to isolate and control single muscle actions, strength and endurance, and functional performance. Several assessments specific to the upper extremity with hemiparesis are available: Functional Test for the Hemiplegic/Paretic Upper Extremity (Wilson et al., 1984) Arm Motor Ability Test (Kopp et al., 1997) Wolf Motor Function Test (Wolf et al., 2001) Copyright © 2024 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or distributed. 9 2nd ed. Jan. 2024  AOTA’s NBCOT® Exam Prep d. Motor learning ability, or the client’s ability to solve challenges of movement for mobility and upper-extremity use: critical for recovery from stroke. V. Occupational therapy intervention A. Intervention principles 1. Focus on improving participation in occupations through early ADL training using both compensatory and remedial approaches. 2. Tasks that emphasize performing an occupation allow the client to feel a sense of competence in engaging in tasks again. Performance skills can also be addressed through occupation-based tasks. 3. Environmental and activity considerations are addressed using the task-oriented approach, which has shown significant effectiveness in stroke rehabilitation compared with traditional therapy approaches. 4. The treatment environment should mimic reality as much as possible (including challenges). 5. Activity simulation should be as realistic as possible. 6. Opportunities should be available for client engagement and practice outside of therapy sessions. 7. Ineffective or inefficient movements should be limited. B. Intervention for performance skills and client factors: Focus on postural adaptation, use of the upper extremity, and motor learning 1. Intervention strategies to facilitate postural stability while seated a. Establish a neutral and active sitting alignment. b. Perform reaching activities while maintaining neutral sitting alignment. c. Perform activity to maintain trunk in midline. 2. Intervention strategies to facilitate postural stability while standing. a. Kitchen activities (e.g., washing dishes at the sink) are particularly useful because they allow for sturdy support with use of countertop if postural correction is needed. b. Maintain center of mass over base of support with activity. c. Maintain or restore equilibrium. d. Use stepping strategies to widen base of support. 3. Interventions to address communication difficulties a. Speech-language pathologists are generally responsible for treatment of communication disorders. b. Occupational therapists can be active in facilitating communication for occupational performance in the following ways: i. Encourage gestures and visual cues, such as having the client communicate through demonstration. ii. Communicate in a quiet, calm area. iii. Allow increased time for client response. iv. Frame questions to allow yes-or-no responses. v. Be concise. vi. Do not be forceful. vii. Encourage speech through routine or familiar ADL performance. 4. Interventions for cognitive and visual–perceptual impairment Copyright © 2024 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or distributed. 10 2nd ed. Jan. 2024  AOTA’s NBCOT® Exam Prep a. Interventions should focus on the client’s participation in the task rather than on remediation of specific cognitive deficits such as attention and memory. b. Transfer of learning should also be considered when addressing cognitive deficits to determine whether the skills learned will transfer from one task to another and from one environment to another. c. Interventions that provide compensatory approaches for perceptual deficits, such as visual field scanning, are shown to improve client performance. d. Visual scanning training: Prism glasses can be worn by people with hemispatial neglect during daily activities to expand the viewing area and help them attend to the neglected side. This training must be combined with visual scanning techniques (Hildebrand et al., 2023). e. Examples of intervention activities are presented in Table 3 at the end of this lesson. 5. Interventions to facilitate upper-extremity use during task performance a. Include the affected upper extremity in functional tasks to promote awareness and use. i. The upper extremity can be included in tasks involving weight bearing, moving objects across a work surface, and reaching and manipulating objects (Gillen, 2018). ii. With limited arm movement or no voluntary movement, the client should facilitate active positioning of the affected upper extremity during all activities, including eating, grooming and hygiene, and wheelchair and bed positioning. b. Constraint-induced movement therapy is another approach to promote forced use of the affected upper extremity, but strict adherence to the protocol is needed (Hildebrand et al., 2023; Nilsen et al., 2021b, pp. 311–314). c. Emerging techniques for upper-extremity function include electrical stimulation, mental practice and imagery, robot-assisted therapy, virtual reality, mirror therapy, and orthotic devices such as Bioness and SaeboFlex. d. Subluxation may limit functional use of the affected upper extremity. Interventions with the client should include the following strategies (Gillen, 2018, p. 832): i. Prevent pulling on the unstable joint. ii. Perform passive and active ROM activities to maintain soft tissue length and promote function. iii. Ensure proper positioning to prevent the arm from hanging in a dependent position. Careful evaluation is required when considering the use of sling (even for limited periods) or a wheelchair tray table. e. Abnormal skeletal muscle activity may also limit functional use of the affected upper extremity. i. Monitor for fluctuations in muscle tone throughout the stroke recovery process, and adjust intervention strategies appropriately based on upper-extremity muscle activity. ii. Promote appropriate ROM procedures for clients and caregivers to prevent prolonged periods of joint immobilization. iii. Provide stretching to identified muscle groups at risk for shortening. Use low-load prolonged stretch for muscles already shortened, keeping tissues in submaximal stretch for prolonged periods. Splint use should be considered to maintain joint alignment and to protect tissue from shortening or overstretching. iv. Begin edema control techniques through positioning, active use of the upper extremity, physical agent modalities, and pressure glove use. Copyright © 2024 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or distributed. 11 2nd ed. Jan. 2024  AOTA’s NBCOT® Exam Prep 6. Psychosocial adjustment involves both the client and the family. a. Clients should be encouraged to use positive coping strategies, including seeking social support systems, positive reframing, and acceptance of current abilities. b. Participation in activities may improve a client’s sense of self-efficacy 7. Transition to the community involves thorough discharge planning throughout the rehabilitation process. a. Family and caregiver education should address adaptations to the home environment, strategies for delivering home programs, and fall prevention. b. The occupational therapist should facilitate the client’s resumption of valued roles and areas of occupational performance, including work, leisure and recreation, sexual activity, and driving. Spinal Cord Injury (Bashar & Adler Hughes, 2018; Budash, 2021) I. Etiology (Bashar & Adler Hughes, 2018, p. 905; Budash, 2021) A. Spinal cord injury (SCI) most often results from trauma, such as motor vehicle accidents, gunshot or stab wounds, falls, and diving accidents. B. SCI may also occur secondary to diseases, including the following: 1. Tumors: abnormal growth of body tissue; may be cancerous (malignant) or noncancerous (benign) 2. Myelomeningocele: birth defect caused when the backbone and spinal canal do not close before birth 3. Syringomyelia: growth of a cyst in the spinal cord 4. Cancer: dysfunctional cellular growth and death. II. Pathophysiology (Bashar & Adler Hughes, 2018, pp. 905–906; Budash, 2021; Shepherd Center, n.d.-b) A. SCI is referred to in terms of the location of the lesion, identified using the letter and number of the specific cervical (C), thoracic (T), lumbar (L), or sacral (S) vertebra. Table 4 at the end of this lesson summarizes functional ability in SCI by injury level. B. SCI can result in tetraplegia (also referred to as quadriplegia) or paraplegia. Quad/tetraplegia is any injury at the T1 level or higher; paraplegia is an injury at the T2 level or lower. C. Complete lesions result in the absence of motor and sensory function below the level of the injury. D. Incomplete lesions may involve a number of neurological segments, and sensorimotor function may be partially or completely intact. E. Zone of partial preservation refers to complete injuries that have some innervation of dermatomes below the level of injury. F. The American Spinal Injury Association International Standards for Neurological Classification of Spinal Cord Injury (Rupp et al., 2019) provide a method for assessing the neurological status of someone with SCI. Copyright © 2024 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or distributed. 12 2nd ed. Jan. 2024  AOTA’s NBCOT® Exam Prep G. Initial stages of SCI are called spinal shock and may last between 24 hours and 6 weeks. Spinal shock can result in the absence of reflexes below the level of injury. If the injury results in paralysis and reflex activity ceases, spasticity can occur. III. Recovery (Bashar & Adler Hughes, 2018, pp. 907–908; Budash, 2021) A. Prognosis for recovery 1. Recovery outlook depends on whether the lesion is complete or incomplete. 