1. First Degree/Superficial burn

1. First Degree/Superficial burn

o   injury to the epidermis, dry  skin, painful, hypertensive, mild edema.

o   blistering

o   epithelium will generate within 2-3 days

1. Second Degree/Superficial Partial Thickness burn

1. Second Degree/Superficial Partial Thickness burn

o   can extend to dermis

o   pain, mottled, red, blisters

o   healing time is 7-10 days

o   may require grafting

o   color change can be permanent

1. Second Degree/Deep Partial Thickness burn

1. Second Degree/Deep Partial Thickness burn

o   extends to dermis

o   waxy, white

o   sensitive to pressure but not touch (burn is past pain receptors)

o   can heal without grafting

o   can convert (burns can progress to more severe burns)

o   moderate to severe scarring

1. Third Degree/Full Thickness burn

o   extends into subcutaneous tissue

o   complete destruction of epidermis and dermis

o   appears hard, dry, tan in color

o   color changes may be permanent

o   possible scarring, limited ROM, and deformities

1. Fourth Degree burn

o   result of prolonged contact with agent

o   damage extends to muscle and bone

o   high risk of amputation

2.      What are the seven primary objectives of OT on a burn unit?

·         pt and family education

·         edema management

o   cause: circulation restriction

o   may be the result of fluid resuscitation

o   at risk for deveopment of contractures, thickening of joint capsules, and adhesions

o   elevation

o   initiate ROM from day one or when medically stable

·         ROM

o   performed daily for maintenance of range and prevention of deformity

·         positioning and splinting

o   position of comfort is position of contracture

o   positioning devices - pre-fab or custom

o   education

o   achieve fullest functional range

o   prevent deformity

o   maintain movement

·         therapeutic exercise

o   PROM

o   AAROM

o   AROM

o   Progressive Strengthening

o   performed daily several times if conceivable

o   stretch through entire motion all joints

o   prolonged stretch - mild discomfort is acceptable, pain may not be

·         scar management

o   if healing occurs within weeks - scarring is minimal to none

o   healing within three weeks - only high risk individuals may have scarring

o   healing after 4 weeks - likely scarring. hypertrophic scarring can develop

·         compression therapy

3.      What are the 12 goals of OT on a burn unit? (Picked this up from Pedretti)

In Acute-Care, p. 1070

3.      What are the 12 goals of OT on a burn unit? (Picked this up from Pedretti)

In Acute-Care, p. 1070

·         provide cognitive reorientation and psychological support

·         reduce edema

·         prevent los of joint and skin mobility

·         prevent loss of strength and activity tolerance

·         promote occupational performance, such as independence with self-care skills

·         provide patient and caregiver education

·         (Surgery and Post-op phase p. 1071): promote cognitive awareness by providing orientation activities when necessary, and continue psychological support

·         protect and preserve graft and donor sites by fabricating splints and establishing positioning techniques that support the surgeon's postop care orders

·         prevent muscular atrophy and loss of activity tolerance and reduce thrombophlebitis risk by providing exercise for areas that are not immobilized

·         increase self-care independence by teaching alternalive techniques and providing adaptive equipment as needed

·         educate and reassure the pt and family members regarding this phase of recovery

·          (Rehabilitation phase, p. 1071): continue to provide psychological support as the pt progresses toward physical and emotional independence

·         improve joint mobility and reduce contractures by using correct positioning, sustained passive stretching exercises, splinting as needed

·         restore m. strength, coordination, and activity tolerance

·         initiate a compression therapy and scar management program using vascular support garments, custom scar compression garments, and pressure adapters to minimize scar hypertrophy, contractures, and disfigurement

·         promote independent self-care skills, including appropriate positioning, exercise, and skin care. Provide instruction and opportunities to practice IADLs, including vocational and home care activities

·         continue to provide instruction regarding scar development, including potential sensory and cosmetic changes, scar management techniques, and related safety precautions

·         guide the implementation of a postdischarge plan that supports resumption of school, work, social, and leisure occupations.

4. In burn therapy, what is meant by the phrase “position of comfort is position of contracture”? Quote from Pedretti’s p 1073

·         typical position of comfort (think semi fetal position): adduction and flexion of the UE, Flexion of the hips and knees, and plantar flexion of the ankles. Toes are typically pulled dorsally.  Burned hands often in “claw hand” position (wrist flexion, MP ext, IP flex and thumb adduction). This position can lead to severe dysfunction if it is not prevented during active scar formation (ped p 1073)

·         Need to use preventive positioning to reduce edema and maintain extremities in antideformity position.

5.      How can you help a burn patient manage pain during ROM activities?

o    can be done around time of hydrotherapy since the pt receives analgesics for that tx and coordinating with scheduled pain meds

o    Teach progressive relaxation, breathing techniques, guided imagery, coping strategies

o    Use aromatherapy, music therapy

6.      What are some ways to address edema to the extremities in a burn patient?

• Acute: Positioning/elevation & AROM exercises (pedretti’s p 1072-1074)
• Rehabilitation Phase: Elevation, progressive compression and activity (Pedr 1079)

7.      At what stage of burn rehabilitation should a client be fitted with custom-made compression garments?  How long should they be worn each day?  How many weeks does a patient typically wear them? Pedretti p1082

• Custom made would be in the Rehabilitation Outpatient phase no later than 3 weeks after wound healing. Interim compression garments are worn until custom is ready
• They should be worn 23 hrs/day
• 12-18 months or until scare maturation is complete

8.      An airplane splint is used to address the risk of contracture to what parts of the body? Pedretti p1073

• Axilla: antideformity position shoulder abduction 90-100 degrees

9.      List seven strategies for managing burn scars.

9.      List seven strategies for managing burn scars.

·         ROM/splinting

·         Excision of scar with integra then grafting

·         Scar massage

·         Compression garment

·         Silicone

·         Kenalog injections

·         Laser surgery

10.      How do silicone and pressure garments help burn patients?

keeps in lost body heat, provides temporary compression and helps with scar management

11.      What is the role of hydrotherapy on a burn unit?

11.      What is the role of hydrotherapy on a burn unit?

·         can be performed 1x/day when pt condition is stable to remove loose debris and “stale” topical antibiotics.  Provides a thorough cleansing of both the wound and uninvolved areas.  

12.      Why do some burn patients suffer peripheral neuropathy? Pedretti’s p1085

• most often occur in high-volatage electrical burns or burns of greater than 20%TBSA
• may be caused by infections, metabolic abnormalities or neurotoxicities

13.      What is the primary cause of functional disability after a burn injury?

• Scar contracture is often the primary cause of dysfunction (Pedretti p 1083)

14.      List elements of a school reentry program for a child with severe burns.

• information sent to teacher, classmates and community-based therapist (school therapist) to acquaint them with the child’s changed appearance and garments.
• possibly a video-taped message by the child or family member explaining what happened and special needs (p 1083 Pedretti)

15.      Define: Keloid scar

15.      Define: Keloid scar

·         hypertrophic scar that rises above skin but also expands horizontally beyond borders of the original scar

16.      Define: Hypertrophic scar (how do these scars develop differently for people at different ages?)

16.      Define: Hypertrophic scar (how do these scars develop differently for people at different ages?)

·         within border of scar (stated during lecture)

·         thick, rigid, erythematous scars that become apparent 6 to 8 weeks after wound closure

·         histologically, these immature scars have increased vascularity, fibroblasts, myofibroblasts, mast cells, and collagen fibers arranged in whorls or nodules that make the scare raised and rigid

·         biochmical investigations have discovered increased synthesis of collagen fingers and connective tissue in

·         as they mature, capillaries, fibroblasts, and myofibroblasts decrease significantly, collagen fibers relax into parallel bands, and the scar becomes flatter and more pliable, especially if the scar is treated with compression throughout the maturation phase

·         the time needed for scars to mature differs markedly among individuals depending on genetics, the age of the patient, the location and depth of the original burn wound, the presence of chronic inflammation, wound contamination, and other factors

·         superficial burns that heal in less than 2 weeks generally do not form a hypertrophic scar

·         deeper burns that take longer than 2 weeks to heal have a greater potential to form hypertrophic scars

·         healing within 3 weeks- only high risk individual may have scarring (Ppt, p.16)

·         healing after 4 weeks- likely scarring (Ppt, p.16)

·         mature in 12 to 24 months

·         Ped, p.1063

·         more common in teens and young adults (Ppt, p.17 )

·         elderly patients may heal more slowly and with less incidence of collagen overgrowth (C&M, p.356)

·         small children tend to heal quickly but have a much higher potential for hypertrophic scarring (C&M, p.356)

17.      Define: Eschar & Escharotomy Pedretti’s p 1064

·         Eschar : adherent dead tissue that forms on skin with deep partial- or full-thickness burns

·         Escharotomy: incision through the necrotic burned tissue, is performed to relase the binding effect of the tight eschar, relieve the interstitial pressure, and restore distal circulation.

18.      Define: Allograft & xenograft & autograft Pedretti’s p 1067

·         Allograft - processed human cadaver skin; biological dressing to provide temporary wound coverage and pain relief

·         Xenograft - processed pigskin; biological dressing to provide temporary wound coverage and pain relief

·         Autograft - permanent surgical transplantation of the upper layers or split-thickness skin graft (STSG) of the person’s own skin with that taken from an unburned donor site.