2. If sensation or return of motor function below the level of the injury does not occur in 24 to 48 hours after injury, motor function is less likely to return. 3. The severity of the original injury is highly correlated with the degree of probable recovery. B. Most recovery occurs within the first 3 months postinjury for both complete and incomplete injuries. C. Recovery continues for 18 months or longer, although the rate of recovery declines during this time. D. Strengthening muscles in the zone of partial preservation for complete injuries may dramatically improve functional performance. IV. Impairments from SCI and implications for therapy (Bashar & Adler Hughes, pp. 909–910; Budash, 2021) A. Skin breakdown 1. Sensory loss increases the risk of skin breakdown, resulting in pressure sores or decubitus ulcers. 2. Skin breakdown can be prevented through the vigilance of the health care team and client and caregiver education on skin examination and techniques to provide pressure relief, such as a weight-shift routine and use of appropriate equipment. B. Breathing difficulty 1. Decreased vital capacity results in breathing difficulty, which can be addressed through the health care team (physician, physical therapy, respiratory therapy). 2. The occupational therapist can support the client’s breathing goals during treatment. C. Orthostatic hypotension 1. Injuries at T6 and above increases the risk for orthostatic hypotension. 2. Orthostatic hypotension can be addressed by positioning the client in supine and elevating the feet above the heart. 3. Therapists should use caution when transferring a client from supine to sitting to avoid a rapid drop in blood pressure. 4. Having the client move slowly to allow time for the blood pressure to adjust minimizes the risk of orthostatic hypotension. D. Autonomic dysreflexia may be addressed by sitting the client upright, loosening restrictive clothing or devices, and checking the catheter for obstruction. E. Spasticity Copyright © 2024 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or distributed. 13 2nd ed. Jan. 2024  AOTA’s NBCOT® Exam Prep 1. If increasingly severe, may be addressed through medical intervention (e.g., botulinum toxin injections). 2. May have functional implications, such as limited ROM for donning clothing or completing self- care. 3. May lead to contractures; attention to bed and wheelchair positioning is essential to preventing them. F. Heterotopic ossification 1. May be controlled through proper positioning in bed and wheelchair along with maintenance of the client’s ROM. 2. Monitoring ROM regularly is important to identify heterotopic ossification. G. Deep vein thrombosis 1. Deep vein thrombosis (DVT) is formation of a blood clot, most often in the lower extremity, abdominal area, or pelvic area. 2. Visual skin inspection for asymmetry of lower-extremity color, size, or temperature is essential. H. Bowel and bladder function is affected for all injuries at and above the S2–S5 level. 1. Establishing new routines and habits for bowel and bladder elimination is essential to minimize risk of infection and decrease the occurrence of autonomic dysreflexia. 2. Nursing typically establishes the bowel and bladder routine with guidance from the physician. 3. Occupational therapy is essential to support new skill and habit acquisition for transfers, clothing management, safety with task performance, and bowel elimination and catheter care. I. Temperature regulation is often affected by SCI, and clients need to be aware of skin exposure to sun and extreme temperatures. J. Pain 1. May be nociceptive, such as with muscle overuse. 2. May be neuropathic, such as with nerve damage that causes noxious sensations below the level of injury, as often occurs with gunshot injuries. K. Fatigue 1. Affected by multiple factors, including physiological, psychological, and environmental 2. Can affect functional outcomes; addressing sleep disturbances, medication side effects, and optimal awake hours for therapy can be useful. L. Sexual function may be affected in clients with SCI. 1. SCI does not alter a person’s sexual drive or need for physical and emotional intimacy. 2. Problems with mobility, functional dependency, altered body image, and additional medical conditions may interfere with the client’s physical and psychological sexual functioning. 3. In men, erections and ejaculations are often affected, potentially compromising fertility. 4. In women, menstruation usually ceases for weeks to months after injury, although no changes occur in fertility. V. Occupational therapy evaluation (AOTA, 2021; Bashar & Adler Hughes, 2018, p. 961– 968; Budash, 2021, pp. 828–836) Copyright © 2024 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or distributed. 14 2nd ed. Jan. 2024  AOTA’s NBCOT® Exam Prep A. Evaluation components 1. Occupational profile: client’s occupational history and experiences, patterns of daily living, interests, values, needs, and relevant contexts 2. Assessment of occupational and psychosocial needs, physical status, and functional status 3. Physical evaluation a. First identify medical precautions, including how much movement and load the client is allowed without jeopardizing spinal integrity. b. Assess upper-extremity ROM, strength, muscle tone, sensation, and trunk balance. Manual muscle testing is used to determine the maximum contraction of a muscle or muscle group. c. Observe the client’s endurance, fatigue, and pain level. d. Evaluate hand and wrist function for clients with tetraplegia. i. Standardized hand function tests may be used beyond the acute rehabilitation phase. ii. A dynamometer for grip strength and pinch gauge for pinch strength are used, although more sensitive measures may be needed for weak pinch and grip. e. Evaluate sensation: light touch, pain, and proprioception. B. Standardized and nonstandardized assessments may include the following: 1. The Spinal Cord Independence Measure III (Itzkovich et al., 2007): completed by the health care team and includes measures of ADL performance, sphincter control, respiration, and mobility. 2. Quadriplegia Index of Function: specific for clients with tetraplegia (Gresham et al., 1986) 3. Section GG Self-Care and Mobility Items (Centers for Medicare & Medicaid Services [CMS], n.d.) 4. Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF–PAI v.4.2; CMS, 2023) 5. Canadian Occupational Performance Measure: measures changes in clients’ self-perception of their occupational performance over time but is not specific to SCI (Law et al., 2019). VI. Occupational therapy intervention (Bashar & Adler Hughes, 2018; Budash, 2021) A. The purpose of rehabilitation is to prevent further medical complications and to maximize the client’s function. B. Intervention objectives 1. Design around goals cooperatively determined by the client, the family, the occupational therapist, and other team members. 2. Goals should be realistic, meaningful to the client, and able to be facilitated by the occupational therapist. 3. Using knowledge and skills in activity analysis, the occupational therapist develops short-term goals centered on performance areas and underlying problems that hinder occupational performance. The occupational therapy assistant implements interventions under the therapist’s guidance and provides feedback on client progress. C. Phases of SCI intervention 1. The acute recovery phase, also called the acute phase, involves occupational therapy for short sessions limited to 15 minutes, often in the intensive care unit. The focus of intervention includes the following components: a. Providing client and family support and education b. Allowing environmental control for the client, such as a nurse call button or bed controls Copyright © 2024 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or distributed. 15 2nd ed. Jan. 2024  AOTA’s NBCOT® Exam Prep c. Maintaining normal upper-extremity ROM, which can be done through ROM exercises and positioning, including splinting. i. Emphasis for ROM is movements involving scapular rotation, shoulder scaption, shoulder external rotation, elbow extension, and forearm pronation. ii. Total body positioning evaluation should include hand splinting needs. iii. Upper extremities should be positioned at 80° shoulder abduction, external rotation with scapular depression, and full elbow extension. The forearm should be in pronation to avoid risk for supination contractures. d. For clients with tetraplegia, training in tenodesis grasp. Splints should be dorsal and support the wrist in extension and thumb in opposition (preserving the web space), allowing the metacarpophalangeal and proximal interphalangeal joints to flex properly. e. Ongoing evaluation of ability to sit upright and to begin training in ADLs f. Possible evaluation of the client’s swallowing ability, depending on the level of injury. 