19.      Define: Debridement

·         Medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue

20.      Define: TBSA (Total Body Surface Area)

·         the extent of a burn is classified as a percentage of the total body surface area burned; common methods: “Rule of Nines” and Lund and Browder chart

21.      Define: Sepsis

·         severe infection, where infection spreads from original site through the bloodstream (Pedretti p1066)

22.      Define: Heterotrophic ossification (ped 1084)

formation of bone in locations that normally do not contain bone tissue

23.      Define: Two layers of the skin (which holds nerves and sebaceous glands?) Pedretti p 1058

·         Epidermis - sebaceous glands (Ped, 1058)

·         Dermis - nerve endings (Ped, 1058

 24.      Be able to explain why hemi-ADL strategies may foster learned non-use of hemiplegic limbs.

 24.      Be able to explain why hemi-ADL strategies may foster learned non-use of hemiplegic limbs.

·         promotes repeated failed attempts to use arm which leads to pattern of misuse (??)

 25.      What is shaping in the context of constraint-induced therapy?

 25.      What is shaping in the context of constraint-induced therapy?

·         10 timed trials, providing cues and encouragement, unilateral

·         Select a task that is the “just right challenge” for a patient according to available ROM

·         Complete 10 trials in one of two ways

·         Patient given 30 seconds to complete task while counting repetitions of task completed      OR

·         Patient completes certain number of repetitions and is timed to see how long it takes (shooting for 45-30 seconds)

·         Give frequent, nearly constant, cues to increase performance and encourage patient

·         Repetitive Training, continued…

·         Shaping Tasks, continued…

·         Repetition of movement leads to neuroplastic change in the brain

·         Better motor program

·         Increase attention to the affected side

·         Overcoming learned nonuse

·         Tell the patient his/her time each trial

·         they tend to get very competitive with themselves!

·         overall average should show decrease in time or increase in reps over 10 trials

·         Task Practice, continued…

·         Promotes increased use of the more affected UE during functional activities

·         Longer than shaping tasks, 15 to 30 minutes

·         Again, not that different from “traditional” OT

·         Feedback: Skilled recommendations for task performance

·         Coaching: Providing specific suggestions every 10-15 minutes

·         Modeling: Physical demonstration of the task

·         Encouragement:  Providing verbal comments for motivation

 26.      The task-oriented approach to rehabilitation is important in stroke rehab.  What are its four components in OT treatment?

·         encourage weightbearing over the involved side

o   weightbearingn over the hemiplegic side is the most effective way of regulating tone

o   it also provides sensory input to the involved side through proprioception

o   as the pts awareness of the involved side improves, fear and neglect will decrease

·         encourage trunk rotation

o   trunk rotation or dissociation of the upper and lower trunk, is another very effective way of facilitating normal movement throughout the upper and lower extremities.

o   hemiplegic pts often move in a 'blocklike' pattern, with little separation of pelvic girdle and shoulder girdle

o   to facilitate normal movement, the therapist should set up activities to stimulate or facilitate trunk rotation

o   when trunk musculature is activated, pts will become more stable and have better potential for upper extremity function.

·         encourage trunk elongation

o   it is common for hemiplegic pts to become 'shortened' on the involved side as muscle tone increase

o   a common posture for some pts is scapular retraction with downward rotation while the pelvis is in retraction

o   this posture can eventually lead to soft tissue tightness

·         encourage scapular protraction

o   the musculature around the scapula plays an important role in the overall recovery of the upper extremity

o   proximal stability is necessary for distal function and the stability of the scapula is critical for hand function

o   however, for full, active, voluntary control of the upper extremity, the scapula needs to have full excursion, as well

26 (second 26 on my handout, oops!).  Dynamic systems theory, on which motor control therapy is based, is seen as an interaction among what three factors? Ped p 792

26 (second 26 on my handout, oops!).  Dynamic systems theory, on which motor control therapy is based, is seen as an interaction among what three factors? Ped p 792

·         The interaction between client factors, the context, and the occupations that must be performed to enact the client’s roles.

27.  What does Pedretti say is the most effective factor in all forms of CIT?

27.  What does Pedretti say is the most effective factor in all forms of CIT?

·         (p795) “the effective factor in all forms of CIT appears to be inducing patients to repeatedly practice use of the weaker arms for many hours  a day for a period of consecutive days”

28.  What UE pathologies can limit the success of CIT?

28.  What UE pathologies can limit the success of CIT?

·         shoulder sublux

·         soft tissue shortening

·         joint contractures/deformities

·         must be able to move affected arm in 45 deg sh flex/abduct; 90 deg elbow flex/ext; 20 degree wrist ext; 10 degree ext of MC phalanges

29.  CIT research protocols assume how many hours of continuous practice a day?

29.  CIT research protocols assume how many hours of continuous practice a day?

·         6 hours

30.  Why would you choose not to try CIT with a hemiplegic patient who has cognitive impairment?

30.  Why would you choose not to try CIT with a hemiplegic patient who has cognitive impairment?

·         (p797) Cognitive impairments might prevent adequate participation in the strict protocol

31.  What is the difference between ischemic and hemorrhagic stroke?  Which is more common?

31.  What is the difference between ischemic and hemorrhagic stroke?  Which is more common?

·         Ischemic = blockage ** most common

·         hemorrhagic = bleeding

32.  7 modifiable stroke risk factors

32.  7 modifiable stroke risk factors

·         Hypertension

·         Cardiac disease

·         Diabetes and glucose metabolism

·         Cigarettes

·         Excessive use of alcohol

·         Illegal drugs

·         Lifestyle factors (diet, emotionally stress, physical inactivity)

33.              Blockage or rupture of which brain artery is most common?  Be able to list all deficits associated with this particular stroke. p 804

33.              Blockage or rupture of which brain artery is most common?  Be able to list all deficits associated with this particular stroke. p 804

Middle cerebral artery

·         Contralateral  hemiplegia (mostly face, arms, and tongue)

·         Sensory deficits

·         Contralateral homonymous hemianopsia

·         Aphasia (if in the dominant hemisphere)

·         Deviation of the head and neck towards the side the lesion

·         Unilateral neglect

·         Perceptual deficits (anosognosia)

·         Impaired vertical perception

·         Visual spatial perception

34.  Top down vs. Bottom Up assessment.  What are they?  When would you use each? (ped p. 810). See Table 33-3 in Pedretti for a comprehensive list of "Assessments Used with Clients Who Sustained a Stroke"

34.  Top down vs. Bottom Up assessment.  What are they?  When would you use each? (ped p. 810). See Table 33-3 in Pedretti for a comprehensive list of "Assessments Used with Clients Who Sustained a Stroke"

·         a top-down approach to assessment is an assessment that focuses on the evaluation of performance areas

·         Principles of this approach include the following:

o   inquiry into role competency and meaningfulness is the starting point for evaluation

o   inquiry is focused on the roles that are important to the client who sustained a stroke, particularly those in which the client was engaged before the stroke

o   any discrepancy of roles in the past, present, r future is identified to help determine a treatment plan

o   the tasks that define a person are identified, as well as whether those tasks can be performed and the reasons that the task is problematic

o   a connection is determined between the components of function and occupational performance

·         a bottom-up approach first focuses on dysfunction of client factors

35.  Be able to name 10 of the 15 items scored on the NIH stroke scale.

35.  Be able to name 10 of the 15 items scored on the NIH stroke scale.

·         level on consciousness (questions and commands)  

·         best gaze                                                                                     

·         visual                                                                                             

·         facial palsy                                                                                   

·         motor arms                                                                                 

·         Motor legs

·         Limb ataxia

·         sensory

·         Best language

·         dysarthria

·         Extinction and inattention (neglect)

36.  Be able to name and describe at least four non-motoric reasons for a person with stroke having difficulty in performing a hemi-ADL task.

36.  Be able to name and describe at least four non-motoric reasons for a person with stroke having difficulty in performing a hemi-ADL task.

·         Pain

·         Edema

·         Muscle tone

·         Joint alignment

·         Cognition

·         Sensory deficit

37.  In stroke rehab, what are five intervention principles that utilize the task-oriented approach (Pedretti, p. 815)?

37.  In stroke rehab, what are five intervention principles that utilize the task-oriented approach (Pedretti, p. 815)?

·      help clients adjust to limitations to roles by exploring new tasks

·      create an enviro that includes everyday life challenges

·      practice functional tasks or close simulations

·      provide opportunities for practice outside of therapy time

·      minimize inefficient motor patterns

38.  What are three effects that a stroke can have on a person’s trunk?

38.  What are three effects that a stroke can have on a person’s trunk?

·         inability to perceive midline

·         inability to shift weight through pelvis

·         spinal contracture secondary to soft-tissue shortening

39.  List three ADL tasks that promote improved trunk control, and explain what the trunk does during those tasks.

39.  List three ADL tasks that promote improved trunk control, and explain what the trunk does during those tasks.

·         feeding: anterior weight shift occurs to bring body toward table, and support hand-mouth pattern

·         dressing: lateral weight shift to one side of the pelvis so that pants can be donned over hips

·         oral care: anterior weight shift occurs so that saliva and paste may be expectorated

40.  Pedretti (p. 816) lists 7 components that you can manage in helping a person with stroke better perform ADL in sitting.  Know them.