2. Postacute phase: Inpatient rehabilitation, also referred to as the active phase of intervention, includes providing education and support and helping the client find meaningful activities that restore a sense of self-efficacy and self-esteem a. Education occurs continuously throughout intervention sessions with the client. Training in basic self-care allows for the opportunity to reinforce management and monitoring of SCI impairments. For example, for a client using a wheelchair and developing upright sitting tolerance, pressure ulcer awareness and reduction should begin, and the client should be trained to shift weight every 15–30 minutes. b. Caregiver training in the areas of ROM, positioning, pressure relief, ADL assistance, and equipment use, along with areas of SCI impairment, is essential for successful discharge. c. Occupational performance interventions involve training the client to perform many ADLs that were mastered earlier in life, such as dressing, grooming, and eating. d. Selecting and training in the use of necessary equipment for ADL and IADL performance is important. i. Occupational therapists should focus on recommending only equipment that is essential to avoid costly and unnecessary purchases. ii. Using equipment that is not essential may minimize compliance with equipment use. e. Physical interventions specific to lower cervical injuries (i.e., C5–C8) should be considered in the areas of upper-extremity ROM and strengthening, bed and wheelchair positioning, and splinting of the upper extremities. i. Clients with C5 tetraplegia may benefit from mobile arm support to assist in supporting the weight of the arm during activities (Hock & DeMott, 2021, pp. 455–457). Grasping and holding objects require wrist stabilization and use of an assistive device such as a universal cuff or C-clamp. ii. Clients with C6 and C7 tetraplegia have more fully innervated shoulder girdles, allowing greater force for rolling in bed and crossing the midline with the arms. Grasping of objects is facilitated by innervation of the radial wrist extensors, which allows for tenodesis. The wrist-drive wrist–hand orthosis (or tenodesis splint) is useful in maximizing pinch strength. iii. C8 tetraplegia interventions should focus on grasping objects with metacarpophalangeal joint extension and proximal and distal interphalangeal joint flexion. f. Psychosocial adaptation begins immediately and is most prominent during the acute rehabilitation phase. Copyright © 2024 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or distributed. 16 2nd ed. Jan. 2024  AOTA’s NBCOT® Exam Prep i. Clients should be encouraged to solve their own problems, be involved in making decisions about their care, and be engaged in meaningful activities. ii. Group learning is particularly beneficial for people with SCI to allow them to learn from their peers. g. Self-management skills, including being proactive, self-monitoring, problem solving, communication, and managing stress, are all important to address by the rehabilitation team. 3. Outpatient rehabilitation: Upon discharge from an inpatient setting, the majority of people with SCI will move to outpatient rehabilitation a. The focus of interventions in this phase is to maximize strength gains in the first year postinjury. b. Goals may include adaptive driving, leisure activities, and vocational rehabilitation. Copyright © 2024 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or distributed. 17 2nd ed. Jan. 2024  AOTA’s NBCOT® Exam Prep Table 1. Continuum of Consciousness Level of Consciousness Characteristics Coma Absence of responses to environmental stimuli No evidence of sleep–wake cycles No intentional movement Eyes do not open to stimuli or spontaneously Vegetative state No awareness or ability to interact with self or environment No sustained, reproducible, voluntary, or behavioral responses to sensory stimuli No apparent receptive language comprehension or verbal expression Sleep–wake cycles of variable length Ability to self-regulate temperature, breathing, and circulation for survival Incontinence of bowel and bladder Variable and unpredictable preserved cranial nerve and spinal reflexes, persistent vegetative state Condition of past and continuing disability with uncertain future Onset within 1 month of TBI With persistent vegetative states there is an exceedingly small chance of the client regaining consciousness before death Minimally conscious Definite behavioral evidence of awareness of self, environment, or both state Discernable, reproducible behavior in one or more of the following areas: – Ability to follow commands – Gestural or verbal yes–no responses – Intelligible verbalizations – Purposeful movements Copyright © 2024 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or distributed. 