40.  Pedretti (p. 816) lists 7 components that you can manage in helping a person with stroke better perform ADL in sitting.  Know them.

·         establishing a neutral yet active starting alignment (i.e., a position of readiness to function)

o   this starting alignment (similar to a typist’s posture) is a prerequisite to engaging the limbs in an activity

o   feet flat on floor and bearing weight

o   equal weight bearing through both ischial tuberosities

o   a neutral to slight anterior pelvic tilt

o   an erect spine

o   head over the shoulders and shoulders over the hips

·         the client should attempt reaching activities from the above posture and do the same activities with a posterior pelvic tilt and flexed spine (a typical trunk pattern after stroke and while studying for this final)

o   the freedom of movement and the available range for each posture should be compared

·         establish the ability to maintain the trunk in midline using external cues

o   many clients have difficulty assuming and maintaining the correct posture

o   the therapist can provide verbal feedback (e.g., “sit up nice and tall”)

o   visual feedback (e.g., using a mirror or the therapist assuming the same postural misalignment as the client) may be helpful

o   environmental cues may be used to correct posture (e.g., the client may be instructed to maintain contact between the shoulder and an external target such as a bolster or wall, positioned so that the trunk is in the correct posture

·         maintaining trunk range of motion (ROM) by wheelchair and armchair positioning that maintains the trunk in proper alignment

o   the therapist can provide an exercise program focused on trunk range of motion and flexibility

o   activities that elicit the desired movement patterns can be chosen, and hands-on mobilization of the trunk can be used if needed

o   trunk ranges that should be addressed include flexion, extension, lateral flexion, and rotation

·         prescribing dynamic weight-shifting activities to allow practice of weight shifts through the pelvis

o   the most effective way to train the client in weight shifts is to coordinate the trunk and limbs

o   successfully engaging in meaningful occupations that require reach beyond the span of either arm requires the client to adjust the posture

o   the client is encouraged to reach beyond arm span in all directions while seated (preferably while reaching for an object) and to analyze the corresponding postural adjustment of the pelvis and trunk

o   the position and goal of the task will dictate the required weight shift

·         strengthening the trunk, best achieved by using tasks that require the client to control the trunk against gravity

o   some examples are bridging the hips in the supine position to strengthen the back extensors and initiating a roll with the arm and upper trunk to strengthen the abdominal muscles

o   strengthening occurs within the context of an activity

·         using compensatory strategies and environmental adaptations when trunk control does not improve to a sufficient level and the client is at risk for injury

o   examples of interventions include wheelchair seating systems (e.g., lateral supports, lumbar rolls, chest straps, and tilt-in-space frames with head supports) and adaptive ADL equipment (e.g., reachers, long-handled equipment) to decrease the amount of required trunk displacements

41.  Pedretti lists 5 strategies for improving task performance in standing.  Know them.

41.  Pedretti lists 5 strategies for improving task performance in standing.  Know them.

·         Establishing a symmetrical base of support and proper alignment to prepare to engage in occupations. This standing alignment is assumed to provide ample proximal stability and to support engagement in functional tasks. The therapist may use hands on support or visual or verbal feedback to establish proper alignment as follows:

o   Feet apart hip width apart

o   Equal weight bearing through feet

o   A neutral pelvis

o   Both knees slightly flexed

o   Aligned and symmetrical trunk.

·         Establishing the ability to bear weight and shift weight through the more affected lower extremity.

·         Encouraging dynamic reaching activities in multiple environments to develop task-specific weight-shifting abilities. For example, kitchen activities that require retrieval of cleaning supplies under the sink, in a broom closet, and in overhead cabinets require mastery of multiple postural adjustments and balance strategies.

·         Using the environment to grade task difficulty and provide external support. Proper use of the environment can decrease the client’s fear of falling and simultaneously improve confidence and challenge underlying balance skills. (e.g. working in front of a high countertop, using one hand for weight bearing as a postural support and using a walker for support.

·         Training upright control within the context of functional tasks that are graded. Tasks are graded in relation to length of required reach, speed, and progressively more challenging bases of support. Examples include, making a bed, changing a pet’s food bowl setting a table, stepping up on a curb, cleaning a wall mirror, playing horseshoes or shuffleboard and doffing slippers in a standing posture.

42.  What are the benefits of sidelying on the affected side after stroke?

42.  What are the benefits of sidelying on the affected side after stroke?

·         sensory input

·         become more aware of this side

·         become less fearful of putting weight on weak side

·         can help prevent painful shoulders

·         can reduce increased tone in flexion syngergies

43.  The shoulder can be at risk in sidelying.  Why?  How can you help?

43.  The shoulder can be at risk in sidelying.  Why?  How can you help?

·         increased risk of subluxation due to instability in glenohumeral jt and malalignment of positioning (i.e. scapula retracted, arm across body). Teach pt to protract scapula and support position with pillows

44.  Why might you discourage clasped hands overhead ranging of UEs after stroke?

44.  Why might you discourage clasped hands overhead ranging of UEs after stroke?

·         risk of increasing pain, prompting impingement syndrome and/or stressing carpal ligaments

45.  List 5 contraindications for the use of a Bioness FES device.

45.  List 5 contraindications for the use of a Bioness FES device.

·         skin cancer, metal pins or plates, at risk for seizures, pacemakers

46.  List 5 contraindications for the use of a REO Go Therapy device.

46.  List 5 contraindications for the use of a REO Go Therapy device.

·         client without supervision

·         clients who can’t be active for 60 min without cardiac or respiratory problems

·         persons with fixed contractures in affected limb

·         persons with significant sensation/cognitive/linguistic/perceptual impairments

47.  What electronic neurotherapy tools explored in our labs can be used in conjunction with CIT therapy?  Which not?

47.  What electronic neurotherapy tools explored in our labs can be used in conjunction with CIT therapy?  Which not?

·         Can be used in conjunction:

o   Reo-go

o   Armeo

o   Bioness H200

·         Can not be used in conjunction:

o   Functional Electrical Stimulation: RT300 by Restorative Therapies- unaffected hand could perform all of the work

48.  Briefly describe what is meant by “computerized dynamic posturography” in the use of the SMART Balance Master.

48.  Briefly describe what is meant by “computerized dynamic posturography” in the use of the SMART Balance Master.

·         method of assessing/isolating functional contributions of vestibular, visual, and somatosensory inputs, and the neuromuscular system in postural control and balance

·         pt stands on moveable platform with moving surround enclosure. Platform moves in various planes and records pt’s postural stability and motor reactions.

49.  Why is the traditional “functional C” design hand splint a poor choice for people with hemiplegic hands (give four reasons)?

49.  Why is the traditional “functional C” design hand splint a poor choice for people with hemiplegic hands (give four reasons)?

·         the traditional functional “C” positions the long finger flexors in a shortened position

·         the bent up sides cause bridging of the straps that allow the fingers to pull back and out

·         the thumb is usually positioned in too much opposition-they usually have one strap for all four fingers

·         the neurologically involved hand is a dynamic component that is constantly changing

o    it changes with postural movements and associated reactions (e.g., sneezing, laughting, or standing up from chair) resulting in increased tone

o   as the fingers move into flexion, something has to give

o   unfortunately, it’s the patient’s IP joints that give under the pressure

o   pain and joint damage are often the end result

·         “chronic imbalances of the force about a joint or series of joints can lead to deformities”

·         (http://www.saebo.com/pdf/SaeboStretch.pdf) <- has good photos...

50.  Why is a Saebo-Stretch splint considered a better choice than a static splint for a hemiplegic hand (four reasons)?

50.  Why is a Saebo-Stretch splint considered a better choice than a static splint for a hemiplegic hand (four reasons)?

·         as tone increases, the SaeboStretch protects the joints by allowing the fingers to move into flexion

o   the neurologically involved hand is a dynamic component that is constantly changing due to postural movements and associated reactions (laugh, sneeze, stands up out of chair) resulting in increased tone

·         provides a low-load, long duration stretch to return fingers to extension

·         improve positioning by utilizing new strapping design with non-slip material

o   utilizes a slot, cutouts and key anatomical points of control to keep the fingers in place

·         maintain and/or improve range of motion

·         (http://www.saebo.com/pdf/SaeboStretch.pdf)

·         to prevent contractures or minimize soft tissue shortening

·         overcomes issues which can result from traditional splints including deformity, joint damage, hypermobility, and contractures

·         http://www.saebo.com/products/saebostretch/

-also known as a resting hand splint or a night-time splint
-stroke, TBI, SCI, CP
-to prevent contractures or minimize soft tissue shortening
-dynamic hand piece
-allows the fingers to move through flexion caused by associated reactions (laugh, sneeze, stands up out of chair) and tone
-utilizes a low-load, long-duration stretch to return the fingers to the desired position
-overcomes issues which can result from traditional splints including deformity, joint damage, hypermobility, and contractures
-http://www.saebo.com/products/saebostretch/

-allows individuals suffering from neurological impairments such as stroke the ability to incorporate their hand functionally into therapy and at home by supporting the weakened wrist, hand, and fingers
-a custom fabricated orthosis that is non-electrically based and is purely mechanical
-positions the wrist and fingers into extension in preparation for functional activities
-the user is able to grasp an object by voluntarily flexing his or her fingers
-the extension spring system assists in re-opening the hand to release the object
-treatment principles are based on the latest advances in neurorehabilitation research documenting the brain’s ability to “re-program” itself through mass practice, task oriented arm training
-takes advantage of the most recent research by allowing patients to immediately begin using their hand for functional grasp and release activities
-the ability to use the hand in therapy and at home has been reported as extremely motivating during the recovery process
-goal: decrease learned non-use, increase learned use, reduce spasticity, improve ROM/strength/control, and improve quality of life
-http://www.saebo.com/products/saeboflex/

52.  Define: Brain plasticity

·         is able to reorganize and adapt to functional  demands after injury (pg 404 ped.)

53.  Define: Cerebral vascular accident-

·         stroke, caused by a lesion in the brain,

·         The WHO defines “acute neurologic dysfunction of vascular origin...with symptoms and signs corresponding to the involvement of focal areas of the brain.” (Ped pg 803)

54.  Define: Embolism

·         obstruction in a blood vessel due to blood clot

55.  Define: Transient ischemic attack (TIA)

·         mild or isolated or repetitive neurological symptoms that develop suddenly, last few mins to several hours but no longer than 24hrs (Ped. pg 804)

56.  Define: Apraxia- gets better with ADLs or practice of doing the task

·         Slide Ppt 10/23/12:

·         Failure to orient to task

·         Poor tool use

·         difficulty sequencing a routine task

·         hesitation or preservation on task

·         context-only movement

57.  Define: Anosagnosia

·         lack of knowledge or denial about deficits or disease process and the implications of the deficit

58.  Define: Broca’s aphasia

·         slow, labored speech with frequent misarticulations, good auditory comprehension except when is rapid, grammatically complex or lengthy.  

·         Reading comprehension and writing may be severely affected and has deficits in monetary concepts and the ability to do calculations

59.  Define: Wernicke’s aphasia

·         impaired auditory comprehension but with fluent, well-articulated but paraphrasic speech. (so clearly spoken words, but the person doesn’t use them in a way that makes sense)

60.  Define: Hemianopsia

·         decreased/impaired vision in half of the visual field in one or both eye

61.  Define: Cortical blindness

·         total or partial loss of vision in a normal-appearing eye caused by damage to the brain's occipital cortex

62.  Define: Anomia

·         word finding difficulty

63.  Define:Agraphia

·         inability to write

64.  Define: Alexia

·         acquired dyslexia, or loss of ability to read due to brain damage

65.  Define: Nystagmus

·         involuntary rapid eye movements, either vertical, horizontal or rotary

66.  Define: Diplopia

·         double vision (simultaneous perception of two images of a single object

67.  Define: Ataxia

·         lack of voluntary coordination of muscle movements

68.  Define: DVT

·         deep venous thrombosis-blood clot that typically forms in large veins of lower leg or thigh. could become embolism. bad.

69.  Define: Shoulder subluxation

temporary/partial dislocation of glenohum jt; typicall due to shoulder instability

70.    What test is considered the gold standard for diagnosing swallowing problems?

 70.    What test is considered the gold standard for diagnosing swallowing problems?

·      Modified Barium Swallow

71.    Name the three phases of a swallow.

·      Oral Preparatory phase: when food or liquid is placed on the tongue

o  Tongue and mandible move side to side (rotary movement) to keep the food between the teeth

o  Bolus is formed

·      Oral phase: tongue moves the bolus toward the back of the mouth

o  Voluntary (person must be alert)

o  About 1 second

·      Pharyngeal phase:

o  Beginning of involuntary part of swallowing process

o  Bolus moves through pharynx into the esophagus

o  About 1 second

·      Esophageal phase: peristalsis

o   Wave action of the esophagus to carry bolus into the stomach

72.    Name several conditions that may lead to dysphagia.

·      Stroke

·      Parkinson’s

·      Head Injury

·      Dementia

·      Head and Neck cancer

73.    What is the most commonly recommended compensatory strategy to improve a swallow?

73.    What is the most commonly recommended compensatory strategy to improve a swallow?

·      Sit upright with the hips flexed to 90 degrees

·      Tilting the patients chin down when swallowing

74.    A person with hemiplegia may swallow more safely by performing what compensatory maneuver?

·      Turning the head to the left or the right when swallowing.

·      Turn to the weak side when swallowing if weakness or paralysis on pharynx.

·      Turn to the stronger side when swallowing if lingual or pharyngeal weakness

75.    A person with hemi-sensory deficits may swallow more safely by performing what two compensatory maneuvers?

·      Tongue sweep

·      Finger sweep

76.    How long should a person sit up after eating?

·      30-60 minutes

77.     List three other strategies that can help a person swallow more safely.

·      Tilt the chin down about 45 degrees to help trigger the pharyngeal swallow, laryngeal closure, or to help the tongue move correctly

·      Thicken the consistency of the liquids they are consuming because this tends to travel through the oral cavity and pharynx at a slower rate to allow more time for the pharyngeal swallow to trigger

·      Reduce the size of the bolus

·      Swallow twice per bite and alternate solids with liquids

78.    What is the great risk that accompanies swallowing difficulties?

·      aspiration

79.    Be able to describe, as if speaking to a client, what is causing the symptoms of:

Multiple Sclerosis

Parkinson’s Disease 

Alzheimer’s Disease

Amyotrophic Lateral Sclerosis

Huntington’s Disease

79.    Be able to describe, as if speaking to a client, what is causing the symptoms of:

·      Multiple Sclerosis

o  The insulator (myelin sheath) on the nerves of the brain and spinal cord (CNS) is being impacted. Changes to this sheath changes the way the signals are conducted, the speed or the ability for the impulse to reach its destination (muscle or sensations). Symptoms are dependent on where the in the CNS inflammation occurs. When there is an inflammation of the myelin sheath, you may experience intermittent symptoms of sensory distortion, incoordination or weakness. This is the unpredicability of MS.

o  When there is a loss of function, this may be due to permanent scarring, or lesions, from the inflammatory period.

·      Parkinson’s Disease

o  PD is a brain disorder.  There is a particular part of the brain (substantia nigra) that produces dopamine.  This chemical dopamine, sends messages around the brain to help controls coordinated movements.  In PD the brain does not produce enough dopamine and so causes incoordination, tremors, rigidity or stiffness, slow movements, instability or impaired balance.

·      Alzheimer’s Disease

o  Progressive neurological disorder of the brain. Higher mental processes are impaired, behavior is altered and mood is disturbed

·      Amyotrophic Lateral Sclerosis:

o  This is a destruction of motor nerves within the spinal cord, brainstem and brain. This does not affect how you think, but how you move.

·      Huntington’s Disease

o  Degeneration of the areas of the brain that control voluntary and involuntary movement as well as cognitive and emotional functions

80. What is the typical age(s) of onset for each of these conditions?

81.    Each of these conditions may evolve over time, leading to increasing physical impairment.  For each of them, be able to list typical symptoms that occur:
See Chart below

1.)    at onset and in early stage (why they come to the doctor)

2.)    middle stage, as disease begins to progress

3.)    late stage, when person may be a wheelchair user

82.    Cognitive changes play a role in all of these conditions, except which one?

·      ALS

83. At each stage in treating a person with these conditions, be able to list OT assessment strategies that may reveal functional performance deficits related to that stage.

84.    Also, at each stage, list interventions that may address performance of everyday functional activities.  It may help to make a table with a column showing symptoms and others showing assessments and interventions you may recommend.  A version of this sort of table is provided for you in Pedretti for ALS and for Alzheimer’s Disease, so some of the work has been done for you.

84.    Also, at each stage, list interventions that may address performance of everyday functional activities.  It may help to make a table with a column showing symptoms and others showing assessments and interventions you may recommend.  A version of this sort of table is provided for you in Pedretti for ALS and for Alzheimer’s Disease, so some of the work has been done for you.

·      ALS Symptom & Intervention table in Pedretti’s p 878-879

·      Alzheimer’s Disease Symptom & Intervention table in Pedretti’s p 882-883

·      Huntington’s p 887-888  

·      MS p892 (throughout disease progression)

o  problem solving compensatory strategies

o  time management

o  role delegation

o  use of adaptive equipment to compensate for motor, sensory, endurance, cognitive and visual deficits

·      Parkinson’s

o  compensatory strategies

o  client and family education

o  environmental and task modifications

o  community involvement

85.    Define: Anterograde amnesia

·      loss of memory for all events after the trauma (C&M, p.383)

86.    Define: Retrograde amnesia

·      memory loss preceding the trauma (C&M, p.386)

87.    Define: Working memory

·      the ability to hold one thought in reserve, while thinking about something else, involves elements of divided attention; important for multi-tasking (handout)

88.    Define: Explicit memory

·      a conscious process whereby information is recalled; is involved with “factual knowledge of people, places, and things, and what these facts mean” (Ped, p.597)

·      also referred to as declarative memory (Ped, p.597)

·      is flexible and “involves association of multiple bits and pieces of information”; it is called on through deliberate, conscious effort (Ped, p.597)

·      both episodic (events that have been personally experienced and are connected to a particular place and time and relevant factual information; recent episodic memory covers facts and events that a relearned on a daily bases or involve orientation to time and place) and semantic (memory for words and factual information, builds on new information using prior knowledge) memory functions are considered types of

·      explicit memory (Ped, p.597)

·      a long-term memory process (Ped, p.597)

89.    Define: Procedural memory

·      unconscious memory ability, such as the ability to perform over-learned tasks without consciously thinking them through (handout)

90.    Define: Orientation

·      a cognitive ability that underlies thinking skills

·      “Alert and Oriented x 3”: meaning alert and oriented to person, place, and time

·      “what is your name?”; “what is the date?”; “where are you?”; “why are you here?”