18 2nd ed. Jan. 2024  AOTA’s NBCOT® Exam Prep Table 2. Medical Assessment for Stages of Consciousness Medical Assessment Areas Assessed Glasgow Coma Scale Quantifies the severity of TBI and predicts outcome; scores range from 3 to 15. Traditional method to Scores ≤8 indicate a severe brain injury. assess levels of Scores 9–12 indicate a moderate brain injury. consciousness post-TBI Scores ≥13 indicate a minor brain injury. (Teasdale et al., 2014) Three behavioral areas assessed: 1. Motor responses to pain and commands o No response to pinch (pain) (1 point) o Rigid, extended response to pinch (pain) (decerebrate posturing; 2 points) o Flexion (decorticate posturing) in response to pinch (pain) (3 points) o Pulls part of body away in response to pinch (pain) (4 points) o Purposeful movement to pinch (pain) (5 points) o Obeys simple commands to perform various movements (6 points) 2. Verbal responses o Makes no noise (1 point) o Incomprehensible speech (2 points) o Talks so examiner can understand but makes no sense (3 points) o Confused conversation, disoriented, but able to answer questions (4 points) o Oriented to person, place, and time, carries on conversation with examiner (5 points) 3. Eye opening o No response to pinch (pain) (1 point) o Opens eyes when pinched (pain) (stimulus not applied to face; 2 points) o Opens eyes when asked with loud voice (speech recognition) (3 points) o Opens eyes on own (spontaneous) (4 points) Rancho Los Amigos Scale of Level I—No response: appears in deep sleep, is completely unresponsive to any Cognitive Functioning stimuli presented A descriptive measurement Level II—Generalized response: exhibits inconsistent and nonpurposeful reactions of awareness and cognitive to stimuli function after traumatic Level III—Localized response: reacts specifically to stimuli, though inconsistently injury, scored from Level I Level IV—Confused/agitated: has heightened state of activity with severely to Level X (Lohmann & decreased ability to process information Vas, 2021, p. 772; Tipton- Level V—Confused, inappropriate nonagitated: appears alert with fairly consistent Burton et al., 2018, pp. 847– reactions, although increased complexity of commands causes more random 848) responses Level VI—Confused, appropriate: exhibits goal-directed behavior but is dependent on external input for direction Level VII—Automatic/appropriate: behaves appropriately and is oriented to place and routine but frequently displays shallow recall Level VIII—Purposeful and appropriate: is alert and oriented and able to recall and integrate past and recent events Level IX—Purposeful, appropriate, stand-by assistance on request: independently shifts back and forth between tasks. Uses assistive memory devices Level X—Purposeful, appropriate, modified independent: independently initiates and carries out steps to complete familiar and unfamiliar activities but may require more time and/or compensatory strategies to complete them Copyright © 2024 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or distributed. 19 2nd ed. Jan. 2024  AOTA’s NBCOT® Exam Prep Table 3. Intervention Activities for Cognitive and Visual–Perceptual Impairment Impairment Activity Spatial relations and Brushing teeth, including positioning the toothbrush for toothpaste positioning application and on teeth Spatial neglect Searching for needed utensils in a silverware caddy Body neglect Brushing teeth on the neglected side of the mouth Motor apraxia Opening kitchen supplies or preparing a small meal Ideational apraxia Grooming with a washcloth, soap, hairbrush, and so forth Organization and sequencing Dressing, including sequencing of task (e.g., putting on socks, putting on shoes, tying shoes) Attention Providing a distraction during an activity (e.g., turning on the faucet) and helping the client refocus after the distraction Figure–ground Distinguishing the toothbrush from the sink Initiation Prompting the client with a command and monitoring for task completion Visual agnosia Promoting the use of touch to identify objects Problem solving Finding alternatives—for example, if milk is not available for a cooking activity Copyright © 2024 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or distributed. 20 2nd ed. Jan. 2024  AOTA’s NBCOT® Exam Prep Table 4. Functional Ability in Spinal Cord Injury, by Injury Level Injury Level Functional Ability C1–C4 Medical management: respiratory assistance required; complete assistance for personal and domestic care Movement: limited head and neck movement; tetraplegia Nervous system: sympathetic nervous system compromised; possible autonomic dysreflexia; no bowel or bladder control Mobility: power wheelchair with sip and puff possible C5 Medical management: low stamina, but breathing with diaphragm; complete assistance for personal and domestic care Movement: full head and neck; ability to raise arms and flex elbows (no extension) Nervous system: sympathetic nervous system compromised; possible autonomic dysreflexia; no bowel or bladder control Mobility: power wheelchair with hand controls C6 Medical management: low stamina, but breathing with diaphragm; moderate assistance