·      people who are disoriented are generally frightened and confused, as you would be if you did not know where you were and why

·      often severely memory impaired, unable to learn new information or keep track of time passing

·      though with supervision, they may be able to perform routine, over-learned activities, such as shaving or dressing, they are unable to martial the more complex cognitive skills needed to organize, plan and carry out less familiar tasks

·      because these patients do not know their situation, they are not likely to understand the importance of taking their medications or participating in therapy

·      they perform robotically, if at all, and sometimes require a bedside companion to keep them safe and unafraid

·      fortunately, in cases involving brain trauma, disorientation is most often a transient state

·      (handout, p. back of page with puzzle piece brain)

91.    Define: Confabulation

·       try to fill in gaps in memory by making things up (Family Guide to the Rancho Levels of Cognitive Functioning Handout)

·      associated with Ranch Level 5 (Family Guide to the Rancho Levels of Cognitive Functioning Handout)

92.    Define: Dyscalculia

·      disturbances of calculation (Ped, p.851)

·      dyslexia (disturbances of reading), agraphia (disorders of writing), and dyscalculia (disturbances of calculation) often accompany the aphasias (disturbances of comprehension and/or formulation of language)- however, with traumatic aphasias, these capabilities may be better preserved than with stroke; treating therapists should always attempt alternative modes of communication (Ped, p.850-851)

93.    Define: Diffuse axonal injury

·      a prototypical lesion caused by rapid deceleration (Ped, p.841)

·      the degree of injury may vary from primary axonotomy, with complete disruption of the nerve, to axonal dysfunction, wherein the structural integrity of the nerve remains but there is loss of ability to transmit normally along neuronal pathways (Ped, p.841)

·      the clinical severity of is measured by the depth and length of coma (i.e., the time from the onset of injury until the individual performs purposeful activity) and associated signs such as papillary abnormalities (Ped, p.841)

94.    Define: Minimally conscious state

·      reproducible cause-and –effect response to stimuli (pursuit eye movement to verbalization) (Ppt, p.3)

·      many individuals emerge from a persistent vegetative state to a minimally conscious state (Ped, p.843)

·      definite behavioral evidence of awareness of self, environment, or both (Ped, p.843)

·      clearly discernible, reproducible behavior in one ore more of the following areas must be demonstrated: (Ped, p.843)

o  ability to follow commands (Ped, p.843)

o  gestural or verbal yes/no responses (regardless of accuracy) (Ped, p.843)

o  intelligible verbalizations (Ped, p.843)

·      purposeful movements or affective responses that are appropriate responses to environmental stimuli (Ped, p.843)

o  examples: reaching for objects; touching or holding objects that accommodate their size and shape; engaging in pursuit eye movements or sustained fixation in direct response to stimuli; and smiling, crying, vocalizing, or gesturing in response to relevant stimuli (Ped, p.843)

95.    Define: Persistent vegetative state

·      eye-opening, reflexive response, autonomic function intact, no purposive activity (medullary- mediated movement, but no sign of higher cognitive function) (Ppt, p.3)

·      refers to a condition of past and continuing disability with an uncertain future; the typical onset is within 1 month of traumatic or non-traumatic brain injury or after a month-long metabolic or degenerative condition (Ped, p.842)

·      The condition may improve, and the client may achieve a minimally conscious state over time (Ped, p.842)

·      if the client does not improve, then the term permanent vegetative state is appropriate, signifying that the change of regaining consciousness before death is exceedingly small (Ped, p.842)

o  no awareness of self or the environment and an inability to interact with others (Ped, p.842)

o  no sustained, reproducible, or voluntary behavioral responses to sensory stimuli (Ped, p.842)

o  no language comprehension or expression (Ped, p.842)

o  sleep-wake cycles of variable length (Ped, p.842)

o  ability to regulate temperature, breathing and circulation to permit survival with routine medical and nursing care (Ped, p.842)

o  incontinence of bowel and bladder (Ped, p.842)

o  variable preserved cranial-nerve and spinal reflexes (Ped, p.842)

96.    What two factors are the best predictors for long-term outcome following brain injury?

·      another important landmark in recovery is post-traumatic amnesia (PTA), which is probably the single best measurable predictor of functional outcome in the research literature (Ped, p.843)

·      the length of time from the injury to the moment when the individual regains ongoing memory of daily events (Ped, p.843)

·      after a brain injury, an individual’s progression along this continuum of consciousness depends on age, prior health status, severity of injury, and the methods of medical, therapeutic, and environmental management (Ped, p.842)

·      although many studies have analyzed factors such as age, severity and etiology of injury, substance abuse, and psychosocial status in predicting outcomes from TBI, they have definite limitations regarding the recovery of an individual patient (Ped, p.844-845)

·      individuals with TBI improve over months to years especially once an individual becomes aware of his or her altered capabilities (Ped, p.845)

·      following an individual’s personal rate of recovery is probably more predictive of future recovery than any other factor (Ped, p.845)

97.    What six areas are typically addressed by OT for patients at Rancho I-III?

·      sensory stimulation (Ped, p.854)

·      bed positioning (Ped, p.854)

·      casting and splinting (Ped, p.854)

·      wheelchair positioning (Ped, p.854)

·      dysphasia management (Ped, p.854)

·      family and caregiver education (Ped, p.854)

·      general aim of intervention for those at Ranch Levels I-III is to increase the individual’s level of response and overall awareness of self and environment (Ped, p.854)

·      all simulation should be well constructed and broken down into simple steps and commands (Ped, p.854)

·      sufficient time is necessary for an individual’s responses because cognitive processing is often significantly delayed during this phase of recover (Ped, p.854)

·      interventions may occur simultaneously to optimize progress- each intervention affects and enhances the next (Ped, p.854)

·      because clients often respond more to familiar and routine, it is important to incorporate close family members and friends into sessions (Ped, p.854)

98.    What are the primary strategies used in ICUs for managing intracranial pressure?

·      effective intracranial pressure (ICP) treatments include mannitol, high-dose barbiturate therapy, ventriculostomy for drainage of cerebrospinal fluid, and craniectomy (i.e., removal of portions of the skull to allow for external brain swelling (Ped, p.841)

·      levels must stay below 20 mm Hg (Ppt, p.1)

·      Emergency: craniotomy (Ppt, p.1)

·      Chronic: shunt (Ppt, p.1)

99.    Be able to describe the 3 part model of cognition offered by Katz and Hartman-Maeir (Ped. 591).

·      a hierarchical feedback-feedforward model describing higher-level cognitive processes (Ped, p.591)

·      has three parts, with self-awareness at the top of the hierarchy, executive functions in the middle of the hierarchy, and sensory-perceptual components at the base of the hierarchy: (Ped, p.591)

·      self-awareness: (Ped, p.591)

·      the ability to perceive the self in relative objectivity while still maintaining a subjective sense of self through one’s thoughts and feelings (Ped, p.591)

·      executive functions: (Ped, p.591)

·      directed, effective activity involving volition to take action; planning to reach a goal by identifying and organizing steps; taking purposive action and actually implementing a plan; and finally ensuring effective performance by monitoring, self-correcting, and regulating aspects of the performance to achieve success (Ped, p.591)

·      sensory-perceptual components: (Ped, p.591)

·      involves the registration of sensory information from the environment (through taste, smell, touch, sound, sight) and internal stimuli that affect the sensory receptors (Ped, p.591)

·      strong relationship among the three processes of the hierarchical feedback-feedforward model, they may not operate together at all times (Ped, p.591)

·      executive functions most likely depend on and control multiple cognitive processes from many different regions of the brain (Ped, p.591)

·      aspects of the hierarchical feedback-feedforward model serve as the main basis for the discussion of higher-level cognition and the information-processing model (Ped, p.591)

100.    How do OTs utilize procedural memory during inpatient treatment for brain injury?

·      ADL IS KEY! (Ppt, p.3)

·      access procedural memory (Ppt, p.3)

·      over-learned tasks= most automatic (Ppt, p.3)

·      I orientation, D agitation, and D amnesia (Ppt, p.3)   

101.    What is agitation?  How does it differ from aggression?

·      agitation: (Handout, p.1)

·      an excess (any behavior that interferes with functional activities) of one or more behaviors that occurs during an altered state of consciousness (amnestic phase of recovery) (Handout, p.1)

·      physical aggression, explosive anger, and increased psychomotor activity; impulsivity, verbal aggression, disorganized thinking, perceptual disturbances, and reduced ability to maintain or appropriately shift attention (Handout, p.1)

·      post-traumatic amnesia plus a behavioral excess of aggression, disinhibition, and/or emotional lability (Handout, p.1)

·      an adaptive attempt to explore the environment (Ppt, p.8)

·      aggression:

o  using violence to get what you want

o  as the individual becomes acclimated, they put cause and effect together

o  behavioral plan

102.    Be able to describe strategies for managing agitation.

·      environmental intervention (Ped, p.866)

o  quiet, isolated room without a roommate (Ped, p.866)

o  all extraneous stimuli (e.g., radios and televisions) should be removed (Ped, p.866)

·      therapy is provided in a private, quiet room away from other people and extraneous stimuli (Ped, p.866)

·      if severe behavioral problems, may require one-to-one care: the client is assigned a rehabilitation aide who remains with the client throughout the day (including during therapy) to monitor and regulate his or her behavior (aide or therapist may wear/carry an alarm bracelet, pager, or walkie-talkie that signals other staff when the client attempts to wander away from the appropriate floor or out of the building or begins to act aggressively and assistance is required) (Ped, p.866)

·      interactive interventions (Ped, p.866)

·      the entire team should implement these interventions in a consistent way (Ped, p.866)

·      speaking in a calm and concise manner (Ped, p.866)

·      deliberately refraining from detailed explanations that will only increase the client’s confusion and frustration (Ped, p.866)

·      for safety’s sake, therapists should also keep the door open when working with the client at bedside and always maintain an awareness of the individual in relation to self (Ped, p.866)

·      a client in the post-acute stages of rehabilitation and who continue to exhibit behavior problems should be placed on a behavioral management program (Ped, p.866)

·      should allow the client to experience the natural consequences of inappropriate behavior (e.g., losing community recreational privileges) in an effort to encourage more appropriate responses (Ped, p.866)

·      drug therapy may be used for those who do not make significant improvements in their behaviors and who prevent a safety risk to themselves and others (Ped, p.866)

·      treatment is based on developing (Ppt, p.3)

o  a safe environment (over-stimulation= I agitation or shut-down= let rest and next time just right challenge) (Ppt, p.3)

o  a consistent routine (e.g., time and pattern) (Ppt, p.3)

o  consistent team member participation (Ppt, p.3)

o  focus on over-learned tasks (ADLs= I orientation, D agitation, and D amnesia) (Ppt, p.3)

o  gradual re-introduction of more complex parameters and tasks (Ppt, p.3)

·      P (can’t do much at the person level as they are not self-directed) E (manage) and O (set up for success) (Ppt, p.3)

o  low-stimulation room (Ppt, p.4)

o  night-day simulation (Ppt, p.4)

o  vail bed or mattress (Ppt, p.4)

o  hand mit to prevent pulling at lines/leads (Ppt, p.4)

o  out of bed therapies followed by rest breaks (Ppt, p.4)

o  trained “sitters” (Ppt, p.4)

o  wean off medications (Ppt, p.4)

o  provide orientation supports (Ppt, p.4)

o  breaks in between treatment (Ppt, p.4)

o  NO restraints, therapies outside of room, television, overmedication, overstimulation, left alone (Ppt, p.4)

103.    List three early assessment tools that are typically used with people who have emerged from coma (from lecture or text).  What do they measure?

·      Glasgow Coma Scale:

o  eye opening response (spontaneously, to speech, to pain, no response)

o  motor response to painful stimuli (obeys verbal commands, localizes pain, withdrawal flexion, abnormal flexion, abnormal extension, no response)

o  verbal response (oriented x 3, converses/disoriented, inappropriate speech, incomprehensible speech, no response

·      Rancho

o  measurement of the levels of awareness and cognitive function

104.    Be able to describe the primary behavioral differences among Rancho Levels 4

104.    Be able to describe the primary behavioral differences among Rancho Levels 5

104.    Be able to describe the primary behavioral differences among Rancho Levels 5

104.    Be able to describe the primary behavioral differences among Rancho Level 6.

104.    Be able to describe the primary behavioral differences among Rancho Level 6.

105.    Be able to explain why consistency in treatment is important during inpatient brain injury rehabilitation.

105.    Be able to explain why consistency in treatment is important during inpatient brain injury rehabilitation.

·      once you have ascertained a patient’s performance level under low stimulation conditions, treatment needs to be performed with strict adherence to environmental management guidelines (handout)

·      ideally, all self-care treatment should be performed at the same time every day, by the same therapist, following the same task sequence, in order to minimize confusion and build on rote memory (handout)

·      even the slightest change in treatment parameters can ruin a treatment session, sparking agitation and frustration by the patient (handout)

106.    Be able to explain the role of the 4 “S’s” in inpatient rehab.

106.    Be able to explain the role of the 4 “S’s” in inpatient rehab.

·      Safety (for yourself and patient) (Ppt, p.4)

·      Stability (posture/movement) (Ppt, p.4)

·      Stimulus (environmental focus) (Ppt, p.4)

·      Sequencing (organized step-by-step routine) (Ppt, p.4)

107.    List several treatment parameters that should be considered when writing TBI treatment goals.

107.    List several treatment parameters that should be considered when writing TBI treatment goals.

·      upgrading task goals: (Ppt, p.7)

·      vary extraneous environmental stimuli (Ppt, p.7)

·      introduce a choice of self-care items (Ppt, p.7)

·      diminish manual assistance (Ppt, p.7)

·      diminish verbal cues (Ppt, p.7)

·      perform task in a different setting (Ppt, p.7)

·      offer tasks in a different sequence (Ppt, p.7)

·      trial self-initiation of tasks (Ppt, p.7)

·      goal writing: (Ppt, p.7)

·      Initial: pt will complete all steps of tooth-brushing task in low-stim environment with sequential set-up, verbal cues, and hand-over-hand guidance. (Ppt, p.7)

·      Upgrade: pt will complete all steps of tooth-brushing task in low-stim environment with sequential set-up and occasional verbal cues. (Ppt, p.7)

108.    What are the components of a memory book?  What is its purpose?

108.    What are the components of a memory book?  What is its purpose?

·      cover of memory book: (handout)

·      in large print, type patient’s name, hospital room number, name of hospital, and its location (handout)

·      first page of memory book: (handout)

·      a brief biography of the patient, including name, age, family members, home address, job or school, date and description of brain injury event, and current situation and location ; ideally, this page can be written in collaboration with patient and family members ; a good speech language pathologist treatment (handout)

·      clinician I.D. page: (handout)

o  lists members of primary treatment team (handout)

·      photo album: (handout)

·      family may bring in key photos of patient and family, home, car, office, pets, etc.; again, pasting these photos into memory book and adding captions can be a good collaborative treatment session for therapist, patient, and family (handout)

·      day planning log: (handout)

·      you’ll want facing pages set up, one for a.m. events, the other for p.m. events, so the patient can review the whole day at once (handout)

o  orientation and anterograde memory remediation (Ppt, p.1)

o  calendar (Ppt, p. 2)

o  staff directory (Ppt, p. 2)

o  daily schedule (Ppt, p. 2)

o  autobiogrpahical sketch (Ppt, p. 2)

o  guest book (Ppt, p. 2)

o  photography album (Ppt, p. 2)

o  cover clearly labeled with patient’s name (Ppt, p. 2)

o  1st page: (Ppt, p.3)

¨    who am i? (Ppt, p.3)

¨    what happened? (Ppt, p.3)

¨    when did it happen? (Ppt, p.3)

¨    where am I? (Ppt, p.3)

¨    why am I here? (Ppt, p.3)

o  2nd page: (Ppt, p.3)

¨    list key rehab players to help patient orient to unit (Ppt, p.3)

109.    What is sun-downing?  What are some strategies for managing it?

109.    What is sun-downing?  What are some strategies for managing it?

·      increasing restlessness or agitation as evening approaches (handout)

·      an element of anxiety has even been noted in normal populations at this time (perhaps dating back to fears of darkness in our cave-dwelling ancestors), so this response in not entirely remarkable (handout)

·      treatment is multi-focal, involving all members of the rehab team, including the family (handout)

·       goal: decrease confusion and increase orientation cues during this difficult time, in order to ease the client toward bedtime and a good night’s sleep (a disturbed sleep-wake cycle is often seen in sun-downing clients, perhaps because they are so often mismanaged during their sun-downing episodes and go to bed frantic) (handout)

·      trial of lorazepam (medication) (handout)

·      don’t turn down the lights- turn them up until bedtime; emerging darkness may be a trigger for sun-downing (handout)

·      limit noise and confusing stimuli- turn off the tv, don’t talk so much, keep too many visitors out of the room (handout)

·      if a family member is available, have them stay with patient at bedtime- a familiar face is a good way to relieve confusion; sit quietly with your family member, holding hands and chatting quietly reminding them as needed that everything is ok; one or two visitors at most as too much activity can increase confusion (handout)
do not quiz patient with orientation questions- offer consistent orientation assistance as patient may be especially confused about where he is and why during this time (handout)

·      if at all possible, avoid use of physical restraints as this only increases fears, confusion, and agitation (handout)

·      organize and run after-dinner group activities- typically low-key social activities such as a sing-a-long, flower arranging, crafts building that help people through this difficult hour or two before bedtime (handout)