for personal care; complete assistance for domestic care Movement: full head and neck; ability to raise arms and flex elbows (no extension); some wrist extension; tenodesis Nervous system: little bowel or bladder control Mobility: power wheelchair with hand controls; manual wheelchair for short distances; may drive a vehicle with hand controls C7 Medical management: low stamina, but breathing with diaphragm; limited assistance for personal care; partial assistance for heavy-duty domestic care Movement: full head and neck; ability to raise arms and flex and extend elbows; wrist flexion and extension; partial finger movement Nervous system: little bowel or bladder control Mobility: independent transfers; power wheelchair with hand controls; manual wheelchair for short distances; may drive with hand controls C8 Medical management: low stamina, but breathing with diaphragm; primarily independent in personal care; partial assistance for heavy-duty domestic care Movement: full head and neck; ability to raise arms and flex and extend elbows; wrist flexion and extension; partial finger movement Nervous system: little bowel or bladder control Mobility: independent transfers; power wheelchair with hand controls; manual wheelchair for short distances; may drive with hand controls T1–T5 Medical management: respiration capacity and endurance may be compromised; independent in personal care; partial assistance for heavy-duty domestic care Movement: normal upper-extremity ROM and strength Nervous system: little bowel or bladder control Mobility: independent transfers; manual wheelchair; may drive with hand controls Copyright © 2024 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or distributed. 21 2nd ed. Jan. 2024  AOTA’s NBCOT® Exam Prep Injury Level Functional Ability T6–T12 Medical management: respiration capacity and endurance may be compromised; independent in personal care; partial assistance for heavy-duty domestic care Movement: normal upper-extremity ROM and strength Nervous system: little bowel or bladder control Mobility: independent transfers; may use manual wheelchair or may stand in standing frame or walk with braces; may drive with hand controls L1–L5 Medical management: normal respiratory system; independent in personal care; partial assistance for heavy-duty domestic care Movement: normal upper-extremity ROM and strength; partial paralysis in hips and legs Nervous system: little bowel or bladder control Mobility: independent transfers; may use manual wheelchair or may walk with braces; may drive with hand controls S1–S5 Medical management: independent in personal care; partial assistance for heavy- duty domestic care Movement: normal upper-extremity ROM and strength; some loss of function in hips and legs Nervous system: little bowel or bladder control Mobility: independent transfers; likely able to walk with assistance or aids, though slowly and with difficulty; may drive with hand controls and load wheelchair into car independently Copyright © 2024 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or distributed. 22 2nd ed. Jan. 2024  AOTA’s NBCOT® Exam Prep References American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001 American Occupational Therapy Association. (2021). Improve your documentation and quality of care with AOTA's updated Occupational Profile Template. American Journal of Occupational Therapy, 75, 7502420010. https://doi.org/10.5014/ajot.2021.752001 Árnadóttir, G. (1990). The brain and behavior: Assessing cortical dysfunction through activities of daily living. Mosby. Bashar, J., & Adler Hughes, C. (2018). Spinal cord injury. In H. M. Pendleton & W. Schultz-Krohn (Eds.), Pedretti’s occupational therapy: Practice skills for physical dysfunction (8th ed, pp. 904–928). Elsevier. 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Functional test for the hemiparetic upper extremity. American Journal of Occupational Therapy, 38, 159–164. https://doi.org/10.5014/ajot.38.3.159 Wolf, S. L., Catlin, P. A., Ellis, M., Archer, A. L., Morgan, B., & Piacentino, A. (2001). Assessing Wolf Motor Function Test as outcome measure for research in patients after stroke. Stroke, 32, 1635–1639. https://doi.org/10.1161/01.STR.32.7.1635 Resources American Occupational Therapy Association. (n.d.). Quality toolkit. https://www.aota.org/practice/practice- essentials/quality/quality-toolkit American Occupational Therapy Association. (2022). Section GG self-care (activities of daily living) and mobility items [form]. https://www.aota.org/-/media/Corporate/Files/Practice/Manage/Documentation/Self-Care- Mobility-Section-GG-Items-Assessment-Template.pdf Copyright © 2024 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or distributed. 24 2nd ed. Jan. 2024