110.    What is the role of “antecedent management” in brain injury rehabilitation?

110.    What is the role of “antecedent management” in brain injury rehabilitation?

·      the best way to manage difficult behaviors is to arrange situations and organize activates so that triggers for troublesome behaviors are minimized, thus stopping the behaviors before they occur

·      each of the environmental modifications listed below (locked TBI unit, private room, no sharps or other items that may allow endangerment to self or others, quiet room for time-outs, bed, door or ankle alarms, craig beds, vail beds, window coverings, rehabilitation companion, video camera observation, television off, orientation aids) is designed to reduce external stimuli that might lead to agitated behaviors by an amnestic patient who is not yet able to filter out extraneous information or cope with sensory overload

·      work to build a nurturing but not over stimulating milieu, in order to optimize the patient’s impaired information processing and reduce confusion

·      (handout)

111.    Distinguish among day rehabilitation, clubhouse and outpatient clinic therapies for brain injury.

111.    Distinguish among day rehabilitation, clubhouse and outpatient clinic therapies for brain injury.

·      Day Rehab Program: (Ppt, p.3)

o  a.m. planning meeting (Ppt, p.3)

o  project-based interventions (Ppt, p.3)

o  individualized therapies (Ppt, p.3)

o  success in everyday routines (Ppt, p.3)

o  group lunch (Ppt, p.3)

o  group cognitive-behavioral modules (Ppt, p.3)

o  skills-based recreation (Ppt, p.3)

o  p.m. review meeting (Ppt, p.3)

o  home visits (Ppt, p.3)

o  family counseling (Ppt, p.3)

o  none in VA- $$$$$ (notes)

o  more intensive than other settings (notes)

·      Club House Model

o  e.g., Mill House (Richmond), Virginia NeuroCare Center (Charlottesville), ADAPT (Fairfax), BIS Club House (Fredricksburg), Denbigh House (Newport News) (Ppt, p.4)

o  cheap due to no OT on staff (notes)

o  community outings/community based (notes)

o  driven by clients themselves (notes)

·      Outpatient Clinic

o  individual therapies: (Ppt, p.3)

¨    neuromotor retraining, visual-perceptual training, vestibular rehabilitation, dysphagia/aphasia, psychological counseling, family counseling, O.T. life skills training, cognitive-behavioral treatment, pharmacological coordination (Ppt, p.3)

o  the problems: (Ppt, p.3)

¨    we are not in the home with them (Ppt, p.3)

¨    we have limited time to plan treatment (Ppt, p.3)

¨    we swap clients back and forth day to day (Ppt, p.3)

¨    the clinic is busy and over-stimulating (Ppt, p.3)

¨    its easier to work on physical and sensory stuff (Ppt, p.3)

¨    the speech therapist says cognitive rehab is their domain (Ppt, p.3)

o  if  you are going to work in an outpatient setting you can treat in the home for a visit or for home safety evaluation under Medicare (so long as

¨    there are no other home health services being billed) (Ppt, p.2)

o  OVERALL GOAL FOR ALL CLIENTS: (Ppt, p.3)

¨    to facilitate improved ability to participate in activities of interest or importance in home, work, and/or community settings, not the clinic (Ppt, p.3)

112.    What home management recommendations would you make to family caregivers as they prepare for a loved one with a brain injury to return home from hospital?

112.    What home management recommendations would you make to family caregivers as they prepare for a loved one with a brain injury to return home from hospital?

·      individuals who have difficulties with orientation and short-term memory cope best with well-structured, predictable, and unthreatening daily routines (handout)

·      avoid unnecessary trips to unfamiliar surroundings, which may provoke anxiety (handout)

·      avoid ambiguity and do not present too many choices or decision- use statements such as “now we must go to the store”, “now it is time to take a shower” and “Brian is coming to visit after supper” (handout)

·      keep grooming and bedside materials in the same place when not in use (for instance, put glasses in the same drawer, place toothpaste beside toothbrush in the bathroom) (handout)

·      avoid confronting the individual with tasks that stress areas of weakness (handout)
therapies should be delivered routinely by the same person (handout)

·      try to maintain a daily routine that features well-established landmarks, such as regualar mealtimes; make life predictable; avoid breaks in routine, whenever possible; extend necessary changes in routine over time instead of changing things all at once (handout)

·      allow extra rest time for the injured individual- schedule doctors appointments after nap times; encourage frequent rest breaks; do not schedule several hours of unbroken activities (handout)

·      limit coffee and tea since their stimulant effects may be amplified (handout)

·      be alert for adverse effects of medications (handout)

·      provide adequate lighting, especially in hallways, stairs, and bathrooms (handout)

·      limit confusing stimulation- family gatherings, for instance, may prove overwhelming; recreational activities are sometimes poorly tolerated, even if they involve previously enjoyed places or activities (handout)

·      be alert for changes in physical or mental status (prolonged agitation, combativeness, changes in sleep or eating patterns) (handout)

·      it may be useful to have a radio tuned to a station playing familiar tunes- television may contribute to the confusion of the environment (handout)

·      anticipate the possibility that the individual may wader off and get lost- sew labels into clothing to identify the person and who to call (handout)

·      schedule respite periods for yourself and other primary caregivers (handout)

113.    Be able to describe some strategies for addressing psychosocial deficits after brain injury.

113.    Be able to describe some strategies for addressing psychosocial deficits after brain injury.

·      alteration of self-concept/identity:  identify roles that were lost; identify the activities that would support desired roles; identify rites of passage that were lost or never transitioned through as a result of TBI.

·      once occupational/social roles, activities and rites of passage have been identified, OT helps pt regain interpersonal skills, find ways to re-engage in community, manage social skills. Group therapy might be helpful

114.    Be able to list and describe at least 3 ecologically valid community-based cognitive-behavioral assessment tools.

114.    Be able to list and describe at least 3 ecologically valid community-based cognitive-behavioral assessment tools.

·      Rivermead Behavioral Memory Test:

o  designed to detect and identify moderate to severe memory impairments that occur in everyday activity and to monitor change over time after acquired brain injury (Asher, p.546-547)

o  consists of 11 subtests administered in sequence (Asher, p.546-547)

o  tasks involve visual and auditory recall, remembering to do a task later in the test (prospective memory), remembering and identifying pictures or drawings, remembering and retelling a story, and retracing a route around the room (Asher, p.546-547)

o  in several subtests, a response is required after a delay during which other test items are used as distracters (Asher, p.546-547)

o  the raw score is either the number of items recalled correctly, or how correct or independent the response is (Asher, p.546-547)

o  Setting: quiet room with a table, chairs, window, and door (Asher, p.546-547)

·      Test of Everyday Attention (TEA)

o  designed to test attentional skills that influence everyday behavior (Asher, p.563)

o  uses familiar materials and tasks to identify attention-related problems in daily task performance (Asher, p.563)

o  eight subtests are sensitive to four types of attention: selective, sustained, attentional switching, and divided (auditory-verbal) attention (Asher, p.563)

o  subtests are based on a mock trip to Philadelphia and real-life tasks encountered in such a trip, including visual and auditory tasks (e.g., searching for symbols in a telephone book or map, listening for digits in lottery numbers, and using an elevator) (Asher, p.563)

o  Scoring instructions differ with each subtest and are based on time, accuracy, or both (Asher, p.563)

o  Setting: quiet room with a table and chairs (Asher, p.563)

·      Behavioral Assessment of Dysexecutive Syndrome (BADS)

o  assesses executive function skills, including organization and planning, problem solving, and decision making, by using challenging real life activities and time frames (Asher, p.499)

o  it also evaluates the respondent’s awareness of behavioral problems caused by executive dysfunction in daily life situations (Asher, p.499)

o  comprises six activity subtests evaluating a range of cognitive functions that represent executive functioning, in areas of cognitive flexibility, novel problem solving, planning, judgment and estimation, and behavioral regulation (Asher, p.499)

o  subtests are temporal judgment, rule shift cards, action program, key search, zoo map, and modifying six elements (Asher, p.499)

o  the respondent is instructed to perform selected tasks, which are scored according to detailed criteria (Asher, p.499)

o  the respondent and an independent observer (clinician or family member) then complete a supplementary 20-item behavioral Dysexective Questionnaire (DEX) which examines the impact of dysexecutive function on daily life situations as well as the respondents insight into behavior (Asher, p.499)

o  Setting: quiet room with table and chairs (Asher, p.499)

·      Multiple Errands Test (MET)

o  a simple performance-based test done in real-life contexts (http://www.health.utah.edu/ot/colleagues/evalreviews/met.pdf)

o  participants are given a set of shopping activities that must be completed in real time in a shopping area (http://www.health.utah.edu/ot/colleagues/evalreviews/met.pdf)

o  administered to assess the degree to which executive impairments due to frontal lobe damage affect every day functioning—like during shopping tasks (http://www.health.utah.edu/ot/colleagues/evalreviews/met.pdf)

o  provides a standard way of categorizing executive performance errors in a naturalistic environment (http://www.health.utah.edu/ot/colleagues/evalreviews/met.pdf)

o  for use in both inpatient (MET-HV: hospital version) and outpatient (MET-SV: simplified version) settings (http://www.health.utah.edu/ot/colleagues/evalreviews/met.pdf)

o  You should buy the following items: small brown loaf, packet of plasters, birthday card, bar of chocolate, single light bulb, key ring (http://eprints.ucl.ac.uk/3699/1/3699.pdf)

o  You should obtain the following information and write it down in the spaces blew: what is the headline from either today’s ‘Daily Mail,’ ‘Daily Mirror,’ or ‘The Sun’ newpaper?; what is the closing time of the library on Saturday?; what is the price of 1 pound or kilogram of tomatoes?; how many shops sell televisions? (http://eprints.ucl.ac.uk/3699/1/3699.pdf)

o  You must meet me under the clock 20 minutes after you have started this task and tell me the time (http://eprints.ucl.ac.uk/3699/1/3699.pdf)

o  Rules: you must carry out all these tasks but may do so in any order; you should spend no more than 5; you should stay within the limits of the upper floor of the shopping center; no shop should be entered other than to buy something; you should not go back into a shop you have already been in; you should not buy any item from the stalls; you should buy no more than 2 items in Tesco; take as little time to complete this exercise without rushing excessively; do not speak to the person observing you unless this is part of the exercise (http://eprints.ucl.ac.uk/3699/1/3699.pdf)

·      Executive Function Performance Test (EFPT)

o  developed to provide a performance-based standardized assessment of cognitive function

o  designed to examine cognitive integration and functioning in an environmental context

o  specifically examines executive functions in the context of performing a task

o  examines the execution of four basic tasks that are essential for self-maintenance and independent living: simple cooking, telephone use, medication management, and bill payment

o  serves three purposes: (1)to determine which executive functions are impaired, (2) to determine an individual’s capacity for independent functioning, and (3) to determine the amount of assistance necessary for task completion

o  http://www.ot.wustl.edu/ot/otweb.nsf/5af541d3cfd036a986257260005bc07d/ecc9551f54901f1d8625791e0063d1a7!OpenDocument

·      Cambridge Test of Prospective Memory (CAMPROMPT)

o  prospective memory is remembering to do things rather than remembering things that have already happened: for people with brain injury, failures in prospective memory, such as forgetting to take medication, can have devastating effects on everyday life and are likely to threaten independence

o  in the test examinees are asked to work on a number of ‘background’ distractor pencil and paper tasks such as a general knowledge quiz or word-finder puzzle for a 20 minute period-while they are doing this, and shortly after the 20-minute period is up, they carry out 6 prospective memory tasks; these tasks are cued in 2 ways: three are cued by time, three are cued by events

o  in all, the test will take about 25 minutes to administer

o  three types of scores are obtained: prospective memory time-based score, event-based score and total score

o  the type of prospective memory tasks that the examinee is asked to do includes such tasks as remembering to change tasks at a certain time and reminding the examiner to do something (e.g. “do not forget your keys”)

o  http://www.pearsonclinical.co.uk/Psychology/AdultCognitionNeuropsychologyandLanguage/AdultMemory/CambridgeProspectiveMemoryTest%28CAMPROMPT%29/ForThisProduct/FrequentlyAskedQuestions.aspx#infoontest 

115.    What brain injury related deficits may have an impact on a driving evaluation?

115.    What brain injury related deficits may have an impact on a driving evaluation?

·      lapses of consciousness; seizure disorders; or cognitive, visual, or perceptual dysfunction caused by TBI: mandate that the driver’s license be revoked until further assessment confirms that the person can drive without posing a safety risk to self or other (Ped, p.861-862)

·      Both types of evaluations are necessary because the client may fail the clinical assessment (evaluation of the individual’s visual, cognitive, perceptual, and physical status as it relates to driving), but pass the on-road assessment using compensatory strategies (Ped, p.862)

·      Conversely, the client may perform successfully on the clinical assessment but fail the on-road assessment (Ped, p.862)

·      Clients with TBI frequently exhibit deficits (e.g., visual processing disorders, figure-ground discrimination dysfunction, and impulsivity) that significantly affect their ability to drive safely (Ped, p.862)

·      Delayed visual processing: hesitate during driving maneuvers and stop in an unsafe manner (e.g., in the middle of the road or at a corner) to allow themselves adequate time to process visual information (Ped, p.862)

·      Figure-ground impairment: unable to identify stop signs and traffic signals at intersections or locate the gearshift near the dashboard (Ped, p.862)

·      Impulsivity: may respond aggressively rather than defensively when driving, increasing the risk of accidents; may use poor judgment when making driving decisions; unable to inhibit inappropriate responses (Ped, p.862)

116.    What are nmemonics?  How might you use them in outpatient therapy after BI?

116.    What are nmemonics?  How might you use them in outpatient therapy after BI?

·      if memory works by association, we actively work to crease an association between two bits of information

·      e.g., for the plane that we need to catch as 2 p.m.: we can imagine the plane in our mind and notice that it has 2 wings

·      e.g., silly story about grocery shopping to remember grocery list

·      the three fundamental principles underlying the use of mnemonics are:

·      association: the method by which you like a thing to be remembered to a method of remembering it; e.g., being placed on top of the associated object, crashing or penetrating into each other, merging together, wrapping around each other, rotating around each other or dancing together; being the same color, smell, shape, or feeling

o  imagination: create the links and associations needed to create effective memory techniques- put simple, imagination is the way in which you use your mind to create the links that have the most meaning for you; the more strongly you imagine and visualize a situation, the more effectively it will stick in your mind for later recall; can be as violent, vivid, or sensual as you like, as long as it helps you to remember what needs to be remembered

o  location: provides you with two things- a coherent context into which information can be placed so that it hangs together, and a way of separating one mnemonic in one village, I can separate it from a similar mnemonic located in another place; location provides context and texture to your mnemonic, and prevents them from being confused with similar mnemonics; we remember things by association

·      impacted by learning style: visual learners, auditory learners, or kinesthetic learners…

·      (handout)

117.    Describe a strategy for remembering names and faces.

117.    Describe a strategy for remembering names and faces.

·      N:otice the person’s special or unusual features (handout)

·      A:sk the person to repeat his or her name (handout)

·      M:ention the name in conversation (handout)

·      E:xaggerate some special feature in building a link between name and face

·      (handout)

·      For example, first look carefully at a person’s face as you are introduced.  Ask the person to repeat their name even if you heard it correctly.  Pretend you didn’t heat it or purposely mispronounce it to get them to say it over again (even ask them to spell it for you if you like).  Then use the name immediately in conversation with the person, always maintaining eye contact.  Focus on some special facial feature and blow it out of proportion in your mind, linking it to the name by rhyme or image (his name is Tony, with a nose like a pony; her name is Yvette, imagine her in a Corvette)

·      (handout)

118.    List at least five concussion symptoms.

118.    List at least five concussion symptoms.

·      attention difficulties (Ppt, p.1)

·      memory impairment (Ppt, p.1)

·      irritability (Ppt, p.1)

·      anxiety (Ppt, p.1)

·      headache (Ppt, p.1)

·      dizziness (Ppt, p.1)

·      diplopia (Ppt, p.1)

·      insomnia (Ppt, p.1)

·      fatigue (Ppt, p.1)

·      depression (Ppt, p.1)

·      slowed cognitive processing, especially in multi-stimuli environments (Ppt, p.1)

119.    Know basic return-to-play guidelines for the management of youth sports concussions.

119.    Know basic return-to-play guidelines for the management of youth sports concussions.

·      No activity for at least 1 week- no physical activity or cognitive activity (dark room and rest) (Ppt, p.2)

·      If symptomless and they pass a cognitive exam (e.g., remembering 7 words), then light aerobic exercise (Ppt, p.2)

·      If light aerobic exercise causes symptoms to return, then return to no activity (Ppt, p.2)

120.    Following concussion, when should an athlete return to the playing field?

·      After 2 weeks with no symptoms you can exercise? then--light jog. Must have physical and cognitive rest.

121.    What is the one common cognitive factor among people who have brain injuries?

121.    What is the one common cognitive factor among people who have brain injuries?

·      they have slowed processing

122.    Describe in lay terms what happens to body fluids and the brain in a blast-related concussion.

122.    Describe in lay terms what happens to body fluids and the brain in a blast-related concussion.

·      Air spaces and fluids in entire body compress by shock wave

·      Followed instantly by vacuum wave (underpressure)

·      Impacts stomach, heart, blood vessels, brain (most fragile), etc.

123.    List at least 5 symptoms of PTSD (use PCL-M checklist).

123.    List at least 5 symptoms of PTSD (use PCL-M checklist).

·      repeated, disturbing memories, thoughts, or images of a stressful military experience (handout)

·      repeated, disturbing dreams of a stressful military experience (handout)

·      suddenly acting or feeling as if a stressful military experience were happening again (as if you were reliving it) (handout)

·      feeling very upset when something reminds you of a stressful military experience (handout)

·      having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminds you of a stressful military experience  (handout)

·      avoid thinking about or talking about a stressful military experience or avoid having feelings related to it (handout)

·      avoid activities or situations because they remind you of a stressful military experience (handout)

·      trouble remembering important parts of a stressful military experience (handout)

·      loss of interest in activities which you use to enjoy (handout)

·      feeling distant or cut off from other people (handout)

·      feeling emotionally numb or being unable to have loving feelings for those close to you (handout)